The accuracy of self-reported driving behaviors, particularly in relation to real-world risky driving in realistic settings over time, remains unclear. This study aimed to examine whether self-reports remain consistent over time, whether they predict real-world driving behaviors, and whether that relationship changes over time. Self-reported driving behaviors included a global rating score of driving ability and four components of the Driver Behavior Questionnaire (lapses, errors, ordinary violations, and aggressive violations). At three separate timepoints [baseline (N = 47), 6-month (N = 43), and 12-month (N = 38)], we obtained these self-ratings along with real-world risky behaviors recorded using the Lytx video telematics platform over a 28-day period. Linear mixed effects models were used to examine whether self-reported driving behaviors changed over time and whether they predicted real-world driving. Neither self-reported nor objective driving behaviors significantly changed over time. Aggressive violations, specifically at the 6-and 12-month follow-up visits, and ordinary violations at the 12-month visit significantly predicted real-world risky driving. Consistent with the literature, these findings indicate that self-reported driving behaviors do not change over time. Aggressive violations, reported at follow-up visits, may be the most indicative of overall real-world risky driving. Their value at follow-up visits specifically may be because participants are more attuned to these behaviors after an initial period of observation. Additionally, aggressive violations are commissive behaviors with a strong negative emotional valence, which could cause them to be remembered better than omissive behaviors and those with a more neutral emotional valence. These results can potentially influence driving assessments and interventions.

OBJECTIVE:This study assesses the efficacy, safety, and tolerability of cenobamate using long-term real-world data, incorporating both seizure reduction and seizure-freedom periods, and examines baseline clinical variables to determine predictors of response. METHODS:We retrospectively analyzed all patients prescribed cenobamate from May 2020 to July 2021. The primary outcome was 12-month seizure frequency reduction for each seizure type, stratified by baseline seizure frequency (higher vs lower frequency: ≥2 seizures vs <2 seizures in the preceding 3 months). Logistic regression identified seizure response predictors. We assessed longest seizure-free periods, considering seizure type and baseline frequency, further differentiating the higher-frequency group into weekly and monthly subgroups. We examined retention, safety, and tolerability. RESULTS:Of 182 patients taking cenobamate, 170 had focal epilepsy. Among those 170, the 12-month retention rate was 82.4%, decreasing to 75% at last follow-up. In patients with higher-frequency baseline seizures, ≥50% seizure reduction rates were 47% (95% confidence interval [CI] = 38%-57%) for focal impaired awareness seizures (FIAS) and 58% (95% CI = 43%-71%) for focal to bilateral tonic-clonic seizures (FBTCS). In patients with lower-frequency seizures, rates were 53% for FIAS (95% CI = 31%-74%) and 68% (95% CI = 49%-82%) for FBTCS. Factors linked to 100% seizure reduction were lower baseline seizure frequency, fewer failed medications, and concomitant clobazam use. Most patients achieving seizure freedom did so at 200 mg/day, although higher doses also showed efficacy, particularly for FBTCS. Among patients with seizures affecting awareness, 7%-43% had ≥12 months of freedom from such seizures. Among patients with FBTCS, 17%-56% had ≥12 months of freedom from FBTCS. Patients with higher-frequency baseline seizures had lower rates of seizure freedom. Adverse effects were reported by 52%, with drowsiness being most common (32%). One patient developed depression necessitating hospitalization. SIGNIFICANCE:Cenobamate is an efficacious drug. Baseline clinical features of seizure type, lower frequency, fewer failed medications, and clobazam use are associated with treatment response and can inform decisions of trialing cenobamate before considering epilepsy surgery.

Human immunodeficiency virus-associated neurocognitive disorders persist in the combination antiretroviral therapy era. CD4 nadir is a well-established predictor of cognition cross-sectionally, but its impact on longitudinal neurocognitive (NC) trajectories is unclear. The few studies on this topic examined trajectories of global cognition, rather than specific NC domains. The current study examined CD4 nadir in relation to domain-specific NC decline. 132 HIV + adults from the Temple/Drexel Comprehensive NeuroHIV Center, Clinical and Translational Research Support Core Cohort were administered comprehensive NC assessments longitudinally, with last visit occurring an average of 12 years after CD4 nadir. Linear mixed models were used to examine CD4 nadir in relation to longitudinal NC trajectories in three empirically identified NC domains: speed/executive function (S/EF), visuospatial memory (VM), and verbal fluency (VF). CD4 nadir was associated with change in VF (p = 0.020), but not with S/EF or VM. Specifically, those with CD4 nadir < 200 demonstrated increasing VF over time (p = .002), whereas those with CD4 nadir > 200 demonstrated stable VF (p = .568), though these differing trajectories may partly reflect regression to the mean or differential practice effect. CD4 dynamics over time were analyzed as potential mechanisms for the identified associations, with mixed findings. While low CD4 nadir has been associated with weaker neurocognition among people living with HIV, the results of this study suggest that low CD4 nadir is not associated with ongoing decline a decade later. Nadir-related deficits in VF may be stable or even improve over time, possibly reflecting the beneficial cognitive effects of long-term treatment and immune reconstitution.

Assess the impact of an opt-out wellness check-in program for residents.

Background and Objectives:To compare long-term seizure control in patients with long-term VNS (vagal nerve stimulator) stimulation (VNS-on) with those who discontinued VNS after >3 years (VNS-off). Methods:Patients with refractory epilepsy with VNS therapy for >3 years (and follow-up for >2 years after VNS discontinuation for VNS-off patients) were included. Patients with brain surgery <3 years after VNS were excluded. We compared the percentage of patients with ≥50% seizure reduction (50% responder rate) and change in seizure frequency within and between groups in follow-up. Results:Thirty-three VNS-on and 16 VNS-off patients were evaluated. VNS-on patients underwent stimulation for 9.7 years (mean). VNS-off patients had VNS treatment for 6.5 years (mean), discontinued treatment, then had additional 8.0 years (mean) follow-up. 50% responder rates were similar between groups (VNS-on: 54.5% vs VNS-off at last-on: 37.5%, p = 0.26; vs VNS-off at the last follow-up: 62.5%, p = 0.60). VNS-on patients had a significant reduction in seizure frequency at the last follow-up compared with baseline (median [Mdn] = -4.5 seizures/month, interquartile range [IQR] = 14.0, 56% reduction, p = 0.013). VNS-off patients also showed significant seizure reduction while still continuing VNS therapy (Mdn = -1.0 seizures/month, IQR = 13.0, 35% reduction, p = 0.020) and, after discontinuing therapy, at the last follow-up compared with baseline (Mdn = -3.2, IQR = 11.0, 52% reduction, p = 0.020). The 2 groups were comparable in seizure frequency change both at the last-on visit (absolute change, p = 0.62; relative change, p = 0.50) at the last follow-up (absolute change, p = 0.67; relative change, p = 0.76). Discussion:Patients who discontinued VNS therapy and those who continued therapy had similar response during active treatment and similar long-term outcomes, suggesting that factors such as the natural disease course and/or medication treatment strongly affect long-term outcomes.

Introduction Abdominal ultrasonography is a key diagnostic tool used in complaints of abdominal pain. The rationale for this study is to examine abdominal ultrasonography's impact on the conclusion of care of abdominal pain in a predominantly Hispanic/Latino patient population. Materials and methods A chart review of 350 patients with a new diagnosis of abdominal pain from a rural family practice clinic in Texas was performed. These patients' charts were reviewed for a new diagnosis of abdominal pain, medications prescribed for abdominal pain, whether abdominal ultrasonography was completed, and the number of visits regarding their complaint. The last visit for their abdominal pain was denoted as the conclusion of care of abdominal pain within the clinic. The primary analyses were logistic regressions with conclusion of pain care or number of visits as the outcome and abdominal ultrasound completion as the primary predictor. Results The sample size was 216 of the 350. Patients were excluded due to age under 18 and if the patient's pain was not coded as epigastric, generalized, or right upper quadrant pain. The patient age range was 18-88 years, and they were all of Hispanic/Latino origin. Abdominal ultrasound was completed on 59 of the patients, and 65 patients experienced conclusion of primary care for abdominal pain. Regarding the number of visits for abdominal pain, 69% had one visit, 25% had two visits, and 6% had three or more visits. Patients who had abdominal ultrasounds were more likely to have multiple visits (typically just two visits) but had markedly higher conclusions of care for abdominal pain. These relationships remained when adjusting for demographic and medical covariates such as age, abdominal pain (all types), and medical treatments used. Conclusion In the outpatient rural care of Hispanic/Latino patients residing in the Rio Grande Valley, patients who had a new complaint of abdominal pain were more likely to have conclusion of primary care for abdominal pain, with only a slight increase in primary care healthcare consumption, if abdominal ultrasonography was completed for abdominal pain.

Objective:Human immunodeficiency virus (HIV) type 1 (HIV-1), cardiovascular disease, and HIV-associated neurocognitive disorders (HAND) disproportionately affect Black/African American individuals compared to other racial and ethnic groups. Understanding the mechanisms of cognitive health disparities is essential for developing policy and health interventions to combat such disparities. Cardiovascular risk factors/diseases are common comorbidities that likely contribute to cognitive health disparities among Black/African American people living with HIV (PWH), but their impacts on cognition longitudinally in this population are unclear. The current study examines the relationship between cardiovascular risk and cognitive functioning over time in Black/African American adults living with HIV.Participants and Methods:A sample of 122 Black/African American adults with HIV (ages 25-68, M=51.8, SD=7.7; 98% on antiretroviral therapy; 91% with undetectable viral load) were selected from the Drexel/Temple Comprehensive NeuroHIV Center, Clinical and Translational Research Support Core (CTRSC; based at Drexel University College of Medicine) Cohort. They completed longitudinal visits (300 total visits, average follow-up time=4.9 years) that included clinical interviews, medical record review, biometric measurements, and comprehensive neuropsychological assessments. Cardiovascular risk factors of interest were body mass index (BMI), waist-to-height ratio (WHtR), and a total vascular risk burden score (VBS) representing five risk factors: obesity, central obesity, diabetes, hyperlipidemia, and hypertension. Based on a prior principal component analysis, three cognitive domains were examined: (1) verbal fluency, (2) visual memory/visuoconstruction, and (3) motor speed/executive functions. Mixed models were used to examine domain-specific cognitive trajectories in relation to baseline cardiovascular risk factors and changes in cardiovascular risk factors.Results:Overall, cognitive test performance improved over time (pConclusions:Higher total vascular risk burden was associated with less favorable verbal fluency trajectories, reflecting the negative cognitive consequences of disorders such as diabetes, hyperlipidemia, and hypertension. Unexpectedly, greater increases in BMI and WHtR were associated with more favorable trajectories in motor speed and executive functioning. In this population, weight gain may be a proxy for other positive health factors, such as immune reconstitution, which will be examined in future analyses. Taken together, cardiovascular risk factors have heterogeneous associations with cognitive trajectories, emphasizing the importance of examining the mechanisms of these varying relationships. Future research will examine how social determinants of health, such as racial/ethnic discrimination, contribute to disparities in cardiovascular risk factors and cognitive outcomes.

Drivers with and without MS exhibited similar turning behavior, but PwMS were more cautious during left turns, possibly reflecting a compensatory strategy. Despite few group differences, several cognitive domains commonly affected by MS were associated with turning behaviors. Slower cognitive/motor speed and worse visuospatial abilities were associated with less smooth control of spatial position and less safe turn preparation, but slower driving. Future studies will include larger samples and other clinical populations and may inform clinical driving recommendations.

Verbal memory was related to better MMT-R performance, but neither cognition nor MMT-R were good predictors of detectable vs. undetectable viral load. However, among those with low-level viral replication, poorer visuospatial memory and difficulty with simple MMT-R items were preliminarily related to higher viral load. Given the small sample, results are limited by low statistical power. Future research will further explore relationships among cognition, MMT-R, RNA, and regimen complexity in larger samples to inform development of tools to monitor adherence difficulties.

Objective:Driving is a cognitively demanding activity commonly affected by brain injury and illness. Accurate driving assessment is essential for reducing risk, optimizing independence, and informing driving-related interventions. Virtual reality driving simulation (VRDS) enables safe, sensitive, objective, and standardized measurement of driving abilities. VRDS has been validated in relation to self-reports and driver records. However, self-reports are subjective, and driver records include only major events (collisions, violations). Video telematics platforms can measure naturalistic driving in a more objective and sensitive manner. The present study used video telematics to examine relationships between VRDS performance and directly observed naturalistic driving.Participants and Methods:20 healthy adult drivers (ages 23-61, mean age=36; 75% women) completed a VRDS assessment that included 1) driving on a straight road, 2) following a truck on a highway, and 3) reacting to a child running into a street to retrieve a ball. Primary VRDS measures were 1) speed and lane management on the straight road; 2) speed and following distance management in the truck-following task; and 3) reaction time, stopping, and distance from the child in the child-ball task. Participants also completed 28 days of naturalistic driving with a video telematics platform in their vehicle. Driving events were detected automatically using accelerometer, GPS, and video data, and driving behaviors were coded by driving risk analysts. The primary naturalistic measure was the number of unsafe driving behaviors per hour driven; specific driving behaviors served as exploratory variables. We examined correlations between VRDS and naturalistic driving variables. Given limited statistical power, we reported correlations that were small-to-medium or greater (r>.2) in primary analyses and medium-to-large or greater (r>.4) in exploratory analyses.Results:On average, drivers exhibited approximately one unsafe driving behavior per hour (M=0.9, SD=0.9, range=0.1-2.7). Common behaviors were failing to stop, unsafe following distance, speeding, and cell phone use. No collisions occurred. Average lane position in VRDS (specifically, leftward deviation from the center of the lane) was correlated with more real-world unsafe driving behaviors per hour (r=.35, p=.13), as were higher average straight road speed (r=.26, p=.27), greater straight road speed variability (r=.28, p=.24), and failing to stop for the child in the child-ball task (r=.22, p=.36). In exploratory analyses, failing to stop for the child was associated with real-world distracted driving (r=.45, p=.047), greater lane position variability in VRDS was associated with real-world unsafe following distance (r=.57, p=.009), and greater speed variability in VRDS was associated with real-world seat belt non-use/misuse (r=.49, p=.03).Conclusions:The present findings provide preliminary evidence that VRDS variables are related to directly observed naturalistic driving, supporting the potential utility of VRDS as a sensitive, ecologically valid driving evaluation tool. As the present study used a small sample of healthy drivers, further research will explore this topic in larger samples and in clinical populations, such as acquired brain injury. Future work will also investigate whether incorporating VRDS with conventional driving evaluation tools (e.g., neuropsychological tests, behind-the-wheel assessments) can enhance the ability of clinical driving evaluations to predict real-world risky driving.

Objective:Approximately half of people living with HIV (PWH) experience HIV-associated neurocognitive disorders (HAND), yet HAND often goes undiagnosed. There is an ongoing need to find efficient, cost-effective ways to screen for HAND and monitor its progression in order to intervene earlier in its course and more effectively treat it. Prior studies that analyzed brief HAND screening tools have demonstrated that certain cognitive test pairs are sensitive to HAND cross-sectionally and outperform other screening tools such as the HIV Dementia Scale (HDS). However, few studies have examined optimal tests for longitudinal screening. This study aims to identify the best cognitive test pairs for detecting cognitive decline longitudinally.Participants and Methods:Participants were HIV+ adults (N=132; ages 25-68; 59% men; 92% Black) from the Temple/Drexel Comprehensive NeuroHIV Center cohort. Participants were currently well treated (98% on cART, 92% with undetectable viral load, and mean current CD4 count=686). They completed comprehensive neurocognitive assessments longitudinally (328 total visits, average follow-up time=4.9 years). Eighteen participants (14% of the cohort) demonstrated significant cognitive decline, defined as a decline in global cognitive z-score of 0.5 (SD) or more. In receiver operating characteristic (ROC) analyses, tests with an area under the curve (AUC) of greater than .7 were included in subsequent test pair analyses. Further ROC analyses examined the sensitivity and specificity of each test pair in detecting significant cognitive decline. Results were compared with the predictive ability of the Modified HIV Dementia Scale (MHDS).Results:The following test pairs demonstrated the best balance between sensitivity and specificity in detecting global cognitive decline: Grooved Pegboard dominant hand (GPD) and category fluency (sensitivity=.89, specificity=.60, AUC=.75, pConclusions:Several cognitive test pairs, particularly those that include GPD, are sensitive to HIV-associated cognitive change, and far more sensitive and specific than the MHDS. Cognitive test pairs can serve as valid, rapid, cost-effective screening tools for detecting cognitive change in PWH, thereby better enabling early detection and intervention. Future research should validate the present findings in other cohorts and examine the implementation of test pair screenings in HIV care settings. Most of the optimal tests identified are consistent with the well-established impact of HAND on frontal-subcortical motor and executive networks. The utility of category fluency is somewhat unexpected as it places more demands on temporal semantic networks; future research should explore the factors driving this finding, such as the potential interaction of HIV with aging and neurodegenerative disease.

Objective:Depression is common in persons with MS (PwMS), substantially contributing to morbidity and mortality. Depression can dually impact PwMS as both a psychosocial reaction to living with the disease and a neurological effect of it. Cardinal features of depression include reduced ability to seek and experience pleasure, often attributed to dysregulation of the brain's reward system. People with depression exhibit atypical reward processing, as do fatigued PwMS. However, it is unclear whether MS itself affects reward processing, and whether it interacts with depression. The current study explored the associations of depression, MS, and their interaction on reward responsiveness. We hypothesized that depression and MS would independently be associated with poorer reward responsiveness and that they would interact synergistically to impair reward responsiveness.Participants and Methods:Forty PwMS and 40 healthy age- and education-matched healthy controls (HC) participated in a computerized switching task with high- and low-reward manipulations. The Chicago Multiscale Depression Inventory (CMDI) Mood subscale measured depressive symptoms. The Behavioral Inhibition/Activation Scales (BIS/BAS) measured self-reported reward responsiveness and behavioral inhibition. Switching task performance was measured as response time (RT) and accuracy. Performance differences between the high- and low-reward conditions represented performance-based reward responsiveness. Linear mixed effects models were used to estimate the associations of MS and depression with reward responsiveness, behavioral inhibition, and task performance.Results:Depression, but not MS, was associated with higher BIS scores (p=.007). Neither depression nor MS was associated with BAS subscales. On the switching task, participants who reported lower depression responded to reward such that they were slightly faster in the high-reward condition compared to the low-reward condition (p=.07). By contrast, in participants who reported higher depression, there was no effect of reward on response time. Additionally, MS (p=.009) and depression (p=.018) were each associated with slower response times. Regarding accuracy, no effects of reward were observed; however, there was an interaction between MS and depression. Among HC participants, depression was not related to accuracy. In comparison, PwMS who reported higher depression were more accurate than PwMS who reported less depression (p=.043).Conclusions:Consistent with hypotheses, higher depressive symptoms were associated with increased behavioral inhibition. Depression was not associated with self-reported reward responsiveness, but it was associated with reduced reward responsiveness on a cognitive task. Contrary to hypotheses, MS was not associated with reduced reward responsiveness. Additionally, higher depression and an MS diagnosis were related to slower response time, consistent with prior findings that psychomotor slowing is a hallmark feature of both disorders. Interestingly, we observed a unique behavioral trend in PwMS, such that PwMS with higher depressive symptoms were more accurate than PwMS with lower depressive symptoms, whereas this relationship was not present among HCs. Altogether, depression in both PwMS and cognitively healthy individuals may be associated with blunted reward responsiveness, but MS does not exacerbate this relationship. In fact, PwMS with depression may be more conscientious in their functioning and therefore perform better on cognitive task accuracy. Continued work should examine how reward processing and its underlying mechanisms may differ in depressed PwMS.

In healthy adult drivers, better performance in the domains of visuospatial memory, processing speed, and attention is associated with greater engagement in unsafe driving behaviors. In the absence of concern about cognitive compromise, individuals may feel more comfortable making risky behaviors. We plan to expand this work to broader samples and clinical populations to increase generalizability and applicability to clinical driving evaluations.

BACKGROUND:Actuarial and statistical methods have been proposed as alternatives to conventional methods of diagnosing mild cognitive impairment (MCI), with the aim of enhancing diagnostic and prognostic validity, but have not been compared in racially diverse samples. OBJECTIVE:We compared the agreement of consensus, actuarial, and statistical MCI diagnostic methods, and their relationship to race and prognostic indicators, among diverse older adults. METHODS:Participants (N = 354; M age = 71; 68% White, 29% Black) were diagnosed with MCI or normal cognition (NC) according to clinical consensus, actuarial neuropsychological criteria (Jak/Bondi), and latent class analysis (LCA). We examined associations with race/ethnicity, longitudinal cognitive and functional change, and incident dementia. RESULTS:MCI rates by consensus, actuarial criteria, and LCA were 44%, 53%, and 41%, respectively. LCA identified three MCI subtypes (memory; memory/language; memory/executive) and two NC classes (low normal; high normal). Diagnostic agreement was substantial, but agreement of the actuarial method with consensus and LCA was weaker than the agreement between consensus and LCA. Among cases classified as MCI by actuarial criteria only, Black participants were over-represented, and outcomes were generally similar to those of NC participants. Consensus diagnoses best predicted longitudinal outcomes overall, whereas actuarial diagnoses best predicted longitudinal functional change among Black participants. CONCLUSION:Consensus diagnoses optimize specificity in predicting dementia, but among Black older adults, actuarial diagnoses may be more sensitive to early signs of decline. Results highlight the need for cross-cultural validity in MCI diagnosis and should be explored in community- and population-based samples.

Significance Existing screening tools for HIV-associated neurocognitive disorders (HAND) are often clinically impractical for detecting milder forms of impairment. The formal diagnosis of HAND requires an assessment of both cognition and impairment in activities of daily living (ADL). To address the critical need for identifying patients who may have disability associated with HAND, we implemented a low-cost screening tool, the Virtual Driving Test (VDT) platform, in a vulnerable cohort of people with HIV (PWH). The VDT presents an opportunity to cost-effectively screen for milder forms of impairment while providing practical guidance for a cognitively demanding ADL. Objectives We aimed to: (1) evaluate whether VDT performance variables were associated with a HAND diagnosis and if so; (2) systematically identify a manageable subset of variables for use in a future screening model for HAND. As a secondary objective, we examined the relative associations of identified variables with impairment within the individual domains used to diagnose HAND. Methods In a cross-sectional design, 62 PWH were recruited from an established HIV cohort and completed a comprehensive neuropsychological assessment (CNPA), followed by a self-directed VDT. Dichotomized diagnoses of HAND-specific impairment and impairment within each of the seven CNPA domains were ascertained. A systematic variable selection process was used to reduce the large amount of VDT data generated, to a smaller subset of VDT variables, estimated to be associated with HAND. In addition, we examined associations between the identified variables and impairment within each of the CNPA domains. Results More than half of the participants (N = 35) had a confirmed presence of HAND. A subset of twenty VDT performance variables was isolated and then ranked by the strength of its estimated associations with HAND. In addition, several variables within the final subset had statistically significant associations with impairment in motor function, executive function, and attention and working memory, consistent with previous research. Conclusion We identified a subset of VDT performance variables that are associated with HAND and assess relevant functional abilities among individuals with HAND. Additional research is required to develop and validate a predictive HAND screening model incorporating this subset.

Objective Sudden unexpected death in epilepsy (SUDEP) is a significant cause of mortality in epilepsy. The aim of this study is to evaluate the validity of the SUDEP-7 inventory and its components as tools for predicting SUDEP risk, and to develop and validate an improved inventory. Methods The study included 28 patients who underwent video-electroencephalography (EEG) monitoring and later died of SUDEP, and 56 age- and sex-matched control patients with epilepsy. The SUDEP-7 score, its individual components, and an alternative inventory were examined as predictors of SUDEP. Results SUDEP-7 scores were significantly higher among SUDEP patients compared with controls, both at time of admission (p = 0.024) and most recent follow-up (p = 0.016). SUDEP-7 scores declined only among controls, who demonstrated reduced seizure frequency. Seizure freedom after epilepsy surgery was also associated with survival. Several components of the SUDEP-7 inventory were independently associated with higher risk of SUDEP, including more than three generalized tonic-clonic (GTC) seizures (p = 0.002), one or more GTC seizures (p = 0.001), or one or more seizures of any type within the last year (p = 0.013), and intellectual disability (p = 0.031). In stepwise regression models, SUDEP-7 scores did not enhance the prediction of SUDEP over either GTC seizure frequency or seizure frequency alone. A novel SUDEP-3 inventory comprising GTC seizure frequency, seizure frequency, and intellectual disability (p < 0.001) outperformed the SUDEP-7 inventory (p = 0.010) in predicting SUDEP. Significance Our findings demonstrate the limitations of the SUDEP-7 inventory. We propose a new three-item SUDEP-3 inventory, which predicts SUDEP better than the SUDEP-7.