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Effective, scalable dementia prevention interventions are needed to address modifiable risk factors given global burden of dementia and challenges in developing disease-modifying treatments. A single-blind randomized controlled trial assessed an online multidomain lifestyle intervention to prevent cognitive decline over 3 years. Participants were dementia-free community-dwelling Australians aged 55-77 years with modifiable dementia risk factors. Eligible participants (n = 6,104, 64% female) were randomized 1:1 to a personalized schedule of online coaching in two to four modules (targeting physical activity, nutrition, cognitive activity and depression or anxiety) or a control group that received module-eligible information only. At 3 years, the mean change in a global cognitive composite, the primary outcome, was met. The mean changes in z scores were 0.28 (95% confidence interval (CI): 0.25-0.32) for intervention, 0.10 (95% CI: 0.07-0.13) for control and 0.18 (95% CI: 0.13-0.23, P < 0.001) for the between-group difference. Trial-related adverse events occurred in 19 (0.60%) intervention and 1 (0.03%) control participant. Randomization of this internet-delivered lifestyle intervention tailored to individual dementia risk factors resulted in significantly better cognition in older adults over 3 years. This intervention is scalable with the potential for population-level rollout that may delay cognitive decline in the general community. Australian New Zealand ClinicalTrials.gov registration: ACTRN12618000851268., Competing Interests: Competing interests: H.B. has been an advisory board member or consultant to Biogen, Eisai, Eli Lilly, Medicines Australia, Roche, Skin2Neuron Pty, Cranbrook Care and Montefiore Homes. P.S.S. was a member of expert panels for Biogen and Roche in 2020 and 2021. M.V. has a financial interest in and is cofounder and CEO of Skin2Neuron Pty, unrelated to this work. The other authors declare no competing interests., (© 2025. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Although the pathophysiology of migraine involves a complex ensemble of peripheral and central nervous system changes that remain incompletely understood, the activation and sensitization of the trigeminovascular system is believed to play a major role. However, non-invasive, in vivo neuroimaging studies investigating the underlying neural mechanisms of trigeminal system abnormalities in human migraine patients are limited. Here, we studied 60 patients with migraine (55 females, mean age ± SD: 36.28 ± 11.95 years) and 20 age-/sex-matched healthy controls (19 females, mean age ± SD: 35.45 ± 13.30 years) using ultra-high field 7 Tesla diffusion tensor imaging and functional MRI, as well as PET with the translocator protein ligand [11C]-PBR28. We evaluated MRI diffusivity measures and PET signal at the trigeminal nerve root, as well as brainstem functional MRI response to innocuous, ophthalmic trigeminal nerve territory stimulation. Patients with migraine demonstrated altered white matter microstructure at the trigeminal nerve root (n=53), including reduced fractional anisotropy, compared to healthy controls (n=18). Furthermore, in patients, lower fractional anisotropy was accompanied by 1) higher neuroinflammation (i.e. elevated [11C]-PBR28 PET signal) at the nerve root (n=36) and 2) lower functional MRI activation in an ipsilateral pontine cluster consistent with spinal trigeminal nucleus (n=51). These findings were more robust on the right side, which was consistent with the observation that right headache dominant patients demonstrated higher migraine severity compared to left headache dominant patients in our cohort. Multimodal imaging of the integrated neural mechanisms that characterize migraine underscores the importance of trigeminal system remodeling as both a key aspect of the dynamics underlying migraine pathophysiology and a target for therapeutic interventions., (© The Author(s) 2025. Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: Reporting of sex and gender analysis in medical research has been shown to improve quality of the science and ensure findings are applicable to women and men. There is conflicting evidence on whether efforts by funding agencies and medical journals to encourage reporting of sex and gender analysis have resulted in tangible improvements. This study mapped the inclusion of sex and gender analysis in stroke and dementia research conducted in the Asia-Pacific region., Methods: A systematic search for Asia-Pacific stroke and dementia research was conducted in PubMed and papers included from the period 2012 to 2022. Eligible studies were reviewed for inclusion of a primary sex or gender focus and categorized by type of sex and gender analysis. Author gender was determined using an algorithm and its associations with inclusion of sex and gender analysis were examined., Results: Total Asia-Pacific publications increased from 109 in 2012 to 313 in 2022, but the rate of studies with a primary sex or gender focus did not increase significantly (R2 = 0.06, F(1, 9) = 0.59, p = 0.46). Australia, China, India, Japan, and South Korea produced the most publications over the study period and were the only countries with at least 50 publications. The impact of author gender was mixed, with female first authorship associated with inclusion of sex or gender analysis and last female authorship associated with studies having a primary sex or gender focus., Conclusions: In the Asia-Pacific, brain health research is currently centred around high-income countries, and efforts are needed to ensure research findings are applicable throughout the region. While there was a general increase in brain health publications over the last decade, the rate of sex and gender analysis was unchanged. This demonstrates that even with efforts in some countries in place, there is currently a lack of progress in the Asia-Pacific region to produce more research focussing on sex and gender analysis., (© 2024 S. Karger AG, Basel.)

Context: The Healthy People 2030 Leading Health Indicators (LHIs) offer a select set of measurable objectives to help community-based organizations focus their efforts to improve health equity and reduce health disparities across the lifespan within the populations they serve. Disparities are observed across LHIs, including infant mortality, maternal mortality, and food insecurity, and reducing these disparities is a key strategy for improving health and well-being for all., Objective: This study was designed to answer the following research questions: (1) What programs and initiatives are organizations implementing to address the LHIs of focus - infant mortality, maternal mortality, and food insecurity? (2) How do organizations determine which programs and initiatives they will implement?, Design: NORC conducted 9 qualitative interviews with Healthy People 2030 Champions, organizations dedicated to furthering Healthy People goals and objectives, who are working to address disparities within infant mortality, maternal mortality, and food insecurity through a variety of strategies, interventions, and programs., Results: Wraparound services, doula programs, and education and advocacy emerged as common strategies for addressing disparities in maternal and infant mortality. Organizations that are working to reduce household food insecurity and hunger implemented food pharmacies and support participant enrollment in federal food assistance programs. Interviewees shared strategies for determining programs to implement and continued program improvement including assessing community needs, leveraging partnerships, and measuring program success., Conclusions: Healthy People Champion organizations are using several multidimensional strategies to address infant mortality, maternal mortality, and food insecurity in their communities. These strategies, and the community-based organizations that implement them, are critical for addressing disparities in priority health outcomes among the people who have the greatest need. These findings offer insights into how local communities are tackling national priorities and underscore opportunities for more rigorous evaluation to demonstrate progress toward addressing disparities in the LHIs., Competing Interests: The authors declare no conflicts of interest., (Copyright ©.)

Purpose: Orofacial Pain (OFP) affects 15% of the general population. OFP conditions can be myofascial, also known as temporomandibular disorders (TMDs) or neuropathic. The underlying pathophysiology in several chronic OFP conditions, is unknown. Small fiber neuropathy (SFN) is a disorder of thinly myelinated A-delta and non-myelinated C-fibers and can manifest as sensory and autonomic neuropathies. SFN has been demonstrated in some OFP conditions. Our study aims to assess the presence of OFP in patients with sensory and autonomic neuropathies and assess the correlation between OFP, skin biopsy and autonomic dysfunction., Patients and Methods: This is a retrospective study (2018-2020) of patients from the SFN registry, Massachusetts General Hospital, Boston, USA, for the presence of OFP. All patients were included. Primary outcome: Prevalence of OFP in patients with chronic neuropathies. Secondary outcomes: Correlation between OFP and skin biopsy, dysautonomia, headaches, chronic nociceptive pain, psychological conditions, and patient factors, such as mean age and BMI., Results: Charts of 450 patients with sensory and autonomic neuropathies were reviewed. 22.67% (n=102) had OFP. The mean (range) age at biopsy in patients with OFP was 48.36 (20-81) years, female: male ratio 3.25:1. More OFP patients had negative skin biopsy results (p value<0.05) than those with sensory neuropathies. Patients with OFP had significantly higher prevalence of psychological conditions (p value 0.000), and higher BMI >30 (p value 0.025). Dysautonomia was significantly higher in patients with TMDs when compared to the ones without TMDs (p value 0.030). There was no significant difference in mean age, gender predilection, presence of headaches, peripheral neuropathies, and nociceptive pain between patients with and without OFP., Conclusion: OFP and sensory neuropathies can be overlapping conditions. Patients presenting with concomitant TMD and dysautonomia can be further tested for SFN. This can further help us understand a correlation if any, between idiopathic TMD/OFP conditions and SFN and further our understanding of the pathophysiology of these conditions., Competing Interests: The authors report no conflicts of interest in this work., (© 2024 Handa et al.)

Objective: This study sought to identify accreditation benefits and impacts among local health departments (LHDs) stratifying by size of population served to determine differences between small, medium, and large LHDs., Background: The Public Health Accreditation Board operates the national accreditation program for public health departments, through which 306 LHDs have been accredited as of August 2022. Benefits of accreditation for LHDs are well documented, despite potential challenges and barriers to seeking accreditation. Research on the benefits of accreditation for small LHDs, specifically, is more limited., Methods: All health departments that completed the accreditation process between December 2013 and May 2022 were surveyed following receipt of the accreditation decision. The analytic sample included 266 LHDs (response rate of 93.7%). Data for LHDs were analyzed for specific variables related to experiences, challenges, and benefits, and stratified by size to compare small LHDs with medium and large LHDs. Bivariate analyses were conducted to identify statistical significance., Results: Generally, small LHDs reported similar outcomes of accreditation to medium and large LHDs. These included improvements in staff competencies, capacity to provide high-quality services, and relationships with partners. Small LHDs were significantly more likely than medium and large LHDs to report that accreditation increased their use of evidence-based practices. LHDs of all sizes reported an increase in quality improvement activities due to accreditation. Challenges for small LHDs included limited staff time or staff turnover and limited funding., Conclusions: The public health accreditation program has offered numerous benefits to LHDs of all sizes, including small LHDs. These accreditation benefits may be particularly important for small LHDs because of their critical role in the public health system and the ongoing need to support performance improvement, strengthen infrastructure, and increase resilience., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The Maintain Your Brain (MYB) trial aims to prevent cognitive decline and dementia through multidomain, web-based risk-reduction. To facilitate translation, it is important to understand drivers of participation., Objective: To describe characteristics associated with participation in MYB., Methods: This was an observational ancillary study of MYB, a randomized controlled trial nested within the 45 and Up Study in New South Wales, Australia. We linked 45 and Up Study survey and MYB participation data. The study cohort comprised 45 and Up Study participants, aged 55-77 years at 1 January 2018, who were invited to participate in MYB. 45 and Up Study participant characteristics and subsequent MYB consent and participation were examined., Results: Of 98,836 invited, 13,882 (14%) consented to participate and 6,190 participated (6%). Adjusting for age and sex, a wide range of factors were related to participation. Higher educational attainment had the strongest relationship with increased MYB participation (university versus school non-completion; AdjOR = 5.15; 95% CI:4.70-5.64) and lower self-rated quality of life with reduced participation (Poor versus Excellent: AdjOR = 0.19; 95% CI:0.11-0.32). A family history of Alzheimer's disease was related to increased participation but most other dementia risk factors such as diabetes, obesity, stroke, high blood pressure, and current smoking were associated with reduced participation., Conclusion: Higher socio-economic status, particularly educational attainment, is strongly associated with engagement in online dementia prevention research. Increasing population awareness of dementia risk factors, and better understanding the participation barriers in at-risk groups, is necessary to ensure online interventions are optimally designed to promote maximum participation.

Introduction: Healthy People establishes national goals and specific measurable objectives to improve the health and well-being of the nation. An overarching goal of Healthy People 2030 is to "eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all." To inform Healthy People 2030 health equity and health disparities content and products, the US Department of Health and Human Services (HHS) Office of Disease Prevention and Health Promotion (ODPHP), in collaboration with NORC at the University of Chicago, conducted a review of peer-reviewed and gray literature to examine how health equity is defined, conceptualized, and measured by public health professionals., Methods: We reviewed (1) peer-reviewed literature, (2) HHS and other public health organization Web sites, and (3) state and territorial health department plans. We also conducted targeted searches of the gray literature to identify tools and recommendations for measuring health equity., Results: While definitions of health equity identified in the scan varied, they often addressed similar concepts, including "highest level of health for all people," "opportunity for all," and "absence of disparities." Measuring health equity is challenging; however, strategies to measure and track progress toward health equity have emerged. There are a range of tools and resources that have the potential to help decision makers address health equity, such as health impact assessments, community health improvement plans, and adapting a Health in All Policies approach. Tools that visualize health equity data also support data-driven decision making., Discussion: Using similar language when discussing health equity will help align and advance efforts to improve health and well-being for all. Healthy People objectives, measures, and targets can help public health professionals advance health equity in their work. HHS ODPHP continues to develop Healthy People tools and resources to support public health professionals as they work with cross-sector partners to achieve health equity., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc.)

The Maintain Your Brain (MYB) trial is one of the largest internet-delivered multidomain randomised controlled trial designed to target modifiable risk factors for dementia. It comprises four intervention modules: physical activity, nutrition, mental health and cognitive training. This paper explains the MYB Nutrition Module, which is a fully online intervention promoting the adoption of the 'traditional' Mediterranean Diet (MedDiet) pattern for those participants reporting dietary intake that does not indicate adherence to a Mediterranean-type cuisine or those who have chronic diseases/risk factors for dementia known to benefit from this type of diet. Participants who were eligible for the Nutrition Module were assigned to one of the three diet streams: Main, Malnutrition and Alcohol group, according to their medical history and adherence to the MedDiet at baseline. A short dietary questionnaire was administered weekly during the first 10 weeks and then monthly during the 3-year follow-up to monitor whether participants adopted or maintained the MedDiet pattern during the intervention. As the Nutrition Module is a fully online intervention, resources that promoted self-efficacy, self-management and process of change were important elements to be included in the module development. The Nutrition Module is unique in that it is able to individualise the dietary advice according to both the medical and dietary history of each participant; the results from this unique intervention will contribute substantively to the evidence that links the Mediterranean-type diet with cognitive function and the prevention of dementia and will increase our understanding of the benefits of a MedDiet in a Western country.

Public health emergency preparedness is a critical health department function. The national public health accreditation program may enhance public health preparedness by building the capabilities and overall capacity of health departments and also by improving capabilities specific to preparedness. This study presents findings from a survey sent to health departments 1 year after achieving accreditation, with a focus on accreditation outcomes related to public health preparedness. Between April 2014 and February 2020, 214 health departments responded to the survey. Most respondents indicated that accreditation had positively influenced their health department's performance within each of the selected topic areas that may influence public health preparedness: workforce development; quality improvement efforts; use of evidence and data to drive decisions; and partnerships, accountability, and credibility among external stakeholders. Enhancing overall health department capacity through accreditation may support the ability of health departments to prepare for, respond to, and recover from public health emergencies., Competing Interests: The authors have indicated that they have no potential conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Self-administered computerized neuropsychological assessments (CNAs) provide lower cost, more accessible alternatives to traditional in-person assessments but lack critical information on psychometrics and subjective experience of older adults in remote testing environments., Objective: We used an online brief battery of computerized tasks selected from the Cogstate Brief Battery (CBB) and Cambridge Brain Sciences (CBS) to 1) determine test-retest reliability in an unsupervised setting; 2) examine convergent validity with a comprehensive 'gold standard' paper-and-pencil neuropsychological test battery administered in-person; and 3) explore user-experience of remote computerized testing and individual tests., Methods: Fifty-two participants (mean age 65.8±5.7 years) completed CBB and CBS tests on their own computer, unsupervised from home, on three occasions, and visited a research center for an in-person paper-and-pencil assessment. They also completed a user-experience questionnaire., Results: Test-retest reliabilities varied for individual measures (ICCs = 0.20 to 0.83). Global cognition composites showed excellent reliability (ICCs > 0.8 over 1-month follow-up). A strong relationship between a combination of CNA measures and paper-and-pencil battery was found (canonical correlation R = 0.87, p = 0.04). Most tests were rated as enjoyable with easy-to-understand instructions. Ratings of general experience with online testing were mostly favorable; few had difficulty concentrating (17%) or using the computer for tasks (10%), although over one-third experienced performance anxiety (38%)., Conclusion: A combined brief online battery selected from two CNAs demonstrated robust psychometric standards for reliability (global composite), and convergent validity with a gold standard battery, and mostly good usability and acceptability in the remote testing environment.

Background: While Healthy People outlines a national framework for improving the health of the nation, many states develop State Health Improvement Plans (SHIPs) to set priorities to improve the health of their residents. The purpose of this study was to understand the processes that states use to develop their SHIPs, how states align their SHIPs with Healthy People, and challenges that states face using Healthy People., Methods: NORC conducted semistructured interviews with 9 state health department representatives who were responsible for SHIPs. The responses were analyzed using qualitative thematic analysis., Results: State health departments used similar approaches to develop their SHIPs. Generally, states began the SHIP development process by performing community health assessments and then assembling diverse stakeholders to recommend key priority areas that should be addressed in the SHIP. States used a similar framework for their SHIPs, outlining priority areas, indicators, and targets. All respondents reported that they referenced Healthy People during the development of their SHIPs. Some states reported aligning their state plans with the Healthy People Framework, while others focused more on the specific Healthy People objectives or target setting guidance., Conclusions: Both the federal government and state public health agencies rely on input from stakeholders and cross-sector collaboration to ensure their initiatives reflect the diverse needs of their population. Stakeholder engagement is increasingly important as public health professionals are shifting toward a health equity approach that considers social determinants outside of the health care sector. Healthy People continues to strengthen this perspective by outlining national priorities on well-being while incorporating language around health equity issues. Reinforcing relationships between the federal government and state public health can help states better understand the role of Healthy People as well as encourage further dissemination of creative strategies and best practices., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.)

Context: Released by the US Department of Health and Human Services (HHS) every decade since 1980, Healthy People identifies science-based objectives with targets to monitor progress and motivate and focus action. Healthy People 2030 is the current iteration of the Healthy People initiative., Program: Healthy People 2030 includes 3 sets of measures-Healthy People 2030 objectives, Leading Health Indicators (LHIs), and Overall Health and Well-being Measures (OHMs). Collectively, these components of Healthy People 2030 drive progress toward the initiative's vision of "a society in which all people can achieve their full potential for health and well-being across the life span.", Implementation: The Healthy People 2030 LHIs and OHMs were developed with input from multiple subject matter experts and launched in December 2020. Designed as an entry point for users interested in improving the health of their communities and selected for their ability to improve health and well-being, the LHIs will be assessed annually. As broad, global outcome measures of overall health and well-being, the OHMs will be assessed at least 3 times before 2030., Evaluation: The 23 LHIs are a subset of Healthy People 2030 core objectives that have been selected to drive action toward improved health and well-being. LHIs are intended to help organizations, communities, and states across the nation focus resources and efforts to improve the health and well-being of all people. The OHMs include 8 broad, global outcome measures of overall health and well-being that help assess progress toward the Healthy People 2030 vision. The Healthy People 2030 OHMs include the addition of a measure of overall well-being., Discussion: Together with the Healthy People 2030 objectives, the LHIs and OHMs provide a plan of action to improve the health and well-being of the nation through a framework for assessing progress, addressing health disparities and social determinants of health, and advancing health equity., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc.)

Context: There is limited data available on the financial benefits of public health accreditation., Objective: This study assessed the financial impacts reported by public health departments as a result of participating in the Public Health Accreditation Board (PHAB) national accreditation program., Design: Data from an ongoing survey of outcomes among health departments accredited for 1 year were linked to PHAB administrative data on health department characteristics to examine self-reported financial impacts of accreditation as of June 2020., Setting: Accredited public health departments in the United States., Participants: Leadership from 214 unique state, local, Tribal, and Army installation health departments that had been accredited for 1 year by PHAB., Main Outcome Measures: Improved utilization of resources, increased competitiveness for funding opportunities, and new funding resulting from accreditation., Results: One year following accreditation, 57% of all responding health departments reported improved utilization of resources whereas less than half reported improved competitiveness for funding (39%) and new funding (23%) as a result of accreditation. Health departments reporting new funding as a result of accreditation, compared with those that did not report new funding, were also more likely to report other outcomes from accreditation, including improved staff competencies, increased health department capacity to address health priorities and provide high-quality programs and services, increased use of evidence-based practices, new opportunities for external partnerships and collaboration, improved understanding of the health department's role among governing entities and policy makers, and improved credibility. Accredited local health departments (LHDs) with annual budgets less than $10 million reported new funding more often than LHDs with larger annual budgets., Conclusions: Accredited health departments that reported new funding were also more likely to report other outcomes of accreditation, including improved staff competencies, new partnerships, and improved credibility. More research is needed to further understand the relationship between accreditation and financial impacts., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study uses qualitative methodology to describe a range of business leaders' attitudes about health., Methods: Five Chambers of Commerce executives and 10 business leaders shared their opinions on the value they place on health in their business and the larger community., Results: Employee health was highlighted as a top priority among business leaders. The importance of business investment in community health more broadly was not discussed as frequently among business leaders. While attitudes may vary across industries and company sizes, many business executives recognized the direct role health plays in their business productivity and revenue. Compared with employee health, community health was not as salient to these business leaders; however, they do recognize the link between community health and economic development., Conclusions: Increasing business leaders' engagement in improving community health may require additional education and resources. Further research is needed to gather representative data on business leaders' attitudes about health.

Objectives. To investigate differences in funding and service delivery between rural and urban local health departments (LHDs) in the United States. Methods. In this repeated cross-sectional study, we examined rural-urban differences in funding and service provision among LHDs over time using 2010 and 2016 National Association of County and City Health Officials data. Results. Local revenue among urban LHDs (41.2%) was higher than that in large rural (31.3%) and small rural LHDs (31.2%; P  < .05). Small (20.9%) and large rural LHDs (19.8%) reported greater reliance on revenue from Center for Medicare and Medicaid Services than urban LHDs (11.5%; P  < .05). All experienced decreases in clinical revenue between 2010 and 2016. Urban LHDs provided less primary care services in 2016; rural LHDs provided more mental health and substance abuse services ( P  < .05). Conclusions. Urban LHDs generated more revenues from local sources, and rural LHDs generated more from the Center for Medicare and Medicaid Services and clinical services. Rural LHDs tended to provide more clinical services. Given rural LHDs' reliance on clinical revenue, decreases in clinical services could have disproportionate effects on them. Public Health Implications. Differences in financing and service delivery by rurality have an impact on the communities. Rural LHDs rely more heavily on state and federal dollars, which are vulnerable to changes in state and national health policy.

Reducing the risk of dementia can halt the worldwide increase of affected people. The multifactorial and heterogeneous nature of late-onset dementia, including Alzheimer's disease (AD), indicates a potential impact of multidomain lifestyle interventions on risk reduction. The positive results of the landmark multidomain Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) support such an approach. The World-Wide FINGERS (WW-FINGERS), launched in 2017 and including over 25 countries, is the first global network of multidomain lifestyle intervention trials for dementia risk reduction and prevention. WW-FINGERS aims to adapt, test, and optimize the FINGER model to reduce risk across the spectrum of cognitive decline-from at-risk asymptomatic states to early symptomatic stages-in different geographical, cultural, and economic settings. WW-FINGERS aims to harmonize and adapt multidomain interventions across various countries and settings, to facilitate data sharing and analysis across studies, and to promote international joint initiatives to identify globally implementable and effective preventive strategies., (© 2020 The Authors. Alzheimer's & Dementia published by Wiley Periodicals, Inc. on behalf of Alzheimer's Association.)

Maintain Your Brain (MYB)i is a randomised controlled trial (RCT) of multiple online interventions designed to target modifiable risk factors for Alzheimer's disease and dementia. Traditional clinical trial management systems (CTMS) requirements consist of features such as management of the study, site, subject (participant), clinical outcomes, external and internal requests, education, data extraction and reporting, security, and privacy. In addition to fulfilling these traditional requirements, MYB has a specific set of features that needs to be fulfilled. These specific requirements include: (i) support for multiple interventions within a study, (ii) flexible interoperability options with third-party software providers, (iii) study participants being able to engage in online activities via web-based interfaces throughout the trial (from screening to follow-up), (iv) ability to algorithmically personalize trial activities based on the needs of the participant, and (v) the ability to handle large volumes of data over a long period. This paper outlines how the existing CTMSs fall short in meeting these specific requirements. The presented system architecture, development approach and lessons learned in the implementation of the MYB digital platform will inform researchers attempting to implement CTMSs for trials comparable to MYB in the future.

Introduction: Appalachia is one of the regions most significantly impacted by the opioid crisis. This study investigated mortality due to diseases of despair within the Appalachian Region, with an additional focus on deaths attributable to opioid overdose., Methods: Diseases of despair include: alcohol, prescription drug and illegal drug overdose, suicide, and alcoholic liver disease/cirrhosis of the liver. Mortality data from the National Center for Health Statistics (NCHS) National Vital Statistics System (NVSS) Multiple Cause of Death database were analyzed for this study, focusing on individuals aged 15-64., Results: Over the past two decades, the mortality rate due to diseases of despair has been increasing across the United States, but the gap has widened between the Appalachian Region and the rest of the nation. In 2017, the combined diseases of despair mortality rate was 45% higher in the Appalachian Region than the non-Appalachian United States. When looking at just overdose mortality, this disparity grows to 65% higher in the Appalachian Region. Within the Appalachian region disparities are most notable in the Central and North Central Appalachian subregions, among males, and among individuals age 45 to 54., Discussion: These findings document the scale and scope of the problem in Appalachia and highlight the need for additional research and discussion in terms of effective interventions, policies, and strategies to address these diseases of despair. Over the past two decades, mortality from overdose, suicide, and alcoholic liver diseases/cirrhosis has increased across the United States, but the disparity between Appalachia and the non-Appalachian U.S. continues to grow., (Copyright © 2019 Michael Meit, Megan Heffernan, and Erin Tanenbaum.)

Objective: This study assesses how the nation's preeminent health promotion and disease prevention initiative, Healthy People, is utilized by key stakeholders., Methods: A Web-based survey was administered to assess awareness and use of Healthy People among state, local, tribal health organizations and other key stakeholder groups. Follow-up interviews were conducted with a subset of respondents., Results: Awareness and use of Healthy People have remained high among state, local, and tribal stakeholders. Healthy People 2020 is most frequently used as a data source. The Leading Health Indicators (LHIs) are an important element of the initiative, and nearly 90% of organizations that use the LHIs found them valuable. Awareness and use of other tools and resources are more limited., Conclusions: Healthy People continues to be a valued resource among public health stakeholders; however, continued outreach is needed to promote the use of tools and resources available on healthypeople.gov for this decade and beyond. Healthy People is a national initiative used most frequently as a data source by state and local health departments, tribal organizations, and other public health practitioners.

Background: Dementia is the leading cause of disability worldwide, and interventions aimed at reducing the prevalence and burden of the disease are urgently needed. Maintain Your Brain (MYB) is a randomized controlled trial of a multimodal digital health intervention targeting modifiable dementia risk factors to combat cognitive decline and potentially prevent dementia. In addition to behavioral modules targeting mood, nutrition, and physical exercise, a new Brain Training System (BTS) will deliver computerized cognitive training (CCT) throughout the trial to provide systematic, challenging, and personally adaptive cognitive activity., Objective: This paper aimed to describe the design and development of BTS., Methods: BTS has been designed with a central focus on the end user. Raw training content is provided by our partner NeuroNation and delivered in several innovative ways. A baseline cognitive profile directs selection and sequencing of exercises within and between sessions and is updated during the 10-week 30-session module. Online trainers are available to provide supervision at different levels of engagement, including face-to-face share-screen coaching, a key implementation resource that is triaged by a "red flag" system for automatic tracking of user adherence and engagement, or through user-initiated help requests. Individualized and comparative feedback is provided to aid motivation and, for the first time, establish a social support network for the user based on their real-world circle of friends and family., Results: The MYB pilot was performed from November 2017 to March 2018. We are currently analyzing data from this pilot trial (n=100), which will make up a separate research paper. The main trial was launched in June 2018. Process and implementation data from the first training module (September to November 2018) are expected to be reported in 2019 and final trial outcomes are anticipated in 2022., Conclusions: The BTS implemented in MYB is focused on maximizing adherence and engagement with CCT over the short and long term in the setting of a fully digital trial, which, if successful, could be delivered economically at scale., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000851268; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?id=370631&isReview=true., (©Courtney Campbell Walton, Amit Lampit, Christos Boulamatsis, Harry Hallock, Polly Barr, Jeewani Anupama Ginige, Henry Brodaty, Tiffany Chau, Megan Heffernan, Perminder Singh Sachdev, Maria A Fiatarone Singh, Michael Valenzuela. Originally published in JMIR Aging (http://aging.jmir.org), 27.02.2019.)

Background: Maintain Your Brain (MYB) is a randomized controlled trial of an online multi-modal lifestyle intervention targeting modifiable dementia risk factors with its primary aim being to reduce cognitive decline in an older age cohort., Methods: MYB aims to recruit 8,500 non-demented community dwelling 55 to 77 year olds from the Sax Institute's 45 and Up Study in New South Wales, Australia. Participants will be screened for risk factors related to four modules that comprise the MYB intervention: physical activity, nutrition, mental health, and cognitive training. Targeting risk factors will enable interventions to be personalized so that participants receive the most appropriate modules. MYB will run for three years and up to four modules will be delivered sequentially each quarter during year one. Upon completing a module, participants will continue to receive less frequent booster activities for their eligible modules (except for the mental health module) until the end of the trial., Discussion: MYB will be the largest internet-based trial to attempt to prevent cognitive decline and potentially dementia. If successful, MYB will provide a model for not just effective intervention among older adults, but an intervention that is scalable for broad use.

The Mediterranean diet is associated with multiple health benefits. Yet, no tool has been specifically developed to assess adherence to the 'traditional' Mediterranean diet and cuisine within a Western cohort, and validated for online use. We tested the reliability and validity of online administration of the Mediterranean Diet and Culinary Index (MediCul) among middle-aged and older adults. Participants were recruited in January⁻March 2017 from the 45 and Up Study, completing MediCul twice. Test-retest reliability was assessed using the paired t -test, intra-class correlation coefficient (ICC) and Bland-Altman plot. Validity was tested against a three-day food record (FR)-derived MediCul score using Bland-Altman and nutrient trends across the MediCul score tertiles. Participants ( n = 84; 60% female; 65.4 years (SD = 5.9)), were overweight (BMI 26.1; SD = 4.0) with 1.7 (SD = 1.5) chronic illnesses/conditions. Sequential MediCul tool scores were 56.1/100.0 and 56.8/100.0, respectively ( t = -1.019; p = 0.311). Reliability via ICC (ICC = 0.86, 95% CI: 0.789, 0.910, p < 0.0001) and Bland-Altman was good. In Bland-Altman validity analyses, the tool over-reported FR MediCul score by 5.6 points with no systematic bias ((y = 8.7 - 0.06*x) (95% CI: -0.278, 0.158, p = 0.584)). Nutrient trends were identified for MediCul consistent with expected Mediterranean patterns. Online MediCul administration demonstrated good reliability and moderate validity for assessing adherence to a 'traditional' Mediterranean pattern among older Australians.

ABSTRACTBackground:Caring for persons with dementia is stressful for family caregivers. Caregiver training programs and respite care can reduce this stress and help maintain persons with dementia living longer in the community. We evaluated a program that combines caregiver training with a residential respite stay., Methods: In total, 90 dyads of persons with dementia and their caregivers, in groups of 3-6 dyads, volunteered to participate in a five-day residential training program and were followed-up 6 and 12 months later. The primary outcome was caregiver depression; secondary outcomes were measures of caregiver burden, unmet needs, person with dementia behavioral symptoms, and the quality of life and function., Results: Caregiver depression and burden were unchanged, despite decreasing function in persons with dementia. Caregivers' unmet needs and behavioral symptoms in persons with dementia decreased significantly. Compared to a group of persons with dementia admitted for routine residential respite care, there was a marked reduction in permanent placement over 12 months., Conclusions: The Going to Stay at Home Program is a feasible and practicable model with benefits for caregivers and persons with dementia. It may lead to delay in institutionalization and may be applicable to other chronic conditions.

Objectives: Despite limited efficacy and significant safety concerns, antipsychotic medications are frequently used to treat behavioral and psychological symptoms of dementia (BPSD) in long-term residential care. This study evaluates the sustained reduction of antipsychotic use for BPSD through a deprescribing intervention and education of health care professionals., Design: Repeated-measures, longitudinal, single-arm study., Setting: Long-term residential care of older adults., Participants: Nursing staff from 23 nursing homes recruited 139 residents taking regular antipsychotic medication for ≥3 months, without primary psychotic illness, such as schizophrenia or bipolar disorder, or severe BPSD., Intervention: An antipsychotic deprescribing protocol was established. Education of general practitioners, pharmacists, and residential care nurses focused on nonpharmacological prevention and management of BPSD., Measurements: The primary outcome was antipsychotic use over 12-month follow-up; secondary outcomes were BPSD (Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory, and social withdrawal) and adverse outcomes (falls, hospitalizations, and cognitive decline)., Results: The number of older adults on regular antipsychotics over 12 months reduced by 81.7% (95% confidence interval: 72.4-89.0). Withdrawal was not accompanied by drug substitution or a significant increase in pro-re-nata antipsychotic or benzodiazepine administration. There was no change in BPSD or in adverse outcomes., Conclusion: In a selected sample of older adults living in long-term residential care, sustained reduction in regular antipsychotic use is feasible without an increase of BPSD., (Copyright © 2018 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the quality improvement (QI) and performance management benefits reported by public health departments as a result of participating in the national, voluntary program for public health accreditation implemented by the Public Health Accreditation Board (PHAB)., Design: We gathered quantitative data via Web-based surveys of all applicant and accredited public health departments when they completed 3 different milestones in the PHAB accreditation process., Participants: Leadership from 324 unique state, local, and tribal public health departments in the United States., Results: Public health departments that have achieved PHAB accreditation reported the following QI and performance management benefits: improved awareness and focus on QI efforts; increased QI training among staff; perceived increases in QI knowledge among staff; implemented new QI strategies; implemented strategies to evaluate effectiveness and quality; used information from QI processes to inform decision making; and perceived achievement of a QI culture. The reported implementation of QI strategies and use of information from QI processes to inform decision making was greater among recently accredited health departments than among health departments that had registered their intent to apply but not yet undergone the PHAB accreditation process. Respondents from health departments that had been accredited for 1 year reported higher levels of staff QI training and perceived increases in QI knowledge than those that were recently accredited., Conclusions: PHAB accreditation has stimulated QI and performance management activities within public health departments. Health departments that pursue PHAB accreditation are likely to report immediate increases in QI and performance management activities as a result of undergoing the PHAB accreditation process, and these benefits are likely to be reported at a higher level, even 1 year after the accreditation decision.

Objective: To identify the benefits and perceptions among health departments not yet participating in the public health accreditation program implemented by the Public Health Accreditation Board (PHAB)., Design: Quantitative and qualitative data were gathered via Web-based surveys of health departments that had not yet applied for PHAB accreditation (nonapplicants) and health departments that had been accredited for 1 year., Participants: Respondents from 150 nonapplicant health departments and 57 health departments that had been accredited for 1 year., Results: The majority of nonapplicant health departments are reportedly conducting a community health assessment (CHA), community health improvement plan (CHIP), and health department strategic plan-3 documents that are required to be in place before applying for PHAB accreditation. To develop these documents, most nonapplicants are reportedly referencing PHAB requirements. The most commonly reported perceived benefits of accreditation among health departments that planned to or were undecided about applying for accreditation were as follows: increased awareness of strengths and weaknesses, stimulated quality improvement (QI) and performance improvement activities, and increased awareness of/focus on QI. Nonapplicants that planned to apply reported a higher level of these perceived benefits. Compared with health departments that had been accredited for 1 year, nonapplicants were more likely to report that their staff had no or limited QI knowledge or familiarity., Conclusions: The PHAB accreditation program has influenced the broader public health field-not solely health departments that have undergone accreditation. Regardless of their intent to apply for accreditation, nonapplicant health departments are reportedly referencing PHAB guidelines for developing the CHA, CHIP, and health department strategic plan. Health departments may experience benefits associated with accreditation prior to their formal involvement in the PHAB accreditation process. The most common challenge for health departments applying for accreditation is identifying the time and resources to dedicate to the process.

Background: Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management., Methods: LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations., Conclusion: While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.

Objective: We sought to understand the trajectory of mild cognitive impairment (MCI) better by examining longitudinally different MCI subtypes and progression to dementia and reversion to normal cognition in a community sample., Methods: We evaluated the stability of MCI subtypes and risk of dementia over 4 biennial assessments as part of an ongoing prospective cohort study, the Sydney Memory and Ageing Study., Results: While prevalence of MCI and different MCI subtypes remains relatively stable across all assessments, reversion from MCI and transitions between different MCI subtypes were common. Up to 46.5% of participants classified with MCI at baseline reverted at some point during follow-up. The majority (83.8%) of participants with incident dementia were diagnosed with MCI 2 years prior to their dementia diagnosis. Both reverters and participants with stable MCI were at an increased risk of progression to dementia compared to those without MCI at baseline (HR 6.4, p = 0.02, and HR 24.7, p < 0.001, respectively); however, the risk of dementia in participants with MCI who did not revert was higher than in reverters (HR 2.5, p = 0.01). This effect was specific to amnestic subtypes (MCI reverters vs nonreverters: amnestic MCI HR 3.3, p = 0.006; nonamnestic MCI: HR 1.3, p = 0.67)., Conclusion: Our findings indicate that the relevance of reversion for progression risk depends on the MCI subtype. Subtype specificity and longitudinal characterization are required for the reliable identification of individuals at high risk of developing dementia., (© 2017 American Academy of Neurology.)

Objective: Mild cognitive impairment (MCI) is considered an intermediate stage between normal aging and dementia. It is diagnosed in the presence of subjective cognitive decline and objective cognitive impairment without significant functional impairment, although there are no standard operationalizations for each of these criteria. The objective of this study is to determine which operationalization of the MCI criteria is most accurate at predicting dementia., Design: Six-year longitudinal study, part of the Sydney Memory and Ageing Study., Setting: Community-based., Participants: 873 community-dwelling dementia-free adults between 70 and 90 years of age. Persons from a non-English speaking background were excluded., Measurements: Seven different operationalizations for subjective cognitive decline and eight measures of objective cognitive impairment (resulting in 56 different MCI operational algorithms) were applied. The accuracy of each algorithm to predict progression to dementia over 6 years was examined for 618 individuals., Results: Baseline MCI prevalence varied between 0.4% and 30.2% and dementia conversion between 15.9% and 61.9% across different algorithms. The predictive accuracy for progression to dementia was poor. The highest accuracy was achieved based on objective cognitive impairment alone. Inclusion of subjective cognitive decline or mild functional impairment did not improve dementia prediction accuracy., Conclusions: Not MCI, but objective cognitive impairment alone, is the best predictor for progression to dementia in a community sample. Nevertheless, clinical assessment procedures need to be refined to improve the identification of pre-dementia individuals., (Copyright © 2016 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Alcohol consumption is a potentially modifiable risk factor for dementia, but the literature is not completely consistent. This inconsistency may be partly due to an interaction with the apolipoprotein E (APOE) genotype, an established risk factor for Alzheimer's dementia. The aim of this study was to examine whether alcohol consumption is associated with incident dementia or decline in specific cognitive domains over 4 years, and if this effect is modified by APOEɛ4 status. Non-demented community dwelling older adults (70-90 years) from an ongoing longitudinal study were assessed for cognitive impairment in attention/processing speed, language, executive function, visuospatial ability, and memory. Incident dementia was diagnosed according to DSM-IV criteria. Compared to those who did not drink in the previous 12 months, neither low consumption (HR 0.64 95% CI 0.3-1.4) or risky consumption (HR 0.58 95% CI 0.2-1.5) was associated with incident dementia. Carriers of the APOEɛ4 allele were more likely to develop dementia, but there was no significant interaction with alcohol consumption.

Objective: A public health workforce taxonomy was published in 2014 to provide a standardized mechanism for describing public health worker characteristics. The Public Health Workforce Interests and Needs Survey (PH WINS) used 7 of the taxonomy's 12 axes as a basis for its survey response choices, 3 of which are the focus of this analysis. The purpose of this study was to determine the relative utility, reliability, and accuracy of the public health workforce taxonomy in categorizing local and state public health workers using a survey tool. This specifically included the goal of reducing the number of responses classified as "other" occupation, certification, or program area by recoding responses into taxonomy categories and determining potential missing categories for recommendation to the advisory committee that developed the taxonomy., Design: Survey questions associated with the occupation, certification, and program area taxonomy axes yielded qualitative data from respondents who selected "other." The "other" responses were coded by 2 separate research teams at the University of Michigan Center of Excellence in Public Health Workforce Studies and NORC at the University of Chicago., Main Outcome Measures: Researchers assigned taxonomy categories to all analyzable qualitative responses and assessed the percentage of PH WINS responses that could be successfully mapped to taxonomy categories., Results: Between respondent self-selection and research team recoding, the public health workforce taxonomy successfully categorized 95% of occupation responses, 75% of credential responses, and 83% of program area responses. Occupational categories that may be considered for inclusion in the taxonomy in the future include disease intervention specialists and occupations associated with regulation, certification, and licensing., Conclusions: The public health workforce taxonomy performed remarkably well in categorizing worker characteristics in its first use in a national survey. The analysis provides some recommendations for future taxonomy refinement.

Background: Caring for a person with dementia has profound physical, psychological, social and financial impacts on the carer, while morbidity in carers has detrimental effects on outcomes in people with dementia. A 10-day hospital-based residential carer training program (BMJ 299(6712):1375-1379, 1989) delayed residential care placement, delayed mortality, reduced carer's psychological morbidity and lowered care costs. This study aims to evaluate the effects of a similar program adapted for use with residential respite., Methods/design: This is a single-arm longitudinal study conducted at a residential aged care facility involving 100 people with dementia and their primary carers. In a 7-day residential program, carers will attend intensive training sessions while the people with dementia are engaged in daily activities. Data will be collected at the start of the residential program (baseline), at 6 months (post 1) and at 12 months (post 2) after completion of the program. The primary outcome is carer psychological distress. Secondary outcomes include carer burden, carer quality of life and time to residential care placement., Discussion: This study will provide evidence on the effectiveness of the program in reducing carer distress and burden as well as delaying institutionalisation of the person with dementia, which may have important implications for policy.

Background: Mild cognitive impairment (MCI) is associated with an increased dementia risk. This study reports incidence of MCI subtypes, rates of progression to dementia, and stability of MCI classification., Methods: We examined 873 community-dwelling adults aged 70 to 90 years over 2 years as part of an ongoing population-based longitudinal study, the Sydney Memory and Ageing Study. Neuropsychological testing assessed five cognitive domains, and a diagnosis of no cognitive impairment, MCI, or dementia (follow-up only) was made according to published criteria., Results: The incidence of MCI was 104.6 (95% confidence interval: 81.6-127.7) per 1000 person-years, with higher incidence in men (men, 156.8; women, 70.3). Incidence rates for single-domain amnestic, multiple-domain amnestic, single-domain nonamnestic, and multiple-domain nonamnestic MCI were 47.7, 7.9, 45.0, and 3.9 per 1000 person-years, respectively. The 2-year rate of progression from MCI at baseline to dementia was 4.8%, being highest for multidomain amnestic MCI (9.1%). Of those with MCI at baseline, 28.2% reverted to no cognitive impairment at follow-up. Sensitivity analyses by redefining criteria for cognitive impairment did not affect stability of diagnosis, although changing the threshold of domain impairment reduced baseline MCI prevalence from 36.7% to 5.7% and incidence to 23.5, and increased 2-year progression rate from MCI to dementia to 14.3%., Conclusions: Incidence rates for MCI are higher than previously reported, particularly in men and for single-domain MCI; rates for amnestic and nonamnestic MCI were comparable. Multidomain amnestic MCI was the most likely subtype to progress to dementia, but overall, the diagnosis of MCI, particularly single-domain MCI, shows considerable instability., (Copyright © 2012 The Alzheimer's Association. All rights reserved.)

Neuropsychiatric symptoms (NPS) are non-cognitive disturbances such as depression. Rates of NPS have been shown to increase as cognitive ability declines and may be useful in predicting transition from mild cognitive impairment (MCI) to dementia. This community-based study reports the association between NPS and cognitive decline over two years. Participants included 873 community dwelling adults aged 70-90 years enrolled in the Sydney Memory and Ageing Study. NPS were assessed by the Neuropsychiatric Inventory (NPI). Cognitive impairment was defined by diagnosis (MCI or incident dementia) or neuropsychological test performance across five cognitive domains. Cognitive decline was defined by progression to dementia or worse neuropsychological performance. Total NPS at baseline did not differ between those without cognitive impairment (26.2%) and those with MCI (28.8%), but agitation and apathy were associated with MCI. Only baseline depression was associated with dementia at follow-up. Total NPS at baseline was cross-sectionally associated with cognitive impairment in executive function, attention, and global cognition, but did not predict cognitive decline. Depression, anxiety, agitation, anxiety, and apathy were all associated with impairment in at least one cognitive domain, but only anxiety and agitation were significantly associated with cognitive decline. Sensitivity analyses applied more stringent criteria for NPS and cognitive impairment in MCI but did not alter interpretation of results from the main analysis. Overall rates of NPS at baseline were not associated with MCI, dementia, or cognitive decline over two years. Additional follow-up is needed to further examine this association over a longer time course.