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Muscular and neurovascular variations in the upper extremity are of utmost clinical significance. Here we report a unique bilateral accessory muscle in the forearm and palm of an 89-year-old male cadaver. The accessory muscle presented two bellies on the right side, one in the forearm, innervated by the anterior interosseous nerve, and the other in the palm, innervated by a branch of the median nerve. A long tendon interconnected the two bellies. On the left side, the muscle had a single belly in the palm, which began at the end of a long tendon that extended from the forearm. However, on both sides, the muscle originated from the posterior surface of the flexor digitorum superficialis belly and inserted along with the first lumbrical muscle into the dorsal digital expansion of the index finger. The proximal parts of the variant muscles were sandwiched between the flexor digitorum muscles. The palmar bellies coursed distally through the carpal canal and lay deep to the superficial palmar arch, and superficial to the first lumbrical, between the thenar muscles and the lateral-most tendon of the flexor digitorum superficialis. Arguably, the accessory muscle might be a variant of a lumbrical muscle, as reported before, but innervation of the proximal belly by the anterior interosseous nerve suggests that the muscle may well be a deep accessory muscle at the forearm, probably appeared as a diverted part of the flexor digitorum profundus. Its space-occupying course through the forearm and palm, especially through the carpal canal, might be clinically significant as it might contribute to nerve compression pathologies in the upper extremity. This accessory muscle also indicates the complex nature of individual muscle formation and evolution of the upper extremity with constant changes in the morphology of muscles based on their changing functions.

It is important to explore the types of conceptualisations and causes presented in online mental health promotion given the implications that these presentations may have on mental health stigma. This study systematically reviewed 92 Australian webpages focused on either mental health, mental illness, depression, or schizophrenia, to explore the types of conceptualisations and aetiologies presented. A minority of mental health and mental illness webpages (n = 8, 8.70%) explicitly presented continuum conceptualisations, with none providing explicit categorical conceptualisations. No depression or schizophrenia webpages presented explicit conceptualisations of any kind. All four webpage foci had a greater proportion of continuum than categorical conceptualisations. Moreover, both depression and schizophrenia webpages presented many mixed conceptualisations which included both continuum and categorical messaging. Most webpages mentioned biological and social causes equally across webpage foci. These findings suggest that Australian mental health websites predominantly present continuum conceptualisations of mental health and mental illness.

The present study investigated the relationships between continuum and categorical beliefs, stigma, and help-seeking in response to vignettes depicting depression and schizophrenia. Participants were 193 adolescents aged 13-18 years. Results showed no relationships between continuum beliefs and stigma or help-seeking intentions for the depression vignette when controlling for other predictors. Stronger categorical beliefs were associated with greater social distance, and endorsement of dangerousness, avoidance, and fear. For the schizophrenia vignette, higher continuum beliefs predicted lower prognostic pessimism, social distance, and stigmatising attitudes. Surprisingly, continuum beliefs predicted greater intentions to not seek help. Categorical beliefs were associated with greater prognostic pessimism, social distance, and stigmatising attitudes. Future research is needed to explore the effect of continuum belief interventions on adolescent mental health stigma.

Background: Little is known regarding healthcare expenditures for patients with dementia with Lewy bodies (DLB) during the end of life. Objective: This study estimated Medicare expenditures during the last 5 years of life in a decedent sample of patients who were clinically diagnosed with Alzheimer’s disease (AD) or DLB and had autopsy confirmed diagnosis. Methods: The study included 58 participants clinically diagnosed with mild dementia at study entry (AD: n = 44, DLB: n = 14) and also had autopsy-confirmed diagnoses of pure AD (n = 32), mixed AD+Lewy body (LB) (n = 5), or pure LB (n = 11). Total Medicare expenditures were compared by clinical and pathology confirmed diagnosis, adjusting for sex, age at death, and patient’s cognition, function, comorbidities, and psychiatric and extrapyramidal symptoms. Results: When pathology diagnoses were not considered, predicted annualized total Medicare expenditures during the last 5 years of life were similar between clinically diagnosed AD ($7,465±1,098) and DLB ($7,783±1,803). When clinical diagnoses were not considered, predicted expenditures were substantially higher in patients with pathology confirmed mixed AD+LB ($12,005±2,455) than either pure AD ($6,173±941) or pure LB ($4,629±1,968) cases. Considering clinical and pathology diagnosis together, expenditures for patients with clinical DLB and pathology mixed AD+LB ($23,592±3,679) dwarfed other groups. Conclusion: Medicare expenditures during the last 5 years of life were substantially higher in patients with mixed AD+LB pathology compared to those with pure-AD and pure-LB pathologies, particularly in those clinically diagnosed with DLB. Results highlight the importance of having both clinical and pathology diagnoses in examining healthcare costs.

Rationale: Mechanical ventilation (MV) is associated with hippocampal apoptosis and inflammation, and it is important to study strategies to mitigate them. Objectives: Explore whether temporary tra...

We investigated the preparatory benefits of counterfactual and prefactual thinking towards cognitive task performance. Experiment 1 replicated the robust finding that individuals focus more on muta...

Caregivers identify the need for continuous supervision of Alzheimer’s disease patients while awake as a “milestone” functional change that has a profound impact on the lives of the caregiver and patient. The specific predictors of this important functional change are not known. We determined specific cognitive, neuropsychiatric, and motor symptoms associated with Alzheimer’s disease patients needing supervision while awake in a longitudinal, ethnically diverse cohort of Alzheimer’s disease patients in Northern Manhattan. At the initial visit, neuropsychiatric and behavioral symptoms, including more hallucinations (OR=3.12) and lower elation (OR=0.13) were associated with the need for supervision while awake, as were poor memory (OR=0.89) and higher letter fluency (OR=1.33) abilities. The findings presented in the current study can aid clinicians and caregivers in prognosis and planning, suggest symptoms to target with non-pharmacological and pharmacological treatments to forestall this important functional “milestone”, and suggest priorities for future research.Significance StatementNeed for supervision while awake is identified by caregivers of AD patients as a “milestone” symptom that greatly changes caregiving needs and quality of lifeSpecific neuropsychiatric and cognitive symptoms, including hallucinations, elation, and memory and executive dysfunction, are associated with a significantly increased or decreased need for supervision while awakeThese patient-centered findings aid prognosis and planning, and indicate symptoms to prioritize for treatment and future research to improve AD patient functioning

To assess the predictive value of neuropsychological tests for severe dependency in Alzheimer’s disease as defined by the Equivalent Institutional Care Rating Scale, in a multiethnic, community cohort. The sample included 146 elders from the Predictors 3 cohort. Cox proportional hazard models tested the predictive value of each neuropsychological test at baseline on relative risk of meeting severe dependency. Higher semantic processing and memory test scores at baseline were associated with lower risk of meeting severe dependency in the adjusted Cox models. The integrity of semantic processing and memory abilities in dementia appears to predict time to severe functional dependency.

BACKGROUND: Neuropsychiatric symptoms are an important and increasingly recognized aspect of Alzheimer’s disease. Psychotic symptoms have been shown to contribute to faster disease progression in clinic-based, demographically homogenous samples with relatively high educational attainment. Less is known about the contribution of these symptoms to disease progression in ethnic minorities and those with less educational attainment, as well as those with more severe dementia. OBJECTIVE: We aimed to study the association of psychotic symptoms at baseline with disease progression among individuals with incident Alzheimer’s disease, or ‘at risk’ of developing Alzheimer’s disease, who were identified from a demographically heterogenous, community-based cohort. METHODS: A total of 212 study participants received the Columbia University Scale of Psychopathology in Alzheimer’s Disease scale and yearly neuropsychological evaluations. Psychotic symptoms were defined as having any of the following: visual illusions, delusions, hallucinations or agitation/aggression. Disease progression was measured by meeting the cognitive endpoint, defined as a decline to ≤10 on the Folstein MMSE, or functional endpoints, defined as worsening to ≥10 on the Blessed Dementia Rating Scale (BDRS) or ≥4 on the Dependence Scale. RESULTS: The mean age was 85 years old. The cohort was 78.3% female, 75.9% Hispanic, and had a mean of 6.96 years of education. Within the study follow-up period of 3.69 years (range 0.97–7.93 years, SD 1.59 years), 24 met the MMSE cognitive endpoint, 59 met the BDRS functional endpoint and 132 met the cutoff for dependence. The presence of at least one psychotic symptom was associated with an increased risk of reaching the functional endpoint (HR 3.12, 95% CI 1.67–5.86, p

Introduction Extrapyramidal signs (EPS) are a common feature of Alzheimer's disease associated with worse outcomes in observational studies of dementia. Less research has been conducted on ethnic minority and non-clinic-based populations. Methods One hundred and forty-two multiethnic community-dwelling participants with dementia were selected. Adjusted Cox models were fitted for mortality, cognitive (Mini Mental State Examination ≤10), functional (Blessed Dementia Rating Scale ≥10), and dependency (needs full-time care) endpoints with baseline EPS as predictor. Results Thirty-seven participants (26.06%) had EPS at baseline. EPS predicted more rapid time to death (hazard ratio [HR] = 2.76, 95% confidence interval [CI] = 1.49, 5.42), and functional endpoint (HR = 3.88, 95% CI = 1.75, 8.62) but not cognitive and dependency endpoints. No evidence of interaction by ethnicity, age, sex, education, or apolipoprotein E e4 polymorphism was found. Discussion Our results partially confirm previous studies on predominantly White, clinic-based samples. Further research is needed to better understand the etiological role of EPS in AD.

To address the impact of COVID-19 in the state of Hawai'i, the Hawai'i Emergency Management Agency Medical Public Health Branch activated its' Community Care Outreach Unit (CCO Unit). A team from this unit developed a survey to assess the impact, needs, and threats to the health and social welfare of individuals and their families as they pertain to COVID-19. This article presents key findings for the City and County of Honolulu (CCH). A total of 5598 CCH residents responded. Approximately half of these respondents reported they or their household members experienced reduced work hours or lost their job as a result of COVID-19. In all questions related to paying for essential living costs, at the time of the survey, the percentage of participants who expected to have future problems nearly doubled. Those preparing for school in the fall school semester expected challenges centered on insufficient funds to purchase school supplies, lack of available face-coverings, and language barriers. Financial assistance, rental assistance, and food assistance seemed to be more difficult to apply for compared to health care services. The most common reasons for difficulty with applications noted by residents included that they could not figure out how to complete the form, did not have all the documents, or could not get through on the telephone. About one-half of CCH participants reported feeling nervous more than half of the days or nearly every day in the past 2 weeks. Most perceived the severity of COVID-19 to be moderate to very high. Less than half reported knowing how to provide care for someone in their family with COVID-19. Half of the CCH participants reported that they practice social distancing usually or all of the time, and the majority reported wearing a face-covering usually or always when outside of the home. A significant portion of respondents reported barriers for providing care for a household member exposed or infected with COVID-19. Such barriers included a lack of space in their home for isolation; not having enough cleaning supplies; no working thermometer in the home, or no family member available to care for them. The results presented may provide a baseline for understanding the impact, needs, and threats to the health and social welfare of individuals and their families in CCH and across the state of Hawai'i. Local stakeholders can utilize this information in developing priorities, strategies, and programs to address the pandemic as it continues to unfold and learn lessons for future pandemics.

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the world. To address the impact of COVID-19 in the state of Hawai'i, the Hawai'i Emergency Management Agency (HI-EMA) Community Care Outreach Unit conducted an assessment survey to determine the impact of COVID-19 on the health and social welfare of individuals and their families across the state. This article presents key statewide findings from this assessment, including areas of need and community-based recommendations to help mitigate the impact of the pandemic, particularly for vulnerable groups. A total of 7927 participants responded to the assessment survey from across the state's counties. In all questions related to paying for essentials, the percentage of participants that expect to have problems in the future, as compared to now, almost doubled. Slightly higher than one-third reported that they would know how to care for a family member in the home with COVID-19, and half of the respondents reported a lack of space for isolation in their home. About half reported that if they got COVID-19, they would have someone available to care for them. Overall, Native Hawaiian, Pacific Islander, and Filipino groups reported greater burden in almost all areas surveyed. The results presented provide a baseline in understanding the impact, needs, and threats to the health and social welfare of individuals and their families across the state of Hawai'i. Local stakeholders can utilize this information when developing priorities, strategies, and programs to address current and future pandemics in the state.

Background and ObjectivesEvaluating and understanding the heterogeneity in dementia course has important implications for clinical practice, health care decision-making, and research. However, inconsistent findings have been reported with regard to the disease courses of the 2 most common dementias: Alzheimer disease (AD) and dementia with Lewy bodies (DLB). Using autopsy-confirmed diagnoses, we aimed to examine the disease trajectories in the years before death among patients with dementia with pure AD, pure DLB, or mixed (AD and DLB) pathologies.MethodsThe current retrospective longitudinal study included 62 participants with autopsy-confirmed diagnoses of pure AD (n = 34), mixed AD and DLB (AD + DLB; n = 17), or pure DLB (n = 11) from the Predictors 2 Cohort Study, a prospective, clinic-based, cohort of patients with dementia. Generalized estimating equation models, with time zero at death, were used to examine the trajectory of cognition (Folstein Mini-Mental State Examination [MMSE]), function (activities of daily living [ADL]), and Dependence Scale among patients with different autopsy-confirmed diagnosis (pure AD, AD + DLB, and pure DLB). The models were adjusted for age, sex, education, and baseline features including extrapyramidal signs, MMSE, ADL, and Dependence Scale.ResultsThe participants on average received 9.4 ± 4.6 assessments at 6-month intervals during a mean 5.4 ± 2.9 years of follow-up. The 3 groups were similar in both cognition and function status at baseline. Cognition and function were highly correlated among patients with AD + DLB but not in pure AD or pure DLB at baseline. Patients of the 3 groups all declined in both cognition and function but had different trajectories of decline. More specifically, the patients with pure DLB experienced approximately double the rate of both cognitive decline and functional decline than the patients with pure AD, and the mixed pathology group showed double the rate of functional decline as compared to pure AD.DiscussionIn this longitudinal study, we found that among patients with dementia, those with Lewy body pathology experienced faster cognitive and functional decline than those with pure AD pathology.

It is important to explore the types of conceptualisations and causes presented in online mental health promotion given the implications that these presentations may have on mental health stigma. This study systematically reviewed 92 Australian webpages focused on either mental health, mental illness, depression, or schizophrenia, to explore the types of conceptualisations and aetiologies presented. A minority of mental health and mental illness webpages (n = 8, 8.70%) explicitly presented continuum conceptualisations, with none providing explicit categorical conceptualisations. No depression or schizophrenia webpages presented explicit conceptualisations of any kind. All four webpage foci had a greater proportion of continuum than categorical conceptualisations. Moreover, both depression and schizophrenia webpages presented many mixed conceptualisations which included both continuum and categorical messaging. Most webpages mentioned biological and social causes equally across webpage foci. These findings suggest that Australian mental health websites predominantly present continuum conceptualisations of mental health and mental illness.

Tidal volume delivered by mechanical ventilation to a sedated patient is distributed in a non-physiological pattern, causing atelectasis (underinflation) and overdistension (overinflation). Activation of the diaphragm during mechanical ventilation provides a way to reduce atelectasis and alveolar inhomogeneity, protecting the lungs from ventilator-induced lung injury while also protecting the diaphragm by preventing ventilator-induced diaphragm dysfunction. We studied the hypothesis that diaphragm contractions elicited by transvenous phrenic nerve stimulation, delivered in synchrony with volume-control ventilation, would reduce atelectasis and lung inhomogeneity in a healthy, normal-lung pig model. Twenty-five large pigs were ventilated for 50 hours with lung-protective volume-control ventilation combined with synchronous transvenous phrenic-nerve neurostimulation on every breath, or every second breath. This was compared to lung-protective ventilation alone. Lung mechanics and ventilation pressures were measured using esophageal pressure manometry and electrical impedance tomography. Alveolar homogeneity was measured using alveolar chord length of preserved lung tissue. Lung injury was measured using inflammatory cytokine concentration in bronchoalveolar lavage fluid and serum. We found that diaphragm neurostimulation on every breath preserved PaO2/FiO2 and significantly reduced the loss of end-expiratory lung volume after 50 hours of mechanical ventilation. Neurostimulation on every breath reduced plateau and driving pressures, improved both static and dynamic compliance and resulted in less alveolar inhomogeneity. These findings support that temporary transvenous diaphragm neurostimulation during volume-controlled, lung-protective ventilation may offer a potential method to provide both lung- and diaphragm-protective ventilation.

Background: Extrapyramidal signs (EPS) are a common feature of Alzheimer's Disease (AD) associated with worse outcomes in observational studies of dementia. Prior studies have been primarily conducted in predominately white, clinic‐based samples. Less is known regarding the role of EPS in the disease course of dementia in ethnic minority and non‐clinic‐based populations. Method: Predictors 3 (P3) is a multi‐ethnic community‐based cohort study of dementia. Recruitment began in 2011 and is ongoing. Participants are evaluated annually by trained investigators. 142 P3 participants with a baseline diagnosis of probable dementia were selected for this study. Moderate EPS was defined as a score of 2 or more on selected items from the Unified Parkinson's Disease Rating Scale. The cognitive endpoint was defined as a score of = 10 on the 17‐point Blessed Dementia Rating Scale, and the institutional equivalent endpoint as need for equivalent to nursing home care. Adjusted Cox models were fitted for time to death and cognitive, functional, and institutional equivalent endpoints with baseline moderate EPS as predictor. Effect modification was assessed by fitting cross‐product terms for moderate EPS by ethnicity, sex, age, education, and APOE polymorphism. Result: Mean follow‐up time was 3.61 years (range: 0.29 ‐ 7.50, SD = 1.95). 33 participants (23.2%) had moderate EPS at baseline. 53 died (37.3%), 23 (17.2%) reached the cognitive endpoint, 45 (36.3%) the functional endpoint, and 44 (37.9%) the institutional equivalent endpoint post‐baseline. Moderate EPS at baseline was significantly associated with an increased hazard of death (HR = 2.57, 95% CI = 1.30, 5.10) and of reaching the functional endpoint (5.59, 95% CI = 2.36, 13.27). Associations between moderate EPS and the cognitive and institutional equivalent endpoints were not statistically significant. No evidence was found for effect modification of associations on either additive or multiplicative scales. Conclusion: In a multi‐ethnic community‐dwelling cohort of demented elders, we found that baseline moderate EPS significantly predicted time to death and time to functional endpoint, but not time to cognitive and institutional equivalent care endpoints. These findings confirm those of previous studies conducted on predominately white, clinic‐based samples.

Mechanical ventilation is the cornerstone of the Intensive Care Unit. However, it has been associated with many negative consequences. Recently, ventilator-induced brain injury has been reported in rodents under injurious ventilation settings. Our group wanted to explore the extent of brain injury after 50 h of mechanical ventilation, sedation and physical immobility, quantifying hippocampal apoptosis and inflammation, in a normal-lung porcine study. After 50 h of lung-protective mechanical ventilation, sedation and immobility, greater levels of hippocampal apoptosis and neuroinflammation were clearly observed in the mechanically ventilated group, in comparison to a never-ventilated group. Markers in the serum for astrocyte damage and neuronal damage were also higher in the mechanically ventilated group. Therefore, our study demonstrated that considerable hippocampal insult can be observed after 50 h of lung-protective mechanical ventilation, sedation and physical immobility.

Introduction: Mechanical ventilation (MV) can cause injury to the lungs and distal organs. We hypothesize that lung-protective MV causes neural inflammation with activation of hippocampal astrocytes. Astrocytes have an essential function in neuronal connection and brain inflammation. Once activated, these cells assist in propagating the inflammatory cascade in the central nervous system. Preclinically, deficits in cognitive function have been associated with an increased number of reactive astrocytes in the CA1 hippocampal area in rodents undergoing MV. The percentage of reactive astrocytes in the hippocampus has not been quantified after 50 hours of lung-protective MV. This data could be used to the development of cognitive impairment after MV. Methods: Six human-size pigs with non-injured lungs were subjected to lung-protective MV for 50 hours (MV group). Six additional never-ventilated pigs were used as a control group (NV group). Lung-protective MV was defined as: tidal volume 8ml/kg, peak pressure Results: The percentages of reactive astrocytes in the DG, CA3 and CA1 combined were significantly higher in the MV group than NV group (26% (130,571/502,195) vs. 11% (44,686/406,235)) (p=0.002). MV group showed higher percentages of reactive astrocytes in each hippocampal region; DG 25% (MV) vs. 10% (NV) (p=0.17); CA3: 22% (MV) vs. 8% (NV) (p Conclusion: Lung-protective MV for 50 hours in pigs leads to activation of hippocampal astrocytes.

Introduction Medical photography is a noninvasive technique used for diagnostic, monitoring, and educational purposes. It is important to understand the patient's attitude to all or part of their body being photographed. The objective of this study was to analyze the attitudes of patients towards medical photography at a district hospital in Tarragona, Spain. Methodology This exploratory study used a questionnaire to evaluate attitudes to medical photography among outpatients at Pius Hospital de Valls. The questionnaire explored the patients’ beliefs about the usefulness of medical photography, the circumstances in which they would agree to be photographed and by whom, as well as their prior experience of medical photography. They were also asked whether they would authorize the use of photography and, if not, to explain their motives. Results The questionnaire was completed by 134 patients. The results showed that patients had a clearly positive attitude to being photographed for medical purposes (94.8%), treatment follow-up (88.1%), and consultation of their case with other physicians (86.6%). Acceptance was 88.8% if the lesion was malignant and 85.1% if it was extensive. For facial lesions, only 78.4% were willing to be photographed and in the case of genitals the percentage fell to 70.2%. Most patients (95.5%) would agree to being photographed by their doctor. The rate of acceptance was 66.4% in the case of a nurse, 64.9% for another doctor, and 21.6% for a professional photographer. Conclusions Our study revealed that patients have a positive attitude to being photographed for medical purposes, particularly when they have a malignant lesion, when the photograph is taken by their specialist, and when they cannot be identified.

Resumen Introduccion La fotografia medica es una tecnica de imagen no invasiva que se utiliza con fines diagnosticos, de monitoreo y educativos. Es importante conocer la actitud del paciente hacia ser fotografiado, en su totalidad o en parte de su cuerpo. El objetivo de este estudio es analizar la actitud de los pacientes del Pius Hospital de Valls hacia la fotografia medica. Metodologia Este estudio exploratorio evaluo, a partir de un cuestionario, la actitud de los pacientes que asistieron a consultas externas del Hospital Pius de Valls (Espana) respecto a ser fotografiados. Las preguntas estaban relacionadas con creencias en torno a la utilidad de la fotografia medica, circunstancias bajo las cuales se autorizaria ser fotografiado y a manos de quien, experiencia con la fotografia medica, intencion de autorizar la fotografia y motivos para no autorizarla. Resultados El cuestionario fue respondido por 134 pacientes. Los resultados mostraron una actitud claramente positiva hacia ser fotografiado con fines medicos (94,8%), por seguimiento de tratamiento (88,1%) y consulta del caso con otros medicos (86,6%). El 88,8% aceptaria ser fotografiado si la lesion es maligna y el 85,1% si es extensa. Para lesiones en el rostro, solamente el 78,4% lo permitiria; en los genitales el porcentaje es aun menor (70,2%). El 95,5% estaria dispuesto a dejarse fotografiar si es el mismo medico quien la hace, si es el enfermero (66,4%), otro medico (64,9%) o un fotografo profesional (21,6%). Conclusiones Nuestro estudio muestra una actitud positiva hacia ser fotografiado con fines medicos, siempre que el fotografo sea el medico tratante, en lesiones malignas y en areas no identificables.

Most research investigating the effect of continuum beliefs on stigma has used weak manipulations which may contribute to mixed findings within the experimental literature. There is also a lack of research into how continuum belief manipulations may impact help-seeking and help-provision. This study used an online manipulation of continuum and categorical beliefs about schizophrenia to examine the subsequent impacts on stigma, help-seeking, and help-provision. A total of 271 participants were randomised into either a continuum, categorical, or control condition. Participants received an informational video, a magazine article, and research highlights relevant to their condition. Prosocial support behaviour was assessed through a novel volunteering measure. The magnitude of change between pre-intervention and post-intervention measures of continuum and categorical beliefs was large. Continuum presentations reduced prognostic pessimism and negative stereotyping. Meanwhile, categorical presentations increased prognostic pessimism. Participants across conditions showed increased help-providing intentions after removing the highest scores to avoid ceiling effects. Fear and blame also decreased significantly across all conditions. There was no difference between conditions on our novel volunteer help-provision measure. Our findings have implications for anti-stigma programs and may help inform the design of future continuum belief manipulations.