A disease-associated gene desert directs macrophage inflammation through ETS2

Increasing rates of autoimmune and inflammatory disease present a burgeoning threat to human health1. This is compounded by the limited efficacy of available treatments1 and high failure rates during drug development2, highlighting an urgent need to better understand disease mechanisms. Here we show how functional genomics could address this challenge. By investigating an intergenic haplotype on chr21q22-which has been independently linked to inflammatory bowel disease, ankylosing spondylitis, primary sclerosing cholangitis and Takayasu's arteritis3-6-we identify that the causal gene, ETS2, is a central regulator of human inflammatory macrophages and delineate the shared disease mechanism that amplifies ETS2 expression. Genes regulated by ETS2 were prominently expressed in diseased tissues and more enriched for inflammatory bowel disease GWAS hits than most previously described pathways. Overexpressing ETS2 in resting macrophages reproduced the inflammatory state observed in chr21q22-associated diseases, with upregulation of multiple drug targets, including TNF and IL-23. Using a database of cellular signatures7, we identified drugs that might modulate this pathway and validated the potent anti-inflammatory activity of one class of small molecules in vitro and ex vivo. Together, this illustrates the power of functional genomics, applied directly in primary human cells, to identify immune-mediated disease mechanisms and potential therapeutic opportunities.

A Principle-Based Approach to Visual Identification Systems for Hospitalized People with Dementia

A large proportion of hospital inpatients are affected by cognitive impairment, posing challenges in the provision of their care in busy, fast-paced acute wards. Signs and symbols, known as visual identifiers, are employed in many U.K. hospitals with the intention of helping healthcare professionals identify and respond to the needs of these patients. Although widely considered useful, these tools are used inconsistently, have not been subject to full evaluation, and attract criticism for acting as a shorthand for a routinized response. In order for visual identifiers to be used effectively in acute care settings, thorough consideration must be given to the ethical and legal issues that are engaged in this context, and their potential benefits and harms must be weighed and balanced. This paper proposes a set of legal and ethical principles that can be used to guide the implementation of visual identifiers. Together, these principles provide a framework applicable in the design and implementation phases to systematically identify relevant considerations arising from the use of these tools. We outline some tensions that arise between principles and conclude that selecting a preferred moral framework could help to guide decision-making, as does clarity around the purpose and objectives of the identifier.

Bilateral accessory flexor indicis muscle: A case study

Muscular variations within the upper extremities are common and widely documented. They can have a range of implications including nerve compression and misdiagnosis but are often silent. Our report herein describes a bilateral accessory muscle found in the forearm during routine cadaveric dissection. The muscle originates from the medial epicondyle of the humerus between the origins of the flexor digitorum superficialis and flexor carpi radialis muscles. The muscle is digastric, with the distal belly existing as the first lumbrical and the proximal serving as a supernumerary flexor. This functionally atavistic variation could prove clinically relevant for the purposes of donor muscle or tendon tissue as well as surgical complications and compressive neuropathies.

A comparison of the efficacy of trastuzumab deruxtecan in advanced HER2-positive breast cancer: active brain metastasis versus progressive extracranial disease alone

BACKGROUND

Trastuzumab deruxtecan (T-DXd) has demonstrated efficacy in patients with brain metastasis (BM), a group historically with poor outcomes. The prevalence of BMs in patients commencing T-DXd is currently unknown. No direct comparisons have been made of the activity of T-DXd in patients with active BM versus those with extracranial progression alone. This real-world study explored the prevalence of BMs in patients commencing T-DXd, the efficacy of T-DXd in active BM versus extracranial progression alone and the safety of T-DXd.

PATIENTS AND METHODS

Patients with human epidermal growth factor receptor 2-positive advanced breast cancer treated with T-DXd between June 2021 and February 2023 at our specialist cancer hospital were identified and notes reviewed. Clinicopathological information, prior treatment, the presence or absence of central nervous system (CNS) disease, outcomes and treatment-emergent adverse events (TEAEs) were recorded.

RESULTS

Twenty-nine female patients, with a median age of 52 years (interquartile range 44-62 years), were identified; the prevalence of BM was 41%. Median number of lines of prior therapy was 2 (range 2-6). At a median follow-up of 13.8 months, median progression-free survival (PFS) for the overall population was 13.9 months [95% confidence interval (CI) 12.4 months-not estimable (NE)], 16.1 months (95% CI 15.1 months-NE) for active BMs and 12.4 months (95% CI 8.3 months-NE) for progressive extracranial disease alone. The 12-month overall survival (OS) rate was 74% (95% CI 59% to 95%) in the overall population, and 83% (95% CI 58% to 100%) and 66% (95% CI 45% to 96%) for active BMs and extracranial disease only, respectively. Most common TEAEs were fatigue, alopecia, and constipation. In nine patients (31%, including two deaths), pneumonitis occurred.

CONCLUSION

In this real-world population, we demonstrate T-DXd to be effective in patients with active BMs and those with progressive extracranial disease alone. PFS and OS were numerically longer in those with active BMs. These data demonstrate that patients with active BM treated with T-DXd have at least comparable outcomes to those with extracranial disease alone. The high rate of pneumonitis warrants further consideration.

Effect of TCDD exposure in adult female and male mice on the expression of miRNA in the ovaries and testes and associated reproductive functions

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is an environmental contaminant found widely across the world. While animal and human studies have shown that exposure to TCDD may cause significant alterations in the reproductive tract, the effect of TCDD on the expression of miRNA in the reproductive organs has not been previously tested. In the current study, we exposed adult female or male mice to TCDD or vehicle and bred them to study the impact on reproduction. The data showed that while TCDD treatment of females caused no significant change in litter size, it did alter the survival of the pups. Also, TCDD exposure of either the male or female mice led to an increase in the gestational period. While TCDD did not alter the gross morphology of the ovaries and testes, it induced significant alterations in the miRNA expression. The ovaries showed the differential expression of 426 miRNAs, of which 315 miRNAs were upregulated and 111 miRNA that were downregulated after TCDD exposure when compared to the vehicle controls. In the testes, TCDD caused the differential expression of 433 miRNAs, with 247 miRNAs upregulated and 186 miRNAs downregulated. Pathway analysis showed that several of these dysregulated miRNAs targeted reproductive functions. The current study suggests that the reproductive toxicity of TCDD may result from alterations in the miRNA expression in the reproductive organs. Because miRNAs also represent one of the epigenetic pathways of gene expression, our studies suggest that the transgenerational toxicity of TCDD may also result from dysregulation in the miRNAs.

Surgeon educator perspectives of implementing a national undergraduate curriculum in otolaryngology

OBJECTIVE

The General Medical Council will be implementing a national medical licensing assessment for all UK medical students by 2024-25. Surgeon educator perceptions on a national undergraduate curriculum in otolaryngology were reviewed accordingly.

METHOD

A mixed methods study was undertaken within a UK school of surgery assessing ENT surgeon educators. Perspectives on teaching content, quality and student experience were assessed with degree of agreement assessed (Likert scoring). Associated qualitative focus group sessions underwent detailed thematic analysis according to grounded theory.

RESULTS

A response rate of 50 per cent was achieved involving 21 participants working across 14 hospitals. These showed strong agreement that implementation of a national curriculum would improve the standard of teaching delivered at a personal, institutional and national level. Further themes were identified relating to the personal, institutional and specialty related factors influencing practical delivery.

CONCLUSION

A series of practical recommendations are made to potentially assist the implementation of a national ENT curriculum.

Developing A Conceptual Framework for Early Intervention Vocational Rehabilitation for People Following Spinal Cord Injury

PURPOSE

Early intervention vocational rehabilitation (EIVR) can improve return to work (RTW) outcomes for people with spinal cord injury (SCI). However, mechanisms explaining how and why EIVR works are not well understood. This study aims to develop a conceptual framework describing key mechanisms of EIVR intervention effect following SCI.

METHODS

We synthesised data from a realist literature review with data from interviews of people with SCI (n = 30), a survey of people with SCI who had received EIVR (n = 37), a focus group of EIVR providers and a focus group of community vocational providers. We first synthesised the literature review and interviews to develop an initial programme theory describing the contexts in which mechanisms are activated to produce EIVR outcomes. Then we used data from the survey and focus groups to further refine the EIVR programme theory. Finally, a conceptual framework was developed to support knowledge dissemination.

RESULTS

By ensuring consistent messaging across the multi-disciplinary team, EIVR programmes establish and maintain hope that work is possible following injury. Conversations about work allow individuals to determine the priority of work following injury. These conversations can also improve self-efficacy by providing individualized support to envisage pathways toward RTW goals and maintain worker identity. The synthesised study findings highlight the contexts and resources required to trigger activation of these mechanisms.

CONCLUSIONS

EIVR key mechanisms of effect are not specific to SCI as a health condition, therefore enabling this framework to be applied to other populations who face similar impairments and return to work barriers.

Measurement of the ν_{e}-Nucleus Charged-Current Double-Differential Cross Section at ⟨E_{ν}⟩=2.4 GeV Using NOvA

The inclusive electron neutrino charged-current cross section is measured in the NOvA near detector using 8.02×10^{20} protons-on-target in the NuMI beam. The sample of GeV electron neutrino interactions is the largest analyzed to date and is limited by ≃17% systematic rather than the ≃7.4% statistical uncertainties. The double-differential cross section in final-state electron energy and angle is presented for the first time, together with the single-differential dependence on Q^{2} (squared four-momentum transfer) and energy, in the range 1  GeV≤E_{ν}<6  GeV. Detailed comparisons are made to the predictions of the GENIE, GiBUU, NEUT, and NuWro neutrino event generators. The data do not strongly favor a model over the others consistently across all three cross sections measured, though some models have especially good or poor agreement in the single differential cross section vs Q^{2}.

Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery

BACKGROUND

Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort.

METHODS

Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups.

RESULTS

The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status.

CONCLUSION

The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.

1027 DEVELOPING A MINIMUM COMMON DATASET FOR HIP FRACTURE AUDIT

Introduction

National hip fracture audits share a common heritage in the work of Rikshöft and the Standardised Audit of Hip Fracture in Europe. However, as more countries develop audit programmes and these evolve to address local needs, divergence in the data they collect compromises their scope for learning from clinical, audit and quality improvement work in other nations.

Method

In 2021 we compared all ten established national hip fracture audits: England/Wales/Northern Ireland; Scotland; Australia/New Zealand; Ireland; Germany; the Netherlands; Sweden; Norway; Denmark; Spain. We tabulated all questions included in each, and cross-referenced them against the 32 questions of the minimum common dataset (MCD) defined by the global Fragility Fracture Network (FFN) in 2014. We identified those consistently used in most national audits, and additional fields that might need to form part of a revised MCD. Any MCD must meet the needs of both developed and developing countries. We presented these findings at the Asia-Pacific FFN meeting, and used an online questionnaire to capture feedback from different countries. A draft revision was presented at the Global FFN conference in September 2021, with feedback again used to finalise this revised MCD.

Results

We tabulated a total of 215 possible questions. Only 72 (34%) were used in &gt;1 national audit, and only 32 (15%) by more than half of audits. Adherence to the 2014 MCD was disappointing; all 32 fields were used by at least one audit, but 5/32 only by one audit. Only 21/32 (65%) were used in the majority, and only three (anaesthetic grade, operation and date/time of surgery) by all ten established audits.

Discussion

This revised MCD will help aspirant nations establish new audit programmes, facilitate the integration of novel analytic techniques and greater multinational collaboration, and serve as an internationally-accepted standard for monitoring and improving hip fracture services.

The reach and benefits of a digital intervention to improve physical activity in people with a musculoskeletal condition delivered during the COVID-19 pandemic in the UK

Aim:

To evaluate a digital intervention to improve physical activity in people in the UK with a musculoskeletal condition delivered during movement restrictions brought about because of the COVID-19 pandemic.

Method:

Service evaluation data collected from 26,041 participants over 5 months was assessed against national datasets to understand the reach and representativeness of the digital physical activity intervention. Measures to restrict the movement and interaction of people were in place during these 5 months. Cross-sectional data from 2752 participants across different stages of the 12-week programme assessed levels of physical activity and the components of behaviour as defined by the COM-B model (Capability, Opportunity, Motivation = Behaviour). Regression analysis investigated the relationship between programme stage and physical activity and the components of behaviour.

Results:

In comparison to the UK population of people with a musculoskeletal condition, the intervention participants were over-represented by females, White, and inactive people. A cross-sectional analysis suggested that the number of participants regularly active increased by programme stage. Scores for the behavioural components of automatic and reflective motivation, physical and psychological capability, and physical opportunity were also improved by programme stage.

Conclusion:

The service evaluation suggests that the digital intervention, designed to improve physical activity in people with a musculoskeletal condition, could be beneficial during measures to restrict movement to slow the spread of infectious disease in those who are already motivated to become or stay active.

Clinical experience of paediatric self-expanding foam cuffed tracheostomy tubes

INTRODUCTION

Use of self-expanding foam-filled tracheostomy tube cuffs (Bivona® FOME cuf®) in paediatrics has become a recent practice within our institution for patients with intractable aspiration. The current literature, clinical indications and subsequent management is lacking. We present our experience with a cohort of children with a foam-cuffed tracheostomy tube managed at Great Ormond Street Hospital, describing their indications and outcomes, as well as routine and emergency management.

METHOD

Our tracheostomy patient population was reviewed and those with a Bivona® FOME cuf® tracheostomy tube were identified and reviewed. The indications for foam-cuffed tracheostomy tube insertion, progress, and further management, including emergency care, were reviewed.

RESULTS

Ten patients were identified, all with a chronic history of respiratory infections secondary to aspiration being the leading indication. All patients had an ongoing improvement in their chest function following insertion with no episodes of cuff trauma. One patient had difficulty when a port line was accidently cut, which resulted in difficulty of removal, and we outline a strategy for dealing with this.

CONCLUSION

The foam-cuffed tracheostomy tube is a useful tracheostomy tube to use in the management of chronic aspiration in children with poor chest health, however due to the lack of knowledge and experience they can prove to be a difficult tube to manage. Further educational information should be available as to the indications, routine care and emergency management of Bivona® FOME cuf® tracheostomy tubes. We believe they represent a useful option for institutions to consider in the paediatric population.

Endocannabinoid Anandamide Attenuates Acute Respiratory Distress Syndrome through Modulation of Microbiome in the Gut-Lung Axis

Acute respiratory distress syndrome (ARDS) is a serious lung condition characterized by severe hypoxemia leading to limitations of oxygen needed for lung function. In this study, we investigated the effect of anandamide (AEA), an endogenous cannabinoid, on Staphylococcal enterotoxin B (SEB)-mediated ARDS in female mice. Single-cell RNA sequencing data showed that the lung epithelial cells from AEA-treated mice showed increased levels of antimicrobial peptides (AMPs) and tight junction proteins. MiSeq sequencing data on 16S RNA and LEfSe analysis demonstrated that SEB caused significant alterations in the microbiota, with increases in pathogenic bacteria in both the lungs and the gut, while treatment with AEA reversed this effect and induced beneficial bacteria. AEA treatment suppressed inflammation both in the lungs as well as gut-associated mesenteric lymph nodes (MLNs). AEA triggered several bacterial species that produced increased levels of short-chain fatty acids (SCFAs), including butyrate. Furthermore, administration of butyrate alone could attenuate SEB-mediated ARDS. Taken together, our data indicate that AEA treatment attenuates SEB-mediated ARDS by suppressing inflammation and preventing dysbiosis, both in the lungs and the gut, through the induction of AMPs, tight junction proteins, and SCFAs that stabilize the gut-lung microbial axis driving immune homeostasis.

Search for Active-Sterile Antineutrino Mixing Using Neutral-Current Interactions with the NOvA Experiment

This Letter reports results from the first long-baseline search for sterile antineutrinos mixing in an accelerator-based antineutrino-dominated beam. The rate of neutral-current interactions in the two NOvA detectors, at distances of 1 and 810 km from the beam source, is analyzed using an exposure of 12.51×10^{20} protons-on-target from the NuMI beam at Fermilab running in antineutrino mode. A total of 121 of neutral-current candidates are observed at the far detector, compared to a prediction of 122±11(stat.)±15(syst.) assuming mixing only between three active flavors. No evidence for ν[over ¯]_{μ}→ν[over ¯]_{s} oscillation is observed. Interpreting this result within a 3+1 model, constraints are placed on the mixing angles θ_{24}<25° and θ_{34}<32° at the 90% C.L. for 0.05  eV^{2}≤Δm_{41}^{2}≤0.5  eV^{2}, the range of mass splittings that produces no significant oscillations at the near detector. These are the first 3+1 confidence limits set using long-baseline accelerator antineutrinos.

Effects of Acute 2,3,7,8-Tetrachlorodibenzo-p-Dioxin Exposure on the Circulating and Cecal Metabolome Profile

2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) is a polyhalogenated planar hydrocarbon belonging to a group of highly toxic and persistent environmental contaminants known as "dioxins". TCDD is an animal teratogen and carcinogen that is well characterized for causing immunosuppression through activation of aryl hydrocarbon receptor (AHR). In this study, we investigated the effect of exposure of mice to an acute dose of TCDD on the metabolic profile within the serum and cecal contents to better define the effects of TCDD on host physiology. Our findings demonstrated that within the circulating metabolome following acute TCDD exposure, there was significant dysregulation in the metabolism of bioactive lipids, amino acids, and carbohydrates when compared with the vehicle (VEH)-treated mice. These widespread changes in metabolite abundance were identified to regulate host immunity via modulating nuclear factor-kappa B (NF-κB) and extracellular signal-regulated protein kinase (ERK1/2) activity and work as biomarkers for a variety of organ injuries and dysfunctions that follow TCDD exposure. Within the cecal content of mice exposed to TCDD, we were able to detect changes in inflammatory markers that regulate NF-κB, markers of injury-related inflammation, and changes in lysine degradation, nicotinamide metabolism, and butanoate metabolism, which collectively suggested an immediate suppression of broad-scale metabolic processes in the gastrointestinal tract. Collectively, these results demonstrate that acute TCDD exposure results in immediate irregularities in the circulating and intestinal metabolome, which likely contribute to TCDD toxicity and can be used as biomarkers for the early detection of individual exposure.

A systematic review of mother-daughter interventions targeting physical activity

Background

Growing gender disparities in levels of physical inactivity put women and female youths at a greater risk of associated health problems. Mother-daughter interventions have been proposed as means to promote physical activity in this at-risk cohort. However, there is a lack of clarity as to if and why these types of interventions might be effective.

Methods

This systematic review examined the intervention characteristics, and behaviour change theory and techniques used in these interventions to promote physical activity for daughters and their mothers. PubMed, EMBASE, PsycINFO, CINAHL and Cochrane Library (Wiley) databases were searched for English language studies from inception to 13th May 2020. Interventions of any design that targeted daughters and mothers' physical activity were included in the review. Data was extracted using the Template for Intervention Description and Replication checklist, and the Behaviour Change Technique Taxonomy v1.

Results

4962 articles were screened and 11 unique studies met the inclusion criteria. Risk of bias was generally high. Narrative summary highlighted that many studies used social cognitive theory as a theoretical foundation, were based in the community and less than three months in duration with multiple sessions per week. Thirty-seven behaviour change techniques were identified across studies. Some techniques were deemed potentially effective including credible source, information on the health consequences of the behaviour and the self-regulatory related techniques of goal-setting, self-monitoring and problem-solving.

Conclusions

Future research should consider using checklists, frameworks and formative work with mothers and daughters to ensure interventions are rigorously designed, implemented, and evaluated, which can inform public policy to combat physical inactivity in this at-risk cohort.

Key messages

This is the first review to assess the intervention characteristics, and behaviour change theory and techniques of mother-daughter interventions targeting physical activity. This review advances the evidence base for future intervention development and more broadly can inform public policy to tackle physical inactivity in this at-risk cohort.

896 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &gt; 62.5mL/Hr for hip fracture patients.

Method

Three prospective audits, each including 100 consecutive acute hip fracture patients, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included implementation of admission/post-take checklist tools and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

In cycle one and two, many patients received inadequate fluids (46/100 and 56/100 respectively). There was no significant difference in the incidence of AKI between patients receiving adequate or inadequate fluid in either cycle (p &lt; 0.05).

In cycle three, more patients received adequate fluids (79/100, p &lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI (2/79, 2.5% vs 3/21, 14.3%; p &lt; 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

113 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Elderly Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &gt;62.5 mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids.

Methods

Three prospective audits, each including 100 consecutive acute hip fracture patients aged &gt;55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p = 0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p &lt; 0.05) Cycle 2: Fewer patients were prescribed adequate fluids (54/100, 54%). There was no significant difference in terms of developing AKI post operatively between patients with adequate fluids (4/54, 7.4%) or inadequate fluids (2/46, 4.3%; p = 0.52). Resolution of pre-operative AKI was similar in patients with adequate or inadequate fluid administration (4/6, 67% vs 2/2, 100%). Cycle 3: More patients received adequate fluids (79/100, 79%, p &lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI than those receiving inadequate fluids (2/79, 2.5% vs 3/21, 14.3%; p &lt; 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

Environmental Distractions during Unsupervised Remote Digital Cognitive Assessment

The current demand for cognitive assessment cannot be met with traditional in-person methods, warranting the need for remote unsupervised options. However, lack of visibility into testing conditions and effort levels limit the utility of existing remote options. This retrospective study analyzed the frequency of and factors associated with environmental distractions during a brief digital assessment taken at home by 1,442 adults aged 23–84. Automated scoring algorithms flagged low data capture. Frequency of environmental distractions were manually counted on a per-frame and per-trial basis. A total of 7.4% of test administrations included distractions. Distractions were more frequent in men (41:350) than women (65:1,092) and the average age of distracted participants (51.7) was lower than undistracted participants (57.8). These results underscore the challenges associated with unsupervised cognitive assessment. Data collection methods that enable review of testing conditions are needed to confirm quality, usability, and actionability.