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In clinical practice, the bodily distribution of chronic pain is often used in conjunction with other signs and symptoms to support a diagnosis or treatment plan. For example, the diagnosis of fibromyalgia involves tallying the areas of pain that a patient reports using a drawn body map. It remains unclear whether patterns of pain distribution independently inform aspects of the pain experience and influence patient outcomes. The objective of the current study was to evaluate the clinical relevance of patterns of pain distribution using an algorithmic approach agnostic to diagnosis or patient-reported facets of the pain experience. A large cohort of patients (N = 21,658) completed pain body maps and a multi-dimensional pain assessment. Using hierarchical clustering of patients by body map selection alone, nine distinct subgroups emerged with different patterns of body region selection. Clinician review of cluster body maps recapitulated some clinically-relevant patterns of pain distribution, such as low back pain with radiation below the knee and widespread pain, as well as some unique patterns. Demographic and medical characteristics, pain intensity, pain impact, and neuropathic pain quality all varied significantly across cluster subgroups. Multivariate modeling demonstrated that cluster membership independently predicted pain intensity and neuropathic pain quality. In a subset of patients who completed 3-month follow-up questionnaires (N = 7,138), cluster membership independently predicted the likelihood of improvement in pain, physical function, and a positive overall impression of change related to multidisciplinary pain care. This study reports a novel method of grouping patients by pain distribution using an algorithmic approach. Pain distribution subgroup was significantly associated with differences in pain intensity, impact, and clinically relevant outcomes. In the future, algorithmic clustering by pain distribution may be an important facet in chronic pain biosignatures developed for the personalization of pain management.

We estimated norms and percentiles for the Pediatric Emotional Distress Scale (PEDS) in order to enhance its utility as a screening tool for emotional and behavioral distress following a major. The PEDS was administered to a nationally representative sample of parents of children ages 5–12 from all 50 states ( N = 1,570). Approximately 15% of the parents reported a trauma/stress in the past 12 months. Results showed good internal consistency (α = .92) and concurrent validity, with significantly higher scores for the trauma/stress subsample compared to the no trauma/stress subsample. PEDS scores were also significantly higher in younger children (age 5–6) compared to older children (7–12), pointing to the need for separate clinical cut-off scores for younger versus older children. Finally, we examined the factor structure of the PEDS with results supporting a four factor solution in the trauma/stress subsample. For screening purposes, we recommend cut-off scores of 39 (ages 5–6) and 35 (ages 7–12) which correspond to the 90 th percentile.

BackgroundIn clinical practice, the bodily distribution of chronic pain is often used in conjunction with other signs and symptoms to support a diagnosis or treatment plan. For example, the diagnosis of fibromyalgia involves tallying the areas of pain that a patient reports using a drawn body map. It remains unclear whether patterns of pain distribution independently inform aspects of the pain experience and influence patient outcomes. The objective of the current study was to evaluate the clinical relevance of patterns of pain distribution using an algorithmic approach agnostic to diagnosis or patient-reported facets of the pain experience.Methods and findingsA large cohort of patients (N = 21,658) completed pain body maps and a multi-dimensional pain assessment. Using hierarchical clustering of patients by body map selection alone, nine distinct subgroups emerged with different patterns of body region selection. Clinician review of cluster body maps recapitulated some clinically-relevant patterns of pain distribution, such as low back pain with radiation below the knee and widespread pain, as well as some unique patterns. Demographic and medical characteristics, pain intensity, pain impact, and neuropathic pain quality all varied significantly across cluster subgroups. Multivariate modeling demonstrated that cluster membership independently predicted pain intensity and neuropathic pain quality. In a subset of patients who completed 3-month follow-up questionnaires (N = 7,138), cluster membership independently predicted the likelihood of improvement in pain, physical function, and a positive overall impression of change related to multidisciplinary pain care.ConclusionsThis study reports a novel method of grouping patients by pain distribution using an algorithmic approach. Pain distribution subgroup was significantly associated with differences in pain intensity, impact, and clinically relevant outcomes. In the future, algorithmic clustering by pain distribution may be an important facet in chronic pain biosignatures developed for the personalization of pain management.

This dissertation is divided into two sections: an essay exploring voice and personality in poetry and a collection of poems.

Understanding spatial variation in biodiversity along environmental gradients is a central theme in ecology. Differences in species compositional turnover among sites (β diversity) occurring along gradients are often used to infer variation in the processes structuring communities. Here, we show that sampling alone predicts changes in β diversity caused simply by changes in the sizes of species pools. For example, forest inventories sampled along latitudinal and elevational gradients show the well-documented pattern that β diversity is higher in the tropics and at low elevations. However, after correcting for variation in pooled species richness (γ diversity), these differences in β diversity disappear. Therefore, there is no need to invoke differences in the mechanisms of community assembly in temperate versus tropical systems to explain these global-scale patterns of β diversity.

Aim: A long-standing challenge in ecology is to identify the suite of factors that lead to turnover in species composition in both space and time. These factors might be stochastic (e.g. sampling and priority effects) or deterministic (e.g. competition and environmental filtering). While numerous studies have examined the relationship between turnover and individual drivers of interest (e.g. primary productivity, habitat heterogeneity, or regional –'gamma' – diversity), few studies have disentangled the simultaneous influences of multiple stochastic and deterministic processes on both temporal and spatial turnover. If turnover is governed primarily by stochastic sampling processes, removing the sampling effects of gamma diversity should result in non-significant relationships between turnover and environmental variables. Conversely, if deterministic processes govern turnover patterns, removing sampling effects will have little influence on turnover gradients. Here, we test these predictions. Location: The United States. Methods: Continental-scale, multidecadal data were used to quantify spatial and temporal turnover in avian community composition within 295 survey routes. A series of regression and structural equation models were coupled with a null model to construct statistical models describing turnover patterns. Results: Examining explanatory variables alone or in combination showed that spatial and temporal turnover increased together, decreased with primary productivity and increased with habitat heterogeneity. The relationships between turnover and all variables became weaker when sampling effects were removed, but relationships with primary productivity and habitat heterogeneity remained relatively strong. In addition, spatial turnover increased strongly with spatial gamma diversity after sampling effects were removed. Main conclusions: Our results show that spatial and temporal turnover are related to each other through a stochastic sampling process, but that each type of turnover is further influenced by deterministic processes. The relative influence of deterministic processes appears, however, to decrease with primary productivity and increase with habitat heterogeneity across an east-west longitudinal gradient in North America.

Powassan virus is an emerging tick-borne virus of concern for public health, but very little is known about its transmission patterns and ecology. Here, we expanded the genomic dataset by sequencing 279 Powassan viruses isolated from Ixodes scapularis ticks from the northeastern United States. Our phylogeographic reconstructions revealed that Powassan virus lineage II was likely introduced or emerged from a relict population in the Northeast between 1940 and 1975. Sequences strongly clustered by sampling location, suggesting a highly focal geographical distribution. Our analyses further indicated that Powassan virus lineage II emerged in the northeastern United States mostly following a south-to-north pattern, with a weighted lineage dispersal velocity of ∼3 km/y. Since the emergence in the Northeast, we found an overall increase in the effective population size of Powassan virus lineage II, but with growth stagnating during recent years. The cascading effect of population expansion of white-tailed deer and I. scapularis populations likely facilitated the emergence of Powassan virus in the northeastern United States.

The human brain is a dynamic networked system. Patients with partial epileptic seizures have focal regions that periodically diverge from normal brain network dynamics during seizures. We studied the evolution of brain connectivity before, during, and after seizures with graph-theoretic techniques on continuous electrocorticographic (ECoG) recordings (5.4 ± 1.7 d per patient, mean ± SD) from 12 patients with temporal, occipital, or frontal lobe partial onset seizures. Each electrode was considered a node in a graph, and edges between pairs of nodes were weighted by their coherence within a frequency band. The leading eigenvector of the connectivity matrix, which captures network structure, was tracked over time and clustered to uncover a finite set of brain network states. Across patients, we found that ( i ) the network connectivity is structured and defines a finite set of brain states, ( ii ) seizures are characterized by a consistent sequence of states, ( iii ) a subset of nodes is isolated from the network at seizure onset and becomes more connected with the network toward seizure termination, and ( iv ) the isolated nodes may identify the seizure onset zone with high specificity and sensitivity. To localize a seizure, clinicians visually inspect seizures recorded from multiple intracranial electrode contacts, a time-consuming process that may not always result in definitive localization. We show that network metrics computed from all ECoG channels capture the dynamics of the seizure onset zone as it diverges from normal overall network structure. This suggests that a state space model can be used to help localize the seizure onset zone in ECoG recordings. Significance In epilepsy, seizures elicit changes in the functional connectivity of the brain that shed insight into the seizures’ nature and onset zone. We investigated the brain connectivity of patients with partial epileptic seizures from continuous multiday recordings and found that ( i ) the connectivity defines a finite set of brain states, ( ii ) seizures are characterized by a consistent progression of states, and ( iii ) the seizure onset zone is isolated from the surrounding regions at seizure onset but becomes most connected toward seizure termination. Our results suggest that a finite-dimensional state space model may characterize the dynamics of the epileptic brain and ultimately help localize the seizure onset zone, which is currently done by clinicians through visual inspection of electrocorticographic recordings.