We propose an automated negotiation for a reinforcement learning agent to adapt the agent to unexpected situations such as demand changes in supply chain management (SCM).
Existing studies that consider reinforcement learning and SCM assume a centralized environment where the coordination of chain components is hierarchical rather than through negotiations between agents.
This study focused on a negotiation agent that considered the value function of reinforcement learning for SCM as its utility function in automated negotiation.
We demonstrated that the proposed approach could avoid inventory shortages under increased demand requests from the terminal customer.

Coordination of Emergent Demand Changes via Value-Based Negotiation for Supply Chain Management (Student Abstract)

Cerebrospinal fluid (CSF) homeostasis in the brain relies on a delicate balance in CSF production, circulation, and excretion. When this balance is compromised, patients develop a spectrum of disorders, including hydrocephalus and neurodegenerative diseases. Emerging studies suggest that the lymphatic system, referred to as the glymphatic system in the brain, may have a previously unknown role in CSF homeostasis. Interestingly, it is unknown whether the glymphatic system has any role in embryonic CSF regulation. Frog Xenopus has been widely used to study fundamental neurodevelopmental processes and is a unique model to investigate CSF dynamics. In Xenopus, unlike any other model system, whole brain CSF circulation can be visualized in real-time and manipulated easily, providing unprecedented insight into CSF hemostasis. In this work, we asked whether frogs have a glymphatic system and its role in CSF regulation. Using the frog Xenopus model system, we show that the glymphatic system is essential in CSF drainage during embryonic brain development. We used post-fertilization day 4-Xenopus tadpoles, where we injected conjugated ovalbumin into the brain ventricle and simultaneously into the tadpole's heart. Then we used confocal imaging to visualize CSF circulation and systemic cardiac circulation in parallel. We showed that there was no overlap between the two circulations. However, when we disrupted lymphatic formation, we showed that CSF excretion was disrupted, suggesting that Xenopus CSF excretion relies on the glymphatic system rather than cardiac circulation. In further studies, we will look at how CSF excretion is conserved among species and relate to our patients with hydrocephalus, Alzheimer’s, and other neurodegenerative diseases where abnormal CSF excretion is critical for disease progression.

The glymphatic system in Xenopus tropicalis – a model system for Congenital Hydrocephalus

Background
Migraines represent one of the leading causes of disability worldwide. While the pathophysiology of migraine pain is complex, the sensitization of the trigeminovascular pathway is implicated. Osteopathic manipulative treatment (OMT) has been used clinically to supplement pharmacologic treatment for patients suffering from migraines, but wide-spread adoption of these treatments has been limited by a lack of physiological and mechanistic evidence supporting its application. We aim to determine if OMT is an effective method of treating the pain associated with an acute migraine, abortively or prophylactically, and investigate its potential mechanisms of action.

Methods
Rats were randomly divided into treatment groups and assessed by behavioral testing and immunohistochemical (IHC) staining. Migraines were induced by a two-hit method. Animals were primed with Complete Freund’s Adjuvant (CFA) via injection and were exposed to umbellulone, a human migraine trigger, via inhalation on day 6. The presence of cutaneous allodynia, indicating a sensitized pain response, at the periorbital and hindpaw areas was determined using von Frey filaments. Subjects receiving OMT were given 2 osteopathic treatments for 1 minute each either before inhalation (prophylactic) or after inhalation of umbellulone (abortive). For the IHC studies, subjects were sacrificed and brain tissue was collected. The trigeminal nucleus caudalis (TNC) and the trigeminal ganglion (TG) were analyzed to determine the activation of the second-order sensory neurons by measuring expression of calcitonin gene-related peptide (CGRP), a neuropeptide implicated in migraine pathophysiology, and c-fos, an immediate early response gene. The experimenter was blinded for the treatment groups.

Results
Our behavioral testing showed that CFA + umbellulone induced significant allodynia. OMT employed as an abortive measure partially blocked the development of cutaneous allodynia. Multiple prophylactic episodes of OMT prevented the development of cutaneous allodynia. IHC analysis showed a significant increase of c-fos expression in TNC samples from subjects treated with CFA + umbellulone, which was blocked by prophylactic OMT. The expression of CGRP positive neurons in the TG samples increased significantly in subjects treated with CFA + umbellulone, which was normalized by prophylactic OMT.

Conclusion
Two osteopathic treatments demonstrated effectiveness in mitigating migraine pain as both a prophylactic and abortive measure. These findings provide insight into the efficacy of OMT for migraines and support its potential as a non-pharmacological approach for migraine management. Future studies will assess other forms of OMT as well as treatment directed to other regions associated with the trigeminovascular pathway.

OMT alleviated migraine-like pain via blockade of trigeminal activation

Background: 
Total hip arthroplasty (THA) is an effective procedure to improve pain, range of motion, and function for a variety of conditions, including osteoarthritis and post-traumatic arthritis. In the absence of surgical complications, some patients have unexplained persistent pain or weakness at the operative joint. It has been shown that up to 28% of patients had persistent pain at the surgical site 12 to 18 months following THA. Importantly, more than 12% of patients had pain that limited their activities of daily living to a moderate or severe degree. Currently, there are no widely accepted non-pharmacological treatments for persistent postoperative pain for THA. The purpose of this case report is to detail a successful reduction of chronic postoperative pain and weakness with implanted peripheral nerve stimulation (PNS) and physical therapy (PT) in a patient with post-traumatic THA. 

Case Presentation: 
The patient is a 53-year-old white male pilot who presented to our pain management clinic in May 2022. In February 2021 he was ejected from an airplane and had polytrauma with multiple facial fractures, an L4 vertebral compression fracture, and a right hip fracture. He had an immediate uncomplicated THA surgery followed by standard physical therapy treatment. Approximately five months following THA, he developed right-sided thigh pain, numbness, and tingling in the femoral nerve distribution, which was recalcitrant to medication and standard physical therapy. 
SPR Therapeutics single-lead percutaneous peripheral nerve stimulator was implanted near the right femoral nerve on 3/10/23. During four months of treatment, the patient attended 11 visits of physical therapy. 

Discussion: 
This case report demonstrates the effectiveness of implanted PNS in a patient with chronic pain and weakness following post-traumatic THA. This treatment improved his hip flexion strength, measured by handheld dynamometer, from 22.83lb to 50.8lb in three weeks. Limb symmetry index improved from 58.19% to 91.87%. His Lower Extremity Functional Scale improved from 35/80 (43.75%) to 54/80 (67.5%) within five weeks. 

Although peripheral nerve field stimulation has been used previously for this indication, single lead implanted PNS has not been studied. This case’s success demonstrates PNS may help eliminate post-operative persistent pain and weakness in many patients, including those with post-traumatic arthroplasty. Future randomized control trials using implanted single-lead PNS are warranted to provide robust results to guide physician clinical practice.

Implanted Peripheral Nerve Stimulation Improves Chronic Pain and Weakness Following Total Hip Arthroplasty

Background: Predicting the discharge destination, otherwise known as discharge disposition, can offer several advantages for the inpatient rehabilitation patient, including treatment and discharge planning. Machine learning (ML) models have demonstrated a strong predictive capacity for discharge disposition, particularly for patients with specific diagnoses such as traumatic brain injuries, or in specific settings such as acute neurologic care, or among specific populations. 



Objective: Explore various ML models’ ability to predict inpatient rehabilitation discharge disposition to home versus non-home using patient encounter data. 



Methods: Patient data included demographics, diagnoses, lab values, length of stay, and insurance status from all inpatient rehabilitation encounters at a large midwestern health system occurring between 2015 and 2022 (N=4919). We compared two commonly used ML approaches: a random forest (RF) classifier and a decision tree (DT) classifier. Two bagging classifiers, which aggregate the results of multiple RF or DT classifiers to improve predictions, were also tested. Because the imbalance in number between home (N=3687) and non-home discharges (N=1232) can impair predictions, balancing techniques were used prior to training the ML classifiers. The ML classifiers were then optimized with grid search and cross validation. Performance of the ML classifiers was determined by the receiver operating characteristic area under the curve (AUC) – a measure of the ability to discriminate the true discharge disposition, accuracy (computed using the Jaccard Index), and macro f1-score (indicative of classification ability across classes). 



Results: 

A bagging classifier using RF showed highest predictive performance in terms of AUC (0.68) and accuracy (0.75), however it struggled to predict non-home discharges (macro f1-score = 0.54). A bagging DT classifier improved prediction of non-home discharges (macro f1-score = 0.59), however AUC (0.65) and accuracy (0.69) were lower. Generally, bagging classifiers combining the predictions from multiple RF or DT classifiers improved predictive performance compared to single RF or DT classifiers. 



Conclusions: As artificial intelligence and ML continue to grow in healthcare applications, this study showcased the effectiveness of ML approaches to predict discharge disposition from inpatient rehabilitation. Our findings complement previous studies in other diagnoses and settings, due to our diversity of available variables and differences in our patient population and treatment paradigms. Of note, utilization of bagging classifiers proved valuable in enhancing the performance of the tested base classifiers. Our results may help guide optimization of ML approaches to predict discharge disposition, in hopes of improving patients' hospital courses and post-hospital planning and treatment.

Evaluation of Machine Learning Approaches for Predicting Inpatient Rehabilitation Patient Discharge Disposition

Background
Social communication is an integral part of everyday functioning and is often employed to interact with familiar and unfamiliar communicative partners to develop friendships and social connections (Macdonald, 2017). People living with acquired brain injury (ABI) often experience challenges with cognitive and communicative functions which limit their socializations or participation in everyday life activities. This affects their ability to develop and maintain friendships, community reintegration, and return to work (Mitchell et al., 2014; Salas et al., 2018).

Participating in leisure activities with peers can enhance self-identity, foster a sense of community, and yield positive health outcomes among adults with and without neurological impairments (Haslam et al., 2014). Conversely, social isolation and loneliness can negatively affect quality of life, emotional wellbeing, and increase the risk of depression and mortality among individuals with acquired brain injury (Holt-Lunstad et al., 2015; Salas et. al., 2021). Furthermore, the COVID-19 pandemic has exacerbated social isolation among individuals with ABI (Bellon et al., 2023). This has led to limited opportunities for social engagement and a lack of access to support services, consequently impacting mental health and well-being, particularly for persons who are homebound due to mobility issues or live in rural communities. Further, very few non-therapeutic opportunities exist that specifically target improvement of social communication in the context of community-based leisure reintegration (e.g., Alves-Stein et al., 2022) highlighting the critical need for such supportive opportunities for persons with ABI, specifically for those who cannot access existing in-person services. The Friends Program was established as a partnership between Brain Injury Connections-Northwest (BIC-NW) and the Department of Speech and Hearing Sciences at Portland State University to address this important gap in services for the ABI community. The program seeks to provide opportunities to reduce social isolation and enhance their social skills by developing friendships by pairing individuals who have different types of ABIs (e.g., traumatic brain injuries, strokes) with student volunteers.

Purpose
The study aims to evaluate the feasibility and acceptability of an updated iteration of the virtual Friends Program to support social connections between individuals with ABI and undergraduate student peers. 

Method
The preliminary portion of the program involved two main phases, namely recruitment and training, which were designed to ensure the successful implementation of the online version of the 5-month Friend’s Program. During the recruitment phase, speech-language pathology graduate student program leaders recruited potential student volunteers using engaging materials (e.g., informational emails, videos). Interested students completed an application to document interest in the program, their comfort and previous experience with ABI, and personal traits they would bring to the program. Matching was accomplished with the help of the leaders at Brain Injury Connection Northwest. Pairs were matched in terms of similarities of interests and specific preferences (e.g., age, gender, availability).
The next phase of the program involved training of the volunteers. Program leaders modified existing program manual and training materials and further developed them to optimize the viability of the online version of the Friends Program. Following review of training materials, all student volunteers completed the “Interact-ABI-lity” program (Togher et al., 2022) and participated in an hour-long remote training session. which covered basic information about brain injury and physical, cognitive, communication, and emotional consequences associated with it. The training also included scenario-based learning opportunities for students. Following training, all friend pairs attended an introductions meeting to exchange information and availability. Informal feedback information was sought from student volunteers regarding the program training. 

Results and Discussion
The program received 15 student volunteers, out of which seven students were selected to be matched with their friends with ABI. Preliminary analysis of the post-training survey responses from undergrad volunteers revealed an increased perception of preparedness in interacting with individuals with ABI. Students felt training was appropriate and not excessively lengthy and that they enjoyed the online formatting of the program (full results will be analyzed and presented at the OSHA conference in October 2023). 

Conclusion
Preliminary results indicate that the updated Friends Program is feasible to implement in a remote format and is well accepted by individuals with ABI and students serving as friends. Programs such as these have an immense potential to address the social communication needs, preserve self identity, and improve quality of life outcomes of those with ABI. 

References
Alves-Stein, S., George, S., Lannin, N. A., & Jolliffe, L. (2022). Implementation of a leisure reintegration programme for people with acquired brain injury in a community rehabilitation programme: A feasibility study. Brain Impairment, 1–13. 
Bellon, M., Idle, J., Lay, K., & Robinson, S. (2023). Community in the pandemic: Experiences and strategies by people with acquired brain injury and their families during COVID-19. Disability and rehabilitation, 45(6), 1038–1045. 
Haslam, C., Cruwys, T., & Haslam, S. A. (2014). “The we’s have it”: Evidence for the distinctive benefits of group engagement in enhancing cognitive health in aging. Social Science & Medicine (1982), 120, 57–66. 
Holt-Lunstad, J., Smith, T. B., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and social isolation as risk factors for mortality: A meta-analytic review. Perspectives on psychological science: a journal of the Association for Psychological Science, 10(2), 227–237. 
MacDonald, S. (2017). Introducing the model of cognitive-communication competence: A model to guide evidence-based communication interventions after brain injury. Brain Injury, 31(13-14), 1760-1780. 
Mitchell, E. J., Veitch, C., & Passey, M. (2014). Efficacy of leisure intervention groups in rehabilitation of people with an acquired brain injury. Disability and rehabilitation, 36(17), 1474–1482. 
Salas, C. E., Rojas-Líbano, D., Castro, O., Cruces, R., Evans, J., Radovic, D., Arévalo-Romero, C., Torres, J., & Aliaga, Á. (2022). Social isolation after acquired brain injury: Exploring the relationship between network size, functional support, loneliness and mental health. Neuropsychological Rehabilitation, 32(9), 2294–2318. 
Salas, C. E., Casassus, M., Rowlands, L., Pimm, S., & Flanagan, D. A. J. (2018). “Relating through sameness”: A qualitative study of friendship and social isolation in chronic traumatic brain injury. Neuropsychological Rehabilitation, 28(7), 1161–1178. 
Togher L, Brunner M, Power E, Avramovic P, Miao M, Riedijk., R (2022). Interact-ABI-lity. https://abi-communicationlab.sydney.edu.au/courses/interact-abi-lity.


Friendship in acquired brain injury: Efficacy of virtual friending program

Phrenic Nerve Injury: Results of a Northwestern Phrenic Nerve Clinic Registry

Background Traumatic brain injury (TBI) impacts 42 million people per year and is especially common among veterans and individuals experiencing homelessness. Effective treatments for TBI remain a major unmet clinical need. Enriched housing environments have been shown to ameliorate TBI symptoms, however, little to no data is available relating TBI pathology to homelessness, despite TBI being two to seven times more prevalent among those experiencing homelessness than the general population. Currently, many trials for TBI therapeutics aim to mitigate neuroinflammation. Individuals experiencing homelessness likely display greater neuroinflammation due to stresses of daily living, potentially exacerbating TBI symptoms. This unique TBI patient population must be considered to design optimal treatments for all patients. 

Methods We developed a rat model of homelessness using a novel cage switching housing environment. We rotated animals (nhomeless = 18, nstandard = 18) into dirty cages daily for 37 days, simulating housing instability and unsanitary conditions. We then induced TBI with moderate controlled cortical impact TBI surgery (nhomeless = 9, nstandard = 9). Following TBI surgery, we performed 4 days of behavioral testing including the beam walk (BW), elevated body swing test (EBST), forelimb akinesia (FA), paw grasp (PG), rotarod, and elevated-T maze. 

Results Averaged over 4 days, significant differences in motor function, demonstrated impaired function in rats with TBI compared to controls, regardless of housing (BW 85.0%, FA 104.7%, and PG 100% greater deficit in TBI). Notably, however, homelessness exacerbated the functional deficits in TBI rats (BW 93.3%, FA 40.5%, and PG 50% greater deficit). TBI rats in the homelessness model also showed a surprising recovery in functional deficits on day 4, while control housing rats continued to decline. 

Conclusion These findings exhibit the magnification of certain motor insufficiencies shortly after TBI due to homelessness, possibly due to an underlying pathophysiology. Interestingly, however, TBI rats in the homeless simulation showed more robust recovery by day 4, suggesting a form of resilience to stressful events like TBI. That exacerbation of TBI symptoms accompanies homelessness suggests that the environmental condition of the patient must be considered in disease diagnosis and to aptly treat all TBI patient populations.


Neurological Surgery - Forgotten veterans: Pathological implications of homelessness on traumatic brain injury - Neurological Surgery

Traumatic brain injury (TBI) is characterized by diffuse axonal injury that leads to neurodegeneration mediated by glial-driven neuroinflammation and neurotoxicity. Several chronic morbidities associated with TBI are psychiatric and stress-related, such as post-traumatic stress disorder. The basolateral (BLA) and central amygdala (CeA) are regulators of emotion, behavior, and autonomic function, and disruption of the amygdala due to experimental TBI has been shown to induce chronic anxiety-like behaviors, dysfunction of neurotransmission, hypertrophy of glutamatergic neurons, and dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. Beyond their role in stress and inflammation, changes in glucocorticoid receptor (GR) expression can mediate behavior, neurotransmission, neuroplasticity, and reflect dysregulation of the HPA axis. To evaluate these processes, 64 young adult, age-matched male and naturally cycling female Sprague-Dawley underwent sham surgery or midline fluid percussion injury (mFPI), and were sacrificed at 7-, 56-, or 168-days post injury (DPI). Image processing was used to analyze ionized calcium binding adaptor molecule 1 (IBA1) and glial fibrillary acid protein (GFAP)-stained photomicrographs to quantify microglia and astrocyte activation, respectively. Visual interpretation of amino-cupric-silver (AmCuAg) staining patterns were subjectively done to assess neuropathology. Simple western blotting was performed in 58 animals (25 from histology cohort) using whole amygdala biopsies to evaluate GR protein at 7- and 56-DPI. Time post-surgery, despite sporadic sex and nuclei-specific instances, was a primary driver of microglia activation and astrogliosis by 168-DPI within the BLA/CeA. The chronic, mild increase in AmCuAg staining intensity visually observed in all groups indicated that age-related neurodegeneration was likely behind histopathologic findings. Midline FPI decreased GR protein in males only at 7-DPI. These data indicate that age and HPA axis dysregulation may be primarily responsible for previously reported behavioral, neurochemical, cellular, and molecular outcomes, ruling out TBI-induced axonal injury and chronic neurodegeneration in the BLA/CeA underlying the pathophysiology of affective-like symptoms after mFPI.

Neurological Surgery - Chronic Histopathological and Glucocorticoid Receptor Assessment of the Amygdala Post-TBI - Neurological Surgery

Objective:
The main objective of this article is to study the efficacy and safety of vedolizumab in the management of moderate to severe Ulcerative Colitis (UC) patients.
Methods:
We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (
guidelines, conducted a literature search in PubMed, Google Scholar, and Science Direct, and nine studies were included in the systematic review.
Results:
At week six, vedolizumab showed a significant clinical response At week 52 vedolizumab showed significant mucosal healing and clinical remission The
most commonly associated adverse effects are nasopharyngitis, oropharyngeal infection, and gastrointestinal infection.
Conclusions:
Most of the included studies showed a significant clinical response and clinical remission of the disease Additionally, vedolizumab is well tolerated with
fewer side effects and is safe to use in UC patients.

Vedolizumab Therapy For Management OF Moderate to Severe Ulcerative Colitis

Making Traditional Articulation Therapy More Efficient

**Objective** Problems with reporting a scientific study can
affect research in different manners. For example, it is known
that study methods are frequently not described in adequate detail and that results are presented ambiguously,
incompletely, or selectively. A previous study1
confirmed that
most of the authors (approximately 67%) publishing
systematic reviews (SRs) in high-impact rehabilitation
journals did not mention the use of a reporting guideline.
Therefore, the objectives of this study were (1) to evaluate the
completeness of reporting of SRs published in rehabilitation
journals by evaluating their adherence to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA) 2009 checklist, (2) to investigate the relationship
between completeness of reporting and risk of bias (ROB),
and (3) to study the association between completeness of
reporting and the characteristics of SRs and journals.

**Design** A random sample of 200 SRs published between
2011 and 2020 in the 68 rehabilitation journals was indexed
under the rehabilitation category in the InCites Journal
Citation Report. Two independent reviewers evaluated the
completeness of reporting as the adherence to the PRISMA
2009 checklist and assessed ROB using the ROBIS tool.
Overall adherence and adherence to each PRISMA 2009 item
and section were calculated as a percentage of the total
number of items described and reported of the total number
of applicable items. Regression analyses investigating the
association between completeness of reporting, ROB, and
other characteristics (impact factor, publication options, year
of publication, and study protocol registration) were
performed.

**Results** The mean overall PRISMA 2009 adherence was
61.4% (**Figure 34**). Studies with high ROB in ROBIS domain
1 had an overall adherence to the PRISMA 2009 checklist,
which was 5.70% (95% CI, −10.07% to −1.34%) lower than
those with low ROB. In domain 2, studies with high ROB had
5.41% (95% CI, −9.74% to −1.07%) lower adherence than
those with low ROB. Studies with high overall ROB had
7.06% (95% CI, −12.10% to −2.01%) lower adherence than
those with low overall ROB. Studies published in fourth-
quartile journals displayed an overall adherence of 7.24%
(95% CI, −13.19% to −1.29%) lower than those published in
the first quartile; there was an 11.95% (95% CI, 5.94%-
17.96%) increase in overall adherence if the SR protocol was
registered.

![](https://assets.underline.io/uploads/markdown_image/1/image/eadc9d58246daba8b9456d19c7356564.png)

**Conclusions** The completeness of reporting in SRs
published in rehabilitation journals is still suboptimal. High
ROB is associated with poorer completeness of reporting, indicating that if a study has better reporting, this could
positively affect the transparency of the ROB evaluation. The
registration of study protocols and journal ranking are also
associated with a more complete reporting. Authors of SRs
should improve adherence to the reporting standards, and
journal editors could implement strategies to optimize the
completeness of reporting.

**Reference**

1. Innocenti T, Salvioli S, Giagio S, Feller D, Cartabellotta N,
Chiarotto A. Declaration of use and appropriate use of
reporting guidelines in high-impact rehabilitation journals is
limited: a meta-research study. J Clin Epidemiol.
2021;131:43-50. doi:10.1016/j.jclinepi.2020.11.010

**Conflict of Interest Disclosures** None reported.

![](https://assets.underline.io/uploads/markdown_image/1/image/c486ab2b5159af9894c4233312feafc4.png)



Underline digital video library

Coordination of Emergent Demand Changes via Value-Based Negotiation for Supply Chain Management (Student Abstract)

The glymphatic system in Xenopus tropicalis – a model system for Congenital Hydrocephalus

OMT alleviated migraine-like pain via blockade of trigeminal activation

Implanted Peripheral Nerve Stimulation Improves Chronic Pain and Weakness Following Total Hip Arthroplasty

Evaluation of Machine Learning Approaches for Predicting Inpatient Rehabilitation Patient Discharge Disposition

Friendship in acquired brain injury: Efficacy of virtual friending program

Phrenic Nerve Injury: Results of a Northwestern Phrenic Nerve Clinic Registry

Neurological Surgery - Forgotten veterans: Pathological implications of homelessness on traumatic brain injury - Neurological Surgery

Neurological Surgery - Chronic Histopathological and Glucocorticoid Receptor Assessment of the Amygdala Post-TBI - Neurological Surgery

Vedolizumab Therapy For Management OF Moderate to Severe Ulcerative Colitis

Making Traditional Articulation Therapy More Efficient

Completeness of Reporting and Its Association With Risk of Bias in Systematic Reviews Published in Rehabilitation Journals: A Meta-research Study

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