Advances in Cognitive Rehabilitation in Acquired Brain Injury: A Review of the Evidence Base

1.25 CE Credit

 

Presented by:

James F. Malec, PhD, ABPP-Cn, Rp, FAPA, FACRM
Chief Scientific Officer for the Foundation to Advance Brain Rehabilitation (FABR)
Emeritus Professor of Psychology, Mayo Clinic-Rochester
Senior Research Professor Emeritus, Physical Medicine and Rehabilitation,
Indiana University School of Medicine







This webinar will describe the best evidence-based practices for cognitive rehabilitation following traumatic brain injury (TBI) and stroke. The focus will be on rehabilitation of attention, memory, and executive and higher-order cognitive functions with evidence for rehabilitation interventions in other cognitive domains briefly noted. Source material includes the INCOG [Bayley et al, J Head Trauma Rehabil  2014:29:290–386] and Cicerone et al. [Arch Phys Med Rehab 2000;81:1596-615; 2005;86:1681-92; 2011;92:519-30; 2019;100:1515-33] reviews as well as more recent literature. Concluding the webinar, participants will be oriented to additional resources for education and training in this area of neuropsychological practice.


After the webinar, participants will be able to:
1. Describe best evidence-based practices for the remediation of attention, memory, and executive and higher-order cognitive abilities following TBI and stroke.
2. Describe specific techniques and practice algorithms for implementing these best practices.
3. List sources for additional guidance in developing practice in these areas of neuropsychological rehabilitation. 

 
Target audience: Neuropsychologists, trainees and associates 
Instructional level: Introductory

Dr. Malec is Professor Emeritus of Psychology at the Mayo Clinic-Rochester and Senior Research Professor Emeritus, Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine. He currently serves as Chief Scientific Officer for the Foundation to Advance Brain Rehabilitation (FABR) and is an Associate Editor for the Archives of Physical Medicine and Rehabilitation and the Journal of Head Trauma Rehabilitation. He is Board Certified in Clinical Neuropsychology and in Rehabilitation Psychology through the American Board of Professional Psychology. He has over 170 peer-reviewed publications and has been active in research and the clinical practice of brain injury rehabilitation for over 40 years.  He has received a number of professional recognitions, including the Lowman Award for interdisciplinary contributions to rehabilitation from the American Congress of Rehabilitation Medicine, the Research Award of the North American Brain Injury Society, the Sheldon Berrol, MD, Clinical Service Award from the Brain Injury Association of America, the Fürst Donnersmarck Foundation Neurorehabilitation Research Award, and the prestigious Robert L. Moody Prize for Distinguished Initiatives in Brain Injury Research and Rehabilitation.  

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Alcohol Misuse from Adolescence to Senescence: Consequences to Brain Structure and Function

1.5 CE Credit

 

Presented by:

Edith V. Sullivan, Ph.D.
Professor, Department of Psychiatry & Behavioral Sciences
Stanford University School of Medicine








Alcohol Use Disorder (AUD) is a highly prevalent neuropsychiatric disorder that affects both sexes across the lifespan. Chronic, excessive drinking often results in serious untoward consequences on family, work, and personal well-being. AUD is marked by a characteristic profile of neuropsychological deficits and damage to selective constellations of neurocircuitry. AUD is often heralded by early life alcohol misuse, which can alter normal neurodevelopmental trajectories. With sustained sobriety in adult AUD, brain structural and functional recovery can ensue. This lecture describes acquisition and measurement approaches used in quantitative neuroimaging and neuropsychological studies for tracking alcoholism's dynamic course of relapse and sobriety. Also considered are modulating factors, including age, sex, nutrition, and common comorbidities. Whether alcohol-related functional impairment in older individuals with AUD constitutes dementia will also be considered. The studies reviewed are controlled and provide evidence for human neuroadaptation and neuroplasticity and hope for recovery in alcoholics who maintain sobriety.

After the session, participants will be able to:
1. Define alcoholism and explain how alcohol use disorder disrupts selective brain structures and functions and can cause aberrations in neurodevelopmental trajectories.
2. Describe how alcoholism-related functional brain changes across the ages are a form of neuroadaptation that may underlie dysfunctions, making alcoholism a self-perpetuating disorder.
3. Discuss how sustained sobriety can result in improvement in brain structure and function.
4. Explain how alcoholism-related brain structural and functional damage might alter self-perception and readiness for treatment.

 
 
Target Audience: Research and clinical neuropsychologists, graduate students, and postdoctoral fellows
Instructional Level: introductory, intermediate

Edith V. Sullivan, Ph.D., is a professor in the Department of Psychiatry & Behavioral Sciences at Stanford University School of Medicine where she has been mentoring students and conducting research for the past 30 years. Dr. Sullivan’s background as an experimental neuropsychologist and brain imaging scientist led to the development of her program of study in alcoholism, focusing on faulty frontocerebellar circuitry underlying a selective subset of cognitive and motor dysfunctions commonly expressed in alcoholism. Her ongoing work focuses on neural mechanisms of structural and functional connectivity underlying cognitive and motor processes in human alcoholism, animal models of high alcohol exposure in interaction with nutritional deficiencies, and how comorbidities of HIV infection along with normal aging compound the throes of alcoholism on brain structure, function, and neural circuitry.  Dr. Sullivan is also an investigator on the National Consortium on Alcohol and NeuroDevelopment in Adolescence (NCANDA), which is a prospective multi-site study aimed at determining the developmental trajectories of brain conjunction with the neuropsychological and emotional development of adolescents before and after initiating drinking. Dr. Sullivan is the author of more than 300 peer-reviewed papers, as well as many chapters and reviews and has presented her alcoholism research nationally and internationally. Her scientific honors include National Institute on Alcohol Abuse and Alcoholism MERIT and Senior Scientist Awards, Research Society on Alcoholism Distinguished Researcher Award and Henri Begleiter Award for Excellence in Research, International Neuropsychological Society Distinguished Career Award, and Doctorate Honoris Causa bestowed by the Ecole Pratique des Hautes Etudes of France. She received her B.A., M.A., and Ph.D. in Experimental Psychology at the University of Connecticut.

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An Update on the Neuropsychology of HIV and Other Infectious Diseases

1.5 CE Credits

Presented by:
Steven Paul Woods, Psy.D.
Professor of Psychology
University of Houston

Clinical neuropsychologists are likely to encounter persons infected with HIV and other neurotropic viruses (e.g., hepatitis C), which may be the primary condition for a referral or an incidental risk factor for neurocognitive impairment. In this 90-minute webinar, we will provide an update on the neuropsychological aspects of infectious disease, focusing primarily on HIV. Specifically, we will critically review and discuss recent literature on: 1) changes in the epidemiology of HIV disease, which is increasingly affecting older adults; 2) brain systems involved in HIV infection; 3) the neuropsychological profile of HIV disease and the diagnosis of HIV-associated neurocognitive disorders; 4) the influence of common moderating factors, such as premorbid variables, psychiatric comorbidity, and co-infection with HCV on the expression of HIV-associated neurocognitive disorders; 5) HIV’s impact on health behaviors (e.g., medication adherence) and everyday functioning (e.g., household management); and 6) emergent pharmacological and rehabilitation efforts to manage HIV-associated neurocognitive disorders.

After the webinar, participants will be able to:

  1. Describe the recent changes in the epidemiology of HIV disease and the influence of infection and its comorbidities on brain structure and function.
  2. Explain the practical advantages and limitations of current approaches to diagnosing HIV-associated neurocognitive disorders.
  3. Discuss the effects of HIV-associated neurocognitive disorders on health behaviors (e.g., medication adherence) and everyday functioning (e.g., household management).

Target Audience: Clinical neuropsychologists

Instructional Level: Intermediate

Steven Paul Woods, Psy.D. is a Professor of Psychology at the University of Houston, where he is the Director of the Cognitive Neuropsychology of Daily Life (CNDL) Laboratory. Dr. Woods also holds appointments as an Adjunct Professor at UC San Diego (Psychiatry) and the University of Western Australia (School of Psychological Science). His program of research uses cognitive theory to enhance the clinical detection, prediction, and remediation of real-world health outcomes in various neuropsychological populations, including HIV disease and aging. In particular, he is interested in how people’s ability to “remember to remember” (i.e., prospective memory) affects health-related behaviors such as adhering to medications. Dr. Woods is the Director of Clinical Neuropsychology Training at the University of Houston and is an active teacher, both in the classroom and in the laboratory. He is a licensed psychologist and operates an evidence-based neuropsychology clinic that serves HIV+ persons at the Thomas Street Health Center in Houston. Dr. Woods is a Fellow of the American Psychological Association (Division 40, Society for Clinical Neuropsychology) and the National Academy of Neuropsychology (NAN).

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Building a Better Brain as We Age

1 CE Credit

 

Presented by:

David A. Bennett, MD
Director, Rush Alzheimer’s Disease Center
Robert C. Borwell Professor of Neurological Sciences 
Rush University Medical Center
Chicago, IL

 




This presentation will focus on potentially modifiable risk factors associated with a higher or lower risk of cognitive decline and Alzheimer’s dementia.   First, two prospective community-based analytic cohort studies in which all participants are brain donors will be described: the Religious Orders Study and the Rush Memory and Aging Project.  Next, it will discuss the continuum of normality to mild cognitive impairment to Alzheimer’s dementia, and highlight the importance of studying cognitive decline in order to understand the neurobiology of dementia.  Third, the relation of mixed neurodegenerative and vascular disease pathologies to cognitive decline and Alzheimer’s dementia will be described, as well as the concept of neural reserve or resilience defined as cognitive decline not explained by known brain pathologies. Then, data will be presented that illustrate a range of experiential (e.g., cognitive, physical, and social activities), psychological (e.g., neuroticism, loneliness, purpose in life), and medical (e.g., diabetes, sleep, diet) factors associated with cognitive decline and discuss their associations with brain pathologies and/or resilience. Finally, a slate of recommendations on how our behaviors during life can lead to better cognitive health in old age will be provided.

After the webinar, participants will be able to:
1. Describe the scientific value of studying cognitive decline to better understand the neurobiology of Alzheimer’s dementia.
2. Explain how Alzheimer’s dementia results from a combination of multiple pathologies and resilience factors.
3. List risk factors for Alzheimer’s dementia.
4. Discuss advice for patients and other stakeholders regarding how to maintain cognitive health in old age.

 
Target audience: Neuropsychologists, trainees and associates 
Instructional level: Introductory

Dr. Bennett Directs the Rush Alzheimer’s Disease Center (RADC) at Rush University Medical Center in Chicago.  He is the Principal Investigator of the Rush Alzheimer’s Disease Research Center including the Religious Orders Study, and the Rush Memory and Aging Project, two prospective studies of risk factors for common diseases of aging in which all participants are organ donors. Dr. Bennett’s group have published on the relation of Alzheimer’s disease and related disorders with decision making, literacy, well-being, and a variety of psychological traits. Over the past decade, Dr. Bennett’s team generated an unprecedented multi-level omic platform in blood, brain, spinal cord and muscle tissue being mined by investigators worldwide to identify novel therapeutic targets for Alzheimer’s disease and related disorders. His group is now generating cell lines on autopsied study participants for ex vivo interrogation of potential targets. Dr. Bennett serves on numerous national and international advisory boards and editorial boards. He is currently a member of the National Advisory Council on Aging for the National Institutes of Health.  Dr. Bennett was the recipient of the 2018 Potampkin Prize for Research on Picks, Alzheimer’s Disease, and Related Dementia.  He has more than 900 peer-reviewed publications with more than 125,000 citations and an h index=166.  

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Cognitive Dysfunction and Rehabilitation following COVID-19 Infection

1.5 CE Credit

Presented by:

Douglas Whiteside, PhD, ABPP /CN
Professor of Rehabilitation Medicine
University of Minnesota, Division of Neuropsychology
Department of Rehabilitation Medicine






William Garmoe, Ph.D., ABPP-CN
Director of Psychology, MedStar National Rehabilitation Network
Board Certified Clinical Neuropsychologist

Severe acute respiratory syndrome coronavirus 2 (SARS-Cov2), which causes COVID-19 illness, has caused considerable economic and social disruption since December 2019. This disruption has stemmed in large part from the highly contagious transmission and high mortality and morbidity rates associated with this novel coronavirus. Broadly, COVID-19 is associated with a range of symptoms including fever, cough, shortness of breath, and, in severe cases, respiratory failure. The short-term and long-term neurological and psychiatric complications (e.g., stroke/vascular changes; acute respiratory distress syndrome[ARDS]) related to COVID-19 infection and treatment (e.g., Intensive Care Unit treatment) are also associated with cognitive dysfunction. In addition, COVID-19 has been associated with direct effects on the central nervous system as well as the respiratory and cardiac systems. Recently, increasing concern about long-term physical and cognitive symptoms amongst patients with initially less severe COVID-19 symptoms has emerged. This presentation will address the current literature on long-term effects of COVID-19 on cognitive functioning and on strategies for rehabilitation of these difficulties. Data will be presented from two COVID-19 recovery programs.

Learning Objectives
After the session, participants will be able to:
1. Describe the medical and psychological factors that may contribute to cognitive dysfunction following COVID-19.
2. Explain a model for understanding cognitive dysfunction following COVID-19.

 
Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate

Dr. Whiteside is a board-certified clinical neuropsychologist and Professor of Rehabilitation Medicine at the University of Minnesota. He is also the Director of Training for the Neuropsychology Division and is currently working on collaborative research examining cognitive sequelae of severe COVID-19 infection. Dr. Whiteside earned his PhD from the University of Nebraska after completing internship at the Ann Arbor VA Medical Center, and he completed postdoctoral training in neuropsychology at the Albuquerque VA Medical Center. Dr. Whiteside is a native Midwesterner, who serves as the Program Director for the Clinical Neuropsychology Residency program. He is actively involved in clinical neuropsychological practice, teaching, research, and community service. His research interests focus primarily on performance validity tests, personality assessment measures in neuropsychological assessment, and long term cognitive and emotional outcome of COVID-19 infection. He is an Associate Editor for The Clinical Neuropsychologist. In addition to his work as Program Director of the postdoctoral fellowship in clinical neuropsychology, Dr. Whiteside has considerable previous experience with training program development, which includes establishing a postdoctoral residency at the University of Iowa, developing a doctoral level neuropsychology concentration, establishing a doctoral level on-campus training clinic, and serving as a member of the Board of Directors for a large multidisciplinary medical practice. He is currently President-Elect for the Association of Postdoctoral Programs in Clinical Neuropsychology (APPCN). In addition to his work as a neuropsychologist, Dr. Whiteside is an avid jazz and classical musician and plays in several bands.

Dr. William Garmoe is the Director of Psychology for MedStar National Rehabilitation Network (MNRN). MNRN is an integrated rehabilitation system including an acute inpatient rehabilitation hospital and network of care through a large number of specialty programs and outpatient clinics. Dr. Garmoe specializes in assessment and treatment of individuals who have and are experiencing traumatic brain injury, aneurysm, dementia, and other neurologic syndromes. Since onset of the pandemic due to SARS-CoV-2, he has worked with both inpatients and outpatients affected by the virus, and was involved in development of the MedStar COVID-19 Recovery Program. Dr. Garmoe also conducts specialty civil and criminal forensic consultations, and is a consultant to the NFL Disability Plans. Dr. Garmoe is board-certified in clinical neuropsychology (ABPP-CN) and is a Fellow of the National Academy of Neuropsychology (NAN).
He holds appointments as Clinical Associate Professor of Rehabilitation Medicine and Neurology in the Georgetown University Medical School. He is a faculty member in the NRH Neuropsychology Fellowship and the Brain Injury Medicine Fellowship programs. Dr. Garmoe has published research in the areas of self-awareness following brain injury and other topics, and is a contributing author to the Clinical Neuropsychology Study Guide and Board Review. Dr. Garmoe is also involved in the bioethics services at MNRN.

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Disparities in Sleep Health and Impact on Brain Health

1.5 CE Credit

 

Azizi Seixas, Ph.D.
NYU Langone Health 
Department of Population Health
Department of Psychiatry





This course will cover sleep and brain health (mental health, cognitive, and neurodegenerative disease) disparities among subgroups, particularly racial/ethnic minorities. Additionally, biological, social, behavioral, and environmental factors that engender/maintain sleep and brain health disparities will be discussed. Mechanisms that explain the relationship between sleep and brain health will be discussed, particularly among racial/ethnic minorities. Lastly, the course will describe potential solutions to addressing sleep and brain health disparities.

After the session, participants will be able to:
1. Describe components of sleep health.
2. Explain how sleep health affects brain health.
3. Discuss mechanisms that explain how sleep health disparities lead to brain health disparities, particularly among racial/ethnic groups.

Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate

Dr. Seixas is recognized as one of the top 100 Inspiring Black Scientists in America by Cell Press.  He has over 100 high impact peer-reviewed publications, book chapters and conference presentations and his work appears in several media-outlets such as CBS, CNN, NBC, Associated Press, The Guardian, Huffington Post, and is the sleep expert for NBC Health News. He is currently the Chair for the American Academy of Sleep Medicine Young Investigator Research Forum, member of the Artificial Intelligence and Machine Learning sub-committee for the American Academy of Sleep Medicine, serves on the NCAA and Department of Defense Task Force on mental health, and the Director of Early Career Faculty Development for the Department of Population Health at NYU Langone Health.

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Electrical Injury: Diagnostic and Treatment Issues

1.5 CE Credits

Presented by:
Neil H. Pliskin, PhD, ABPP
University of Illinois-Chicago
Chicago Electrical Trauma Rehabilitation Institute

Electrical injury can be associated with cognitive and behavioral health changes that often persist and are not well understood. In addition to physical concerns and chronic pain, cognitive difficulties and problems with emotion regulation can develop and, if not adequately treated, these symptoms can interfere with the survivor’s functioning and quality of life. The focus of this presentation will be on the neuropsychological issues that can arise following electrical shock injuries based on research conducted over two decades at the Chicago Electrical Trauma Rehabilitation Institute, and how this form of trauma compares to other types of traumatic injuries.
 



After the session, participants will be able to:
1. Identify common physiological changes that emerge after electrical injury.
2. Describe factors that influence recognition of cognitive changes in electrical injury.
3. Assess differences in clinical presentation between electrical injury and closed head injury.

Target Audience:  Psychologists and other behavioral health providers who work with trauma patients
Instructional Level:  Introductory

Dr. Neil Pliskin is a board-certified clinical neuropsychologist and Professor of Clinical Psychiatry and Neurology in the University of Illinois College of Medicine. Dr. Pliskin serves as Director of Neuropsychology services at UI Health, and has had 30+ years of experience working as a clinical neuropsychologist and directing clinical neuropsychology training programs. Dr. Pliskin is past President of the Society for Clinical Neuropsychology of the American Psychological Association and is a Fellow of APA and NAN. Dr. Pliskin has strong scientific interests in the neuropsychological sequelae of medical illness and brain trauma (particularly electrical shock injuries). Dr. Pliskin is a Fellow of the APA’s Division of Clinical Neuropsychology and was awarded a Presidential Citation by the American Psychological Association in 2010 for dedicated service to the profession “as an advocate, scientist, educator and practitioner of clinical neuropsychology”.

 

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Effects of Alcohol on Cognitive Functioning 

1.5 CE Credits

Presented by:
Robin C. Hilsabeck, Ph.D., ABPP
Clinical Scientist II at INC Research
Associate Clinical Professor of Psychiatry at University of Texas Health Science Center in San Antonio

Approximately 17 million adults and 855,000 adolescents had an alcohol use disorder (AUD) in 2012.  Deaths related to alcohol are the third leading cause of preventable death in the U.S.  Given these statistics, almost all neuropsychologists will be faced at some point with a patient who has an AUD. Understanding both the acute and chronic effects of alcohol on cognitive functioning is a primary objective of this webinar. Recent advances in neuropathophysiology, as well as common findings on neuroimaging and neuropsychological tests are reviewed.  The evolution from chronic alcohol use to Wernicke’s encephalopathy to Korsakoff’s syndrome is discussed, along with the effects of alcohol use in special populations, including adolescents and elderly. Risk factors, comorbidity, emerging pharmacotherapies, and cognitive rehabilitation strategies are also highlighted.  

After the webinar, participants will be able to:

  1. Explain cognitive abilities affected by acute and chronic alcohol use.
  2. Describe the role of thiamine deficiency in cognitive impairment associated with AUDs.
  3. Differentiate between cognitive profiles of chronic alcohol use and Korsakoff’s syndrome.
  4. Identify risk factors for AUDs in adolescents.  

Target Audience:Neuropsychologists, advanced neuropsychological trainees, physicians, psychologists, and other professionals with specialty training in AUDs

Instructional Level:Intermediate to Advanced (some prior knowledge of neuroanatomy, neurotransmitter systems, and neuropsychological constructs is expected)

About Robin C. Hilsabeck, Ph.D., ABPP
Dr. Hilsabeck is a board certified clinical neuropsychologist who earned her Ph.D. in clinical psychology from Louisiana State University in 1999 with internship training in neuropsychology at University of Oklahoma Health Science Center. She completed a 2-year postdoctoral fellowship in neuropsychology at University of California, San Diego where she worked primarily with patients with chronic liver disease, including those with alcohol dependence and chronic hepatitis C infection.

Dr. Hilsabeck is Clinical Scientist II at INC Research, a contract research organization that assists in running global clinical trials.  She also is Associate Clinical Professor of Psychiatry at University of Texas Health Science Center in San Antonio where she has been on faculty since 2006.  From January 2005 through June 2012, she served in multiple roles at the South Texas Veterans Health Care System in San Antonio, including Director of the Neuropsychology Service and Director of the Neuropsychology Residency Program.  She continues to collaborate in clinical research at the VA in San Antonio. 

Dr. Hilsabeck has obtained grant funding from both private funders, as well as the NIH, and has 50 publications, including a recent book chapter on substance use in the edited book by Shane Bush entitled, “Neuropsychological Practice with Veterans.”  She is Associate Editor of The Clinical Neuropsychologist and serves on the editorial board of the Archives of Clinical Neuropsychology.  She also is Past President of the National Academy of Neuropsychology.

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Evaluating and Designing Lifestyle and Social Factors to Promote Neurocognitive Health

1.5 CE Credit


Presented by:
Michelle C. Carlson, Ph.D.
Professor, Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health (SPH)







Our society is aging rapidly and living longer. Every day another 10,000 Americans celebrate their 65th birthday. From a developmental and societal perspective, maintaining cognitive health over the life course is a high priority. There is a high degree of heterogeneity in individual rates of cognitive and brain aging, some of which can be accounted for by early to late lifestyle and broader environmental factors that can make physical and social activity prohibitive, particularly among socioeconomic groups at higher risk for dementia.  This course will explore some individual and environmental factors that contribute to cognitive and brain health in aging, and describe methodologies for more precisely studying the link between lifestyle activities and brain health. These findings inform the design of real-world social interventions, such as Experience Corps, to promote activity and neurocognitive health on a large scale and boost one’s resilience to dementia.
 
After the webinar, participants will be able to:
1. Describe key lifestyle factors that impact cognitive aging and risk for dementia.
2. Explain the role of neighborhood and geospatial methods being used to measure environmental factors that likely influence both activity on cognition.
3. Compare methods for understanding the impact of lifestyle activities on cognitive aging, including frequency versus variety and activity metrics obtained from wearables.
4. Discuss how social engagement through volunteering promotes lifestyle activity and cognitive and targeted brain changes.
5. Summarize next steps toward designing and scaling this and other social health promotion programs.

Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate 


Dr. Carlson focuses on modifiable risk factors of cognitive and functional aging and Alzheimer’s disease. She uses neuroimaging, wearable technology, and geocoded census and retail data to examine environmental, physiologic and lifestyle risk modifiers of cognitive aging and dementia to inform intervention design that boosts neuroplasticity and buffers the brain to delay dementia and disability, particularly in underserved populations.  Dr. Carlson leads these investigations using both observational studies, such as the Women’s Health and Aging Study II (WHAS II) and the Cardiovascular Health Study (CHS), and intervention trials, including the Ginkgo Evaluation of Memory (GEMS) trial and multi-modal activity in the Baltimore Experience Corps Trial (BECT).  Recently, this intervention work has expanded to reach sedentary and those with past TBI through a, safe and immersive 3-D game simulating activity in an underwater world to entrain executive cognitive-motor integration and mobility.  

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Functional Neurological Disorders

1.5 CE Credit

Presented by:
Mark Hallett, M.D.NIH 
Distinguished Investigator and the Chief of the Human Motor Control Section
National Institute of Neurological Disorders and Stroke, NIH

Functional neurological disorders (FND) are common conditions that fall between neurology and psychiatry. Having been neglected for many years, knowledge and expertise in such disorders within the health professions has been lacking, but the situation is improving. FNDs are neurological disorders, characterized by almost any type of neurological symptom, caused by a brain network dysfunction that does not exclude the possibility of normal function, is sometimes due in part to a psychological cause, and cannot be explained by other neurological pathology that may or may not be present. The pathophysiology often seems related to hyperactivity of the limbic system of the brain, and is maintained by abnormal illness beliefs. Symptoms may be inconsistent or incompatible/incongruent with other known neurological disorders or with human anatomy and physiology. The diagnosis should be based on positive features, with the characteristics of inconsistency and incompatibility as noted in the definition. Psychological factors are often important in etiology, and the cause of FNDs is best understood within a biopsychosocial model. Rehabilitation of FND is multidisciplinary and typically involves neuropsychology. Psychotherapy of various types can be useful but the best validated is cognitive behavioral therapy (CBT). For functional movement disorders, psychologically-supported physical and occupational therapy has proven to be successful. 


After the session, participants will be able to:
1. Describe the nature of functional neurological disorders.
2. Discuss how to diagnose a patient with a functional neurological disorder.
3. Explain approaches to rehabilitation of patients with functional neurological disorders.

Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate

Dr. Hallett is an NIH Distinguished Investigator and the Chief of the Human Motor Control Section, National Institute of Neurological Disorders and Stroke, NIH, Bethesda. He is currently past President of the International Federation of Clinical Neurophysiology and the President of the newly founded Functional Neurological Disorder Society. Dr. Hallett is also remote past President of the Movement Disorder Society and past Editor-in-Chief of Clinical Neurophysiology. He has won many awards including, in October 2019, the World Federation of Neurology Medal for Contributions to Neuroscience. His work mainly deals with principles of motor control and the pathophysiology of movement disorders. The work in his Section has a major focus on Functional Movement Disorders. 

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Harnessing Positive Psychosocial Factors to Optimize Cognitive Aging

1.5 CE Credit

 

Laura B. Zahodne, PhD
Assistant Professor, Department of Psychology
Co-Director, Michigan Center for Contextual Factors in Alzheimer’s Disease
University of Michigan






A rapidly aging global population and repeated clinical trials failures underscore the need for dementia prevention. This workshop will present and evaluate evidence for modifiable risk and protective factors in cognitive aging with a detailed emphasis on psychosocial factors in diverse populations. While ample research implicates depression as a modifiable risk factor for late-life cognitive impairment, cognitive decline, and dementia, emerging research points to the importance of positive psychosocial factors that not only reduce the prevalence and impact of depression, but may also help to maintain cognitive functioning independent of depressive symptoms. We will unpack potential mechanisms underlying the beneficial cognitive effects of positive affect and self-efficacy, as well as critically evaluate the “active ingredients” of multidimensional exposures such as social relations and religiosity. Cutting-edge research on large, nationally representative samples, as well as on smaller samples with more detailed neuroimaging and cognitive phenotyping, will be presented, and both observational and interventional studies will be discussed. Throughout the workshop, we will consider critical sociodemographic and contextual factors, including race/ethnicity, discrimination, and migration history. The research presented will reveal the interdependence of psychosocial and cognitive functioning for diverse older adults and highlight potential avenues to promote cognitive and neurobehavioral health.

After the session, participants will be able to:
1. Describe the evidence for purported dementia risk and protective factors.
2. Discuss potential mechanisms underlying the beneficial cognitive effects of positive psychosocial factors.
3. List specific psychosocial factors with the highest likelihood of optimizing cognitive aging.
4. Use the information from this workshop to inform clinical recommendations.

Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate

Dr. Zahodne trained in Clinical Neuropsychology at the University of Florida, the Warren Alpert Medical School of Brown University, and the Columbia University Medical Center. She is currently an Assistant Professor of Psychology at the University of Michigan, where she also co-directs an NIA-funded Resource Center for Minority Aging Research. Dr. Zahodne is an investigator on multiple community-based longitudinal studies of brain and cognitive aging in racially/ethnically diverse older adults, and her research focuses on modifiable determinants of dementia risk and dementia inequalities.

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Innovations in Neuropsychological Rehabilitation

1.0 CE Credit

Presented by:
Professor Barbara A. Wilson, OBE, Ph.D., D. Sc., C
Psychol., FBPsS, FmedSC, AcSS
The Oliver Zangwill Centre, Ely
Cambridgeshire and St George’s Hospital, London, UK


Following a definition of neuropsychological rehabilitation (NR), this presentation addresses some recent developments in the field. It stresses that cognition, emotion, and psychosocial problems are intertwined and hard to separate, as illustrated through examples, and all should be addressed in NR. We consider ways to improve new learning for people with an insult to the brain before looking at some of the new compensatory techniques to help those with cognitive, emotional, and behavioral impairments. We also think about environmental modifications to help those with severe and widespread difficulties. These approaches are not, of course, mutually exclusive. The need to include theories and models from different sources in order to avoid poor clinical practice is considered.

After the session, participants will be able to:
1. Explain how NR is concerned with dealing with everyday problems.
2. List the cognitive, emotional, and psychosocial consequences of brain injury.
3. Describe the main treatment approaches involved in NR.

Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate

Barbara Wilson is a clinical neuropsychologist who has worked in brain injury rehabilitation for 43 years. She has published 32 books, 206 peer-reviewed papers, 124 chapters and 8 neuropsychological tests. She has won many awards for her work including an OBE from the Queen in 1998, for services in rehabilitation; five lifetime achievement awards, one from the British Psychological Society, one from the International Neuropsychological Society, one from the National Academy of Neuropsychology, one from the Encephalitis Society and one from the NHS 70-year anniversary parliamentary awards where she was regional champion for the Midlands and East Region. In 2011 she received the Ramon Y Cahal award from the International Neuropsychiatric Association. In 2014 she received an honorary degree from The University of Cordoba, Argentina. Also, in 2014 she received the M.B. Shapiro award from The Division of Clinical Psychology (affiliated with The British Psychological Society) for Distinguished Contributions to Clinical Psychology. In 2019, she received the annual award from the Spanish Clinical Neuropsychological Society. She is editor of the journal “Neuropsychological Rehabilitation” which she founded in 1991, and in 1996, she established the Oliver Zangwill Centre for Neuropsychological Rehabilitation. A rehabilitation centre in Quito, Ecuador, is named after her. She is president emeritus of the UK Encephalitis Society and is on the management committee of The World Federation of NeuroRehabilitation. The UK Division of Neuropsychology has named a prize after her, the ‘Barbara A. Wilson prize for Distinguished Contributions to Neuropsychology’. She is a Fellow of The British Psychological Society, The Academy of Medical Sciences and The Academy of Social Sciences. She is honorary professor at the University of Hong Kong, the University of Sydney and the University of East Anglia.

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Marijuana Mindset: Assessing the Impact of Recreational and Medical Use on Cognition

1.5 CE Credit

 

Presented by:
Dr. Staci Gruber 
Director of the Cognitive and Clinical Neuroimaging Core
McLean Hospital’s Brain Imaging Center











During this presentation, Dr. Gruber will discuss the cognitive and clinical impacts associated with cannabis use, and will explain important distinctions between recreational cannabis users and medical cannabis (MC) patients. She will review recent findings from the Marijuana Investigations for Neuroscientific Discovery (MIND) program, including data from the first observational and longitudinal study of medical cannabis (MC) patients. To date, findings indicate that after initiation of MC treatment, patients exhibit notable changes on measures of cognitive function, clinical state, quality of life, conventional medication use, and neuroimaging variables. Dr. Gruber will explain potential reasons for these changes and areas in need of further investigation.

 After the webinar, participants will be able to:

1) Discuss important distinctions between medical cannabis use and recreational cannabis use.
2) Summarize cognitive and neural changes associated with medical versus recreational cannabis use.
3) Explain potential reasons for cognitive and clinical changes observed after initiation of MC treatment.

Target Audience: This webinar is intended for neuropsychologists, clinicians, and other professionals wanting a clearer understanding of the impact of medical and recreational cannabis use on the brain.

Instructional Level: Intermediate

Dr. Staci Gruber is the Director of the Cognitive and Clinical Neuroimaging Core at McLean Hospital’s Brain Imaging Center and an Associate Professor of Psychiatry at Harvard Medical School. She has been studying the impact of recreational cannabis use on the brain for over two decades using neurocognitive, clinical and diagnostic assessments, and multimodal brain imaging techniques. Dr. Gruber’s work has been published in numerous peer reviewed journals and has been the basis for national and international symposia, documentaries, news stories and press conferences. Her ongoing initiative to educate policymakers, judges, attorneys and the general public about the neurobiologic differences between adults and adolescents as well as additional factors that contribute to the impact of cannabis on the brain have had both local and national impact on policy formation. She was recently invited to speak to the US Senate about the need for expanded abilities to conduct medical cannabis research. Given the differences between recreational and medical cannabis use, Dr. Gruber launched Marijuana Investigations for Neuroscientific Discovery (MIND) in 2014, the first ever program of its kind designed to clarify the specific effects of medical cannabis use. MIND utilizes valid, robust research models and supports numerous projects designed to address the impact of medical marijuana on a number of important variables including cognition, brain structure and function, clinical state, quality of life, pain, sleep, and other health-related measures. As the director of MIND, Dr. Gruber has generated major contributions to the field as the first investigator to assess medical cannabis patients longitudinally, first to acquire neuroimaging data in medical cannabis patients, and as Principal Investigator of the first ever clinical trial of a whole plant-derived, high CBD product custom formulated to treat anxiety. 


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Medication & Cognition 

1.5 CE Credits

Presented by:
Joseph E. Comaty, Ph.D., M.P.
Adjunct Assistant Professor in Psychology at Louisiana State University
Emeritus Faculty of the Southern Louisiana Internship Consortium in Psychology at Louisiana State University

This course is designed to provide the audience with the most up-to-date information on those psychotropic medications often misused in older adults. The course will cover identification of the medications in the classes of antipsychotics, antidepressants, benzodiazepines, non-benzodiazepine hypnotics, stimulants, cognitive enhancers, and acetylcholinesterase inhibitors.  The audience will be provided information on the indications for the use of these classes of medications and their most common adverse effects, particularly as experienced by older adults especially those with dementia.  Finally, the course will provide the audience with a summary of the BEERS criteria and other initiatives that have attempted to reduce the use of potentially inappropriate medications in the population of older adults.  

After the webinar, participants will be able to:

  1. Describe the most commonly used psychotropic drugs in the elderly.
  2. Discuss the difference between the current use of psychotropic drugs versus their FDA indications.
  3. Explain the most frequently encountered adverse effects of the currently used psychotropic drugs, especially the impact on cognition.
  4. Discuss the effectiveness of psychotropic medications in treating psychiatric/behavioral disorders of the elderly including risk / benefit ratios.  

Target Audience:This presentation is designed for prescribing psychologists; psychologists who work with older adults in a variety of clinical settings; psychologists who may be conducting research on medication effects in the elderly; or psychologists who are teaching courses on psychopharmacology and/or behavioral health treatment of special populations including the elderly.   Other behavioral health practitioners may also benefit from the information provided in this course.

Instructional Level:Intermediate

About Joseph E. Comaty, Ph.D., M.P.  
Dr. Comaty received his M.S. in experimental psychology from Villanova University; his Ph.D. in psychology with a specialization in clinical neuropsychology from the Rosalind Franklin University of Medicine and Science, in Illinois; and his postdoctoral Masters Degree in clinical psychopharmacology from Alliant University/CSPP of California. He is a licensed psychologist under the Louisiana State Board of Examiners of Psychologists (LSBEP) and a licensed Medical Psychologist (i.e., prescribing psychologist) under the Louisiana State Board of Medical Examiners. He retired from the Louisiana Department of Health and Hospitals, Office of Behavioral Health in 2013 where he was the Chief Psychologist and Medical Psychologist and Director of the Division of Quality Management. He is an adjunct assistant professor in psychology at Louisiana State University (LSU) in Baton Rouge and serves as emeritus faculty of the Southern Louisiana Internship Consortium (SLIC) in psychology at LSU. He is currently serving a second term as member of the LSBEP where he was previously a member and past chair; he has just completed his term as a charter member and most recent chair of the RxP Designation Committee of APA, and is a current site reviewer for APA’s Committee on Accreditation. He is a member of the Model Act and Regulation Revision Committee for the Association of State and Provincial Psychology Boards (ASPPB). His research is in the areas of behavior therapy, pharmacology, and clinical psychopharmacology. He is the author of over 60 articles, book chapters, and presentations. He is a co-author of the psychopharmacology textbook, Julien’s Primer of Drug Action, the most recent edition being published in April 2014. He has served on federal grant review committees and has been a reviewer for Psychiatric Services; The Journal of Gerontology: Psychological Sciences; the Journal of Behavioral Health Services and Research; and the Journal of Psychology & Clinical Psychiatry.

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Mindfulness Meditation and Cognitive Augmentation

1.5 CE Credit

 

Ruchika S. Prakash, Ph.D.
Associate Professor at the Department of Psychology
The Ohio State University






Mindfulness, as defined in the contemporary sciences, is the practice of purposefully directing attention, in a non-judgmental way, to observe the unfolding of each moment as it takes place. Mindfulness training has gained increasing popularity for its potential to improve behavioral and neural correlates of cognitive functioning, with a special emphasis on improving attention. In this talk, an overview will be provided of the current state of the literature on mindfulness training and its potential to enhance various facets of attentional control. Employing the classical taxonomy proposed by Posner and Petersen (1990), outcome measures in the literature were broadly categorized based on whether they involved maintenance of an aroused state (alerting), selective prioritization of attention to target items (orienting), or assessed conflict monitoring (executive attention). Although many non-randomized and retreat studies provide promising evidence of gains in both alerting and conflict monitoring following mindfulness training, evidence from randomized controlled trials, especially those involving active control comparison groups, is more mixed. Five  criteria will be proposed through which we should evaluate future clinical trials of mindfulness training. Adoption of such methodological rigor will allow for causal claims supporting mindfulness training as an efficacious treatment modality for cognitive rehabilitation and enhancement.

After the session, participants will be able to:
1. Define mindfulness and explain differences among various meditative practices included in mindfulness-based stress reduction programs.
2. Critique the current state of the literature examining the effects of mindfulness training on attention.
3. Assess the methodological rigor of mindfulness training studies using a set of five criteria designed to evaluate the strength of causal evidence claimed by randomized controlled trials. 

Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate

Dr. Prakash is an associate professor at the Department of Psychology at The Ohio State University. She is the Director of the Center for Cognitive and Behavioral Brain Imaging; a state-of-the-art neuroimaging research facility housed in the Department of Psychology. Dr. Prakash received her doctoral degree at University of Illinois at Urbana-Champaign. Her research interests center around designing and evaluating methodologically-rigorous randomized controlled trials of exercise training and mindfulness meditation. She has published 70 peer-reviewed journal articles, with many of her papers published in top tier psychology and neuroscience journals such as Psychology and Aging, Proceedings of the National Academy of Sciences, NeuroImage, Cerebral Cortex, and Developmental Psychology. She received the “Rising Star Designation” given by the Association for Psychological Science in 2013 and the Springer Early Career Achievement in Research on Adult Development and Aging by the American Psychological Association in 2016. Her research program is funded by the National Institute of Health and the National Multiple Sclerosis Society.  


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Positive Neuropsychology: Orienting Toward Brain and Cognitive Health

1.5 CE Credit

Presented by:

John J. Randolph, Ph.D., ABPP-CN
Geisel School of Medicine at Dartmouth
Randolph Neuropsychology Associates, PLLC








 While positive psychology has experienced considerable growth and empirical support over the past 20 years, related principles have been adopted inconsistently by those working in neuropsychology and other clinical neurosciences.  The present seminar will clarify an orientation to neuropsychological practice focused on the study and promotion of brain and cognitive health—positive neuropsychology—that incorporates perspectives from positive psychology.  First, the concept of cognitive health will be examined in the context of developments in positive psychology and the neuropsychological literature.  This will be followed by discussion of an evidence-based model (C.A.P.E. model) that delineates four key domains of brain and cognitive health.  Recent and historical research covering these domains will be discussed as related to healthy and neuropsychiatric populations.  Practical cognitive and lifestyle strategies that can promote executive and other cognitive abilities will be reviewed, including a discussion of ways to incorporate related interventions into one’s professional repertoire.  

 After the webinar, participants will be able to:

1. Describe the emerging field of positive neuropsychology.
2. List four key domains of brain and cognitive health promotion.  
3. Explain lifestyle factors and practical strategies associated with neuropsychological health, and identify ways to incorporate these strategies into clinical practice.  

 

Target Audience: This webinar is intended for neuropsychologists and other professionals interested in learning about foundations and applications of positive neuropsychology.

Instructional Level: Intermediate 

Dr. John Randolph is a board-certified clinical neuropsychologist in independent practice and Adjunct Assistant Professor of Psychiatry at the Geisel School of Medicine at Dartmouth.  He is a Past President of the New Hampshire Psychological Association and a National Academy of Neuropsychology Fellow.  He is editor of the professional reference, Positive Neuropsychology: Evidence-Based Perspectives on Promoting Cognitive Health, and author of the recently released general audience book, The Brain Health Book: Using the Power of Neuroscience to Improve Your Life.  His research has focused on contributors to cognitive health and resilience, metacognition, executive functioning, and cognitive and neuroimaging aspects of multiple sclerosis.  He earned his Ph.D. in clinical psychology (neuropsychology specialization) from Washington State University, and completed clinical and research fellowships in neuropsychology and neuroimaging at the Geisel School of Medicine at Dartmouth.

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Social Cognition and Communication in Acquired Brain Injury in Adolescents and Adults

1.0 CE Credit

 

Presented by:
Lyn S. Turkstra, Ph.D.
Professor and Assistant Dean, Rehabilitation Science; Faculty, Graduate Program in Neuroscience 
McMaster University, Hamilton, Ontario, CANADA

“Social thinking” and social communication have been targets of acquired brain injury (ABI) rehabilitation for decades, with limited evidence of generalizable benefits. The lack of benefit may be due in part to the historical assessment and intervention focus on social symptoms, without considering underlying neuropsychological mechanisms. Research on social cognition in other clinical groups, particularly in autism, has spurred a growing interest in mechanisms underlying social problems in individuals with ABI and has informed rehabilitation targets and methods. In this session, we will summarize current research on social cognition and communication in adolescents and adults, and critically apply findings to rehabilitation of individuals with ABI. As social communication is, by definition, context-dependent, participants will also evaluate their own communication skills and styles and reflect on the contribution of communication partner behaviors to social symptoms in people with ABI. We also will consider other contextual factors that intersect with social cognition skills, such as sex, gender, race, and ethnicity. The aim of the session is to provide participants with a framework for assessment of, and intervention for, social cognition and communication problems in adolescents and adults with ABI.

Learning Objectives
After the session, participants will be able to:
1. Summarize current research on social cognition and communication in typical populations and individuals with acquired brain injury (ABI), and critique its potential application to clinical assessment and intervention.
2. Describe evidence that factors such as culture, race, sex, and age affect social communication, and identify principles that apply across groups.
3. Assess your own social communication skills and generate strategies to minimize examiner bias in assessment and intervention.
4. Contrast results from TBI research with results from other populations with social communication impairments, including individuals with social (pragmatic) communication disorder and autism spectrum disorder.

Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate


Dr. Lyn S. Turkstra is a Professor in the School of Rehabilitation Science at McMaster University, head of the graduate program in Speech-Language Pathology, and a faculty member in the McMaster Neuroscience Graduate Program. Her research focuses on understanding social communication challenges in adolescents and adults with acquired brain injury, and developing intervention strategies that will optimize long-term social outcomes. Dr. Turkstra was a member of the INCOG practice guidelines committee for TBI rehabilitation, funded by the Ontario Neurotrauma Foundation and Monash University, and is a consultant to the Veterans Health System and Department of Defense for clinical practice guidelines in mild TBI. She lectures nationally and internationally on development of evidence-informed models of cognitive rehabilitation for adolescents and adults with ABI in acute, sub-acute, and long-term care settings. 

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Social Cognition: An Important Face of Neuropsychology

1.5 CE Credits

Presented by:
Skye McDonald, Ph.D.
UNSW AUSTRALIA

This course introduces the concept of social cognition as a critical facet of neuropsychological function and a target for assessment and intervention. We discuss the regions of the brain that are implicated in social cognition and the range of clinical conditions that may give rise to social cognitive impairment. We discuss three main tenets of social cognition: (1) emotion perception (i.e., the ability to read emotions in others); (2) theory of mind (i.e., the ability to understand another’s point of view); and (3) empathy (i.e., the ability to engage with another and share their experience). We discuss various ways in which impairments in these attributes manifest and how they can be measured. Common instruments used for their assessment are covered, and we conclude with an overview of relevant interventions to ameliorate these impairments.


After the webinar, participants will be able to:

1. Describe the main aspects of social cognition that may be impaired in clinical conditions.
2. List a range of clinical disorders that are likely to include impairment in social cognition.
3. Identify a range of tests of social cognition that are suitable for clinical use.
4. Discuss possible approaches to remediate social cognitive disorders.

Target Audience: Suitable for experienced neuropsychologists with little to no knowledge of social cognition

Instructional Level: Intermediate

Skye McDonald is a Professor of Clinical Neuropsychology at UNSW Australia.  She has a BSc (Hons) from Monash University, a Masters degree in Clinical Neuropsychology from the University of Melbourne and a PhD from Macquarie University. She worked as a clinician with people with acquired brain disorders for 10 years before taking up her academic post at UNSW where she has been for 25 years. Skye is a world leader in understanding social cognitive disorders after brain injury. She has published 188 peer reviewed journal articles, 19 book chapters, 2 books and 140 conference presentations, most of which focus on social cognition and its disorders, especially following acquired brain injury, as well as ways to remediate such disorders.  In 2018 she was elected President of the International Neuropsychological Society (term: 2019-2021).

 
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How Can Cognitive Reserve Promote Cognitive and Neurobehavioral Health?

1 CE Credits

Presented by:
Yaakov Stern, Ph.D.
Chief, Cognitive Neuroscience Division, Department of Neurology
Professor of Neuropsychology (in Neurology, Psychiatry, the Gertrude H. Sergievsky
Center and the Taub Institute) at Columbia University Irving Medical Center

Description
Research indicates that lifestyle factors such as achieving educational and work milestones and participating in leisure and social activities, as well as IQ, are all associated with reduced risk of cognitive decline in normal aging and of developing dementia. Many of these lifestyle factors have also been associated with lower rates of better cognition in other psychiatric and neurological conditions. The cognitive reserve hypothesis posits that these lifestyle factors result in individual differences in the flexibility and adaptability of brain networks that may allow some people to cope better than others with age- or dementia-related brain changes. Recent evidence also supports the idea that specific genetic and lifestyle factors may help preserve a healthy brain or enhance brain reserve, a process that has been called brain maintenance. The complementary concept of brain reserve posits that the status of structural brain features can guard against dementia and related conditions. This talk will review these theoretical concepts, their research bases, and their clinical applications.

After the session, participants will be able to:
Summarize basic theory underlying cognitive reserve and related concepts.
Assess the evidence for these concepts.
Apply these concepts to research and clinical practice.

Target Audience: Neuropsychologists and trainees
Instructional Level: Intermediate

Yaakov Stern is Professor of Neuropsychology in the Departments of Neurology and Psychiatry, as well as the Taub Institute for the Research on Alzheimer’s Disease and the Aging Brain and the Gertrude H. Sergievsky Center, at Columbia University Irving College of Physicians and Surgeons. He is chief of the Cognitive Neuroscience Division of the Department of Neurology.
 
Dr. Stern earned his B.A. in Psychology from Touro College, and his Ph.D. from the Experimental Cognition program of City University of New York.

Dr. Stern’s research focuses on cognition in normal aging and in diseases of aging, particularly Alzheimer’s disease. One strong focus of his current research program is investigating the neural basis of cognitive reserve. Dr. Stern’s work was crucial to identifying and clarifying the nature of cognitive reserve, which is a theory that explains individual differences in the susceptibility to age-and disease-related brain changes. Dr. Stern also leads a large scale imaging study to identify unique neural networks underlying the major cognitive abilities affected by aging, and another long-term study that models the natural history of Alzheimer’s disease.

Dr. Stern’s research approach includes classic neuropsychological and cognitive experimental techniques, with a strong focus on functional imaging. He has published over 600 peer-reviewed papers, numerous chapters, and edited a book on cognitive reserve.

 
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