Journal articles: 'Older-driver ability' – Grafiati (2024)

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A sample of 555 drivers aged 50 or more were assessed in terms of their confidence in a range of driving situations, self-ratings of their driving ability, self-reported driving behaviour, and personality as measured by Eysenck's EPQ. Levels of nervousness when driving were surprisingly low, although there was no evidence of unrealistic self-ratings of driving ability. Female drivers reported significantly fewer errors and intentional violations than did male drivers. Female drivers were also found to score higher on the Extroversion, Neuroticism and Lie scales than did males. However, the males in the sample scored higher on the Psychoticism scale than the females. Driving confidence was associated with the following: a low level of lapses and errors, and a high level of violations; a low score on the Neuroticism scale and a high score on the Extroversion scale; being male, and high annual mileage. Personality did not mediate the relationship between driving confidence and self-rated driving ability.

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We assessed the relationship between three-dimensional multiple-object-tracking (3D-MOT) ability and older driver simulated driving performance. Participants included 30 older drivers from the local community who completed two experimental driving scenarios, as well as a three-dimensional multiple object tracking task, called the 3D-MOT task. The speed thresholds on the 3D-MOT task were strongly negatively associated with lane deviation and crash rates during a simulated highway drive. Our findings help to expand the existing knowledge regarding multiple object tracking and driving, as it is commonly assumed that some aspects of driving include the ability to track the movement of many objects. Our findings further elucidate the relationship that motion processing has with driving performance in the older driver population.

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ABSTRACTAlthough automobiles remain the mobility method of choice for older adults, late-life cognitive impairment and progressive dementia will eventually impair the ability to meet transport needs of many. There is, however, no commonly utilized method of assessing dementia severity in relation to driving, no consensus on the specific types of assessments that should be applied to older drivers with cognitive impairment, and no gold standard for determining driving fitness or approaching loss of mobility and subsequent counseling. Yet, clinicians are often called upon by patients, their families, health professionals, and driver licensing authorities to assess their patients’ fitness-to-drive and to make recommendations about driving privileges. We summarize the literature on dementia and driving, discuss evidenced-based assessments of fitness-to-drive, and outline the important ethical and legal concerns. We address the role of physician assessment, referral to neuropsychology, functional screens, dementia severity tools, driving evaluation clinics, and driver licensing authority referrals that may assist clinicians with an evaluation. Finally, we discuss mobility counseling (e.g. exploration of transportation alternatives) since health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance our patients’ social connectedness and quality of life, while meeting their psychological and medical needs and maintaining personal and public safety.

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In Japan, drivers over the age of 65 years are classified as ‘older drivers’. On 1 October 2006, people over the age of 65 years comprised 20.8 per cent of the population, and 13.1 per cent of these are licensed drivers. Ageing causes a decrease in both physical and psychom*otor abilities. Older drivers tend to cause traffic accidents owing to complex traffic conditions. The major goals of this study are to investigate the characteristics of older drivers' eye fixation movement and responses under heavy traffic volume at an intersection with a traffic signal. A personal-computer-based driving simulator was used to evaluate driver behaviours and to reproduce unexpected roadway hazards and realistic four-step traffic volume. An eye position recorder on a near-infrared system was used to collect eye movement data. The drivers' initial cognition ability was determined on the basis of reaction time tests under three different conditions. The older driver group in this study shows the following characteristics: first, as the task complexity increases, the reaction time increases (i.e. a slowed reaction); second, as the drivers become older, the time interval between recognition of a hazard and avoidance of the hazard increases; third, as the traffic volume increases, the driver has fewer eye fixations, shorter mean fixation time, and slower fixation speed compared with the younger drivers' group; fourth, traffic volume is one of the most important factors that complicates the driving task and causes hesitation in decision making. These results provide basic data to improve traffic services to make them suitable for older drivers in an ageing society.

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Older drivers are an at-risk population for automobile crashes, especially at intersections. Intersection maneuvers demand a series of motor and visual responses executed at specific proximities and timings during a turn. Previous research indicates that older drivers are more likely than middle-aged drivers to neglect anticipatory glances to areas where latent hazards could materialize at intersections. Calibration, which reflects the degree of agreement (or discordance) between a driver’s self-perception of their driving ability and their actual ability, might be a factor that drives the age-related differences in visual scanning at intersections. This study examined relationships between eye movement patterns while driving through intersection scenarios in a medium-fidelity simulator and their subjective performance scores for middle-aged and older drivers. The data indicated no difference in calibration scores between older and middle-aged drivers. However, data showed that older drivers with higher subjective performance executed fewer secondary glances: this pattern was not present for middle aged drivers. Further research is necessary to identify psychological mechanisms involving driver calibration that control the age-related declines in anticipatory glance behavior at intersections.

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Objective: The aim of this study was to examine the effects of an alertness-maintaining task (AMT) in older, fatigued drivers. Background: Fatigue during driving increases crash risk, and previous research suggests that alertness and driving in younger adults may be improved using a secondary AMT during boring, fatigue-eliciting drives. However, the potential impact of an AMT on driving has not been investigated in older drivers whose ability to complete dual tasks has been shown to decline and therefore may be negatively affected with an AMT in driving. Method: Younger ( n = 29) and older drivers ( n = 39) participated in a 50-minute simulated drive designed to induce fatigue, followed by four 10-minute sessions alternating between driving with and without an AMT. Results: Younger drivers were significantly more affected by fatigue on driving performance than were older drivers but benefitted significantly from the AMT. Older drivers did not demonstrate increased driver errors with fatigue, and driving did not deteriorate significantly during participation in the AMT condition, although their speed was significantly more variable with the AMT. Conclusion: Consistent with earlier research, an AMT applied during fatiguing driving is effective in improving alertness and reducing driving errors in younger drivers. Importantly, older drivers were relatively unaffected by fatigue, and use of an AMT did not detrimentally affect their driving performance. Application: These results support the potential use of an AMT as a new automotive technology to improve fatigue and promote driver safety, though the benefits of such technology may differ between different age groups.

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ABSTRACTGovernments are challenged by the need to ensure that ageing populations stay active and engaged as they age. Therefore, it is critical to investigate the role of mobility in older people's engagement in out-of-home activities, and to identify the experiences they have within their communities. This research investigates the use of transportation by older people and its implications for their out-of-home activities within suburban environments. The qualitative, mixed-method approach employs data collection methods which include a daily travel diary (including a questionnaire), Global Positioning System (GPS) tracking and semi-structured interviews with older people living in suburban environments in Brisbane, Australia. Results show that older people are mobile throughout the city, and their car provides them with that opportunity to access desired destinations. This ability to drive allows older people to live independently and to assist others who do not drive, particularly where transport alternatives are not as accessible. The ability to transport goods and other people is a significant advantage of the private car over other transport options. People with no access to private transportation who live in low-density environments are disadvantaged when it comes to participation within the community. Further research is needed to better understand the relationship between transportation and participation within the community environment, to assist policy makers and city and transportation planners to develop strategies for age-friendly environments within the community.

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This study was conducted to detennine if contrast sensitivity could predict age-related differences in the ability to discriminate simple road signs, as these differences have not been predicted by Snellen visual acuity. Contrast sensitivity, Snellen visual acuity, and discrimination distances for projected images of highway signs were measured for 7 older observers, ages 55 to 79, and 13 younger observers, ages 19 to 30. All subjects had 20/20 visual acuity or better, but the older group had significantly lower contrast sensitivity than did the younger group at three spatial frequencies: 3, 6, and 12 cycles/deg of visual angle. The older group required a significantly larger sign symbol in order to determine if it denoted a + or T intersection. Correlations between measures showed that highway-sign discrimination distance was significantly related to contrast sensitivity at two spatial frequencies, 1.5 and 12 cycles/deg, but discrimination distance was not related to visual acuity. Implications for highway-sign design and driver vision standards are discussed.

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Self-driving vehicles have been heralded as a dramatic new advancement in personal mobility. This emerging technology, beyond potentially improving driving safety, also represents a redefined relationship between the human driver and the vehicle. As this artificial intelligence-based vehicular technology becomes more intelligent, conventional interaction design methodologies may be challenged in their ability to fully encompass this redefined relationship. This problem may be even more pronounced for specific populations like older adults (60+) whose perspectives, we argue, have been underexplored in the self-driving vehicle context. Within this report we describe an emerging methodology, user enactment, and explore its use as a generative design process in two studies focused on older adults. This work adds additional support to the contention that user enactment may be an effective methodological tool for researchers in exploring the relationship between humans and intelligent technologies.

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A person’s vision, perception, judgment, and operation of a vehicle decline with age. To analyze the influence of age on traffic accidents, we apply the adaptive boosting algorithm (AdaBoost) to investigate the most significant factors for two age groups (older and young driver groups) based on real-world accident data in California. Accident factors include gender, road type, pavement condition, weather, time of day, vehicle behavior, etc., as well as their corresponding subfactors. We first train some weak learners to find importance and then linearly combine those weak learners into a unified stronger learner. The proposed method has several advantages: (1) ability to handle unbalanced data, (2) no requirement on the assumption of data distribution, and (3) being robust for different datasets. Results show that the major factors regarding road safety for older drivers are weather and time of day, while for young drivers are traffic violations and vehicle behaviors.

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ABSTRACTBackground: Older drivers are at a higher risk of being involved in a motor vehicle accident. However, on-road assessments of all older drivers are impractical, highlighting the need to screen for potentially unsafe drivers. This study undertook a meta-analysis of research examining the cognitive predictors of driving ability in older drivers in order to provide an evidence-based method for screening drivers.Methods: Comprehensive searches were undertaken of the PubMed, PsycINFO, CINAHL, and Health-Source Nursing electronic databases between 1980 and 2007 in order to identify studies that examined cognitive differences between drivers aged over 55 years who either passed or failed a driving assessment. Twenty-one studies were eligible for inclusion. Weighted Cohen's d effect sizes, percentage overlap statistics, Fail-safe Ns and 95% CIs were calculated for all cognitive tests.Results: The best predictors of on-road driving were the Ergovision and Useful Field of View (UFOV) tests, a complex RT task, Paper Folding task, Dot Counting, WMS Visual Reproduction, and Computerized Visual Attention Task. Simulator driving performance was best predicted by the Benton Line Orientation Task, Clock Drawing, a Driver Scanning task, the UFOV, WAIS Picture Arrangement and MMSE. Finally, the Trail Making Test, Stroop, UFOV, WAIS Block Design, and Automated Psychophysical Test were good predictors of driving problems.Conclusions: There are a variety of tests that appear suitable for screening older drivers, the exact choice of which depends on the “gold standard” for determining driving ability (on-road driving, driving simulator, driving problems) and whether a computerized or paper-and-pencil task is required.

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Interventions designed to target ability deficiencies common among older commercial vehicle drivers were evaluated during the course of this effort. Four interventions, consisting of three in-vehicle compensatory aids and a single driver training program, were used in the study. A between-subjects design was used to assess the effects of each intervention; subjects assigned to an experimental group received all four interventions, while those in a control condition were not exposed to the countermeasures. The degree to which the interventions enhanced, or otherwise influenced driving performance was examined by contrasting performance with versus without the interventions (i.e., comparing the experimental and control groups). Assignment to each experimental condition was blocked (or grouped) by age. Results indicated that all four interventions led to enhanced performance.

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The proportion of older drivers has increased with the aging population. In order to improve the driving behavior and safety of older drivers, we aim to analyze behavior differences between older and younger drivers and then study an improvement strategy based on the older drivers’ behavioral characteristics. Older drivers’ behaviors can be enhanced through training, thereby improving driving safety. Simulated scenarios for behavior analysis and training are constructed for drivers who are recruited from the general driving population. Data on the drivers’ eye movement, physiological and psychological conditions, operation behavior, and vehicle status are collected and analyzed. The theory of planned behavior is adopted to construct a driving behavior enhancement training model for older drivers. Finally, a structural equation model is developed to comprehend the relationship between training level, driver characteristics, and traffic safety. The ability and speed of older drivers to obtain traffic information is worse than those of young and middle-aged drivers, and the vehicle control capability of older drivers has a larger volatility. The driving behavior training model can improve older drivers’ driving stability and safety, as follows: the positive effect of training on driving behavioral improvement is larger than the negative effect of aging; the negative effect of training level on dangerous driving tendency is larger than the positive effect of driver’s aging. The driving behavior of older drivers should be improved for the safety and stability of driving operations through the PNE (perceived-norm-execution) model. The relationship between training level, driving behavior characteristics, and traffic safety is discussed using the structural equation model, and results show that the training can improve the effect of the drivers’ age on the characteristics of driving behavior, and that older drivers tend to decrease dangerous driving tendencies.

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Background: To maintain the mobility of older people in later life, it is essential to sustain their autonomy; however, driving is a complex task, requiring a large range of visual, psychom*otor and cognitive abilities. Subsequently, a key issue is to measure and evaluate the fitness to drive of older drivers. Several methods have been proposed, among them the useful field of view (UFOV) test. Objective: The present study aimed to identify driving characteristics in older drivers and the relationship between the UFOV test and the on-road driving results. Method: A total of 80 drivers aged 70 years or older performed both the UFOV test and the on-road driving assessment. The ‘B On-Road' (Behaviour On-Road) protocol was used for the fitness-to-drive assessment. Results: ‘Driving too fast' was the item reported most often during the on-road assessment, followed by problems with the manual gearbox and ‘attention to signs, road lines and traffic lights'. Overall, the results showed that the older the driver, the more errors were reported during the on-road driving assessment, as well as the slower the performance on the UFOV test. A significant relationship between the total number of on-road errors, as measured by the B On-Road protocol, and the UFOV 3, which stresses the capacity of selective attention, was found. Conclusion: The recommendation is still to use on-road driving assessment to fully assess fitness to drive for older drivers whose ability to drive requires assessment. However, to supplement this, the UFOV test, in particular the UFOV 3, is a valuable complement in selecting those drivers requiring to be assessed.

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Introduction: Certain cognitive and physical conditions have been associated with increased risk of injury, particularly risk of vehicle crashes among older car drivers. This study aims to examine the association of seven select medical conditions among hospitalised road users compared to other hospitalised injuries, and to estimate the hospitalised injury rates of car drivers, car passengers and pedestrians with these medical conditions. Method: An examination of road transport and nonroad transport hospitalised injury involving adults aged ≥50 years identified during 2003-2012 in New South Wales, Australia was conducted. Medical conditions were identified from hospital diagnosis records. Conditional fixed effects logistic regression conditioned on the matched cases and comparison-cohort estimated odds ratios for each medical condition by road user type. Results: There were 35,134 road transport injuries (10,664 car drivers and 4,907 pedestrians) and 447,858 nonroad transport injuries. Individuals with vision disorders, cardiovascular disease including stroke, diabetes, and osteoarthritis had higher odds of hospitalisation for an injury as a car driver compared to all other hospitalised injuries. Individuals with diagnoses of dementia or alcohol dependence had a lower odds of an injury hospital admission as a road user (excluding pedestrians) compared to all other hospitalised injuries. Conclusions: As the population ages, there are likely to be more older road users with comorbidities that may affect their ability to drive or safely cross the road. Community mobility strategies need to take into account the influence of comorbid health conditions for older adults.

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Background Despite the progress in achieving gender equality to a certain extent, women are found to be more susceptible to health disadvantages compared to men in the older ages. However, research in the Indian context has mainly remained restricted to subjective health that heavily depends on the individual’s perception, which may affect the validity of results. This study addresses this gap by complementing the investigation of the gender differentials in self-reported health outcomes (mobility and functional limitations) with that of objectively measured health status (hand-grip strength and static balance) among the older population of India. Besides, there is a dearth of literature that considers financial empowerment in explaining the gender differentials in health. Women’s ability to participate in household decision-making, especially for important matters like major purchases, including property, indicates their empowerment status. Furthermore, the ability to extend financial support can be considered an important ‘non-altruistic’ driver for kins to care for older adults, indirectly affecting their health and well-being. Thus, the present paper explores the influence of financial empowerment on gender differentials in poor health outcomes. Methods Using the Longitudinal Aging Study in India, Wave-1 (2017–18), six logistic regression models have been specified to capture the adjusted association between gender and poor health outcomes. The first three models successively control for the demographic and social support factors; socioeconomic factors and pre-existing health conditions; and financial empowerment indicators. The last three models investigate the interactions between gender and marital status, living arrangement and involvement in financial decisions, respectively. Results The findings reveal that women tend to be more perceptive about their physical discomfort than men and reported a higher prevalence of poor subjective health. In terms of objectively measured health status, older men had a higher prevalence of low hand-grip strength but a lower prevalence of poor balance. Gender demonstrated a strong, adjusted association with poor health outcomes among older adults. However, the magnitude of gender difference either shrunk considerably or became statistically insignificant for all the poor health outcomes after controlling the effect of indicators of financial empowerment. Further, the interaction between gender and involvement in financial matters demonstrated a stronger effect for men in reversing poor subjective health. Conclusion The study reinforced the positive effect of financial empowerment in mitigating gender disparity in health among older adults.

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Abstract Introduction: Classical Hodgkin lymphoma (cHL) is characterized by a small fraction of Hodgkin and Reed-Sternberg (HRS) tumor cells (~1%) which are surrounded by an extensive immune infiltrate. The rare nature of HRS cells limits the ability to study the genomics of cHL using standard platforms. To circumvent this, our group has optimized fluorescence-activated cell sorting to isolate HRS cells and intratumor B- and T- cells and to perform whole exome sequencing (WES; Reichel, Blood 2015). To date, however, there have been no reports on whole genome sequencing (WGS) of cHL. Methods: We performed flow-sorting of HRS cells and WGS to define the genomic landscape of cHL including: i) mutational processes involved in pathogenesis, ii) large and focal copy number variants, iii) structural variants including complex events, iv) the sequence and evolution of molecular events in cHL. We interrogated WGS from 25 cases of cHL: 10 pediatric patients (age<18), 9 adolescents and young adults (AYA, age 18-40), and 6 older adults (age>40). Intra-tumoral T-cells were used as germline control. An additional 36 cHL cases were evaluated by WES. Results: The average depth of coverage among the 25 WGS cases was 27.5x. After having identified and removed amplification-based palindromic sequencing artifacts, we observed a median of 5006 single base substitutions (SBS; range 1763-18436). Pediatric and AYA patients had a higher SBS burden compared to older adults (median 5279 vs. 2945, p=0.009). Five main SBS signatures were identified: SBS1 and SBS5 (aging), SBS2 and SBS13 (APOBEC), and SBS25 (chemotherapy, in a relapsed case). A dNdScv driver discovery analysis performed on the combined WES and WGS cases identified 24 driver genes including BCL7A and CISH which had not been previously reported as drivers in cHL. An investigation of copy number alterations (CNAs) confirmed high ploidy in cHL (median 2.95, range 1.66-5.33). Whole genome duplication was identified in 64% cases. We also observed clear evidence of complex events such as chromothripsis (n=4), double minutes (dm, n=2), breakage-fusion-bridge (bfb; n=4). Some of these events were responsible for the acquisition of distinct drivers. For example, we observed one dm and one bfb responsible for CD274 and REL gains, respectively (>10 copies). Leveraging the high prevalence of large chromosomal gains, we performed an investigation of the relative timing of acquisition of driver mutations. Clonal mutations within chromosomal gains can be defined as duplicated (VAF~66%; acquired before the gain) or non-duplicated (VAF~33%; acquired before or after the gain). Sixty-one percent (152/249) of driver genes were duplicated suggesting that they were acquired prior to large chromosomal gains. Next, we used the corrected ratio between duplicated and non-duplicated mutations within large chromosomal gains to estimate the molecular time of each duplicated segment (Rustad, Nat Comm 2020). In 11/22 genomes the final CNA profile was acquired through at least two temporally distinct events. To convert these relative estimations into absolute timing (i.e., the age at which events occurred), we leveraged the clock-like mutation signatures (SBS1, SBS5). We first confirmed that the SBS1 and SBS5 mutation rate were constant over time (R 2=0.84; p<0.0001 in Peds/AYA; R 2 =0.82; p=0.002 in older adults). We observed a higher mutation rate in Pediatric/AYA cases compared to older adults (p=0.01), which is consistent with the higher mutational burden observed in this age group. By estimating the SBS1- and SBS5-based molecular time for large chromosomal gains and converting relative estimates to absolute time, we are able to estimate the age in years at the time of the first multi-chromosomal gain event. We observed that the first multi-chromosomal gain in cHL is often acquired several years before the diagnosis/sample collection: median latency of 19.5 (range 12-27) and 5.6 (range 1.8-16) years in older adults and pediatric/AYA patients respectively. Conclusion: Here we report the first WGS in cHL. We identify novel drivers and genomic mechanisms involved in cHL pathogenesis. We found that mutations in driver genes are often acquired earlier then chromosomal gains, potentially preceding the cHL diagnosis by several years. In addition, we observed key differences in biology of cHL across age groups including accelerated mutagenesis and increased mutational burden among younger patients. Disclosures Maura: OncLive: Honoraria; Medscape: Consultancy, Honoraria. Oberley: Caris LIfe Science: Current Employment. Lim: EUSA Pharma: Honoraria. Landgren: Janssen: Other: IDMC; Celgene: Research Funding; Janssen: Honoraria; Amgen: Honoraria; Janssen: Research Funding; Amgen: Research Funding; Takeda: Other: IDMC; GSK: Honoraria. Moskowitz: Merck & Co., Inc.: Research Funding. Roshal: Celgene: Other: Provision of services; Auron Therapeutics: Other: Ownership / Equity interests; Provision of services; Physicians' Education Resource: Other: Provision of services. Elemento: Owkin: Consultancy, Other: Current equity holder; AstraZeneca: Research Funding; Champions Oncology: Consultancy; Volastra Therapeutics: Consultancy, Other: Current equity holder, Research Funding; One Three Biotech: Consultancy, Other: Current equity holder; Eli Lilly: Research Funding; Johnson and Johnson: Research Funding; Freenome: Consultancy, Other: Current equity holder in a privately-held company; Janssen: Research Funding. Roth: Janssen: Consultancy; Merck: Consultancy.

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Demographic changes, increasing life expectancy, and increasing healthy life expectancy lead to an increasingly ageing workforce. This condition has a growing impact on the workforce in today’s industries. However, old workers are not a burden for companies and industries. They are a fundamental part of the industrial ecosystem due to the consistency of their human factors, namely their large knowledge, experience, and decision-making ability. For this reason, the ageing workforce must be incorporated and engaged through the introduction of digital age technologies to improve their working conditions and extend their active life. This paper focuses on a novel design of assistive technologies based on the interconnection of motion capture (MoCap) and virtual reality (VR) systems as a driver for the improvement of the task performance of the ageing workforce. We intend to explore how this technological tool can help and enhance the work of the ageing workforce. For this, we study two different areas of application: the training, learning, and communication of the older workers and the ergonomic analysis and workplace design for the ageing operators. In the end, a pilot study is proposed to apply this technology in real work environments.

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Context.—In recent years, there has been a tremendous amount of interest in the development of targeted therapies for the treatment of human cancers. Increased understanding of the specific molecular pathways and driver mutations critical to cancer cell growth have allowed the development of these advanced therapeutics. Among these, inhibitors of the epidermal growth factor receptor and HER2/neu pathways now play a major role in the management of gastrointestinal cancers in addition to other solid malignancies. In colorectal and gastric cancers, the use of epidermal growth factor receptor inhibitors and HER2/neu inhibitors has increased the available treatment options for patients with advanced disease. Objective.—To focus on the current targeted therapies and predictors of response in malignancies of the gastrointestinal tract. Data Sources.—Medical literature searchable on PubMed (US National Library of Medicine) as well as older studies revealed by the literature review were used as the source of data. Conclusion.—Gene testing of critical elements of the pathways targeted by these agents (such as KRAS mutational analysis in colorectal tumors and HER2/neu testing in gastric cancers) allows the ability to predict which patients will respond to these treatments. As the molecular profiling of tumors and our understanding of cancer genomics and epigenetic alterations continues to grow, it is expected that these personalized targeted therapies will form one of the mainstays of gastrointestinal cancer treatment.

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Background Self-report assessments for elderly drivers are used in various countries for accessible, widespread self-monitoring of driving ability in the elderly population. Likewise, in South Korea, a paper-based Self-Report Assessment for Elderly Driving Risk (SAFE-DR) has been developed. Here, we implemented the SAFE-DR through an Android app, which provides the advantages of accessibility, convenience, and provision of diverse information, and verified its reliability and validity. Objective This study tested the validity and reliability of a mobile app-based version of a self-report assessment for elderly persons contextualized to the South Korean culture and compared it with a paper-based test. Methods In this mixed methods study, we recruited and interviewed 567 elderly drivers (aged 65 years and older) between August 2018 and May 2019. For participants who provided consent, the app-based test was repeated after 2 weeks and an additional paper-based test (Driver 65 Plus test) was administered. Using the collected data, we analyzed the reliability and validity of the app-based SAFE-DR. The internal consistency of provisional items in each subdomain of the SAFE-DR and the test-retest stability were analyzed to examine reliability. Exploratory factor analysis was performed to examine the validity of the subdomain configuration. To verify the appropriateness of using an app-based test for older drivers possibly unfamiliar with mobile technology, the correlation between the results of the SAFE-DR app and the paper-based offline test was also analyzed. Results In the reliability analysis, Cronbach α for all items was 0.975 and the correlation of each item with the overall score ranged from r=0.520 to r=0.823; 4 items with low correlations were removed from each of the subdomains. In the retest after 2 weeks, the mean correlation coefficient across all items was r=0.951, showing very high reliability. Exploratory factor analysis on 40 of the 44 items established 5 subdomains: on-road (8 items), coping (16 items), cognitive functions (5 items), general conditions (8 items), and medical health (3 items). A very strong negative correlation of –0.864 was observed between the total score for the app-based SAFE-DR and the paper-based Driver 65 Plus with decorrelation scales. The app-based test was found to be reliable. Conclusions In this study, we developed an app-based self-report assessment tool for elderly drivers and tested its reliability and validity. This app can help elderly individuals easily assess their own driving skills. Therefore, this assessment can be used to educate drivers and for preventive screening for elderly drivers who want to renew their driver’s licenses in South Korea. In addition, the app can contribute to safe driving among elderly drivers.

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Ikääntyvien kuljettajien määrän lisääntyessä myös muistisairaiden ihmisten osuus ajokortin haltijoissa kasvaa. Artikkelissa tarkastellaan etenevää muistisairautta sairastavan ihmisen ajo-oikeutta hyödyntäen lainopin menetelmiä. Vaikka muistisairaus johtaa edetessään ajokortista luopumiseen, ei pelkkä diagnoosi sairauden lievässä vaiheessa tarkoita ajoluvan menettämistä kaikissa ajokorttiryhmissä. Onnettomuusriski kasvaa sairauden edetessä, mutta yksilölliset erot voivat olla merkittäviä, ja ajokyvyn arvioinnissa tulee kiinnittää huomiota muistisairaan kokonaistilanteeseen. Oikeus ajoneuvon kuljettamiseen on usein keskeinen osa sairastuneen identiteettiä ja osa hänen autonomiansa toteutumista. Ajo-oikeuden poistaminen voi kuitenkin olla välttämätöntä paitsi sairastuneen itsensä suojaamiseksi myös muiden turvallisuuden takaamiseksi. Artikkelin lopuksi pohditaan ratkaisuja muistisairaan ihmisen liikkumisen turvaamiseksi. Tutustuminen vaihtoehtoisiin ja turvallisiin liikkumisen keinoihin tulisi aloittaa riittävän ajoissa. Rajoitetun ajo-oikeuden mahdollisuutta tulisi edelleen maassamme selvittää erityisesti syrjäseuduilla asuvien varhaisvaiheen muistisairaiden näkökulmasta. Lisäksi muistisairaille ihmisille tulee taata muiden sairaus- ja vammaryhmien tavoin yhdenvertainen oikeus vammaispalvelulain nojalla myönnettäviin kuljetuspalveluihin. People with dementia in traffic As the number of older drivers increases, so too does the number of people with dementia who hold driving licences. In the course of the disease’s progress, the capacity to drive diminishes and is at some point inevitably lost. This article examines how dementia affects an individual’s driving ability and how elderly people and people with dementia are taken into account in the legislation governing driving licences. The article also assesses the issue of the autonomy enjoyed by a driver and the importance of a driving licence for people with dementia. Finally, the article offers solutions aimed at safeguarding the right to liberty of movement and transportation for people with dementia so that they can live independently and participate fully in all aspects of life. People with dementia should be treated in the same way as those who have other types of illness and those who fall within other disability groups and be guaranteed equal access to transport services under the Disability Services Act.

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AimsDeveloping a mental illness and being commenced on psychotropic medication are factors that may interfere with the ability of an individual to drive safely as both can impact information processing, psychom*otor actions and social interpretation. The Driver and Vehicle Licensing Agency (DVLA) suggests that certain medical conditions require driving licence holders to notify them for further assessment of their ability to drive. DVLA notifiable mental disorders include psychosis, schizophrenia, bipolar disorder, dementia and personality disorders. The doctor's legal duty is to assess the patient for any relevant diagnosis, inform the patient of their duty to report their medical condition to the DVLA and for the doctor to comply with the legal duty to inform the DVLA of any patient who won't or can't notify the DVLA of their medical condition. The authors conducted a quality improvement project to evaluate and improve the number of fitness to drive assessments completed for patients admitted to the five wards (three general adult, one older adult and the Psychiatric Intensive Care Unit) at Clock View Hospital.MethodsThe electronic (RiO) record for each inpatient on the five wards was scrutinised for: whether the patient's driving status was established on admission; whether the patient was notified of the DVLA rules if they did drive; whether the patient agreed to fulfil their duty of notification and, in instances where they were not, whether the medical professional had taken appropriate steps to address this.Results74 patients on the five wards were included in the sample. Only nine of the 74 patients had driving status documented on admission. Three of these nine patients were noted to be driving or learning to drive and were not notified of the DVLA rules. Four of the nine patients were no longer driving and so discussion about DVLA guidance was unnecessary. The remaining two patients were confirmed to be driving and informed of the DVLA regulations. Both patients agreed to comply and therefore no further action was indicated.ConclusionA review of current practice indicates a deficit in incorporating driving status and fitness to drive assessment into the clerking proforma following admission to Clock View Hospital. The second half of this cycle will implement change and raise awareness amongst inpatient medical and nursing staff of the need to consider this important issue prior to discharge. A re-assessment of the effectiveness of these changes will be carried out in the future.

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AbstractAlfalfa is recommended as a rotational crop in corn production, due to its ability to contribute to soil nitrogen (N) and carbon (C) stocks through atmospheric N2fixation and above- and belowground biomass production. However, there is little information on how alfalfa management practices affect contributions to soil and subsequent corn crop yields, and research has not been targeted to organic systems. A study was conducted to determine the effects of alfalfa stand age, cutting frequency and biomass removal on soil C and N status and corn yields at three organically managed Minnesota locations. In one experiment, five cutting treatments were applied in nine environments: two, three and four cuts with biomass removal; three cuts with biomass remaining in place; and a no-cut control. In the other experiment, corn was planted following 1-, 2-, 3- or 4-year-old alfalfa stands and a no-alfalfa control. Yield was measured in the subsequent corn crop. In the cutting experiment, the two- and three-cut treatments with biomass removal reduced soil mineral N by 12.6 and 11.5%, respectively, compared with the control. Potentially mineralizable N (PMN) was not generally affected by cutting treatments. The three-cut no-removal increased potentially mineralizable C by 17% compared with the other treatments, but lowered soil total C in two environments, suggesting a priming effect in which addition of alfalfa biomass stimulated microbial mineralization of native soil C. Although both yields and soil mineral N tended to be higher in treatments where biomass remained in place, this advantage was small and inconsistent, indicating that farmers need not forgo hay harvest to obtain the rotational benefits of an alfalfa stand. The lack of overall correlation between corn grain yields and mineral and potentially mineralizable N suggests that alfalfa N contribution was not the driver of the yield increase in the no-removal treatments. Alfalfa stand age had inconsistent effects on fall-incorporated N and soil N and C parameters. Beyond the first year, increased alfalfa stand age did not increase soil mineral N or PMN. However, corn yield increased following older stands. Yields were 29, 77 and 90% higher following first-, second- and third-year alfalfa stands than the no-alfalfa control, respectively. This indicates that alfalfa may benefit succeeding corn through mechanisms other than N contribution, potentially including P solubilization and weed suppression. These effects have been less studied than N credits, but are of high value in organic cropping systems.

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Background: Long-term survival after intensive induction chemotherapy in acute myeloid leukemia (AML) is limited by both early mortality and disease resistance. A central clinical challenge is predicting which patients will experience early toxicity during induction or resistant disease. Limitations of prior analyses include a specific focus on either early treatment-related mortality or overall survival (OS), an absence of genetic annotation in early mortality studies, and reliance on clinical trial cohorts which may not be broadly representative. Here, we perform a detailed analysis of pretreatment clinical and disease characteristics in a cohort of real-world AML patients to elucidate factors associated with early mortality and with OS after induction. Methods: We identified 290 consecutive adult patients treated with standard induction chemotherapy ("7+3" with cytarabine and an anthracycline, or CPX-351) for newly diagnosed AML (2014-2019). We collected pretreatment clinical, pathology, and laboratory data, and annotated clinical outcomes. Gene mutations were determined at the time of diagnosis using targeted next-generation sequencing of recurrently mutated genes. The median age at diagnosis was 61 years (range 19-76), with 56% of patients aged 60 or older. Most patients (71%) had de novo AML; 15% had clinically defined secondary AML and 14% had therapy-related AML. Median follow-up for survivors landmarked at 60 days was 26.1 months, with a minimum follow up of at least 60 days for all patients. Median OS and relapse-free survival (RFS), both landmarked at day 60, were 33.9 months and 28.0 months, respectively. Results: In total, 24 of 290 (8%) patients died within the first 60 days of receiving induction chemotherapy, with shock being the most common cause of death (42%), followed by respiratory failure (21%) (Figure 1A). In a multivariable logistic regression model, we found that pretreatment albumin < 3 mg/dL, pretreatment LDH >= 600 U/L, and mutations in TET2 or RUNX1 were independently associated with death within 60 days (Figure 1B). Factors not independently associated with early mortality included older age (<60 versus 60 or older), clinical ontogeny (secondary or treatment-related AML), complex karyotype, and pretreatment blood counts. To identify factors associated with outcomes among patients surviving past 60 days, we generated a multivariable model with allogeneic stem cell transplantation as a time-varying covariate. In this model, age >= 60, secondary AML, pretreatment LDH >= 600 U/L, and the presence of TP53 mutation, U2AF1 mutation, or 11q23 rearrangement were independently associated with inferior OS after day 60, whereas the presence of CBF rearrangement was independently associated with superior OS after day 60 (Figure 1C). To determine the contribution of resistant disease to OS landmarked at day 60, we developed multivariable models for failure to achieve remission by day 60 and for RFS landmarked at day 60, and then applied them to the OS model. All variables remained significant, indicating that disease resistance is a main driver of OS after 60 days. Conclusions: Early treatment-related mortality is most commonly the result of shock and respiratory failure, irrespective of disease status, and is associated with specific pretreatment lab values (elevated LDH, low albumin) and disease-specific mutations (TET2 and RUNX1). Among patients surviving induction, survival is driven primarily by resistant disease (primary refractoriness and disease relapse) and is associated with factors previously correlated with outcome in AML, including age, clinical ontogeny, and disease genetics. Overall, we show that early and late outcomes in AML are associated with distinct sets of pretreatment clinical, genetic, and laboratory characteristics and for the first time show that disease-specific mutations are associated specifically with induction toxicity. Improved ability to identify patients likely to experience toxicity after receiving anthracycline-based AML induction may help develop mitigation strategies for these patients. Figure 1: Predictors of early mortality and overall survival in AML patients undergoing induction. A. Clinical and genetic characteristics of early mortality patients. B-C. Forest plots of multivariate analysis of pretreatment risk factors associated with early mortality (B) and with OS landmarked at 60 days (C). Disclosures Lindsley: Jazz Pharmaceuticals: Consultancy, Research Funding; Takeda Pharmaceuticals: Consultancy; MedImmune: Research Funding; Bluebird Bio: Consultancy.

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Myelodysplastic syndromes (MDS) are clonal hematopoietic stem cell (HSC) malignancies characterized by ineffective hematopoiesis. Genetic alterations do not fully explain the molecular pathogenesis of the disease, indicating that other types of lesions, such as transcriptional aberrations, may play a role in its development. Moreover, MDS prevalence is almost exclusive to older patients, suggesting that elderly-related alterations may predispose to the development of this clinical entity. Thus, study of the transcriptional lesions occurring in the aging-MDS axis could shed some light of the molecular bases of the disease. To characterize the transcriptional profile of HSCs in aging and MDS, we isolated CD34+, CD38-, CD90+, CD45RA- cells from 11 untreated MDS patients with unilineage and multilineage dysplasia (median of 75 y/o), as well as from 16 young and 8 elderly healthy donors (median of 21 and 70 y/o, respectively), and their expression profile was analyzed using MARS-seq. Unsupervised principal component analysis demonstrated that the three groups of HSCs clustered separately, indicating that different expression profiles characterize healthy young and elderly, and MDS-associated HSCs. To better understand the gene expression deregulation of HSCs, we analyzed the transcriptional dynamisms along the aging-MDS axis, detecting groups of genes following different patterns of expression. Some gene clusters showed exclusive alteration either in aging or in the progression from elderly HSCs to MDS-HSCs, other groups of genes presented a continuous alteration along the axis, and some displayed opposite regulation in aging and in the transition to MDS (Figure 1). Genes showing specific downregulation in aging were involved in DNA damage sensing and repair, and in cell cycle regulation, whereas genes overexpressed in this process were enriched in apoptosis regulators and in cancer-associated genes, including AML-related factors. These findings indicate that transcriptional changes in aging may predispose for MDS and AML, and potentially other malignancies. Interestingly, we detected a group of genes in which the age-mediated upregulation of gene expression was reversed to that of young HSCs in MDS, indicating a "rejuvenation" profile of malignant HSCs. These genes were involved in response to inflammation, to different types of stress conditions such as hypoxia or radiation, and to cytokines. Elderly HSCs may upregulate such genes in response to the known inflammatory microenvironment of elderly bone marrow. Intriguingly, the decrease in expression detected in MDS suggests that malignant HSCs lose the ability of reacting to such stimuli, possibly favoring their survival in a hostile microenvironment. Finally, the analyses performed allowed for the identification of genes showing MDS-specific deregulation. Genes specifically overexpressed in MDS compared to normal (both young and elderly) HSCs, we enriched in transcriptional and epigenetic regulators, and among them, we detected the presence of DDIT3/CHOP, a member of the CCAAT/enhancer-binding protein (C/EBP) family of transcription factors. To determine its potential effects on hematopoietic deregulation, DDIT3 was exogenously overexpressed in healthy HSCs. Notably, its upregulation produced an erythroid bias in an ex-vivo differentiation system, with an increase in the percentage of erythroblasts and a decrease in granulocytes and monocytes compared to HSCs transduced with the empty vector. Transcriptomic analysis of transduced HSCs not subjected to differentiation demonstrated how DDIT3 overexpression produced an erythroid-prone state of HSCs, suggesting it may act as a pioneer factor in MDS-HSCs. Furthermore, gene set enrichment analysis showed that DDIT3 overexpression produced an MDS-like transcriptional profile, suggesting this factor may be key in the acquisition of the disease. Altogether, our results demonstrate that HSCs undergo transcriptional changes in the aging-MDS axis that may alter their intrinsic functions as well as their response to the microenvironment, ultimately contributing to the acquisition of the disease. In particular, our data show that DDIT3 may be a potential driver of MDS transformation. Disclosures Paiva: Amgen, Bristol-Myers Squibb, Celgene, Janssen, Merck, Novartis, Roche, and Sanofi; unrestricted grants from Celgene, EngMab, Sanofi, and Takeda; and consultancy for Celgene, Janssen, and Sanofi: Consultancy, Honoraria, Research Funding, Speakers Bureau. Díez-Campelo:Celgene Corporation: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding.

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A study was done to assess the ability for visual search and recognition of roadside targets and safety errors during a landmark and traffic sign identification task in drivers with stroke, that is, drivers who have had a stroke. Visual search for roadside targets during automobile driving can compete for a driver's cognitive resources and may impair driving, especially in drivers with cognitive impairment caused by stroke. Thirty-two drivers with stroke and 137 neurologically normal older adults underwent a battery of visual, cognitive, and motor tests and were asked to report sightings of specific landmarks and traffic signs along a segment of an experimental drive. The drivers with stroke identified significantly fewer landmarks and traffic signs and showed a tendency to make more at-fault safety errors during the task than did control subjects. Roadside target identification performance and safety errors were predicted by scores on standardized tests of visual, cognitive, and motor function. Drivers with stroke are impaired in a task of visual search and recognition of roadside targets whose demands on visual perception, attention, executive functions, and memory probably increased the cognitive load and worsened their driving safety.

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Background: Older AML patients often present with comorbidities and may have a compromised ability to tolerate intensive chemotherapy. These patients are more likely to have AML secondary to MDS/MPN and are considered to have a biologically distinct disease compared to their younger counterparts, with more frequent occurrence of adverse-risk cytogenetic abnormalities and mutations in genes regulating epigenetic modifications. In addition, the heterogeneity of driver mutations within a single patient contributes to limited responses to standard induction chemotherapy. While FLT3 mutations occur in this population, they are often subclonal, adding to the challenge of eradicating AML in older adult patients. Studies combining sorafenib or midostaurin with standard induction chemotherapy have shown relatively modest improvements in response rates and survival, and relapses, both early and late, remain a major concern. There is a major unmet need for optimizing chemotherapy and TKI treatment in this medically fragile population. We here report the safety and efficacy results in newly diagnosed older patients with FLT3 mutant AML treated with crenolanib, a type I FLT3 inhibitor, in combination with intensive induction and consolidation chemotherapy (NCT02283177). Methods: Fifteen consecutively treated patients, aged 61-75 (median age: 68), at four academic cancer centers were included in this analysis. Patients received 7+3 induction with cytarabine 100 mg/m2 for 7 days and either daunorubicin 60 mg/m2 or idarubicin 12 mg/m2 for 3 days. Crenolanib 100 mg TID was administered continuously starting 24 hours after chemotherapy until 72 hours prior to the next chemotherapy cycle. Consolidation consisted of up to 4 cycles of high-dose cytarabine (HiDAC: 1 g/m2) q12h on days 1, 3, and 5 with crenolanib starting 24 hours after the final HiDAC dose. Eligible patients proceeded to allogeneic hematopoietic stem cell transplant (HSCT). Maintenance with crenolanib at 100mg TID was started after HiDAC or 30-90 days after HSCT for up to 12 cycles. Results: Fourteen patients completed induction chemotherapy (one patient withdrew consent at day 19). Crenolanib could be safely combined with either daunorubicin or idarubicin based induction chemotherapy. The most common adverse events (grade ≥3) were diarrhea, nausea, and febrile neutropenia. Ten of 14 patients were able to receive full doses of crenolanib during induction. The major reason for dose reduction was edema in 3 patients and GI bleeding in 1 patient. There was one treatment-related death, with 93% survival at 30 and 60 days and 87% survival at 100 days. Complete remissions with full count recovery (CR) were achieved in 10 of 15 patients after just one cycle of induction chemotherapy. Two patients achieved a complete remission after reinduction for an overall CR rate of 86%. Of the 12 patients who achieved CR, 10 patients received HiDAC consolidation, with two patients unable to receive consolidation therapy on study. Three patients received crenolanib maintenance after multiple cycles of HiDAC consolidation. Six patients underwent HSCT and 3 received crenolanib maintenance. As of July 2019, median OS for the intent to treat population is 20.2 months. One-year survival was 67% and 5 patients remain alive and in remission. All 5 long term survivors were ≤70 years old. All surviving patients received either multiple cycles of HiDAC or HiDAC plus transplant, and 4/5 underwent crenolanib maintenance. The patient who did not receive transplant completed 3 cycles of HiDAC consolidation and a full year of crenolanib maintenance. Summary/Conclusion: This safety study shows that crenolanib can be combined at full doses (100mg TID) for the duration of 7+3 induction, consolidation, and maintenance in older patients with FLT3 mutant AML. Therapy was relatively well tolerated, with less than one third of patients requiring dose reductions. Long-term survival rates are encouraging in this high-risk population, but additional studies are needed to confirm the efficacy of this combination older adults. Figure 1 Disclosures Wang: Pfizer: Other: Advisory role, Speakers Bureau; Stemline: Other: Advisory role, Speakers Bureau; Abbvie: Other: Advisory role; Kite: Other: Advisory role; Jazz: Other: Advisory role; Astellas: Other: Advisory role, Speakers Bureau; celyad: Other: Advisory role; Daiichi: Other: Advisory role; Amgen: Other: Advisory role; Agios: Other: Advisory role. Griffiths:Abbvie, Inc.: Consultancy; Genentech, Inc.: Research Funding; Celgene, Inc: Consultancy, Research Funding; Onconova Therapeutics: Other: PI on a clinical trial; Novartis Inc.: Consultancy; Appelis Pharmaceuticals: Other: PI on a clinical trial; Onconova Therapeutics: Other: PI on a clinical trial; Appelis Pharmaceuticals: Other: PI on a clinical trial; New Link Genetics: Consultancy; Partner Therapeutics: Consultancy; Genentech, Inc.: Research Funding; Astex Phramaceuticals/Otsuka Pharmaceuticals: Consultancy, Research Funding; Astex Phramaceuticals/Otsuka Pharmaceuticals: Consultancy, Research Funding; Abbvie, Inc.: Consultancy, PI on a clinical trial; Celgene, Inc: Consultancy, Research Funding; Boston Scientific: Consultancy; Boston Scientific: Consultancy; Persimmune: Consultancy; Persimmune: Consultancy; New Link Genetics: Consultancy; Partner Therapeutics: Consultancy; Novartis Inc.: Consultancy. Walter:Jazz Pharmaceuticals: Consultancy; Agios: Consultancy; Amgen: Consultancy; Amphivena Therapeutics: Consultancy, Equity Ownership; Aptevo Therapeutics: Consultancy, Research Funding; Argenx BVBA: Consultancy; Astellas: Consultancy; BioLineRx: Consultancy; Kite Pharma: Consultancy; New Link Genetics: Consultancy; Pfizer: Consultancy, Research Funding; Race Oncology: Consultancy; Seattle Genetics: Research Funding; Boston Biomedical: Consultancy; Covagen: Consultancy; BiVictriX: Consultancy; Daiichi Sankyo: Consultancy; Boehringer Ingelheim: Consultancy. Tallman:Hematology Oncology of Indiana: Honoraria; Salzberg Weill Cornall MSKCC Seminar in Hematologic Malignancies: Honoraria; University of Oklahoma Medical Center: Honoraria; Bioline: Membership on an entity's Board of Directors or advisory committees, Research Funding; BioSight: Membership on an entity's Board of Directors or advisory committees, Research Funding; Daiichi-Sankyo: Membership on an entity's Board of Directors or advisory committees; KAHR: Membership on an entity's Board of Directors or advisory committees; Nohla: Membership on an entity's Board of Directors or advisory committees, Research Funding; Rigel: Membership on an entity's Board of Directors or advisory committees; AbbVie: Membership on an entity's Board of Directors or advisory committees, Research Funding; ADC Therapeutics: Research Funding; Arog Pharmaceuticals: Research Funding; Cellerant Therapeutics: Research Funding; Orsenix: Membership on an entity's Board of Directors or advisory committees, Research Funding; UpToDate: Patents & Royalties; Mayo Clinic: Honoraria; New Orleans Summer Cancer Conference: Honoraria; Indy Hematology Review: Honoraria; Amgen: Consultancy; 14th Annual Miami Cancer Meeting: Honoraria; Danbury Hospital Tumor Board: Honoraria; International Conference in Leukemia: Honoraria. Goldberg:ADC Therapeutics: Research Funding; Arog Pharmaceuticals: Research Funding; American Society of Clinical Oncology: Research Funding; American Society of Hematology: Research Funding; Celgene: Consultancy; Abbvie: Research Funding; Pfizer: Research Funding; Abbvie: Consultancy; Daiichi-Sankyo: Consultancy, Research Funding; DAVA Oncology: Honoraria. Messahel:Arog Pharmaceuticals: Employment. Stone:Pfizer: Consultancy; Stemline: Consultancy; Astra-Zeneca: Consultancy; Argenix: Other: DSMB; Otsuka: Consultancy; Astellas: Consultancy; Argenix: Other: DSMB; Celgene: Consultancy, Other: DSMB; Stemline: Consultancy; Actinium: Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy; Biolinerx: Consultancy; Biosight: Consultancy; Trovagene: Consultancy; Arog: Consultancy, Research Funding; Takeda: Other: DSMB; Novartis: Consultancy, Research Funding; Daiichi-Sankyo: Consultancy; Celgene: Consultancy, Other: DSMB; Abbvie: Consultancy, Research Funding; Agios: Consultancy, Research Funding; Takeda: Other: DSMB; Biolinerx: Consultancy; Daiichi-Sankyo: Consultancy; Actinium: Membership on an entity's Board of Directors or advisory committees; Otsuka: Consultancy; Jazz: Consultancy; Trovagene: Consultancy; Astra-Zeneca: Consultancy; Novartis: Consultancy, Research Funding; Roche: Consultancy; Macrogenics: Consultancy; Agios: Consultancy, Research Funding; Biosight: Consultancy; Abbvie: Consultancy, Research Funding; Arog: Consultancy, Research Funding; Pfizer: Consultancy; Trovagene: Consultancy; Novartis: Consultancy, Research Funding; Agios: Consultancy, Research Funding; Arog: Consultancy, Research Funding; Macrogenics: Consultancy; Otsuka: Consultancy; Argenix: Other: DSMB; Astellas: Consultancy; Amgen: Membership on an entity's Board of Directors or advisory committees; Jazz: Consultancy; Biolinerx: Consultancy.

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The accumulation of protein damage is one of the major drivers of replicative ageing, describing a cell’s reduced ability to reproduce over time even under optimal conditions. Reactive oxygen and nitrogen species are precursors of protein damage and therefore tightly linked to ageing. At the same time, they are an inevitable by-product of the cell’s metabolism. Cells are able to sense high levels of reactive oxygen and nitrogen species and can subsequently adapt their metabolism through gene regulation to slow down damage accumulation. However, the older or damaged a cell is the less flexibility it has to allocate enzymes across the metabolic network, forcing further adaptions in the metabolism. To investigate changes in the metabolism during replicative ageing, we developed an multi-scale mathematical model using budding yeast as a model organism. The model consists of three interconnected modules: a Boolean model of the signalling network, an enzyme-constrained flux balance model of the central carbon metabolism and a dynamic model of growth and protein damage accumulation with discrete cell divisions. The model can explain known features of replicative ageing, like average lifespan and increase in generation time during successive division, in yeast wildtype cells by a decreasing pool of functional enzymes and an increasing energy demand for maintenance. We further used the model to identify three consecutive metabolic phases, that a cell can undergo during its life, and their influence on the replicative potential, and proposed an intervention span for lifespan control.

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OBJECTIVES/SPECIFIC AIMS: To access obesity risk perceptions, knowledge and behaviors of Hispanic taxi cab drivers and develop a better understanding of the factors that influence health outcomes in this population. METHODS/STUDY POPULATION: Focus groups were conducted at NYC H+H/Lincoln, where subjects were screened and recruited from taxi bases with the help of the local Federation of Taxi Drivers. This was done by utilizing flyers, messages through taxi-base radios, and referrals from livery cab drivers. Approval from the local Institutional Review Board was obtained. The research investigators, developed a structured focus group procedural protocol of open-ended interview questions related to cardiovascular disease. Participants for the focus groups were older than 18 years old and working as livery cab drivers in NYC for at least 6 months. Three focus groups were held with informed consent obtained from each participant in their primary language before the start of each session. After completion of the focus group, participants received a gift voucher for attending the approximately 1-hour session. Focus groups were moderated by trained research staff members at Lincoln. Three main categories of questions were organized based on perception, knowledge, and behavior. Participants were questioned on topics about obesity, CVD and diabetes knowledge; knowledge about etiology, risk perception, possible prevention and interventions. Responses were recorded using audiotapes and transcribed verbatim. If participants did not elaborate on the initial question, a probing question was asked to clarify. The transcript was translated from Spanish by trained bilingual staff and analyzed using standard qualitative techniques with open code method. Four research investigators read the transcript separately and formulated concepts, which were then categorized and formulated into dominant themes. These themes were then compared and analyzed with a group consensus to ensure representative data. Once recurring themes emerged and the saturation point was reached, the study concluded, after enrolling 25 participants. The Health Believe Model (HBM) was employed to understand and explain the perceptions and behaviors of taxi drivers. HBM is one of the most widely recognized models and is used to understand, predict and modify health behavior. HBM helps to identify perception of risks of unhealthy behavior, barriers for having healthy behavior, actions taken by patients to stay healthy, self-efficacy and commitment to goals [12]. RESULTS/ANTICIPATED RESULTS: Of the 25 Hispanic livery cab drivers, 92% were male. The majority of taxi drivers that participated in the study were immigrants (96%), with a mean age of 53 years (ranged 21–69), and 92%, were spoke Spanish. In total, 52% participants identified themselves as Hispanic, 20% White, 4% Black, and 20% did not identify their race. Mean body mass index (BMI) was 31 (22.8–38.7) kg/m2. In all, 56% were obese and another 40% were overweight. From this sample, 50% had been diagnosed with hypertension and 27% were living with diabetes. In all, 64% had a high school education or higher. Answers provided by the taxi drivers to focus group questions were recorded, reviewed and divided into 8 dominant themes based on concepts that emerged from the focus groups discussions. (a) Focus group study findings: Themes recorded during the focus group discussions, include poor diet, sedentary lifestyle, comorbidities/risk factors, stress, health not being a priority, discipline, education, and intervention. Participants shared their opinions in regards to these themes with minimal differences, making an emphasis on the fact that the nature of their profession was the root cause. Of the themes, the top 3 dominant themes include poor diet, sedentary/lifestyle and comorbidities/risk factors. (1) Diet: The theme “Poor diet” evolved from 151 related concepts that were described by participants. All 25 participants perceived their diet as bad due to eating high-fat meals associated with the cultural food and restaurant chains with lower food prices and ease of car parking. Drivers also reported that they did not have enough time to eat healthy foods based on their long working hours. They say: “comemos muy tarde por que preferimos montar un pasajero” … stating that they preferred to pick up passengers and delay their meals. However, they consider poor diet as the most decisive factor in their increased risk for obesity, diabetes, and hypertension. (2) Life Style: The theme “Sedentary lifestyle” was derived from 147 similar concepts described by participants. They believe that physical inactivity is another leading risk factor for obesity, diabetes, and CVD. The demands of the profession force them to drive more than 10 hours per day. They understand the importance of daily exercise but they admit that at the end of the workday they are too tired to exercise or “stop working” to participate in exercise as this means less money. They also understand that family history of obesity in addition to poor diet increases their risk of obesity, diabetes, and cardiovascular risks. (3) Comorbidity: The theme “Comorbidities” developed from 143 concepts grouped together. Taxi-drivers perceived that obesity complications directly affects many vital organs, such as the kidneys, the heart, and vasculature. Participants perceive obesity as important risk factor for high blood sugar and cholesterol levels. Taxi drivers see an association between their health condition and their work as a taxi driver. However, taxi-drivers reported that they are more concerned about the economic well-being of their families than themselves. Taxi-drivers begin to intervene in their own health only when more serious health conditions related to obesity, diabetes, and hypertension developed. (4) Work Stress: The theme “Stress/other risk factors” was derived from 141 concepts. Taxi-drivers perceive their profession with lack of organization and high-stress levels as one of the leading risk factors contributing to obesity, diabetes, and cardiovascular disease. They also attribute a combination of stressful lifestyle, poor diet, lack of exercise, consumption of alcohol and cigarettes as determining factors in developing negative health outcomes. “One participant says; Tenemos el paquete completo” … we have the entire package. (5) Health as a priority: The theme “Health is not a priority” was derived from 120 concepts based on the cab drivers’ responses. Taxi drivers prioritize their work while their health takes a back seat. They work long shifts as they feel the pressures of financial responsibilities of their family. They admitted lack of intentions to change their behavior and they consider themselves as “hard headed.” Drivers changed their behavior only when serious health conditions develop that require professional medical attention. Taxi drivers explain that the lack of time as being a big factor in pursuing preventative care. (6) Personal Discipline: The theme “Discipline” evolved from 80 concepts derived from the driver’s transcripts. Taxi drivers are aware of their lack of organizational skills in general, especially when it comes to the balance between work and a healthy lifestyle. Taxi drivers recognize that not being disciplined results in the development of their obesity and chronic health conditions. Drivers admit that they do not have a fixed schedule, with no direct supervision, and cannot find the time to go to the doctor or change their behavior. (7) Health Education: The theme “Education” was derived from79 concepts noted from the focus group discussion. Taxi drivers know that their lack of health education is affecting them. With little understanding about the severity of the disease process it is difficult to take proactive measures. They are interested in the development of programs that will educate them about obesity, diabetes and CVD prevention. They want to attend programs that can educate them about prevention of obesity, diabetes, and CVD prevention with strong focus on healthy eating. They understand that this would increase their ability to change their unhealthy behavior. (8) Health interventions: The last major theme “Intervention” was derived out of 71 concepts. When asked about possible interventions that might help them towards healthy behaviors, taxi drivers think that the use of technology as a means of education is very effective. They understand the most direct route to reach them is by cellphone, email, and social media such as Facebook. They also feel that it would be good to use this type of communication to not only to inform them about health issues, but to also educate them directly. (b) Application of Health Behavior Model: We employed the HBM, one of the most utilized and easy to understand health models (18, 20–22) to explain the knowledge, perception, and health behaviors of our study participants. The HBM consist of 6 posits: (1) risk susceptibility, (2) risk severity, (3) benefits of action, and (4) barriers to action, (5) self-efficacy, and (6) cues to action [23]. According to the HBM, people’s beliefs about their risk and their perception of the benefits of taking action to avoid it, influence their readiness to take action [15, 21–22, 24]. Using the HBM, health behavior can be modified positively if the 6 posits are perceived by the person [23]. According to the results of our study, taxi drivers that participated in our study, do not perceive the severity of their risk. Participants admitted that they go to the doctor and start paying attention to their health condition only when they get seriously sick. Another posit of the HBM, understanding benefit of actions, is also not perceived by taxi drivers. Participants understand that they should be involved in physical activity, but do not pursue physical activity. They stated that they are too busy and tired to exercise daily without realizing the benefits of having a healthy life style. Findings from the focus groups also demonstrate that taxi drivers do not possess self-efficacy, as they are not confident that they are able to change their own health behavior. They openly admitted to having poor discipline, lack of organizational skills, and lack of time management skills. But, they expressed their wish to get information about time management, healthy snacks, places where they can get affordable and healthy food, learn more about different physical activities, and places where they can exercise. The sixth posit of the HBM model is the cues for action which should trigger the action to change behavior. Cues such as physical pain or illness in them or family members of cab drivers, trigger a visit to the physician’s office. Cab drivers were open to receiving educational material provided by physicians or health information provided on TV/cellphone about disease prevention. DISCUSSION/SIGNIFICANCE OF IMPACT: Obesity is steadily on the increase in the US population and has become a major public health concern [1–3]. Latinos are at the higher risk of heart diseases such as obesity, hypertension compared to other ethnical groups [3, 13]. There is a higher prevalence of obesity among particular occupational groups with cab drivers having one of the highest obesity prevalence among all professions [5, 7–9, 13]. Obesity risks therefore seem to affect NYC cab drivers who are of Latino background more than others. Surveys conducted in different countries in Asia, Europe, and Africa reported that taxi, truck, and bus show that drivers are at a higher risk of developing obesity, diabetes, and hypertension [5, 8–11]. This study is the first to evaluate the knowledge, perception, and behaviors of NYC Latino taxi cab drivers with respect to obesity. The study uncovers factors and barriers that contribute to their behavior, and identify possible ways that can modify their behavior and decrease their chances of developing obesity. The study results demonstrated that Latino immigrant taxi drivers perceive themselves at a high risk for obesity development. As the result of discussions with focus groups, the eight dominant themes were identified. Participants perceive their risk susceptibility and understand that working as a driver is a sedentary occupation with lack of physical activity significantly contributing to obesity development. Additionally, taxi drivers report that their unhealthy diet is a major factor that contributes to their weight gain. Taxi drivers perceive their poor diet as the result of the food they consume being high in fat content. Due to financial constraints and their cultural diet requirements, they feel limited to unhealthy food options. They acknowledge the risk that poor diet contributes to obesity, high cholesterol, obesity development. Participants also expressed that work stress is another important factor. Busy traffic, lack of organization, financial stress to support their families-push them to work prolonged hours. Participants also admitted that in their leisure time, they use alcohol, smoke cigarettes, and watch TV, instead of going to the gym, because they feel too tired to exercise. Taxi drivers perceive their barriers as a lack of education and knowledge about healthy food choices, places where they can buy healthy affordable snacks, information about physical activities, stress management skills, and organizational skills. Other perceived barriers that prevent them from leading healthy lifestyle include lack of discipline, lack of time for physical activity, economic uncertainty, financial responsibility and the perception that the wellbeing of their families is more important than themselves and their health. HBM is a widely used model that helps to identify perception of risks of unhealthy behavior, barriers to healthy behavior, actions taken by patients to stay healthy, self-efficacy, and commitment to goals. Based on the Glasgow theory, the core of health behavior models is the identification of the barriers and self-efficacy [25]. Our study is unique as it involves using the HBM to explain the basis of taxi cab drivers’ behavior. Results of our research study showed that our participants perceived barriers very well. However, lack of self-efficacy, lack of perceiving benefits of action, lack of cues to action, and lack of understanding the risk of disease severity explain why taxi drivers have greater risk for obesity among occupations, and are not ready to embrace health behavior modification. This qualitative study shows us where the window of opportunity for intervention lies, how we can intervene and modify the health behavior of the at-risk NYC Latino cab driver population. By Glasgow theory, self-efficacy is an important factor in behavior modification models [25]. If the barriers that are perceived by participants as too high, and self-efficacy is low, one can intervene by improving self-efficacy. Bandura has offered ways to increase patients’ self-efficacy by using three strategies: (a) setting small, incremental, and achievable goals; (b) using formalized behavioral contracting to establish goals and specify rewards; and (c) monitoring and reinforcement, including patient self-monitoring by keeping records [20]. We can also improve perception of the benefits of action by providing cues to action namely education during the office visits, by providing reading materials, and the use of modern technology (emails, interactive Web sites, apps, etc.). A study was conducted in South Asia, encouraging taxi drivers to exercise through the use of pedometers [7]. This study provides an example of ways to motivate taxi drivers, improve their self-efficacy, overcome barriers, and provide cues to action. As one of the theories that can explain and help in behavioral modification, the Health Belief model includes the impact of the environment and elements of social learning. Using this model, we were able to differentiate and identify the factors that influence their behavior that need to be addressed by health care workers and public health representatives to improve obesity related risks among inner city taxi cab drivers in NYC.

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AbstractEvidence suggests that drivers with cataract self-regulate their driving, but there is a lack of objective information. This study compared speed behavior in older drivers with and without cataract and how the parameter is influenced by road traffic complexity and driver characteristics. The study included 15 drivers with cataract and a control group of 20 drivers. Visual status was assessed using visual acuity, contrast sensitivity, and intraocular straylight. Speed management was studied using a driving simulator. Driving difficulty and self-regulation patterns were evaluated by means of the Driver Habits Questionnaire (DHQ). The cataract group showed a significant decrease in visual function in all the parameters evaluated (p < 0.05). These drivers tended to drive at lower speeds than the control group. Road characteristics, gender, and intraocular straylight in the better eye were identified as significant predictors of speed management. Drivers with cataract experience greater driving difficulty, particularly when driving at night (p < 0.05). Drivers with cataract reduce their driving speed more than older drivers without visual impairment. The straylight parameter may be a good indicator of each driver’s subjective perception of their own visual ability to drive. This work helps shed light on the mechanisms through which age-related visual impairment influences driving behavior.

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PurposeProper understanding and interaction with the dashboard is an essential aspect of safely operating a motor vehicle. A portion of this task is dependent on vision, yet no published information exists regarding dashboard ergonomics and visual function. This study sought to associate visual functions and person abilities of dashboard ergonomic dimensions relevant to older driver design preferences and attitudes.MethodsIn this population-based study of drivers, participants completed functional testing for habitual distance visual acuity, contrast sensitivity, visual field sensitivity, visual processing speed, and spatial ability. A questionnaire assessed attitudes and understanding of dashboard design, with questionnaire items generated from the content of focus groups of older drivers. Dashboard design domains identified in Rasch analysis of questionnaire responses were quantified using person ability measures for the cognitive processing, lighting, obstructions, and pattern recognition domains. Visual functions and person abilities were correlated using Spearman partial correlations, adjusting for age and sex.ResultsA total of 997 participants completed functional testing and the dashboard questionnaire. The mean age was 77.4 ± 4.6 years, and the majority were male (55%) and white (81%). The sample had a range of person abilities and visual functions. Contrast and visual field sensitivities were significantly associated with the cognitive processing, lighting, and pattern recognition dashboard design dimensions (p ≤ 0.0052). For all significant associations, increased visual function was indicative of better person ability. Visual processing speed, as measured by Trails B and UFOV2, was significantly associated with the lighting domain (p = 0.0008 and p = 0.0007, respectively). The UFOV2 measure was correlated with pattern recognition (p = 0.0165). Spatial ability was the only visual function associated with the visual obstruction dimension (p = 0.0347).ConclusionsPerson ability for dashboard design domains are related to visual function in older drivers. Results show person ability for domains increased with improved visual function. Future automotive engineering and design initiatives should consider these associations in improving dashboard designs to increase vehicle utility and accessibility.

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BackgroundImpaired driving ability in patients with Alzheimer’s disease (AD) is associated with a decline in cognitive processes and a deterioration of their basic sensory visual functions. Although a variety of ocular abnormalities have been described in patients with AD, little is known about the impact of those visual disorders on their driving performance.AimAim of this mini-review is to provide an update on the driving ability of patients with dementia and summarize the primary visual disorders affecting their driving behavior.MethodsDatabases were screened for studies investigating dementia, associated visual abnormalities and driving ability.ResultsThere is consistent evidence that dementia affects driving ability. Patients with dementia present with a variety of visual disorders, such as visual acuity reduction, visual field defects, impaired contrast sensitivity, decline in color vision and age-related pathological changes, that may have a negative impact on their driving ability. However, there is a paucity in studies describing the impact of oculovisual decline on the driving ability of AD subjects. A bidirectional association between cognitive and visual impairment (VI) has been described.ConclusionGiven the bidirectional association between VI and dementia, vision screening and cognitive assessment of the older driver should aim to identify at-risk individuals and employ timely strategies for treatment of both cognitive and ocular problems. Future studies should characterize the basic visual sensory status of AD patients participating in driving studies, and investigate the impact of vision abnormalities on their driving performance.

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Objective We explored the convergent and discriminant validity of three driving simulation scenarios by comparing behaviors across gender and age groups, considering what we know about on-road driving. Background Driving simulators offer a number of benefits, yet their use in real-world driver assessment is rare. More evidence is needed to support their use. Method A total of 104 participants completed a series of increasingly difficult driving simulation scenarios. Linear mixed models were estimated to determine if behaviors changed with increasing difficulty and whether outcomes varied by age and gender, thereby demonstrating convergent and discriminant validity, respectively. Results Drivers adapted velocity, steering, acceleration, and gap acceptance according to difficulty, and the degree of adaptation differed by gender and age for some outcomes. For example, in a construction zone scenario, drivers reduced their mean velocities as congestion increased; males drove an average of 2.30 km/hr faster than females, and older participants drove more slowly than young (5.26 km/hr) and middle-aged drivers (6.59 km/hr). There was also an interaction between age and difficulty; older drivers did not reduce their velocities with increased difficulty. Conclusion This study provides further support for the ability of driving simulators to elicit behaviors similar to those seen in on-road driving and to differentiate between groups, suggesting that simulators could serve a supportive role in fitness-to-drive evaluations. Application Simulators have the potential to support driver assessment. However, this depends on the development of valid scenarios to benchmark safe driving behavior, and thereby identify deviations from safe driving behavior. The information gained through simulation may supplement other forms of assessment and possibly eliminate the need for on-road testing in some situations.

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Abstract Background and Objectives Although poor diet is a major driver of morbidity and mortality in people 60 and older, few dietary interventions are widely implemented for this population. We mapped behavior change theories, agents, and techniques in dietary interventions for adults 60+ and explored relationships between these factors and ability to retain at least 80% of the study participants. Research Design and Methods We conducted a scoping review using MEDLINE, CINAHL, and Web of Science through April 2021 for dietary interventions in adults 60 and older. We collated, summarized, and calculated frequency distributions of behavior change theories, behavior change agents, and behavior change techniques (BCTs) using BCTv1 taxonomy with regard to participant retention across 43 studies. Results Only 49% and 30% of the studies reported behavior theory and change agents respectively. Of the studies reporting on theory and agents, the most common were social cognitive theory and the related mechanism of self-efficacy. The most common BCTv1 were “shaping knowledge” and “goals and planning.” Several BCTv1 such as “antecedents” and “reward and threat” and evidence for concordance between BCTs and change agents were more common in interventions with higher retention rates. Discussion and Implications Mechanistically concordant studies with BCTs that involve resource allocation and positive reinforcement through rewards may be advantageous for retention in dietary intervention for older adults. Future studies should continue developing theory and mechanism-oriented research. Furthermore, future studies should consider diversifying the portfolio of currently deployed BCTs and strengthening a concordance between BCTs and mechanisms of change.

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Abstract Background The etiology of the low-level chronic inflammatory state associated with aging is likely multifactorial, but a number of animal and human studies have implicated a functional decline of the gastrointestinal immune system as a potential driver. Gut tissue-resident memory T cells play critical roles in mediating protective immunity and in maintaining gut homeostasis, yet few studies have investigated the effect of aging on human gut T cell immunity. To determine if aging impacted CD4 T cell immunity in the human large intestine, we utilized multi-color flow cytometry to measure colonic lamina propria (LP) CD4 T cell frequencies and immune-modulatory marker expression in younger (mean ± SEM: 38 ± 1.5 yrs) and older (77 ± 1.6 yrs) adults. To determine cellular specificity, we evaluated colon LP CD8 T cell frequency and phenotype in the same donors. To probe tissue specificity, we evaluated the same panel of markers in peripheral blood (PB) CD4 T cells in a separate cohort of similarly aged persons. Results Frequencies of colonic CD4 T cells as a fraction of total LP mononuclear cells were higher in older persons whereas absolute numbers of colonic LP CD4 T cells per gram of tissue were similar in both age groups. LP CD4 T cells from older versus younger persons exhibited reduced CTLA-4, PD-1 and Ki67 expression. Levels of Bcl-2, CD57, CD25 and percentages of activated CD38+HLA-DR+ CD4 T cells were similar in both age groups. In memory PB CD4 T cells, older age was only associated with increased CD57 expression. Significant age effects for LP CD8 T cells were only observed for CTLA-4 expression, with lower levels of expression observed on cells from older adults. Conclusions Greater age was associated with reduced expression of the co-inhibitory receptors CTLA-4 and PD-1 on LP CD4 T cells. Colonic LP CD8 T cells from older persons also displayed reduced CTLA-4 expression. These age-associated profiles were not observed in older PB memory CD4 T cells. The decline in co-inhibitory receptor expression on colonic LP T cells may contribute to local and systemic inflammation via a reduced ability to limit ongoing T cell responses to enteric microbial challenge.

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Abstract Background Older drivers have a crash rate nearly equal to that of young drivers whose crash rate is the highest among all age groups. Contrast sensitivity impairment is common in older adults. The purpose of this study is to examine whether parameters from the photopic and mesopic contrast sensitivity functions (CSF) are associated with incident motor vehicle crash involvement by older drivers. Methods This study utilized data from older drivers (ages ≥60 years) who participated in the Strategic Highway Research Program Naturalistic Driving Study, a prospective, population-based study. At baseline participants underwent photopic and mesopic contrast sensitivity testing for targets from 1.5–18 cycles per degree. Model fitting generated area under the log CSF (AULCSF) and peak log sensitivity. Participant vehicles were instrumented with sensors that captured continuous driving data when the vehicle was operating (accelerometers, global positioning system, forward radar, 4-channel video). They participated for 1–2 years. Crashes were coded from the video and other data streams by trained analysts. Results The photopic analysis was based on 844 drivers, and the mesopic on 854 drivers. Photopic AULCSF and peak log contrast sensitivity were not associated with crash rate, whether defined as all crashes or at-fault crashes only (all p > 0.05). Mesopic AULCSF and peak log sensitivity were associated with an increased crash rate when considered for all crashes (rate ratio (RR): 1.36, 95% CI: 1.06–1.72; RR: 1.28, 95% CI: 1.01–1.63, respectively) and at-fault crashes only (RR: 1.50, 95% CI: 1.16–1.93; RR: 1.38, 95% CI: 1.07–1.78, respectively). Conclusions Results suggest that photopic contrast sensitivity testing may not help us understand future crash risk at the older-driver population level. Results highlight a previously unappreciated association between older adults’ mesopic contrast sensitivity deficits and crash involvement regardless of the time of day. Given the wide variability of light levels encountered in both day and night driving, mesopic vision tests, with their reliance on both cone and rod vision, may be a more comprehensive assessment of the visual system’s ability to process the roadway environment.

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Abstract Background and Aims Leaf functional traits are strongly tied to growth strategies and ecological processes across species, but few efforts have linked intraspecific trait variation to performance across ontogenetic and environmental gradients. Plants are believed to shift towards more resource-conservative traits in stressful environments and as they age. However, uncertainty as to how intraspecific trait variation aligns with plant age and performance in the context of environmental variation may limit our ability to use traits to infer ecological processes at larger scales. Methods We measured leaf physiological and morphological traits, canopy volume and flowering effort for Artemisia californica (California sagebrush), a dominant shrub species in the coastal sage scrub community, under conditions of 50, 100 and 150 % ambient precipitation for 3 years. Key Results Plant age was a stronger driver of variation in traits and performance than water availability. Older plants demonstrated trait values consistent with a more conservative resource-use strategy, and trait values were less sensitive to drought. Several trait correlations were consistent across years and treatments; for example, plants with high photosynthetic rates tended to have high stomatal conductance, leaf nitrogen concentration and light-use efficiency. However, the trade-off between leaf construction and leaf nitrogen evident in older plants was absent for first-year plants. While few traits correlated with plant growth and flowering effort, we observed a positive correlation between leaf mass per area and performance in some groups of older plants. Conclusions Overall, our results suggest that trait sensitivity to the environment is most visible during earlier stages of development, after which intraspecific trait variation and relationships may stabilize. While plant age plays a major role in intraspecific trait variation and sensitivity (and thus trait-based inferences), the direct influence of environment on growth and fecundity is just as critical to predicting plant performance in a changing environment.

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AbstractThe development of highly automated vehicles can meet elderly drivers’ mobility needs; however, worse driving performance after a takeover request (TOR) is frequently found, especially regarding non-driving related tasks (NDRTs). This study aims to detect the correlation between takeover performance and underlying cognitive factors comprising a set of higher order cognitive processes including executive functions. Thirty-five young and 35 elderly participants were tested by computerized cognitive tasks and simulated driving tasks to evaluate their executive functions and takeover performance. Performance of n-back tasks, Simon tasks, and task switching were used to evaluate updating, inhibition, and shifting components of executive functions by principal component analysis. The performance of lane changing after TOR was measured using the standard deviation of the steering wheel angle and minimum time-to-collision (TTC). Differences between age groups and NDRT engagement were assessed by two-way mixed analysis of variance. Older participants had significantly lower executive function ability and were less stable and more conservative when engaged in NDRT. Furthermore, a significant correlation between executive function and lateral driving stability was found. These findings highlight the interaction between age-related differences in executive functions and takeover performance; thus, provide implications for designing driver screening tests or human–machine interfaces.

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Abstract Patients with multiple sclerosis acquire disability either through: (1) Relapse-associated worsening (RAW), or (2) progression independent of relapse activity (PIRA). This study addresses the relative contribution of relapses to disability worsening over the course of the disease, how early progression begins, and the extent to which multiple sclerosis therapies delay disability accumulation. Using the Novartis-Oxford MS (NO.MS) data pool spanning all multiple sclerosis phenotypes and pediatric multiple sclerosis, we evaluated ∼200,000 EDSS transitions from &gt;27,000 patients with ≤15 years follow-up. We analyzed three datasets: (A) A full analysis dataset containing all observational and randomized controlled clinical trials in which disability and relapses were assessed (N = 27,328); (B) All phase 3 clinical trials (N = 8364); and (C) All placebo-controlled phase 3 clinical trials (N = 4970). We determined the relative importance of RAW and PIRA, investigated the role of relapses on all-cause disability worsening using Andersen-Gill models, and observed the impact of the mechanism of worsening and disease modifying therapies (DMTs) on the time to reach milestone disability levels using time continuous Markov models. PIRA started early in multiple sclerosis, occurred in all phenotypes, and became the principal driver of disability accumulation in the progressive phase of the disease. Relapses significantly increased the hazard of all-cause disability worsening events: Following a year in which relapses occurred (vs a year without relapses), the hazard increased by 31–48%; all p &lt; 0.001. Pre-existing disability and older age were the principal risk factors for incomplete relapse recovery. For placebo-treated patients with minimal disability (EDSS 1) it took 8.95 years until increased limitation in walking ability (EDSS 4) and 18.48 years to require walking assistance (EDSS 6). Treating patients with DMTs delayed these times significantly by 3.51 years (95% confidence limit: 3.19, 3.96) and by 3.09 years (2.60, 3.72), respectively. In relapsing-remitting multiple sclerosis (RRMS), patients who worsened exclusively due to RAW events took a similar time to reach milestone EDSS values compared with those with PIRA events; the fastest transitions were observed in patients with PIRA and superimposed relapses. Our data confirm relapses contribute to the accumulation of disability, primarily early in multiple sclerosis. PIRA starts already in RRMS and becomes the dominant driver of disability accumulation as the disease evolves. Pre-existing disability and older age are the principal risk factors for further disability accumulation. Using DMTs delays disability accrual by years, with the potential to gain time being highest in the earliest stages of multiple sclerosis.

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Older drivers face the prospect of having to adjust their driving habits because of health problems, which can include neurocognitive disorders. Self-awareness of driving difficulties and the interaction between individual with neurocognitive disorders and natural caregiver seem to be important levers for the implementation of adaptation strategies and for the subsequent voluntary cessation of driving when the cognitive disorders become too severe. This study aims to evaluate an educational program for patient/natural caregiver dyads who wish to implement self-regulation strategies in driving activity, and to improve self-awareness of driving ability. The ACCOMPAGNE program is based on seven group workshops, which target the dyad. The workshops deal with the impact of cognitive, sensory and iatrogenic disorders on driving. They tackle questions about responsibility, and about autonomy and social life. They also provide alternative solutions aimed at maintaining outward-looking activities even if driving is reduced or stopped. A randomized controlled trial is planned to evaluate the effectiveness of the program 2 months and 6 months after inclusion, and to compare this to the effectiveness of conventional approaches. The main outcome of this trial (i.e., the implementation of self-regulated driving strategies), will be measured based on scores on the “Current Self-Regulatory Practices” subscale of the Driver Perception and Practices Questionnaire. The Driving Habits Questionnaire will be used to measure secondary outcomes (indicators of driving changes; indicators of changes in mood, quality of life and caregiver burden; and self-awareness of driving abilities). Indicators will be collected for both patients and natural caregivers. This cognitive, social and psychological program should allow older individuals with cognitive disorders to drive more safely, and help to maintain the quality of life and mood of both patient and natural caregiver despite driving limitations. The patient's care path would be optimized, as he/she would become an actor in the process of giving up driving, which will, most certainly, be needed at some point in the progress of neurocognitive disorders. This process ranges from becoming aware of driving difficulties, to implementing self-regulation strategies, through to complete cessation of driving when necessary.Clinical trial registration numberNCT04493957.

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Introduction Most studies of the Latin American immigrant experience and care for relatives living with dementia have been in the United States (US). In the United Kingdom (UK), unlike the US, most Latin Americans are first generation immigrants and are a rapidly increasing population. Therefore, we aimed to explore the UK experiences of Latin Americans caring for a relative with dementia. Methods We purposively recruited UK-based Latin American family carers of people with dementia ensuring maximum diversity. We conducted semi-structured qualitative interviews (in English or Spanish) with 11 family carers, stopping recruiting when we reached thematic saturation. We took an inductive thematic analytic approach. Findings Four main themes were identified: (1) Family comes first, particularly older people, leading to an obligation to care; (2) dementia as an illness that is accepted and talked about, which is regarded as positive with close networks but not wider society; (3) difficult behaviours are not the responsibility of the person with dementia, who is often conceptualised as a child; and (4) caring expectations lead to incompatibility with formal services, and a reluctance to leave people with dementia alone. Conclusions Familial obligation is the driver for family carers and acceptance of the illness helped despite adversities. Openness to talk about dementia with close networks was distinctive and helpful, contrasting with wider society, where greater awareness of dementia is needed. Considering the person with dementia as a child did not seem to undermine personhood and enabled maintenance of compassion. The relative with dementia was a priority. There was a lack of culturally and linguistically appropriate services, thus restricting family carers’ ability to fulfil other roles, such as parental.

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Abstract Background Transportation problems are known barriers to health care and can result in late arrivals and delayed or missed care. Groups already prone to greater social and economic disadvantage, including low-income individuals and people with chronic conditions, encounter more transportation barriers and experience greater negative health care consequences. Addressing transportation barriers is important not only for mitigating adverse health care outcomes among patients, but also for avoiding additional costs to the health care system. In this study, we investigate transportation barriers to accessing health care services during the COVID-19 pandemic among high-frequency health care users. Methods A web-based survey was administered to North Carolina residents aged 18 and older in the UNC Health system who were enrolled in Medicaid or Medicare and had at least six outpatient medical appointments in the past year. 323 complete responses were analyzed to investigate the prevalence of reporting transportation barriers that resulted in having arrived late to, delayed, or missed care, as well as relationships between demographic and other independent variables and transportation barriers. Qualitative analyses were performed on text response data to explain transportation barriers. Results Approximately 1 in 3 respondents experienced transportation barriers to health care between June 2020 and June 2021. Multivariate logistic regressions indicate individuals aged 18–64, people with disabilities, and people without a household vehicle were significantly more likely to encounter transportation barriers. Costs of traveling for medical appointments and a lack of driver or car availability emerged as major transportation barriers; however, respondents explained that barriers were often complex, involving circ*mstantial problems related to one’s ability to access and pay for transportation as well as to personal health. Conclusions To address transportation barriers, we recommend more coordination between transportation and health professionals and the implementation of programs that expand access to and improve patient awareness of health care mobility services. We also recommend transportation and health entities direct resources to address transportation barriers equitably, as barriers disproportionately burden younger adults under age 65 enrolled in public insurance programs.

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IntroductionFor over five years, Romanians have been using their bodies in public spaces to challenge politicians’ disregard for the average citizen. In a region low in standards of civic engagement, such as voter turnout and petition signing, Romanian people’s “citizenship of the streets” has stopped environmentally destructive mining in 2013, ousted a corrupt cabinet in 2015, and blocked legislation legalising abuse of public office in 2017 (Solnit 214). This article explores the democratic affordances of collective resistive walking, by focusing on Romania’s capital, Bucharest. I illustrate how walking in protest of political corruption cultivates a democratic public and reconfigures city spaces as spaces of democratic engagement, in the context of increased illiberalism in the region. I examine two sites of protest: the Parliament Palace and Victoriei Square. The former is a construction emblematic of communist dictator Nicolae Ceaușescu and symbol of an authoritarian regime, whose surrounding area protestors reclaim as a civic space. The latter—a central part of the city bustling with the life of cafes, museums, bike lanes, and nearby parks—hosts the Government and has become an iconic site for pro-democratic movements. Spaces of Democracy: The Performativity of Public Assemblies Democracies are active achievements, dependent not only on the solidity of institutions —e.g., a free press and a constitution—but on people’s ability and desire to communicate about issues of concern and to occupy public space. Communicative approaches to democratic theory, formulated as inquiries into the public sphere and the plurality and evolution of publics, often return to establish the significance of public spaces and of bodies in the maintenance of our “rhetorical democracies” (Hauser). Speech and assembly, voice and space are sides of the same coin. In John Dewey’s work, communication is the main “loyalty” of democracy: the heart and final guarantee of democracy is in free gatherings of neighbors on the street corner to discuss back and forth what is read in the uncensored news of the day, and in gatherings of friends in the living rooms of houses and apartments to converse freely with one another. (Dewey qtd. in Asen 197, emphasis added) Dewey asserts the centrality of communication in the same breath that he affirms the spatial infrastructure supporting it.Historically, Richard Sennett explains, Athenian democracy has been organised around two “spaces of democracy” where people assembled: the agora or town square and the theatre or Pnyx. While the theatre has endured as the symbol of democratic communication, with its ideal of concentrated attention on the argument of one speaker, Sennett illuminates the square as an equally important space, one without which deliberation in the Pnyx would be impossible. In the agora, citizens cultivate an ability to see, expect, and think through difference. In its open architecture and inclusiveness, Sennett explains, the agora affords the walker and dweller a public space to experience, in a quick, fragmentary, and embodied way, the differences and divergences in fellow citizens. Through visual scrutiny and embodied exposure, the square thus cultivates “an outlook favorable to discussion of differing views and conflicting interests”, useful for deliberation in the Pnyx, and the capacity to recognise strangers as part of the imagined democratic community (19). Also stressing the importance of spaces for assembly, Jürgen Habermas’s historical theorisation of the bourgeois public sphere moves the functions of the agora to the modern “third places” (Oldenburg) of the civic society emerging in late seventeenth and eighteenth-century Europe: coffee houses, salons, and clubs. While Habermas’ conceptualization of a unified bourgeois public has been criticised for its class and gender exclusivism, and for its normative model of deliberation and consensus, such criticism has also opened paths of inquiry into the rhetorical pluralism of publics and into the democratic affordances of embodied performativity. Thus, unlike Habermas’s assumption of a single bourgeois public, work on twentieth and twenty-first century publics has attended to their wide variety in post-modern societies (e.g., Bruce; Butler; Delicath and DeLuca; Fraser; Harold and DeLuca; Hauser; Lewis; Mckinnon et al.; Pezzullo; Rai; Tabako). In contrast to the Habermasian close attention to verbal argumentation, such criticism prioritizes the embodied (performative, aesthetic, and material) ways in which publics manifest their attention to common issues. From suffragists to environmentalists and, most recently, anti-precarity movements across the globe, publics assemble and move through shared space, seeking to break hegemonies of media representation by creating media events of their own. In the process, Judith Butler explains, such embodied assemblies accomplish much more. They disrupt prevalent logics and dominant feelings of disposability, precarity, and anxiety, at the same time that they (re)constitute subjects and increasingly privatised spaces into citizens and public places of democracy, respectively. Butler proposes that to best understand recent protests we need to read collective assembly in the current political moment of “accelerating precarity” and responsibilisation (10). Globally, increasingly larger populations are exposed to economic insecurity and precarity through government withdrawal from labor protections and the diminishment of social services, to the profit of increasingly monopolistic business. A logic of self-investment and personal responsibility accompanies such structural changes, as people understand themselves as individual market actors in competition with other market actors rather than as citizens and community members (Brown). In this context, public assembly would enact an alternative, insisting on interdependency. Bodies, in such assemblies, signify both symbolically (their will to speak against power) and indexically. As Butler describes, “it is this body, and these bodies, that require employment, shelter, health care, and food, as well as a sense of a future that is not the future of unpayable debt” (10). Butler describes the function of these protests more fully:[P]lural enactments […] make manifest the understanding that a situation is shared, contesting the individualizing morality that makes a moral norm of economic self-sufficiency precisely […] when self-sufficiency is becoming increasingly unrealizable. Showing up, standing, breathing, moving, standing still, speech, and silence are all aspects of a sudden assembly, an unforeseen form of political performativity that puts livable life at the forefront of politics […] [T]he bodies assembled ‘say’ we are not disposable, even if they stand silently. (18)Though Romania is not included in her account of contemporary protest movements, Butler’s theoretical account aptly describes both the structural and ideological conditions, and the performativity of Romanian protestors. In Romania, citizens have started to assemble in the streets against austerity measures (2012), environmental destruction (2013), fatal infrastructures (2015) and against the government’s corruption and attempts to undermine the Judiciary (from February 2017 onward). While, as scholars have argued (Olteanu and Beyerle; Gubernat and Rammelt), political corruption has gradually crystallised into the dominant and enduring framework for the assembled publics, post-communist corruption has been part and parcel of the neoliberalisation of Central and Eastern-European societies after the fall of communism. In the region, Leslie Holmes explains, former communist elites or the nomenklatura, have remained the majority political class after 1989. With political power and under the shelter of political immunity, nomenklatura politicians “were able to take ethically questionable advantage in various ways […] of the sell-off of previously state-owned enterprises” (Holmes 12). The process through which the established political class became owners of a previously state-owned economy is known as “nomenklatura privatization”, a common form of political corruption in the region, Holmes explains (12). Such practices were common knowledge among a cynical population through most of the 1990s and the 2000s. They were not broadly challenged in an ideological milieu attached, as Mihaela Miroiu, Isabela Preoteasa, and Jerzy Szacki argued, to extreme forms of liberalism and neoliberalism, ideologies perceived by people just coming out of communism as anti-ideology. Almost three decades since the fall of communism, in the face of unyielding levels of poverty (Zaharia; Marin), the decaying state of healthcare and education (Bilefsky; “Education”), and migration rates second only to war-torn Syria (Deletant), Romanian protestors have come to attribute the diminution of life in post-communism to the political corruption of the established political class (“Romania Corruption Report”; “Corruption Perceptions”). Following systematic attempts by the nomenklatura-heavy governing coalition to undermine the judiciary and institutionalise de facto corruption of public officials (Deletant), protestors have been returning to public spaces on a weekly basis, de-normalising the political cynicism and isolation serving the established political class. Mothers Walking: Resignifying Communist Spaces, Imagining the New DemosOn 11 July 2018, a protest of mothers was streamed live by Corruption Kills (Corupția ucide), a Facebook group started by activist Florin Bădiță after a deadly nightclub fire attributed to the corruption of public servants, in 2015 (Commander). Organized protests at the time pressured the Social-Democratic cabinet into resignation. Corruption Kills has remained a key activist platform, organising assemblies, streaming live from demonstrations, and sharing personal acts of dissent, thus extending the life of embodied assemblies. In the mothers’ protest video, women carrying babies in body-wraps and strollers walk across the intersection leading to the Parliament Palace, while police direct traffic and ensure their safety (“Civil Disobedience”). This was an unusual scene for many reasons. Walkers met at the entrance to the Parliament Palace, an area most emblematic of the former regime. Built by Communist dictator, Nicolae Ceaușescu and inspired by Kim Il-sung’s North Korean architecture, the current Parliament building and its surrounding plaza remain, in the words of Renata Salecl, “one of the most traumatic remnants of the communist regime” (90). The construction is the second largest administrative building in the world, after the Pentagon, a size matching the ambitions of the dictator. It bears witness to the personal and cultural sacrifices the construction and its surrounded plaza required: the displacement of some 40,000 people from old neighbourhood Uranus, the death of reportedly thousands of workers, and the flattening of churches, monasteries, hospitals, schools (Parliament Palace). This arbitrary construction carved out of the old city remains a symbol of an authoritarian relation with the nation. As Salecl puts it, Ceaușescu’s project tried to realise the utopia of a new communist “centre” and created an artificial space as removed from the rest of the city as the leader himself was from the needs of his people. Twenty-nine years after the fall of communism, the plaza of the Parliament Palace remains as suspended from the life of the city as it was during the 1980s. The trees lining the boulevard have grown slightly and bike lanes are painted over decaying stones. Still, only few people walk by the neo-classical apartment buildings now discoloured and stained by weather and time. Salecl remarks on the panoptic experience of the Parliament Palace: “observed from the avenue, [the palace] appears to have no entrance; there are only numerous windows, which give the impression of an omnipresent gaze” (95). The building embodies, for Salecl, the logic of surveillance of the communist regime, which “created the impression of omnipresence” through a secret police that rallied members among regular citizens and inspired fear by striking randomly (95).Against this geography steeped in collective memories of fear and exposure to the gaze of the state, women turn their children’s bodies and their own into performances of resistance that draw on the rhetorical force of communist gender politics. Both motherhood and childhood were heavily regulated roles under Ceaușescu’s nationalist-socialist politics of forced birth, despite the official idealisation of both. Producing children for the nationalist-communist state was women’s mandated expression of citizenship. Declaring the foetus “the socialist property of the whole society”, in 1966 Ceaușescu criminalised abortion for women of reproductive ages who had fewer than four children, and, starting 1985, less than five children (Ceaușescu qtd. in Verdery). What followed was “a national tragedy”: illegal abortions became the leading cause of death for fertile women, children were abandoned into inhumane conditions in the infamous orphanages, and mothers experienced the everyday drama of caring for families in an economy of shortages (Kligman 364). The communist politicisation of natality during communist Romania exemplifies one of the worst manifestations of the political as biopolitical. The current maternal bodies and children’s bodies circulating in the communist-iconic plaza articulate past and present for Romanians, redeploying a traumatic collective memory to challenge increasingly authoritarian ambitions of the governing Social Democratic Party. The images of caring mothers walking in protest with their babies furthers the claims that anti-corruption publics have made in other venues: that the government, in their indifference and corruption, is driving millions of people, usually young, out of the country, in a braindrain of unprecedented proportions (Ursu; Deletant; #vavedemdinSibiu). In their determination to walk during the gruelling temperatures of mid-July, in their youth and their babies’ youth, the mothers’ walk performs the contrast between their generation of engaged, persistent, and caring citizens and the docile abused subject of a past indexed by the Ceaușescu-era architecture. In addition to performing a new caring imagined community (Anderson), women’s silent, resolute walk on the crosswalk turns a lifeless geography, heavy with the architectural traces of authoritarian history, into a public space that holds democratic protest. By inhabiting the cultural role of mothers, protestors disarmed state authorities: instead of the militarised gendarmerie usually policing protestors the Victoriei Square, only traffic police were called for the mothers’ protest. The police choreographed cars and people, as protestors walked across the intersection leading to the Parliament. Drivers, usually aggressive and insouciant, now moved in concert with the protestors. The mothers’ walk, immediately modeled by people in other cities (Cluj-Napoca), reconfigured a car-dominated geography and an unreliable, driver-friendly police, into a civic space that is struggling to facilitate the citizens’ peaceful disobedience. The walkers’ assembly thus begins to constitute the civic character of the plaza, collecting “the space itself […] the pavement and […] the architecture [to produce] the public character of that material environment” (Butler 71). It demonstrates the possibility of a new imagined community of caring and persistent citizens, one significantly different from the cynical, disconnected, and survivalist subjects that the nomenklatura politicians, nested in the Panoptic Parliament nearby, would prefer.Persisting in the Victoriei Square In addition to strenuous physical walking to reclaim city spaces, such as the mothers’ walking, the anti-corruption public also practices walking and gathering in less taxing environments. The Victoriei Square is such a place, a central plaza that connects major boulevards with large sidewalks, functional bike lanes, and old trees. The square is the architectural meeting point of old and new, where communist apartments meet late nineteenth and early twentieth century architecture, in a privileged neighbourhood of villas, museums, and foreign consulates. One of these 1930s constructions is the Government building, hosting the Prime Minister’s cabinet. Demonstrators gathered here during the major protests of 2015 and 2017, and have walked, stood, and wandered in the square almost weekly since (“Past Events”). On 24 June 2018, I arrive in the Victoriei Square to participate in the protest announced on social media by Corruption Kills. There is room to move, to pause, and rest. In some pockets, people assemble to pay attention to impromptu speakers who come onto a small platform to share their ideas. Occasionally someone starts chanting “We See You!” and “Down with Corruption!” and almost everyone joins the chant. A few young people circulate petitions. But there is little exultation in the group as a whole, shared mostly among those taking up the stage or waving flags. Throughout the square, groups of familiars stop to chat. Couples and families walk their bikes, strolling slowly through the crowds, seemingly heading to or coming from the nearby park on a summer evening. Small kids play together, drawing with chalk on the pavement, or greeting dogs while parents greet each other. Older children race one another, picking up on the sense of freedom and de-centred but still purposeful engagement. The openness of the space allows one to meander and observe all these groups, performing the function of the Ancient agora: making visible the strangers who are part of the polis. The overwhelming feeling is one of solidarity. This comes partly from the possibilities of collective agency and the feeling of comfortably taking up space and having your embodiment respected, otherwise hard to come by in other spaces of the city. Everyday walking in the streets of Romanian cities is usually an exercise in hypervigilant physical prowess and self-preserving numbness. You keep your eyes on the ground to not stumble on broken pavement. You watch ahead for unmarked construction work. You live with other people’s sweat on the hot buses. You hop among cars parked on sidewalks and listen keenly for when others may zoom by. In one of the last post-socialist states to join the European Union, living with generalised poverty means walking in cities where your senses must be dulled to manage the heat, the dust, the smells, and the waiting, irresponsive to beauty and to amiable sociality. The euphemistic vocabulary of neoliberalism may describe everyday walking through individualistic terms such as “grit” or “resilience.” And while people are called to effort, creativity, and endurance not needed in more functional states, what one experiences is the gradual diminution of one’s lives under a political regime where illiberalism keeps a citizen-serving democracy at bay. By contrast, the Victoriei Square holds bodies whose comfort in each other’s presence allow us to imagine a political community where survivalism, or what Lauren Berlant calls “lateral agency”, are no longer the norm. In “showing up, standing, breathing, moving, standing still […] an unforeseen form of political performativity that puts livable life at the forefront of politics” is enacted (Butler 18). In arriving to Victoriei Square repeatedly, Romanians demonstrate that there is room to breathe more easily, to engage with civility, and to trust the strangers in their country. They assert that they are not disposable, even if a neoliberal corrupt post-communist regime would have them otherwise.ConclusionBecoming a public, as Michael Warner proposes, is an ongoing process of attention to an issue, through the circulation of discourse and self-organisation with strangers. For the anti-corruption public of Romania’s past years, such ongoing work is accompanied by persistent, civil, embodied collective assembly, in an articulation of claims, bodies, and spaces that promotes a material agency that reconfigures the city and the imagined Romanian community into a more democratic one. The Romanian citizenship of the streets is particularly significant in the current geopolitical and ideological moment. In the region, increasing authoritarianism meets the alienating logics of neoliberalism, both trying to reduce citizens to disposable, self-reliant, and disconnected market actors. Populist autocrats—Recep Tayyip Erdogan in Turkey, the Peace and Justice Party in Poland, and recently E.U.-penalized Victor Orban, in Hungary—are dismantling the system of checks and balances, and posing threats to a European Union already challenged by refugee debates and Donald Trump’s unreliable alliance against authoritarianism. In such a moment, the Romanian anti-corruption public performs within the geographies of their city solidarity and commitment to democracy, demonstrating an alternative to the submissive and disconnected subjects preferred by authoritarianism and neoliberalism.Author's NoteIn addition to the anonymous reviewers, the author would like to thank Mary Tuominen and Jesse Schlotterbeck for their helpful comments on this essay.ReferencesAnderson, Benedict R. Imagined Communities: Reflections on the Origin and Spread of Nationalism. London: Verso, 2016.Asen, Robert. “A Discourse Theory of Citizenship.” Quarterly Journal of Speech 90.2 (2004): 189-211. 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Stand-up is a global phenomenon. It is Australia’s most significant form of advocatorial theatre and a major platform for challenging stigma and prejudice. In the twenty-first century, Australian stand-up is transforming into a more culturally diverse form and extending the spectrum of material addressing human rights. Since the 1980s Australian stand-up routines have moved beyond the old colonial targets of England and America, and Indigenous comics such as Kevin Kopinyeri, Andy Saunders, and Shiralee Hood have gained an established following. Additionally, the turn to Asia is evident not just in trade agreements and the higher education market but also in cultural exchange and in the billing of emerging Asian stand-ups at mainstream events. The major cultural driver for stand-up is the Melbourne International Comedy Festival (MICF), Australia’s largest cultural event, now over 30 years old, and an important site for dissecting constructs of democracy and nationhood. As John McCallum has observed, popular humour in post-World War II Australia drew on widespread feelings of “displacement, migration and otherness—resonant topics in a country of transplanted people and a dispossessed indigenous population arguing over a distinct Australian identity” (205–06). This essay considers the traditional comic strategies of first and second generation immigrant stand-ups in Australia and compares them with the new wave of post 9/11 Asian-Australian and Middle-Eastern-Australian stand-ups whose personas and interrogations are shifting the paradigm. Self-identifying Muslim stand-ups challenge myths of dominant Australian identity in ways which many still find confronting. Furthermore, the theories of incongruity, superiority, and psychological release re-rehearsed in traditional humour studies, by figures such as Palmer (1994) and Morreall (2009), are predicated on models of humour which do not always serve live performance, especially stand-up with its relational dependence on audience interaction.Stand-ups who immigrated to Australia as children or whose parents immigrated and struggled against adversity are important symbols both of the Australian comedy industry and of a national self-understanding of migrant resilience and making good. Szubanski and Berger hail from earlier waves of European migrants in the 1950s and 1960s. Szubanski has written eloquently of her complex Irish-Polish heritage and documented how the “hand-me-down trinkets of family and trauma” and “the culture clash of competing responses to calamity” have been integral to the development of her comic success and the making of her Aussie characters (347). Rachel Berger, the child of Polish holocaust survivors, advertises and connects both identities on her LinkedIn page: “After 23 years as a stand-up comedian, growing up with Jewish guilt and refugee parents, Rachel Berger knows more about survival than any idiot attending tribal council on reality TV.”Anh Do, among Australia’s most famous immigrant stand-ups, identifies as one of the Vietnamese “boat people” and arrived as a toddler in 1976. Do’s tale of his family’s survival against the odds and his creation of a persona which constructs the grateful, happy immigrant clown is the staple of his very successful routine and increasingly problematic. It is a testament to the power of Do’s stand-up that many did not perceive the toll of the loss of his birth country; the grinding poverty; and the pain of his father’s alcoholism, violence, and survivor guilt until the publication of Do’s ironically titled memoir The Happiest Refugee. In fact, the memoir draws on many of the trauma narratives that are still part of his set. One of Do’s most legendary routines is the story of his family’s sea journey to Australia, told here on ABC1’s Talking Heads:There were forty of us on a nine metre fishing boat. On day four of the journey we spot another boat. As the boat gets closer we realise it’s a boatload of Thai pirates. Seven men with knives, machetes and guns get on our boat and they take everything. One of the pirates picks up the smallest child, he lifts up the baby and rips open the baby’s nappy and dollars fall out. And the pirate decides to spare the kid’s life. And that’s a good thing cos that’s my little brother Khoa Do who in 2005 became Young Australian of the Year. And we were saved on the fifth day by a big German merchant ship which took us to a refugee camp in Malaysia and we were there for around three months before Australia says, come to Australia. And we’re very glad that happened. So often we heard Mum and Dad say—what a great country. How good is this place? And the other thing—kids, as you grow up, do as much as you can to give back to this great country and to give back to others less fortunate.Do’s strategy is apparently one of genuflection and gratitude, an adoption of what McCallum refers to as an Australian post-war tradition of the comedy of inadequacy and embarrassment (210–14). Journalists certainly like to bill Do as the happy clown, framing articles about him with headlines like Rosemary Neill’s “Laughing through Adversity.” In fact, Do is direct about his gallows humour and his propensity to darkness: his humour, he says, is a means of countering racism, of “being able to win people over who might have been averse to being friends with an Asian bloke,” but Neill does not linger on this, nor on the revelation that Do felt stigmatised by his refugee origins and terrified and shamed by the crippling poverty of his childhood in Australia. In The Happiest Refugee, Do reveals that, for him, the credibility of his routines with predominantly white Australian audiences lies in the crafting of himself as an “Aussie comedian up there talking about his working-class childhood” (182). This is not the official narrative that is retold even if it is how Do has endeared himself to Australians, and ridding himself of the happy refugee label may yet prove difficult. Suren Jayemanne is well known for his subtle mockery of multiculturalist rhetoric. In his 2016 MICF show, Wu-Tang Clan Name Generator, Jayemanne played on the supposed contradiction of his Sri Lankan-Malaysian heritage against his teenage years in the wealthy suburb of Malvern in Melbourne, his private schooling, and his obsession with hip hop and black American culture. Jayemanne’s strategy is to gently confound his audiences, leading them slowly up a blind alley. He builds up a picture of how to identify Sri Lankan parents, supposedly Sri Lankan qualities such as an exceptional ability at maths, and Sri Lankan employment ambitions which he argues he fulfilled in becoming an accountant. He then undercuts his story by saying he has recently realised that his suburban background, his numerical abilities, his love of black music, and his rejection of accountancy in favour of comedy, in fact prove conclusively that he has, all along, been white. He also confesses that this is a bruising disappointment. Jayemanne exposes the emptiness of the conceits of white, brown, and black and of invented identity markers and plays on his audiences’ preconceptions through an old storyteller’s device, the shaggy dog story. The different constituencies in his audiences enjoy his trick equally, from quite different perspectives.Diana Nguyen, a second generation Vietnamese stand-up, was both traumatised and politicised by Pauline Hanson when she was a teenager. Hanson described Nguyen’s community in Dandenong as “yellow Asian people” (Filmer). Nguyen’s career as a community development worker combating racism relates directly to her activity as a stand-up: migrant stories are integral to Australian history and Nguyen hypothesises that the “Australian psyche of being invaded or taken over” has reignited over the question of Islamic fundamentalism and expresses her concern to Filmer about the Muslim youths under her care.Nguyen’s alarm about the elision of Islamic radicalism with Muslim culture drives an agenda that has led the new generation of self-identified Muslim stand-ups since 9/11. This post 9/11 world is described by Wajahat as gorged with “exaggerated fear, hatred, and hostility toward Islam and Muslim [. . . ] and perpetuated by negative discrimination and the marginalisation and exclusion of Muslims from social, political, and civic life in western societies.” In Australia, Aamer Rahman, Muhamed Elleissi, Khaled Khalafalla, and Nazeem Hussain typify this newer, more assertive form of second generation immigrant stand-up—they identify as Muslim (whether religious or not), as brown, and as Australian. They might be said to symbolise a logical response to Ghassan Hage’s famous White Nation (1998), which argues that a white supremacism underlies the mindset of the white elite in Australia. Their positioning is more nuanced than previous generations of stand-up. Nazeem Hussain’s routines mark a transformation in Australian stand-up, as Waleed Aly has argued: “ethnic comedy” has hitherto been about the parading of stereotypes for comfortable, mainstream consumption, about “minstrel characters” [. . .] but Hussain interrogates his audiences in every direction—and aggravates Muslims too. Hussain’s is the world of post 9/11 Australian Muslims. It’s about more than ethnic stereotyping. It’s about being a consistent target of political opportunism, where everyone from the Prime Minister to the Foreign Minister to an otherwise washed-up backbencher with a view on burqas has you in their sights, where bombs detonate in Western capitals and unrelated nations are invaded.Understandably, a prevalent theme among the new wave of Muslim comics, and not just in Australia, is the focus on the reading of Muslims as manifestly linked with Islamic State (IS). Jokes about mistaken identity, plane crashes, suicide bombing, and the Koran feature prominently. English-Pakistani Muslim, Shazia Mirza, gained comedy notoriety in the UK in the wake of 9/11 by introducing her routine with the words: “My name’s Shazia Mirza. At least that’s what it says on my pilot’s licence” (Bedell). Stand-ups Negin Farsad, Ahmed Ahmed, and Dean Obeidalla are all also activists challenging prevailing myths about Islam, skin colour and terrorism in America. Egyptian-American Ahmed Ahmed acquired prominence for telling audiences in the infamous Axis of Evil Comedy Tour about how his life had changed much for the worse since 9/11. Ahmed Ahmed was the alias used by one of Osama Bin Laden’s devotees and his life became on ongoing struggle with anti-terrorism officials doing security checks (he was once incarcerated) and with the FBI who were certain that the comedian was among their most wanted terrorists. Similarly, Obeidalla, an Italian-Palestinian-Muslim, notes in his TEDx talk that “If you have a Muslim name, you are probably immune to identity theft.” His narration of a very sudden experience of becoming an object of persecution and of others’ paranoia is symptomatic of a shared understanding of a post 9/11 world among many Muslim comics: “On September 10th 2001 I went to bed as a white American and I woke up an Arab,” says Obeidalla, still dazed from the seismic shift in his life.Hussain and Khalafalla demonstrate a new sophistication and directness in their stand-up, and tackle their majority white audiences head-on. There is no hint of the apologetic or deferential stance performed by Anh Do. Many of the jokes in their routines target controversial or taboo issues, which up until recently were shunned in Australian political debate, or are absent or misrepresented in mainstream media. An Egyptian-Australian born in Saudi Arabia, Khaled Khalafalla arrived on the comedy scene in 2011, was runner-up in RAW, Australia’s most prestigious open mic competition, and in 2013 won the best of the Melbourne International Comedy Festival for Devious. Khalafalla’s shows focus on racist stereotypes and identity and he uses a range of Middle Eastern and Indian accents to broach IS recruitment, Muslim cousin marriages, and plane crashes. His 2016 MICF show, Jerk, was a confident and abrasive routine exploring relationships, drug use, the extreme racism of Reclaim Australia rallies, controversial visa checks by Border Force’s Operation Fortitude, and Islamophobia. Within the first minute of his routine, he criticises white people in the audience for their woeful refusal to master Middle Eastern names, calling out to the “brown woman” in the audience for support, before lining up a series of jokes about the (mis)pronunciation of his name. Khalafalla derives his power on stage by what Oliver Double calls “uncovering.” Double contends that “one of the most subversive things stand-up can do is to uncover the unmentionable,” subjects which are difficult or impossible to discuss in everyday conversation or the broadcast media (292). For instance, in Jerk Khalafalla discusses the “whole hating halal movement” in Australia as a metaphor for exposing brutal prejudice: Let me break it down for you. Halal is not voodoo. It’s just a blessing that Muslims do for some things, food amongst other things. But, it’s also a magical spell that turns some people into f*ckwits when they see it. Sometimes people think it’s a thing that can get stuck to your t-shirt . . . like ‘Oh f*ck, I got halal on me’ [Australian accent]. I saw a guy the other day and he was like f*ck halal, it funds terrorism. And I was like, let me show you the true meaning of Islam. I took a lamb chop out of my pocket and threw it in his face. And, he was like Ah, what was that? A lamb chop. Oh, I f*cking love lamb chops. And, I say you fool, it’s halal and he burst into flames.In effect, Khalafalla delivers a contemptuous attack on the white members of his audience, but at the same time his joke relies on those same audience members presuming that they are morally and intellectually superior to the individual who is the butt of the joke. Khalafalla’s considerable charm is a help in this tricky send-up. In 2015 the Australian Department of Defence recognised his symbolic power and invited him to join the Afghanistan Task Force to entertain the troops by providing what Doran describes as “home-grown Australian laughs” (7). On stage in Australia, Khalafalla constructs a persona which is an outsider to the dominant majority and challenges the persecution of Muslim communities. Ironically, on the NATO base, Khalafalla’s act was perceived as representing a diverse but united Australia. McCallum has pointed to such contradictions, moments where white Australia has shown itself to be a “culture which at first authenticates emigrant experience and later abrogates it in times of defiant nationalism” (207). Nazeem Hussain, born in Australia to Sri Lankan parents, is even more confrontational. His stand-up is born of his belief that “comedy protects us from the world around us” and is “an evolutionary defence mechanism” (8–9). His ground-breaking comedy career is embedded in his work as an anti-racism activist and asylum seeker supporter and shaped by his second-generation migrant experiences, law studies, community youth work, and early mentorship by American Muslim comic trio Allah Made Me Funny. He is well-known for his pioneering television successes Legally Brown and Salam Café. In his stand-up, Hussain often dwells witheringly on the failings and peculiarities of white people’s attempts to interact with him. Like all his routines, his sell-out show Fear of the Brown Planet, performed with Aamer Rahman from 2004–2008, explored casual, pathologised racism. Hussain deliberately over-uses the term “white people” in his routines as a provocation and deploys a reverse racism against his majority white audiences, knowing that many will be squirming. “White people ask me how can Muslims have fun if they don’t drink? Muslims have fun! Of course we have fun! You’ve seen us on the news.” For Hussain stand-up is “fundamentally an art of protest,” to be used as “a tool by communities and people with ideas that challenge and provoke the status quo with a spirit of counterculture” (Low 1–3). His larger project is to humanise Muslims to white Australians so that “they see us firstly as human beings” (1–3). Hussain’s 2016 MICF show, Hussain in the Membrane, both satirised media hype and hysterical racism and pushed for a better understanding of the complex problems Muslim communities face in Australia. His show also connected issues to older colonial traditions of racism. In a memorable and beautifully crafted tirade, Hussain inveighed against the 2015 Bendigo riots which occurred after local Muslims lodged an application to Bendigo council to build a mosque in the sleepy Victorian town. [YELLING in an exaggerated Australian accent] No we don’t want Muslims! NO we don’t want Muslims—to come invade Bendigo by application to the local council! That is the most bureaucratic invasion of all times. No place in history has been invaded by lodging an application to a local council. Can you see ISIS running around chasing town planners? Of course not, Muslims like to wait 6–8 months to invade! That’s a polite way to invade. What if white people invaded that way? What a better world we’d be living in. If white people invaded Australia that way, we’d be able to celebrate Australia Day on the same day without so much blood on our hands. What if Captain Cook came to Australia and said [in a British accent] Awe we would like to apply to invade this great land and here is our application. [In an Australian accent] Awe sorry, mate, rejected, but we’ll give you Bendigo.As Waleed Aly sees it, the Australian cultural majority is still “unused to hearing minorities speak with such assertiveness.” Hussain exposes “a binary world where there’s whiteness, and then otherness. Where white people are individuals and non-white people (a singular group) are not” (Aly). Hussain certainly speaks as an insider and goes so far as recognising his coloniser’s guilt in relation to indigenous Australians (Tan). Aly well remembers the hate mail he and Hussain received when they worked on Salam Café: “The message was clear. We were outsiders and should behave as such. We were not real Australians. We should know our place, as supplicants, celebrating the nation’s unblemished virtue.” Khalafalla, Rahman, Elleissi, and Hussain make clear that the new wave of comics identify as Muslim and Australian (which they would argue many in the audiences receive as a provocation). They have zero tolerance of racism, their comedy is intimately connected with their political activism, and they have an unapologetically Australian identity. No longer is it a question of whether the white cultural majority in Australia will anoint them as worthy and acceptable citizens, it is a question of whether the audiences can rise to the moral standards of the stand-ups. The power has been switched. For Hussain laughter is about connection: “that person laughs because they appreciate the point and whether or not they accept what was said was valid isn’t important. What matters is, they’ve understood” (Low 5). ReferencesAhmed, Ahmed. “When It Comes to Laughter, We Are All Alike.” TedXDoha (2010). 16 June 2016 <http://tedxtalks.ted.com/video/TEDxDoha-Ahmed-Ahmed-When-it-Co>.Aly, Waleed. “Comment.” Sydney Morning Herald 24 Sep. 2013."Anh Do". Talking Heads with Peter Thompson. ABC1. 4 Oct. 2010. Radio.Bedell, Geraldine. “Veiled Humour.” The Guardian (2003). 8 Aug. 2016 <https://www.theguardian.com/stage/2003/apr/20/comedy.artsfeatures?CMP=Share_iOSApp_Other>.Berger, Rachel. LinkedIn [Profile page]. 14 June 2016 <http://www.linkedin.com/company/rachel-berger>.Do, Anh. The Happiest Refugee. Sydney: Allen and Unwin, 2010. Doran, Mark. "Service with a Smile: Entertainers Give Troops a Taste of Home.” Air Force 57.21 (2015). 12 June 2016 <http://www.defence.gov.au/Publications/NewsPapers/Raaf/editions/5721/5721.pdf>.Double, Oliver. Getting the Joke: The Inner Workings of Stand-Up Comedy. 2nd ed. London: Bloomsbury, 2014.Filmer, Natalie. "For Dandenong Comedian and Actress Diana Nguyen The Colour Yellow has a Strong Meaning.” The Herald Sun 3 Sep. 2013.Hage, Ghassan. White Nation: Fantasies of a White Supremacy in a Multicultural Age. Sydney: Pluto Press, 1998.Hussain, Nazeem. Hussain in the Membrane. Melbourne International Comedy Festival, 2016.———. "The Funny Side of 30.” Spectrum. The Age 12 Mar. 2016.Khalafalla, Khaled. Jerk. Melbourne International Comedy Festival, 2016.Low, Lian. "Fear of a Brown Planet: Fight the Power with Laughter.” Peril: Asian Australian Arts and Culture (2011). 12 June 2016 <http://peril.com.au/back-editions/edition10/fear-of-a-brown-planet-fight-the-power-with-laughter>. McCallum, John. "Cringe and Strut: Comedy and National Identity in Post-War Australia.” Because I Tell a Joke or Two: Comedy, Politics and Social Difference. Ed. Stephen Wagg. New York: Routledge, 1998. Morreall, John. Comic Relief. Oxford: Wiley-Blackwell, 2009.Neill, Rosemary. "Laughing through Adversity.” The Australian 28 Aug. 2010.Obeidalla, Dean. "Using Stand-Up to Counter Islamophobia.” TedXEast (2012). 16 June 2016 <http://tedxtalks.ted.com/video/TEDxEast-Dean-Obeidalla-Using-S;TEDxEast>.Palmer, Jerry. Taking Humour Seriously. London: Routledge, 1994. Szubanski, Magda. Reckoning. Melbourne: Text Publishing, 2015. Tan, Monica. "Aussie, Aussie, Aussie! Allahu Akbar! Nazeem Hussain's Bogan-Muslim Army.” The Guardian 29 Feb. 2016. "Uncle Sam.” Salam Café (2008). 11 June 2016 <https://www.youtube.com/watch?v=SeQPAJt6caU>.Wajahat, Ali, et al. "Fear Inc.: The Roots of the Islamophobia Network in America.” Center for American Progress (2011). 11 June 2016 <https://www.americanprogress.org/issues/religion/report/2011/08/26/10165/fear-inc>.

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Introduction This article explores the changing relational quality of “the shadow of hierarchy”, in the context of the merging of platforms with infrastructure as the source of the shadow of hierarchy. In governance and regulatory studies, the shadow of hierarchy (or variations thereof), describes the space of influence that hierarchal organisations and infrastructures have (Héritier and Lehmkuhl; Lance et al.). A shift in who/what casts the shadow of hierarchy will necessarily result in changes to the attendant relational values, logics, and (techno)socialities that constitute the shadow, and a new arrangement of shadow that presents new challenges and opportunities. This article reflects on relevant literature to consider two different ways the shadow of hierarchy has qualitatively changed as platforms, rather than infrastructures, come to cast the shadow of hierarchy – an increase in scalability; and new socio-technical arrangements of (non)participation – and the opportunities and challenges therein. The article concludes that more concerted efforts are needed to design the shadow, given a seemingly directionless desire to enact data-driven solutions. The Shadow of Hierarchy, Infrastructures, and Platforms The shadow of hierarchy refers to how institutional, infrastructural, and organisational hierarchies create a relational zone of influence over a particular space. This commonly refers to executive decisions and legislation created by nation states, which are cast over private and non-governmental actors (Héritier and Lehmkuhl, 2). Lance et al. (252–53) argue that the shadow of hierarchy is a productive and desirable thing. Exploring the shadow of hierarchy in the context of how geospatial data agencies govern their data, Lance et al. find that the shadow of hierarchy enables the networked governance approaches that agencies adopt. This is because operating in the shadow of institutions provides authority, confers bureaucratic legitimacy and top-down power, and offers financial support. The darkness of the shadow is thus less a moral or ethicopolitical statement (such as that suggested by Fisher and Bolter, who use the idea of darkness to unpack the morality of tourism involving death and human suffering), and instead a relationality; an expression of differing values, logics, and (techno)socialities internal and external to those infrastructures and institutions that cast it (Gehl and McKelvey). The shadow of hierarchy might therefore be thought of as a field of relational influences and power that a social body casts over society, by virtue of a privileged position vis-a-vis society. It modulates society’s “light”; the resources (Bourdieu) and power relationships (Foucault) that run through social life, as parsed through a certain institutional and infrastructural worldview (the thing that blocks the light to create the shadow). In this way the shadow of hierarchy is not a field of absolute blackness that obscures, but instead a gradient of light and dark that creates certain effects. The shadow of hierarchy is now, however, also being cast by decentralised, privately held, and non-hierarchal platforms that are replacing or merging with public infrastructure, creating new social effects. Platforms are digital, socio-technical systems that create relationships between different entities. They are most commonly built around a relatively fixed core function (such as a social media service like Facebook), that then interacts with a peripheral set of complementors (advertising companies and app developers in the case of social media; Baldwin and Woodard), to create new relationships, forms of value, and other interactions (van Dijck, The Culture of Connectivity). In creating these relationships, platforms become inherently political (Gillespie), shaping relationships and content on the platform (Suzor) and in embodied life (Ajunwa; Eubanks). While platforms are often associated with optional consumer platforms (such as streaming services like Spotify), they have increasingly come to occupy the place of public infrastructure, and act as a powerful enabler to different socio-technical, economic, and political relationships (van Dijck, Governing Digital Societies). For instance, Plantin et al. argue that platforms have merged with infrastructures, and that once publicly held and funded institutions and essential services now share many characteristics with for-profit, privately held platforms. For example, Australia has had a long history of outsourcing employment services (Webster and Harding), and nearly privatised its entire visa processing data infrastructure (Jenkins). Platforms therefore have a greater role in casting the shadow of hierarchy than before. In doing so, they cast a shadow that is qualitatively different, modulated through a different set of relational values and (techno)socialities. Scalability A key difference and selling point of platforms is their scalability; since they can rapidly and easily up- and down-scale their functionalities in a way that traditional infrastructure cannot (Plantin et al.). The ability to respond “on-demand” to infrastructural requirements has made platforms the go-to service delivery option in the neo-liberalised public infrastructure environment (van Dijck, Governing Digital Societies). For instance, services providers like Amazon Web Services or Microsoft Azure provide on demand computing capacity for many nations’ most valuable services, including their intelligence and security capabilities (Amoore, Cloud Ethics; Konkel). The value of such platforms to government lies in the reduced cost and risk that comes with using rented capabilities, and the enhanced flexibility to increase or decrease their usage as required, without any of the economic sunk costs attached to owning the infrastructure. Scalability is, however, not just about on-demand technical capability, but about how platforms can change the scale of socio-technical relationships and services that are mediated through the platform. This changes the relational quality of the shadow of hierarchy, as activities and services occurring within the shadow are now connected into a larger and rapidly modulating scale. Scalability allows the shadow of hierarchy to extend from those in proximity to institutions to the broader population in general. For example, individual citizens can more easily “reach up” into governmental services and agencies as a part of completing their everyday business through platform such as MyGov in Australia (Services Australia). Using a smartphone application, citizens are afforded a more personalised and adaptive experience of the welfare state, as engaging with welfare services is no-longer tied to specific “brick-and-mortar” locations, but constantly available through a smartphone app and web portal. Multiple government services including healthcare and taxation are also connected to this platform, allowing users to reach across multiple government service domains to complete their personal business, seeking information and services that would have once required separate communications with different branches of government. The individual’s capacities to engage with the state have therefore upscaled with this change in the shadow, retaining a productivity and capacity enhancing quality that is reminiscent of older infrastructures and institutions, as the individual and their lived context is brought closer to the institutions themselves. Scale, however, comes with complications. The fundamental driver for scalability and its adaptive qualities is datafication. This means individuals and organisations are inflecting their operational and relational logics with the logic of datafication: a need to capture all data, at all times (van Dijck, Datafication; Fourcade and Healy). Platforms, especially privately held platforms, benefit significantly from this, as they rely on data to drive and refine their algorithmic tools, and ultimately create actionable intelligence that benefits their operations. Thus, scalability allows platforms to better “reach down” into individual lives and different social domains to fuel their operations. For example, as public transport services become increasingly datafied into mobility-as-a-service (MAAS) systems, ride sharing and on-demand transportation platforms like Uber and Lyft become incorporated into the public transport ecosystem (Lyons et al.). These platforms capture geospatial, behavioural, and reputational data from users and drivers during their interactions with the platform (Rosenblat and Stark; Attoh et al.). This generates additional value, and profits, for the platform itself with limited value returned to the user or the broader public it supports, outside of the transport service. It also places the platform in a position to gain wider access to the population and their data, by virtue of operating as a part of a public service. In this way the shadow of hierarchy may exacerbate inequity. The (dis)benefits of the shadow of hierarchy become unevenly spread amongst actors within its field, a function of an increased scalability that connects individuals into much broader assemblages of datafication. For Eubank, this can entrench existing economic and social inequalities by forcing those in need to engage with digitally mediated welfare systems that rely on distant and opaque computational judgements. Local services are subject to increased digital surveillance, a removal of agency from frontline advocates, and algorithmic judgement at scale. More fortunate citizens are also still at risk, with Nardi and Ekbia arguing that many digitally scaled relationships are examples of “heteromation”, whereby platforms convince actors in the platform to labour for free, such as through providing ratings which establish a platform’s reputational economy. Such labour fuels the operation of the platform through exploiting users, who become both a product/resource (as a source of data for third party advertisers) and a performer of unrewarded digital labour, such as through providing user reviews that help guide a platform’s algorithm(s). Both these examples represent a particularly disconcerting outcome for the shadow of hierarchy, which has its roots in public sector institutions who operate for a common good through shared and publicly held infrastructure. In shifting towards platforms, especially privately held platforms, value is transmitted to private corporations and not the public or the commons, as was the case with traditional infrastructure. The public also comes to own the risks attached to platforms if they become tied to public services, placing a further burden on the public if the platform fails, while reaping none of the profit and value generated through datafication. This is a poor bargain at best. (Non)Participation Scalability forms the basis for a further predicament: a changing socio-technical dynamic of (non)participation between individuals and services. According to Star (118), infrastructures are defined through their relationships to a given context. These relationships, which often exist as boundary objects between different communities, are “loosely structured in common use, and become tightly bound in particular locations” (Star, 118). While platforms are certainly boundary objects and relationally defined, the affordances of cloud computing have enabled a decoupling from physical location, and the operation of platforms across time and space through distributed digital nodes (smartphones, computers, and other localised hardware) and powerful algorithms that sort and process requests for service. This does not mean location is not important for the cloud (see Amoore, Cloud Geographies), but platforms are less likely to have a physically co-located presence in the same way traditional infrastructures had. Without the same institutional and infrastructural footprint, the modality for participating in and with the shadow of hierarchy that platforms cast becomes qualitatively different and predicated on digital intermediaries. Replacing a physical and human footprint with algorithmically supported and decentralised computing power allows scalability and some efficiency improvements, but it also removes taken-for-granted touchpoints for contestation and recourse. For example, ride-sharing platform Uber operates globally, and has expressed interest in operating in complement to (and perhaps in competition with) public transport services in some cities (Hall et al.; Conger). Given that Uber would come to operate as a part of the shadow of hierarchy that transport authorities cast over said cities, it would not be unreasonable to expect Uber to be subject to comparable advocacy, adjudication, transparency, and complaint-handling requirements. Unfortunately, it is unclear if this would be the case, with examples suggesting that Uber would use the scalability of its platform to avoid these mechanisms. This is revealed by ongoing legal action launched by concerned Uber drivers in the United Kingdom, who have sought access to the profiling data that Uber uses to manage and monitor its drivers (Sawers). The challenge has relied on transnational law (the European Union’s General Data Protection Regulation), with UK-based drivers lodging claims in Amsterdam to initiate the challenge. Such costly and complex actions are beyond the means of many, but demonstrate how reasonable participation in socio-technical and governance relationships (like contestations) might become limited, depending on how the shadow of hierarchy changes with the incorporation of platforms. Even if legal challenges for transparency are successful, they may not produce meaningful change. For instance, O’Neil links algorithmic bias to mathematical shortcomings in the variables used to measure the world; in the creation of irritational feedback loops based on incorrect data; and in the use of unsound data analysis techniques. These three factors contribute to inequitable digital metrics like predictive policing algorithms that disproportionately target racial minorities. Large amounts of selective data on minorities create myopic algorithms that direct police to target minorities, creating more selective data that reinforces the spurious model. These biases, however, are persistently inaccessible, and even when visible are often unintelligible to experts (Ananny and Crawford). The visibility of the technical “installed base” that support institutions and public services is therefore not a panacea, especially when the installed base (un)intentionally obfuscates participation in meaningful engagement like complaints handling. A negative outcome is, however, also not an inevitable thing. It is entirely possible to design platforms to allow individual users to scale up and have opportunities for enhanced participation. For instance, eGovernance and mobile governance literature have explored how citizens engage with state services at scale (Thomas and Streib; Foth et al.), and the open government movement has demonstrated the effectiveness of open data in understanding government operations (Barns; Janssen et al.), although these both have their challenges (Chadwick; Dawes). It is not a fantasy to imagine alternative configurations of the shadow of hierarchy that allow more participatory relationships. Open data could facilitate the governance of platforms at scale (Box et al.), where users are enfranchised into a platform by some form of membership right and given access to financial and governance records, in the same way that corporate shareholders are enfranchised, facilitated by the same app that provides a service. This could also be extended to decision making through voting and polling functions. Such a governance form would require radically different legal, business, and institutional structures to create and enforce this arrangement. Delacoix and Lawrence, for instance, suggest that data trusts, where a trustee is assigned legal and fiduciary responsibility to achieve maximum benefit for a specific group’s data, can be used to negotiate legal and governance relationships that meaningfully benefit the users of the trust. Trustees can be instructed to only share data to services whose algorithms are regularly audited for bias and provide datasets that are accurate representations of their users, for instance, avoiding erroneous proxies that disrupt algorithmic models. While these developments are in their infancy, it is not unreasonable to reflect on such endeavours now, as the technologies to achieve these are already in use. Conclusions There is a persistent myth that data will yield better, faster, more complete results in whatever field it is applied (Lee and Cook; Fourcade and Healy; Mayer-Schönberger and Cukier; Kitchin). This myth has led to data-driven assemblages, including artificial intelligence, platforms, surveillance, and other data-technologies, being deployed throughout social life. The public sector is no exception to this, but the deployment of any technological solution within the traditional institutions of the shadow of hierarchy is fraught with challenges, and often results in failure or unintended consequences (Henman). The complexity of these systems combined with time, budgetary, and political pressures can create a contested environment. It is this environment that moulds societies' light and resources to cast the shadow of hierarchy. Relationality within a shadow of hierarchy that reflects the complicated and competing interests of platforms is likely to present a range of unintended social consequences that are inherently emergent because they are entering into a complex system – society – that is extremely hard to model. The relational qualities of the shadow of hierarchy are therefore now more multidimensional and emergent, and experiences relating to socio-technical features like scale, and as a follow-on (non)participation, are evidence of this. Yet by being emergent, they are also directionless, a product of complex systems rather than designed and strategic intent. This is not an inherently bad thing, but given the potential for data-system and platforms to have negative or unintended consequences, it is worth considering whether remaining directionless is the best outcome. There are many examples of data-driven systems in healthcare (Obermeyer et al.), welfare (Eubanks; Henman and Marston), and economics (MacKenzie), having unintended and negative social consequences. Appropriately guiding the design and deployment of theses system also represents a growing body of knowledge and practical endeavour (Jirotka et al.; Stilgoe et al.). Armed with the knowledge of these social implications, constructing an appropriate social architecture (Box and Lemon; Box et al.) around the platforms and data systems that form the shadow of hierarchy should be encouraged. This social architecture should account for the affordances and emergent potentials of a complex social, institutional, economic, political, and technical environment, and should assist in guiding the shadow of hierarchy away from egregious challenges and towards meaningful opportunities. To be directionless is an opportunity to take a new direction. The intersection of platforms with public institutions and infrastructures has moulded society’s light into an evolving and emergent shadow of hierarchy over many domains. With the scale of the shadow changing, and shaping participation, who benefits and who loses out in the shadow of hierarchy is also changing. Equipped with insights into this change, we should not hesitate to shape this change, creating or preserving relationalities that offer the best outcomes. Defining, understanding, and practically implementing what the “best” outcome(s) are would be a valuable next step in this endeavour, and should prompt considerable discussion. 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