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Symptomatic lumbar spinal stenosis (LSS) is a common indication for surgery in the elderly. Preoperative radiographic evaluation of patients with LSS often reveals redundant nerve roots (RNRs). The clinical significance of RNRs is uncertain. RNRs have not been studied in the setting of minimally invasive surgery. This study investigates the relationship between RNRs and clinical outcomes after minimally invasive tubular decompression.Chart review was performed for patients with degenerative LSS who underwent minimally invasive decompression. Preoperative magnetic resonance imaging parameters were assessed, and patient-reported outcomes were analyzed.Fifty-four patients underwent surgery performed at an average of 1.8 ± 0.8 spinal levels. Thirty-one patients (57%) had RNRs. Patients with RNRs were older (median = 72 years vs. 66 years, P = 0.050), had longer median symptom duration (32 months vs. 15 months, P 0.01), and had more levels operated on (2.1 vs. 1.4; P 0.01). The median follow-up after surgery was 2 months (range = 1.3-12 months). Preoperative and postoperative patient-reported outcomes were similar based on RNR presence. Patients without RNRs had larger lumbar cross-sectional areas (CSAs) (median = 121 mmPreoperative RNRs are associated with increased age, symptom duration, and lumbar stenosis severity. Patients improved after minimally invasive decompression regardless of RNR presence. RNR presence had no effect on short-term clinical outcomes. Further study is required to assess their long-term significance.

Frontotemporal dementia (FTD) is a neurodegenerative disorder characterized by cortical and subcortical atrophies, with early involvement of the hippocampus and amygdala. A 58-year-old man with clinical presentation of primary progressive aphasia-particularly its svPPA (semantic variant)-and bilateral asymmetric (left-predominant) anterior temporal lobe atrophy on MRI was referred for brain perfusion SPECT. This revealed bilateral hypoperfusion of the anterior temporal lobe (sustained by software-fused SPECT/MRI), pointing toward FTD rather than Alzheimer disease. Furthermore, voxel-based MRI volumetric analysis confirmed bilateral atrophy affecting the hippocampus and amygdala. Combining SPECT with MRI was supportive of the early-onset FTD-related svPPA diagnosis.

Background A better understanding of the role of structural barriers for physical activity (PA) after a cancer diagnosis could help to increase PA among people with cancer. Thus, the present study aimed to identify determinants of structural barriers to PA in people with cancer and investigate the association between structural barriers and insufficient post-diagnosis PA, taking different PA change patterns into account. Methods A total of 1299 people with breast, prostate, or colorectal cancer completed a questionnaire assessing their socio-demographic and medical characteristics, pre- and post-diagnosis PA, and perceived PA impediment by seven structural barriers. Regression analyses were used to investigate determinants of the perception of structural barriers and to examine the association between structural barriers and insufficient post-diagnosis PA, also with regard to different pre-diagnosis PA levels. Results Overall 30–60% of participants indicated to feel impeded by structural barriers. The analyses revealed a younger age, higher BMI, lower educational level, no current work activity, co-morbidities, and lacking physicians’ exercise counseling as significant determinants of the perception of structural barriers. Individuals reporting stronger impediments by structural barriers were significantly less likely to be meeting PA guidelines post-diagnosis, particularly those with sufficient pre-diagnosis PA levels. Conclusions The study highlights the need for tailored PA programs for people with cancer as well as for more guidance and support in overcoming structural barriers to improve PA behavior. The study has been registered under NCT02678832 at clinicaltrials.gov on February 10th 2016.

To bridge the gap between what is known and what is done, quality improvement collaboratives (QICs) enable health programs to rapidly address quality challenges at scale. Two QICs in Cameroon and Zambia improved coverage of early infant HIV testing and initiating antiretroviral therapy in HIV-exposed infants. The QIC approach empowers health care workers to design solutions tailored for their specific settings., Key Findings Although the designs of the QICs varied to fit local contexts in Cameroon and Zambia, they used similar indicators and methods, and each resulted in improvement of testing coverage and timely return of test results for HIV-exposed infants.The social dynamics of the QIC approach enhanced the sense of shared purpose and community, fostered teamwork and friendly competition, and built leadership support while creating an internal enabling environment at the facility level. The quarterly learning sessions, monthly data collection, and ongoing mentoring for quality improvement led to significant improvements that were sustained for the life of the intervention. Key Implications The use of QIC methodology empowered health care workers to design solutions tailored to their specific settings, and each QIC resulted in a “change package” of successful initiatives that were disseminated within each country.Health sector policy makers should consider institutionalizing the QIC approach and fostering its targeted implementation to address refractory quality challenges, including the inclusion of QIC methods in national policies, guidelines, training, and monitoring systems., Introduction: Early infant diagnosis (EID) and rapid antiretroviral therapy (ART) initiation are lifesaving interventions for HIV-infected infants. In Cameroon and Zambia, EID coverage for HIV-exposed infants (HEIs) is suboptimal and the time to ART initiation for infants infected with HIV often exceeds national standards despite numerous policy and training initiatives. Methods: ICAP at Columbia University supported the Cameroon and Zambia Ministries of Health (MOHs) and local partners to implement quality improvement collaboratives (QICs) to improve EID coverage and ART initiation at 17 health facilities (HFs) in Cameroon (March 2016 to June 2017) and 15 HFs in Zambia (March 2017 to June 2018). In each country, MOH led project design and site selection. MOH and ICAP provided quality improvement training and monthly supportive supervision, which enabled HF teams to conduct root cause analyses, design and implement contextually appropriate interventions, conduct rapid tests of change, analyze monthly progress, and convene at quarterly learning sessions to compare performance and share best practices. Results: In Cameroon, EID testing coverage improved from 57% (113/197 HEIs tested) during the 5-month baseline period to 80% (165/207) in the 5-month endline period. In Zambia, EID testing coverage improved from 77% (4,773/6,197) during the 12-month baseline period to 89% (2,144/2,420) during the 3-month endline period. In a comparison of the same baseline and endline periods, the return of positive test results to caregivers improved from 18% (36/196 caregivers notified) to 86% (182/211) in Cameroon and from 44% (94/214) to 79% (44/56) in Zambia. ART initiation improved from 44% (94/214 HIV-infected infants) to 80% (45/56) in Zambia; the numbers of HIV-infected infants in Cameroon were too small to detect meaningful differences. Conclusions: QICs improved coverage of timely EID and ART initiation in both countries. In addition to building quality improvement capacity and improving outcomes, the QICs resulted in a “change package” of successful initiatives that were disseminated within each country.

Emotional computing has been previously applied to assess physiological behavior in a wide variety of tasks and activities. This study extends for the first time the use of emotional computing in the field of balance rehabilitation training. A proof-of-concept study was conducted to assess arousal and pleasure response to a range of physical exercises from the OTAGO and HOLOBALANCE balance rehabilitation programs with varying levels of difficulty and physical demand. Eleven participants were enrolled and performed a set of exercises wearing an ECG sensor, reporting arousal and pleasure at the end of each session. A dataset of 264 unique sessions was collected and used to extract heart rate variability (HRV) features from the measured RR intervals and automatically assess user arousal and pleasure, evaluating different classification algorithms. The results suggested that assessment of both emotions is feasible, reaching an accuracy of 72% and 74% for arousal and pleasure estimation, resnectively. Clinical Relevance- Arousal and pleasure are clinically useful indicators of patient's experience and engagement while performing balance rehabilitation exercises with novel sensing technologies and monitoring platforms.

HIV testing with rapid antiretroviral therapy (ART) initiation are life-saving interventions for adolescents living with HIV. However, in Zambia, HIV diagnosis and immediate ART initiation among adolescents living with HIV is lagging. In collaboration with the Zambian Ministry of Health, the U.S. Health Resources and Services Administration, the U.S. Centers for Disease Control and Prevention in Zambia, and ICAP at Columbia University designed and implemented a quality improvement collaborative (QIC) to improve adolescent immediate ART initiation at 25 health facilities in Lusaka. Over the 12-month implementation period, quality improvement teams tested and identified targeted intervention, that significantly improved ART initiation within 14 days of receiving positive test results, from 24% at baseline to more than 93% for the final 6 months of implementation. The quality improvement collaborative approach empowered health care workers to innovate addressing the root causes of suboptimal performance and produced a package of successful interventions that will be shared throughout Zambia.

Triple elimination is an initiative supporting the elimination of mother-to-child transmission of three diseases - human immunodeficiency virus (HIV) infection, syphilis and hepatitis B. Significant progress towards triple elimination has been made in some regions, but progress has been slow in sub-Saharan Africa, the region with the highest burden of these diseases. The shared features of the three diseases, including their epidemiology, disease interactions and core interventions for tackling them, enable an integrated health-systems approach for elimination of mother-to-child transmission. Current barriers to triple elimination in sub-Saharan Africa include a lack of policies, strategies and resources to support the uptake of well established preventive and treatment interventions. While much can be achieved with existing tools, the development of new products and models of care, as well as a prioritized research agenda, are needed to accelerate progress on triple elimination in sub-Saharan Africa. In this paper we aim to show that health systems working together with communities in sub-Saharan Africa could deliver rapid and sustainable results towards the elimination of mother-to-child transmission of all three diseases. However, stronger political support, expansion of evidence-based interventions and better use of funding streams are needed to improve efficiency and build on the successes in prevention of mother-to-child transmission of HIV. Triple elimination is a strategic opportunity to reduce the morbidity and mortality from HIV infection, syphilis and hepatitis B for mothers and their infants within the context of universal health coverage.La triple élimination est une initiative visant à soutenir l'éradication de la transmission mère-enfant de trois maladies – l'infection au virus de l'immunodéficience humaine (VIH), la syphilis et l'hépatite B. Bien que des avancées considérables aient été observées en ce sens dans certaines régions, les progrès demeurent lents en Afrique subsaharienne, pourtant durement touchée par ces maladies. Les caractéristiques communes aux trois affections, notamment leur épidémiologie, les interactions entre elles et les principales interventions nécessaires à leur prise en charge permettent aux systèmes de santé d'adopter une approche intégrée pour éviter la transmission mère-enfant. Plusieurs obstacles entravent actuellement la triple élimination en Afrique subsaharienne, parmi lesquels l'absence de politiques, de stratégies et de ressources pour garantir la disponibilité de traitements préventifs et curatifs bien établis. Les outils existants offrent déjà de nombreuses solutions; mais pour accélérer la progression de cette triple élimination en Afrique subsaharienne, il est indispensable de développer de nouveaux produits et modèles de soins, ainsi qu'un programme de recherche prioritaire. Dans le présent document, nous voulons montrer que si les systèmes de santé collaborent avec les communautés en Afrique subsaharienne, ils pourront obtenir des résultats rapides et durables en vue d'éradiquer la transmission mère-enfant des trois maladies susmentionnées. Néanmoins, une telle démarche implique un soutien politique massif, l'expansion des interventions fondées sur des données scientifiques, et une meilleure utilisation des sources de financement afin d'améliorer l'efficacité et de s'appuyer sur les réussites en matière de prévention de la transmission du VIH de la mère à l'enfant. La triple élimination représente une occasion stratégique de réduire la morbidité et la mortalité liées à l'infection au VIH, à la syphilis et à l'hépatite B, tant chez les mères que chez les nourrissons, dans un contexte de couverture maladie universelle.La triple eliminación es una iniciativa que apoya la eliminación de la transmisión maternoinfantil de tres enfermedades: la infección por el virus de la inmunodeficiencia humana (VIH), la sífilis y la hepatitis B. En algunas regiones se han logrado avances significativos hacia la triple eliminación, pero los progresos se han desarrollado con mayor lentitud en el África subsahariana, la región con la mayor carga de estas enfermedades. Las características comunes de las tres enfermedades, como su epidemiología, las interacciones entre ellas y las intervenciones básicas para combatirlas, permiten un enfoque integrado de los sistemas de salud para la eliminación de la transmisión maternoinfantil. Los obstáculos actuales para la triple eliminación en el África subsahariana incluyen la falta de políticas, estrategias y recursos para apoyar la adopción de intervenciones preventivas y de tratamiento bien establecidas. Aunque se puede lograr mucho con las herramientas existentes, se necesita el desarrollo de nuevos productos y modelos de atención, así como una agenda de investigación prioritaria, para acelerar el progreso de la triple eliminación en el África subsahariana. En este documento pretendemos demostrar que los sistemas de salud que trabajan conjuntamente con las comunidades del África subsahariana podrían obtener resultados rápidos y sostenibles hacia la eliminación de la transmisión maternoinfantil de las tres enfermedades. Sin embargo, se necesita un mayor apoyo político, la ampliación de las intervenciones basadas en la evidencia y un mejor uso de los flujos de financiación para mejorar la eficiencia y aprovechar los éxitos en la prevención de la transmisión maternoinfantil del VIH. La triple eliminación es una oportunidad estratégica para reducir la morbilidad y la mortalidad de la infección por el VIH, la sífilis y la hepatitis B para las madres y sus hijos en el contexto de la cobertura sanitaria universal.إن القضاء على هذه الأمراض الثلاثة هو مبادرة لدعم القضاء على انتقال ثلاثة أمراض من الأم إلى الطفل، وهي عدوى فيروس نقص المناعة البشرية (HIV)، والزهري، والالتهاب الكبدي ب. تم إحراز تقدم كبير نحو القضاء على هذه الأمراض الثلاثة في ​​بعض المناطق، إلا أن التقدم المحرز كان بطيئًا في جنوب الصحراء الكبرى بأفريقيا، وهي المنطقة التي تزخر بأكبر عبء لهذه الأمراض. إن السمات المشتركة لهذه الأمراض الثلاثة، بما يشمل سماتها في علم الأوبئة، وتفاعلاتها المرضية والتدخلات الأساسية للتعامل معها، تتيح اتباع نهج النظم الصحية المتكاملة للقضاء على انتقال العدوى من الأم إلى الطفل. إن العوائق الحالية أمام القضاء على الأمراض الثلاثة في جنوب الصحراء الكبرى بأفريقيا، تشمل الافتقار إلى السياسات والاستراتيجيات والموارد لدعم استيعاب التدخلات الوقائية والعلاجية الراسخة. بينما يمكن إنجاز الكثير باستخدام الأدوات الحالية، إلا أن هناك حاجة إلى تطوير منتجات ونماذج جديدة للرعاية، وكذلك وضع جدول أعمال بحثي على رأس الأولويات، لتسريع التقدم في القضاء على الأمراض الثلاثة في جنوب الصحراء الكبرى بأفريقيا. نهدف في هذه الورقة البحثية إلى توضيح أن الأنظمة الصحية التي تعمل جنبًا إلى جنب مع المجتمعات في جنوب الصحراء الكبرى بأفريقيا، يمكنها أن تحقق نتائج سريعة ومستدامة في سبيل القضاء على انتقال الأمراض الثلاثة من الأم إلى الطفل. وبالرغم من ذلك، فإن هناك حاجة إلى دعم سياسي أقوى، وتوسيع نطاق التدخلات المعتمدة على الدلائل، واستخدام أفضل لتدفقات التمويل، وذلك لتحسين الكفاءة، واستغلال النجاحات في الحيلولة دون انتقال فيروس نقص المناعة البشرية من الأم إلى الطفل. إن القضاء على الأمراض الثلاثة هو فرصة استراتيجية للحد من الحالات المرضية والوفيات من جراء عدوى فيروس نقص المناعة البشرية والزهري والالتهاب الكبدي ب، لكل من الأمهات ومواليدهن في سياق التغطية الصحية الشاملة.三重消除是一项支持消除三种疾病【人类免疫缺陷病毒 (HIV) 感染、梅毒和乙型肝炎】母婴传播的计划。在有些地区，三重消除取得了重大进展，但在撒哈拉以南非洲地区，该计划的进展缓慢，因此，该地区在对抗这些疾病方面的任务最为繁重。这三种疾病在其流行病学、疾病相互作用和相关核心干预措施方面具有共同特点，因此，卫生系统能够综合采取方法来消除母婴传播。目前阻碍撒哈拉以南非洲地区三重消除计划实施的障碍包括缺乏支持采用既定预防和治疗措施的政策、战略和资源。虽然利用现有工具可取得很大的成就，但还是需要开发新的护理产品和模式，并制定优先研究议程，以加快撒哈拉以南非洲地区三重消除计划的进展。在本文中，我们的目的在于表明撒哈拉以南非洲地区的卫生系统与社区开展合作，能够为消除这三种疾病的母婴传播带来迅速且可持续的效果。但是，需要加强政治支持、扩大循证干预措施和更好地利用资金流，以提高效率，并在预防 HIV 母婴传播方面奠定成功的基础。三重消除是一种战略机遇，可以在全民保健范围内降低母亲及其婴儿因感染 HIV、梅毒和乙型肝炎而导致的发病率和死亡率。.Тройная элиминация, это инициатива, поддерживающая элиминацию передачи от матери ребенку трех заболеваний: инфекции, вызванной вирусом иммунодефицита человека (ВИЧ), сифилиса и гепатита В. В некоторых регионах был достигнут значительный прогресс в направлении тройной элиминации, однако на территориях к югу от Сахары (в регионе Африки с самым высоким бременем этих болезней) такой прогресс был медленным. Общие характеристики трех болезней, включая их эпидемиологию, взаимодействие болезней и основные меры по борьбе с ними, позволяют использовать комплексный подход в рамках систем здравоохранения к элиминации передачи от матери ребенку. Текущие препятствия на пути тройной элиминации в странах Африки к югу от Сахары включают отсутствие политик, стратегий и ресурсов для поддержки внедрения хорошо зарекомендовавших себя профилактических и лечебных мер. Несмотря на то что с помощью существующих инструментов можно добиться многого, для ускорения прогресса в области тройной элиминации в странах Африки к югу от Сахары необходима разработка новых продуктов и моделей оказания медицинской помощи, а также повестка дня в области приоритетных научных исследований. В этом документе авторы стремятся показать, что системы здравоохранения, работающие вместе с общественностью в странах Африки к югу от Сахары, могут обеспечить быстрые и устойчивые результаты в направлении элиминации передачи всех трех заболеваний от матери ребенку. Однако для повышения эффективности и достижения успехов в профилактике передачи ВИЧ от матери ребенку необходимы: более сильная политическая поддержка, расширение научно обоснованных мер и лучшее использование потоков финансирования. Тройная элиминация, это стратегическая возможность снизить заболеваемость и смертность от ВИЧ-инфекции, сифилиса и гепатита B для матерей и их младенцев в контексте всеобщего охвата услугами здравоохранения.

Evidence on the benefits of physical activity (PA) during cancer has caused a paradigm shift from people with cancer being advised to save energy (rest paradigm) to guidelines recommending them to engage in regular PA (activity paradigm). This study examined the rest and the activity paradigm among people with cancer based on the theory of planned behaviour (TPB).A cross-sectional survey was completed by N = 1244 people (58% women; M = 59.95 years) with breast, prostate and colorectal cancer, including 15 items on rest and activity attitudes. To explain the intention to engage in PA, hierarchical regression analyses were calculated.The two-dimensional structure of attitudes (rest and activity) was confirmed. The agreement with the activity paradigm (M = 4.11; SD = 0.78) was higher compared to the rest paradigm (M = 2.56; SD = 0.78, p .001). The TPB was an appropriate model to explain the intention to engage in PA (RResults indicate that the paradigm shift has successfully reached attitudes of people with cancer. Interventions focusing on the benefits of PA rather than addressing rest cognitions promise higher effectiveness in affecting PA levels.NCT02678832.

Improving the use of viral load (VL) testing for adolescents and young people living with HIV (AYPLWH) is a priority for Kenya’s Ministry of Health (MOH). Despite expansion of VL testing coverage and rollout of national policies, guidelines and training, VL result utilisation for AYPLWH remains suboptimal, with inadequate adherence to national guidelines recommending everyone on antiretroviral therapy (ART) with unsuppressed viral load (UVL) (≥401 copies/mL) receive three enhanced adherence counselling (EAC) sessions and a repeat VL test within 3 months. In March 2019, ICAP at Columbia University partnered with the MOH to launch a Quality Improvement Collaborative (QIC) at 22 health facilities in the Eastern Province to optimise management of AYPLWH on ART with UVL. Over 17 months, facility QI teams tested interventions targeting client education, workflow modifications, commodity management, community engagement and improved documentation. The QIC led to marked improvement in the proportion of clients completing three EAC sessions and repeat VL testing. Median completion rate was 16% (n=479) at baseline (from March 2018 to February 2019) and rose to 73% (n=755) during the implementation period (from March 2019 to July 2020). In the final month (July 2020), rates rose to 90% (n=31). Another success was the increase in the proportion of clients whose VL was resuppressed on repeat testing, which improved from 34% (n=273) at baseline to 62% (n=710) during the implementation period and 77% (n=44) in the final month. The QIC also led to improvement in the proportion of AYPLWH on first-line ART whose regimens were switched within 2 months of recorded UVL results, which rose from 58% (n=48) at baseline to 94% (n=128) during the implementation period. In summary, the QIC helped facility teams to identify and prioritise local, contextually appropriate innovations which led to swift improvement in three critical indicators of VL utilisation.

Background In recent years, concerns have been raised on the potential adverse effects of nonselective beta-blockers, and particularly carvedilol, on renal perfusion and survival in decompensated cirrhosis with ascites. We investigated the long-term impact of converting propranolol to carvedilol on systemic hemodynamics and renal function, and on the outcome of patients with stable cirrhosis and grade II/III nonrefractory ascites. Patients and methods Ninety-six patients treated with propranolol for esophageal varices' bleeding prophylaxis were prospectively evaluated. These patients were randomized in a 2:1 ratio to switch to carvedilol at 12.5 mg/d (CARVE group; n=64) or continue propranolol (PROPRA group; n=32). Systemic vascular resistance, vasoactive factors, glomerular filtration rate, and renal blood flow were evaluated at baseline before switching to carvedilol and after 6 and 12 months. Further decompensation and survival were evaluated at 2 years. Results During a 12-month follow-up, carvedilol induced an ongoing improvement of systemic vascular resistance (1372±34 vs. 1254±33 dynes/c/cm5; P=0.02) along with significant decreases in plasma renin activity (4.05±0.66 vs. 6.57±0.98 ng/mL/h; P=0.01) and serum noradrenaline (76.7±8.2 vs. 101.9±10.5 pg/mL; P=0.03) and significant improvement of glomerular filtration rate (87.3±2.7 vs. 78.7±2.3 mL/min; P=0.03) and renal blood flow (703±17 vs. 631±12 mL/min; P=0.03); no significant effects were noted in the PROPRA group. The 2-year occurrence of further decompensation was significantly lower in the CARVE group than in the PROPRA group (10.5% vs. 35.9%; P=0.003); survival at 2 years was significantly higher in the CARVE group (86% vs. 64.1%; P=0.01, respectively). Conclusion Carvedilol at the dose of 12.5 mg/d should be the nonselective beta-blocker treatment of choice in patients with cirrhosis and nonrefractory ascites, as it improves renal perfusion and outcome.

Background and purpose The ability to predict high-grade meningioma preoperatively is important for clinical surgical planning. The purpose of this study is to evaluate the performance of comprehensive multiparametric MRI, including susceptibility weighted imaging (SWI) and quantitative susceptibility mapping (QSM) in predicting high-grade meningioma both qualitatively and quantitatively. Methods Ninety-two low-grade and 37 higher grade meningiomas in 129 patients were included in this study. Morphological characteristics, quantitative histogram analysis of QSM and ADC images, and tumor size were evaluated to predict high-grade meningioma using univariate and multivariate analyses. Receiver operating characteristic (ROC) analyses were performed on the morphological characteristics. Associations between Ki-67 proliferative index (PI) and quantitative parameters were calculated using Pearson correlation analyses. Results For predicting high-grade meningiomas, the best predictive model in multivariate logistic regression analyses included calcification (β = 0.874, P = 0.110), peritumoral edema (β = 0.554, P = 0.042), tumor border (β = 0.862, P = 0.024), tumor location (β = 0.545, P = 0.039) for morphological characteristics, and tumor size (β = 4 × 10−5, P = 0.004), QSM kurtosis (β = − 5 × 10−3, P = 0.058), QSM entropy (β = − 0.067, P = 0.054), maximum ADC (β = − 1.6 × 10−3, P = 0.003), ADC kurtosis (β = − 0.013, P = 0.014) for quantitative characteristics. ROC analyses on morphological characteristics resulted in an area under the curve (AUC) of 0.71 (0.61–0.81) for a combination of them. There were significant correlations between Ki-67 PI and mean ADC (r = − 0.277, P = 0.031), 25th percentile of ADC (r = − 0.275, P = 0.032), and 50th percentile of ADC (r = − 0.268, P = 0.037). Conclusions Although SWI and QSM did not improve differentiation between low and high-grade meningiomas, combining morphological characteristics and quantitative metrics can help predict high-grade meningioma.

The use of magnetic resonance imaging (MRI) during pregnancy is on the rise due its ability to provide detailed cross-sectional anatomy without ionizing radiation. Despite the favorable radiation profile, theoretically concerns regarding the safety of MRI and gadolinium-based contrast agent (GBCA) administration have been raised. Currently there are no studies that have shown any attributable harms of MRI during any trimester of pregnancy although prospective and longitudinal studies are lacking. GBCA administration may be associated with a slightly higher rate of neonatal death, although this is based on a single, large cohort study. Understanding the available evidence regarding MRI safety during pregnancy in the context of current society guidelines will help the radiologist serve as a valuable resource to patients and referring providers.

INTRODUCTION: HIV testing at birth of HIV-exposed infants (HEIs) may improve the identification of infants infected with HIV in utero and accelerate antiretroviral treatment (ART) initiation. METHODS: ICAP at Columbia University supported implementation of a national pilot of HIV testing at birth (0–7 days) in Eswatini at 2 maternity facilities. Dried blood spot (DBS) samples from neonates of women living with HIV (WLHIV) were collected and processed at the National Molecular Reference Laboratory using polymerase chain reaction (PCR). Mothers received birth test results at community health clinics. We report data on HIV birth testing uptake and outcomes for HIV-positive infants from the initial intensive phase (October 2017–March 2018) and routine support phase (April–December 2018). RESULTS: During the initial intensive pilot phase, 1669 WLHIV delivered 1697 live-born HEI at 2 health facilities and 1480 (90.3%) HEI received birth testing. During the routine support phase, 2546 WLHIV delivered and 2277 (93.5%) HEI received birth testing. Overall October 2017–December 2018, 22 (0.6%) infants of 3757 receiving birth testing had a positive PCR test, 15 (68.2%) of whom were successfully traced and linked for confirmatory testing (2 infants were reported by caregivers to have negative follow-up HIV tests). Median time from birth test to receipt of results by the caregiver was 13 days (range: 8–23). Twelve (60.0%) of 20 infants confirmed to be HIV-positive started ART at median age of 17.5 days (12–43). One mother of an HIV-positive infant who was successfully traced refused ART following linkage to care and another child died after ART initiation. Three infants (15.0%) had died by the time their mothers were reached and 4 (15.0%) infants were never located. CONCLUSION: This pilot of universal birth testing in Eswatini demonstrates the feasibility of using a standard of care approach in a low resource and high burden setting. We document high uptake of testing for newborns among HIV-positive mothers and very few infants were found to be infected through birth testing.

It is well recognized that bone-seeking radiotracers localize in muscles sustaining an injury from various causes (e.g., strenuous physical activity, trauma, hereditary myopathies, inflammatory myositides, medications, electrical burns, etc.). This report presents the case of an active 50-yr-old man (body mass index = 29) that was recently referred to our nuclear medicine department for bone scintigraphy, for the skeletal staging of a newly diagnosed prostate adenocarcinoma. The scan findings were unremarkable for its oncological indication but revealed extraosseous radiotracer absorption in the medial region of the hamstrings bilaterally. Hybrid scintitomography (single-photon emission computed tomography) with computed tomography indicated that this uptake involved the semitendinosus muscle. On a more meticulous repeat history questioning, he recalled experiencing muscle cramps on both posterior thighs 5 days earlier, during intense work-related physical activity (plumbing) under warm environmental conditions. The combination of strenuous exercise with likely dehydration contributed to bilateral self-limiting heat cramps of the hamstrings, leading to an inconsequential localized minor rhabdomyolysis that was discovered coincidentally a few days later during a bone scan. Although extraskeletal absorption of bone-seeking radiotracers in muscles is widely documented as a result of exertion or injury, this is the first report of radiotracer absorption induced by cramping.

To estimate the prevalence of the left-sided aortic arch (LSAA) variants, and the effect of possible moderators on variants' detection.A systematic online literature search was conducted. The pooled prevalence with 95% confidence intervals was estimated for the typical and atypical branching patterns to compare the overall proportions of different variants. Meta-regression analyses were performed to investigate the effect of the subjects' gender and geographical region, and the multidetector computed tomography (MDCT) scanner's technology on the estimated prevalence.In total, 18,075 cases from 23 imaging studies were included and 33 different LSAA variants were detected. The estimated heterogeneity was statistically significant. Based on the estimated prevalence, approximately 77% of the population is expected to have the typical branching anatomy with sequence brachiocephalic trunk-left common carotid artery-left subclavian artery, and 23% variant branching patterns. Approximately 71%, 23%, 2%, and 0.1% of the atypical populations are expected to have two, four, three, and five emerging branches, respectively. The meta-regression analyses showed that the number of detector rows of the MDCT scanner, and the subjects' geographical region are statistically significant moderators of the estimated prevalence.The current findings indicate that the prevalence of the LSAA variant branching anatomy is significantly affected by the subjects' geographical region and the MDCT scanner's technological improvement, with the advanced scanners to facilitate the detection of the aortic arch variants. However, due to the heterogeneity among studies, further research is required.

Although physical activity (PA) is beneficial for patients with cancer, healthcare professionals (HCP) still scarcely recommend it. This study aimed to determine how HCP’ sociodemographic and professional characteristics and their subjective assessments of patient characteristics are associated with their PA recommendations to patients with cancer. A cross-sectional survey (paper-pencil or online) was completed by 929 HCP (159 general practitioners, 382 specialized physicians, and 388 oncology nurses). The survey collected information on HCP’ sociodemographic and professional characteristics, PA recommendation frequency, and the likelihood of 13 patient characteristics influencing PA recommendations (on a 7-point Likert scale). Descriptive results showed that 37.6% of HCP indicated often recommending PA and 41.7% indicated routinely recommending PA. More professional experience was associated with a higher reported PA recommendation frequency among specialized physicians and oncology nurses. Patient characteristics could be assigned to three higher-level categories. Characteristics from the categories “medical side effects” and “low affinity for PA” were more frequently judged by HCP as reasons for recommending PA and characteristics belonging to “indicators of poor general health” as reasons for not recommending PA. In all professional groups, the inclusion of patient characteristics resulted in additional variance explained in the prediction of a routine PA recommendation. HCP in this study reported that they frequently recommend PA to patients with cancer. However, HCP consider cancer patient characteristics to influence their decision whether to recommend PA. Future research and interventions should aim to enable HCP to provide adequate PA recommendations to patients with cancer having different characteristics.

Background The One Health (OH) approach integrates multiple competencies in the prevention and control of disease outbreaks. Through a range of OH competence-based activities, the Africa One Health University Network (AFROHUN) built the capacity of selected students at Makerere University and Mbarara University of Science and Technology. This study applied the Systems Theoretical Framework (STF) of career development to establish the employment status of AFROHUN-Uganda alumni, and the facilitators and barriers to application of the OH approach in their organisations. Methods We conducted an embedded mixed-methods study among a random sample of 182 AFROHUN-Uganda alumni of the 2013–2018 cohorts. For quantitative data, descriptive statistics were computed using Stata 14.0 statistical software. A total of 12 in-depth interviews were conducted, and NVivo 12 Pro was used to organise data during thematic analysis. Results While the majority, 87.4% were or got employed after participating in the AFROHUN Uganda capacity building programme, 68.1% were employed at the time of the survey, 57.7% had worked with their current employer for at least a year, and 39% held managerial positions. The facilitators of applying the OH approach into employing organisations included being knowledgeable about OH, the presence of a multidisciplinary workforce, the nature of activities implemented, and existing partnerships and collaborations between organisations. The barriers to the application of the OH approach included limited funding, a negative attitude towards working with people from other disciplines, and limited knowledge of the One Health approach. Conclusion Notably, more than two-thirds of the OH alumni were employed, and more than a third held managerial position. While these findings portray a fairly good absorption rate of the OH alumni into the workforce, they also highlight the facilitators of application of the OH approach that need to be promoted as well as the barriers that need to be addressed if the application of the OH approach is to be improved within the workforce.

Background The Africa One Health University Network (AFROHUN) with support from the United States Agency for International Development (USAID), has since 2012 conducted pre and in-service One health (OH) trainings with the objective of improving global health security. These trainings aim to build competencies that, enhance a multidisciplinary approach to solving global health challenges. Despite the investment in OH trainings, there is limited documentation of the extent of acquisition and application of the OH competencies at workplaces. This tracer study explored the extent of acquisition and application of the OH competencies by the AFROHUN-Uganda alumni. Methods A cross-sectional study was conducted among a random sample of 182 AFROHUN-Uganda alumni of 2013–2018 cohorts. A blended approach of interviewer-administered and self-administered questionnaires was used. Virtual platforms such as Zoom, Microsoft teams, and Skype, and phone interviews were used to collect data when face-to-face interactions with alumni were not possible. Data were collected electronically, either through a link or with the aid of the KoboCollect mobile application, pre-installed on android enabled devices, and analysed using STATA14.0. Results The majority of respondents, 78.6% (143/182) had jobs that required application of OH knowledge and skills, 95.6% (174/182) had learned employable skills from OH activities and 89.6% (163/182) had applied such skills when searching for employment. About 21.7% (34/180) to a very high extent required OH field-specific theoretical knowledge at their workplaces, 27.4% (43/80) to a very high extent required OH field-specific practical knowledge/skills, 42.7% (67/180) to a high extent required a change in attitude and perceptions towards working with people from different disciplines, 49.0% (77/180) required collaboration and networking skills, and more than half, 51.0% (80/180) required team building skills. Conclusions The majority of OH alumni to a very high extent acquired and applied OH competences such as teamwork, effective communication, community entry and engagement, report writing and problem-solving skills. This study revealed the significant contribution of the AFROHUN Uganda OH activities towards supportive work environments, and highlights areas of improvement such as supporting the trainees to acquire people-management skills, innovation, and an entrepreneurial mind set.

Background The global spread of the SARS-CoV-2 virus highlights both the importance of frontline healthcare workers (HCW) in pandemic response and their heightened vulnerability during infectious disease outbreaks. Adequate preparation, including the development of human resources for health (HRH) is essential to an effective response. ICAP at Columbia University (ICAP) partnered with Resolve to Save Lives and MOHs to design an emergency training initiative for frontline HCW in 11 African countries, using a competency-based backward-design approach and tailoring training delivery and health facility selection based on country context, location and known COVID-19 community transmission. Methods Pre- and post-test assessments were conducted on participants completing the COVID-19 training. Parametric and non-parametric methods were used to examine average individual-level changes from pre- to post-test, and compare performance between countries, cadres, sex and facility types. A post-evaluation online training survey using Qualtrics was distributed to assess participants’ satisfaction and explore training relevance and impact on their ability to address COVID-19 in their facilities and communities. Results A total of 8797 HCW at 945 health facilities were trained between June 2020 and October 2020. Training duration ranged from 1 to 8 days (median: 3 days) and consisted of in person, virtual or self guided training. Of the 8105 (92%) HCW working at health facilities, the majority (62%) worked at secondary level facilities as these were the HF targeted for COVID-19 patients. Paired pre- and post-test results were available for 2370 (25%) trainees, and 1768 (18%) participants completed the post-evaluation training survey. On average, participants increased their pre- to post-test scores by 15 percentage points (95% CI 0.14, 0.15). While confidence in their ability to manage COVID-19 was high following the training, respondents reported that lack of access to testing kits (55%) and PPE (50%), limited space in the facility to isolate patients (45%), and understaffing (39%) were major barriers. Conclusion Ongoing investment in health systems and focused attention to health workforce capacity building is critical to outbreak response. Successful implementation of an emergency response training such as this short-term IPC training initiative in response to the COVID-19 pandemic, requires speed, rigor and flexibility of its design and delivery while building on pre-existing systems, resources, and partnerships.

Pre-clinical evidence suggests bevacizumab (BV) depletes the GBM peri-vascular cancer-stem cell niche. This phase I/II study assesses the safety and efficacy of repeated doses of superselective intra-arterial cerebral infusion (SIACI) of BV after blood-brain barrier disruption (BBBD).Date of surgery was day 0. Evaluated patients received repeated SIACI bevacizumab (15 mg/kg) with BBBD at days 30 ± 7, 120 ± 7, and 210 ± 7 along with 6 weeks of standard chemoradiation. Response assessment in neuro-oncology criteria and the Kaplan-Meier product-limit method was used to evaluate progression free and overall survival (PFS and OS, respectively).Twenty-three patients with a median age of 60.5 years (SD = 12.6; 24.7-78.3) were included. Isocitrate dehydrogenase mutation was found in 1/23 (4%) patients. MGMT status was available for 11/23 patients (7 unmethylated; 3 methylated; 1 inconclusive). Median tumor volume was 24.0 cm3 (SD = 31.1, 1.7-48.3 cmRepeated dosing of IA BV after BBBD offers an encouraging outcome in terms of PFS and OS. Phase III trials are warranted to determine whether repeated IA BV combined with Stupp protocol is superior to Stupp protocol alone for newly diagnosed GBM.

The purpose of this study was to examine and compare pre- to post-diagnosis change patterns of physical activity (PA) among breast, prostate, and colorectal cancer patients. Moreover, the study aimed to investigate sociodemographic and medical determinants of post-diagnosis PA and to identify patient subgroups at increased risk of inactivity. A total of 912 cancer patients (457 breast, 241 prostate, 214 colorectal cancer) completed a questionnaire assessing their pre- and post-diagnosis PA behavior, and sociodemographic and medical variables. Age-adjusted regression and classification tree analyses were used to investigate PA determinants and detect subgroups that were most likely to meet or not meet PA guidelines. Across cancer types, we found that PA yet decreased from pre- to post-diagnosis, but that 54.1% of participants still reported to be meeting PA guidelines after the diagnosis. While post-diagnosis PA was strongly affected by previous PA behavior among individuals of all patient groups, other sociodemographic and medical determinants played different roles depending on cancer type. The results yielded that previously active, longer diagnosed patients with higher education levels were most likely to be meeting PA guidelines post-diagnosis, whereas specifically previously inactive prostate cancer patients had an increased likelihood of insufficient activity. An encouragingly high number of cancer patients indicated sufficient PA levels. For those having difficulties to maintain or adopt PA post-diagnosis, interventions should be tailored to the specific characteristics of each cancer type, as different factors are associated with PA for each patient group.

While the diagnosis of traumatic brain injury (TBI) is a clinical decision, neuroimaging remains vital for guiding management on the basis of identification of intracranial pathologic conditions. CT is the mainstay of imaging of acute TBI for both initial triage and follow-up, as it is fast and accurate in detecting both primary and secondary injuries that require neurosurgical intervention. MRI is more sensitive for the detection of certain intracranial injuries (eg, axonal injuries) and blood products 24-48 hours after injury, but it has limitations (eg, speed, accessibility, sensitivity to motion, and cost). The evidence primarily supports the use of MRI when CT findings are normal and there are persistent unexplained neurologic findings or at subacute and chronic periods. Radiologists should understand the role and optimal imaging modality to use, in addition to patterns of primary brain injury and their influence on the risk of developing secondary brain injuries related to herniation. ©RSNA, 2019 See discussion on this article by Mathur and Nicolaou.

LVAD-related strokes occur at a much higher rate compared to traditional open heart surgery. The pathophysiology of ischemic and hemorrhagic strokes after LVAD implantation is not well defined. The aim of this study was to better describe the etiopathogenesis of strokes during continuous flow LVAD support based on our institutional experience. We performed a retrospective analysis of 200 patients, with and without stroke that underwent implantation of a continuous flow LVAD from 2011 to 2016. The incidences of stroke in our patient population were 13% (26/200), of which 50% (13/26) were ischemic and 50% hemorrhagic (13/26). Only 8% of strokes occurred within the first 48 h from LVAD implantation, all of which were ischemic. The median duration of support was 148 days for ischemic and 351 days (p = 0.012) for hemorrhagic strokes. The average mean arterial pressure measurements at the time of hospital discharge were 89 mmHg for patients who subsequently developed stroke and 72 mmHg (p = 0.03) for stroke-free patients. The average outpatient pressure measurements were 96 mmHg and 76 mmHg (p = 0.02) for the stroke and stroke-free patients, respectively. The mean velocity index showed the potential impairment of cerebral autoregulation. Multivariate analysis demonstrated that INR, COPD, aortic cross clamping, previous stroke, and device infections were statistically significant risk factors for stroke occurrence after LVAD implantation. In addition to LVAD-related thrombogenicity, the subsequent need for anticoagulation, and an acquired von Willebrand syndrome, several clinical factors, such as deviation from the anticoagulation regimen, hypertension, COPD, device infections, and aortic cross clamping, appear to have an influence on the extremely high rate of postoperative ischemic and hemorrhagic strokes.

Mild traumatic brain injury (mTBI) affects about 42 million people worldwide. It is often associated with headache, cognitive deficits, and balance difficulties but rarely shows any abnormalities on conventional computed tomography (CT) or magnetic resonance imaging (MRI). Although in most mTBI patients the symptoms resolve within 3 months, 10-15% of patients continue to exhibit symptoms beyond a year. Also, it is known that there exists a vulnerable period post-injury, when a second injury may exacerbate clinical prognosis. Identifying this vulnerable period may be critical for patient outcome, but very little is known about the neural underpinnings of mTBI and its recovery. In this work, we used advanced functional neuroimaging to study longitudinal changes in functional organization of the brain during the 3-month recovery period post-mTBI. Fractional amplitude of low frequency fluctuations (fALFF) measured from resting state functional MRI (rs-fMRI) was found to be associated with symptom severity score (SSS, r = -0.28, p = 0.002). Decreased fALFF was observed in specific functional networks for patients with higher SSS, and fALFF returned to higher values when the patient recovered (lower SSS). In addition, functional connectivity of the same networks was found to be associated with concurrent SSS, and connectivity immediately after injury (10 days) was capable of predicting SSS at a later time-point (3 weeks to 3 months, p 0.05). Specific networks including motor, default-mode, and visual networks were found to be associated with SSS (p 0.001), and connectivity between these networks predicted 3-month clinical outcome (motor and visual: p 0.001, default-mode: p 0.006). Our results suggest that functional connectivity in these networks comprise potential biomarkers for predicting mTBI recovery profiles and clinical outcome.

Immuno-oncology (IO) with immune checkpoint inhibitors (ICIs) is the new landmark in cancer treatment. However, due to its economical-related burden and the possibility of tumor pseudoprogression with late response patterns, it is imperative to find new ways for early discrimination of patients with IO-sensitive versus IO-resistant disease. ICI-mediated antitumor responses depend on tumor immune infiltration by T-cells capable of recognizing and killing tumor cells. Nevertheless, patients may experience different responses to immunotherapy according to their tumor microenvironment and inflammatory infiltration. T-cell infiltrated tumors are referred to as 'hot' and are potential candidates for a good response to ICIs, whereas 'cold' are those tumors lacking T-cell infiltration and exhibit a narrow likelihood of response to IO therapy. Gallium-67 (67Ga) scintigraphy may hold potential for separating 'hot' from 'cold' tumors, thus providing an imaging tool to distinguish 'hot' ICI-induced pseudoprogression from real early 'cold' progression. Even so, various tumors (lymphomas, lung cancer, breast cancer, hepatoma, malignant melanoma) exhibit an inherent affinity for 67Ga that is independent of the ICI-induced immune infiltration, and this raises issues about false positivity. For that reason, future investigational studies to evaluate the prospective role of this radiotracer in the early prediction of ICI response should be confined to tumors with an inherently low 67Ga affinity (thyroid carcinoma, gastrointestinal and genitourinary tract tumors). We describe our experience with a patient with recurrent metastatic lung adenocarcinoma under ICI therapy that was submitted to 67Ga scanning for a fever of unknown origin and we discuss the aforementioned topics, alongside current imaging trends and future perspectives in the field.

Chromogranin A (CgA) is a soluble polypeptide stored within and released from secretory granules of endocrine and other cell types (including cardiomyocytes); CgA appears to be a marker of the overall neuroendocrine activity. Increased levels of serum CgA have been found not only in patients with neuroendocrine neoplasms but also with other malignancies, hypertension, myocardial infarction, heart, or renal failure.A population of 307 patients (202 males, 105 females) was enrolled. The study group consisted of 118 individuals (38.4%) with myocardial infarction more than one year old (MI group); the remaining 189 (61.6%) had no known heart disease (control group). All patients underwent myocardial perfusion scintigraphy (MPS) after blood withdrawal for serum CgA measurement. To test whether a possible effect of old infarction on serum CgA is mediated by MPS findings, we employed analysis of covariance for three distinct categories of left ventricular (LV) perfusion deficits as dichotomous predictors: (1) any-type deficits (abnormal MPS); (2) reversible deficits (ischemia); and (3) fixed deficits (scar).In all three MPS conditions, the effect of age, gender, and LV ejection fraction (EFLV) on serum CgA was statistically significant: women exhibited higher CgA levels than men (P=0.008-0.023), whereas increasing age and decreasing EFLV were associated with increasing CgA (all P0.001). Conversely, no statistically significant differences in mean CgA levels were found between MI patients and normal controls with either abnormal MPS, scar, or ischemia, or their degree and extent.Although serum CgA is significantly associated with age, gender, and EFLV in patients with an old MI, no association was found between CgA levels and either old MI history or MPS findings. The verified involvement of circulating CgA in the acute/subacute phase of infarction appears to be blunted in infarctions older than a year.

Involving potential end users in the development process of digital interventions makes it possible to ensure that these programs meet the needs, requirements and expectations of future users, which in turn has a positive impact on acceptance and adherence. This contribution presents a participatory development approach for the patient-centered design of the psycho-oncological online self-helpPatients were involved in the developmental process at two points. At an early stage of development, semi-standardized in-depth interviews were conducted with patients diagnosed by different types of cancer (N=10) and were qualitatively evaluated with regard to their view of (1) the cancer disease and (2) the design of an online self-help on the content, structural and design levels. At a later stage, a prototype of the online self-help was evaluated in a pilot phase.The qualitative analysis of the interviews with a total of N=742 codings resulted in five main content categories (changes in everyday life and future experience, changes in social relationships, processing mechanisms, loss of control, difficult emotions), which provide information about the central challenges and burdens of people with cancer. Participants showed particularly strong emotions around interpersonal concerns, so in addition to the emotion-based focus, the online self-help also included a focus on social relationships. Structural and design implications for development related primarily to clarity and user-friendliness. The pilot phase allowed evaluating whether the requirements for the online self-help that were described by cancer patients at an early stage of development were met.Patient participation in the development process of the digital online self-helpDer Einbezug potenzieller Endnutzerinnen und -nutzer in den Entwicklungsprozess digitaler Interventionen ermöglicht, dass entwickelte Programme den Bedürfnissen, Anforderungen und Erwartungen der zukünftigen Nutzerinnen und Nutzer entsprechen, was sich wiederum positiv auf die Akzeptanz und Adhärenz auswirkt. In diesem Beitrag wird ein partizipativer Entwicklungsansatz für die patientennahe Gestaltung der psychoonkologischen Online-SelbsthilfePatientinnen und Patienten wurden an 2 Stellen in den Entwicklungsprozess einbezogen. Zu einem frühen Zeitpunkt der Entwicklung wurden halbstandardisierte Tiefeninterviews mit Betroffenen unterschiedlicher Krebsarten (N=10) durchgeführt und qualitativ hinsichtlich ihrer Sicht auf (1) die Krebserkrankung und (2) die Ausgestaltung einer Online-Selbsthilfe auf inhaltlicher, struktureller und gestalterischer Ebene ausgewertet. Zu einem späteren Zeitpunkt wurde ein Prototyp der Online-Selbsthilfe in einer Pilotphase evaluiert.Die inhaltsanalytische Auswertung der Interviews mit insgesamt N=742 Codierungen ergab fünf inhaltliche Hauptkategorien (Veränderungen im Alltags- und Zukunftserleben, Veränderungen der sozialen Beziehungen, Verarbeitungsmechanismen, Kontrollverlust, schwierige Emotionen), die Aufschluss über die zentralen Herausforderungen und Belastungen der Betroffenen geben. Besonders starke Emotionen zeigten die Interviewten bei Themen, die den zwischenmenschlichen Bereich betrafen, sodass in der Online-Selbsthilfe zusätzlich zum emotionsbasierten Fokus auch ein Schwerpunkt auf soziale Beziehungen gelegt wurde. Strukturelle und gestalterische Implikationen für die Entwicklung bezogen sich vor allem auf Übersichtlichkeit und Nutzerfreundlichkeit. Die Pilotphase ermöglichte die Überprüfung, ob die vorab durch die Betroffenen beschriebenen Anforderungen an eine Online-Selbsthilfe erfüllt wurden.Der Einbezug von Patientinnen und Patienten in den Entwicklungsprozess der digitalen Online-Selbsthilfe

Former research has identified stigmatizing attitudes toward cancer patients in the general population. Little is known about (implicit) attitudes of physicians toward cancer patients. By using the prototype approach, the study investigated German physicians’ prototypical perceptions of cancer patients. Five hundred nineteen physicians (mean age: 46 years, 47% female) who regularly treat cancer patients participated in the questionnaire study. Participants were asked to state three prototype attributes that describe the “typical cancer patient.” Open format answers were coded on the dimensions favorability (coded with unfavorable, favorable, or neutral) and gender-stereotypicality (coded with masculine stereotypical, feminine stereotypical, or gender-neutral). Of all prototype attributes ( N = 1,589), 69.9% were coded as unfavorable and 14.3% as favorable, the remaining attributes were neutral (15.9%). Analysis of gender-stereotypicality revealed that nearly half of the attributes (49.5%) were compatible with the feminine, whereas only 6.5% were compatible with the masculine stereotype. The remaining attributes (44.0%) were gender-neutral. There were no significant associations between prototype favorability or gender-stereotypicality and demographic/professional characteristics of physicians. The prototype approach was successful to identify (implicit) attitudes toward cancer patients and might be more sensitive than social distance scales when investigating stigmatizing attitudes. Physicians described the “typical cancer patient” with predominantly unfavorable and feminine attributes, while favorable attributes were underrepresented and positive masculine attributes were barely mentioned. The finding that the “typical cancer patient” lacks (positive) masculine attributes should be followed up in further research.

Objective This study examined cancer patients’ reporting on physicians’ physical activity (PA) counseling, its associations with patients’ PA, and comparisons of patients’ and physicians’ reports of the type(s) of PA counseling provided. Methods Patients with breast, colorectal, or prostate cancer (n = 1206) participated in a nationwide cross-sectional study. Cancer patients’ sociodemographic and treatment-related characteristics as well as self-reported PA levels (pre- and post-diagnosis) were assessed. PA counseling was queried according to the counseling steps of the 5As framework (Assess/Advise/Agree/Assist/Arrange). For a subsample (n = 135), matched patient-physician data were available. Results Patient-reported PA counseling was categorized into “no counseling” (indicated by 20.8% of participants), “basic counseling” (Assess and/or Advise; 58.8%), and “in-depth counseling” (Agree, Assist, and/or Arrange; 20.4%). “In-depth counseling” was associated with an increase in PA levels pre- to post-diagnosis. This relationship was enhanced for patients with metastases. There were low agreements between patients’ and physicians’ reporting of PA counseling steps. Conclusion In-depth PA counseling is rarely provided to cancer patients but seems to be required to affect PA levels. Patients often report receiving less intensive PA counseling than reported by their physician. Practice implications Physicians should be enabled to provide routine in-depth PA counseling to all patients with cancer.

Absence seizures are expressed with distinctive spike-and-wave complexes in the electroencephalogram (EEG), which can be used to automatically distinguish them from other types of seizures and interictal activity. Considering the chaotic nature of the EEG signal, it is very unlikely that such continuous, repetitive patterns with strict periodic behavior would occur naturally under normal conditions. Searching for spectral activity in the range of 2.5-4.5 Hz and assessing the presence of synchronous, repeated patterns across multiple EEG channels in an unsupervised manner, the proposed methodology provides high absence seizure detection sensitivity of 93.94% with a low false detection rate of 0.168 FD/h using the open TUSZ dataset.

Introduction Findings from biomedical, behavioural and implementation studies provide a rich foundation to guide programmatic efforts for the prevention of mother‐to‐child HIV transmission (PMTCT). Methods We summarized the current evidence base to support policy makers, programme managers, funding agencies and other stakeholders in designing and optimizing PMTCT programmes. We searched the scientific literature for PMTCT interventions in the era of universal antiretroviral therapy for pregnant and breastfeeding women (i.e. 2013 onward). Where evidence was sparse, relevant studies from the general HIV treatment literature or from prior eras of PMTCT programme implementation were also considered. Studies were organized into six categories: HIV prevention services for women, timely access to HIV testing, timely access to ART, programme retention and adherence support, timely engagement in antenatal care and services for infants at highest risk of HIV acquisition. These were mapped to specific missed opportunities identified by the UNAIDS Spectrum model and embedded in UNICEF operational guidance to optimize PMTCT services. Results and discussion From May to November 2019, we identified numerous promising, evidence‐based strategies that, properly tailored and adopted, could contribute to population reductions in vertical HIV transmission. These spanned the HIV and maternal and child health literature, emphasizing the importance of continued alignment and integration of services. We observed overlap between several intervention domains, suggesting potential for synergies and increased downstream impact. Common themes included integration of facility‐based healthcare; decentralization of health services from facilities to communities; and engagement of partners, peers and lay workers for social support. Approaches to ensure early HIV diagnosis and treatment prior to pregnancy would strengthen care across the maternal lifespan and should be promoted in the context of PMTCT. Conclusions A wide range of effective strategies exist to improve PMTCT access, uptake and retention. Programmes should carefully consider, prioritize and plan those that are most appropriate for the local setting and best address existing gaps in PMTCT health services.

Accurate and timely diagnosis of amyotrophic lateral sclerosis (ALS) is a diagnostic challenge given the lack of specific diagnostic and imaging biomarkers as well as the significant clinic overlap with mimic syndromes. We hypothesize that MR quantitative susceptibility mapping (QSM) can help differentiate ALS from mimic diagnoses.In a blinded retrospective study of MRIs with QSM from 2015 to 2018, we compared motor cortex susceptibility along the hand and face homunculi in ALS patients and patients with similar clinical presentations. Inclusion required a confirmed ALS or a mimic diagnosis. Comparative groups included age-matched patients with MRIs performed for non-motor neuron symptoms that were reported as normal or demonstrated leukoaraiosis. Quantitative susceptibility values were compared with ANOVA and Tukey-Kramer (post-hoc). ROC analysis and Youden's index were used to identify optimal cutoff values.Fifty ALS, 35 mimic, and 70 non-motor neuron symptom patients (35 normal, 35 leukoaraiosis) were included. Hand and face homunculus mean susceptibility values were significantly higher in the ALS group compared to the mimic (p=0.001, p=0.004), leukoaraiosis (p0.001, p=0.003), and normal (p0.001, p0.001) groups. ROC curve analysis comparing ALS to mimics resulted in an area under the curve of 0.71 and 0.67 for the hand and face homunculus measurements, respectively. In differentiating ALS from mimics, Youden's index showed 100% specificity and 36% sensitivity for hand homunculus measurements.QSM has diagnostic potential in the assessment of suspected ALS patients, demonstrating very high specificity in differentiating ALS from mimic diagnoses.

Objectives The purpose of this study was to examine the association between physicians' exercise counseling and post-diagnosis physical activity (PA) in patients with cancer by investigating the mediating role of patients' satisfaction with exercise counseling as well as the moderating role of patients' previous PA. Methods The study sample consisted of 1002 people with cancer (503 breast, 265 prostate, and 234 colorectal cancer). Participants reported their pre- and post-diagnosis moderate-to-vigorous PA (MVPA) levels, indicated whether their physician had covered different steps of exercise counseling as defined by the 5A framework (Assess, Advise, Agree, Assist, and Arrange) and rated their satisfaction with exercise counseling. A conditional process analysis was used to determine the direct and indirect effects of counseling on post-diagnosis MVPA through satisfaction at different levels of pre-diagnosis MVPA. Results Physicians' exercise counseling was associated with post-diagnosis MVPA in patients with cancer. However, the association differed by patients' pre-diagnosis MVPA (P = .039). While counseling was directly associated with higher post-diagnosis MVPA for individuals with low pre-diagnosis MVPA (CI: 0.02-0.20, P = .014), the effect was mediated through satisfaction with exercise counseling for previously highly active individuals (Boot CI: 0.01-0.08). Conclusions Our findings emphasize the relevance of physicians' exercise counseling for PA in patients with cancer. However, the results indicate that in order to effectively influence patients' PA, it appears important to provide a comprehensive counseling that is adjusted to the patients' exercise experiences.

Background and Objective Parkinson's disease (PD) is a degenerative disorder of the central nervous system for which currently there is no cure. Its treatment requires long-term, interdisciplinary disease management, and usage of typical medications, including levodopa, dopamine agonists, and enzymes, such as MAO-B inhibitors. The key goal of disease management is to prolong patients' independence and keep their quality of life. Due to the different combinations of motor and non-motor symptoms from which PD patients suffer, in addition to existing comorbidities, the change of medications and their combinations is difficult and patient-specific. To help physicians, we developed two decision support models for PD management, which suggest how to change the medication treatment. Methods The models were developed using DEX methodology, which integrates the qualitative multi-criteria decision modelling with rule-based expert systems. The two DEX models differ in the way the decision rules were defined. In the first model, the decision rules are based on the interviews with neurologists (DEX expert model), and in the second model, they are formed from a database of past medication change decisions (DEX data model). We assessed both models on the Parkinson's Progression Markers Initiative (PPMI) and on a questionnaire answered by 17 neurologists from 4 European countries using accuracy measure and the Jaccard index. Results Both models include 15 sub-models that address possible medication treatment changes based on the given patients' current state. In particular, the models incorporate current state changes in patients' motor symptoms (dyskinesia intensity, dyskinesia duration, OFF duration), mental problems (impulsivity, cognition, hallucinations and paranoia), epidemiologic data (patient's age, activity level) and comorbidities (cardiovascular problems, hypertension and low blood pressure). The highest accuracy of the developed sub-models for 15 medication treatment changes ranges from 69.31 to 99.06 %. Conclusions Results show that the DEX expert model is superior to the DEX data model. The results indicate that the constructed models are sufficiently adequate and thus fit for the purpose of making “second-opinion” suggestions to decision support users.

Aggressive behaviors in those with intellectual disability (ID) and autism (ASD) have been linked to a variety of factors including ID level, age, sex, psychiatric disorders, and medical conditions but these factors have not been studied, in large samples, in terms of how they affect the stimuli that trigger aggression. In this survey of 2243 adults, four triggers of aggression associated with frustration, discomfort, change in the physical/social environment, and defensive reactions were analyzed for their relation to ID level, ASD, age, sex, number of psychiatric diagnoses, sleeping problems, seizures, visual impairment, ear infections and gastrointestinal problems. All four triggers were associated with increasing number of psychiatric disorders, with frustration, discomfort, and change intolerance commonly linked to sleeping problems and ASD. Implications for assessment and intervention are discussed.

Spontaneous sphenoid sinus cerebrospinal fluid (CSF) encephaloceles have been postulated to arise from a persistent Sternberg’s canal. However, recent evidence has questioned this embryological etiology. We examined the anatomic location of a series of lateral sphenoid sinus encephaloceles to determine if they corresponded with the location of Sternberg’s canal. We queried a prospectively acquired database of surgically treated spontaneous CSF leaks and identified those arising from the sphenoidal sinus. Images were reviewed to characterize the leaks with respect to the foramen rotundum (FR) and the vidian canal (VC). Four leak types were classified of which Type I (medial to FR and VC entering nasopharynx) was theoretically located in the precise location of Sternberg’s canal. Type II was medial to FR; Type III was lateral to FR; Type IV passed through an enlarged FR into sphenoid sinus. Demographic data were analyzed. Of 103 repaired CSF leaks, 17 arose from the lateral sphenoid sinus. There were no true Type I leaks, 3 Type II leaks, 12 Type III leaks, and 2 Type IV leaks. No differences were found with respect to sphenoid pneumatization, BMI, age, sex, arachnoid pits, or postoperative leak between different types. No evidence was found to support the existence of a classic Sternberg canal CSF leak, supporting the hypothesis that most sphenoid spontaneous leaks likely occur secondary to chronically elevated ICP. Rare cases may be related to a weakness in the sphenoid wall in the region of Sternberg’s canal.

This vignette based study aimed to examine recommendations of health care professionals (HCPs) in promoting self-management strategies to cancer patients. Nine-hundred-forty-two physicians and nurses were asked to (1) indicate if they would recommend self-management strategies to a vignette cancer patient, and (2) to specify those in an open format. Vignettes included a manipulation of patient age (60 vs. 75 years) and treatment phase (currently treated versus treatment completed). Six categories emerged through coding a total of 2303 recommendations: physical activity (71.8%), nutrition (64.3%), psychological support (36.7%), medical support (29.2%), conscious living (17.2%) and naturopathy (12.3%). While psychological support was particularly recommended during treatment, physical activity was more frequently recommended after completion of treatment. Results suggest that HCPs recommend a variety of self-management strategies besides standard medical treatment. Patient's treatment phase and age seem to partly influence recommendation behavior, potentially indicating insecurities regarding acute treatment situations and age-related stereotypes.

Summarization: The electroencephalogram (EEG) is the most prominent means to study epilepsy and capture changes in electrical brain activity that could declare an imminent seizure. In this work, Long Short-Term Memory (LSTM) networks are introduced in epileptic seizure prediction using EEG signals, expanding the use of deep learning algorithms with convolutional neural networks (CNN). A pre-analysis is initially performed to find the optimal architecture of the LSTM network by testing several modules and layers of memory units. Based on these results, a two-layer LSTM network is selected to evaluate seizure prediction performance using four different lengths of preictal windows, ranging from 15 min to 2 h. The LSTM model exploits a wide range of features extracted prior to classification, including time and frequency domain features, between EEG channels cross-correlation and graph theoretic features. The evaluation is performed using long-term EEG recordings from the open CHB-MIT Scalp EEG database, suggest that the proposed methodology is able to predict all 185 seizures, providing high rates of seizure prediction sensitivity and low false prediction rates (FPR) of 0.11–0.02 false alarms per hour, depending on the duration of the preictal window. The proposed LSTM-based methodology delivers a significant increase in seizure prediction performance compared to both traditional machine learning techniques and convolutional neural networks that have been previously evaluated in the literature. Presented on: Computers in Biology and Medicine

Although many cancer patients benefit from physical activity (PA), healthcare professionals (HCP) still do not promote it routinely. Including different groups of HCP, this study aimed to examine how structural barriers are perceived as impeding by HCP for promoting PA to cancer patients, how the perceptions of structural barriers are associated with promoting PA, and how HCP react to information resources. A total of 287 physicians in outpatient care, 242 physicians in inpatient care, and 388 oncology nurses completed our questionnaire (paper-pencil or online). Participants assessed nine different structural barriers (on a 4-point Likert Scale) and reported their PA promotion frequency. Further, they could request three different kinds of information resources about PA in oncological settings. Across professional groups, more than 70% of HCP indicated that they promoted PA to their cancer patients often or routinely. Oncology nurses indicated that they were more impeded in promoting PA by six structural barriers than physicians (all p

We describe our technique and evaluate clinical and radiographic outcomes for patients undergoing L4/5 posterior lumbar interbody fusion with 3D-navigation guided cortical bone trajectory screws (PLIF-CBT) for grade 1 or 2 degenerative spondylolisthesis with a minimum follow-up time of 12 months.A single-institution series of 18 patients was evaluated with data prospectively collected and retrospectively analyzed. Pain and disability scores were collected preoperatively and at a minimum of 12 months postoperatively, including back and bilateral leg pain visual analog scores (VAS) and Oswestry Disability Index (ODI) scores. Radiographic fusion was assessed as complete, partial, or none based on the presence of bridging bones across the disc space, posterior elements, or both.Patients demonstrated statistically significant reductions in back pain VAS (P = 0.0025), leg pain VAS (P 0.0001), and ODI (P0.0001) at a minimum of 12 months postoperatively. Radiographic fusion at an average of 14.9 months postoperatively was available for 16/18 patients, with 6 patients demonstrating fusion (4/6 with complete fusion; 2/6 with partial fusion). There were no instances of intraoperative complications or delayed complications requiring subsequent interventions.PLIF-CBT can be performed in a safe and reproducible fashion with excellent clinical outcomes at 1 year postoperatively. The outcomes did not correlate with fusion status, which was unexpectedly low at 37.5% without significant hardware abnormalities necessitating reoperations. PLIF-CBT offers several perioperative advantages compared with traditional open PLIF and requires longer-term studies to demonstrate its durability with regard to improvement in clinical pain and radiographic endpoints, including anterior and/or posterior element fusion.

The aim of this study was to analyze risk factors and outcomes of vasoplegia after cardiac surgery based on our experience with almost 2000 cardiac operations performed at our institution.We retrospectively analyzed patients who underwent cardiac surgery with cardiopulmonary bypass (CPB) between 2011 and 2013. Data were available for a total of 1992 patients. We defined vasoplegia as hypotension with persistently low systemic vascular resistance (800 dyn/s/cm) and preserved Cardiac Index (2.5).The rate of vasoplegia in our cohort was 20.3% (n = 405). The incidences of mild, moderate, and severe vasoplegia were 13.2, 5.7, and 1.5%, respectively. Factors that increased risk of vasoplegia included valve operations, heart transplants, dialysis-dependent renal failure, age65, diuretic therapy, and recent myocardial infarction. B blocker therapy was protective against vasoplegia.Vasoplegic syndrome is still a frequently occurring adverse event following cardiac surgery. In high risk patients for vasoplegia, it may be sensible to proceed with preoperative volume loading (instead of diuresis), initiation of low dose vasopressin therapy if needed, and attempting to up titrate beta-blocker therapy.

Chronic traumatic encephalopathy (CTE) evolved from the term dementia pugilistica describing the dementia found in many boxers to its current use in describing the dementia and depression sometimes found in athletes subjected to multiple concussions or subconcussive blows to the head. Concurrently, the neuropathology evolved to specify a unique type of tauopathy found in perivascular spaces at the depth of sulci and other features not typically seen in neurodegenerative tauopathies. Four stages of CTE have been proposed, with 4 corresponding clinical syndromes of traumatic encephalopathy syndrome. However, it remains unclear whether this is a syndrome unique to repetitive head trauma, especially in contact sports, because the epidemiology has been difficult to establish. In particular, research to date has had a denominator problem in not establishing the total number of potential cases at risk for developing CTE. The current review examines the evidence to date for these syndromes and contributing or complicating factors affecting the neuropathology, neuroimaging, and clinical presentations associated with them.

We report a 61-year-old woman who presented because of gradually progressive speech disorders. MRI scan revealed left temporal lobe atrophy with ex vacuo dilatation of the temporal horn and atrophy of the left inferior frontal gyrus and the left inferior parietal lobe. These findings in brain perfusion SPECT corresponded to a generalized hypoperfusion of the left hemisphere, particularly prominent on the rear parietal cortex and the temporal lobe. After taking into consideration the clinical presentation and imaging findings on MRI and SPECT, the diagnosis of the logopenic variant of primary progressive aphasia was finally reached.

Superselective intra-arterial cerebral infusion (SIACI) of bevacizumab (BV) has emerged as a novel therapy in the treatment of recurrent glioblastoma (GB). This study assessed the use of apparent diffusion coefficient (ADC) in predicting length of survival after SIACI BV and overall survival in patients with recurrent GB. Sixty-five patients from a cohort enrolled in a phase I/II trial of SIACI BV for treatment of recurrent GB were retrospectively included in this analysis. MR imaging with a diffusion-weighted (DWI) sequence was performed before and after treatment. ROIs were manually delineated on ADC maps corresponding to the enhancing and non-enhancing portions of the tumor. Cox and logistic regression analyses were performed to determine which ADC values best predicted survival. The change in minimum ADC in the enhancing portion of the tumor after SIACI BV therapy was associated with an increased risk of death (hazard ratio = 2.0, 95% confidence interval(CI) [1.04–3.79], p = 0.038), adjusting for age, tumor size, BV dose, and prior IV BV treatments. Similarly, the change in ADC after SIACI BV therapy was associated with greater likelihood of surviving less than 1 year after therapy (odds ratio = 7.0, 95% CI [1.08–45.7], p = 0.04). Having previously received IV BV was associated with increased risk of death (OR 18, 95% CI [1.8–180.0], p = 0.014). In patients with recurrent GB treated with SIACI BV, the change in ADC value after treatment is predictive of overall survival.

OBJECTIVE Surgery within the cavernous sinus (CS) remains a controversial topic because of the delicate and complex anatomy. The risk also varies with tumor consistency. Softer tumors such as pituitary adenomas are more likely to be surgically treated, while firm tumors such as meningiomas are often treated with radiosurgery. However, a wide range of pathologies that can involve the CS are amenable to surgery. The authors describe and analyze their results using endonasal endoscopic “medial-to-lateral” approaches for nonadenomatous, nonmeningeal tumors, in relation to the degree of invasion within the CS. METHODS A prospectively acquired database of consecutive endoscopic approaches for tumors with verified intraoperative CS invasion was reviewed. Pituitary adenomas and meningiomas were excluded. Degree of invasion of the CS was classified using the Knosp-Steiner (KS) grading system as well as the percentage of cavernous carotid artery (CCA) encasement. Extent of resection of the entire tumor and of the CS component was assessed by independent neuroradiologists using volumetric measurements of the pre- and postoperative MRI studies. Demographic data and complications were noted. RESULTS Fifteen patients (mean age 51.1 years who received endoscopic surgery between 2007 and 2013 met the selection criteria. There were 11 malignant tumors, including chordoma, chondrosarcoma, hemangiopericytoma, lymphoma, and metastatic cancer, and 4 benign tumors, including 3 cavernous hemangiomas and 1 dermoid. All cases were discussed before treatment in a tumor board. Adjuvant treatment options included chemotherapy and radiotherapy. The mean pre- and postoperative tumor volumes were 12.74 ml and 3.86 ml. Gross-total resection (GTR; ie, resection greater than 95%) was the goal in 13 cases and was achieved in 6 patients (46%) while in addition 5 patients had a greater than 80% resection. Gross-total resection in the CS was accomplished in 55% of the tumors with KS Grades 1–2 and in 16.6% of the tumors with KS grades 3–4, respectively. Likewise, GTR was accomplished in 55% of the tumors with CCA encasement under 75% and in 14.3% of the lesions with CCA encasement over 75%, irrespective of tumor volume and underlying pathology. There were 18 preexisting cranial neuropathies involving cranial nerves III–VI, of which 9 fully resolved, 4 improved, and 3 remained unchanged; 2 of these worsened with tumor recurrence. Surgical complications included 1 transient new cranial nerve VI palsy associated with Horner's syndrome and 1 case of panhypopituitarism. There were no postoperative CSF leaks and no infections. The mean extended follow-up was 34.4 months. CONCLUSIONS Endonasal endoscopic approaches can play a role in the management of nonmeningeal, nonadenomatous tumors invading the CS, either through biopsy, debulking, or GTR. An advantage of this method is the relief of preexisting cranial neuropathies with low risk for new neurological deficit. Extent of resection within the CS varies with KS grade and degree of carotid encasement irrespective of the underlying pathology. The goals of surgery should be clearly established preoperatively in consultation with radiation and medical oncologists.

A 54-year-old woman presented with a 30-year history of worsening left blepharoptosis. Neuro-ophthalmic examination was significant for blepharoptosis, limited levator function, and supraduction in the left eye with left hypotropia, and normal pupils without diplopia. MRI brain/orbits revealed subtle atrophy of the left superior rectus (figure 1, A and B), without any orbital pathology. Superior compression of the left oculomotor nerve by the posterior cerebral artery (PCA) was observed (figure 1, C–E). Given the microanatomy of oculomotor nerve in the cistern space,1,2 this is a rare selective compression of the superolateral oculomotor nerve by the PCA vessel (figure 2), sparing the superomedial parasympathetic limb.

Cerebral gliomas comprise a heterogeneous group of primary neoplasms of the central nervous system, representing a signifcant cause of cancer morbidity and mortality. Contrast-enhanced magnetic resonance imaging (MRI) is paramount for identifying structural brain abnormalities related to the development of gliomas. Although morphological MRI remains the current standard of care for initial diagnostic workup, surgical planning, monitoring therapy response and surveillance during follow-up, it is rather diffcult to define tumor grade and boundaries and to assess response to radiochemotherapy solely by contrast-enhancement, due to a variety of factors influencing blood-brain barrier (BBB) permeability and contrast agent distribution. The nature of a lesion lies beyond often misleading gross structural patterns, down to the cellular and molecular level, hence the imaging techniques of advanced multimodal MRI and positron emission tomography (PET) have emerged to provide critical non-invasive insight into the underlying biology of primary brain cancer. Out of the various PET radiotracers, labeled amino acids are of particular significance due to their non-dependency on BBB disruption to reach glioma cells and their excellent tumor-to-background contrast. After discussing the basic imaging principles of MR perfusion, diffusion, spectroscopy and PET in glioma, this review focuses on the correlative imaging with amino acid PET and advanced MRI techniques in tumor grading and staging, in guiding stereotactic biopsy and surgical excision and in assessing therapy response, post-therapy surveillance and prognosis. Lastly, a reference is made on the expanding availability of integrated PET/MRI systems and the resulting benefits of simultaneous image acquisition.