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Background: Congenital heart disease (CHD) is often associated with chronic right ventricular (RV) volume overload. Real-time magnetic resonance imaging (MRI) enables the analysis of cardiac function during free breathing., Objective: To evaluate the influence of respiration in pediatric patients with CHD and chronic RV volume overload., Methods and Materials: RV volume overload patients (n=6) and controls (n=6) were recruited for cardiac real-time MRI at 1.5 tesla during free breathing. Breathing curves from regions of interest reflecting the position of the diaphragm served for binning images in four different tidal volume classes, each in inspiration and expiration. Tidal volumes were estimated from these curves by data previously obtained by magnetic resonance-compatible spirometry. Ventricular volumes indexed to body surface area and Frank-Starling relationships referenced to the typical tidal volume indexed to body height (TTVi) were compared., Results: Indexed RV end-diastolic volume (RV-EDVi) and indexed RV stroke volume (RV-SVi) increased during inspiration (RV-EDVi/TTVi: RV load: + 16 ± 4%; controls: + 22 ± 13%; RV-SVi/TTVi: RV load: + 21 ± 6%; controls: + 35 ± 17%; non-significant for comparison). The increase in RV ejection fraction during inspiration was significantly lower in RV load patients (RV load: + 1.1 ± 2.2%; controls: + 6.1 ± 1.5%; P=0.01). The Frank-Starling relationship of the RV provided a significantly reduced slope estimate in RV load patients (inspiration: RV load: 0.75 ± 0.11; controls: 0.92 ± 0.02; P=0.02)., Conclusion: In pediatric patients with CHD and chronic RV volume overload, cardiac real-time MRI during free breathing in combination with respiratory-based binning indicates an impaired Frank-Starling relationship of the RV., (© 2023. The Author(s).)

Due to the low proton density of the lung parenchyma and the rapid signal decay at the air-tissue interfaces, for a long time the lungs were difficult to access using magnetic resonance imaging (MRI); however, technical advances could address most of these obstacles. Pulmonary alterations associated with tissue proliferation ("plus pathologies"), can now be detected with high diagnostic accuracy because of the locally increased proton density. Compared to computed tomography (CT), MRI provides a comprehensive range of functional imaging procedures (respiratory mechanics, perfusion and ventilation). In addition, as a radiation-free noninvasive examination modality, it enables repeated examinations for assessment of the course or monitoring of the effects of treatment, even in children. This article discusses the technical aspects, gives suggestions for protocols and explains the role of MRI of the lungs in the routine assessment of various diseases., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Rationale: Magnetic resonance imaging (MRI) detects improvements in mucus plugging and bronchial wall thickening, but not in lung perfusion in patients with cystic fibrosis (CF) treated with elexacaftor/tezacaftor/ivacaftor (ETI). Objectives: To determine whether bronchial artery dilatation (BAD), a key feature of advanced lung disease, indicates irreversibility of perfusion abnormalities and whether BAD could be reversed in CF patients treated with ETI. Methods: A total of 59 adults with CF underwent longitudinal chest MRI, including magnetic resonance angiography twice, comprising 35 patients with CF (mean age, 31 ± 7 yr) before (MRI1) and after (MRI2) at least 1 month (mean duration, 8 ± 4 mo) on ETI therapy and 24 control patients with CF (mean age, 31 ± 7 yr) without ETI. MRI was assessed using the validated chest MRI score, and the presence and total lumen area of BAD were assessed with commercial software. Results: The MRI global score was stable in the control group from MRI1 to MRI2 (mean difference, 1.1 [-0.3, 2.4]; P  = 0.054), but it was reduced in the ETI group (-10.1 [-0.3, 2.4]; P  < 0.001). In the control and ETI groups, BAD was present in almost all patients at baseline (95% and 94%, respectively), which did not change at MRI2. The BAD total lumen area did not change in the control group from MRI1 to MRI2 (1.0 mm 2 [-0.2, 2.2]; P  = 0.099) but decreased in the ETI group (-7.0 mm 2 [-8.9, -5.0]; P  < 0.001). This decrease correlated with improvements in the MRI global score ( r  = 0.540; P  < 0.001). Conclusions: Our data show that BAD may be partially reversible under ETI therapy in adult patients with CF who have established disease.

Study Objective: End-tidal carbon dioxide (etCO 2 ) is used to guide ventilation after achieving return of spontaneous circulation (ROSC) in certain out-of-hospital systems, despite an unknown difference between arterial and end-tidal CO 2 (partial pressure of carbon dioxide [paCO 2 ]-etCO 2 difference) levels in this population. The primary aim of this study was to evaluate and quantify the paCO 2 -etCO 2 difference in out-of-hospital patients with ROSC after nontraumatic cardiac arrest., Methods: This retrospective single-center study included patients aged 18 years and older with sustained ROSC after nontraumatic out-of-hospital cardiac arrest. In patients with an existing out-of-hospital arterial blood gas analysis within 30 minutes after achieving ROSC, matching etCO 2 values were evaluated. Linear regression and Bland-Altman plot analysis were performed to ascertain the primary endpoint of interest., Results: We included data of 60 patients in the final analysis. The mean paCO 2 -etCO 2 difference was 32 (±18) mmHg. Only a moderate correlation (R 2 =0.453) between paCO 2 and etCO 2 was found. Bland-Altman analysis showed a bias of 32 mmHg (95% confidence interval [CI], 27 to 36) [the upper limit of agreement of 67 mmHg (95% CI, 59 to 74) and the lower limit of agreement of -3 mmHg (95% CI, -11 to 5)]., Conclusion: The paCO 2 -etCO 2 difference in patients with ROSC after out-of-hospital cardiac arrest is far from physiologic ranges, and the between-patient variability is high. Therefore, etCO 2 -guided adaption of ventilation might not provide adequate accuracy in this setting., (Copyright © 2023 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: The aim of the present study was to examine tunnel widening and clinical outcomes after anterior cruciate ligament reconstruction (ACLR) using two different fixation methods: aperture fixation with biodegradable interference screws versus all-inside ACLR with suspensory cortical buttons., Methods: Tunnel widening was assessed using volumetric and diameter measurements on magnetic resonance imaging (MRI) scans directly after surgery, as well as 6 months and 2 and 5 years postoperatively. Clinical outcomes were assessed after 5 years with instrumented tibial anteroposterior translation measurement (KT-1000), single-leg hop testing, and the IKDC, Lysholm, and Tegner activity scores., Results: At the final follow-up, the study population consisted of 21 patients, 12 of whom underwent screw fixation and 9 of whom had button fixation. 3 patients with all-inside ACLR had sustained early repeat ruptures within 6 months after surgery and had to be excluded from the further analysis. With screw fixation, the tibial tunnel volume changed significantly more over time compared to all-inside button fixation, with a larger initial increase at 6 months (from postoperative 2.9 ± 0.2 to 3.3 ± 0.2 cm 3 at 6 months versus 1.7 ± 0.1 to 1.9 ± 0.2 cm 3 ) and a greater final decrease over 2-5 years postoperatively (from 3.1 ± 0.2 to 1.9 ± 0.2 cm 3 versus 1.8 ± 0.2 ± 0.1 to 1.3 ± 0.1 cm 3 ) (P < 0.001). The femoral tunnel volume remained comparable between the two groups throughout the follow-up period, with an initial 1.6 ± 0.1 cm 3 in both groups and 1.2 ± 0.1 vs. 1.3 ± 0.1 after 5 years in the screw and button groups, respectively (P ≥ 0.314). The maximum tibial and femoral tunnel diameters were significantly larger with screw fixation at all four time points. Tibial diameters measured 11.1 ± 0.2, 12.3 ± 0.3, 12.3 ± 0.4, and 11.2 ± 0.4 mm in the screw group versus 8.1 ± 0.3, 8.9 ± 0.3, 9.1 ± 0.4 and 8.2 ± 0.5 mm in the button group (P < 0.001). Femoral diameters measured 8.6 ± 0.2, 10.5 ± 0.4, 10.2 ± 0.3, and 8.9 ± 0.3 versus 7.3 ± 0.3, 8.4 ± 0.4, 8.4 ± 0.3, 7.5 ± 0.3, respectively (P ≤ 0.007). Four patients (33%) in the screw group exceeded a diameter of 12 mm on the tibial side after 5 years versus none in the button group (not significant, P = 0.104). Tibial anteroposterior translation measurement with KT-1000 after 5 years was 2.3 ± 2.4 mm in the screw group versus 3.2 ± 3.5 mm in the button group (not significant, P = 0.602). There were no significant differences between the groups in any of the other clinical outcomes., Conclusion: Tibial tunnels in ACLR with screw fixation were associated with a larger increase in tunnel volume within the first 2 years and a greater decrease up to 5 years after surgery, while femoral tunnel volumes did not differ significantly. On the tibial side, the need for staged revision ACLR may be greater after biodegradable interference screw fixation if repeat ruptures occur, especially within the first 2 years after primary ACLR. Concerns may remain regarding a higher graft failure rate with all-inside ACLR., Level of Evidence: II., Rct Consort: NCT01755819., (© 2023. The Author(s).)

Background: Outcome reports for Alpha Ankle Arthroplasty (AAA), a third-generation implant relying on a mobile bearing design for total ankle replacement, are sparse. This retrospective study evaluated the midterm survivorship, clinical, and radiologic outcomes after implantation of this implant., Methods: For 64 patients who received 65 Triple A ankle implants between 2009 and 2020, implant survival was calculated using the Kaplan-Meier curve. Clinical outcomes were evaluated by measuring the range of motion, stability, Western Ontario and McMaster Universities Osteoarthritis Questionnaire score (WOMAC), and American Orthopaedic Foot & Ankle Society ankle-hindfoot score (AOFAS). The average pain level and satisfaction with the postoperative result were rated on a numeric rating scale (0-10). Additionally, radiologic analysis was performed using anteroposterior and lateral radiographs and tibiotalar alignment was assessed., Results: The implant-survival rate was 61.5% at a mean follow-up of 8.2 years. Twenty-five patients (38.5%) required revision surgery (average time to revision, 3.1 years, 95% CI 2.1-4.1 years). For patients without revisions, the average range of motion in dorsiflexion and plantarflexion were 3.6 ± 4.2 degrees and 21.9 ± 7.8 degrees, respectively. The mean WOMAC and AOFAS scores were 44.7 ± 47.5 and 75.1 ± 14.0, respectively. The average pain and subjective satisfaction scores were 2.0 ± 1.7 and 8.5 ± 1.9, respectively. Mean alignment values did not differ significantly for patients who required revision surgery., Conclusion: We found a high revision rate with use of the AAA. However, patients who did not require revision surgery had, on average, high satisfaction and good functional outcomes., Level of Evidence: Level IV, case series., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ICMJE forms for all authors are available online.

Non-tuberculous mycobacterial pulmonary disease (NTM-PD) is a chronic inflammatory lung disease caused by infection with non-tuberculous mycobacteria (NTM). International guidelines provide evidence-based recommendations on appropriate diagnosis and treatment strategies, but there is a need for sharing day-to-day best practice between treatment centers to optimize patient care. This is particularly valuable for rare diseases like NTM-PD. In this cross-sectional analysis of NTM-PD management in Germany, medical and administrative staff from seven treatment centers were interviewed to identify best practice in the diagnosis, treatment, and ongoing management of patients with NTM-PD, including related hospital infrastructure and administration processes. A prioritization led to a collection of best practices for the management of patients with NTM-PD in Germany, which is presented here. Selected current best practices included performance of regular sputum tests for diagnosis, use of medical reports, and regular follow-up visits as well as increased interaction between physicians across different specialties. Future best practices that may be implemented to overcome current barriers comprised disease awareness activities, patient empowerment, and new approaches to enhance physician interaction. Challenges related to their implementation are also discussed and will help to raise disease awareness. The presented best practices may guide and optimize patient management in other centers.

Background: As the climate and environmental crises unfold, eco-anxiety, defined as anxiety about the crises' devastating consequences for life on earth, affects mental health worldwide. Despite its importance, research on eco-anxiety is currently limited by a lack of validated assessment instruments available in different languages. Recently, Hogg and colleagues proposed a multidimensional approach to assess eco-anxiety. Here, we aim to translate the original English Hogg Eco-Anxiety Scale (HEAS) into German and to assess its reliability and validity in a German sample., Methods: Following the TRAPD (translation, review, adjudication, pre-test, documentation) approach, we translated the original English scale into German. In total, 486 participants completed the German HEAS. We used Bayesian confirmatory factor analysis (CFA) to assess whether the four-factorial model of the original English version could be replicated in the German sample. Furthermore, associations with a variety of emotional reactions towards the climate crisis, general depression, anxiety, and stress were investigated., Results: The German HEAS was internally consistent (Cronbach's alphas 0.71-0.86) and the Bayesian CFA showed that model fit was best for the four-factorial model, comparable to the factorial structure of the original English scale (affective symptoms, rumination, behavioral symptoms, anxiety about personal impact). Weak to moderate associations were found with negative emotional reactions towards the climate crisis and with general depression, anxiety, and stress., Discussion: Our results support the original four-factorial model of the scale and indicate that the German HEAS is a reliable and valid scale to assess eco-anxiety in German speaking populations., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Heinzel, Tschorn, Schulte-Hutner, Schäfer, Reese, Pohle, Peter, Neuber, Liu, Keller, Eichinger and Bechtoldt.)

To avoid hydrogen flaking in rail production, it is of crucial importance to understand the differences in hydrogen diffusion and trapping between different production steps. Therefore, as-cast unfinished material was compared with two finished rails, hot-rolled and head-hardened, using electron backscattered diffraction (EBSD), electrochemical permeation, and thermal desorption spectroscopy (TDS). A significant increase in dislocation density was in the head-hardened rail compared with the other material states. This leads to an effective hydrogen diffusion coefficient of 5.8 × 10 -7 cm 2 /s which is lower by a factor of four than the diffusion coefficients examined in the other states. Thermal desorption spectroscopy analyses show a clear difference between unfinished and finished rail materials. While a peak in activation energy between 32 and 38 kJ/mol is present at all states, only as-cast unfinished material shows a second peak with an activation energy of 47 kJ/mol, which is related to microvoids. The results show that in the investigated material, the effect of increasing dislocation density has a stronger influence on the effective diffusion coefficient than the presence of a second active trapping site.

Rationale: Lumacaftor/ivacaftor (LUM/IVA) was shown to be safe and well tolerated in children 2 through 5 years of age with cystic fibrosis (CF) homozygous for F508del-CFTR in a Phase 3 open-label study. Improvements in sweat chloride concentration, markers of pancreatic function, and lung clearance index 2.5 (LCI 2.5 ), along with increases in growth parameters, suggested the potential for early disease modification with LUM/IVA treatment. Objective: To further assess the effects of LUM/IVA on CF disease progression in children 2 through 5 years of age using chest magnetic resonance imaging (MRI). Methods: This Phase 2 study had two parts: a 48-week, randomized, double-blind, placebo-controlled treatment period in which children 2 through 5 years of age with CF homozygous for F508del-CFTR received either LUM/IVA or placebo (Part 1) followed by an open-label period in which all children received LUM/IVA for an additional 48 weeks (Part 2). The results from Part 1 are reported. The primary endpoint was absolute change from baseline in chest MRI global score at Week 48. Secondary endpoints included absolute change in LCI 2.5 through Week 48 and absolute changes in weight-for-age, stature-for-age, and body mass index-for-age z -scores at Week 48. Additional endpoints included absolute changes in sweat chloride concentration, fecal elastase-1 levels, serum immunoreactive trypsinogen, and fecal calprotectin through Week 48. The primary endpoint was analyzed using Bayesian methods, where the actual Bayesian posterior probability of LUM/IVA being superior to placebo in the chest MRI global score at Week 48 was calculated using a vague normal prior distribution; secondary and additional endpoints were analyzed using descriptive summary statistics. Results: Fifty-one children were enrolled and received LUM/IVA ( n  = 35) or placebo ( n  = 16). For the change in chest MRI global score at Week 48, the Bayesian posterior probability of LUM/IVA being better than placebo (treatment difference, <0; higher score indicates greater abnormality) was 76%; the mean treatment difference was -1.5 (95% credible interval, -5.5 to 2.6). Treatment with LUM/IVA also led to within-group numerical improvements in LCI 2.5 , growth parameters, and biomarkers of pancreatic function as well as greater decreases in sweat chloride concentration compared with placebo from baseline through Week 48. Safety data were consistent with the established safety profile of LUM/IVA. Conclusions: This placebo-controlled study suggests the potential for early disease modification with LUM/IVA treatment, including that assessed by chest MRI, in children as young as 2 years of age. Clinical trial registered with www.clinicaltrials.gov (NCT03625466).

Introduction: Increased inflammatory processes after non-cardiac surgery are very common. The association between postoperative inflammation and the occurrence of cardiovascular complications after non-cardiac surgery are still not entirely clear. Therefore, we will evaluate the association between postoperative inflammation and the occurrence of major cardiovascular complications in patients at-risk for cardiovascular complications undergoing non-cardiac surgery. We will further evaluate the association of postoperative inflammation and days-at-home within 30 days after surgery (DAH 30 ), the incidence of acute kidney injury, postoperative N-terminal probrain natriuretic peptide (NT-proBNP) concentrations and neurocognitive decline., Methods and Analysis: In this multicentre study, we will include 1400 patients at-risk for cardiovascular complications undergoing non-cardiac surgery. Our primary aim is to evaluate the association of postoperative maximum C-reactive protein concentration and the occurrence of a composite of five major cardiovascular complications (myocardial infarction, myocardial injury after non-cardiac surgery, new onset of atrial fibrillation, stroke and death) within 30 days after surgery using a Mann-Whitney-U test as well as a logistic regression model. As our secondary aim, we will evaluate the association of a composite of three inflammatory biomarkers (interleukin 6, procalcitonin and copeptin) on the occurrence of our composite of five cardiovascular complications within 30 days and 1 year after surgery, acute kidney injury, DAH 30 and NT-proBNP concentrations using linear or logistic regression models. We will measure inflammatory biomarkers before surgery, and on the first, second, third and fifth postoperative day. We will check medical records and conduct a telephone survey 30 days and 1 year after surgery. We evaluate neurocognitive function, using a Montreal Cognitive Assessment, before and 1 year after surgery., Ethics and Dissemination: This study was approved by the ethics committees at the Medical University of Vienna (2458/2020) and at the Medical University of Graz (33-274 ex 20/21)., Trial Registration Number: NCT04753307., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Covid-19 patients who require admission to an intensive care unit (ICU) have a higher risk of mortality. Several risk factors for severe Covid-19 infection have been identified, including cardiovascular risk factors. Therefore, the aim was to investigate the association between cardiovascular (CV) risk and major adverse cardiovascular events (MACE) and mortality of Covid-19 ARDS patients admitted to an ICU. A prospective cross-sectional study was conducted in a university hospital in Graz, Austria. Covid-19 patients who were admitted to an ICU with a paO2/fiO2 ratio < 300 were included in this study. Standard lipid profile was measured at ICU admission to determine CV risk. 31 patients with a mean age of 68 years were recruited, CV risk was stratified using Framingham-, Procam- and Charlson Comorbidity Index (CCI) score. A total of 10 (32.3%) patients died within 30 days, 8 patients (25.8%) suffered from MACE during ICU stay. CV risk represented by Framingham-, Procam- or CCI score was not associated with higher rates of MACE. Nevertheless, higher CV risk represented by Procam score was significantly associated with 30- day mortality (13.1 vs. 6.8, p = 0.034). These findings suggest that the Procam score might be useful to estimate the prognosis of Covid-19 ARDS patients., (© 2023. The Author(s).)

Objective: To assess whether video laryngoscopy (VL) for tracheal intubation of neonates results in a higher first-attempt success rate and fewer adverse tracheal intubation-associated events (TIAEs) when compared with direct laryngoscopy (DL)., Design: Single-centre, parallel group, randomised controlled trial., Setting: University Medical Centre Mainz, Germany., Patients: Neonates <44 0/7 weeks postmenstrual age in whom tracheal intubation was indicated either in the delivery room or in the neonatal intensive care unit., Intervention: Intubation encounters were randomly assigned to either VL or DL at first attempt., Primary Outcome: First-attempt success rate during tracheal intubation., Results: Of 121 intubation encounters assessed for eligibility, 32 (26.4%) were either not randomised (acute emergencies (n=9), clinicians' preference for either VL (n=8) or DL (n=2)) or excluded from the analysis (declined parental consent (n=13)). Eighty-nine intubation encounters (41 in the VL and 48 in the DL group) in 63 patients were analysed. First-attempt success rate was 48.8% (20/41) in the VL group compared with 43.8% (21/48) in the DL group (OR 1.22, 95% CI 0.51 to 2.88).The frequency of adverse TIAEs was 43.9% (18/41) and 47.9% (23/48) in the VL and DL group, respectively (OR 0.85, 95% CI 0.37 to 1.97). Oesophageal intubation with concomitant desaturation never occurred in the VL group but in 18.8% (9/48) of intubation encounters in the DL group., Conclusion: This study provides effect sizes for first-attempt success rates and frequency of TIAEs with VL compared with DL in the neonatal emergency setting. This study was underpowered to detect small but clinically important differences between the two techniques. The results of this study may be useful in planning future trials., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Excessive use of screen media is a global public health issue and especially extensive screen exposure during very early childhood. This review was conducted in order to update previous reviews on the effectiveness of interventions to reduce screen time. An electronic literature search was carried out in MEDLINE, COCHRANE LIBRARY and CINAHL for articles indexed from June 2011 until October 2019. The search identified 933 publications of which 11 publications were included in this review. There are studies showing interventions with a positive influence on reduction of screen time and the participants' awareness and behavior concerning the use of screen media, as well as studies without such effects. No intervention was identified to be superior. This warrants further investigation of potentially effective combinations of intervention components and long-term follow-up., (© 2021. The Author(s).)

Aim of the Study: This study sought to assess the effects of increasing the ventilatory rate from 10 min -1 to 20 min -1 using a mechanical ventilator during cardio-pulmonary resuscitation (CPR) for out-of-hospital cardiac arrest (OHCA) on ventilation, acid-base-status, and outcomes., Methods: This was a randomised, controlled, single-centre trial in adult patients receiving CPR including advanced airway management and mechanical ventilation offered by staff of a prehospital physician response unit (PRU). Ventilation was conducted using a turbine-driven ventilator (volume-controlled ventilation, tidal volume 6 ml per kg of ideal body weight, positive end-expiratory pressure (PEEP) 0 mmHg, inspiratory oxygen fraction (FiO 2 ) 100%), frequency was pre-set at either 10 or 20 breaths per minute according to week of randomisation. If possible, an arterial line was placed and blood gas analysis was performed., Results: The study was terminated early due to slow recruitment. 46 patients (23 per group) were included. Patients in the 20 min -1 group received higher expiratory minute volumes [8.8 (6.8-9.9) vs. 4.9 (4.2-5.7) litres, p < 0.001] without higher mean airway pressures [11.6 (9.8-13.6) vs. 9.8 (8.5-12.0) mmHg, p = 0.496] or peak airway pressures [42.5 (36.5-45.9) vs. 41.4 (32.2-51.7) mmHg, p = 0.895]. Rates of ROSC [12 of 23 (52%) vs. 11 of 23 (48%), p = 0.768], median pH [6.83 (6.65-7.05) vs. 6.89 (6.80-6.97), p = 0.913], and median pCO 2 [78 (51-105) vs. 86 (73-107) mmHg, p > 0.999] did not differ between groups., Conclusion: 20 instead of 10 mechanical ventilations during CPR increase ventilation volumes per minute, but do not improve CO 2 washout, acidaemia, oxygenation, or rate of ROSC., Clinicaltrials: gov Identifier: NCT04657393., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Rationale: Chronic rhinosinusitis (CRS) contributes to morbidity in patients with cystic fibrosis (CF). However, longitudinal data on CRS onset and progression is lacking. Objectives: To longitudinally evaluate CRS in CF from infancy to school age with paranasal sinus magnetic resonance imaging (MRI). Methods: A total of 64 children with CF (mean age at baseline, 1.1 ± 1.6 yr; range, 0-5 yr) underwent a mean of 5.8 ± 2.2 (range, 3-11 yr) subsequent annual MRI examinations. Additional 24 children (9.2 ± 4.4 yr; range, 3-17 yr) homozygous for the F508del mutation underwent MRI before and at least 2 months after starting lumacaftor/ivacaftor. MRI was assessed using the previously evaluated CRS-MRI score. Results: In infancy, 65-87% of paranasal sinuses were opacified, and mucosal swelling was the dominant abnormality (58-97%). At preschool age (1-5 yr), 79-94% of sinuses were opacified ( P  < 0.05 vs. infancy), and mucosal swelling was the most dominant abnormality (79-94%; P  < 0.05). At school age (at least 6 yr), almost all sinuses were opacified (71-99%; P  < 0.001-0.357 vs. preschool age), and mucopyoceles were the dominant abnormality in maxillary and frontal sinuses (53-56%; P  < 0.05-0.808). The CRS-MRI sum score increased from 22.4 ± 9.6 in infancy to 34.2 ± 9.6 in preschool age ( P  < 0.001) and was 34.0 ± 5.7 in school age ( P  = 0.052). In children under lumacaftor/ivacaftor therapy, the CRS-MRI sum score (-0.5 ± 3.3; P  < 0.05) and maxillary sinus subscore (-0.5 ± 1.5; P  < 0.05) improved. Conclusions: Longitudinal paranasal sinus MRI detects an early onset and progression of the severity of CRS from infancy to school age, and response to lumacaftor/ivacaftor therapy in children with CF. Our data support its role in the comprehensive noninvasive monitoring of CRS in children with CF. Clinical trial registered with www.clinicaltrials.gov (NCT02270476).

Purpose: To investigate morphofunctional chest MRI for the detection and management of incidental pulmonary nodules in participants with chronic obstructive pulmonary disease (COPD)., Materials and Methods: In this prospective study, 567 participants (mean age, 66 years ± 9 [SD]; 340 men) underwent same-day contrast-enhanced MRI and nonenhanced low-dose CT (LDCT) in a nationwide multicenter trial (clinicaltrials.gov: NCT01245933). Nodule dimensions, morphologic features, and Lung Imaging Reporting and Data System (Lung-RADS) category were assessed at MRI by two blinded radiologists, and consensual LDCT results served as the reference standard. Comparisons were performed using the Student t test, and agreements were assessed using the Cohen weighted κ., Results: A total of 525 nodules larger than 3 mm in diameter were detected at LDCT in 178 participants, with a mean diameter of 7.2 mm ± 6.1 (range, 3.1-63.1 mm). Nodules were not detected in the remaining 389 participants. Sensitivity and positive predictive values with MRI for readers 1 and 2, respectively, were 63.0% and 84.8% and 60.2% and 83.9% for solid nodules ( n = 495), 17.6% and 75.0% and 17.6% and 60.0% for part-solid nodules ( n = 17), and 7.7% and 100% and 7.7% and 50.0% for ground-glass nodules ( n = 13). For nodules 6 mm or greater in diameter, sensitivity and positive predictive values were 73.3% and 92.2% for reader 1 and 71.4% and 93.2% for reader 2, respectively. Readers underestimated the long-axis diameter at MRI by 0.5 mm ± 1.7 (reader 1) and 0.5 mm ± 1.5 (reader 2) compared with LDCT ( P < .001). For Lung-RADS categorization per nodule using MRI, there was substantial to perfect interreader agreement (κ = 0.75-1.00) and intermethod agreement compared with LDCT (κ = 0.70-1.00 and 0.69-1.00)., Conclusion: In a multicenter setting, morphofunctional MRI showed moderate sensitivity for detection of incidental pulmonary nodules in participants with COPD but high agreement with LDCT for Lung-RADS classification of nodules.Clinical trial registration no. NCT01245933 and NCT02629432 Keywords: MRI, CT, Thorax, Lung, Chronic Obstructive Pulmonary Disease, Screening© RSNA, 2023 Supplemental material is available for this article., Competing Interests: Disclosures of conflicts of interest: Q.L. No relevant relationships. L.Z. No relevant relationships. O.v.S. No relevant relationships. S.M.F.T. No relevant relationships. J.B. Siemens Healthineers helped with MRI protocol design; Bayer provided contrast material used in the study; payment for honorarium for presentation at a workshop from Roche, Boehringer Ingelheim, and Fuji; president of European Society of Thoracic Imaging 2022–2023. O.W. No relevant relationships. M.E. Honoraria to author and institution from Vertex Pharmaceutical. C.F.V. Grants or contracts from German Ministry of Education and Science (BMBF), AstraZeneca, Boehringer Ingelheim, Grifols, GlaxoSmithKline, and Novartis; consulting fees from Aerogen, AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, and Nuvaira; payment or honoraria for lectures/presentations from Aerogen, AstraZeneca, Boehringer Ingelheim, CSL Behring, Chiesi, GlaxoSmithKline, Grifols, Insmed, MedUpdate, Novartis, Roche, and Sanofi; support for attending meetings or travel from Boehringer Ingelheim and Sanofi; participation on a data safety monitoring or advisory board from AstraZeneca and Sanofi; Chair of the Science Committee of GOLD, Chairman of the German Lung Foundation (DLS). R.A.J. No relevant relationships. H.U.K. Bayer provided consumables to the consortium; institution receives payment from Siemens, Philips, and Boehringer Ingelheim; consulting fees to author from Median; payment or honoraria for lectures/presentations to author from Siemens, Philips, Boehringer Ingelheim, MSD, and Sanofi. C.P.H. Grants/contracts from Siemens (2012–2014), Pfizer (2012–2014), MeVis (2012, 2013), Boehringer Ingelheim (2014), and German Center for Lung Research (2011ff); consulting fees from Schering-Plough (2009, 2010), Pfizer (2008–2014), Basilea (2008, 2009, 2010), Boehringer Ingelheim (2010–2014), Novartis (2010, 2012, 2014), Roche (2010), Astellas (2011, 2012), Gilead (2011–2015), MSD (2011–2013), Lilly (2011), Intermune (2013-2014), and Fresenius (2013, 2014); lecture fees from Gilead (2008–2014), Essex (2008, 2009, 2010), Schering-Plough (2008, 2009, 2010), AstraZeneca (2008–2014, 2022), Lilly (2008, 2009, 2012), Roche (2008, 2009), MSD (2009–2014), Pfizer (2010–2014), Bracco (2010, 2011), MEDA Pharma (2011), Intermune (2011–2014), Chiesi (2012), Siemens (2012), Covidien (2012), Pierre Fabre (2012), Boehringer Ingelheim (2012, 2013, 2022), Grifols (2012), Novartis (2013–2016), Basilea (2015, 2016), and Bayer (2016); patent: Method and Device For Representing the Microstructure of the Lungs. IPC8 Class: AA61B5055FI, PAN: 20080208038, Inventors: W Schreiber, U Wolf, AW Scholz, CP Heussel; participation on a data safety monitoring board or advisory board: Schering-Plough (2009, 2010), Pfizer (2008–2014), Basilea (2008, 2009, 2010), Boehringer Ingelheim (2010–2014, 2022ff), Novartis (2010, 2012, 2014), Roche (2010), Astellas (2011, 2012), Gilead (2011–2015), MSD (2011–2013), Lilly (2011), Intermune (2013–2014), Fresenius (2013, 2014); leadership or fiduciary roles: chest working group of the German Roentgen Society (national guidelines: bronchial carcinoma, mesothelioma, COPD, screening for bronchial carcinoma, CT and MRI of the chest, pneumonia); consultant of ECIL-3, ECCMID, EORTC/MSG (guideline for diagnosis of infections in immunocompromised hosts); founding member of the working team in infections in immunocompromised hosts of the German Society of Hematology/Oncology (guideline for diagnosis of infections in immunocompromised hosts); faculty member of European Society of Thoracic Radiology (ESTI), European Respiratory Society (ERS), and member in EIBALL (European Imaging Biomarkers Alliance); editor of Medizinische Klinik, Intensivmedizin und Notfallmedizin at Springer publishing; stock/stock options GSK. B.J.J. No relevant relationships. M.O.W. Bayer provided contrast material for MRI examinations; study grants paid to institution from Vertex Pharmaceuticals and Boehringer Ingelheim; consultancy fees paid to institution from Vertex Pharmaceuticals and Boehringer Ingelheim., (© 2023 by the Radiological Society of North America, Inc.)

Introduction: Chronic rhinosinusitis (CRS) usually presents with nasal congestion, rhinorrhea and anosmia impacts quality of life in cystic fibrosis (CF). Especially mucopyoceles pathognomonic for CRS in CF may cause complications such as spread of infection. Previous studies using magnetic resonance imaging (MRI) demonstrated early onset and progression of CRS from infancy to school age in patients with CF, and mid-term improvements of CRS in preschool and school-age children with CF treated with lumacaftor/ivacaftor for at least 2 months. However, long-term data on treatment effects on paranasal sinus abnomalities in preschool and school-age children with CF are lacking. Methods: 39 children with CF homozygous for F508del (mean age at baseline MRI 5.9 ± 3.0 years, range 1-12 years) underwent MRI before (MRI1) and about 7 months after starting lumacaftor/ivacaftor and then annually (median 3 follow-up MRI, range 1-4) (MRI2-4). MRI were evaluated using the previously evaluated CRS-MRI score with excellent inter-reader agreement. For intraindividual analysis ANOVA mixed-effects analysis including Geisser-Greenhouse correction and Fisher's exact test, and for interindividual group analysis Mann-Whitney test were used. Results: The CRS-MRI sum score at baseline was similar in children starting lumacaftor/ivacaftor in school age and children starting therapy at preschool age (34.6 ± 5.2 vs.32.9 ± 7.8, p = 0.847). Mucopyoceles were the dominant abnormality in both, especially in maxillary sinus (65% and 55%, respectively). In children starting therapy in school age the CRS-MRI sum score decreased longitudinally from MRI1 to MRI2 (-2.1 ± 3.5, p < 0.05), MRI3 (-3.0 ± 3.7, p < 0.01) and MRI4 (-3.6 ± 4.7, p < 0.01), mainly due to a decrease in the mucopyoceles subscore (-1.0 ± 1.5, p = 0.059; -1.2 ± 2.0, p < 0.05; -1.6 ± 1.8, p < 0.01; and -2.6 ± 2.8, p = 0.417, respectively). In children starting lumacaftor/ivacaftor in preschool age, the CRS-MRI sum score remained stable under therapy over all three follow-up MRI (0.6 ± 3.3, p = 0.520; 2.4 ± 7.6, p = 0.994; 2.1 ± 10.5, p > 0.999 and -0.5 ± 0.5, p = 0.740; respectively). Conclusion: Longitudinal paranasal sinus MRI shows improvements in paranasal sinus abnormalities in children with CF starting lumacaftor/ivacaftor therapy at school age. Further, MRI detects a prevention of an increase in paranasal sinus abnormalities in children with CF starting lumacaftor/ivacaftor therapy at preschool age. Our data support the role of MRI for comprehensive non-invasive therapy and disease monitoring of paranasal sinus abnormalities in children with CF., Competing Interests: H-UK declares relationships with the following companies: Siemens, Philips, Bayer, Boehringer Ingelheim, Astra Zeneca, Merck Sharp Dohme. CPH declares advisory board membership with Boehringer Ingelheim unrelated to the present study. ME declares advisory board membership with Boehringer Ingelheim unrelated to the present study and speaker honoraria by Boehringer Ingelheim, Roche Pharma and Vertex Pharmaceuticals unrelated to the present study. MW declares advisory board membership with Boehringer Ingelheim unrelated to the present study and receives study grants from Vertex Pharmaceuticals unrelated to the present study. S-YG and MS are participants of the BIH-Charité Clinician Scientist Program funded by the Charité–Universitätsmedizin Berlin and the BIH. MM received grants from Vertex Pharmaceuticals and personal fees for participation in advisory boards or consulting from Abbvie, Antabio, Arrowhead Pharmaceuticals, Boehringer Ingelheim, Enterprise Therapeutics, Kither Biotech, Pieris Pharmaceuticals, Santhera, Sterna Biologicals, Vertex Pharmaceuticals, outside the submitted work. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Wucherpfennig, Wuennemann, Eichinger, Seitz, Baumann, Stahl, Graeber, Zhao, Chung, Schenk, Alrajab, Kauczor, Mall, Sommerburg and Wielpütz.)

Objectives: National and regional systems for emergency medical care provision may differ greatly. We sought to determine whether or not physicians are utilized in prehospital care and to what extent they are present in differentEuropean countries., Material and Methods: We collected information on 32 European countries by reviewing publications and sending questionnaires to authors of relevant articles as well as to officials of ministries of health (or equivalent), representatives of national societies in emergency medicine, or well-known experts in the specialty., Results: Thirty of the 32 of European countries we studied (94%) employ physicians in prehospital emergency medical services. In 17 of the 32 (53%), general practitioners also participate in prehospital emergency care. Emergency system models were described as Franco-German in 27 countries (84%), as hybrid in 17 (53%), and as Anglo-American in 14 (44%). Multiple models were present simultaneously in 17 countries (53%). We were able to differentiate between national prehospital emergency systems with a novel classification based on tiers reflecting the degree of physician utilization in the countries. We also grouped the national systems by average population and area served., Conclusion: There are notable differences in system designs and intensity of physician utilization between different geographic areas, countries, and regions in Europe. Several archetypal models (Franco-German, hybrid, and Anglo- American) exist simultaneously across Europe.

Background: Bronchial artery dilatation (BAD) is associated with haemoptysis in advanced cystic fibrosis (CF) lung disease. Our aim was to evaluate BAD onset and its association with disease severity by magnetic resonance imaging (MRI)., Methods: 188 CF patients (mean±sd age 13.8±10.6 years, range 1.1-55.2 years) underwent annual chest MRI (median three exams, range one to six exams), contributing a total of 485 MRI exams including perfusion MRI. Presence of BAD was evaluated by two radiologists in consensus. Disease severity was assessed using the validated MRI scoring system and spirometry (forced expiratory volume in 1 s (FEV 1 ) % pred)., Results: MRI demonstrated BAD in 71 (37.8%) CF patients consistently from the first available exam and a further 10 (5.3%) patients first developed BAD during surveillance. Mean MRI global score in patients with BAD was 24.5±8.3 compared with 11.8±7.0 in patients without BAD (p < 0.001) and FEV 1 % pred was lower in patients with BAD compared with patients without BAD (60.8% versus 82.0%; p<0.001). BAD was more prevalent in patients with chronic Pseudomonas aeruginosa infection versus in patients without infection (63.6% versus 28.0%; p<0.001). In the 10 patients who newly developed BAD, the MRI global score increased from 15.1±7.8 before to 22.0±5.4 at first detection of BAD (p < 0.05). Youden indices for the presence of BAD were 0.57 for age (cut-off 11.2 years), 0.65 for FEV 1 % pred (cut-off 74.2%) and 0.62 for MRI global score (cut-off 15.5) (p < 0.001)., Conclusions: MRI detects BAD in patients with CF without radiation exposure. Onset of BAD is associated with increased MRI scores, worse lung function and chronic P. aeruginosa infection, and may serve as a marker of disease severity., Competing Interests: Conflict of interest: P. Leutz-Schmidt has nothing to disclose. D-E. Optazaite has nothing to disclose. O. Sommerburg declares payments for lectures and presentations from Vertex Pharmaceuticals, in the 36 months prior to manuscript submission. M. Eichinger declares clinical reader honoraria paid to their institution by Vertex Pharmaceuticals and speaker fees from Vertex Pharmaceuticals, in the 36 months prior to manuscript submission. S. Wege has nothing to disclose. E. Steinke declares funding from the Junior Clinician Scientist Program of Berlin Institute of Health – Charité Berlin, starting in July 2022; and a travel grant from Mukoviszidose e.V. to attend the European Cystic Fibrosis Young Investigator Meeting, Paris, 2022. S.Y. Graeber declares grants paid to their institution from Mukoviszidose e.V., Vertex Pharmaceuticals, the German Federal Ministry for Education and Research (BMBF) and Deutsche Forschungsgemeinschaft; and personal fees for presentations and serving on advisory boards from Chiesi GmbH and Vertex Pharmaceuticals, all in the 36 months prior to manuscript submission. M.U. Puderbach has nothing to disclose. J-P. Schenk declares an unpaid role as head of the radiology panel and member of the steering committee of the SIOP-RTSG association. A. Alrajab has nothing to disclose. S.M.F. Triphan has nothing to disclose. H-U. Kauczor declares funding to their institution for the present manuscript from Siemens. M. Stahl declares grants paid to their institution by Vertex Pharmaceuticals; and personal payments for serving on an advisory board from Vertex Pharmaceuticals, all in the 36 months prior to manuscript submission; as well as unpaid roles as Chairwoman of the FGM, Treasurer of the GPP and Secretary of the Cystic Fibrosis Group of the ERS. M.A. Mall declares funding paid to their institution for the work in the present manuscript from the German Federal Ministry for Education and Research (BMBF; grant 82DZL009B1); grants to their institution from Vertex Pharmaceuticals (IIS-2018-107555) and the Deutsche Forschungsgemeinschaft (DFG; CRC 1449–431232613); personal fees for consultancy from Boehringer Ingelheim, Arrowhead Pharmaceuticals, Vertex Pharmaceuticals, Santhera, Sterna Biologicals, Enterprise Therapeutics, Kither Biotech and Antabio; lecture fees from Boehringer Ingelheim, Arrowhead Pharmaceuticals and Vertex Pharmaceuticals; travel reimbursement from Boehringer Ingelheim and Vertex Pharmaceuticals; personal fees for participation on advisory boards from Boehringer Ingelheim, Arrowhead Pharmaceuticals, Vertex Pharmaceuticals, Santhera, Enterprise Therapeutics, Antabio and Kither Biotech, all in the 36 months prior to manuscript submission; and an unpaid role as an elected member of the ECFS board. M.O. Wielpütz declares funding paid to their institution for the work in the present manuscript from the German Federal Ministry for Education and Research (BMBF); grants, lecture fees and consultancy fees (all paid to their institution) from Boehringer Ingelheim and Vertex Pharmaceuticals, all in the 36 months prior to manuscript submission; and that they are an ESTI Board Member (personal payments) and an IWPFI Board Member (unpaid)., (Copyright ©The authors 2023.)

Background: Recent studies support magnetic resonance angiography (MRA) as a diagnostic tool for pulmonary arterial disease., Purpose: To determine MRA image quality and reproducibility, and the dependence of MRA image quality and reproducibility on disease severity in patients with chronic obstructive pulmonary disease (COPD) and cystic fibrosis (CF)., Material and Methods: Twenty patients with COPD (mean age 66.5 ± 8.9 years; FEV1% = 42.0 ± 13.3%) and 15 with CF (mean age 29.3 ± 9.3 years; FEV1% = 66.6 ± 15.8%) underwent morpho-functional chest magnetic resonance imaging (MRI) including time-resolved MRA twice one month apart (MRI1, MRI2), and COPD patients underwent non-contrast computed tomography (CT). Image quality was assessed visually using standardized subjective 5-point scales. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were measured by regions of interest. Disease severity was determined by spirometry, a well-evaluated chest MRI score, and by computational CT emphysema index (EI) for COPD., Results: Subjective image quality was diagnostic for all MRA at MRI1 and MRI2 (mean score = 4.7 ± 0.6). CNR and SNR were 4 43.8 ± 8.7 and 50.5 ± 8.7, respectively. Neither image quality score nor CNR or SNR correlated with FEV1% or chest MRI score for COPD and CF (r = 0.239-0.248). CNR and SNR did not change from MRI1 to MRI2 ( P  = 0.434-0.995). Further, insignificant differences in CNR and SNR between MRA at MRI1 and MRI2 did not correlate with FEV1% nor chest MRI score in COPD and CF (r = -0.238-0.183), nor with EI in COPD (r = 0.100-0.111)., Conclusion: MRA achieved diagnostic quality in COPD and CF patients and was highly reproducible irrespective of disease severity. This supports MRA as a robust alternative to CT in patients with underlying muco-obstructive lung disease.

Physicians play an important role in adapting to and mitigating the adverse health effects of the unfolding climate and ecological crises. To fully harness this potential, future physicians need to acquire knowledge, values, skills, and leadership attributes to care for patients presenting with environmental change-related conditions and to initiate and propel transformative change in healthcare and other sectors of society including, but not limited to, the decarbonization of healthcare systems, the transition to renewable energies and the transformation of transport and food systems. Despite the potential of Planetary Health Education (PHE) to support medical students in becoming agents of change, best-practice examples of mainstreaming PHE in medical curricula remain scarce both in Germany and internationally. The process of revising and updating the Medical Licensing Regulations and the National Competency-based Catalog of Learning Objectives for Medical Education in Germany provided a window of opportunity to address this implementation challenge. In this article, we describe the development and content of national Planetary Health learning objectives for Germany. We anticipate that the learning objectives will stimulate the development and implementation of innovative Planetary Health teaching, learning and exam formats in medical schools and inform similar initiatives in other health professions. The availability of Planetary Health learning objectives in other countries will provide opportunities for cross-country and interdisciplinary exchange of experiences and validation of content, thus supporting the consolidation of Planetary Health learning objectives and the improvement of PHE for all health professionals globally., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Wabnitz, Schwienhorst-Stich, Asbeck, Fellmann, Gepp, Leberl, Mezger and Eichinger.)

Aim of This Study: This study seeks to investigate, whether extubation of tracheally intubated patients admitted to intensive care units (ICU) postoperatively either immediately at the day of admission (day 1) or delayed at the first postoperative day (day 2) is associated with differences in outcomes., Materials and Methods: We performed a retrospective analysis of data from an Austrian ICU registry. Adult patients admitted between January 1st, 2012 and December 31st, 2019 following elective and emergency surgery, who were intubated at the day 1 and were extubated at day 1 or day 2, were included. We performed logistic regression analyses for in-hospital mortality and over-sedation or agitation following extubation., Results: 52 982 patients constituted the main study population. 1 231 (3.3%) patients extubated at day 1 and 958 (5.9%) at day 2 died in hospital, 464 (1.3%) patients extubated at day 1 and 613 (3.8%) at day 2 demonstrated agitation or over-sedation after extubation during ICU stay; OR (95% CI) for in-hospital mortality were OR 1.17 (1.01-1.35, p = 0.031) and OR 2.15 (1.75-2.65, p<0.001) for agitation or over-sedation., Conclusions: We conclude that immediate extubation as soon as deemed feasible by clinicians is associated with favourable outcomes and may thus be considered preferable in tracheally intubated patients admitted to ICU postoperatively., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Zajic et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Public knowledge of out-of-hospital cardiac arrest (OHCA), and initiation of basic life support (BLS) is crucial to increase survival in OHCA., Methods: The study analysed the knowledge and willingness to perform BLS of laypersons passing an AED at a public train station. Interviewees were recruited at two time points before and after a four year-long structured regional awareness campaign, which focused on call , compress , shock in a mid-size European city (270,000 inhabitants). Complete BLS was defined as multiple responses for call for help ; initiation of chest compressions ; and usage of an AED, without mentioning recovery position . Minimal BLS was defined as call for help and initiation of chest compressions ., Results: A total of 784 persons were interviewed, 257 at baseline and 527 post-campaign. Confronted with a fictional OHCA, at baseline 8.5% of the interviewees spontaneously mentioned actions for complete BLS and 17.9% post-campaign (p = 0.009). An even larger increase in knowledge was seen in minimal BLS (34.6% vs 60.6%, p < 0.001)., Conclusion: After a regional cardiac arrest awareness campaign, we found an increase in knowledge of BLS actions in the lay public. However, our investigation revealed severe gaps in BLS knowledge, possibly resulting in weak first links of the chain of survival., (© 2022 The Author(s).)

Due to rapid urbanisation, food systems in sub-Saharan African cities are increasingly under pressure. Through the lens of a foodshed, this paper quantitatively analyses the spatial extent of the food provisioning area for consumers of different socio-economic status in Kampala (Uganda). Based on a primary dataset of surveys with households and food vendors, we map the foodshed by registering where consumers obtain their food, and the origin of where it is grown. We show that 50% of the food consumed in the city originates from within a 120 km proximity to Kampala, including 10% from within the city itself. At present, urban agricultural activities are twice as important as international imports for the urban food provision. Established, high-income urban dwellers have a more local foodshed due to their broad participation in urban agriculture, while low-income newcomers rely heavily on retailers who source food from rural Uganda., Competing Interests: Competing interestsThe authors declare no competing interests., (© The Author(s) 2023.)

Introduction: Participation is an important dimension of healthy child development and is associated with higher self-rated health, educational attainment and civic engagement. Many children with special healthcare needs (SHCN) experience limited participation and are thus at risk for adverse health and developmental outcomes. Despite this, interventions that promote participation in healthcare are scarce. We therefore evaluate the effectiveness of a complex age- and condition-generic intervention that strengthens participation-centred care involving parents and their children with SHCN by, inter alia , assessing preferences, specifying participation goals and facilitating shared decision-making in care., Methods and Analysis: In this study protocol we describe the design and procedures for an unblinded, stepped wedge, cluster randomised trial conducted in 15 German interdisciplinary healthcare facilities providing services for children aged 0-18 years with SHCN. Sites are randomised to five periods in which they switch from control to intervention condition in blocks of three. The intervention includes: (1) team training focused on participation-centred care, (2) introduction of a new software facilitating participation-focused documentation and (3) implementation support promoting the transfer of training content into routine care. Study sites deliver routine care while in the control condition. As primary outcome, the degree of perceived shared decision-making with parents (CollaboRATE pediatric parent scale), a potential antecedent of achieving participation goals in everyday life, is assessed on one randomly selected day per week during the entire study period, directly following care appointments. We aim to sample 70 parents per study site and period. Additionally, participation of children is assessed within a closed embedded cohort with three parent and patient surveys. Intervention effectiveness will be modelled with a marginal model for correlated binary outcomes using generalised estimation equations and complete cases. A comprehensive mixed-methods process evaluation complements the effectiveness analyses.

Background: Therapy with Elexacaftor/Tezacaftor/Ivacaftor (ETI) was recently approved for adult cystic fibrosis (CF) patients with at least one F508del mutation. However, its effects on structural and functional lung abnormalities and chronic rhinosinusitis have not been studied by imaging., Methods: 19 adults with CF (mean age 31±9y, range 19-55y) underwent standardized chest magnetic resonance imaging (MRI), and nine also same-session sinonasal MRI, before (MRI1) and after (MRI2) at least one month (mean duration 5 ± 3mon) on ETI. 24 control CF patients (30±7y, range 20-44y) without ETI underwent longitudinal chest MRI, and eleven also sinonasal MRI, twice (mean interval 40±15mon). MRI was assessed using the validated chest MRI score and chronic rhinosinusitis (CRS)-MRI score. Forced expiratory volume in 1 s percent predicted (FEV1%) was measured in all patients., Results: In controls, the chest MRI global score and CRS-MRI sum score were stable from MRI1 to MRI2. In patients under ETI, the chest MRI global score improved (-11.4 ± 4.6, P<0.001), mainly due to reduction of bronchiectasis/wall thickening and mucus plugging subscores (-3.3 ± 2.2 and -5.2 ± 1.5, P<0.001, respectively). The improvement in chest MRI score correlated well with improved FEV1% (r=-0.703, P<0.001). The CRS-MRI sum score also improved in patients under ETI (-6.9 ± 3.0, P<0.001), mainly due to a reduction of mucopyoceles in the maxillary and ethmoid sinus (-50% and -39%, P<0.05, respectively)., Conclusions: MRI detects improvements of chest MRI and CRS-MRI scores in adult CF patients who first received ETI, demonstrating reversibility of structural lung and paranasal sinus abnormalities in patients with established disease., Competing Interests: Declaration of Competing Interest HUK declares relationships with the following companies: Siemens, Philips, Bayer, Boehringer Ingelheim, Astra Zeneca, Merck Sharp Dohme. CPH declares advisory board membership with Boehringer Ingelheim unrelated to the present study. ME declares advisory board membership with Boehringer Ingelheim unrelated to the present study and speaker honoraria by Boehringer Ingelheim, Roche Pharma and Vertex Pharmaceuticals unrelated to the present study. MOW declares advisory board membership with Boehringer Ingelheim unrelated to the present study and receives study grants from Vertex Pharmaceuticals unrelated to the present study. The other authors have nothing to declare., (Copyright © 2022 European Cystic Fibrosis Society. Published by Elsevier B.V. All rights reserved.)

Background: Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) allows the assessment of pulmonary perfusion, which may play a key role in the development of muco-obstructive lung disease. One problem with quantifying pulmonary perfusion is the high variability of metrics. Quantifying the extent of abnormalities using unsupervised clustering algorithms in residue function maps leads to intrinsic normalization and could reduce variability., Purpose: We investigated the reproducibility of perfusion defects in percent (QDP) in clinically stable patients with cystic fibrosis (CF) and chronic obstructive pulmonary disease (COPD)., Methods: 15 CF (29.3 ± 9.3y, FEV1%predicted = 66.6 ± 15.8%) and 20 COPD (66.5 ± 8.9y, FEV1%predicted = 42.0 ± 13.3%) patients underwent DCE-MRI twice 1 month apart. QDP, pulmonary blood flow (PBF), and pulmonary blood volume (PBV) were computed from residue function maps using an in-house quantification pipeline. A previously validated MRI perfusion score was visually assessed by an expert reader., Results: Overall, mean QDP, PBF, and PBV did not change within 1 month, except for QDP in COPD ( p < 0.05). We observed smaller limits of agreement (± 1.96 SD ) related to the median for QDP (CF: ± 38%, COPD: ± 37%) compared to PBF (CF: ± 89%, COPD: ± 55%) and PBV (CF: ± 55%, COPD: ± 51%). QDP correlated moderately with the MRI perfusion score in CF ( r = 0.46, p < 0.05) and COPD ( r = 0.66, p < 0.001). PBF and PBV correlated poorly with the MRI perfusion score in CF ( r =-0.29, p = 0.132 and r =-0.35, p = 0.067, respectively) and moderately in COPD ( r =-0.57 and r =-0.57, p < 0.001, respectively)., Conclusion: In patients with muco-obstructive lung diseases, QDP was more robust and showed a higher correlation with the MRI perfusion score compared to the traditionally used perfusion metrics PBF and PBV., Competing Interests: Authors MW, H-UK, and CH declared advisory board membership with Boehringer Ingelheim unrelated to the present study. Authors MK, SB, HH, and FR were employed by the Boehringer Ingelheim. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Konietzke, Triphan, Eichinger, Bossert, Heller, Wege, Eberhardt, Puderbach, Kauczor, Heußel, Heußel, Risse and Wielpütz.)

Introduction: Public health crises such as pandemics can cause serious disruptions to the utilisation and provision of healthcare services with negative effects on morbidity and mortality. Despite the important role of paediatric primary care in maintaining high-quality healthcare services during crises, evidence about service utilisation and provision remains limited especially in Germany. This study, therefore, explores the utilisation and provision of paediatric primary care services during the ongoing COVID-19 pandemic and their barriers and facilitators., Methods and Analysis: The study uses a convergent mixed-methods design and comprises online surveys to parents, adolescents and primary care paediatricians (PCPs) and semistructured interviews with parents and PCPs. We recruit parents and adolescents from paediatric primary care practices and PCPs via email using mailing lists of the German Professional Association of Paediatricians and the German Society of Ambulatory Primary Care Paediatrics. The parent and adolescent surveys assess, inter alia , the utilisation of paediatric primary care services and its correlates, aspects of parental and child health as well as socioeconomic characteristics. The PCP survey investigates the provision of paediatric primary care services and its correlates, aspects of PCP health as well as sociodemographic and practice characteristics. The semistructured interviews with parents and PCPs explore several aspects of the online surveys in more detail. We use descriptive statistics and generalised linear mixed models to assess service utilisation and provision and specific correlates covered in the online surveys and apply qualitative content analysis to explore barriers and facilitators of service utilisation and provision more broadly in the semistructured interviews. We will integrate findings from the quantitative and qualitative analyses at the interpretation stage., Ethics and Dissemination: The study was approved by the Medical Ethics Review Board of the Medical Faculty Mannheim at Heidelberg University (2020-650N). Study results will be published in journals with external peer-review., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Lung cancer screening may provide a favorable opportunity for a spirometry examination, to diagnose participants with undiagnosed lung function impairments, or to improve targeting of computed tomography (CT) screening intensity in view of expected net benefit., Methods: Spirometry was performed in the CT screening arm (n=2,029) of the German Lung Cancer Screening Intervention Study (LUSI)-a trial examining the effects of annual CT screening on lung cancer mortality, in 50-69-year-old long-term smokers. Participants were classified as having chronic obstructive pulmonary disease (COPD) [forced expiration in one second (FEV 1 )/forced vital lung capacity (FVC) <0.7], preserved ratio impaired spirometry (PRISm; FEV 1 /FVC ≥0.7 and FEV 1 % predicted <80%), or normal spirometry. Descriptive statistics were used to examine associations of COPD or PRISm with respiratory symptoms, and self-reported medical diagnoses of respiratory and other morbidities. Logistic regression and proportional hazards regression were used to examine associations of COPD and PRISm, as well as their self-reported medical diagnoses, with risks of lung cancer and all-cause mortality., Results: A total of 1,987 screening arm participants (98%) provided interpretable spirometry measurements; of these, 34.3% had spirometric patterns consistent with either COPD (18.6%) or PRISm (15.7%). Two thirds of participants with COPD or PRISm were asymptomatic, and only 23% reported a previous medical diagnosis concordant with COPD. Participants reporting a diagnosis tended to be more often current and heavier smokers, and more often had respiratory symptoms, cardiovascular comorbidities, or more severe lung function impairments. Independently of smoking history, moderate-to-severe (GOLD 2-4) COPD (OR =2.14; 95% CI: 1.54-2.98), and PRISm (OR =2.68; 95% CI: 1.61-4.40), were associated with increased lung cancer risk. Lung cancer patients with PRISm less frequently had adenocarcinomas, and more often squamous cell or small cell tumors, compared to those with normal spirometry (n=45), and both PRISm and COPD were associated with more advanced lung cancer tumor stage for screen-detected cancers. PRISm and COPD, depending on GOLD stage, were also associated with about 2- to 4-fold increases in risk of overall mortality, which to 87 percent had causes other than lung cancer., Conclusions: About one third of smokers eligible for lung cancer screening in Germany have COPD or PRISm. As these conditions were associated with detection of lung cancer, spirometry may help identify populations at high risk for death of lung cancer or other causes, and who might particularly benefit from CT screening., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-22-63/coif). HUK reports grants and personal fees from Siemens, grants and personal fees from Philips, personal fees from Boehringer Ingelheim, personal fees from Merck Sharp Dohme, personal fees from Astra Zeneca, personal fees from Median, outside the submitted work. CPH reports personal fees from Novartis in 2013–2016; personal fees from Basilea in 2015 and 2016; and personal fees from Bayer in 2016, outside the submitted work. CPH has a patent, Method and Device For Representing the Microstructure of the Lungs (IPC8 Class: AA61B5055FI, PAN: 20080208038, Inventors: W Schreiber, U Wolf, AW Scholz, CP Heussel). CPH reports stock ownership in medical industry: GSK. CPH also reports a committee membership: Chest working group of the German Roentgen society for national guidelines: bronchial carcinoma, mesothelioma, COPD, screening for bronchial carcinoma, CT and MR imaging of the chest, pneumonia. MOW and ME report study grants outside the submitted work from Boehringer Ingelheim Pharma and Vertex Pharmaceuticals. The other authors have no conflicts of interest to declare., (2022 Translational Lung Cancer Research. All rights reserved.)

Introduction: School-based programmes may promote knowledge and skills required to address climate change and better health and well-being in adolescents, yet evidence of their effectiveness is limited. In preparation for evaluating the Public Climate School, a school-based intervention to promote climate awareness and action in adolescents, we conduct a pilot study intended to assess procedures for participant recruitment, retention, and data collection, data quality issues and to provide preliminary parameter estimates to guide sample size calculations. Methods and analysis: This unblinded, cluster-controlled pilot study targets students in twelve classes from grades seven to thirteen in German public schools. Seven and five classes were allocated to the intervention and waitlist control arms, respectively. The intervention consisted of (1) live lessons on YouTube, (2) climate-related challenges of the day, (3) workshops and (4) peer exchange sessions. Waitlist control classes participated three weeks later. Measures included the proportion of students completing baseline and follow-up surveys, a comparison of baseline characteristics between students in the retained subsample and those lost to follow-up, proportions of students completing online and paper-pencil-based surveys and problems during data collection based on information reported by teachers. Data quality was assessed as proportions of missing data, associations between missingness and sociodemographic measures using logistic regression models and basic psychometric properties of scales including ceiling effects and internal consistency. Intentions to reduce one's ecological footprint, the primary outcome, and all secondary outcomes for effect estimation were assessed one week pre- and post-intervention from November to December 2021 using items adapted from internationally used instruments and will be investigated using generalised linear mixed models and intention-to-treat analyses. Conclusions: The pilot study will lay the methodological groundwork for a large-scale cluster-randomised effectiveness and process evaluation of the Public Climate School. If proven effective and rolled out more broadly, the Public Climate School has the potential to contribute meaningfully to national climate mitigation and adaptation efforts by reaching a substantial share of adolescents in public schools, including those traditionally less involved in climate action.

Objective: To conduct a preliminary evaluation of psychometric properties of CollaboRATE pediatric , a set of three scales to assess shared decision making (SDM) with pediatric patients, parents and parents on behalf of their children (parent-proxy reports). As secondary objectives we examined the scales' distributional characteristics, acceptability, and agreement between scales., Methods: Patients aged ≥ 7 years and parents were recruited in two outpatient facilities providing healthcare services for children with neurological and behavioral health conditions. We collected 46, 169 and 227 pediatric patient, parent-proxy and parent reports, respectively. Convergent, divergent and discriminative validity were investigated. Acceptability of the scales and agreement between patient and parent-proxy reports were explored by assessing item nonresponse and Bland-Altman plots., Results: While convergent and divergent validity were established for the parent scale, discriminative validity was not demonstrated for any of the scales. The scales showed good to excellent acceptability. Parent-proxy reports agreed to a moderate extent with patients' self-reports of SDM., Conclusion: CollaboRATE pediatric offers a starting point for parsimoniously assessing SDM in Pediatrics, however further psychometric testing is warranted., Practice Implications: Given limited psychometric support for the pediatric patient scale, we recommend using both the pediatric patient and parent-proxy report scales to assess SDM in pediatric patients until further psychometric testing is concluded., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Patient Blood Management (PBM) programmes seek to reduce the number of missed anaemic patients in the run-up to surgery. The aim of this study was to evaluate the usefulness of haemoglobin (Hb) measured non-invasively (SpHb) in preoperative screening for anaemia. We conducted a prospective observational study in a preoperative clinic. Adult patients undergoing examination for surgery who had their Hb measured by laboratory means also had their Hb measured non-invasively by a trained health care provider. 1216 patients were recruited. A total of 109 (9.3%) patients (53 men and 56 women) was found to be anaemic by standard laboratory Hb measurement. Sensitivity for SpHb to detect anaemic patients was 0.50 (95% CI 0.37-0.63) in women and 0.30 (95% CI 0.18-0.43) in men. Specificity was 0.97 (95% CI 0.95-0.98) in men and 0.93 (95% CI 0.84-1.0) in women. The rate of correctly classified patients was 84.7% for men and 89.4% for women. Positive predictive value for SpHb was 0.50 (95% CI 0.35-0.65) in men and 0.40 (95% CI 0.31-0.50) in women; negative predictive value was 0.93 (95% CI 0.92-0.94) in men and 0.95 (95% CI 0.94-0.96) in women. We conclude that due to low sensitivity, SpHb is poorly suitable for detecting preoperative anaemia in both sexes under standard of care conditions., (© 2022. The Author(s).)

Objectives: Pulmonary perfusion abnormalities are prevalent in patients with chronic obstructive pulmonary disease (COPD), are potentially reversible, and may be associated with emphysema development. Therefore, we aimed to evaluate the clinical meaningfulness of perfusion defects in percent (QDP) using DCE-MRI., Methods: We investigated a subset of baseline DCE-MRIs, paired inspiratory/expiratory CTs, and pulmonary function testing (PFT) of 83 subjects (age = 65.7 ± 9.0 years, patients-at-risk, and all GOLD groups) from one center of the "COSYCONET" COPD cohort. QDP was computed from DCE-MRI using an in-house developed quantification pipeline, including four different approaches: Otsu's method, k-means clustering, texture analysis, and 80 th percentile threshold. QDP was compared with visual MRI perfusion scoring, CT parametric response mapping (PRM) indices of emphysema (PRM Emph ) and functional small airway disease (PRM fSAD ), and FEV1/FVC from PFT., Results: All QDP approaches showed high correlations with the MRI perfusion score (r = 0.67 to 0.72, p < 0.001), with the highest association based on Otsu's method (r = 0.72, p < 0.001). QDP correlated significantly with all PRM indices (p < 0.001), with the strongest correlations with PRM Emph  (r = 0.70 to 0.75, p < 0.001). QDP was distinctly higher than PRM Emph  (mean difference = 35.85 to 40.40) and PRM fSAD (mean difference = 15.12 to 19.68), but in close agreement when combining both PRM indices (mean difference = 1.47 to 6.03) for all QDP approaches. QDP correlated moderately with FEV1/FVC (r = - 0.54 to - 0.41, p < 0.001)., Conclusion: QDP is associated with established markers of disease severity and the extent corresponds to the CT-derived combined extent of PRM Emph  and PRM fSAD . We propose to use QDP based on Otsu's method for future clinical studies in COPD., Key Points: • QDP quantified from DCE-MRI is associated with visual MRI perfusion score, CT PRM indices, and PFT. • The extent of QDP from DCE-MRI corresponds to the combined extent of PRM Emph  and PRM fSAD from CT. • Assessing pulmonary perfusion abnormalities using DCE-MRI with QDP improved the correlations with CT PRM indices and PFT compared to the quantification of pulmonary blood flow and volume., (© 2021. The Author(s).)

In unconscious individuals, rapid sequence intubation (RSI) may be necessary for cardiopulmonary stabilisation and avoidance of secondary damage. Opinions on such invasive procedures in people of older age vary. We thus sought to evaluate a possible association between the probability of receiving prehospital RSI in unconsciousness and increasing age. We conducted a retrospective study in all missions (traumatic and non-traumatic) of the prehospital emergency physician response unit in Graz between January 1st, 2010 and December 31st, 2019, which we searched for Glasgow Coma Scale (GCS) below 9. Cardiac arrests were excluded. We performed multivariable regression analysis for RSI with age, GCS, independent living, and suspected cause as independent variables. Of the 769 finally included patients, 256 (33%) received RSI, whereas 513 (67%) did not. Unadjusted rates of RSI were significantly lower in older patients (aged 85 years and older) compared to the reference group aged 50-64 years (13% vs. 51%, p < 0.001). In multivariable regression analysis, patients aged 85 years and older were also significantly less likely to receive RSI [OR (95% CI) 0.76 (0.69-0.84)]. We conclude that advanced age, especially 85 years or older, is associated with significantly lower odds of receiving prehospital RSI in cases of unconsciousness., (© 2022. The Author(s).)

Purpose: To test the feasibility of cardiac real-time MRI in combination with retrospective gating by MR-compatible spirometry, to improve motion control, and to allow quantification of respiratory-induced changes during free-breathing., Methods: Cross-sectional real-time MRI (1.5T; 30 frames/s) using steady-state free precession contrast during free-breathing was combined with MR-compatible spirometry in healthy adult volunteers (n = 4). Retrospective binning assigned images to classes that were defined by electrocardiogram and spirometry. Left ventricular eccentricity index as an indicator of septal position and ventricular volumes in different respiratory phases were calculated to assess heart-lung interactions., Results: Real-time MRI with MR-compatible spirometry is feasible and well tolerated. Spirometry-based binning improved motion control significantly. The end-diastolic epicardial eccentricity index increased significantly during inspiration (1.04 ± 0.04 to 1.19 ± 0.05; P < .05). During inspiration, right ventricular end-diastolic volume (79 ± 17 mL/m 2 to 98 ± 18 mL/m 2 ), stroke volume (41 ± 8 mL/m 2 to 59 ± 11 mL/m 2 ) and ejection fraction (53 ± 3% to 60 ± 1%) increased significantly, whereas the end-systolic volume remained almost unchanged. Left ventricular end-diastolic volume, left ventricular stroke volume, and left ventricular ejection fraction decreased during inspiration, whereas the left ventricular end-systolic volume increased. The relationship between stroke volume and end-diastolic volume (Frank-Starling relationship) based on changes induced by respiration allowed for a slope estimate of the Frank-Starling curve to be 0.9 to 1.1., Conclusion: Real-time MRI during free-breathing combined with MR-compatible spirometry and retrospective binning improves image stabilization, allows quantitative image analysis, and importantly, offers unique opportunities to judge heart-lung interactions., (© 2021 The Authors. Magnetic Resonance in Medicine published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Rationale: Previous cross-sectional studies have demonstrated that chest magnetic resonance imaging (MRI) is sensitive to detect early lung disease in infants and preschool children with cystic fibrosis (CF) without radiation exposure. However, the ability of MRI to detect the progression of lung disease and the impact of early diagnosis in preschool children with CF remains unknown. Objectives: To investigate the potential of MRI to detect progression of early lung disease and impact of early diagnosis by CF newborn screening (NBS) in preschool children with CF. Methods: An annual MRI was performed from diagnosis over 4 years in a cohort of 96 preschool children with CF (age, 0-4 yr) who received concurrent diagnoses on the basis of NBS ( n  = 28) or clinical symptoms ( n  = 68). MRI scans were evaluated using a dedicated morphofunctional score, and the relationship between longitudinal MRI score and respiratory symptoms, pulmonary exacerbations, upper airway microbiology, and mode of diagnosis was determined. Measurements and Main Results: The MRI global score increased in the total cohort of children with CF during preschool years ( P  < 0.001) and was associated with cough, pulmonary exacerbations ( P  < 0.0001), and the detection of Staphylococcus aureus and Haemophilus influenzae ( P  < 0.05). MRI-defined abnormalities in lung morphology-especially airway wall thickening/bronchiectasis-were lower in children with CF diagnosed by NBS than in children with clinically diagnosed CF throughout the observation period ( P  < 0.01). Conclusions: MRI detected progression of early lung disease and benefits of early diagnosis by NBS in preschool children with CF. These findings support MRI as a sensitive outcome measure for diagnostic monitoring and early intervention trials in preschool children with CF. Clinical trial registered with www.clinicaltrials.gov (NCT02270476).

Background: The indirect impact of the COVID-19 pandemic on cancer care and timely diagnosis is of increasing concern. We investigated the impact of the COVID-19 pandemic on incidence, time of diagnosis and delivery of healthcare among paediatric oncology patients in Germany in 2020., Methods: We analysed incident paediatric cancer cases diagnosed in 0- to 17-year olds in Germany in 2020 using data of the German Childhood Cancer Registry. Absolute numbers and age-standardised incidence rates (ASR) in 2020 were compared to the previous five years (2015-2019). Moreover, we conducted a survey with open-ended questions, gathering perceptions of the diagnostic process and healthcare delivery for paediatric oncology patients during the COVID-19 pandemic., Findings: More or similar numbers of paediatric cancer patients were newly diagnosed each month throughout 2020 in comparison to the previous five years. The estimated ASRs showed markedly higher incidence rates, overall and across diagnostic groups, in 2020 compared to 2015-2019. Results from the qualitative survey indicated that diagnostic processes, timeliness of diagnosis, and delivery of treatment were hardly affected during the COVID-19 pandemic. However, psychosocial supportive care and non-urgent appointments were considerably reduced during the lockdown periods., Interpretation: We found no indications of severe adverse effects of the COVID-19 pandemic on diagnosis and delivery of healthcare among children with cancer in Germany. The underlying reasons of the increase in incidence rates remain speculative. Continued close monitoring of incidence patterns may shed light on the underlying reasons of the present increase and contribute to understanding disease aetiology., Funding: None., Competing Interests: The authors declare that the research was conducted in the absence of any commercial, personal or financial relationships with other people or organisations that could be construed as a potential conflict of interest., (© 2021 The Authors.)

Chronic rhinosinusitis (CRS) is a characteristic feature of cystic fibrosis (CF) multiorgan disease and develops early in the life of patients with CF. The study aimed to correlate the inflammatory markers and the presence of structural abnormalities detected by MRI in the paranasal sinuses of patients with CF. Methods: Nasal lavage and MRI of the paranasal sinuses was performed in a cohort of 30 CF patients (median age 14 y; range 7-20 y). Morphological abnormalities characteristic of CF were evaluated with a dedicated CRS MRI scoring system and correlated with different inflammation parameters measured in nasal lavage. Inflammation of the paranasal sinuses was positively associated with structural abnormalities in MRI. The concentration of the pro-inflammatory markers neutrophil elastase (NE) and the neutrophil elastase/alpha1-antitrypsin (NE/A1AT) complex correlated significantly with CRS-MRI sum score ( p < 0.05, r = 0.416 and p < 0.05, r = 0.366, respectively). S. aureus infection was associated with the increased pro-inflammatory cytokine activity of IL-6 and IL-8, and increased levels of NE/A1AT complex in our patients ( p < 0.05, respectively). CRS-MRI sum score and individual sinus MRI scores were positively associated with inflammatory activity as a sign of CRS pathology present in CF.

Background: Despite a widely acknowledged increase in older people presenting with traumatic injury in western populations there remains a lack of research into the optimal prehospital management of this vulnerable patient group. Research into this cohort faces many uniqu1e challenges, such as inconsistent definitions, variable physiology, non-linear presentation and multi-morbidity. This scoping review sought to summarise the main challenges in providing prehospital care to older trauma patients to improve the care for this vulnerable group., Methods and Findings: A scoping review was performed searching Google Scholar, PubMed and Medline from 2000 until 2020 for literature in English addressing the management of older trauma patients in both the prehospital arena and Emergency Department. A thematic analysis and narrative synthesis was conducted on the included 131 studies. Age-threshold was confirmed by a descriptive analysis from all included studies. The majority of the studies assessed triage and found that recognition and undertriage presented a significant challenge, with adverse effects on mortality. We identified six key challenges in the prehospital field that were summarised in this review., Conclusions: Trauma in older people is common and challenges prehospital care providers in numerous ways that are difficult to address. Undertriage and the potential for age bias remain prevalent. In this Scoping Review, we identified and discussed six major challenges that are unique to the prehospital environment. More high-quality evidence is needed to investigate this issue further., (© 2021. The Author(s).)

The field of sexual homicide research is relatively recent, with many existing studies limited by small sample sizes and sampling bias. In Australia and New Zealand specifically, only one study to date addresses this phenomenon but there is a lack of comprehensive descriptive data. This study aims to fill this research gap using a representative sample gathered from public legal databases. A total of 118 cases of sexual homicide offenders are described to create a portrait of this type of offender, their victims and their offence behaviour. Findings are similar to those found in other large samples from the UK, Canada and Germany. Because this crime is rare and practitioners tend to have limited experience of them, the findings of this research have the potential to inform investigative, criminal justice and clinical practice., (© 2021 The Australian and New Zealand Association of Psychiatry, Psychology and Law.)

The urgency of the climate and sustainability crises and their health effects are receiving increasing attention in the German health system. To avoid further exacerbation of these crises, profound transformative processes in all sectors of society are needed (e.g. transport, energy production, and food systems). Based on the ethical imperative of non-maleficence and the high levels of trust in society, health professionals have great potential to make an important contribution to the necessary transformative processes.In order to fully harness this potential, health professionals should be supported in developing competencies to take transformative action during their pre- and postgraduate education and professional training. In this article, we introduce the concept of planetary health, as this concept provides orientation for this both ethically and with regards to the subject matter. Furthermore, we provide an overview of current teaching and learning formats and identify aspects that could contribute to further developing planetary health education.

Objective: To develop parsimonious German scales (CollaboRATE pediatric ) to assess shared decision making (SDM) with patients aged 7-18 years, parents and parents on behalf of their children (parent-proxy reports), and to establish comprehensibility and preliminary face validity., Methods: Based on an existing SDM scale for adults (CollaboRATE) we developed CollaboRATE pediatric in a two-step approach: (1) team-based translation of the English CollaboRATE scale into German and adaptation for pediatric patients, parents and parent-proxy reports, followed by (2) iterative revisions of the CollaboRATE pediatric scales based on cognitive interviews with patients and parents until comprehensibility and preliminary face validity were established., Results: Taking into account seven problem areas identified in four rounds of cognitive interviews (e.g., item complexity) we developed CollaboRATE pediatric scales for patients, parents and parent-proxy reports. By iteratively revising items we were able to resolve all problem areas and achieved full comprehensibility and intended interpretation of all items., Conclusion: The scales enable the parsimonious assessment of SDM with pediatric patients and parents as well as comparisons between the two groups. Future empirical work will establish the psychometric performance of CollaboRATE pediatric ., Practice Implications: CollaboRATE pediatric can be used in quality improvement initiatives to foster the comprehensive implementation of SDM in pediatrics., Competing Interests: Declaration of Competing Interest The authors reported no declarations of interest., (Copyright © 2020. Published by Elsevier B.V.)

Objective: Evaluation of software tools for segmentation, quantification, and characterization of fibrotic pulmonary parenchyma changes will strengthen the role of CT as biomarkers of disease extent, evolution, and response to therapy in idiopathic pulmonary fibrosis (IPF) patients., Methods: 418 nonenhanced thin-section MDCTs of 127 IPF patients and 78 MDCTs of 78 healthy individuals were analyzed through 3 fully automated, completely different software tools: YACTA, LUFIT, and IMBIO. The agreement between YACTA and LUFIT on segmented lung volume and 80th (reflecting fibrosis) and 40th (reflecting ground-glass opacity) percentile of the lung density histogram was analyzed using Bland-Altman plots. The fibrosis and ground-glass opacity segmented by IMBIO (lung texture analysis software tool) were included in specific regression analyses., Results: In the IPF-group, LUFIT outperformed YACTA by segmenting more lung volume (mean difference 242 mL, 95% limits of agreement -54 to 539 mL), as well as quantifying higher 80th (76 HU, -6 to 158 HU) and 40th percentiles (9 HU, -73 to 90 HU). No relevant differences were revealed in the control group. The 80th/40th percentile as quantified by LUFIT correlated positively with the percentage of fibrosis/ground-glass opacity calculated by IMBIO (r = 0.78/r = 0.92)., Conclusions: In terms of segmentation of pulmonary fibrosis, LUFIT as a shape model-based segmentation software tool is superior to the threshold-based YACTA, tool, since the density of (severe) fibrosis is similar to that of the surrounding soft tissues. Therefore, shape modeling as used in LUFIT may serve as a valid tool in the quantification of IPF, since this mainly affects the subpleural space., (© 2021 S. Karger AG, Basel.)

Objectives: Assessment of patients' wellbeing in the post anaesthesia care unit and how much each disturbance influences it. Furthermore, assessment of the incidence of the correlated disturbances and whether there are gender-specific aspects., Design/setting: Observational anonymised survey with a validated questionnaire in a university hospital in central Europe., Main Outcome Measures: Incidence rates of wellbeing and disturbances in the post anaesthesia care unit., Results: The patients' most frequently reported early postsurgical disturbances (n = 349) were i) dry mouth (35.4%), ii) pain in the surgical area (12.7%) and iii) hunger (12.2%). Every other disturbance was below 10% (e.g. nausea). Subjective wellbeing was reported by 57.2% of our patients. There were weak correlations between wellbeing and physical discomfort, pain in the surgical area, sleepiness and nausea. The strongest correlation was with physical discomfort. Female patients showed more feelings of cold, nausea and headache., Conclusion: Even in hospitals repeatedly certified in pain management, a high percentage of patients still claim early postoperative discomfort. We see the necessity for an increased focus on this topic and the need for investigations regarding patients' perception. The most frequent claims were related to pain in the surgical area and a dry mouth., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objective: All arthroscopic treatment of deep cartilage defects in the knee for reconstruction of the articular surface., Indications: Focal cartilage defects of the knee (ICRS ≥ grade 3) from a size of 2.5 cm 2 and more., Contraindications: Osteoarthritis (Kellgren-Lawrence > grade 2), osseus defect situation, cartilage lesion of the opposing articular surfaces (ICRS > grade 2), instability, malalignment (>3-4°), inflammatory joint diseases., Surgical Technique: First procedure (cell harvesting): Treatment of additional pathologies, preparation of the cartilage defect, harvesting of osteochondral cylinders for cell culture. Second procedure (cell implantation): Dry arthroscopy, cleaning and drying of the already prepared defect, implantation of the in situ crosslinking cartilage cell suspension., Postoperative Management: First procedure (cell harvesting): Early functional treatment with weight bearing as tolerated. Second procedure (cell implantation): No drains, extension brace for 4 days, then free range of motion, partial weight bearing for 4 weeks in patellofemoral implantation and for 8 weeks in tibiofemoral implantation, continuous passive motion beginning in postoperative week 2, cycling from postoperative week 9., Results: In the literature, results for ACI in the knee are reported to be good, especially for larger cartilage defects. Arthroscopic techniques should lead to a decrease of complications and perioperative morbidity. No technique-specific complications occurred in our cohort. From 2012-2015, 98 patients were treated using the above mentioned technique, whereby 62 patients were retrospectively evaluated after 31.0 ± 14.8 (12.5-61.4) months. In 15 patients (28%) additional procedures were performed (7 anterior cruciate ligament reconstructions, 3 correction osteotomies and 5 medial patellofemoral ligament reconstructions). Average cartilage defect size was 4.7 ± 2.8 cm 2 , in 18 patients (29%) more than one cartilage defect was treated. The subjective IKDC and total KOOS scores resulted in 66 ± 10 and 73 ± 19 points.

Background: Noninvasive monitoring of early abnormalities and therapeutic intervention in cystic fibrosis (CF) lung disease using MRI is important. Lung T 1 mapping has shown potential for local functional imaging without contrast material. Recently, it was discovered that observed lung T 1 depends on the measurement echo time (TE)., Purpose: To examine TE-dependence of observed T 1 in patients with CF and its correlation with clinical metrics., Study Type: Prospective., Population: In all, 75 pediatric patients with CF (8.6 ± 6.1 years, range 0.1-23 years), with 32 reexamined after 1 year., Field Strength/sequence: Patients were examined at 1.5T using an established MRI protocol and a multiecho inversion recovery 2D ultrashort echo time (UTE) sequence for T 1 (TE) mapping at five TEs including TE 1 = 70 μs., Assessment: Morphological and perfusion MRI were assessed by a radiologist (M.W.) with 11 years of experience using an established CF-MRI scoring system. T 1 (TE) was quantified automatically. Clinical data including spirometry (FEV1pred%) and lung clearance index (LCI) were collected., Statistical Tests: T 1 (TE) was correlated with the CF-MRI score, clinical data, and LCI., Results: T 1 (TE) showed a different curvature in CF than in healthy adults: T 1 at TE 1 was shorter in CF (1157 ms ± 73 ms vs. 1047 ms ± 70 ms, P < 0.001), but longer at TE 3 (1214 ms ± 72 ms vs. 1314 ms ± 68 ms, P < 0.001) and later TEs. The correlations of T 1 (TE) with patient age (ρ TE1-TE5 = -0.55, -0.44, -0.24, -0.30, -0.22), and LCI (ρ TE1-TE5 = -0.43, -0.42, -0.33, 0.27, -0.22) were moderate at ultra-short to short TE (P < 0.001) but decreased for longer TE. Moderate but similar correlations at all TE were found with MRI perfusion score (ρ TE1-TE5 = -0.43, -0.51, -0.47, -0.46, -0.44) and FEV1pred% (ρ TE1-TE5 = +0.44, +0.44, +0.43, +0.40, +0.39) (P < 0.05)., Data Conclusion: TE should be considered when measuring lung T 1 , since observed differences between CF and healthy subjects strongly depend on TE. The different variation of correlation coefficients with TE for structural vs. functional metrics implies that TE-dependence holds additional information which may help to discern effects of tissue structural abnormalities and abnormal perfusion., Level of Evidence: 2 TECHNICAL EFFICACY STAGE: 1 J. MAGN. RESON. IMAGING 2020;52:1645-1654., (© 2020 The Authors. Journal of Magnetic Resonance Imaging published by Wiley Periodicals LLC on behalf of International Society for Magnetic Resonance in Medicine.)

Aims: Non-small-cell lung cancer (NSCLC) and breast cancer are common entities. Staining for oestrogen receptor (ER), progesterone receptor (PgR), mammaglobin (MAMG) and GATA-binding protein 3 (GATA3) is frequently performed to confirm a mammary origin in the appropriate diagnostic setting. However, comprehensive data on the immunohistological expression of these markers in NSCLC are limited. Therefore, the aim of this study was to analyse a large cohort of NSCLCs and correlate the staining results with clinicopathological variables., Methods and Results: A tissue microarray was stained for ER, PgR, MAMG, human epidermal growth factor receptor 2 (HER2), and GATA3, and included 636 adenocarcinomas (ADCs), 536 squamous cell carcinomas (SqCCs), 65 large-cell-carcinomas, 34 pleomorphic carcinomas, and 20 large-cell neuroendocrine carcinomas. HER2 status was determined for immunohistochemically positive cases with chromogenic in-situ hybridisation. Markers with a proportion of ≥5% positive cases in ADC and SqCC were considered for survival analysis. Among ADCs, 62 (10%), 17 (3%), one (<1%), seven (1%), and 49 (8%) cases were positive for ER, PgR, MAMG, HER2, and GATA3, respectively. Among SqCCs, 10 (2%), 14 (3%), two (<1%) and 109 (20%) cases were positive for ER, PgR, HER2, and GATA3, but none of the samples showed positivity for MAMG. ER positivity was associated with ADC, female sex, smaller tumour size, and lower clinical stage. None of the markers had an impact on survival., Conclusion: We report on ER, PgR, MAMG, HER2 and GATA3 expression in a large cohort of NSCLCs. Interpretation of these markers in the differential diagnostic setting should be based on a multimarker panel., (© 2020 The Authors. Histopathology published by John Wiley & Sons Ltd.)