Observation of the effect of gravity on the motion of antimatter

Einstein's general theory of relativity from 19151 remains the most successful description of gravitation. From the 1919 solar eclipse2 to the observation of gravitational waves3, the theory has passed many crucial experimental tests. However, the evolving concepts of dark matter and dark energy illustrate that there is much to be learned about the gravitating content of the universe. Singularities in the general theory of relativity and the lack of a quantum theory of gravity suggest that our picture is incomplete. It is thus prudent to explore gravity in exotic physical systems. Antimatter was unknown to Einstein in 1915. Dirac's theory4 appeared in 1928; the positron was observed5 in 1932. There has since been much speculation about gravity and antimatter. The theoretical consensus is that any laboratory mass must be attracted6 by the Earth, although some authors have considered the cosmological consequences if antimatter should be repelled by matter7-10. In the general theory of relativity, the weak equivalence principle (WEP) requires that all masses react identically to gravity, independent of their internal structure. Here we show that antihydrogen atoms, released from magnetic confinement in the ALPHA-g apparatus, behave in a way consistent with gravitational attraction to the Earth. Repulsive 'antigravity' is ruled out in this case. This experiment paves the way for precision studies of the magnitude of the gravitational acceleration between anti-atoms and the Earth to test the WEP.

Measurement of the ν_{e}-Nucleus Charged-Current Double-Differential Cross Section at ⟨E_{ν}⟩=2.4 GeV Using NOvA

The inclusive electron neutrino charged-current cross section is measured in the NOvA near detector using 8.02×10^{20} protons-on-target in the NuMI beam. The sample of GeV electron neutrino interactions is the largest analyzed to date and is limited by ≃17% systematic rather than the ≃7.4% statistical uncertainties. The double-differential cross section in final-state electron energy and angle is presented for the first time, together with the single-differential dependence on Q^{2} (squared four-momentum transfer) and energy, in the range 1  GeV≤E_{ν}<6  GeV. Detailed comparisons are made to the predictions of the GENIE, GiBUU, NEUT, and NuWro neutrino event generators. The data do not strongly favor a model over the others consistently across all three cross sections measured, though some models have especially good or poor agreement in the single differential cross section vs Q^{2}.

Role of estrogen in women's Alzheimer's disease risk as modified by APOE

Alzheimer's disease (AD) is characterized by numerous sexual dimorphisms that impact the development, progression, and probably the strategies to prevent and treat the most common form of dementia. In this review, we consider this topic from a female perspective with a specific focus on how women's vulnerability to the disease is affected by the individual and interactive effects of estrogens and apolipoprotein E (APOE) genotype. Importantly, APOE appears to modulate systemic and neural outcomes of both menopause and estrogen-based hormone therapy. In the brain, dementia risk is greater in APOE4 carriers, and the impacts of hormone therapy on cognitive decline and dementia risk vary according to both outcome measure and APOE genotype. Beyond the CNS, estrogen and APOE genotype affect vulnerability to menopause-associated bone loss, dyslipidemia and cardiovascular disease risk. An emerging concept that may link these relationships is the possibility that the effects of APOE in women interact with estrogen status by mechanisms that may include modulation of estrogen responsiveness. This review highlights the need to consider the key AD risk factors of advancing age in a sex-specific manner to optimize development of therapeutic approaches for AD, a view aligned with the principle of personalized medicine.

Investigating how researcher-defined buffers and self-drawn neighbourhoods capture adolescent availability to physical activity facilities and greenspaces: An exploratory study

BACKGROUND

Modifying the environment is considered an effective population-level approach for increasing healthy behaviours, but associations remain ambiguous. This exploratory study aims to compare researcher-defined buffers and self-drawn neighbourhoods (SDN) to objectively measured availability of physical activity (PA) facilities and greenspaces in adolescents.

METHODS

Seven consecutive days of GPS data were collected in an adolescent sample of 14-18 year olds (n = 69). Using Points of Interest and greenspace data, availability of PA opportunities within activity spaces were determined. We compared 30 different definitions of researcher-defined neighbourhoods and SDNs to objectively measured availability.

RESULTS

Findings showed low agreement for all researcher-defined buffers in measuring the availability of PA facilities in activity spaces. However, results were less clear for greenspace. SDNs also demonstrate low agreement for capturing availability to the PA environment.

CONCLUSION

This exploratory study highlights the inadequacy of researcher-defined buffers and SDNs to define availability to environmental features.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

CHALLENGE and Face Your Fears: Virtual Reality Treatment for Auditory Hallucinations and Paranoid Ideations

Background: Many patients suffering from schizophrenia spectrum disorders continue having distressing auditory hallucinations and paranoid ideations despite receiving current treatment. Virtual reality assisted treatment offers the potential of advancing current psychotherapies for psychotic symptoms by creating virtual environments that can elicit responses (e.g. thoughts, feelings, behaviours) mirroring real-world settings. In two large-scale randomised clinical trials, we are investigating whether targeted virtual reality assisted psychotherapy can reduce psychotic symptoms and increase daily life functioning and quality of life. The CHALLENGE trial examines whether nine sessions of virtual reality-assisted psychotherapy is superior to nine sessions of standard treatments in reducing the severity, frequency, and distress of auditory hallucinations in patients with psychosis. In the Face your Fears trial we are investigating whether virtual reality assisted cognitive behavioral therapy (CBT) is superior to standard CBT in reducing levels of paranoid ideation in patients with psychosis spectrum disorders. Methods: The CHALLENGE and Face your Fears trials are randomised, assessor-blinded parallel-groups superiority clinical trials, allocating a total of 266 and 256 patients, respectively to either the experimental intervention or a control condition. The trials are currently enrolling patients; thus, no quantitative data is available yet. The main objective of this presentation is to give a qualitative account of this new psychotherapeutic methods as it is applied in both trials. Results: Qualitative data comprising case descriptions and video material will be presented at the conference. Discussion: The preliminary findings indicate great potential for these innovative treatments albeit important concerns regarding implementation will be raised.

Search for Active-Sterile Antineutrino Mixing Using Neutral-Current Interactions with the NOvA Experiment

This Letter reports results from the first long-baseline search for sterile antineutrinos mixing in an accelerator-based antineutrino-dominated beam. The rate of neutral-current interactions in the two NOvA detectors, at distances of 1 and 810 km from the beam source, is analyzed using an exposure of 12.51×10^{20} protons-on-target from the NuMI beam at Fermilab running in antineutrino mode. A total of 121 of neutral-current candidates are observed at the far detector, compared to a prediction of 122±11(stat.)±15(syst.) assuming mixing only between three active flavors. No evidence for ν[over ¯]_{μ}→ν[over ¯]_{s} oscillation is observed. Interpreting this result within a 3+1 model, constraints are placed on the mixing angles θ_{24}<25° and θ_{34}<32° at the 90% C.L. for 0.05  eV^{2}≤Δm_{41}^{2}≤0.5  eV^{2}, the range of mass splittings that produces no significant oscillations at the near detector. These are the first 3+1 confidence limits set using long-baseline accelerator antineutrinos.

Digitally designed, personalized bone cement spacer for staged TMJ and mandibular reconstruction - Introduction of a new technique

The aim of this paper is to introduce an innovative workflow for staged reconstruction of the mandible, including the temporomandibular joint (TMJ), using a temporary, patient-specific spacer. In cases of partial mandibular resection including disarticulation, sometimes needed to treat inflammatory bone disease, the spacer is intended to retain symmetry of the hard tissues, to preserve the soft tissues, and to act as a bactericidal agent. When complete healing of the affected surrounding tissues has occurred, final reconstruction using a patient-matched total TMJ endoprosthesis, in combination with an autogenous free bone flap, can be performed as a second-stage procedure. The crucial steps of the workflow are virtual surgical planning, manufacturing of a two-part silicone mold, and chairside manufacturing of the spacer using an established bone cement with gentamycin. The method was first introduced in two patients suffering from therapy-resistant chronic osteomyelitis. The presented protocol of staged surgery allows a much safer and predictable reconstruction compared with immediate reconstruction. The workflow also minimizes the potential risk of endoprosthesis infection - one of the major risks of implant failure.

Accuracy of buffers and self-drawn neighbourhoods in representing adolescent GPS measured activity spaces: An exploratory study

BACKGROUND

There continues to be a lack of understanding as to the geographical area at which the environment exerts influence on behaviour and health. This exploratory study compares different potential methods of both researcher- and participant-defined definitions of neighbourhood reflect an adolescent's activity space.

METHODS

Seven consecutive days of global positioning system (GPS) tracking data were collected at 15 s intervals using a small exploratory adolescent sample of 14-18 year olds (n = 69) in West Yorkshire, England. A total of 304,581 GPS tracking points were collected and compared 30 different definitions of researcher-defined neighbourhoods including radial, network and ellipse buffers at 400 m, 800 m, 1000 m, 1600 m and 3000 m, as well as participant-defined self-drawn neighbourhoods.

RESULTS

This exploratory study supports emerging evidence cautioning against the use of static neighbourhood definitions for defining exposure. Traditional buffers (network and radial) capture at most 67% of activity space (home radial), and at worst they captured only 3.5% (school network) and range from capturing between 3 and 88% of total time. Similarly, self-drawn neighbourhoods captured only 10% of actual daily movement. Interestingly, 40% of an adolescent's self-drawn neighbourhood was not used. We also demonstrate that buffers capture a range of space (22-95%) where adolescents do not go, thus misclassifying the exposure.

CONCLUSION

Our exploratory findings demonstrate that neither researcher- nor participant-defined definition of neighbourhood adequately captures adolescent activity space. Further research with larger samples are needed to confirm the findings of this exploratory study.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Laser cooling of antihydrogen atoms

The photon-the quantum excitation of the electromagnetic field-is massless but carries momentum. A photon can therefore exert a force on an object upon collision1. Slowing the translational motion of atoms and ions by application of such a force2,3, known as laser cooling, was first demonstrated 40 years ago4,5. It revolutionized atomic physics over the following decades6-8, and it is now a workhorse in many fields, including studies on quantum degenerate gases, quantum information, atomic clocks and tests of fundamental physics. However, this technique has not yet been applied to antimatter. Here we demonstrate laser cooling of antihydrogen9, the antimatter atom consisting of an antiproton and a positron. By exciting the 1S-2P transition in antihydrogen with pulsed, narrow-linewidth, Lyman-α laser radiation10,11, we Doppler-cool a sample of magnetically trapped antihydrogen. Although we apply laser cooling in only one dimension, the trap couples the longitudinal and transverse motions of the anti-atoms, leading to cooling in all three dimensions. We observe a reduction in the median transverse energy by more than an order of magnitude-with a substantial fraction of the anti-atoms attaining submicroelectronvolt transverse kinetic energies. We also report the observation of the laser-driven 1S-2S transition in samples of laser-cooled antihydrogen atoms. The observed spectral line is approximately four times narrower than that obtained without laser cooling. The demonstration of laser cooling and its immediate application has far-reaching implications for antimatter studies. A more localized, denser and colder sample of antihydrogen will drastically improve spectroscopic11-13 and gravitational14 studies of antihydrogen in ongoing experiments. Furthermore, the demonstrated ability to manipulate the motion of antimatter atoms by laser light will potentially provide ground-breaking opportunities for future experiments, such as anti-atomic fountains, anti-atom interferometry and the creation of antimatter molecules.

Implementation fidelity of an Integrated Healthy Lifestyle Service: a process evaluation

Aims:

The current study aimed to evaluate implementation fidelity of an Integrated Healthy Lifestyle Service (IHLS).

Methods:

A pragmatic sample of 28 individual interviews and 11 focus groups were conducted. This resulted in a total of 81 (22 male) individuals comprising key stakeholders (n = 18), as well as intervention staff across senior management (n = 4), team lead (n = 14) and practitioner (n = 11) roles, and intervention clients (n = 34).

Results:

A mixed degree of implementation fidelity was demonstrated throughout the five a priori fidelity domains of study design, provider training, intervention delivery, intervention receipt, and enactment. Stakeholders, staff and clients alike noted a high degree of intervention receipt across all services offered. Contrastingly, practitioners noted that they received minimal formal operational, data systems, clinical, and curriculum training as well as a lack of personal development opportunities. Consequently, practitioners reported low confidence in delivering sessions and collecting and analysing any data. A top-down approach to information dissemination within the service was also noted among practitioners which affected motivation and overall team morale.

Conclusion:

Results can be used to conceptualise best practices as a process to further strengthen the design, delivery and recruitment strategies of the IHLS.

Natural history of the electrical axis during the first four weeks of life

Background

The QRS axis represents the sum of the amplitudes and orientation of the ventricular depolarization. In newborns, the QRS axis is generally directed downward and to the right and left axis deviation (LAD) may be associated with heart disease. Accurate interpretation of abnormalities in the QRS axis may facilitate early diagnosis of heart diseases in newborns.

Purpose

To describe the evolution of the QRS axis during the first four weeks of life and provide updated, digitalized, normal values from healthy newborns.

Methods

Electrocardiograms from 12,317 newborns (age 0–28 days) included in a regional, prospective, general population study from 2016–2018 were analyzed. Electrocardiograms were obtained and analyzed with a computerized algorithm with manual validation. The algorithm calculated the QRS mean axis using the net amplitudes of three leads I, II, and III. The four main QRS axis classifications were: “adult normal” axis (+1° to +90°), left axis deviation (LAD, 0° to −90°), right axis deviation (RAD, +91° to +180°), and extreme axis deviation (EAD, +181° to +270°). Echocardiograms were performed according to standard guidelines. Only newborns with an echocardiography excluding structural heart disease were included.

Results

Electrocardiograms from 12,317 newborns with a median age at examination of 12 days (52% boys) were included. The median QRS axis was 119° at the ages 0–7 days and shifted leftwards to 102° at the ages 22–28 days (p&lt;0.001). We found that girls had significant less pronounced right axis deviation than boys (111° vs 117°, p&lt;0.001) and that increasing gestational age was associated with more pronounced right axis deviation (104° vs 116°, p&lt;0.05). Infant size did not affect the axis (p&gt;0.05). Only 0.5% had LAD (0° to −90°) and 1.1% had an axis within the interval +240° to +30° indicating that a QRS axis in this expanded interval is unusual in healthy newborns.

Conclusion

The QRS axis showed a gradual leftward-shift during the first four weeks of life and was affected by sex and gestation age but unaffected by infant size. LAD occurred in only 0.5% of the newborns. Our data serve as updated reference values, which may facilitate clinical handling of newborns.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): This work was supported by the Danish Children Heart Foundation, Snedkermester Sophus Jacobsen and wife Astrid Jacobsen's foundation (Grant 19-R112-A5248-26048), the Research Council at Herlev-Gentofte Hospital and Toyota-Fonden, Denmark.

Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: adult cardiac conditions

BACKGROUND

Medical 3D printing as a component of care for adults with cardiovascular diseases has expanded dramatically. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness criteria for adult cardiac 3D printing indications.

METHODS

A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with a number of adult cardiac indications, physiologic, and pathologic processes. Each study was vetted by the authors and graded according to published guidelines.

RESULTS

Evidence-based appropriateness guidelines are provided for the following areas in adult cardiac care; cardiac fundamentals, perioperative and intraoperative care, coronary disease and ischemic heart disease, complications of myocardial infarction, valve disease, cardiac arrhythmias, cardiac neoplasm, cardiac transplant and mechanical circulatory support, heart failure, preventative cardiology, cardiac and pericardial disease and cardiac trauma.

CONCLUSIONS

Adoption of common clinical standards regarding appropriate use, information and material management, and quality control are needed to ensure the greatest possible clinical benefit from 3D printing. This consensus guideline document, created by the members of the RSNA 3D printing Special Interest Group, will provide a reference for clinical standards of 3D printing for adult cardiac indications.

OP0064 AUTOMATIC SCORING OF ARTHRITIS DISEASE ACTIVITY ON ULTRASOUND IMAGES FROM RHEUMATOID ARTHRITIS PATIENTS WITH CASCADED CONVOLUTIONAL NEURAL NETWORKS

Background:

Systematic Power or Color Doppler (CD) ultrasound (US) of joints can be used for early detection of Rheumatoid Arthritis (RA), predicting radiographic progression and early detection of disease flare in established RA [1, 2]. The international standard for performing RA US scanning and evaluation of disease activity is the OMERACT-ELUAR Synovitis Scoring (OESS) system [1, 3].

To further mitigate the operator-dependency in scoring disease activity on CD US images in future trials and clinical practice, we proposed the use of convolutional neural networks (CNN) to automatically grade CD US images according to the OESS definitions. This study is a continuation of the findings in our previous work, where we developed a CNN for four-class CD US OESS scoring with a test accuracy of 75.0% [4].

Objectives:

Since our last contribution, we have further developed the architecture of this neural network and can here present a new idea applying a Cascaded Convolutional Neural Network design. We evaluate the generalizability of this method on unseen data, comparing the CNN with an expert rheumatologist.

Methods:

The images used for developing the algorithms were graded by a single expert rheumatologist according to the OESS system. The CNNs in the cascade were trained individually, after which they were combined to form the cascade model as shown in figure 1. The algorithms were evaluated on a separate test dataset, which came from the same distribution as the training dataset. The algorithms were compared to the gradings of an expert rheumatologist on a per-joint basis using a Kappa test, and on a per-patient basis using a Wilcoxon Signed Rank test.

Figure 1.

CNN-1 is the first CNN in the model and distinguishes between RA disease grade (DG) 0 and DG’s 1, 2 and 3. CNN-2 is the second CNN and distinguishes between DG 1 and DG’s 2 and 3. CNN-3 is the final CNN which distinguishes between DG’s 2 and 3.

Results:

With 1678 images available for training and 322 images for testing the model, the model achieved an overall 4-class accuracy of 83.9%. On a per-patient level, there was no significant difference between the classifications of the model and of a human expert (p=0.85).

Conclusion:

We have shown that dividing a four-degree classification task into three successive binary classification tasks has resulted in a model capable of making correct classifications in 83.9% of the cases for a test set of ultrasound images with a naturally occurring distribution of RA joint disease activity scores.

Furthermore, we have shown that the cascade model can produce classification decisions comparable with a human rheumatologist when applied on a per-patient basis. This emphasizes the potential of using CNNs with this architecture as a strong assistive tool for the objective assessment of disease activity of RA patients.

References:

[1]D’Agostino M-A, Terslev L, Aegerter P, et al. (2017). Scoring ultrasound synovitis in rheumatoid arthritis: a OMERACT-EULAR ultrasound taskforce-Part 1: definition and development of a standardised, consensus-based scoring system. RMD Open.

[2]Paulshus NS, Aga A-B, Olsen I, et al. (2018). Clinical and ultrasound remission after 6 months of treat-to-target therapy in early rheumatoid arthritis: associations to future good radiographic and physical outcomes. Ann Rheum Dis, 77, s. 1425-25.

[3]Terslev L, Naredo E, Aegerter P, et al. (3 2017). Scoring ultrasound synovitis in rheumatoid arthritis: a OMERACT-EULAR ultrasound taskforce-Part 2: reliability and application to multiple joints of a standardised consensus-based scoring system. RMD Open.

[4]Andersen JKH, Pedersen JS, Laursen MS, et al. Neural networks for automatic scoring of arthritis disease activity on ultrasound images. RMD Open 2019; 5:e000891. doi:10.1136/ rmdopen-2018-000891

Disclosure of Interests:

None declared

Applying Modern Virtual and Augmented Reality Technologies to Medical Images and Models

Recent technological innovations have created new opportunities for the increased adoption of virtual reality (VR) and augmented reality (AR) applications in medicine. While medical applications of VR have historically seen greater adoption from patient-as-user applications, the new era of VR/AR technology has created the conditions for wider adoption of clinician-as-user applications. Historically, adoption to clinical use has been limited in part by the ability of the technology to achieve a sufficient quality of experience. This article reviews the definitions of virtual and augmented reality and briefly covers the history of their development. Currently available options for consumer-level virtual and augmented reality systems are presented, along with a discussion of technical considerations for their adoption in the clinical environment. Finally, a brief review of the literature of medical VR/AR applications is presented prior to introducing a comprehensive conceptual framework for the viewing and manipulation of medical images in virtual and augmented reality. Using this framework, we outline considerations for placing these methods directly into a radiology-based workflow and show how it can be applied to a variety of clinical scenarios.

Radiological Society of North America (RSNA) 3D printing Special Interest Group (SIG): guidelines for medical 3D printing and appropriateness for clinical scenarios

Medical three-dimensional (3D) printing has expanded dramatically over the past three decades with growth in both facility adoption and the variety of medical applications. Consideration for each step required to create accurate 3D printed models from medical imaging data impacts patient care and management. In this paper, a writing group representing the Radiological Society of North America Special Interest Group on 3D Printing (SIG) provides recommendations that have been vetted and voted on by the SIG active membership. This body of work includes appropriate clinical use of anatomic models 3D printed for diagnostic use in the care of patients with specific medical conditions. The recommendations provide guidance for approaches and tools in medical 3D printing, from image acquisition, segmentation of the desired anatomy intended for 3D printing, creation of a 3D-printable model, and post-processing of 3D printed anatomic models for patient care.

Fast-food outlet availability and obesity: Considering variation by age and methodological diversity in 22,889 Yorkshire Health Study participants

This study investigated if the relationship between residential fast-food outlet availability and obesity varied due to methodological diversity or by age. Cross-sectional data (n = 22,889) from the Yorkshire Health Study, England were used. Obesity was defined using self-reported height and weight (BMI ≥ 30). Food outlets ("fast-food", "large supermarkets", and "convenience or other food retail outlets") were mapped using Ordnance Survey Points of Interest (PoI) database. Logistic regression was used for all analyses. Methodological diversity included adjustment for other food outlets as covariates and continuous count vs. quartile. The association between residential fast-food outlets and obesity was inconsistent and effects remained substantively the same when considering methodological diversity. This study contributes to evidence by proposing the use of a more comprehensive conceptual model adjusting for wider markers of the food environment. This study offers tentative evidence that the association between fast-food outlets and obesity varies by age.

Leptomeningeal collateral status predicts outcome after middle cerebral artery occlusion

OBJECTIVES

Perfusion through leptomeningeal collateral vessels is a likely pivotal factor in the outcome of stroke patients. We aimed to investigate the effect of collateral status on outcome in a cohort of unselected, consecutive stroke patients with middle cerebral artery occlusion undergoing reperfusion therapy.

MATERIALS AND METHODS

This retrospectively planned analysis was passed on prospectively collected data from 187 consecutive patients with middle cerebral artery occlusion admitted within 4.5 hours to one center and treated with intravenous thrombolysis alone (N = 126), mechanical thrombectomy alone (N = 5), or both (N = 56) from May 2009 to April 2014. Non-contrast CT (NCCT) and computed tomography angiography (CTA) were provided on admission and NCCT repeated at 24 hours. Collateral status was assessed based on the initial CTA. Hemorrhagic transformation was evaluated on the 24-hour NCCT and according to European Cooperative Acute Stroke Study (ECASS) criteria. Modified Rankin Scale score was assessed at 90 days, and mortality at 1 year.

RESULTS

At 90 days, median (IQR) modified Rankin Scale score in patients with poor collateral status was 4 (3-6) compared to 2 (1-4) in patients with good collateral status (P < .0001). Patients with poor collateral status were less likely to achieve a good 90-day outcome (modified Rankin Scale score 0-2) (Adjusted odds ratio 0.27, 95% CI: 0.09-0.86). During the first year, 40.9% of patients with poor collateral status died vs 18.2% of the remaining population (P = .001).

CONCLUSIONS

Leptomeningeal collateral status predicts functional outcome, mortality, and hemorrhagic transformation following middle cerebral artery occlusion.

Preoperative planning and tracheal stent design in thoracic surgery: a primer for the 2017 Radiological Society of North America (RSNA) hands-on course in 3D printing

In this work, we provide specific clinical examples to demonstrate basic practical techniques involved in image segmentation, computer-aided design, and 3D printing. A step-by-step approach using United States Food and Drug Administration cleared software is provided to enhance surgical intervention in a patient with a complex superior sulcus tumor. Furthermore, patient-specific device creation is demonstrated using dedicated computer-aided design software. Relevant anatomy for these tasks is obtained from CT Digital Imaging and Communications in Medicine images, leading to the generation of 3D printable files and delivery of these files to a 3D printer.

Maintaining safety and efficacy for 3D printing in medicine

Background

The increased and accelerating utilization of 3D printing in medicine opens up questions regarding safety and efficacy in the use of medical models. The authors recognize an important shift towards point-of-care manufacturing for medical models in a hospital environment. This change, and the role of the radiologist as a central facilitator of these services, opens discussion about topics ranging from clinical uses to patient safety to regulatory implications.

Results

This project first defines three groups of patients for whom 3D printing positively impacts patient care. The steps needed for each group are described.

Conclusions

We provide our opinions regarding the regulatory role that we feel is most appropriate, balancing safety and efficacy with the autonomy of individuals in the field to make the greatest positive impact on healthcare.

Multidrug-resistant tuberculosis in New South Wales, Australia, 1999-2010: a case series report

SETTING

The emergence of multidrug-resistant tuberculosis (MDR-TB) threatens the ongoing control of tuberculosis (TB). The Australian state of New South Wales (NSW) has low TB and MDR-TB incidence.

OBJECTIVE

To examine the epidemiology and the clinical and public health management of MDR-TB in NSW.

DESIGN

A retrospective case-series analysis of MDR-TB diagnosed in NSW between 1999 and 2010 was undertaken. A standardised questionnaire was used to collect information from the public health surveillance system, medical records and the State Mycobacterium Reference Laboratory about clinical features, drug susceptibility, treatment regimens, hospitalisation, risk factors for tuberculous infection, contact tracing and patient outcomes.

RESULTS

Fifty-five cases of culture-confirmed MDR-TB, including two cases of extensively drug-resistant TB, were diagnosed. All cases were reviewed by an expert management panel. Fifty cases (91%) were foreign-born, and 50 cases (91%) had fully supervised treatment. Of the 55 cases, 46 (84%) successfully completed treatment, 3 (5%) died of TB and 3 (5%) required surgery. No MDR-TB cases were reported among contacts.

CONCLUSION

Using a multidisciplinary, expert guided, case-management approach, the NSW TB Control Program achieved excellent MDR-TB outcomes. The impact of global increases in MDR-TB requires sustained commitment to TB in all settings.

Detection and monitoring of human bocavirus 1 infection by a new rapid antigen test

Clinically relevant diagnosis of human bocavirus 1 (HBoV1) is challenging, as the virus is frequently detected in asymptomatic patients, and cofindings with other respiratory viruses are common. The clinical value of current diagnostic methods, such as PCR, is therefore low, and alternative diagnostic strategies are needed. We describe for the first time the use of an antigen detection assay for the rapid identification of HBoV1 in a paediatric patient with respiratory tract infection symptoms. We estimate the duration of active HBoV1 infection to be 6 days.

SYSTEMIC SCLEROSIS RELATED CALCINOSIS: PATIENTS PROVIDE WHAT SPECIALISTS WANT TO LEARN

BACKGROUND

Calcinosis is a disabling, rarely discussed manifestation of systemic sclerosis (SSc) for which the natural history and management is understood poorly.

OBJECTIVES

To develop a calcinosis specific patient reported outcome measure (PROM) that can be used for future clinical research to test the effects of therapy on scleroderma related calcinosis.

METHODS

Patients were selected for participation by their scleroderma physicians. Four focus groups and individual interviews were recorded and transcribed verbatim. Patients were asked to frame questions to help a physician learn if calcinosis was better, worse or the same. Patient transcripts underwent an iterative inductive process (no preconceived coding, content drives coding and analysis) by at least five independent analysts including at least one research team member with SSc. Concepts were triangulated to identify a comprehensive set of meaningful concepts with occurrence quantified per participant.

RESULTS

Twenty-three patients (22/23 female, 19/23 white, with mean disease duration 14.8 years) consented and were interviewed. Responses included concepts of self-management strategies and recurrent hypotheses relating calcinosis development to trauma, Raynaud's and cold exposure. We identified discrete concepts such as the perceived association between cold exposure, Raynaud's and calcinosis severity. Calcinosis tended to present along with or soon after SSc diagnosis and remained throughout disease duration - though was not yet compared to report of first Raynaud experience.

CONCLUSIONS

Patient observations and self-management behavior provide opportunities for experts to learn from and to preemptively educate physicians and patients. Patients are eager for self-management guidance. These concepts are the groundwork for PROM development. However, patients suggested a composite of scales anchored in pain, size, frequency, number and related impairment may reasonably serve as an interim instrument for SSc calcinosis.

Stroke Severity and Incidence of Acute Large Vessel Occlusions in Patients with Hyper-Acute Cerebral Ischemia: Results from a Prospective Cohort Study Based on CT-Angiography (CTA)

Background

The frequency of acute large vessel occlusions in relation to clinical severity has not yet been established in a comprehensive, consecutive and unselected cohort of patients with hyper-acute cerebral ischemia.

Aim

The aim of this study was to establish the frequency of acute large vessel occlusions and describe the relations to the National Institutes of Health Stroke Scale (NIHSS), lesion site and time from symptom onset in unselected consecutive patients with hyper-acute cerebral ischemia.

Methods

A prospective single hospital registry was based on consecutive unselected patients admitted from July 2009 to December 2011 with symptoms of acute cerebral ischemia within 4·5 h from symptom onset. ICA, M1, M2, ACA, PCA, BA and VA were assed for occlusions. Best NIHSS-cut-off values were calculated based on sensitivity and specificity for detecting any, anterior and posterior occlusions and the effect of time after symptom onset was assessed.

Results

Six hundred thirty-seven patients, with admission NIHSS: 1–42, were included; 183 patients presented with acute vessel occlusions (28·7%) in 15 different combinations of occlusions. The best NIHSS-cut-off for detecting any occlusion was 6. NIHSS is highly depending on lesion site, highest values being observed in relation to combined and M1 occlusions.

Conclusion

Acute vessel occlusions are frequent in unselected patients. Occlusions occurred in all NIHSS score values but a NIHSS cut-off value of 6 most optimally predicted acute vessel occlusion, even though accuracy was low.

Patient-centered primary health care: synergy potential for health systems strengthening

The ultimate goal of government health systems is to provide highly effective equitable services that save lives and reduce morbidity and mortality. The pressure to conform to duplicative global and donor initiatives compounds existing challenges to health systems strengthening such as shortages of human resources for health, weak supply chains, inadequate laboratory services and parallel data management systems. This article illustrates how primary health care, as the point of entry into the health care system for the majority of individuals in sub-Saharan Africa, should be strengthened to ensure that individuals and their communities receive essential, holistic care.

Extraction of social information from gait in schizophrenia

BACKGROUND

The human face and body are rich sources of socio-emotional cues. Accurate recognition of these cues is central to adaptive social functioning. Past studies indicate that individuals with schizophrenia (SZ) show deficits in the perception of emotion from facial cues but the contribution of bodily cues to social perception in schizophrenia is undetermined. The present study examined the detection of social cues from human gait patterns presented by computer-generated volumetric walking figures.

METHOD

A total of 22 SZ and 20 age-matched healthy control participants (CO) viewed 1 s movies of a 'digital' walker's gait and subsequently made a forced-choice decision on the emotional state (angry or happy) or the gender of the walker presented at three intensity levels. Overall sensitivity to the social cues and bias were computed. For SZ, symptom severity was assessed.

RESULTS

SZ were less sensitive than CO on both emotion and gender discrimination, regardless of intensity. While impaired overall, greater signal intensity did improve performance of SZ. Neither group differed in their response bias in either condition. The discrimination sensitivity of SZ was unrelated to their social functioning or symptoms but a bias toward perceiving gait as happy was associated with better social functioning.

CONCLUSIONS

These results suggest that SZ are impaired in extracting social information from gait but SZ benefited from increased signal intensity of social cues. Inaccurate perception of social cues in others may hinder adequate preparation for social interactions.

Vascular pathology in the extracranial vertebral arteries in patients with acute ischemic stroke

Introduction

Vascular pathology in the extracranial vertebral arteries remains among the possible causes in cryptogenic stroke. However, the diagnosis is challenged by the great variety in the anatomy of the vertebral arteries, clinical symptoms and difficulties in the radiological assessments. The aim of this study was to assess the prevalence of CT angiography (CTA)-detected pathological findings in the extracranial vertebral arteries in an acute stroke population and secondly to determine the frequency of posterior pathology as probable cause in patients with otherwise cryptogenic stroke.

Method

The analysis was based on 657 consecutive patients with symptoms of acute stroke and a final diagnosis of ischemic stroke or transient ischemic attack. On admission, a noncontrast CT cerebrum and CTA were performed. A senior consultant neuroradiologist, blinded to clinical data, reviewed all CTA scans systematically, assessing the four segments of the extracranial vertebral arteries. First, the frequency of pathological findings including stenosis, plaques, dissection, kinked artery and coiling was assessed. Subsequently, we explored the extent of the pathological findings that were the most plausible causes of stroke, namely either a possible dissection or a kinked artery.

Results

Findings in the extracranial vertebral arteries included significant stenosis (0.8%), atherosclerotic plaque types (3.8%), possible dissections (2.6%), kinked arteries (2.6%) and coiling (32.0%). Eighteen patients (2.8%) with pathological findings had an unknown cause of stroke, likely posterior symptoms and no clinical stroke symptoms from the anterior circuit. Of these, 3 cases were kinked arteries (0.5%) and 15 cases (2.3%) were possible dissections.

Conclusion

We found that in approximately 3% of the study population, the most plausible cause of the cryptogenic strokes was due to a pathological finding in the posterior extracranial vertebral arteries, being either a possible dissection or a kinked artery. In general, posterior vascular pathology is not uncommon, and CTA is a useful modality in the detection of changes based on characteristics and locations of findings in the extracranial vertebral arteries. Ultrasound examination can be a useful supplementary tool in deciding the consequence of vascular findings on CTA.

External validation of the ability of the DRAGON score to predict outcome after thrombolysis treatment

Easy-to-perform and valid assessment scales for the effect of thrombolysis are essential in hyperacute stroke settings. Because of this we performed an external validation of the DRAGON scale proposed by Strbian et al. in a Danish cohort. All patients treated with intravenous recombinant plasminogen activator between 2009 and 2011 were included. Upon admission all patients underwent physical and neurological examination using the National Institutes of Health Stroke Scale along with non-contrast CT scans and CT angiography. Patients were followed up through the Outpatient Clinic and their modified Rankin Scale (mRS) was assessed after 3 months. Three hundred and three patients were included in the analysis. The DRAGON scale proved to have a good discriminative ability for predicting highly unfavourable outcome (mRS 5-6) (area under the curve-receiver operating characteristic [AUC-ROC]: 0.89; 95% confidence interval [CI] 0.81-0.96; p<0.001) and good outcome (mRS 0-2) (AUC-ROC: 0.79; 95% CI 0.73-0.85; p<0.001). When only patients with M1 occlusions were selected the DRAGON scale provided good discriminative capability (AUC-ROC: 0.89; 95% CI 0.78-1.0; p=0.003) for highly unfavourable outcome. We confirmed the validity of the DRAGON scale in predicting outcome after thrombolysis treatment.

Waiting times for diagnosis and treatment of head and neck cancer in Denmark in 2010 compared to 1992 and 2002

BACKGROUND AND AIM

Significant tumour progression was observed during waiting time for treatment of head and neck cancer. To reduce waiting times, a Danish national policy of fast track accelerated clinical pathways was introduced in 2007. This study describes changes in waiting time and the potential influence of fast track by comparing waiting times in 2010 to 2002 and 1992.

METHODS

Charts of all new patients diagnosed with squamous cell carcinoma of the oral cavity, pharynx and larynx at the five Danish head and neck oncology centres from January to April 2010 (n=253) were reviewed and compared to similar data from 2002 (n=211) and 1992 (n=168).

RESULTS

The median time to diagnosis was 13 days (2010) versus 17 days (2002; p<0.001) and 20 days (1992; p<0.001). Median days from diagnosis to treatment start were 25 (2010) versus 47 (2002; p<0.001) and 31 (1992; p<0.001). Total pre-treatment time was median 41 days in 2010 versus 69 days (2002) (p<0.001) and 50 days (1992; p<0.001). Significantly more diagnostic imaging was done in 2010 compared to 2002 and 1992. When compared to current fast track standards the adherence to diagnosis improved slightly from 47% (1992) to 51% (2002) and 64% (2010); waiting time for radiotherapy was within standards for 7%, 1% and 22% of cases, respectively; waiting time for surgery was within standards for 17%, 22% and 48%, respectively.

CONCLUSION

The study showed a significant reduction in delay of diagnosis and treatment of head and neck cancer in 2010, but still less than half of all patients start treatment within the current standards.

Hormonal regulation of female reproduction

Reproduction is an event that requires the coordination of peripheral organs with the nervous system to ensure that the internal and external environments are optimal for successful procreation of the species. This is accomplished by the hypothalamic-pituitary-gonadal axis that coordinates reproductive behavior with ovulation. The primary signal from the central nervous system is gonadotropin-releasing hormone (GnRH), which modulates the activity of anterior pituitary gonadotropes regulating follicle stimulating hormone (FSH) and luteinizing hormone (LH) release. As ovarian follicles develop they release estradiol, which negatively regulates further release of GnRH and FSH. As estradiol concentrations peak they trigger the surge release of GnRH, which leads to LH release inducing ovulation. Release of GnRH within the central nervous system helps modulate reproductive behaviors providing a node at which control of reproduction is regulated. To address these issues, this review focuses on several critical questions. How is the HPG axis regulated in species with different reproductive strategies? What internal and external conditions modulate the synthesis and release of GnRH? How does GnRH modulate reproductive behavior within the hypothalamus? How does disease shift the activity of the HPG axis?

Evaluation of family intervention through unobtrusive audio recordings: experiences in "bugging" children

Five children referred to a child-family intervention program wore a radio transmitter in the home during pre-intervention and termination assessments. The transmitter broadcast to a receiver-recording apparatus in the home (either activated by an interval timer at predetermined "random" times or by parents at predetermined "picked" times). "Picked" times were parent-selected situations during which problems typically occurred (e.g., bedtime). Parents activated the recorder regularly whether or not problems occurred. Child-deviant, parent-negative, and parent-commanding behaviors were significantly higher at the picked times during pretest than at random times. At posttest, behaviors in all three classes were substantially reduced at picked times, but not at random times. For individual subject data, reductions occurred in at least two of the three dependent variables for three of the five cases during random time assessments. In general, the behavioral outcome data corresponded to parent-attitude reports and parent-collected observation data.