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Limited therapies exist for neurofibromatosis type 1 (NF1)-associated plexiform neurofibroma (PN). For this reason, the activity of vinblastine (VBL) and methotrexate (MTX) was evaluated in children and young adults with NF1 and PN. Patients ≤ 25 years of age with progressive and/or inoperable NF1-PN received VBL 6 mg/m2 and MTX 30 mg/m2 weekly for 26 weeks, followed by every 2 weeks for 26 weeks. Objective response rate was the primary endpoint. Of 25 participants enrolled, 23 were evaluable. The median age of participants was 6.6 years (range 0.3–20.7). The most frequent toxicities were neutropenia and elevation of transaminases. On two-dimensional (2D) imaging, 20 participants (87%) had stable tumor, with a median time to progression of 41.5 months (95% confidence interval 16.9, 64.9). Two of eight participants (25%) with airway involvement demonstrated functional improvements including decreased positive pressure requirements and apnea-hypopnea index. A post hoc three-dimensional (3D) analysis of PN volumes was completed on 15 participants with amenable imaging; 7 participants (46%) had progressive disease on or by the end of therapy. VBL/MTX was well-tolerated but did not result in objective volumetric response. Furthermore, 3D volumetric analysis highlighted the lack of sensitivity of 2D imaging for PN response evaluation.

PURPOSE: The introduction of whole slide imaging and digital pathology has enabled greater scrutiny of visual search behaviors among pathologists. We aim to investigate zooming and panning behaviors, external markers of visual processing capabilities, and the changes with experience. APPROACHES: Twenty digitized breast core needle biopsy histopathology slides were obtained from the circulating slides from the main digital pathology trial (IRAS number: 258799). These were presented to five pathologists with varying experience (1.5 to 40 years) whose examinations were recorded. Data of visual fixations were collected using eye-tracking cameras, and the magnification data and zooming behaviors were extracted in an objective fashion by an automated algorithm. The relationship between experience and metrics was analyzed using mixed-effects regression analyses. RESULTS: There was a significant association between experience and both reading times ([Formula: see text]) and a number of fixations ([Formula: see text]), with these relationships being inversely proportional. The greater experience was also associated with greater diagnostic accuracy ([Formula: see text]). We found that experience was significantly associated with greater use of magnification changes ([Formula: see text]). Conversely, less experience showed a near significant association with the increased proportion of time spent panning ([Formula: see text]). CONCLUSIONS: Fewer fixations needed to reach a diagnosis and quicker reading times are indicative of greater cognitive and visual processing capabilities with greater experience. These cognitive capabilities may be a prerequisite for the more frequent zooming changes that are more prevalent with increasing experience.

This study builds on the findings of previous research into church-related tweets by considering and analysing the content of 1,004 tweets containing the word “church” which were posted from within Greater London during a 10-week period. The qualitative analysis of the resultant Twitter dataset enabled the research team to validate a previously proposed coding framework for church-related tweets, subject to a minor change, and provide new evidence around the types of content discussed in church-related tweets posted from across all London boroughs. This paper concludes by drawing-out some of the key lessons which sociologists of religion can learn by exploring church-related tweets.

Background/Aims The UK Government piloted a COVID-19 digital contact tracing smartphone app on the Isle of Wight, England, in June 2020 in attempt to contain the spread of the virus. This study aimed to investigate the factors that affected the decision to download the app among individuals in the Isle of Wight. Methods Online questionnaires were distributed over social media to the sample population. Quantitative data were analysed, both descriptively and using a Chi-square or Fisher's test. Qualitative data were analysed through content analysis. Results Overall, 74.2% of participants downloaded the COVID-19 app, citing compliance, protection and fighting the pandemic or returning to normal as their main reasons. There was a significant negative correlation between having concerns about the app and downloading the app (P=Conclusions Concerns about the COVID-19 app, particularly in terms of its security, significantly affected whether participants were likely to download it. The results provide insight into factors influencing mass public health behaviours and can form the basis for future research into app-based interventions.

Background: Overuse of antibiotics and inappropriate prescribing has resulted in a rapid increase in the rate of antibiotic resistance, with poorer patient outcomes and increased health costs. In the out-of-hours setting, a high proportion of antibiotics are prescribed and practices need to improve to reduce antibiotic resistance.Purpose: To identify antibiotic prescribing practices in European out-of-hours primary care services that are contributing to antibiotic resistance.Design: The review was conducted in alignment with the PRISMA statement (Moher, Liberati, Tetzlaff, Altman, & PRISMA Group, 2009).Methods: A literature search was performed using MySearch to identify European literature. The search was focused on antibiotic/antimicrobial prescribing in an out-of-hours environment, and any reports that described factors correlating with the nature of prescribing practices were examined.Results: The literature search located 91 articles, out of which seven met the inclusion criteria. Two articles described clinicians’ experiences in antibiotic prescribing in out-of-hours, two compared in-office and after-hours prescribing, two described prescribing patterns in out-of-hours and one examined prescribing in children. Four main themes were identified: antibiotics prescribed and conditions associated with prescribing; consultation time; the day of consultation; and parental opinion.Conclusion: Overprescribing to self-limiting conditions, prescribing of broad-spectrum antibiotics, time constraints, safeguarding issues and poor communication are all contributing to inappropriate antibiotic prescribing. Further research is needed relating to whether clinicians are adhering to antibiotic guidelines and to explore patients’ experiences and expectations from the out-of-hours practitioners with respect to antibiotic prescribing.

Purpose: To design, implement and evaluate the effect of an educational intervention on student radiographer attitudes across their educational tenure. \ud \ud Methods: In the first phase, an educational intervention that involved didactic lectures, reflective exercises and simulation suits, aimed at improving student radiographer attitudes towards the older person, was designed and implemented. Kogan’s attitudes towards older people (KoP) scale was administrated at five test points; pre-intervention; post-intervention; 6 months post intervention; 12 months post intervention and 24 months post intervention. At the final test point these quantitative data was supplemented with qualitative data for triangulation of the findings. \ud \ud Results: Students held positive attitudes towards older people pre intervention, these increased significantly post intervention (p=0.01). However, this increase in positive scores was not noted at 6 months and 12-months post intervention. At 24-months post intervention, although there was a slight increase in positive attitudes when compared to the 6 and 12 month scores, this increase was not found to be significant (p=.178) \ud \ud Conclusions: The results post-intervention suggested that an educational intervention can have a significant impact on student radiographer’s attitudes towards older people. However, the qualitative data suggests that experiences on initial clinical placement can be detrimental to attitudinal scores, particularly if the intervention does not include Dementia care strategies.

We aimed to identify the effect of computer-aided detection (CAD) on visual search and performance in CT Colonography (CTC) of inexperienced and experienced readers. Fifteen endoluminal CTC examinations were recorded, each with one polyp, and two videos were generated, one with and one without a CAD mark. Forty-two readers (17 experienced, 25 inexperienced) interpreted the videos during infrared visual search recording. CAD markers and polyps were treated as regions of interest in data processing. This multi-reader, multi-case study was analysed using multilevel modelling. CAD drew readers’ attention to polyps faster, accelerating identification times: median ‘time to first pursuit’ was 0.48 s (IQR 0.27 to 0.87 s) with CAD, versus 0.58 s (IQR 0.35 to 1.06 s) without. For inexperienced readers, CAD also held visual attention for longer. All visual search metrics used to assess visual gaze behaviour demonstrated statistically significant differences when “with” and “without” CAD were compared. A significant increase in the number of correct polyp identifications across all readers was seen with CAD (74 % without CAD, 87 % with CAD; p

Objective: Eye tracking in three dimensions is novel, but established descriptors derived from two-dimensional (2D) studies are not transferable. We aimed to develop metrics suitable for statistical comparison of eye-tracking data obtained from readers of three-dimensional (3D) “virtual” medical imaging, using CT colonography (CTC) as a typical example.\ud \ud Methods: Ten experienced radiologists were eye tracked while observing eight 3D endoluminal CTC videos. Sub-sequently, we developed metrics that described their visual search patterns based on concepts derived from 2D gaze studies. Statistical methods were developed to allow analysis of the metrics.\ud \ud Results: Eye tracking was possible for all readers. Visual dwell on the moving region of interest (ROI) was defined as pursuit of the moving object across multiple frames. Using this concept of pursuit, five categories of metrics were defined that allowed characterization of reader gaze behaviour. These were time to first pursuit, identi-fication and assessment time, pursuit duration, ROI size and pursuit frequency. Additional subcategories allowed us to further characterize visual search between readers in the test population.\ud \ud Conclusion: We propose metrics for the characterization of visual search of 3D moving medical images. These metrics can be used to compare readers’ visual search patterns and provide a reproducible framework for the analysis of gaze tracking in the 3D environment. Advances in knowledge: This article describes a novel set of metrics that can be used to describe gaze behaviour when eye tracking readers during interpretation of 3D medical images. These metrics build on those established for 2D eye tracking and are applicable to increasingly common 3D medical image displays.

In this paper a new approach is proposed to track the perceptual behaviour of radiologists when they examine mammographic images displayed on large dual clinical monitors. Zooming and panning are inevitably performed by the radiologist to examine such large images by using the DICOM viewing software. Such image manipulating movements on the target displays makes eye tracking techniques difficult to perform and also the size of the dual clinical monitors makes existing eye tracking techniques generally inadequate. Hence a method using the Smart Eye Pro eye tracker and optical character recognition techniques was designed to relate the recorded radiologists’ eye gaze behaviour on the monitors to the actual zoomed and panned medical image areas. This then allows clinical studies involving radiologists interacting with these mammographic images to be successfully carried out.

This article presents a case study in which the author piloted the flipped classroom on a cohort of paramedic science students at a UK higher education institution. The flipped classroom will be explained alongside the rationale for considering it as a good pedagogical addition for paramedic students. As a new pedagogy, the flipped classroom will be considered against what is currently known about learning theories and teaching styles. There are potential drawbacks to this method of teaching and learning and these will be discussed, as will suggestions to mitigate these drawbacks. Finally, the impact upon the students will be considered and the author will comment on the pilot and what this means for paramedic education in the future.

Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG geförderten) Allianz- bzw. Nationallizenz frei zugänglich., This publication is with permission of the rights owner freely accessible due to an Alliance licence and a national licence (funded by the DFG, German Research Foundation) respectively., Objective: The aim of this study was to explore reader gaze, performance, and preference during interpretation of cranial computed tomography (cCT) in stack mode at two different sizes. Background: Digital display of medical images allows for the manipulation of many imaging factors, like image size, by the radiologists, yet it is often not known what display parameters better suit human perception. Method: Twenty-one radiologists provided informed consent to be eye tracked while reading 20 cCT cases. Half of these cases were presented at a size of 14 x 14 cm (512 x 512 pixels), half at 28 x 28 cm (1,024 x 1,024 pixels). Visual search, performance, and preference for the two image sizes were assessed. Results: When reading small images, significantly fewer, but longer, fixations were observed, and these fixations covered significantly more slices. Time to first fixation of true positive findings was faster in small images, but dwell time on true findings was longer. Readers made more false positive decisions in small images, but no overall difference in either jackknife alternative free-response receiver operating characteristic or reading time was found. Conclusion: Overall performance is not affected by image size. However, small-stack-mode cCT images may better support the use of motion perception and acquiring an overview, whereas large-stack-mode cCT images seem better suited for detailed analyses. Application: Subjective and eye-tracking data suggest that image size influences how images are searched and that different search strategies might be beneficial under different circumstances.

BACKGROUND: There are limited data measuring the impact of expanded human immunodeficiency virus (HIV) prevention activities on the tuberculosis epidemic at the country level. Here we characterized the potential impact of the US Presidents Emergency Plan for AIDS Relief (PEPFAR) on the tuberculosis epidemic in sub-Saharan Africa. METHODS: We selected 12 focus countries (countries receiving the greatest US government investments) and 29 nonfocus countries (controls). We used tuberculosis incidence and mortality rates and relative risks to compare time periods before and after PEPFARs inception and a tuberculosis/HIV indicator to calculate the rate of change in tuberculosis incidence relative to the HIV prevalence. RESULTS: Comparing the periods before and after PEPFARs implementation both tuberculosis incidence and mortality rates have diminished significantly and to a higher degree in focus countries. The relative risk for developing tuberculosis comparing those with and without HIV was 22.5 for control and 20.0 for focus countries. In most focus countries the tuberculosis epidemic is slowing down despite some regions still experiencing an increase in HIV prevalence. CONCLUSIONS: This ecological study showed that PEPFAR had a more consistent and substantial effect on HIV and tuberculosis in focus countries highlighting the likely link between high levels of HIV investment and broader effects on related diseases such as tuberculosis.

Purpose: To develop an eye-tracking method applicable to three-dimensional (3D) images, where the abnormality is both moving and changing in size.\ud \ud Materials and Methods: Research ethics committee approval was granted to record eye-tracking data from six inexperienced readers who inspected eight short (

Extrapulmonary infection withPneumocystis carinii, although uncommon, is increasingly recognized. Use of aerosolized pentamidine versus a systemic medication is thought to be a contributing factor due to the low concentrations of drug that are incapable of suppressing systemic infection. Infection withP cariniihas been reported in every organ system including the gastrointestinal system. A 28-year-old acquired immunodeficiency syndrome patient receiving prophylaxis with aerosolized pentamidine who presented with a solitary rectal ulcer is reported. Initial biopsy was characteristic of extrapulmonaryP cariniiinfection, with numerous organisms present. Occasional cytomegalovirus inclusion bodies were noted which may have been a copathogen but which were not treated. Treatment with intravenous pentamidine resulted in documented eradication ofP cariniiand complete resolution of the ulcer. Although lower gastrointestinal pneumocystosis has been described without ulceration, this is the first description of rectal ulceration presenting as the initial manifestation of extrapulmonary pneumocystosis.

Objective: To describe patients with fungal infections in whom drug interactions and bioavailability problems were associated with itraconazole treatment failure.Design: Retrospective chart review.Setting: Two tertiary care university-affiliated teaching hospitals.Population Studied: Itraconazole-treated patients between 1990 and 1992.Main Results: Four patients treated with itraconazole were identified in whom suboptimal serum itraconazole levels were associated with relapse of disseminated histoplasmosis, treatment failure of invasive aspergillosis or development of superficial mycoses. Low serum itraconazole levels were associated with concurrent therapy with rifampin or agents inhibiting gastric acid secretion, with administration of itraconazole capsule contents through a nasogastric tube or with the presence ofaids.Conclusions: It is recommended that serum itraconazole levels be measured in patients with potentially life-threatening mycoses if coexistent factors may interfere with itraconazole therapy.

Objectives: Invasive fungal infections are a major cause of mortality among patients at risk. Treatment guidelines vary on optimal treatment strategies. We aimed to determine the effects of different antifungal therapies on global response rates, mortality and safety. Methods We searched independently and in duplicate 10 electronic databases from inception to May 2009. We selected any randomized trial assessing established antifungal therapies for confirmed cases of invasive candidiasis among predominantly adult populations. We performed a meta-analysis and then conducted a Bayesian mixed treatment comparison to differentiate treatment effectiveness. Sensitivity analyses included dosage forms of amphotericin B and fluconazole compared to other azoles. Results Our analysis included 11 studies enrolling a total of 965 patients. For our primary analysis of global response rates, we pooled 7 trials comparing azoles to amphotericin B, Relative Risk [RR] 0.87 (95% Confidence Interval [CI], 0.78–0.96, P = 0.007, I2 = 43%, P = 0.09. We also pooled 2 trials of echinocandins versus amphotericin B and found a pooled RR of 1.10 (95% CI, 0.99–1.23, P = 0.08). One study compared anidulafungin to fluconazole and yielded a RR of 1.26 (95% CI, 1.06–1.51) in favor of anidulafungin. We pooled 7 trials assessing azoles versus amphotericin B for all-cause mortality, resulting in a pooled RR of 0.88 (95% CI, 0.74–1.05, P = 0.17, I2 = 0%, P = 0.96). Echinocandins versus amphotericin B (2 trials) for all-cause mortality resulted in a pooled RR of 1.01 (95% CI, 0.84–1.20, P = 0.93). Anidulafungin versus fluconazole resulted in a RR of 0.73 (95% CI, 0.48–1.10, P = 0.34). Our mixed treatment comparison analysis found similar within-class effects across all interventions. Adverse event profiles differed, with amphotericin B exhibiting larger adverse event effects. Conclusion Treatment options appear to offer preferential effects on response rates and mortality. When mycologic data are available, therapy should be tailored.

Traditional diagnostic modalities have been, for the most part, static two-dimensional images displayed on film or computer screen. More recent diagnostic modalities are solely computer-based and consist of large data-sets of multiple images. Image perception and visual search using these new modalities are complicated by the need to interact with the computer in order to navigate through the data. This paper reports the late-breaking results from two small studies into visual search within two types of CT Colonography (CTC) visualisations. The twelve novice observers in the study were taking part in a week-long course in CTC and were tested at the beginning and end of the course. A number of expert observers were also recorded. The two visualisations used in the study were 2D axial view and 3D colon fly-through. In both cases, searching was performed by inspecting the colon wall, but by two distinct mechanisms. The first study recorded observer eye-gaze and image navigation in a CTC axial view. The search strategy was to follow the lumen of the colon and detect abnormalities in the colon wall. The observer used the physical computer interface to navigate through the set of axial images to perform this task. The 3D fly-through study recorded observer eye-gaze whilst watching a recording of a computed flight through the colon lumen. Unlike the axial view there was no computer control, so inspection of the colon surface was dictated by the speed of flight through the colon.

BACKGROUND: The management of HIV-infected patients with cytomegalovirus (CMV) disease has changed significantly with the availability of highly active antiretroviral therapy (HAART).OBJECTIVES: These updated guidelines are intended to provide practical help to physicians managing HIV-positive patients with or at risk for CMV disease.METHODS: The 10 members of the Canadian CMV Disease in HIV/AIDS Consensus Group were infectious disease specialists, a primary care physician and ophthalmologists with expertise in HIV and CMV infection. Financial support by Hoffmann-La Roche Canada Ltd was unrestricted, and was limited to travel expenses and honoraria. The consensus group met in June and October 2002. Key areas to be considered were identified, and group members selected, reviewed and presented relevant recent literature for their assigned section for the group's consideration. Evidence was assessed based on established criteria, which were expert opinions of the members. Draft documents were circulated to the entire group and modified until consensus was reached. The final guidelines represent the group's consensus agreement. The guidelines were approved by the Canadian Infectious Disease Society.RESULTS AND CONCLUSIONS: The guidelines address symptom monitoring, screening for early detection and prevention, and treatment using oral, intravenous and intraocular anti-CMV therapies in conjunction with HAART.