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Before the introduction of antiretroviral therapy, human immunodeficiency virus (HIV) infection was often accompanied by central nervous system (CNS) opportunistic infections and HIV encephalopathy marked by profound structural and functional alterations detectable with neuroimaging. Treatment with antiretroviral therapy nearly eliminated CNS opportunistic infections, while neuropsychiatric impairment and peripheral nerve and organ damage have persisted among virally suppressed people with HIV (PWH), suggesting ongoing brain injury. Neuroimaging research must use methods sensitive for detecting subtle HIV-associated brain structural and functional abnormalities, while allowing for adjustments for potential confounders, such as age, sex, substance use, hepatitis C coinfection, cardiovascular risk, and others. Here, we review existing and emerging neuroimaging tools that demonstrated promise in detecting markers of HIV-associated brain pathology and explore strategies to study the impact of potential confounding factors on these brain measures. We emphasize neuroimaging approaches that may be used in parallel to gather complementary information, allowing efficient detection and interpretation of altered brain structure and function associated with suboptimal clinical outcomes among virally suppressed PWH. We examine the advantages of each imaging modality and systematic approaches in study design and analysis. We also consider advantages of combining experimental and statistical control techniques to improve sensitivity and specificity of biotype identification and explore the costs and benefits of aggregating data from multiple studies to achieve larger sample sizes, enabling use of emerging methods for combining and analyzing large, multifaceted data sets. Many of the topics addressed in this article were discussed at the National Institute of Mental Health meeting “Biotypes of CNS Complications in People Living with HIV,” held in October 2021, and are part of ongoing research initiatives to define the role of neuroimaging in emerging alternative approaches to identifying biotypes of CNS complications in PWH. An outcome of these considerations may be the development of a common neuroimaging protocol available for researchers to use in future studies examining neurological changes in the brains of PWH.

Family accommodation (FA) has been shown to relate to poorer treatment outcomes in pediatric obsessive compulsive disorder (OCD), yet few studies have examined the trajectory of change in FA throughout treatment and its relation to treatment outcomes. This study examined change in FA in relation to change in symptom severity and impairment in 63 youth receiving a family-based intervention for early-onset OCD. FA, symptom severity and functional impairment were assessed at baseline, week 5, week 9, and post-treatment (week 14). Results suggested that changes in FA in the beginning stages of treatment preceded global symptom improvement (but not OCD specific improvement) whereas changes in functional impairment preceded changes in FA. In the latter half of treatment, changes in FA preceded improvement in global and OCD specific symptom severity as well as functional impairment. These findings highlight the importance of reducing FA, especially in the later stages of treatment, in order to optimize treatment outcomes in early-onset OCD.

BackgroundRecovery after SARS-CoV-2 infection is extremely variable, with some individuals recovering quickly, and others experiencing persistent long-term symptoms or developing new symptoms after the acute phase of infection, including fatigue, poor concentration, impaired attention, or memory deficits. Many existing studies reporting cognitive deficits associated with SARS-CoV-2 infection are limited by the exclusive use of self-reported measures or a lack of adequate comparison groups.MethodsForty-five participants, ages 18-70, (11 Long-COVID, 14 COVID, and 20 No-COVID) underwent behavioral testing with the NIH Toolbox Neuro-Quality of Life survey and selected psychometric tests, including a flanker interference task and the d2 Test of Attention.ResultsWe found greater self-reported anxiety, apathy, fatigue, emotional dyscontrol, sleep disturbance and cognitive dysfunction in COVID compared No-COVID groups. After categorizing COVID patients according to self-reported concentration problems, we observed declining performance patterns in multiple attention measures across No-COVID controls, COVID and Long-COVID groups. COVID participants, compared to No-COVID controls, exhibited worse performance on NIH Toolbox assessments, including the Eriksen Flanker, Nine-Hole Pegboard and Auditory Verbal Learning tests.ConclusionThis study provides convergent evidence that previous SARS-CoV-2 infection is associated with impairments in sustained attention, processing speed, self-reported fatigue and concentration. The finding that some patients have cognitive and visuomotor dysfunction in the absence of self-reported problems suggests that SARS-CoV-2 infection can have unexpected and persistent subclinical consequences.

BACKGROUND Strategy training, a rehabilitation intervention, reduces disability and improves functional skills associated with goal-directed behavior. Stroke lesions impacting selected ventromedial regions of interest associated with initiation of goal-directed behavior may attenuate intervention response. If so, strategy training may not be optimal for people with stroke lesions in these regions. OBJECTIVE To examine whether ventromedial regions of interest attenuate changes in disability status attributed to strategy training. DESIGN Secondary analysis of data from two randomized controlled clinical trials. SETTING Inpatient stroke rehabilitation. PARTICIPANTS People with acute stroke diagnosis and available diagnostic studies enrolled in inpatient rehabilitation randomized controlled studies between 2009 and 2017. INTERVENTION Participants were randomized to strategy training or a control condition in addition to the usual care during inpatient rehabilitation. MAIN OUTCOME MEASURES Diagnostic magnetic resonance imaging studies were retrieved from electronic medical records, and stroke lesion location was characterized by a neuroradiologist. Intervention response was defined by Functional Independence Measure change scores of 22 points or greater. RESULTS Only 186 of 275 participants had diagnostic studies available; 13 patients showed no apparent lesion on their diagnostic study. Among 173 cases, 156 had complete data at discharge (strategy training n = 71, control n = 85). Twenty-five cases had a lesion within a region of interest (strategy training n = 14, control n = 11). Intervention response was attenuated in the strategy training group for those with lesions in regions of interest [χ2 (1, n = 71) = 4.60, P = .03], but not for those in the control group [Fisher exact test, n = 85, P = .19). CONCLUSIONS Lesions in the ventromedial regions of interest may attenuate response to strategy training.

Low academic performance in middle childhood/early adolescence has long-term negative implications. The link between early performance and later outcomes is of special concern for boys, who tend to evidence lower levels of achievement than girls by early adolescence. Scholars have demonstrated that variations by gender in quality of teacher–student relationships may partly explain this achievement gap. That is, girls tend to have higher quality teacher–student relationships (i.e., higher levels of closeness and lower levels of conflict) than boys. Centering low-income early adolescents of color, the present analyses found that girls outperformed boys in both English Language Arts (ELA; p < .001) and math (p = .009). Teacher–student closeness fully and significantly mediated the association between gender and ELA (p = .05) and partially mediated the association between gender and math achievement (effects were nonsignificant). Teacher–student conflict partially mediated associations between gender and ELA and math achievement, although effects similarly did not reach significance. Results have the capacity to inform future interventions aiming to increase the utility of education and decrease school dropout among low-income boys of color.

The present study examined whether teacher–child closeness and conflict across kindergarten and first grade varied by gender and disruptive behavior at kindergarten entry within a sample of 324 predominantly Black children from low-income, urban households. Three main findings emerged from the analyses. First, contrary to findings from previous work that revealed stability in closeness and conflict across the first few years of elementary school, this study identified significant changes in closeness across the kindergarten and first grade years. Second, girls experienced more closeness with teachers than boys across both kindergarten and first grade, and the rate of change in teacher–child closeness differed by child gender across time. Finally, across both school years, associations between gender and teacher–child conflict varied by level of disruptive behavior at the beginning of kindergarten, such that boys with high levels of disruptive behavior experienced more overall conflict with teachers than girls with high levels of disruptive behavior.

Social-Emotional Learning (SEL) programs are school-based preventive interventions that aim to improve children’s social-emotional skills and behaviors. Although meta-analytic research has shown th...

Despite significant advances in treatment, chronic obstructive pulmonary disease (COPD) remains a chronic and progressive disease that frequently leads to premature mortality. COPD is associated with a constellation of significant symptoms, including dyspnea, cough, wheezing, pain, fatigue, anxiety, depression, and insomnia, and is associated with increased morbidity. Palliative care is appropriate to support these patients. However, historically, palliative care has focused on supporting patients with malignant disease, rather than progressive chronic diseases such as COPD. Therapies for COPD often result in functional and symptomatic improvements, including health-related quality of life (HRQL), and palliative care may further improve symptoms and HRQL. Provision of usual palliative care therapies for this patient population requires understanding the pathogenesis of COPD and common disease-targeted pharmacotherapies, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes COPD and current targeted therapies and their effects on symptoms, exercise tolerance, HRQL, and survival. It is important to note that medications commonly used for symptom management in palliative care can interact with COPD medications resulting in increased risk of adverse effects, enhanced toxicity, or changes in clearance of medications. To address this, we review pharmacologic interactions with and precautions related to use of COPD therapies in conjunction with commonly used palliative care medications.

Using data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (NICHD SECCYD), we used 2-level random effects models to examine whether the quality of school and home environments during elementary school moderated associations between pre-K quality and math, reading, and vocabulary achievement from first through fifth grade. Results showed that the quality of the home environment moderated the association between pre-K quality and children’s vocabulary achievement. Supportive home environments during elementary school had an additive effect over and above the positive effects of pre-K quality in predicting children’s vocabulary achievement. In contrast, when children experienced high levels of pre-K quality and lower quality home learning environments, the positive effects of pre-K were less likely to be sustained. Findings suggest the importance of considering programs and policies to support home-based learning as one potential mechanism to sustain early effects of pre-K. (PsycInfo Database Record (c) 2020 APA, all rights reserved)

Cognitive impairment may be greater in HIV-positive (HIV+) women than in HIV+ men. Whether sex-specific differences exist in brain microstructure of HIV+ individuals is unknown and was evaluated.39 HIV+ (21 men, 18 women) and 45 seronegative (SN, 20 men, 25 women) participants were assessed with brain diffusion tensor imaging and cognitive assessments (7 neuropsychological domains). Fractional anisotropy (FA) and mean diffusivity (MD) were measured with an automated atlas in selected brain regions. Group comparisons were assessed with linear mixed effects models, with sub-regions and hemisphere (left/right) as repeated factors for each region.HIV+ women, but not HIV+ men, were slower than sex-matched SN controls on sensorimotor function (Dominant-hand: interaction-p = 0.007; Non-dominant hand: interaction-p = 0.039). Similarly, only HIV+ women had lower FA in the globus pallidus (GP, interaction-p = 0.011). Additionally, regardless of sex, the HIV+ group had poorer Fluency, Speed, and Attention than SN-controls (p = 0.006-0.008), as well as lower FA and higher MD in multiple brain regions (p = 0.001-0.044). Across all participants, performance on Attention was predicted by uncinate-FA (p 0.001, r = 0.5) and corpus callosum (CC)-FA (p = 0.038, r = 0.23), while the Speed of Information Processing was predicted by CC-FA (p = 0.009, r = 0.3). Furthermore, faster sensorimotor function correlated with higher CC-FA and uncinate-FA in men but not in women (Sex*DTI-interaction-p = 0.03-0.06).The relatively poorer sensorimotor function and abnormally lower GP_FA, suggesting lesser neuronal integrity, in HIV+ women demonstrate sex-specific effects from HIV-infection on these measures. These findings may be related to the greater immune activation and neuroinflammation in HIV+ women compared to HIV+ men. Graphical Abstract.

Typical machine learning frameworks heavily rely on an underlying assumption that training and test data follow the same distribution. In medical imaging which increasingly begun acquiring datasets from multiple sites or scanners, this identical distribution assumption often fails to hold due to systematic variability induced by site or scanner dependent factors. Therefore, we cannot simply expect a model trained on a given dataset to consistently work well, or generalize, on a dataset from another distribution. In this work, we address this problem, investigating the application of machine learning models to unseen medical imaging data. Specifically, we consider the challenging case of Domain Generalization (DG) where we train a model without any knowledge about the testing distribution. That is, we train on samples from a set of distributions (sources) and test on samples from a new, unseen distribution (target). We focus on the task of white matter hyperintensity (WMH) prediction using the multi-site WMH Segmentation Challenge dataset and our local in-house dataset. We identify how two mechanically distinct DG approaches, namely domain adversarial learning and mix-up, have theoretical synergy. Then, we show drastic improvements of WMH prediction on an unseen target domain., IEEE International Symposium on Biomedical Imaging 2021

Family accommodation (FA) has been shown to relate to poorer treatment outcomes in pediatric obsessive compulsive disorder (OCD), yet few studies have examined the trajectory of change in FA throughout treatment and its relation to treatment outcomes. This study examined change in FA in relation to change in symptom severity and impairment in 63 youth receiving a family-based intervention for early-onset OCD. FA, symptom severity and functional impairment were assessed at baseline, week 5, week 9, and post-treatment (week 14). Results suggested that changes in FA in the beginning stages of treatment preceded global symptom improvement (but not OCD specific improvement) whereas changes in functional impairment preceded changes in FA. In the latter half of treatment, changes in FA preceded improvement in global and OCD specific symptom severity as well as functional impairment. These findings highlight the importance of reducing FA, especially in the later stages of treatment, in order to optimize treatment outcomes in early-onset OCD.

We consider a model-agnostic solution to the problem of Multi-Domain Learning (MDL) for multi-modal applications. Many existing MDL techniques are model-dependent solutions which explicitly require nontrivial architectural changes to construct domain-specific modules. Thus, properly applying these MDL techniques for new problems with well-established models, e.g. U-Net for semantic segmentation, may demand various low-level implementation efforts. In this paper, given emerging multi-modal data (e.g., various structural neuroimaging modalities), we aim to enable MDL purely algorithmically so that widely used neural networks can trivially achieve MDL in a model-independent manner. To this end, we consider a weighted loss function and extend it to an effective procedure by employing techniques from the recently active area of learning-to-learn (meta-learning). Specifically, we take inner-loop gradient steps to dynamically estimate posterior distributions over the hyperparameters of our loss function. Thus, our method is model-agnostic, requiring no additional model parameters and no network architecture changes; instead, only a few efficient algorithmic modifications are needed to improve performance in MDL. We demonstrate our solution to a fitting problem in medical imaging, specifically, in the automatic segmentation of white matter hyperintensity (WMH). We look at two neuroimaging modalities (T1-MR and FLAIR) with complementary information fitting for our problem., Comment: IEEE International Symposium on Biomedical Imaging 2021

Background Age, human immunodeficiency virus (HIV) infection, illicit drug use, and central nervous system (CNS) opportunistic infections can affect brain structure, with the striatum being particularly sensitive to HIV effects. Nevertheless, the impact of non-CNS AIDS-defining illness (ADI) on brain structure has been less investigated. We examined ADI and HIV effects on brain volume. Methods In a cross-sectional study, including 95 virally suppressed seropositive and 84 demographically matched, seronegative participants, we examined serostatus and ADI effects. Cortical and subcortical gray matter volume (GMV) regions of interest were estimated with computational neuroanatomy techniques applied to high-resolution, T1-weighted magnetic resonance imaging data. Linear regression was used to model HIV serostatus and ADI effects on global and regional GMV, adjusting for age, sex, CD4 nadir, drug use, and total intracranial volume. Results While HIV serostatus was associated with lower striatal volume (B = −.59 [95% confidence interval {CI}, −1.08 to −.10]), co-occurring ADI was independently associated with lower striatal volume (B = −.73 [95% CI, −1.36 to −.09]). ADI was also associated with lower global (B = −19.35 [95% CI, −32.42 to −6.29]) and regional GMV. Conclusions While HIV infection is associated with a localized effect on striatal structure, having a prior ADI is a strong predictor of smaller global and regional GMV. The lack of interaction between HIV serostatus or ADI with age suggests that chronic HIV infection and ADI have independent effects on brain structure, without associated accelerated lower volume with age. ADI history should be incorporated into statistical adjustments in HIV neuroimaging analysis. These findings also lend support to current HIV treatment guidelines urging prompt antiretroviral therapy initiation after HIV diagnosis.

Objectives Primary Objective: To determine if pre-exposure prophylaxis (PrEP) with 400mg hydroxychloroquine (HCQ), taken orally once daily reduces microbiologically confirmed COVID-19 among front line health care workers at high risk for SARS-CoV-2 exposure. Secondary Objectives: To compare the following between study arms: adverse events; symptomatic COVID-19; duration of symptomatic COVID-19; days hospitalized attributed to COVID-19; respiratory failure attributable to COVID-19 requiring i) non-invasive ventilation or ii) intubation/mechanical ventilation; mortality attributed to COVID-19, number of days unable to work attributed to COVID-19, seroconversion (COVID-19 negative to COVID-19 positive over the study period); ability of participant plasma to neutralize SARS-CoV-2 virus in vitro; To describe short-term psychological distress associated with risk of COVID-19 exposure at 1, 60, 120 days of the study. To explore laboratory markers within participants with confirmed COVID-19: including circulating markers of host immune and endothelial activation in participant plasma and their correlation with disease severity and outcome Trial design The HEROS study is a two-arm, parallel-group, individually randomized (1:1 allocation ratio), placebo controlled, participant and investigator-blinded, multi-site superiority trial of oral HCQ 400 mg taken once daily for 90 days as PrEP to prevent COVID-19 in health care workers at high risk of SARS-CoV-2 exposure. At 90 days, there is an open label extension wherein all participants are offered a one-month course of HCQ 400mg once daily for PrEP of COVID-19. Participants Frontline HCWs aged 18 years of age or older, at high risk of SARS-CoV-2 exposure (including staff of emergency departments, intensive care units, intubation teams, COVID-wards, and staff deployed to Long Term Care facilities) of five academic hospitals in downtown Toronto, Canada. Exclusion criteria include: currently pregnant, planning to become pregnant during the study period, and/or breast feeding; known hypersensitivity/allergy to hydroxychloroquine or to 4-aminoquinoline compounds; current use of hydroxychloroquine; known prolonged QT syndrome and/or baseline resting ECG with QTc>450 ms and/or concomitant medications which simultaneously may prolong the QTc that cannot be temporarily suspended/replaced; known pre-existing retinopathy, G6PD deficiency, porphyria, liver disease including cirrhosis, encephalopathy, hepatitis or alcoholism, diabetes on oral hypoglycemics or insulin, or renal insufficiency/failure; disclosure of self-administered use of hydroxychloroquine or chloroquine within 12 weeks prior to study; confirmed symptomatic COVID-19 at time of enrollment. Intervention and comparator Intervention: hydroxychloroquine, 400mg (2 tablets) orally per day. Comparator: placebo, two tablets visually identical to the intervention, orally per day Main outcomes The primary outcome is microbiologically confirmed COVID-19 (i.e. SARS-CoV-2 infection). This is a composite endpoint which includes positive results from any validated SARS-CoV-2 diagnostic assay including detection of viral RNA, and/or seroconversion. Participants will be assessed at baseline, and then undergo monthly follow-up at day 30, 60, and 90, 120. At each visit, participants will provide an oropharyngeal sample, blood sample, and will undergo electrocardiogram monitoring of the QTc interval. Secondary outcome measures include: adverse events; symptom duration of COVID-19; days of hospitalization attributed to COVID-19; respiratory failure requiring ventilator support attributed to COVID-19; mortality attributed to COVID-19; total days off work attributed to COVID-19; seropositivity (reactive serology by day 120); and short term psychological impact of exposure to SARS-CoV-2 at day 1, 60, 120 days using the K10, a validated measure of non-specific psychological distress. Randomisation Within each site, participants will be individually randomized to either the intervention arm with HCQ or the placebo arm using a fixed 1:1 allocation ratio using an interactive web-based response system to ensure concealment of allocation. Randomization schedules will be computer-generated and blocked using variable block sizes. Blinding (masking) All participants, research coordinators, technicians, clinicians and investigators will be blinded to the participant allocation group. Numbers to be randomised (sample size) N=988, randomised into two groups of 494 patients. Trial Status This summary describes protocol version No. 1.6, May 15, 2020. Recruitment is ongoing - started April 20, 2020 and anticipated end date is July 30, 2021 Trial registration ISRCTN.com Identifier: ISRCTN14326006, registered April 14, 2020. Full protocol The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

The current study builds on past research on mother-child attachment and affective teacher-child relationships by explicitly considering the role of child-teacher dependency in preschool as a pathway through which early mother-child attachment is associated with children’s behavior problems across middle childhood. Data include direct assessments of attachment security and attachment styles, teacher reports of child-teacher dependency, and maternal reports of behavior problems from the NICHD SECCYD (N = 769 children). Children with more secure attachments at 24 months were less likely to exhibit child-teacher dependency at 54 months. Children with ambivalent, controlling, or insecure/other attachments at 36 months had higher levels of child-teacher dependency at 54 months, relative to securely attached children. Results from multi-level models showed that child-teacher dependency at 54 months was associated with higher levels of internalizing behavior problems across middle childhood (first to fifth grade), but not with externalizing behaviors. Child-teacher dependency partially mediated the association between insecure/other mother-child attachment and internalizing behaviors in middle childhood. Supporting teachers to reduce child-teacher dependency in preschool settings may help ameliorate risk for internalizing behaviors posed by insecure/other attachment.

Objective Parental accommodation contributes to the maintenance of child anxiety and related symptoms. The current study examines the contributions of parent and child factors to parental accommodation in a sample of anxious youth. Methods Sixty-four treatment-seeking youth (6-16 years) and their mothers, as well as a subset of fathers (N = 41) reported on parental accommodation, parental distress and emotion regulation, child psychopathology, child externalizing behaviors, and child intolerance of uncertainty. Results Parental accommodation was not related to parental distress or emotion regulation. Parents who viewed their child as being more symptomatic (e.g., anxious, externalizing, and intolerant of uncertainty) were more likely to engage in accommodation. For mothers, child anxiety and externalizing symptoms were notable predictors of accommodation. Conclusions Parent perceptions of child symptomology is an important factor significantly related to accommodation behaviors. This finding can be used to inform programming designed to target parental responses to child anxiety and related disorders.

Objective This study investigates where parents learn about, and what parents know about child mental health services. Parents who are better informed about mental health services may be more likely to utilize services for their children. Methods In a national online survey, 196 parents of children between the ages of 4 and 17 years reported on their information-seeking behaviors and their familiarity and experience with psychosocial approaches. Results Parents reported utilizing multiple information sources with mental health providers, pediatricians, and social networks being the most prominent. Parents' trust in different sources varied, with parents generally trusting healthcare professionals the most. Parents exposed to mental health services were more aware of specific therapeutic approaches. Conclusions Data on how parents receive and understand mental health-related information contributes to ongoing dissemination and implementation efforts.

Rationale and Objectives Although substantial increases in publications by female academic radiologists have appeared over the last several decades, it is possible that the rate of increase is decreasing. We examined temporal trends in gender composition for full-time radiology faculty, radiology residents, and medical students over a 46-year period. Methods We examined authorship gender trends to determine if the increases in female authorship seen since 1970 have been sustained in recent years and whether female radiologists continue to publish in proportion to their numbers in academic departments. Original articles for selected years in Radiology and in the American Journal of Roentgenology between 1970 and 2016 were examined to determine the gender of first, corresponding, and last authors. Generalized linear models evaluated (1) changes in proportions of female authorship over time and (2) associations between proportions of female authorship and female radiology faculty representation. Results While linear increases in first, corresponding, and senior authorships were observed for female radiologists from 1970 to 2000, the rate of increase in female first and corresponding authorships then changed, with the slope of the first author relationship decreasing from 0.81 to 0.34, corresponding to 47% fewer female first authors added per year. In contrast, the proportion of female last authorship continued to increase at the same rate. The proportion of female first authorship was linearly related to the proportion of female radiology faculty from 1970 to 2016. Conclusions Annual increases in first author academic productivity of female radiologists have lessened in the past 16 years, possibly related to reductions in the growth of female radiology faculty and trainees. As mixed, compared to homogeneous gender, authorship teams are associated with more citations, efforts to encourage more women to pursue careers in academic radiology could benefit the radiology research community.

ObjectiveFew studies have examined the challenges faced by emergency medicine (EM) physicians in conducting goals of care discussions. This study is the first to describe the perceived barriers and facilitators to these discussions as reported by Canadian EM physicians and residents.MethodsA team of EM, palliative care, and internal medicine physicians developed a survey comprising multiple choice, Likert-scale and open-ended questions to explore four domains of goals-of-care discussions: training; communication; environment; and patient beliefs.ResultsSurveys were sent to 273 EM staff and residents in six sites, and 130 (48%) responded. Staff physicians conducted goals-of-care discussions several times per month or more, 74.1% (80/108) of the time versus 35% (8/23) of residents. Most agreed that goals-of-care discussions are within their scope of practice (92%), they felt comfortable having these discussions (96%), and they are adequately trained (73%). However, 66% reported difficulty initiating goals-of-care discussions, and 54% believed that admitting services should conduct them. Main barriers were time (46%), lack of a relationship with the patient (25%), patient expectations (23%), no prior discussions (21%), and the inability to reach substitute decision-makers (17%). Fifty-four percent of respondents indicated that the availability of 24-hour palliative care consults would facilitate discussions in the emergency department (ED).ConclusionsImportant barriers to discussing goals of care in the ED were identified by respondents, including acuity and lack of prior relationship, highlighting the need for system and environmental interventions, including improved availability of palliative care services in the ED.

Research Findings: This study investigated how mean classroom-level shyness scores moderated the impacts of INSIGHTS into Children’s Temperament on instructional support and students’ math and read...

BACKGROUND: Numerous studies have used structural neuroimaging to measure HIV effects on brain macroarchitecture. While many have reported changes in total brain volume, gray matter volume, white matter volume, CSF volume, and basal ganglia volume following HIV infection, quantitative inconsistencies observed across studies are large. PURPOSE: Our aim was to evaluate the consistency and temporal stability of serostatus effects on a range of structural neuroimaging measures. DATA SOURCES: PubMed, reference lists, and corresponding authors. STUDY SELECTION: The meta-analysis included 19 cross-sectional studies reporting HIV effects on cortical and subcortical volume from 1993 to 2016. DATA ANALYSIS: Random-effects meta-analysis was used to estimate individual study standardized mean differences and study heterogeneity. Meta-regression was used to examine the effects of the study publication year. DATA SYNTHESIS: Meta-analysis revealed standardized mean differences related to the serostatus of −0.65 ( P = .002) for total brain volume, −0.28 for gray matter volume ( P = .008), −0.24 ( P = .076) for white matter volume, and 0.56 ( P = .001) for CSF volume. Basal ganglia volume differences related to serostatus were not significant. Nevertheless, estimates of between-study heterogeneity suggested that much of the observed variance was between studies. Publication year was associated with recent reductions in many neurostructural effects. LIMITATIONS: Many studies pooled participants with varying durations of treatment, disease, and comorbidities. Image-acquisition methods changed with time. CONCLUSIONS: While published studies of HIV effects on brain structure had substantial variations that are likely to result from changes in HIV treatment practice during the study period, quantitative neurostructural measures can reliably detect the effects of HIV infection during treatment, serving as reliable biomarkers.

Spontaneous visual recovery is rare after cortical blindness. While visual rehabilitation may improve performance, no visual therapy has been widely adopted, as clinical outcomes are variable and rarely translate into improvements in activities of daily living (ADLs). We explored the potential value of a novel rehabilitation approach "cognitive therapeutic exercises" for cortical blindness.The subject of this case study was 48-year-old woman with cortical blindness and tetraplegia after cardiac arrest. Prior to the intervention, she was dependent in ADLs and poorly distinguished shapes and colors after 19 months of standard visual and motor rehabilitation. Computed tomographic images soon after symptom onset demonstrated acute infarcts in both occipital cortices.The subject underwent 8 months of intensive rehabilitation with "cognitive therapeutic exercises" consisting of discrimination exercises correlating sensory and visual information.Visual fields increased; object recognition improved; it became possible to watch television; voluntary arm movements improved in accuracy and smoothness; walking improved; and ADL independence and self-reliance increased. Subtraction of neuroimaging acquired before and after rehabilitation showed that focal glucose metabolism increases bilaterally in the occipital poles.This study demonstrates feasibility of "cognitive therapeutic exercises" in an individual with cortical blindness, who experienced impressive visual and sensorimotor recovery, with marked ADL improvement, more than 2 years after ischemic cortical damage.Video Abstract available for additional insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A173).

Research Findings: Home-based involvement—defined as the actions parents take to promote children’s learning outside of school—is often the most efficient way for low-income parents to be involved with their children’s education. However, there is limited research examining the factors predicting home-based involvement at kindergarten entry for low-income families. This is a notable oversight given established links between parent involvement and children’s educational outcomes. To learn more about this gap, we used data from 220 low-income, urban students to examine associations between 4 dimensions of child temperament—negative reactivity, task persistence, withdrawal/shyness, and motor activity—and home-based parent involvement. Parent–child conflict was also examined as a mechanism explaining associations between dimensions of child temperament and parent involvement. Hierarchical multiple regression analyses revealed that a withdrawn/shy temperament in children predicted lower levels of home-...

Innovation Concept: Research training programs for students, especially in emergency medicine (EM), may be difficult to initiate due to lack of protected time, resources, and mentors (Chang Y, Ramnanan CJ. Academic Medicine 2015). We developed a ten-week summer program for medical students aimed at cultivating research skills through mentorship, clinical enrichment, and immersion in EM research culture through shadowing and project support. Methods: Five second year Ontario medical students were recruited to participate in the Summer Training and Research in Emergency Medicine (STAR-EM) program at University Health Network, Toronto, from June - Aug, 2019. Program design followed review of existing summer research programs and literature regarding challenges to EM research (McRae, Perry, Brehaut et al. CJEM 2018). The program had broad emergency physician (EP) engagement, with five EP research project mentors, and over ten EPs delivering academic sessions. Curriculum development was collaborative and iterative. All projects were approved by the hospital Research Ethics Board (REB). Curriculum, Tool or Material: Each weekly academic morning comprised small group teaching (topics including research methodology, manuscript preparation, health equity, quality improvement, and wellness), followed by EP-led group progress review of each student's project. Each student spent one half day per week in the emergency department (ED), shadowing an EP and identifying patients for recruitment for ongoing mentor-initiated ED research projects. Remaining time was spent on independent student project work. Presentation to faculty and program evaluation occurred in week 10. Scholarly output included one abstract submitted for publication per student. Program evaluation by students reflected a uniform impression that course material and mentorship were each excellent (100%, n = 5). Interest in pursuing academic EM as a career was identified by all students. Faculty researchers rated the program as very effective (80%, n = 4) or somewhat effective (20%, n = 1) in terms of enhancing productivity and scholarly output. Conclusion: The STAR-EM program provides a transferable model for other academic departments seeking to foster the development of future clinician investigators and enhance ED research culture. Program challenges included delays in REB approval for student projects and engaging recalcitrant staff to participate in research.

Introduction: Outpatient oncology clinics have become the mainstay of cancer treatment, but their limited services and hours of operation often lead to emergency department (ED) referrals. With Canada's aging population and cancer survival rates improving, cancer-related ED visits are becoming a significant aspect of emergency medicine. A cancer-related visit to the ED is associated with unique challenges for patients, their caregivers and clinicians. This study focuses on understanding the ED experience of patients and their caregivers sent from an outpatient oncology clinic to a separate affiliated large academic hospital. Methods: A descriptive, phenomenological study of interviews was conducted using the method of Giorgi. The sample included 12 participants (n = 9 patients, 3 caregivers) referred to the ED at a large academic hospital (i.e., Toronto General Hospital, TGH) following a same-day outpatient oncology appointment at an affiliated cancer centre (i.e., Princess Margaret Hospital, PMH). Interviews continued until thematic saturation. All transcripts were analyzed by 2 reviewers with bracketing to ensure accuracy. Results: Four themes were identified from analysis: (1) communication; (2) expectations; (3) care and symptom management and (4) potential improvements. Overall patients and caregivers felt communication between PMH and TGH, and from providers could have been better. Many felt there was a break-down in communication as they did not expect to go through the usual ED triage process, which caused additional anxiety and frustration with the wait times. The majority felt their symptoms were managed in a timely manner and reported the staff to be friendly, caring and professional; however, often felt forgotten and anxious due to a lack of “checking-in”. Their experience could have been improved by receiving more information on the process, a more welcoming environment and separate waiting area or private room for those who are immunocompromised. Conclusion: Although referral from an outpatient oncology clinic to the ED of an affiliated hospital is a common process within Canada, this is the first study to explore the patient and caregiver experience. Understanding the patient and caregiver experience is valuable for identifying quality improvement initiatives. Our analysis revealed the patient and caregiver experience could be improved with better communication and expectation setting regarding the ED process before and throughout the visit.

Depression is one of the leading causes of disability worldwide. Its effects impact individuals as well as families, communities, and the broader society. When depression is comorbid with other conditions, such as intellectual disabilities, a unique combination of challenges is presented that can make treatment efficacy difficult. The treatment efficacy literature contains much evidence from research on adults without intellectual disabilities, which provides the best support for combined treatments of CBT and psychopharmacological interventions. Although a smaller base of research exists for depression in youth, similar conclusions can be found; however, effect sizes tend to be smaller. For individuals with depression and comorbid disability, the research is very much in nascent stages. Conclusions for a clinical course of treatment must therefore rely on evidence from typically developing adults and youth, with appropriate adaptations based on the particular intellectual deficits that are present. This chapter explores evidence for depression treatment in typically developing adults and youth as well as for individuals with comorbid intellectual disabilities. Implications for treatment adaptations and directions for future research are also considered.

Background: Autopsy data suggest a causative link between meningeal inflammation and cortical lesions (CLs) in multiple sclerosis (MS). Objective: To use leptomeningeal enhancement (LME) and CLs on 7-Tesla (7T) magnetic resonance imaging (MRI) to investigate associations between meningeal inflammation and cortical pathology. Methods: Forty-one participants with MS underwent 7T MRI of the brain. CLs and foci of LME were quantified. Results: All MS participants had CLs; 27 (65.8%) had >1 focus of LME. Except for hippocampal CL count (ρ = 0.32 with spread/fill-sulcal pattern LME, p = 0.042), no significant correlations were seen between LME and CLs. Mean cortical thickness correlated with the number of LME foci (ρ = –0.43, p = 0.005). Participants with relapsing–remitting multiple sclerosis (RRMS) showed no correlation with neocortical CLs, but significant correlations were seen between LME and hippocampal lesion count (ρ = 0.39, p = 0.030), normalized cortical gray matter (GM) volume (ρ = –0.49, p = 0.005), and mean cortical thickness (ρ = –0.59, p Conclusion: This study supports a relationship between LME and cortical GM atrophy but does not support an association of LME and neocortical CLs. This may indicate that meningeal inflammation is involved with neurodegenerative inflammatory processes, rather than focal lesion development.

While resting state fMRI (rs-fMRI) has gained widespread application in neuroimaging clinical research, its penetration into clinical medicine has been more limited. We surveyed a neuroradiology professional group to ascertain their experience with rs-fMRI, identify perceived barriers to using rs-fMRI clinically and elicit suggestions about ways to facilitate its use in clinical practice. The electronic survey also collected information about demographics and work environment using Likert scales. We found that 90% of the respondents had adequate equipment to conduct rs-fMRI and 82% found rs-fMRI data easy to collect. Fifty-nine percent have used rs-fMRI in their past research and 72% reported plans to use rs-fMRI for research in the next year. Nevertheless, only 40% plan to use rs-fMRI in clinical practice in the next year and 82% agreed that their clinical fMRI use is largely confined to pre-surgical planning applications. To explore the reasons for the persistent low utilization of rs-fMRI in clinical applications, we identified barriers to clinical rs-fMRI use related to the availability of robust denoising procedures, single-subject analysis techniques, demonstration of functional connectivity map reliability, regulatory clearance, reimbursement, and neuroradiologist training opportunities. In conclusion, while rs-fMRI use in clinical neuroradiology practice is limited, enthusiasm appears to be quite high and there are several possible avenues in which further research and development may facilitate its penetration into clinical practice.

Reseña de Estado y colonialidad. Mujeres y familias quichuas de la Sierra del Ecuador, 1925-1975

BACKGROUND AND PURPOSE: Many scientific journals use double-blind peer review to minimize potential reviewer bias concerning publication recommendations. However, because neuroradiology is a relatively small subspecialty, this process may be limited by prior knowledge of the authors9 work or associated institutions. We sought to investigate the efficacy of reviewer blinding and determine the impact that unblinding may have on manuscript acceptance. MATERIALS AND METHODS: For manuscripts submitted to the American Journal of Neuroradiology (AJNR) from January through June 2015, reviewers completed a brief anonymous questionnaire after submitting their evaluations, assessing whether they were familiar with the research or had knowledge of the authors or institutions from which the work originated. RESULTS: The response rate for 1079 questionnaires was 98.8%; 12.9% of reviewers knew or suspected that they knew authors, and 15.3% knew or suspected that they knew the associated institutions. Reviewers correctly identified the authors in 90.3% of cases and correctly stated the institutions in 86.8% of cases. Unblinding resulted from self-citation in 34.1% for both authorship and institutions. The acceptance rate when reviewers knew or suspected that they knew the authors was 57/137 (41.6%) and 262/929 (28.2%) when reviewers did not. The acceptance rate when reviewers knew or suspected that they knew the institutions was 60/163 (36.8%) and 259/903 (28.7%) when they did not. The Fisher exact test showed that author (P CONCLUSIONS: While the AJNR process of double-blind peer review minimizes reviewer bias, perceived knowledge of the author and institution is associated with a higher rate of manuscript acceptance.

Maternal depression is a well-documented risk factor for youth depression, and taking into account its severity and chronicity may provide important insight into the degree of risk conferred. This study explored the degree to which the severity/chronicity of maternal depression history explained variance in youth internalizing and externalizing symptoms above and beyond current maternal depressive symptoms among 171 youth (58% male) ages 8 to 12 over a span of three years. Severity and chronicity of past maternal depression and current maternal depressive symptoms were examined as predictors of parent-reported youth internalizing and externalizing symptomatology, as well as youth self-reported depressive symptoms. Severity and chronicity of past maternal depression did not account for additional variance in youth internalizing and externalizing symptoms at Time 1 beyond what was accounted for by maternal depressive symptoms at Time 1. Longitudinal growth curve modeling indicated that prior severity/chronicity of maternal depression predicted levels of youth internalizing and externalizing symptoms at each time point when controlling for current maternal depressive symptoms at each time point. Chronicity of maternal depression, apart from severity, also predicted rate of change in youth externalizing symptoms over time. These findings highlight the importance of screening and assessing for current maternal depressive symptoms, as well as the nature of past depressive episodes. Possible mechanisms underlying the association between severity/chronicity of maternal depression and youth outcomes, such as residual effects from depressive history on mother–child interactions, are discussed.

Rationale and ObjectivesIn flipped learning, medical students independently learn facts and concepts outside the classroom, and then participate in interactive classes to learn to apply these facts. Although there are recent calls for medical education reform using flipped learning, little has been published on its effectiveness. Our study compares the effects of flipped learning to traditional didactic instruction on students' academic achievement, task value, and achievement emotions.Materials and MethodsAt three institutions, we alternated flipped learning with traditional didactic lectures during radiology clerkships, with 175 medical students completing a pretest on general diagnostic imaging knowledge to assess baseline cohort comparability. Following instruction, posttests and survey examinations of task value and achievement emotions were administered. Linear mixed effects analysis was used to examine the relationship between test scores and instruction type. Survey responses were modeled using ordinal category logistic regression. Instructor surveys were also collected.ResultsThere were no baseline differences in test scores. Mean posttest minus pretest scores were 10.5% higher in the flipped learning group than in the didactic instruction group (P = 0.013). Assessment of task value and achievement emotions showed greater task value, increased enjoyment, and decreased boredom with flipped learning (all P

Social-Emotional Learning (SEL) programs aim to improve students' social-emotional competencies in order to enhance their achievement. Although SEL programs typically implement classroom curricula, some programs also include a component for parents. Yet, little is known about the types of parents likely to participate in services, and whether parent participation moderates program effects on student outcomes in low-income urban schools. This article aims to fill these gaps in the literature using data from the randomized trial of the SEL program INSIGHTS into Children's Temperament (N = 435 parent/child dyads), which was conducted in 22 low-income urban elementary schools during children's kindergarten and first-grade year. Descriptive findings revealed that children at lower risk for poor achievement had parents who were more likely to participate in program services. In addition, findings from inverse probability of treatment-weighting models demonstrated larger effects of INSIGHTS on academic, ...

Parental accommodation plays a key role in the maintenance of child anxiety, yet much of the research to date has been correlational, making it difficult to draw conclusions about underlying mechanisms. Given preliminary evidence that parental beliefs play a role in parental accommodation, the present study sought to experimentally reduce accommodation by targeting parental attitudes about child anxiety. Mothers of children ages 4-9 (N = 47) were randomly assigned to either receive brief instruction in cognitive reappraisal (EXP) or to a control intervention in which they received no instruction (CON). At pre- and post-intervention mothers were presented with bogus information that their child was experiencing varying levels of distress while completing a task in a nearby room. Maternal distress, negative affect and perceived likelihood of accommodation in the context of child distress were measured pre- and post-intervention. EXP mothers reported greater pre- to post-intervention decreases in distress and perceived likelihood of accommodation, compared to CON mothers. EXP and CON mothers showed similar changes in negative affect. Findings from this study provide preliminary experimental evidence that targeting maternal beliefs about child anxiety can result in changes in maternal distress and behavior following exposure to child distress. Implications for prevention and treatment are discussed.

Introduction: Nearly 50% of Canadians will develop cancer in their lifetime (1), and the vast majority of those with cancer will visit the emergency department (ED) in their last 6 months of life (2). Considering the aging population, improvement in cancer survival and current practice of managing cancer in outpatient settings, cancer-related emergencies are becoming a significant aspect of emergency medicine. The presenting symptoms and rates of hospitalization for cancer-related ED visits have largely been established. The current study characterizes the patterns of ED utilization and time-course of events for cancer-related ED visits following same-day outpatient oncology appointments resulting in admission to hospital compared to those not admitted. Methods: A retrospective chart-review was used to identify 231 adult patients who visited the ED at a large academic hospital (i.e., Toronto General Hospital) following a same-day outpatient oncology appointment at an affiliated cancer centre (i.e., Princess Margaret Hospital) from March to May 2019, using administrative data. Results: All visits occurred on weekdays (avg = 4 visits/d) and 57% of visits resulted in hospitalization. Between those admitted and not admitted to hospital, there was no difference in triage time [17:23 + 0:14 vs. 17:01 + 0:20 h, p = 0.47; mean(SD)]. Visits resulting in hospitalization were more urgent (median CTAS score = 2 vs. 3, p 0.05) between groups. The patients transferred from oncology clinics were triaged at 17:13(0:11) h compared to 13:56(0:03) h for all ED visits during the same time frame. Conclusion: Most patients sent from oncology clinics to the ED are admitted, and when admitted they spend an additional 10 h waiting for a bed on the ward. These patients tend to arrive later in the day compared to other ED patients. Understanding utilization patterns and time-course of events allows for objective identification of quality improvement initiatives. 1 Canadian Cancer Society, 2015 2 Barbera et al. CMAJ, 2010

The age of the HIV-infected population is increasing. Although many studies document gray matter volume (GMV) changes following HIV infection, GMV also declines with age. Findings have been inconsistent concerning interactions between HIV infection and age on brain structure. Effects of age, substance use, and inadequate viral suppression may confound identification of GMV serostatus effects using quantitative structural measures. In a cross-sectional study of HIV infection, including 97 seropositive and 84 seronegative, demographically matched participants, ages 30–70, we examined serostatus and age effects on GMV and neuropsychological measures. Ninety-eight percent of seropositive participants were currently treated with anti-retroviral therapies and all were virally suppressed. Gray, white, and CSF volumes were estimated using high-resolution T1-weighted MRI. Linear regression modeled effects of serostatus, age, education, comorbidities, and magnetic field strength on brain structure, using both a priori regions and voxel-based morphometry. Although seropositive participants exhibited significant bilateral decreases in striatal GMV, no serostatus effects were detected in the thalamus, hippocampus, or cerebellum. Age was associated with cortical, striatal, thalamic, hippocampal, and cerebellar GMV reductions. Effects of age and serostatus on striatal GMV were additive. Although no main effects of serostatus on neuropsychological performance were observed, serostatus moderated the relationship between pegboard performance and striatal volume. Both HIV infection and age were associated with reduced striatal volume. The lack of interaction of these two predictors suggests that HIV infection is associated with premature, but not accelerated, brain age. In serostatus groups matched on demographic and clinical variables, there were no observed differences in neuropsychological performance. Striatal GMV measures may be promising biomarker for use in studies of treated HIV infection.

Clinically apparent HIV infection, accompanied by CNS opportunistic infections and HIV encephalopathy, was often associated with profound structural and functional brain effects prior to the introduction of anti-retroviral therapy (ART). With treatment, HIV structural and functional brain effects are smaller and have not been as easily detected. With near complete elimination of CNS opportunistic infections, the HIV neuroimaging research community now grapples with the problem of detecting subtler structural and functional changes against a background of persisting confounds, such as comorbidities and clinical features common in the HIV infected population. This situation also raises the question of whether imaging measure changes that are reported as HIV brain effects are purely related to viral infection, rather than originating from confounding effects that might include age, substance use, hepatitis C coinfection, cerebrovascular risk factors, ART, premorbid cognitive skills and illness duration. In addition to cohort characteristics, variation in image acquisition and analysis techniques may also contribute to study outcome heterogeneity. We review the potential effects of these confounds on detection of HIV infection effects and discuss strategies to avoid or mitigate the effects of these confounds. We then present a systematic approach to measurement, design and analysis in HIV neuroimaging studies, combining both experimental and statistical control techniques to determine if HIV infection effects persist, fluctuate or worsen in groups achieving viral suppression from ART.

ObjectiveThe need for clinical staff to reliably identify patients with a shortened life expectancy is an obstacle to improving palliative and end-of-life care. We developed and evaluated the feasibility of an automated tool to identify patients with a high risk of death in the next year to prompt treating physicians to consider a palliative approach and reduce the identification burden faced by clinical staff.MethodsTwo-phase feasibility study conducted at two quaternary healthcare facilities in Toronto, Canada. We modified the Hospitalised-patient One-year Mortality Risk (HOMR) score, which identifies patients having an elevated 1-year mortality risk, to use only data available at the time of admission. An application prompted the admitting team when patients had an elevated mortality risk and suggested a palliative approach. The incidences of goals of care discussions and/or palliative care consultation were abstracted from medical records.ResultsOur model (C-statistic=0.89) was found to be similarly accurate to the original HOMR score and identified 15.8% and 12.2% of admitted patients at Sites 1 and 2, respectively. Of 400 patients included, the most common indications for admission included a frailty condition (219, 55%), chronic organ failure (91, 23%) and cancer (78, 20%). At Site 1 (integrated notification), patients with the notification were significantly more likely to have a discussion about goals of care and/or palliative care consultation (35% vs 20%, p = 0.016). At Site 2 (electronic mail), there was no significant difference (45% vs 53%, p = 0.322).ConclusionsOur application is an accurate, feasible and timely identification tool for patients at elevated risk of death in the next year and may be effective for improving palliative and end-of-life care.

HIV and hepatitis C virus (HCV) have both been associated with cognitive impairment. Combination antiretroviral therapy (cART) has dramatically changed the nature of cognitive impairment in HIV-infected persons, while the role of direct-acting antivirals (DAA) in neurocognition of HCV-infected individuals remains unclear. Also, whether HIV and HCV interact to promote neurocognitive decline or whether they each contribute an individual effect continues to be an open question. In this work, we review the virally mediated mechanisms of HIV- and HCV-mediated neuropathogenesis, with an emphasis on the role of dual infection, and discuss observed changes with HIV viral suppression and HCV functional cure on neurocognitive impairments.