Search

Carotid plaque vulnerability features beyond the degree of stenosis may play a key role in the pathogenesis and recurrence of ischemic cerebrovascular events. This study sought to compare intraplaque hemorrhage (IPH) as a marker of plaque vulnerability in symptomatic patients with mild ( We included patients who experienced ischemic cerebrovascular events with no other identifiable sources and underwent carotid endarterectomy for mild (n=32), moderate (n=47), and severe (n=58) carotid artery stenosis. The degree of stenosis and imaging hallmarks were assessed by computed tomography angiography or magnetic resonance angiography. Plaque specimens were stained with hematoxylin and eosin and Movat pentachrome staining. Carotid plaques of patients with mild stenosis had a higher extent of IPH (%) on tissue analysis compared with patients with moderate (mild, 15.7% [interquartile range, 7.8%–26.7%]; moderate, 3.9% [0.0%–9.2%]; P P P Our major finding is the association of IPH with mild carotid artery stenosis based on histological analysis. The current study may suggest that IPH potentially plays a role in the mechanism of stroke in patients with nonobstructive carotid stenosis.

Background Vaccinating children (≤17 years old) is important for controlling the COVID-19 pandemic. As parents are primary decision makers for their children, we aimed to assess parents’ perceptions and intentions regarding COVID-19 vaccination for their children, including for some underserved populations (e.g., newcomers, Indigenous peoples, and visible minority groups). Methods We conducted a cross-sectional national survey of Canadian parents in December 2020, just as COVID-19 vaccines were approved for adults, to assess intention to vaccinate their children (aged 0–17 years) against COVID-19, perceptions of COVID-19 disease and vaccines, previous uptake of influenza and routine vaccines, and sociodemographic characteristics. Binomial logistic regression was used to assess the association between parents' lack of COVID-19 vaccination intention for their children and various independent variables. Results Sixty-three percent of parents (1074/1702) intended to vaccinate their children against COVID-19. Those employed part-time (compared to full-time) had lower intention to vaccinate their children (aOR = 1.73, 95% CI: 1.06–2.84), while those who spoke languages other than English, French, or Indigenous languages were less likely to have low intention (aOR = 0.55, 95% CI: 0.32–0.92). Low vaccination intention was also associated with children not receiving influenza vaccine pre-pandemic (aOR = 1.51, 95% CI: 1.04–2.21), parents having low intention to vaccinate themselves against COVID-19 (aOR = 9.22, 95% CI: 6.43–13.34), believing COVID-19 vaccination is unnecessary (aOR = 2.59, 95% CI: 1.72–3.91) or unsafe (aOR = 4.21, 95% CI: 2.96–5.99), and opposing COVID-19 vaccine use in children without prior testing (aOR = 3.09, 95% CI: 1.87–5.24). Interpretation Parents’ COVID-19 vaccination intentions for their children are better predicted by previous decisions regarding influenza vaccination than routine childhood vaccines, and other perceptions of COVID-19 vaccine-related factors. Public communication should highlight the safety and necessity of COVID-19 vaccination in children to support a return to normal activities. Further research should assess actual COVID-19 vaccination uptake in children, particularly for underserved populations.

Hip pain is a common and complex clinical entity. The causes of hip injuries in athletes are many and diverse, requiring efficient, accurate diagnosis for proper management. Imaging is an important step in the clinical evaluation of hip pain, and familiarity with multiple imaging modalities as well as characteristic imaging findings is a helpful tool for sports medicine clinicians. This article discusses imaging recommendations and gives imaging examples of common causes of intra-articular and extra-articular hip pain including femoroacetabular impingement, labral tears, cartilage defects, ligamentum teres injuries, snapping hip syndrome, femoral stress injuries, thigh splints, athletic pubalgia, avulsion injuries, and hip dislocation.

Longitudinal follow-up, resource utilization, and health disparities are top congenital heart research and care priorities. Medicaid claims include longitudinal data on inpatient, outpatient, emergency, pharmacy, rehabilitation, home health utilization, and social determinants of health-including mother-infant pairs.The New York Congenital Heart Surgeons Collaborative for Longitudinal Outcomes and Utilization of Resources linked robust clinical details from locally held state and national registries from 10 of 11 New York congenital heart centers to Medicaid claims, building a novel, statewide mechanism for longitudinal assessment of outcomes, expenditures, and health inequities.The authors included all children 18 years of age undergoing cardiac surgery in The Society of Thoracic Surgeons Congenital Heart Surgery Database or the New York State Pediatric Congenital Cardiac Surgery Registry from 10 of 11 New York centers, 2006 to 2019. Data were linked via iterative, ranked deterministic matching on direct identifiers. Match rates were calculated and compared. Proportions of the linked cohort trackable over 3, 5, and 10 years were described.Of 14,097 registry cases, 59% (n = 8,322) reported Medicaid use. Of these, 7,414 were linked to New York claims, at an 89% match rate. Of matched cases, the authors tracked 79%, 74%, and 65% of children over 3, 5, and 10 years when requiring near-continuous Medicaid enrollment. Allowing more lenient enrollment criteria, the authors tracked 86%, 82%, and 76%, respectively. Mortality over this time was 7.7%, 8.4%, and 10.0%, respectively. Manual validation revealed ∼100% true matches.This establishes a novel statewide data resource for assessment of longitudinal outcome, health expenditure, and disparities for children with congenital heart disease.

Blood pressure variability (BPV), defined as the degree of variation between discrete blood pressure readings, is associated with poor outcomes in acute care settings. Acute kidney injury (AKI) is a common and serious postoperative complication of cardiac surgery with cardiopulmonary bypass (CPB) in children. No studies have yet assessed the association between intraoperative BPV during cardiac surgery with CPB and the development of AKI in children. A retrospective chart review of children undergoing cardiac surgery with CPB was performed. Intraoperative BPV was calculated using average real variability (ARV) and standard deviation (SD). Multiple regression models were used to examine the association between BPV and outcomes of AKI, hospital and intensive care unit (PICU) length of stay, and length of mechanical ventilation. Among 231 patients (58% males, median age 8.6 months) reviewed, 51.5% developed AKI (47.9% Stage I, 41.2% Stage II, 10.9% Stage III). In adjusted models, systolic and diastolic ARV were associated with development of any stage AKI (OR 1.40, 95% CI 1.08–1.8 and OR 1.4, 95% CI 1.05–1.8, respectively). Greater diastolic SD was associated with longer PICU length of stay (β 0.94, 95% CI 0.62–1.2). When stratified by age, greater systolic ARV and SD were associated with AKI in infants ≤ 12 months, but there was no relationship in children > 12 months. Greater BPV during cardiac surgery with CPB was associated with development of postoperative AKI in infants, suggesting that BPV is a potentially modifiable risk factor for AKI in this high-risk population.

Supplemental Digital Content is available in the text., Background: Cellular diversity of the lung endothelium has not been systematically characterized in humans. We provide a reference atlas of human lung endothelial cells (ECs) to facilitate a better understanding of the phenotypic diversity and composition of cells comprising the lung endothelium. Methods: We reprocessed human control single-cell RNA sequencing (scRNAseq) data from 6 datasets. EC populations were characterized through iterative clustering with subsequent differential expression analysis. Marker genes were validated by fluorescent microscopy and in situ hybridization. scRNAseq of primary lung ECs cultured in vitro was performed. The signaling network between different lung cell types was studied. For cross-species analysis or disease relevance, we applied the same methods to scRNAseq data obtained from mouse lungs or from human lungs with pulmonary hypertension. Results: Six lung scRNAseq datasets were reanalyzed and annotated to identify >15 000 vascular EC cells from 73 individuals. Differential expression analysis of EC revealed signatures corresponding to endothelial lineage, including panendothelial, panvascular, and subpopulation-specific marker gene sets. Beyond the broad cellular categories of lymphatic, capillary, arterial, and venous ECs, we found previously indistinguishable subpopulations; among venous EC, we identified 2 previously indistinguishable populations: pulmonary–venous ECs (COL15A1neg) localized to the lung parenchyma and systemic–venous ECs (COL15A1pos) localized to the airways and the visceral pleura; among capillary ECs, we confirmed their subclassification into recently discovered aerocytes characterized by EDNRB, SOSTDC1, and TBX2 and general capillary EC. We confirmed that all 6 endothelial cell types, including the systemic–venous ECs and aerocytes, are present in mice and identified endothelial marker genes conserved in humans and mice. Ligand-receptor connectome analysis revealed important homeostatic crosstalk of EC with other lung resident cell types. scRNAseq of commercially available primary lung ECs demonstrated a loss of their native lung phenotype in culture. scRNAseq revealed that endothelial diversity is maintained in pulmonary hypertension. Our article is accompanied by an online data mining tool (www.LungEndothelialCellAtlas.com). Conclusions: Our integrated analysis provides a comprehensive and well-crafted reference atlas of ECs in the normal lung and confirms and describes in detail previously unrecognized endothelial populations across a large number of humans and mice.

Neurosurgeons represent 0.5% of all physicians and currently face a high burden of disease. Physician-scientists are essential to advance the mission of National Academies of Science (NAS) and National Institutes of Health (NIH) through discovery and bench to bedside translation. We investigated trends in NIH neurosurgeon-scientist funding over time as an indicator of physician-scientist workforce training. We used NIH Research Portfolio Online Reporting Tools (RePORTER) to extract grants to neurosurgery departments and neurosurgeons from 1993 to 2017. Manual extraction of each individual grant awardee was conducted. After adjusting for U.S. inflation (base year: 1993), NIH funding to neurosurgery departments increased yearly (P

Type 2 diabetes (T2D) is often seen as primarily caused by weight, and its amelioration associated with individual behaviour change, which has the potential for negative consequences for people living with the disease. The aims of this study were to explore how weight was framed by diabetes resource nurses and to determine the implications of that framing for nurse practice in a primary care setting in Australia. The research was a qualitative empirical case study using semistructured interviews with nurses focusing on meanings and interpretations. The findings were interpreted using a constructivist epistemology of both inductive and deductive inference. The study found that nurses viewed overweight and obesity as unhealthy and the primary causes of T2D, and that weight was frequently discussed in the health care encounter. Nurses emphasised individual responsibility through behaviour change to manage T2D, downplaying other known causes such as age and family history and important social inequalities. Studies show that nurses have negative attitudes towards overweight and obese patients. The implications of this research are that the nurses’ views could potentially negatively affect clients’ management of T2D, which has the potential for poor health outcomes.

OBJECTIVE The objective of this study was to isolate extracellular vesicles (EVs) from plasma in a cohort of patients with traumatic brain injury (TBI) and analyze their contents for novel biomarkers that could prove useful for rapid diagnosis and classification of brain injury during initial evaluation. METHODS Plasma EVs were isolated by serial ultracentrifugation from patients with TBI (n = 15) and healthy controls (n = 5). Samples were obtained from the TRACK-TBI biorepository (2010–present). Size and concentration were determined by nanoparticle tracking. Glial fibrillary acidic protein (GFAP) concentration was determined in EV protein. EV RNA was isolated and deep sequencing of short noncoding RNA was performed. RESULTS Plasma EVs are physically similar but contained approximately 10 times more GFAP in TBI patients with altered consciousness than patients and controls with normal consciousness. Eleven highly differentially expressed microRNAs (miRNAs) were identified between these groups. Genes targeted by these miRNAs are highly associated with biologically relevant cellular pathways, including organismal injury, cellular development, and organismal development. Multiple additional coding and noncoding RNA species with potential biomarker utility were identified. CONCLUSIONS Isolating plasma EVs in patients with TBI is feasible. Increased GFAP concentration—a validated plasma TBI marker—in EVs from TBI patients with altered consciousness, along with differential expression of multiple miRNAs targeting TBI-relevant pathways, suggests that EVs may be a useful source of TBI biomarkers. Additional evaluation in larger patient cohorts is indicated.

Objective To discuss optimal treatment strategy for spindle cell oncocytoma (SCO) of the pituitary gland. Methods Institutional cases were retrospectively reviewed. A systematic literature search and subsequent quantitative synthesis were performed for further analysis. The detailed features were summarized and the tumor control rate (TCR) was calculated. Results Eighty-five patients (6 institutional and 79 literature) were included. The annual incidence was approximately 0.01–0.03/100,000. The mean age was 56 years. Vision loss was present in 60%. Seventy-three percent showed hormonal abnormalities. On magnetic resonance imaging, tumor was avidly enhancing, and the normal gland was commonly displaced anterosuperiorly. Evidence of hypervascularity was seen in 77%. Gross total resection (GTR) was achieved in only 24% because of its hypervascular, fibrous, and adhesive nature. The mean postoperative follow-up was 3.3 years for institutional cases and 2.3 years for the integrated cohort. The TCR was significantly better after GTR (5-year TCR, 75%; P = 0.012) and marginally better after non-GTR + upfront radiotherapy (5-year TCR, 76%; P = 0.103) than after non-GTR alone (5-year TCR, 24%). The TCRs for those with low Ki-67 index (≤5%) were marginally better than those with higher Ki-67 index (5-year rate, 57% vs. 23%; P = 0.110). Conclusions Frequent endocrine-related symptoms, hypervascular signs, and anterosuperior displacement of the gland support preoperative diagnosis of SCO. GTR seems to have better long-term tumor control, whereas the fibrous, hypervascular, and adhesive nature of SCO makes it difficult to achieve GTR. In patients with non-GTR, radiotherapy may help decrease tumor progression.

Objective To highlight the early experience of implementing a robotic spine surgery program at a three-site medical center, evaluating the impact of increasing experience on the operative time and number of procedures performed. Patients and Methods A retrospective chart review of patients undergoing robotic screw placement between September 4, 2018, and October 16, 2019, was conducted. Baseline characteristics as well as intraoperative and post-operative outcomes were obtained. Results For a total of 77 patients, the mean age (SD) was 55.7 years (11.5) and 49.4% (n=38) were female. A total of 402 screws were placed (384 pedicle screws, 18 cortical screws) using robotic guidance with a median of two operative levels (interquartile range [IQR], 1 to 2). Median (IQR) estimated blood loss was 100 mL (50 to 200 mL) and the median (IQR) operative time was 224 minutes (193 to 307 minutes). With accrual of surgical experience, operative time declined significantly (R=-0.39; P Conclusion Early experience at our institution using a spinal robot has demonstrated no requirement for postoperative screw revisions and no complications related to screw malposition. The increased operative times were reduced as the frequency of procedures increased. Moreover, procedural times diminished over a short period with a weekly increasing number of procedures.

Objective The collision of pituitary adenoma and craniopharyngioma is extremely rare and thus there remains a paucity of data. Methods We described a patient from our institution. We also performed a systematic review and subsequent quantitative synthesis of the literature (n = 21) and our institutional case to yield an integrated cohort, and a descriptive analysis was carried out. Results Twenty-two patients (15 males and 7 females) were included in the integrated cohort. The median age was 47.0 years (range, 8–75 years). The tumor subtypes were 5 somatotropic, 5 lactotropic, 4 nonfunctioning, 3 gonadotropic, 2 corticotropic, 1 plurihormonal, and 1 silent subtype 3 for pituitary adenomas, and 19 adamantinomatous, 2 papillary, and 1 unknown subtype for craniopharyngiomas. Three different radiographic patterns were observed: solid mass with cystic component (n = 5), coexistence of two distinct solid components (n = 3), and a mixed-intensity solid mass (n = 5). The first 2 were consistent with histologically separate collision, whereas the third was consistent with histologically admixed collision. Among 19 patients in whom the postoperative course was recorded, a secondary intervention was required in 14 (73.7%) because of tumor progression or residual. The recurrence rate after gross total resection was 33.3%. Postoperative hormone replacement was required in 33.3%. The 10-year cumulative overall survival was 73.1%. Conclusions Most craniopharyngiomas were adamantinomatous. There are 2 types of collisions: separated and admixed. Tumor control, overall survival, and endocrinologic remission are more challenging to achieve than for solitary tumors, but gross total resection of both tumors is important for satisfactory tumor control.

Background As the uncertainty surrounding the future of U.S. health care policy intensifies, political advocacy and campaign contributions have become increasingly relevant. This study describes the trends of political contributions of U.S. neurosurgeons from the years 2003–2019. Methods Individual contribution data from 2003–2019 were obtained from the Federal Election Commission website. Contributions were filtered for occupation lines matching either “neurosurg,” “neurologic surgeon,” or “neurological surgeon.” Each contribution is designated to a recipient committee associated with a political candidate or group. The party designations of these committees were used to catalogue donations as “Republican,” “Democratic,” or “Independent.” Results From 2003–2019 a total of 9242 political donations were made by self-identified neurosurgeons amounting to $8,469,121. Most of these contribution dollars were directed to Independent committees (47.9%). Of all Independent contribution dollars from 2005–2019, 95.9% were directed to the American Association of Neurological Surgeons Political Action Committee. The total number of unique contributions increased from 442 contributions in 2003 to 650 in 2019. Democrats experienced the most substantial increase in support, from 4.8% of all contribution dollars in 2003 to 26.3% in 2019. Republican support was noted to be more widespread across the United States compared with Democratic support. Conclusions Political contributions from U.S. neurosurgeons have increased steadily over time. Donations were largely Independent but became increasingly partisan in recent years. Overall, this displays an increase in political involvement among the neurosurgeon community. Future studies are warranted into how this involvement translates to representative health policy.

Objective Decision-making around tracheostomy placement and chronic respiratory support in children is complicated. Families often seek support and advice from outside the medical care team, including from social media. We undertook this study to characterize the content and nature of online resources created and managed primarily by caregivers of children living with tracheostomy and chronic mechanical ventilation. Design/setting We used a "grey literature" search methodology to identify internet resources created by caregivers of children with tracheostomy. We included only publicly available, nonindustry associated, English language, North American websites updated at least once in 2019. We then applied inductive content analysis to establish central themes, patterns and associations. Measurements/main results We identified six blogs/forums that met our search criteria. We identified four main themes: (1) Uncertainty, (2) Lived experience-wants, needs, and emotions, (3) Seeking context and meaning, and (4) Advice/information sharing/support. Two patterns of coping were identified on the basis of the relationships between codes. The "Acceptance pathway" is associated with a sense of self-actualization, mastery, satisfaction, return to normalcy, and ultimately acceptance. The "Resignation pathway" is associated with a sense of lack of control, frustration, burnout and stress, persistent lack of normalcy, and resignation to the tracheostomy as a negative but necessary outcome. Conclusion Caregivers often come to see themselves as experts in the care of children with tracheostomy, though many still express ambivalence about their knowledge and skills. Those early in the experience express a desire for community and can potentially benefit from online resources.

The biology of regenerative medicine has steadily matured, providing the foundation for randomized clinical trials and translation into validated applications. Today, the growing regenerative armamentarium is poised to impact disease management, yet a gap in training next-generation healthcare providers, equipped to adopt and deliver regenerative options, has been exposed. This special report highlights a multiyear experience in developing and deploying a comprehensive regenerative curriculum for medical trainees. For academicians and institutions invested in establishing a formalized regenerative medicine syllabus, the Regenerative Medicine and Surgery course provides a patient-focused prototype for next-generation learners, offering a dedicated educational experience that encompasses discovery, development and delivery of regenerative solutions. Built with the vision of an evolving regenerative care model, this transdisciplinary endeavor could serve as an adoptable education portal to advance the readiness of the emergent regenerative healthcare workforce globally.

The doors of the Mayo Clinic College of Medicine and Science (MCCMS) are open to all meritorious learners, including learners who come from communities that have endured longstanding and profound health and economic disparities. In our contemporary world, upward mobility in socioeconomic status is often a function of successful attainment of higher education. One may justifiably ask if all sociodemographic groups in the United States have equal access to higher education so they can gain knowledge and acquire skill sets often necessary to lead a productive life. Several biopsychosocial factors may determine as to whether those that see the "mountain" of higher education at a distance will eventually succeed at surmounting obstacles to rise to the highest peaks. In this article, our earlier experiences are analyzed with the goal of offering insights into novel approaches to train meritorious learners from all sociodemographic groups, including those who come from underserved communities. In addition, we highlight an apolitical and academically rigorous social cognition model that informs the contemporary academic agenda of diversity and inclusion, and we trace its root to the work of the founding father of experimental social psychology.

ObjectiveSymptom checkers are potentially beneficial tools during pandemics. To increase the use of the platform, perspectives of end users must be gathered. Our objectives were to understand the perspectives and experiences of young adults related to the use of symptom checkers for assessing COVID-19-related symptoms and to identify areas for improvement.MethodsWe conducted semistructured qualitative interviews with 22 young adults (18–34 years of age) at a university in Ontario, Canada. Interviews were audio-recorded, transcribed, and analysed using inductive thematic analysis.ResultsWe identified six main themes related to the decision of using a symptom checker for COVID-19 symptoms: (1) presence of symptoms or a combination of symptoms, (2) knowledge about COVID-19 symptoms, (3) fear of seeking in-person healthcare services, (4) awareness about symptom checkers, (5) paranoia and (6) curiosity. Participants who used symptom checkers shared by governmental entities reported an overall positive experience. Individuals who used non-credible sources reported suboptimal experiences due to lack of perceived credibility. Five main areas for improvement were identified: (1) information about the creators of the platform, (2) explanation of symptoms, (3) personalised experience, (4) language options, and (5) option to get tested.ConclusionsThis study suggests an increased acceptance of symptom checkers due to the perceived risks of infection associated with seeking in-person healthcare services. Symptom checkers have the potential to reduce the burden on healthcare systems and health professionals, especially during pandemics; however, these platforms could be improved to increase use.

Between 2015 and 2017, over 24,000 Syrian women came to Canada as refugees. Refugees are two to three times more likely than native Canadians to suffer from depression and other mental health challenges. A qualitative approach was taken to understand roles of social networks in shaping the mental and emotional health resource-seeking behaviours of twelve Syrian women who are refugees. Semi-structured telephone interviews were conducted in both English and Arabic. Interviews were audio-recorded, transcribed, and thematically coded using NVivo 12. Findings reveal that (1) families play large roles in teaching and providing information about Canada's health system, including mental health services; (2) Social networks influence assumptions about mental and physical health services; (3) women feel more welcomed into social networks in Canada than in countries of first asylum; and (4) social networks act as alternatives to seeking formal mental and emotional health care. Through first-hand stories and experiences of Syrian women's transitions into Canada, this study identifies the ways in which social networks may help or hinder engagement with mental and emotional health services.

Interrupted aortic arch (IAA) often presents with a wide gap between the proximal and distal portions of the arch which challenge a tension-free anastomosis, potentially increasing the risk for residual or recurrent arch obstruction, and left main bronchial compression. When possible, to preserve potential for growth of the repair, native tissue-to-tissue reconstruction is always preferred. Accordingly, rather than forcing a direct anastomosis with native tissue under tension or needing an interposition graft, the ascending aortic slide is an alternative useful technique to repair interrupted aortic arch in neonates and infants with difficult anatomy. Using a bridging flap of native tissue from the split ascending aorta and completion with patch material to fill in the lesser arch curvature, it has successfully been used in nine babies for bi-ventricular repair and uni-ventricular palliation with satisfactory results, and potential for growth.

PurposeConsumers’ trust in food systems is essential to their functioning and to consumers’ well-being. However, the literature exploring how food safety incidents impact consumer trust is theoretically underdeveloped. This study explores the relationship between consumers’ expectations of the food system and its actors (regulators, food industry and the media) and how these influence trust-related judgements that consumers make during a food safety incident.Design/methodology/approachIn this study, two groups of purposefully sampled Australian participants (n = 15) spent one day engaged in qualitative public deliberation to discuss unfolding food incident scenarios. Group discussion was audio recorded and transcribed for the analysis. Facilitated group discussion included participants' expected behaviour in response to the scenario and their perceptions of actors' actions described within the scenario, particularly their trust responses (an increase, decrease or no change in their trust in the food system) and justification for these.FindingsThe findings of the study indicated that food incident features and unique consumer characteristics, particularly their expectations of the food system, interacted to form each participant's individual trust response to the scenario. Consumer expectations were delineated into “fundamental” and “anticipatory” expectations. Whether fundamental and anticipatory expectations were in alignment was central to the trust response. Experiences with the food system and its actors during business as usual contributed to forming anticipatory expectations.Originality/valueTo ensure that food incidents do not undermine consumer trust in food systems, food system actors must not only demonstrate competent management of the incident but also prioritise trustworthiness during business as usual to ensure that anticipatory expectations held by consumers are positive.

The purpose of this study was to identify which domains of family functioning were associated with odds of internalizing versus externalizing mental health disorder, past-year health professional consultations, hospitalizations, and length of hospital stay in a sample of children with a mental health disorder. One hundred children aged 6–17 years who received mental health services (inpatient or outpatient) and their parents at a large clinical paediatric tertiary care centre in Ontario were recruited in this cross-sectional study. The final recruited and analyzed sample was children aged 8–17 years. Family functioning was measured using the McMaster Family Assessment Device (FAD), child mental health disorder using the Mini International Neuropsychiatric Interview, and mental health service use using items from the 2012 Canadian Community Health Survey (Mental Health). Higher scores on affective involvement and problem solving were associated with greater odds of major depressive disorder [OR = 2.12 (1.01, 4.43)] and social phobia [OR = 1.80 (1.09, 2.98)]. Reports of better communication were correlated with lower odds of generalized anxiety disorder [OR = 0.55 (0.35, 0.84)] and shorter length of stay in hospital [OR = 0.93 (0.89, 0.97)]. Higher scores on behaviour control were associated with lower odds of social phobia and oppositional defiant disorder [OR = 0.48 (0.27, 0.86) and OR = 0.52 (0.32, 0.84)], respectively. Future research should aim to gain an understanding of strategies that ameliorate family functioning to limit the impact and severity of childhood mental health conditions.

Food safety and food security are two important public health sectors within Canada, which aim to address foodborne disease and food insecurity, respectively. While these sectors are often siloed within public health organizations, the actions of the two sectors often interact and conflict at the program level despite their common goal of improving population health. The objective of the present study was to identify determinants that influenced the success of collaboration between practitioners of the two sectors in British Columbia, to inform Canadian food policy. We inductively analyzed 14 interviews with practitioners working in the two sectors who had experience with successful collaboration. Data were interpreted in consultation with an inter-professional collaboration framework. Participants identified determinants at the systemic level, including the cultural, professional, educational, legislative, and political systems, which were often considered barriers to collaboration. Participants also identified determinants at the organizational level that influenced the success of collaboration between the sectors, including: the organization’s structure and philosophy, leadership, resources, and communication mechanisms. Finally, participants identified interactional determinants as ways to overcome existing barriers, including: willingness to collaborate, trust, communication, mutual respect, and taking a solutions-oriented approach. Practitioners working in food safety and food security can apply the interactional determinants identified in this study to mitigate existing barriers to collaboration and support more synergistic food policies.

Background: In a time of rapid modernization in Nepal, most Nepalese men are engaging in more risky sexual health behaviours. As most of these Nepali men have little factual information or guidance...

Departments of neurosurgery in the United States have had a long history of hosting international visitors for the advancement of their neurosurgical education. The goal of the present study was to determine the existence of a geographic profile of international visitors for education purposes, both students and graduates, to the United States through the anecdotal experience of 1 department to explore the reach and worth of hosting such opportunities.Administrative records were retrospectively reviewed for international visitors over the preceding 10 years, 2009-2019, were surveyed at 1 institution. Visitors were grouped as either medical students or graduates, visiting for clinical or research purposes. Geographic trends were compared using the Pearson chi-squared test.We identified 128 visitors from 33 countries during the study period. The most common home countries were Italy (10%), China (9%), and India (7%). The cohort involved 62 (48%) students and 66 (52%) graduates, and 59 (46%) and 69 (54%) visited for clinical and research purposes, respectively. The geographic distribution of student versus graduate visitors was statistically significant by region (P0.01). However, the geographic distribution of clinical versus research visitors was not statistically different by region (P = 0.62).There appears to be international appeal worldwide to participate in neurosurgical education in the United States. At our institution, every geographic region was represented in our most recent decade of experience. International visitor profiles appear to be associated with particular geographic patterns depending on their status as either a medical student or graduate.

Background Ventriculopleural shunting (VPLS) is recognized as an alternative method when the standard ventriculoperitoneal shunting (VPS) is not applicable. Nevertheless, there is limited clinical evidence of its effectiveness including long-term patency. Methods Data on 35 consecutive patients who underwent VPLS at a single institution were retrospectively analyzed. The rates of shunt survival and incidence of symptomatic pleural effusion were calculated, and risk factors were evaluated. Results Mean follow-up after VPLS was 64.1 months. The cumulative overall shunt survival rates were 70%, 44%, and 28% at 1, 3, and 5 years, respectively. Among patients with shunt failure, 3 (8.6%) with overdrainage underwent simple valve replacement (from fixed to programmable valve) and retained a VPLS. If these patients are excluded, shunt survival rates were 76%, 51%, and 34% at 1, 3, and 5 years, respectively, and the median shunt survival time was 3.0 years. No factor was significantly associated with shunt survival. Cumulative rates of symptomatic pleural effusion were 18%, 23%, and 46% at 1, 2, and 3 years, respectively. Median time from VPLS placement to symptomatic pleural effusion was 1.1 years. Conclusions It seems that VPLS survival has improved with more modern shunt technology. VPLS is a reasonable second-line option when VPS is not feasible. The possibility of pleural effusion is not negligible, but asymptomatic/mild effusions may be managed conservatively.

Background Intracranial aneurysms (IA) are associated with moyamoya disease (MMD). There are no clinically tested treatment guidelines. Reporting of cases is vital to better understand the underlying pathophysiology and potential ethnic predispositions and improve patient selection for intervention. Methods Records of all patients diagnosed with MMD with concomitant IA who presented to our institution were retrospectively reviewed. Data related to demographic, clinical, MMD characteristics, aneurysm characteristics, surgical intervention, and follow-up were collected from the records of each patient. Aneurysm location was categorized into circle of Willis (CoW) aneurysms (originating from the CoW or its major branches) and peripheral aneurysms (arising from choroidal or lenticulostriate arteries). Results Ten patients were found to have a total of 14 IA. All patients were white. Ten aneurysms (71%) were classified as CoW aneurysms and 4 (29%) were classified as peripheral. Seven of 10 CoW aneurysms (70%) were located in the anterior circulation, whereas 3 (30%) were located in the posterior circulation. Aneurysms of anterior and posterior circulations were most commonly treated with coil embolization, whereas peripheral artery aneurysms were most commonly treated with either cerebral revascularization alone or aneurysm excision. Conclusions Revascularization surgery seems to be an effective method of indirectly treating IA in patients with MMD. Previous literature in addition to our series shows that endovascular embolization is safe and efficacious in treating IA of most locations in patients with MMD. The use of open microsurgery for direct aneurysm treatment in this population poses many challenges.

A number of countries have implemented vaccination in pregnancy as a strategy to reduce the burden of influenza and pertussis. The aim of this study was to assess the involvement of Canadian maternity care providers in administration of vaccines to their pregnant patients. A cross-sectional web-based survey was sent to family physicians, obstetricians-gynecologists, midwives, pharmacists, and nurses. A multivariable logistic regression model was used to determine variables independently associated with offering vaccination services in pregnancy in providers’ practice. A total of 1,135 participants participated. Overall, 64% (n = 724) of the participants reported offering vaccines in their practice and 56% (n = 632) reported offering vaccines to pregnant patients. The main reasons reported for not offering vaccination services in pregnancy were the belief that vaccination was outside of the scope of practice; logistical issues around access to vaccines; or lack of staff to administer vaccines. In multivariable analysis, the main factors associated with vaccination of pregnant patients in practices where vaccination services were offered were: providers’ confidence in counseling pregnant patients about vaccines, seeing fewer than 11 pregnant patients on average each week, and being a nurse or a family physician. Although the majority of participants expressed strong support for vaccination during pregnancy, half were not offering vaccination services in their practice. Many were not equipped to offer vaccines in their practice or felt that it was not their role to do so. To enhance vaccine acceptance and uptake in pregnancy, it will be important to address the logistical barriers identified in this study.

Introduction: Canada is home to one of the highest global prevalence rates of multiple sclerosis; a disease with causes and treatments that continue to challenge physicians and patients alike. The ...

OBJECTIVEMultiple endocrine neoplasia type 1 (MEN1) is a rare, autosomal-dominant tumor disorder characterized by the development of pituitary tumors and other endocrine neoplasms. Diagnosis is made clinically based on the development of 2 or more canonical lesions (parathyroid gland, anterior pituitary, and enteropancreatic tumors) or in family members of a patient with a clinical diagnosis of MEN1 and the occurrence of one of the MEN1-associated tumors. The goal of this study was to characterize pituitary tumors arising in the setting of MEN1 at a single institution. The probability of tumor progression and the likelihood of surgical intervention in patients with asymptomatic nonfunctional pituitary adenomas were also analyzed.METHODSA retrospective review of a prospectively maintained institutional database was performed for patients with MEN1 diagnosed from 1970 to 2017. Data included patient demographics, tumor characteristics, treatment strategies, and outcomes.RESULTSA review of the database identified 268 patients diagnosed with MEN1, of whom 158 (59%) were female. Among the 268 patients, 139 (51.8%) had pituitary adenomas. There was a higher prevalence in women than in men (65% vs 35%, p < 0.005). Functional adenomas (57%) were more common. Prolactin-secreting adenomas were the most common functional tumors. Macroadenomas were seen in 27% of patients and were more likely to be symptomatic and locally aggressive (p < 0.001). Forty-nine patients (35%) underwent transsphenoidal resection at some point during their disease course. In 52 patients who were initially observed with MEN1 asymptomatic nonfunctional adenomas, only 5 (10%) progressed to need surgery. In MEN1 patients, an initial parathyroid lesion is most likely followed in order by pituitary, pancreatic, adrenal, and, finally, rare carcinoid tumors.CONCLUSIONSAsymptomatic nonfunctional pituitary adenomas in patients with MEN1 may be followed safely with MRI. In this series, parathyroid tumors developed at the lowest median age of all cardinal tumors, and development of additional cardinal MEN1 lesions followed a predictable pattern. This pattern of disease progression could have significant implications for disease surveillance in clinical practice and may help to target clinical resources to the lesions most likely to develop next. This may aid with early detection and treatment and warrants further study.

Systematic reviews and meta-analyses in the neurosurgical literature have surged in popularity over the last decade. It is our concern that, without a renewed effort to critically interpret and appraise these studies as high or low quality, we run the risk of the quality and value of evidence-based medicine in neurosurgery being misinterpreted. Correspondingly, we have outlined 4 major domains to target in interpreting neurosurgical systematic reviews and meta-analyses based on the lessons learned by a collaboration of clinicians and academics summarized as 4 pearls. The domains of (1) heterogeneity, (2) modeling, (3) certainty, and (4) bias in neurosurgical systematic reviews and meta-analyses were identified as aspects in which the authors' approaches have changed over time to improve robustness and transparency. Examples of how and why these pearls were adapted were provided in areas of cranial neuralgia, spine, pediatric, and neuro-oncology to demonstrate how neurosurgical readers and writers may improve their interpretation of these domains. The incorporation of these pearls into practice will empower neurosurgical academics to effectively interpret systematic reviews and meta-analyses, enhancing the quality of our evidence-based medicine literature while maintaining a critical focus on the needs of the individual patients in neurosurgery.

Rationale & Objective: The In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey, introduced into the End-Stage Renal Disease Quality Incentive Program, is the only patient-reported outcome currently used for value-based reimbursement in dialysis. Current response rates are ∼30% and differences in long-term clinical outcomes between survey responders and nonresponders are unknown. Study Design: Retrospective cohort study. Setting & Participants: Patients from all Dialysis Clinic Incorporated facilities from across the United States who met survey eligibility (aged ≥18 years and had been treated at their facility for at least 3 months). Exposures: Patient-level demographic, clinical, and treatment-related characteristics. Outcomes: Mortality, all-cause hospitalization, and kidney transplantation. Analytical Approach: Time-to-event analyses using competing-risks models. Sensitivity analyses performed after multiple imputation for missing covariate data. Results: Among 10,395 eligible patients, 3,794 (36%) responded to the survey. During a median follow-up of 33 months, 4,588 patients died, 7,638 patients were hospitalized at least once, and 789 patients received a transplant. In multivariable models, survey response was associated with lower mortality (subdistribution hazard ratio [sHR], 0.80; 95% CI, 0.75-0.86) and hospitalization (sHR, 0.94; 95% CI, 0.89-0.99) and higher likelihood for a kidney transplant (sHR, 1.27; 95% CI, 1.10-1.46). Results were consistent across sensitivity analyses after multiple imputation for missing covariates. Limitations: Small amount of missing covariate data, baseline covariate data assigned at the first month of the 3-month survey administration period, reasons for nonresponse unknown. Conclusions: Response to the ICH CAHPS survey is associated with lower risk for mortality and hospitalization and higher likelihood for kidney transplantation. These findings suggest that survey responders are healthier than nonresponders, emphasizing the need for caution when interpreting facility-level survey results to inform quality improvement and public policy efforts and the critical need to better capture patient-reported outcomes from more vulnerable patients. Index Words: CAHPS, ICH CAHPS, hemodialysis, patient experience, patient satisfaction

Lung cancer is the leading cause of cancer-related death in the world. In contrast to many other cancers, a direct connection to modifiable lifestyle risk in the form of tobacco smoke has long been established. More than 50% of all smoking-related lung cancers occur in former smokers, often many years after smoking cessation. Despite extensive research, the molecular processes for persistent lung cancer risk are unclear.To examine whether risk stratification in the clinic and in the general population can be improved upon by the addition of genetic data, and to explore the mechanisms of the persisting risk in former smokers, we have analysed transcriptomic data from accessible airway tissues of 487 subjects, including healthy volunteers and clinic patients of different smoking status. We developed a model to assess smoking associated gene expression changes and their reversibility after smoking is stopped, comparing healthy subjects to clinic patients with and without lung cancer. We find persistent smoking-associated immune alterations to be a hallmark of the clinic patients. Integrating previous GWAS data using a transcriptional network approach, we demonstrate that the same immune and interferon related pathways are strongly enriched for genes linked to known genetic risk factors, demonstrating a causal relationship between immune alteration and lung cancer risk. Finally, we used accessible airway transcriptomic data to derive a non-invasive lung cancer risk classifier.Our results provide initial evidence for germline-mediated personalised smoke injury response and risk in the general population, with potential implications for managing long-term lung cancer incidence and mortality.

T1 Figure 1ConclusionsOverall, this largest paediatric single cell COVID-19 study to date showed significant differences in response to SARS-CoV-2 between children and adults, reflecting the changes of the immune landscape over developmental time, which in children are dominated by naive and innate responses.

Digital, OBJECTIVE Recent studies have proposed resection of the T2 FLAIR hyperintensity beyond the T1 contrast enhancement (supramarginal resection [SMR]) for IDH–wild-type glioblastoma (GBM) to further improve patients’ overall survival (OS). GBMs have significant variability in tumor cell density, distribution, and infiltration. Advanced mathematical models based on patient-specific radiographic features have provided new insights into GBM growth kinetics on two important parameters of tumor aggressiveness: proliferation rate (ρ) and diffusion rate (D). The aim of this study was to investigate OS of patients with IDH–wild-type GBM who underwent SMR based on a mathematical model of cell distribution and infiltration profile (tumor invasiveness profile). METHODS Volumetric measurements were obtained from the selected regions of interest from pre- and postoperative MRI studies of included patients. The tumor invasiveness profile (proliferation/diffusion [ρ/D] ratio) was calculated using the following formula: ρ/D ratio = (4π/3)2/3 × (6.106/[VT21/1 − VT11/1])2, where VT2 and VT1 are the preoperative FLAIR and contrast-enhancing volumes, respectively. Patients were split into subgroups based on their tumor invasiveness profiles. In this analysis, tumors were classified as nodular, moderately diffuse, or highly diffuse. RESULTS A total of 101 patients were included. Tumors were classified as nodular (n = 34), moderately diffuse (n = 34), and highly diffuse (n = 33). On multivariate analysis, increasing SMR had a significant positive correlation with OS for moderately and highly diffuse tumors (HR 0.99, 95% CI 0.98–0.99; p = 0.02; and HR 0.98, 95% CI 0.96–0.99; p = 0.04, respectively). On threshold analysis, OS benefit was seen with SMR from 10% to 29%, 10% to 59%, and 30% to 90%, for nodular, moderately diffuse, and highly diffuse, respectively. CONCLUSIONS The impact of SMR on OS for patients with IDH–wild-type GBM is influenced by the degree of tumor invasiveness. The authors’ results show that increasing SMR is associated with increased OS in patients with moderate and highly diffuse IDH–wild-type GBMs. When grouping SMR into 10% intervals, this benefit was seen for all tumor subgroups, although for nodular tumors, the maximum beneficial SMR percentage was considerably lower than in moderate and highly diffuse tumors., Ciencias Médicas y de la Salud

There has been a growing use of social media by patients to share their healthcare experiences and produce information that can be helpful to other patients seeking healthcare services. These stories can reveal issues in healthcare quality. However, faced with the inherent risks of social media, healthcare providers have been skeptical about the value of these stories, and many healthcare systems have adopted restrictive and protective policies to control the use of social media by healthcare providers. This study explores healthcare providers' and administrators' perspectives on patient stories on social media and whether they can use the stories to evaluate healthcare experiences. Semi-structured interviews (n = 21) were conducted with healthcare providers and administrators, including physicians, nurses, and quality managers in Ontario, Canada, between April 2018 and May 2019. Inductive and data-driven thematic analysis was used to analyze the data. Several barriers prevent healthcare providers from realizing the benefits of social media, including concerns about the quality of patients' feedback, the professional codes of conduct, and the time and effort required to process these stories. The study findings suggest that cultural changes in the healthcare system might be required to foster the use of social media for healthcare quality improvement and enable the development of a safe patient-provider communication environment that facilitates the exchange of constructive feedback between the two parties without the fear of legal consequences, breaches of patient privacy, or violation of professional codes of conduct.

Home dialysis has been underused in the United States, especially among minority groups. We investigated whether adjustment for socioeconomic factors would attenuate racial/ethnic differences in the initiation of home dialysis.Retrospective observational cohort study.Adult patients in the US Renal Data System who initiated dialysis on day 1 with either in-center hemodialysis (HD), home HD (HHD), or peritoneal dialysis (PD) from 2005 to 2013.Race/ethnicity: non-Hispanic white, Hispanic, black, or Asian.Initiating dialysis with PD versus in-center HD and HHD versus in-center HD for each minority group compared with non-Hispanic whites.Odds ratios and 95% CIs estimated by logistic regression.Of 523,526 patients, 55% were white, 28% were black, 13% were Hispanic, and 4% were Asian; 8% started dialysis on PD, and 0.1%, on HHD. In unadjusted analyses, blacks and Hispanics were 30% and 19% less likely and Asians were 31% more likely to start on PD than whites. The differences narrowed when fully adjusted for demographic, medical, and socioeconomic factors. Adjustment for socioeconomic factors reduced these differences between white and black, Hispanic, and Asian patients by 13%, 28%, and 1%, respectively. Blacks were just as likely and Hispanics and Asians were less likely to start on HHD than whites. This did not change appreciably when fully adjusted for demographic, medical, and socioeconomic factors.No data for physician and patient preferences or modality education.Black and Hispanic patients are less likely to start on PD than white patients, attributable partly, though not completely, to socioeconomic factors. Hispanics and Asians are less likely to start on HHD than whites. This was materially unaffected by socioeconomic factors. More research is needed to determine whether urgent-start PD programs and transitional care units in socioeconomically disadvantaged areas might reduce these disparities and increase home dialysis use among all groups.

Post-traumatic hydrocephalus (PTH) is a potentially morbid sequela of decompressive craniectomy for traumatic brain injury (TBI). Subdural hygromas are commonly identified following decompressive craniectomy, but the clinical relevance and predictive relationship with PTH in this patient cohort is not completely understood. Survey of seven electronic databases from inception to June 2019 was conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Multivariate hazard ratios (HRs) for PTH by the presence of subdural hygroma were extracted and pooled by meta-analysis of proportions with random effects modeling. We systematically identified nine pertinent studies describing outcomes of 1010 TBI patients managed by decompressive craniectomy. Of the overall cohort, there were 211 (21%) females and median age was 37.5 years (range 33–53). On presentation, median Glasgow Coma Scale was 7 (range, 5–8). In sum, PTH was reported in 228/840 (27%) cases, and subdural hygroma was reported in 449/1010 (44%) cases across all studies. Pooling multivariate-derived HRs indicated that subdural hygroma was a significant, independent predictor of PTH (HR, 7.1; 95% CI, 3.3–15.1). The certainty of this association was deemed low due to heterogeneity concerns. The presence of subdural hygroma is associated with increased risk of PTH after decompressive craniectomy among TBI patients based on the current literature and may mandate closer clinical surveillance when detected. Prospective studies, including those of intracranial hydrodynamics following decompressive craniectomy in the setting of TBI, will better validate the certainty of these findings.

We hypothesize that there are post-operative, non-surgical risk factors that could be modified to prevent the occurrence of chylothorax, and we seek to determine those factors. Retrospective chart review of 285 consecutive patients

Identifying patients who are likely to transfer from peritoneal dialysis (PD) to hemodialysis (HD) before transition could improve their subsequent care. This study developed a prediction tool for transition from PD to HD.Retrospective cohort study.Adults initiating PD between January 2008 and December 2011, followed up through June 2015, for whom data were available in the US Renal Data System (USRDS).Clinical characteristics at PD initiation and peritonitis claims.Transfer to HD, with the competing outcomes of death and kidney transplantation.Outcomes were ascertained from USRDS treatment history files. Subdistribution hazards (competing-risk) models were fit using clinical characteristics at PD initiation. A nomogram was developed to classify patient risk at 1, 2, 3, and 4 years. These data were used to generate quartiles of HD transfer risk; this quartile score was incorporated into a cause-specific hazards model that additionally included a time-dependent variable for peritonitis.29,573 incident PD patients were followed up for a median of 21.6 (interquartile range, 9.0-42.3) months, during which 41.2% transferred to HD, 25.9% died, 17.1% underwent kidney transplantation, and the rest were followed up to the study end in June 2015. Claims for peritonitis were present in 11,733 (40.2%) patients. The proportion of patients still receiving PD decreased to 50% at 22.6 months and 14.2% at 5 years. Peritonitis was associated with a higher rate of HD transfer (HR, 1.82; 95% CI, 1.76-1.89; P 0.001), as were higher quartile scores of HD transfer risk (HRs of 1.31 [95% CI, 1.25-1.37), 1.51 [95% CI, 1.45-1.58], and 1.78 [95% CI, 1.71-1.86] for quartiles 2, 3, and 4 compared to quartile 1 [P 0.001 for all]).Observational data, reliant on the Medical Evidence Report and Medicare claims.A large majority of the patients who initiated renal replacement therapy with PD discontinued this modality within 5 years. Transfer to HD was the most common outcome. Patient characteristics and comorbid diseases influenced the probability of HD transfer, death, and transplantation, as did episodes of peritonitis.

Primary central nervous system lymphomas (PCNSLs) are typically intraparenchymal. A subset of PCNSLs predominantly arises in the ventricles, with minimal parenchymal involvement. We review the clinical, radiological, and pathological features of ventricle-predominant PCNSLs (VP-PCNSLs) in 40 previously reported cases and report 5 additional cases. Including all cases of VP-PCNSLs (n = 45), 38% were diffuse large B-cell lymphomas (DLBCL), 11% were Burkitt lymphomas, 7% were MALT lymphomas, 4% were T-cell lymphomas, and 40% were lymphomas, not otherwise classified. VP-PCNSLs show rapid clinical progression. Patients present at a median age of 60.5 years. Unique clinical and radiological features distinguish them from other intraventricular tumors, including advanced age, edema, multifocality, hyperdensity, early and avid post-contrast enhancement, restricted diffusion, and positron emission tomography (PET) hypermetabolism. Including our cases, which were all DLBCL, and all previously reported DLBCL cases (n = 10), 8 of 10 show germinal center B-cell-like (GCB) phenotype, contrasting the high prevalence of non-germinal center B-cell-like (non-GCB) phenotype of parenchymal DLBCL PCNSLs. MYD88 L265P mutation was detected in three of our five cases. Ventricle-predominant PCNSLs are clinically and radiologically distinct, and the DLBCLs may be pathologically distinct. Further recognition of this entity may help to evaluate the role of therapies, possibly including surgical resection.

In the era in which people are bombarded with misinformation about vaccination, research regarding the degree to which various types of risk or benefit information affect perceptions of vaccines and intentions to vaccinate is critical. The present research utilizes a robust methodology to quantify the extent to which risk and benefit information affects vaccination intentions. Our work demonstrates an inverse relationship between the perceived risks and benefits of a vaccine. By providing information about either risks or benefits of a vaccine, our findings suggest that we can change one's perception of both the risks and benefits of the vaccine. Considering that the main cognitive barriers to vaccination are related to concerns about efficacy and safety, our results suggest that vaccine messages can be framed to address the audience's main concerns, whether it be about the low efficacy of the vaccine or its safety, knowing that both frames would carry similar outcomes.

Rationale and Objectives To evaluate whether a computed tomography (CT)-based computerized decision-support system for muscle-invasive bladder cancer treatment response assessment (CDSS-T) can improve identification of patients who have responded completely to neoadjuvant chemotherapy. Materials and Methods Following Institutional Review Board approval, pre-chemotherapy and post-chemotherapy CT scans of 123 subjects with 157 muscle-invasive bladder cancer foci were collected retrospectively. CT data were analyzed with a CDSS-T that uses a combination of deep-learning convolutional neural network and radiomic features to distinguish muscle-invasive bladder cancers that have fully responded to neoadjuvant treatment from those that have not. Leave-one-case-out cross-validation was used to minimize overfitting. Five attending abdominal radiologists, four diagnostic radiology residents, two attending oncologists, and one attending urologist estimated the likelihood of pathologic T0 disease (complete response) by viewing paired pre/post-treatment CT scans placed side-by-side on an internally-developed graphical user interface. The observers provided an estimate without use of CDSS-T and then were permitted to revise their estimate after a CDSS-T-derived likelihood score was displayed. Observer estimates were analyzed with multi-reader, multi-case receiver operating characteristic methodology. The area under the curve (AUC) and the statistical significance of the difference were estimated. Results The mean AUCs for assessment of pathologic T0 disease were 0.80 for CDSS-T alone, 0.74 for physicians not using CDSS-T, and 0.77 for physicians using CDSS-T. The increase in the physicians' performance was statistically significant (P Conclusion CDSS-T improves physician performance for identifying complete response of muscle-invasive bladder cancer to neoadjuvant chemotherapy.

Researchers and food system actors have developed a best practice model to assist with (re)building or maintaining consumer trust in the food system in the event of a food incident. The aim of the present study was to determine how well the model aligns with consumer views of the strategies required to maintain consumer trust during and following a food incident. This qualitative public deliberation study employed experimental, developmental vignettes during 2 full-day sessions in May 2018. Following general discussion of the food incident scenario presented in the vignettes, 15 South Australian adults (in two groups) developed a collated and ranked list of key strategies to be used by food system actors during a food incident to assist in maintaining consumer trust. Participants were then introduced to the existing model, and engaged in discussions about if and how their strategies aligned with those in the existing model. Findings demonstrate broad consistency between the two groups and the model in the strategies identified as key for (re)building and maintaining consumer trust during a food incident. For example, timely transparency was reported by consumers as the key strategy for maintaining consumer trust during and after a food incident. However, participants expressed pessimism regarding actors’ ability to implement strategies. Although minimal, differences were noted in strategy descriptions between the groups and the Model. This study suggests that overall the model is highly consistent with consumer views. If actors are to demonstrably apply the Model in the event of a food incident, our data suggest that the identified strategies will successfully assist them in (re)building and/or maintaining consumer trust in the food supply.

Food security governance is broadening and diversifying, resulting in organizations coming together in novel collaborative actions, despite little history of working together. Alternative food initiatives coexist alongside traditional charitable, emergency-based approaches. Tensions can arise between approaches and collaborating organizations due to differences in philosophy, priorities, constraints and practices. There is limited knowledge on how converging interests are interacting with one another within shifting landscapes of collaborative intervention, or the experiences of governance stakeholders involved. Through in-depth interviews this case-study examines the experiences of diverse stakeholders involved in a novel food security coalition and their perceived benefits, challenges, tensions and lessons learned. Benefits included greater communication, information sharing, understanding of diverse needs, more frequent and customized referrals, and the development of a community food centre that has increased access to affordable fresh produce in inclusive manners. Simultaneously changes in governance have produced turf wars and competition over resources. We reveal the importance of sensitivity when advocating for food system reforms to avoid ‘villainizing’ organizations that have been supporting those in need through charitable means, or further marginalizing populations who may perceive less access barriers when using food banks. Our findings suggest perceptions on what it means to provide ‘dignified’ food access vary according to unique needs and lived experiences, and one delivery model is likely inappropriate. Food banks and alternative food initiatives serve unique roles and efforts should be made to ensure they can co-exist and that those with lived experience play an influential role in changing food governance systems.

Obesity is an important risk factor for various chronic diseases. While people with obesity use the health system more and incur higher costs, they may forego using preventive care services (e.g., gynecological cancer screenings) due to issues of service use and service access. The aim of this paper was to use a public health lens to elucidate system level factors that affect healthcare access and utilization for preventive and weight management care by patients with obesity. Some elucidated factors include lack of access to a Primary Care Provider (PCP) and multidisciplinary healthcare settings, gender of the PCP, duration of medical visits and health professionals' attitudes about obesity. We highlight potential strategies for leaders to use when improving access and use of health services by patients with obesity in Canada and the need for future empirical studies in this research area.