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Background and Purpose: Transcranial Doppler (TCD) identifies acute stroke patients with arterial occlusion where treatment may not effectively open the blocked vessel. This study aimed to examine the clinical utility and prognostic value of TCD flow findings in patients enrolled in a multicenter prospective study (CLOTBUST-PRO)., Methods: Patients enrolled with intracranial occlusion on computed tomography angiography (CTA) who underwent urgent TCD evaluation before intravenous thrombolysis was included in this analysis. TCD findings were assessed using the mean flow velocity (MFV) ratio, comparing the reciprocal ratios of the middle cerebral artery (MCA) depths bilaterally (affected MCA-to-contralateral MCA MFV [aMCA/cMCA MFV ratio])., Results: A total of 222 patients with intracranial occlusion on CTA were included in the study (mean age: 64 ± 14 years, 62% men). Eighty-eight patients had M1 MCA occlusions; baseline mean National Institutes of Health Stroke Scale (NIHSS) score was 16, and a 24-hour mean NIHSS score was 10 points. An aMCA/cMCA MFV ratio of <.6 had a sensitivity of 99%, specificity of 16%, positive predictive value (PV) of 60%, and negative PV of 94% for identifying large vessel occlusion (LVO) including M1 MCA, terminal internal carotid artery, or tandem ICA/MCA. Thrombolysis in Brain Ischemia scale, with (grade ≥1) compared to without flow (grade 0), showed a sensitivity of 17.1%, specificity of 86.9%, positive PV of 62%, and negative PV of 46% for identifying LVO., Conclusions: TCD is a valuable modality for evaluating arterial circulation in acute ischemic stroke patients, demonstrating significant potential as a screening tool for intravenous/intra-arterial lysis protocols., (© 2024 The Author(s). Journal of Neuroimaging published by Wiley Periodicals LLC on behalf of American Society of Neuroimaging.)

Objective: This study aimed to investigate how medication adherence is addressed in online gout resources in six countries. We investigated how often adherence was referred to, the strategies suggested to improve patient adherence, and the types of nonadherence that were targeted. We also examined the readability of the adherence material., Methods: A content analysis was conducted on 151 online gout resources from medical and health organisations in six predominantly English-speaking countries. Two reviewers coded the content of the websites into categories (kappa 0.80). The analysis involved coding the resources for reasons for nonadherence, and adherence-promoting strategies. Flesch-Kincaid Reading Ease scores and word count were also computed., Results: Out of 151 websites examined, 77 websites discussed medication adherence (51%), with intentional nonadherence being more prevalent than unintentional nonadherence. 67 websites targeted different types of nonadherence, including drug-specific concerns (50%), misconceptions of gout curability and the necessity of medication (16%), forgetfulness (16%), and other practical challenges (5%). Strategies to promote adherence were found in one-third of the websites, with medication education being the most prevalent strategy (17%), followed by healthcare provider engagement (13%) and memory aid strategies (6%). On average, about 11% of the words (89.27, SD = 76.35) in the entire document were focused on adherence. Difficult reading comprehension was found in one-fifth of adherence-related websites., Conclusion: Findings reveal limited medication adherence coverage and narrow strategies in online gout resources. Improved adherence portrayal is needed for effective gout management through comprehensive strategies and clear, understandable information., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Society for Rheumatology.)

Background: The postacute COVID-19 syndrome (PACS) can be addressed with multidisciplinary approaches, including professional support and digital interventions., Objective: This research aimed to test whether patients who received a health care facilitation program including medical internet support from human personal pilots and digital interventions (intervention group [IG] and active control group [ACG]) would experience fewer symptoms and have higher work ability and social participation than an untreated comparison group (CompG). The second objective was to compare the impact of a diagnostic assessment and digital interventions tailored to patients' personal capacity (IG) with that of only personal support and digital interventions targeting the main symptoms (ACG)., Methods: In total, 1020 patients with PACS were recruited. Using a randomized controlled trial design between the IG and the ACG, as well as propensity score matching to include the CompG, analyses were run with logistic regression and hierarchical-linear models., Results: Symptoms decreased significantly in all groups over time (βT1-T2=0.13, t 549 =5.67, P<.001; βT2-T4=0.06, t 549 =2.83, P=.01), with a main effect of the group (β=-.15, t 549 =-2.65, P=.01) and a more pronounced effect in the IG and ACG compared to the CompG (between groups: βT1-T2=0.14, t 549 =4.31, P<.001; βT2-T4=0.14, t 549 =4.57, P<.001). Work ability and social participation were lower in the CompG, but there was no significant interaction effect. There were no group differences between the IG and the ACG., Conclusions: Empowerment through personal pilots and digital interventions reduces symptoms but does not increase work ability and social participation. More longitudinal research is needed to evaluate the effects of a diagnostic assessment. Social support and digital interventions should be incorporated to facilitate health care interventions for PACS., Trial Registration: ClinicalTrials.gov NCT05238415; https://classic.clinicaltrials.gov/ct2/show/NCT05238415., International Registered Report Identifier (irrid): RR2-10.1186/s12879-022-07584-z., (©Christina Derksen, Robin Rinn, Lingling Gao, Alina Dahmen, Cay Cordes, Carina Kolb, Petra Becker, Sonia Lippke. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 04.10.2023.)

Applying health psychological theories can improve communication interventions to empower pregnant women and ensure safe births. The aim was to test a short digital communication intervention based on the health action process approach. A randomized-controlled trial was conducted with pregnant women at two German university hospitals. The intervention group (N T1  = 225; N T2  = 142) received a 2.5 h online training focusing on communication planning, self-efficacy and communicating personal needs and preferences under difficult circumstances. This group was compared with a passive control group (N T1  = 199; N T2  = 144). Data from the N = 286 women with complete datasets were used for multilevel analyses. Data from all recruited N = 424 women were used for intention-to-treat analyses with multiple imputation. Both groups improved regarding communication behavior, quality of birth, action planning, coping planning and coping self-efficacy after birth, which was more pronounced in the intervention group. The intention-to-treat analyses confirmed the higher improvement for communication behavior, perceived quality of birth and coping planning. The intervention was related to improvements in pregnant women's communication behavior and quality of birth. Hence, future research and practice should apply and evaluate health psychological theories when targeting communication and empowerment., (© 2022 The Authors. Applied Psychology: Health and Well-Being published by John Wiley & Sons Ltd on behalf of International Association of Applied Psychology.)

Background: Medical internet interventions such as asynchronous apps and synchronous digital live seminars can be effective behavior change interventions. The research question of this study was whether digital interventions based on the Health Action Process Approach can improve pregnant women's safe communication and patient safety in obstetric care., Objective: This study aims to compare a digital live seminar with a web-based application intervention and a passive control group and to identify which social cognitive variables determine safe communication behavior and patient safety., Methods: In total, 657 pregnant women were recruited, and hereof, 367 expectant mothers from 2 German university hospitals participated in the pre-post study (live seminar: n=142; web-based app: n=81; passive control group: n=144). All interventions targeted intention, planning, self-efficacy, and communication of personal preferences. The 2.5-hour midwife-assisted live seminar included exercises on empathy and clear communication. The fully automated web-based application consisted of 9 consecutive training lessons with the same content as that of the live seminar., Results: Controlled for sociodemographic characteristics, repeated measures analyses of covariance revealed that pregnant women significantly improved their self-reported communication behavior in all groups. The improvement was more pronounced after the digital live seminar than after the web-based application (P<.001; η p 2 =0.043). Perceived patient safety improved more for pregnant women participating in the live seminar than for those participating in the web-based application group (P=.03 η p 2 =0.015). A regression analysis revealed that social cognitive variables predicted safe communication behavior., Conclusions: Overall, the web-based application intervention appeared to be less effective than the digital live training in terms of communication behavior. Application interventions addressing communication behaviors might require more face-to-face elements. Improving intention, coping planning, and coping self-efficacy appeared to be key drivers in developing safe communication behavior in pregnant women. Future research should include social learning aspects and focus on the practical application of medical internet interventions when aiming to improve pregnant women's communication and patient safety in obstetrics., Trial Registration: ClinicalTrials.gov NCT03855735; https://clinicaltrials.gov/ct2/show/NCT03855735., (©Lukas Kötting, Christina Derksen, Franziska Maria Keller, Sonia Lippke. Originally published in JMIR Pediatrics and Parenting (https://pediatrics.jmir.org), 24.07.2023.)

Background: Effective teamwork and communication are imperative for patient safety and quality care. Communication errors and human failures are considered the main source of patient harm. Thus, team trainings focusing on communication and creating psychologically safe environments are required. This can facilitate challenging communication and teamwork scenarios, prevent patient safety risks, and increase team performance perception. The sparse research concerning communication interventions calls for an understanding of psychological mechanisms. Therefore, this study investigated mechanisms of an interpersonal team intervention targeting communication and the relation of psychological safety to patient safety and team performance perception based on the applied input-process-output model of team effectiveness., Methods: Before and after a 4-h communication intervention for multidisciplinary teams, a paper-pencil survey with N = 137 healthcare workers from obstetric units of two university hospitals was conducted. Changes after the intervention in perceived communication, patient safety risks, and team performance perception were analyzed via t- tests. To examine psychological mechanisms regarding psychological safety and communication behavior, mediation analyses were conducted., Results: On average, perceived patient safety risks were lower after the intervention than before the intervention ( M T 1 = 3.220, SD T 1 = 0.735; M T 2 = 2.887, SD T 2 = 0.902). This change was statistically significant ( t (67) = 2.760, p =.007). However, no such effect was found for interpersonal communication and team performance perception. The results illustrate the mediating role of interpersonal communication between psychological safety and safety performances operationalized as perceived patient safety risks ( α 1 ∗ β 1 = -0.163, 95% CI [-0.310, -0.046]) and team performance perception ( α 1 ∗ β 1 = 0.189, 95% CI [0.044, 0.370])., Discussion: This study demonstrates the psychological mechanisms of communication team training to foster safety performances and psychological safety as an important predecessor for interpersonal communication. Our results highlight the importance of teamwork for patient safety. Interpersonal and interprofessional team training represents a novel approach as it empirically brings together interpersonal communication and collaboration in the context of patient safety. Future research should work on follow-up measures in randomized-controlled trials to broaden an understanding of changes over time., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Dietl, Derksen, Keller and Lippke.)

Background Childbirth is combined with emotional challenges and individual anxiety. Unexpected birth experiences can trigger stress reactions and even post-traumatic stress disorders. Aim of the study The aim of the study was the qualitative evaluation of stressful perceived birth experiences and desired interventions.Methods A content-analytic evaluation of 117 free-text answers was conducted regarding stressful birth experiences and desired interventions using categories and frequencies in relation to birth mode.Findings Five themes emerged from the structured free text analysis: 1) Stressful experiences describing fear concerning the child and separation from the child after an emergency caesarean section; 2) Inadequate communication after an operative vaginal birth and unplanned caesarean section; 3) Feelings of failure and guilt after unplanned birth modes; 4) Helplessness with loss of personal control and the feeling of being at the mercy after an emergency caesarean section; 5) Inadequate support due to the absence of empathy or insufficient care. Expected interventions include immediate debriefing and professional psychological support.Conclusion Women-centered communication during childbirth and debriefing of stressful birth experiences are significant interventions for strengthening maternal well-being and mental health. They can have a positive impact on the development of a healthy mother-child relationship., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Interpersonal communication, as a central form of social resource derived from social relations, is crucial for individuals coping with threats in the workplace, especially for hospitals that provide high-quality care and patient safety. Using social system mentalization as a theoretical background, we applied psychosocial processes and a psychodynamic system approach to get insights on how healthcare workers interact with team members and patients. The goal was to test the following hypotheses: H1: Better communication is associated with fewer patient safety threats (H1a) and higher-quality care (H1b). H2: The associations between communication and patient safety threats (H2a) and higher-quality care (H2b) are mediated by psychological safety. In this two-studies design, we conducted a cross-sectional hospital survey ( N = 129) and a survey of obstetric team members ( N = 138) in Germany. Simple mediation analyses were run. Results revealed that communication is associated with safety performance. Further, the mediating effect of psychological safety between communication and safety performance was demonstrated. These findings contribute to an understanding of social relation representations, as individuals' communication interrelates with safety performance mediated by psychological safety to complement healthcare and public health strategies. With a better understanding of communication and psychological safety, tools, routines, and concrete trainings can be designed.

(1) Background: Better understanding of post-/long-COVID and limitations in daily life due to the symptoms as well as the preventive potential of vaccinations is required. It is unclear whether the number of doses and timepoint interrelate with the trajectory of post-/long-COVID. Accordingly, we examined how many patients positively screened with post-/long-COVID were vaccinated and whether the vaccination status and the timepoint of vaccination in relation to the acute infection were related to post-/long-COVID symptom severity and patients' functional status (i.e., perceived symptom severity, social participation, workability, and life satisfaction) over time. (2) Methods: 235 patients suffering from post-/long-COVID were recruited into an online survey in Bavaria, Germany, and assessed at baseline (T1), after approximately three weeks (T2), and approximately four weeks (T3). (3) Results: 3.5% were not vaccinated, 2.3% were vaccinated once, 20% twice, and 53.3% three times. Overall, 20.9% did not indicate their vaccination status. The timepoint of vaccination was related to symptom severity at T1, and symptoms decreased significantly over time. Being vaccinated more often was associated with lower life satisfaction and workability at T2. (4) Conclusions: This study provides evidence to get vaccinated against SARS-CoV-2, as it has shown that symptom severity was lower in those patients who were vaccinated prior to the infection compared to those getting infected prior to or at the same time of the vaccination. However, the finding that being vaccinated against SARS-CoV-2 more often correlated with lower life satisfaction and workability requires more attention. There is still an urgent necessity for appropriate treatment for overcoming long-/post-COVID symptoms efficiently. Vaccination can be part of prevention measures, and there is still a need for a communication strategy providing objective information about the usefulness and risks of vaccinations.

COVID-19 restrictions such as lockdowns or quarantines may increase the risk for social isolation and perceived loneliness. The mechanisms can be modeled by Cacioppo's Evolutionary Theory of Loneliness (ETL), which predicts that a lack of perceived social connectedness may lead, in the long-term, to mental and physical health consequences. However, the association between COVID-19 pandemic distress, mental health, and loneliness is not sufficiently understood. The present longitudinal study examined the relationship between distress and depression, and the mediating effects of anxiety and loneliness in a German rehabilitation sample (N = 403) at two timepoints (≤6 weeks pre-rehabilitation; ≥12 weeks post-rehabilitation; mean time between T1 and T2 was  52 days). Change scores between T1 and T2 were examined for the variables COVID-19 Peritraumatic Distress Index (CPDI), anxiety, loneliness, and depression. The results of the serial mediation analysis indicated that anxiety and loneliness were able to explain the relationship between distress and depression with 42% of variance in depression accounted for. Findings extend research on the relationship between COVID-19 and mental health by considering anxiety and loneliness as sustaining factors of depressive symptoms, thus, successfully applying the ETL. Results stress the necessity to consider anxiety and loneliness in the treatment or prevention of depression., (© 2022 The Authors. Applied Psychology: Health and Well-Being published by John Wiley & Sons Ltd on behalf of International Association of Applied Psychology.)

Background: Progress in medicine involves the structured analysis and communication of errors. Comparability between the individual disciplines is only possible to a limited extent and obstetrics plays a special role: the expectation of a self-determined and joyful event meets with possibly serious complications in highly complex care situations. This must be managed by an interdisciplinary team with an increasingly condensed workload. Adverse events cannot be completely controlled. However, taking controllable risk factors into account and with a focused communication a reduction of preventable adverse events is possible. In the present study, the effect of interprofessional team training on preventable adverse events in an obstetric department was investigated., Methods: The training consisted of a 4-h interdisciplinary training session based on psychological theories. Preventable adverse events were defined in six categories according to potential patterns of causation. 2,865 case records of a refence year (2018) and 2,846 case records of the year after the intervention (2020) were retrospectively evaluated. To determine the communication training effect, the identified preventable adverse events of 2018 and 2020 were compared according to categories and analyzed for obstetrically relevant controllable and uncontrollable risk factors. Questionnaires were used to identify improvements in self-reported perceptions and behaviors., Results: The results show that preventable adverse events in obstetrics were significantly reduced after the intervention compared to the reference year before the intervention (13.35% in the year 2018 vs. 8.83% in 2020, p < 0.005). Moreover, obstetrically controllable risk factors show a significant reduction in the year after the communication training. The questionnaires revealed an increase in perceived patient safety (t(28) = 4.09, p < .001), perceived communication behavior (t(30) = -2.95, p = .006), and self-efficacy to cope with difficult situations (t(28) = -2.64, p = .013)., Conclusions: This study shows that the communication training was able to reduce preventable adverse events and thus increase patient safety. In the future, regular trainings should be implemented alongside medical emergency trainings in obstetrics to improve patient safety. Additionally, this leads to the strengthening of human factors and ultimately also to the prevention of second victims. Further research should follow up implementing active control groups and a randomized-controlled trail study design., Trial Registration: The study was approved by the Ethics Committee of University Hospital  (protocol code 114/19-FSt/Sta, date of approval 29 May 2019), study registration: NCT03855735 ., (© 2023. The Author(s).)

(1) Background: Patient safety is a pressing issue in healthcare. Besides economical and organizational issues, human factors play a crucial role in providing safe care. Safe and clear communication on both the healthcare workers' and patients' sides contribute to the avoidance of medical errors and increase patients' and healthcare workers' satisfaction. Globally, the incidence of experiencing at least one adverse event in obstetrics is about 10%, of which half are classified as preventable. According to international research, improving communication skills may decrease preventable adverse events. The research question was to what extent communication training for pregnant women impacts the quality of communication and mutual understanding during birth. (2) Methods: Communication interventions with pregnant women were conducted in two German university obstetric departments in a mixed methods research design, based on the Health Action Process Approach. The online classes covered the awareness of personal wishes, the understanding and usage of communication strategies, self-efficacy and empathy. This study presents the qualitative results. Out of 142 mothers who answered two questionnaires before the communication training and after the birth, 24 in-depth semistructured interviews were conducted to explore the subjective impact of the communication training. The results were analyzed with qualitative content analysis. (3) Results: The majority of participants felt incentivized to be aware of their personal wishes for birth and to express them. Perceived positive experiences with sufficient competency in communication, empathy and mutual understanding outweighed negative treatments and experiences in the hospital, some of which could be attributed to structural problems. (4) Discussion: The reported positive effects of the communication training underline the need but also the potential for communication lessons to reflect and improve communication skills in obstetrics. However, negative experiences due to structural problems in the healthcare system may be buffered by communication skills but not solved.

Background: Because the clinical patterns and symptoms that persist after a COVID-19 infection are diverse, a diagnosis of post-acute COVID-19 syndrome (PACS) is difficult to implement. The current research project therefore aims to evaluate the feasibility and the practicability of a comprehensive, interdisciplinary, and cross-sectoral treatment program consisting of a low-threshold online screening and holistic assessment for PACS. Furthermore, it aims to evaluate digital interventions and the use of so-called personal guides that may help to facilitate the recovery of PACS., Methods: This German study consists of a low-threshold online screening for PACS where positively screened participants will be supported throughout by personal pilots. The personal pilots are aimed at empowering patients and helping them to navigate through the study and different treatment options. Patients will then be randomly assigned either to an intervention group (IG) or an active control group (ACG). The IG will receive a comprehensive assessment of physiological and psychological functioning to inform future treatment. The ACG does not receive the assessment but both groups will receive a treatment consisting of an individual digital treatment program (digital intervention platform and an intervention via a chatbot). This digital intervention is based on the needs identified during the assessment for participants in the IG. Compared to that, the ACG will receive a more common digital treatment program aiming to reduce PACS symptoms. Importantly, a third comparison group (CompG) will be recruited that does not receive any treatment. A propensity score matching will take place, ensuring comparability between the participants. Primary endpoints of the study are symptom reduction and return to work. Secondary outcomes comprise, for example, social participation and activities in daily life. Furthermore, the feasibility and applicability of the online screening tool, the holistic assessment, digital trainings, and personal pilots will be evaluated., Discussion: This is one of the first large-scale studies to improve the diagnosis and the care of patients with PACS by means of empowerment. It is to be evaluated whether the methods utilized can be used for the German and international population. Trial registration ClinicalTrials.gov Identifier: NCT05238415; date of registration: February 14, 2022., (© 2022. The Author(s).)

Background: Human failure and a lack of effective communication are the main reasons for preventable adverse events, compromising patient safety in obstetrics. In order to improve safety, team and communication interventions have been implemented but lack feasibility in obstetric care. Psychological models such as the health action process approach might help to improve interventions., Methods: In a cross-sectional online survey with N = 129 healthcare workers (Study 1) and a paper-pencil survey with N = 137 obstetric healthcare workers at two obstetric university hospitals (Study 2), associations of social-cognitive variables were tested in a path analysis and a multiple regression. Preliminary results informed a communication training for all obstetric healthcare workers. A repeated-measures MANOVA was used to compare pre- and post-intervention data., Results: Social-cognitive variables were associated according to model suggestions (β = -0.26 to 0.45, p < 0.05) except for planning in the first study. Triggers of adverse events were associated (β = -0.41 to 0.24, p < 0.05) with communication behavior (Study 2), action self-efficacy and planning (Study 1), as well as barriers to effective communication (both studies). The intervention was rated positively ( M = 3.3/4). Afterward, fewer triggers were reported and coping self-efficacy increased. There were group differences regarding hospital, experience, and time., Discussion: The health action process approach was examined in the context of safe communication in obstetrics and can be used to inform interventions. A theory-based, short training was feasible and acceptable. Perceived patient safety improved but communication behavior did not. Future research should aim to test a more comprehensive psychological communication intervention in a thorough RCT design., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Derksen, Kötting, Keller, Schmiedhofer and Lippke.)

Background: The COVID-19 pandemic and the necessary containment measures challenge obstetric care. Support persons were excluded while protection measures burdened and disrupted the professionals' ability to care and communicate. The objective of this study was to explore the first-hand experience of the impact of the COVID-19 pandemic on mothers, their partners, and obstetric professionals regarding birth and obstetric care in a university hospital., Methods: To answer the descriptive research questions, we conducted a qualitative content analysis using a data triangulation approach. We carried out 35 semi-structured interviews with two stratified purposive samples. Sample one consisted of 25 mothers who had given birth during the pandemic and five partners. Sample two included 10 obstetric professionals whose insights complemented the research findings and contributed to data validation. Participants were recruited from the study sample of a larger project on patient safety from two German university hospitals from February to August 2021. The study was approved by two ethics committees and informed consent was obtained., Results: Mothers complied with the rules, but felt socially isolated and insecure, especially before transfer to the delivery room. The staff equally reported burdens from their professional perspective: They tried to make up for the lack of partner and social contacts but could not live up to their usual professional standards. The exclusion of partners was seen critically, but necessary to contain the pandemic. The undisturbed time for bonding in the maternity ward was considered positive by both mothers and professionals., Conclusion: The negative effects of risk mitigation measures on childbirth are to be considered carefully when containment measures are applied.

(1) Background: Adverse events (AEs) are an inherent part of all medical care. Obstetrics is special: it is characterized by a very high expectation regarding safety and has rare cases of harm, but extremely high individual consequences of harm. However, there is no standardized identification, documentation, or uniform terminology for the preventability of AEs in obstetrics. In this study, therefore, an obstetrics-specific matrix on the preventable factors of AEs is established based on existing literature to enable standardized reactive risk management in obstetrics. (2) Methods: AEs in obstetrics from one hospital from the year 2018 were retrospectively evaluated according to a criteria matrix regarding preventability. Risk factors for preventable AEs (pAEs) were identified. (3) Results: Out of 2865 births, adverse events were identified in 659 cases (23%). After detailed case analysis, 88 cases (13%) showed at least 1 pAE. A total of 19 risk factors could be identified in 6 categories of pAEs. (4) Conclusion: Preventable categories of error could be identified. Relevant obstetric risk factors related to the error categories were identified and categorized. If these can be modified in the future with targeted measures of proactive risk management, pAEs in obstetrics could also be reduced.

Objective: The COVID-19 pandemic requires numerous measures to protect against infection, such as contact reduction and adherence to hygiene and social distancing rules. The former leads to mental disorders (possibly requiring treatment) due to social isolation, the latter require adaptation in the implementation of medical therapies. With overall limited therapy capacities, the use of digital (health) applications can be of particular importance in the therapy of chronic and psychological diseases in particular. The present study investigates which health apps are being used by people with mental health problems., Methods: 1,060 insured persons in preparation for psychosomatic rehabilitation measures were surveyed by means of an online questionnaire. Descriptive analyses, frequency analyses, and analyses of variance with post-hoc tests and correlation analyses were used for evaluation., Results: Participants used on average three apps; the most common topics were "nutrition" (n=313), "self-diagnosis" (n=244) and "relaxation" (n=234). Female participants were more likely to use apps than male participants, and younger participants were more likely to use apps than older participants. Symptoms of anxiety were correlated to the use of digital applications, especially concerning heart rate and blood pressure monitoring, while depressive symptoms were not associated with a more frequent use of apps., Discussion: Digital apps are being frequently used by people with mental health problems. Increasing acceptance of digital (health) apps has significant potential in the treatment of chronic mental illness in particular. The focus should be on individual applications with integration into the regular care process., Conclusion: Increasing digitalization, also in the healthcare sector, can be used to ensure care, especially in times of contact restrictions and limited human resources., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: The COVID-19 pandemic has largely affected people's mental health and psychological well-being. Specifically, individuals with a pre-existing mental health disorder seem more impaired by lockdown measures posing as major stress factors. Medical rehabilitation treatment can help people cope with these stressors. The internet and digital apps provide a platform to contribute to regular treatment and to conduct research on this topic., Objective: Making use of internet-based assessments, this study investigated individuals from the general population and patients from medical, psychosomatic rehabilitation clinics. Levels of depression, anxiety, loneliness, and perceived stress during the COVID-19 pandemic, common COVID-19-related worries, and the intention to use digital apps were compared. Furthermore, we investigated whether participating in internet-delivered digital trainings prior to and during patients' rehabilitation stay, as well as the perceived usefulness of digital trainings, were associated with improved mental health after rehabilitation., Methods: A large-scale, online, cross-sectional study was conducted among a study sample taken from the general population (N=1812) in Germany from May 2020 to April 2021. Further, a longitudinal study was conducted making use of the internet among a second study sample of psychosomatic rehabilitation patients at two measurement time points-before (N=1719) and after (n=738) rehabilitation-between July 2020 and April 2021. Validated questionnaires and adapted items were used to assess mental health and COVID-19-related worries. Digital trainings were evaluated. Propensity score matching, multivariate analyses of covariance, an exploratory factor analysis, and hierarchical regression analyses were performed., Results: Patients from the psychosomatic rehabilitation clinics reported increased symptoms with regard to depression, anxiety, loneliness, and stress (F 4,2028 =183.74, P<.001, η 2 p =0.27) compared to the general population. Patients perceived greater satisfaction in communication with health care professionals (F 1,837 =31.67, P<.001, η 2 p =0.04), had lower financial worries (F 1,837 =38.96, P<.001, η 2 p =0.04), but had higher household-related worries (F 1,837 =5.34, P=.02, η 2 p =0.01) compared to the general population. Symptoms of depression, anxiety, loneliness, and perceived stress were lower postrehabilitation (F 1,712 =23.21, P<.001, η 2 p =0.04) than prior to rehabilitation. Psychosomatic patients reported a higher intention to use common apps and digital trainings (F 3,2021 =51.41, P<.001, η 2 p =0.07) than the general population. With regard to digital trainings offered prior to and during the rehabilitation stay, the perceived usefulness of digital trainings on rehabilitation goals was associated with decreased symptoms of depression (β=-.14, P<.001), anxiety (β=-.12, P<.001), loneliness (β=-.18, P<.001), and stress postrehabilitation (β=-.19, P<.001). Participation in digital group therapy for depression was associated with an overall change in depression (F 1,725 =4.82, P=.03, η 2 p =0.01) and anxiety (F 1,725 =6.22, P=.01, η 2 p =0.01) from pre- to postrehabilitation., Conclusions: This study validated the increased mental health constraints of psychosomatic rehabilitation patients in comparison to the general population and the effects of rehabilitation treatment. Digital rehabilitation components are promising tools that could prepare patients for their rehabilitation stay, could integrate well with face-to-face therapy during rehabilitation treatment, and could support aftercare., Trial Registration: ClinicalTrials.gov NCT04453475; https://clinicaltrials.gov/ct2/show/NCT04453475 and ClinicalTrials.gov NCT03855735; https://clinicaltrials.gov/ct2/show/NCT03855735., (©Franziska Maria Keller, Alina Dahmen, Christina Derksen, Lukas Kötting, Sonia Lippke. Originally published in JMIR Mental Health (https://mental.jmir.org), 26.08.2021.)

The need for new technologies in healthcare services has been stressed. However, little is known about the effectiveness of digital interventions integrated in psychosomatic rehabilitation processes. Data from 724 patients from psychosomatic rehabilitation clinics were analyzed with regard to the effectiveness of digital trainings indicated by a change in symptoms related to depression, anxiety, stress, and loneliness from pre- to post-rehabilitation. Rehabilitation satisfaction was examined in association with reaching rehabilitation goals and satisfaction with communication. A mixed repeated measures analyses of covariance, analyses of covariance, and hierarchical stepwise regression analyses were performed. Results indicated a superior effectiveness for the intervention group receiving all offered digital treatments in addition to the regular face-to-face rehabilitation program with regard to symptoms of depression (F (2674) = 3.93, p < 0.05, η p 2 = 0.01), anxiety (F (2678) = 3.68, p < 0.05, η p 2 = 0.01) post-rehabilitation, with large effect sizes for both depression (d = 1.28) and anxiety (d = 1.08). In addition, rehabilitation satisfaction was positively associated with reaching rehabilitation goals and perceived communication with healthcare workers. Digital interventions appeared effective in supporting mental health of psychosomatic rehabilitation patients' post-rehabilitation. These findings support the inclusion of multidisciplinary and interdisciplinary digital and face-to-face treatment programs and call for more implementations of new technologies in a context of complexity to improve health and healthcare service.

We describe the Northern Hemisphere terrestrial snow water equivalent (SWE) time series covering 1979-2018, containing daily, monthly and monthly bias-corrected SWE estimates. The GlobSnow v3.0 SWE dataset combines satellite-based passive microwave radiometer data (Nimbus-7 SMMR, DMSP SSM/I and DMSP SSMIS) with ground based synoptic snow depth observations using bayesian data assimilation, incorporating the HUT Snow Emission model. The original GlobSnow SWE retrieval methodology has been further developed and is presented in its current form in this publication. The described GlobSnow v3.0 monthly bias-corrected dataset was applied to provide continental scale estimates on the annual maximum snow mass and its trend during the period 1980 to 2018.

Background: Patient-centered care and patient involvement have been increasingly recognized as crucial elements of patient safety. However, patient safety has rarely been evaluated from the patient perspective with a quantitative approach aiming at making patient safety and preventable adverse events measurable., Objectives: The objectives of this study were to develop and evaluate the psychometric properties of a questionnaire assessing patient safety by perceived triggers of preventable adverse events among patients in primary health-care settings while considering mental health., Methods: Two hundred and ten participants were recruited through various digital and print channels and asked to complete an online survey between November 2019 and April 2020. Exploratory factor analysis was performed to identify domains of triggers of preventable adverse events affecting patient safety. Furthermore, a multi-trait scaling analysis was performed to evaluate internal reliability as well as item-scale convergent-discriminant validity. A multivariate analysis of covariance evaluated whether individuals below and above the symptom threshold for depression and generalized anxiety perceive triggers of preventable adverse events differently., Results: The five factors determined were information and communication with patients, time constraints of health-care professionals, diagnosis and treatment, hygiene and communication among health-care professionals, and knowledge and operational procedures. The questionnaire demonstrated a good total and subscale internal consistency (α = 0.90, range = 0.75-0.88), good item-scale convergent validity with significant correlations between 0.57 and 0.78 (P < 0.05; P < 0.01) for all items with their associated subscales, and satisfactory item-scale discriminant validity between 0.14 and 0.55 (P > 0.05) with no significant correlations between the items and their competing subscales. The questionnaire further revealed to be a generic measure irrespective of patients' mental health status. Patients older than 50 years of age perceived a significantly greater threat to their own safety compared to patients below that age., Conclusion: The developed Perceptions of Preventable Adverse Events Assessment Tool (PPAEAT) exhibits good psychometric properties, which supports its use in future research and primary health-care practice. Further validation of the PPAEAT in different settings, languages and larger samples is needed. The results of this study need to be considered when assessing patient safety in the context of health-care research., (© The Author(s) 2021. Published by Oxford University Press on behalf of International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The COVID-19 pandemic requires containment measures such as contact restrictions and hygiene requirements. It is accompanied by psychological problems and the fear of infection or of a severe course of the disease. This paper examines the relationship between fear of infection and adherence to rules of hygiene as well as the utilization of medical services., Methods: 1005 patients (20-79 years, 626=62.4% female) were interviewed by online questionnaire before starting a psychosomatic rehabilitation program. Data are presented descriptively and analysed by variance analyses., Results: 68.6% were rarely/sometimes afraid and 17.9% were always afraid of contracting coronavirus or of a severe course of the disease. Those who were afraid intended to wash their hands more frequently (97.2%) than those who were not afraid. Regardless of any change in their physical and mental health status, participants felt it to be risky to seek medical care., Conclusion: The intention to follow hygiene rules in people with pre-existing mental illness depends on a fear of infecting oneself or others with the coronavirus or of contracting a severe form of the disease. Especially mentally or psychosomatically affected individuals need to be informed adequately about the coronavirus and the necessary individual protective measures in order to reduce resistance and to increase willingness to seek medical help., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

(1) Background: Obstetric work requires good communication, which can be trained through interventions targeting healthcare providers and pregnant women/patients. This systematic review aims to aggregate the current state of research on communication interventions in obstetrics. (2) Methods: Using the PICOS scheme, we searched for studies published in peer-reviewed journals in English or German between 2000 and 2020. Out of 7018 results, 71 studies were included and evaluated in this synthesis using the Oxford Level of Evidence Scale. (3) Results: The 63 studies that included a communication component revealed a positive effect on different proximal outcomes (i.e., communication skills). Three studies revealed a beneficial effect of communication trainings on distal performance indicators (i.e., patient safety), but only to a limited extent. Most studies simultaneously examined different groups, however, those addressing healthcare providers were more common than those with students (61 vs. 12). Only nine studies targeted expectant mothers. Overall, the evidence level of studies was low (only 11 RCTs), with 24 studies with an evidence level I-II, 35 with level III, and 10 with level IV. (4) Conclusions: Communication trainings should be more frequently applied to improve communication of staff, students, and pregnant women and their partners, thereby improving patient safety.

Background and Purpose: Conventional angiography is the benchmark examination to diagnose cerebral vasospasm, but there is limited evidence regarding its reliability. Our goals were the following: 1) to systematically review the literature on the reliability of the diagnosis of cerebral vasospasm using conventional angiography, and 2) to perform an agreement study among clinicians who perform endovascular treatment., Materials and Methods: Articles reporting a classification system on the degree of cerebral vasospasm on conventional angiography were systematically searched, and agreement studies were identified. We assembled a portfolio of 221 cases of patients with subarachnoid hemorrhage and asked 17 raters with different backgrounds (radiology, neurosurgery, or neurology) and experience (junior ≤10 and senior >10 years) to independently evaluate cerebral vasospasm in 7 vessel segments using a 3-point scale and to evaluate, for each case, whether findings would justify endovascular treatment. Nine raters took part in the intraobserver reliability study., Results: The systematic review showed a very heterogeneous literature, with 140 studies using 60 different nomenclatures and 21 different thresholds to define cerebral vasospasm, and 5 interobserver studies reporting a wide range of reliability (κ = 0.14-0.87). In our study, only senior raters reached substantial agreement (κ ≥ 0.6) on vasospasm of the supraclinoid ICA, M1, and basilar segments and only when assessments were dichotomized (presence or absence of ≥50% narrowing). Agreement on whether to proceed with endovascular management of vasospasm was only fair (κ ≤ 0.4)., Conclusions: Research on cerebral vasospasm would benefit from standardization of definitions and thresholds. Dichotomized decisions by experienced readers are required for the reliable angiographic diagnosis of cerebral vasospasm., (© 2021 by American Journal of Neuroradiology.)

Patient safety is an important objective in health care. Preventable adverse events (pAEs) as the counterpart to patient safety are harmful incidents that fell behind health care standards and have led to temporary or permanent harm or death. As safe communication and mutual understanding are of crucial importance for providing a high quality of care under everyday conditions, we aimed to identify barriers and facilitators that impact safe communication in obstetrics from the subjective perspective of health care workers. A qualitative study with 20 semi-structured interviews at two university hospitals in Germany was conducted to explore everyday perceptions from a subjective perspective (subjective theories). Physicians, midwives, and nurses in a wide span of professional experience and positions were enrolled. We identified a structural area of conflict at the professional interface between midwives and physicians. Mandatory interprofessional meetings, acceptance of subjective mistakes, mutual understanding, and debriefings of conflict situations are reported to improve collaboration. Additionally, emergency trainings, trainings in precise communication, and handovers are proposed to reduce risks for pAEs. Furthermore, the participants reported time-constraints and understaffing as a huge burden that hinders safe communication. Concluding, safety culture and organizational management are closely entwined and strategies should address various levels of which communication trainings are promising.

Background: Fictional portrayals of illness and medical management in film and television can reflect and perpetuate cultural stereotypes about illness. The aim of this study was to analyse fictional depictions of gout in contemporary film and television., Methods: We conducted a search for English language depictions of gout in film and television since 1990 using the Internet Movie Database (IMDb), other internet media databases, and member suggestions from the Gout, Hyperuricemia and Crystal-Associated Disease Network (G-CAN). Film and television episodes with gout content were analysed for depictions of characters with gout, causal factors, and management strategies (n=44)., Results: Gout was used to denote royalty or nobility in historical settings, and as a plot device to explain the absence of characters from key events. The most commonly depicted causes of gout were overindulgence of food and alcohol (61%), and portrayals of biological causes were infrequent (12%). Common management strategies were change in diet (36%) and short-term pain relief (32%), with only one mention of urate-lowering therapy (5%). The majority of films and television episodes depicted gout as humorous (59%) and embarrassing (50%)., Conclusions: In contemporary film and television, gout is portrayed as a humorous and embarrassing condition, caused by dietary indulgence. These depictions may reinforce inaccurate beliefs about the causes of gout and its management.

Description: Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular malformations (VMs). These result in chronic bleeding, acute hemorrhage, and complications from shunting through VMs. The goal of the Second International HHT Guidelines process was to develop evidence-based consensus guidelines for the management and prevention of HHT-related symptoms and complications., Methods: The guidelines were developed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) framework and GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The guidelines expert panel included expert physicians (clinical and genetic) in HHT from 15 countries, guidelines methodologists, health care workers, health care administrators, patient advocacy representatives, and persons with HHT. During the preconference process, the expert panel generated clinically relevant questions in 6 priority topic areas. A systematic literature search was done in June 2019, and articles meeting a priori criteria were included to generate evidence tables, which were used as the basis for recommendation development. The expert panel subsequently convened during a guidelines conference to conduct a structured consensus process, during which recommendations reaching at least 80% consensus were discussed and approved., Recommendations: The expert panel generated and approved 6 new recommendations for each of the following 6 priority topic areas: epistaxis, gastrointestinal bleeding, anemia and iron deficiency, liver VMs, pediatric care, and pregnancy and delivery (36 total). The recommendations highlight new evidence in existing topics from the first International HHT Guidelines and provide guidance in 3 new areas: anemia, pediatrics, and pregnancy and delivery. These recommendations should facilitate implementation of key components of HHT care into clinical practice.

Background: Hand hygiene is crucial to avoid healthcare-associated infections and the transmission of COVID-19. Although the WHO has issued global hand hygiene recommendations for healthcare, adherence remains challenging. Considering social-cognitive theories such as the health action process approach (HAPA) can help to improve healthcare workers' adherence. This study aimed to observe adherence and to assess determinants in obstetric hospitals during and after the onset of the COVID-19 pandemic., Methods: In all, 267 observations of behaviour were conducted in two German obstetric university hospitals over three time periods (pre-COVID-19 pandemic, heightened awareness, and strict precautions). In addition, 115 healthcare workers answered questionnaires regarding social-cognitive determinants of hand hygiene behaviour. Multiple regression and multiple mediation analyses were used to analyse associations., Results: Adherence to hand hygiene recommendations increased from 47 per cent pre-COVID-19 pandemic to 95 per cent just before lockdown while simple measures against the pandemic were taken. Self-efficacy was associated with the intention to sanitise hands (β = .397, p < .001). Coping self-efficacy mediated the association of intention with hand hygiene adherence., Conclusions: Obstetric healthcare workers seem to adapt their hand hygiene behaviour to prevent infections facing the global COVID-19 pandemic. To further improve interventions, social-cognitive determinants should be considered, especially intention and (coping) self-efficacy., (© 2020 The Authors. Applied Psychology: Health and Well-Being published by John Wiley & Sons Ltd on behalf of International Association of Applied Psychology.)

Objective: The aim of this study was to evaluate which concepts about gout and its treatment are reflected in images in online educational resources about gout., Methods: A Google search was performed to identify English-language patient resources from medical and health organizations and health education websites in 7 countries: Australia, Canada, Ireland, New Zealand, South Africa, UK, and USA. Two raters independently coded the images in the resources into 5 main categories: clinical presentations of gout, urate/monosodium urate (MSU) crystals, medicines, food/healthy lifestyle, and other advice for people with gout., Results: In total, 103 resources were identified; 28 resources without images were excluded. Seventy-one educational resources with a total of 310 images were included in the study sample. Of the 310 images, clinical presentations of gout were depicted in 92 images (30%), food/healthy lifestyle in 73 images (24%), urate/MSU crystals in 50 (16%), medicines in 14 (5%). Urate-lowering medication was shown only in 1 image (0.3%) and just 6 images (2%) depicted a serum urate target. Ninety-one images (29%) did not convey specific information about gout., Conclusion: Key concepts about gout and treatment are underrepresented in the images used in educational resources for patients. A large proportion of the images do not convey useful information about gout or its management.

Warming surface temperatures have driven a substantial reduction in the extent and duration of Northern Hemisphere snow cover 1-3 . These changes in snow cover affect Earth's climate system via the surface energy budget, and influence freshwater resources across a large proportion of the Northern Hemisphere 4-6 . In contrast to snow extent, reliable quantitative knowledge on seasonal snow mass and its trend is lacking 7-9 . Here we use the new GlobSnow 3.0 dataset to show that the 1980-2018 annual maximum snow mass in the Northern Hemisphere was, on average, 3,062 ± 35 billion tonnes (gigatonnes). Our quantification is for March (the month that most closely corresponds to peak snow mass), covers non-alpine regions above 40° N and, crucially, includes a bias correction based on in-field snow observations. We compare our GlobSnow 3.0 estimates with three independent estimates of snow mass, each with and without the bias correction. Across the four datasets, the bias correction decreased the range from 2,433-3,380 gigatonnes (mean 2,867) to 2,846-3,062 gigatonnes (mean 2,938)-a reduction in uncertainty from 33% to 7.4%. On the basis of our bias-corrected GlobSnow 3.0 estimates, we find different continental trends over the 39-year satellite record. For example, snow mass decreased by 46 gigatonnes per decade across North America but had a negligible trend across Eurasia; both continents exhibit high regional variability. Our results enable a better estimation of the role of seasonal snow mass in Earth's energy, water and carbon budgets.

Background and Purpose: Although onset-to-treatment time is associated with early clinical recovery in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (tPA), the effect of the timing of tPA-induced recanalization on functional outcomes remains debatable., Methods: We conducted a multicenter, prospective observational cohort study to determine whether early (within 1-hour from tPA-bolus) complete or partial recanalization assessed during 2-hour real-time transcranial Doppler monitoring is associated with improved outcomes in patients with proximal occlusions. Outcome events included dramatic clinical recovery (DCR) within 2 and 24-hours from tPA-bolus, 3-month mortality, favorable functional outcome (FFO) and functional independence (FI) defined as modified Rankin Scale (mRS) scores of 0-1 and 0-2 respectively., Results: We enrolled 480 AIS patients (mean age 66±15 years, 60% men, baseline National Institutes of Health Stroke Scale score 15). Patients with early recanalization (53%) had significantly (P<0.001) higher rates of DCR at 2-hour (54% vs. 10%) and 24-hour (63% vs. 22%), 3-month FFO (67% vs. 28%) and FI (81% vs. 39%). Three-month mortality rates (6% vs. 17%) and distribution of 3-month mRS scores were significantly lower in the early recanalization group. After adjusting for potential confounders, early recanalization was independently associated with higher odds of 3-month FFO (odds ratio [OR], 6.19; 95% confidence interval [CI], 3.88 to 9.88) and lower likelihood of 3-month mortality (OR, 0.34; 95% CI, 0.17 to 0.67). Onset to treatment time correlated to the elapsed time between tPA-bolus and recanalization (unstandardized linear regression coefficient, 0.13; 95% CI, 0.06 to 0.19)., Conclusions: Earlier tPA treatment after stroke onset is associated with faster tPA-induced recanalization. Earlier onset-to-recanalization time., Results: in improved functional recovery and survival in AIS patients with proximal intracranial occlusions.

Background: Patient safety is a key target in public health, health services and medicine. Communication between all parties involved in gynecology and obstetrics (clinical staff/professionals, expectant mothers/patients and their partners, close relatives or friends providing social support) should be improved to ensure patient safety, including the avoidance of preventable adverse events (pAEs). Therefore, interventions including an app will be developed in this project through a participatory approach integrating two theoretical models. The interventions will be designed to support participants in their communication with each other and to overcome difficulties in everyday hospital life. The aim is to foster effective communication in order to reduce the frequency of pAEs. If communication is improved, clinical staff should show an increase in work satisfaction and patients should show an increase in patient satisfaction., Methods: The study will take place in two maternity clinics in Germany. In line with previous studies of complex interventions, it is divided into three interdependent phases. Each phase provides its own methods and data. Phase 1: Needs assessment and a training for staff (n = 140) tested in a pre-experimental study with a pre/post-design. Phase 2: Assessment of communication training for patients and their social support providers (n = 423) in a randomized controlled study. Phase 3: Assessment of an app supporting the communication between staff, patients, and their social support providers (n = 423) in a case-control study. The primary outcome is improvement of communication competencies. A range of other implementation outcomes will also be assessed (i.e. pAEs, patient/treatment satisfaction, work satisfaction, safety culture, training-related outcomes)., Discussion: This is the first large intervention study on communication and patient safety in gynecology and obstetrics integrating two theoretical models that have not been applied to this setting. It is expected that the interventions, including the app, will improve communication practice which is linked to a lower probability of pAEs. The app will offer an effective and inexpensive way to promote effective communication independent of users' motivation. Insights gained from this study can inform other patient safety interventions and health policy developments., Trial Registration: ClinicalTrials.gov Identifier: NCT03855735; date of registration: February 27, 2019.

Background and Purpose: The purpose of this study was to compare Doppler ultrasound (DUS) to other angiographic modalities: computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA)., Methods: All DUS studies performed at Stroke Prevention Clinic (SPC) from 2011 to 2013 and referred for further angiographic modalities were included. Patients were excluded if the corresponding angiographic modality was not performed within 6 months of DUS. Patients were also excluded if they underwent interventions before DUS or between the time of DUS and the corresponding angiographic modality. The degree of stenosis was classified as mild (<50%), moderate (50-69%), severe (70-99%), or occlusion (100%)., Results: In total, 245 patients were identified. Nine patients were excluded (3.7%). Overall 472 Doppler studies of single ICAs from 236 patients were included in our analysis. Age was 65 ± 13 years and 136 patients were males (57.6%). There was an excellent agreement between DUS and CTA (kappa = .9 [P < .001], n = 274), good agreement with MRA (kappa = .8 [P < .001], n = 242), and excellent agreement with DSA (kappa = .92 [P < .001], n = 18). There was excellent agreement between CTA and MRA (kappa = .87, n = 46)., Conclusion: Doppler ultrasound performed in a dedicated SPC by an experienced sonographer and reviewed by a certified stroke neurologist serves as a reliable initial screening tool in determining carotid artery stenosis., (© 2018 by the American Society of Neuroimaging.)

In an acute stroke setting, transcranial Doppler (TCD) and transcranial color-coded duplex (TCCD) have an important diagnostic utility in the monitoring of an arterial occlusion and microemboli detection. In addition, TCD has proven to be a very useful tool in the detection and progression of cerebral vasospasm in patients with subarachnoid hemorrhage. TCD/TCCD may have an important role in defining collateral blood flow (CF) in stroke patients. It is a noninvasive technique and can be utilized repeatedly allowing for changes in the blood flow dynamics as treatment is delivered. In this review, we outlined the evolving role of TCD/TCCD in defining CF in patients with an acute ischemic stroke, predicting clinical outcome and monitoring the treatment's efficacy of the CF augmentation., (© 2018 by the American Society of Neuroimaging.)

Background and Purpose: Flow diversion is a relatively new strategy used to treat complex cerebral aneurysms. The optimal method for radiographic follow-up of patients treated with flow diverters has not been established. The rate and clinical implications of in-stent stenosis for these devices is unclear. We evaluate the use of transcranial Doppler ultrasound (TCD) for follow-up of in-stent stenosis., Materials and Methods: We analyzed 28 patients treated with the Pipeline embolization device (PED) over the course of 42 months from January 2009 to June 2012. Standard conventional cerebral angiograms were performed in all patients. TCD studies were available in 23 patients., Results: Angiographic and TCD results were compared and found to correlate well., Conclusions: TCD is a potentially useful adjunct for evaluating in-stent stenosis after flow diversion., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: Inaccurate lay views of an illness can lead to the adoption of unhelpful coping strategies and treatments. Gout is an example of an illness where the popular view of the condition conflicts with a modern understanding of the illness by overemphasizing the role of diet and alcohol in the development and management of the disease. In this study we investigated the effect of renaming gout as urate crystal arthritis on the perceptions of the illness., Method: One-hundred and 89 supermarket shoppers participated in a study examining the perceptions of different types of arthritis. Participants completed a questionnaire that either used the term "urate crystal arthritis" (UCA) or "gout" for the label and a description of the disease. Participants rated likely causal factors, illness perceptions and the usefulness of various management strategies., Results: Gout was perceived as being more likely caused by the patient's own behavior through poor diet and overconsumption of alcohol, while UCA was attributed to aging. The UCA-labeled illness was also viewed as a more chronic and serious condition, while the gout-labeled illness was seen as being more socially embarrassing and more under the patient's personal control. Management for the gout-labeled illness centered on dietary interventions, while the UCA-labeled illness was perceived as requiring long-term medication., Conclusion: Changing an illness label can have a significant effect on causal beliefs, illness perceptions, and management strategies. Changing illness labels may be useful where the lay perceptions of an illness are not aligned with a current understanding of the condition. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Background: Social media is increasingly used by patients to source information for managing chronic disease. The aim of this study was to understand patient information needs about gout by a content analysis of questions posted on the social news website Reddit., Methods: We analysed questions posted onto the 'Gout sufferers unite' subreddit site. Two reviewers coded questions into categories (inter-reviewer kappa 0.70), with discordant coding resolved by a third reviewer. Data were analysed by calculating the frequency of questions within the categories. Where relevant, categories were further separated into sub-categories to allow organisation and interpretation of the data., Results: We analysed 359 questions in 287 posts by 213 individuals. A wide range of questions arose. The single most common category related to uncertainty of diagnosis (22.3% questions), with questions about disease management common. Information-seeking about medications was generally cautious, with questions about side-effects, risk of flares after starting urate-lowering therapy, and decision to start urate-lowering therapy. Community users experiencing flares posted questions about flare management, including medications, sometimes in real-time. Dietary management questions included the effectiveness of dietary changes as a management strategy, choice of alcoholic beverage, and weight loss strategies. Questions about serum urate levels were rare (2.8% questions)., Conclusions: Questions about gout posted on the subreddit site most often related to uncertainty about symptoms and disease management strategies, with infrequent questions about serum urate testing, results or targets. These findings may inform development of strategies to address the information needs of people with gout.

We determine the annual timing of spring recovery from space-borne microwave radiometer observations across northern hemisphere boreal evergreen forests for 1979-2014. We find a trend of advanced spring recovery of carbon uptake for this period, with a total average shift of 8.1 d (2.3 d/decade). We use this trend to estimate the corresponding changes in gross primary production (GPP) by applying in situ carbon flux observations. Micrometeorological CO 2 measurements at four sites in northern Europe and North America indicate that such an advance in spring recovery would have increased the January-June GPP sum by 29 g⋅C⋅m -2 [8.4 g⋅C⋅m -2 (3.7%)/decade]. We find this sensitivity of the measured springtime GPP to the spring recovery to be in accordance with the corresponding sensitivity derived from simulations with a land ecosystem model coupled to a global circulation model. The model-predicted increase in springtime cumulative GPP was 0.035 Pg/decade [15.5 g⋅C⋅m -2 (6.8%)/decade] for Eurasian forests and 0.017 Pg/decade for forests in North America [9.8 g⋅C⋅m -2 (4.4%)/decade]. This change in the springtime sum of GPP related to the timing of spring snowmelt is quantified here for boreal evergreen forests., Competing Interests: The authors declare no conflict of interest.

Peak runoff in streams and rivers of the western United States is strongly influenced by melting of accumulated mountain snowpack. A significant decline in this resource has a direct connection to streamflow, with substantial economic and societal impacts. Observations and reanalyses indicate that between the 1980s and 2000s, there was a 10-20% loss in the annual maximum amount of water contained in the region's snowpack. Here we show that this loss is consistent with results from a large ensemble of climate simulations forced with natural and anthropogenic changes, but is inconsistent with simulations forced by natural changes alone. A further loss of up to 60% is projected within the next 30 years. Uncertainties in loss estimates depend on the size and the rate of response to continued anthropogenic forcing and the magnitude and phasing of internal decadal variability. The projected losses have serious implications for the hydropower, municipal and agricultural sectors in the region.

In patients with critical carotid stenosis and ischemic stroke, it is crucial to determine whether distal hypoperfusion or artery-to-artery embolism is the predominant mechanism. The role of transcranial doppler (TCD) in this setting is vital. We report a patient with fibromuscular dysplasia and recurrent orthostatic transient ischemic attacks where fall in cerebral perfusion was clearly demonstrated by TCD., (Copyright © 2012 by the American Society of Neuroimaging.)

Background: Transcranial Doppler (TCD) has been subjected to criticism for detecting vasospasm (VSP). Our study's aim is to derive criteria for middle cerebral artery (MCA) vasospasm (MCA-VSP) based on cerebral angiography (CA)., Methods: A prospective data of patients with aneurysmal subarachnoid hemorrhage (aSAH) from January 2004 to August 2009. TCD was performed daily from day 2 to 14 from symptom's onset. Follow-up CA was done at day 7-9. TCD mean flow velocities (MFV) of all vessels at baseline (b), middle (m) and before CA (preangio) were recorded. Several MCA MFV ratios were computed. Moderate to severe VSP on CA was defined as >1/3 luminal narrowing. Univariate and stepwise logistic regression analysis were performed., Results: One hundred sixty-nine patients (338 MCA) with aSAH were included, mean age: 54.8 ± 13, women: 103 (62%). Twenty-nine patients (8.6%) had angiographic MCA-VSP. TCD scoring system of 3 points for MCA-VSP was computed based on (a) bMCA MFV ≥ 120 cm/s (sensitivity: 59.3%, specificity: 85%, PPV: 36.4%, NPV: 93.5%, P < .001) (1 point), Preangio MCA MFV ≥ 150 cm/s (79.3%, 89.9%, 39%, 97.3%, <.001) (1 point), and affected preangio MCA/bMCA MFV ratio ≥ 1.5 (84%, 63%, 25.6%, 96.3%, .001) (1 point). The score of 3 has 96% sensitivity and 96% specificity (OR: 300) whereas the score of 1 has 12% sensitivity and 58% specificity (OR: 4.3) for identifying MCA-VSP., Conclusion: TCD stringent criteria for moderate to severe MCA-VSP are feasible and applicable in aSAH population., (Copyright © 2012 by the American Society of Neuroimaging.)

Background: Collateral flow augmentation using partial aortic occlusion may improve cerebral perfusion in acute stroke. We assessed the effect of partial aortic occlusion on arterial flow velocities of acute stroke patients., Methods: Patients with neurological deficits following thrombolysis were treated with partial aortic occlusion. Transcranial Doppler ultrasound (TCD) was used to measure arterial flow velocities at baseline, before and during balloon inflation. The augmented mean flow velocity (MFV), peak systolic velocity (PSV), and end diastolic velocity flow percentages (aMFV%, aPSV%, aEDV%) were calculated and compared based on outcome., Results: Of 11 patients, 3 did not have a temporal window and thus were excluded from our analysis. Six of the remaining 8 patients had middle cerebral artery (MCA) occlusions; the final 2 had terminal internal carotid artery (TICA) occlusions. Three of these 8 patients had good outcome at 90 days (mRS < 3). Before intra-aortic balloon inflation (IABI), the mean affected artery MFV was 23 ± 11 cm/s; during the procedure it was 26 ± 12 cm/s (P = .2). Mean affected artery PSV at baseline and during balloon inflation were 37 ± 16 and 46 ± 23, respectively (P = .1). Mean augmented affected artery MFV% in patients with good long-term outcome was 65.4 ± 46, while the result in those with poor outcome was -3.7 ± 21 (P = .03). Three patients developed anterior cross-filling, and of these 2 had good long-term outcome., Conclusion: TCD monitoring of patients treated with IABI may help in predicting outcome in this novel device., (Copyright © 2012 by the American Society of Neuroimaging.)

Positional intermittent carotid ischemia has rarely been reported in the literature. We report a case of fluctuating hemiparesis in a 88-year-old woman in whom transcranial Doppler ultrasonography at various head positions proved useful in establishing the mechanism of the hypoperfusion transient ischemic attack. Head rotation to the side of the stenotic internal carotid artery resulted in significant drop in ipsilateral middle cerebral artery mean flow velocity., (Copyright © 2011 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Contrast transthoracic echocardiography (TTCE) is used to screen hereditary hemorrhagic telangiectasia (HHT) patients for right-to-left shunts (RLS) associated with increased stroke risk. We hypothesized that contrast transcranial Doppler (TCDc), shown to be highly sensitive for detecting RLS in patent foramen ovale, will be as comparable to TTCE for screening HHT patients., Methods: We compared TTCE and TCDc for detecting RLS in 12 patients with HHT who also underwent CT pulmonary studies to determine pulmonary arteriovenous malformation (PAVM) presence. The sensitivity and specificity of TTCE and TCDc in detecting PAVM were determined and the agreement between TTCE and TCDc in detecting RLS was assessed., Results: Both TTCE and TCDc had 100% sensitivity in detecting underlying PAVM; the specificity was 25% and 38%, respectively. The agreement in detecting RLS between TTCE and TCD was high (κ=0.76). TCD was well-tolerated with no immediate adverse or embolic events over the next 3 months., Conclusions: TCDc offers a simple office-based alternative to TTCE for screening RLS associated with PAVM in HHT patients.

Intracranial arterial stenosis (IAS) is thought to be responsible for 8% of all ischemic stroke subtypes. The best medical treatment for this condition is still controversial. Transcranial Doppler (TCD) emboli monitoring may help to guide the treatment by measuring the frequency of microembolic signals (MES). We report a case of IAS where TCD emboli monitoring proved useful in establishing the mechanism of stroke by being artery-to-artery emboli and guiding therapy based on the frequent symptoms and number of MES., (Copyright © 2009 by the American Society of Neuroimaging.)

Background: Arterial flow velocity changes on transcranial Doppler can reflect changes in cerebral flow during position-induced ischemia if obtained during short-term monitoring of positional changes., Subjects and Methods: Our multicenter group monitored symptomatic and asymptomatic arteries in patients with recurrent neurological deficits during positional changes and documented intracranial arterial stenosis. Bilateral posterior cerebral and middle cerebral arteries were monitored dependent on clinical symptom localization. The symptomatic artery was monitored distal to the intracranial stenosis, and mean flow velocities (MFV) were recorded at different body positions. The symptomatic artery relative MFV ratio was defined as the ratio of symptomatic artery MFV in the asymptomatic position--MFV in the symptomatic position/MFV in the asymptomatic position., Results: Sixteen patients underwent transcranial Doppler monitoring: mean age 62 +/- 19 years, 11 (69%) men, 6 (40%) with transient ischemic attacks. Ten patients (63%) had posterior and 6 anterior circulation symptoms. Patients developed neurological symptoms while standing up (63%) and/or sitting (44%), walking (13%) or during neck extension (6%). Symptomatic artery MFV dropped by > or =25% from the resting to the symptomatic position in all patients except for one. The mean symptomatic artery MFV relative ratio was higher compared with the mean asymptomatic artery MFV relative ratio: 0.5 +/- 0.28 versus -0.02 +/- 0.1 (p = 0.001, Wilcoxon test). The symptomatic artery relative ratio of >0.25 had a 94% sensitivity and 100% specificity for predicting neurological symptom development during testing (kappa = 0.9, p < 0.001)., Conclusions: A significant reduction in intracranial flow velocity distal to an intracranial stenosis can identify patients whose symptoms can worsen with positional changes. These patients may prove a target for interventional revascularization techniques., (Copyright (c) 2010 S. Karger AG, Basel.)