Contrast echocardiography has an established role for enhancement of the right heart Doppler signals, the detection of intra-cardiac shunts, and most recently for left ventricular cavity opacification (LVO). The use of intravenously administered micro-bubbles to traverse the myocardial microcirculation in order to outline myocardial viability and perfusion has been the source of research studies for a number of years. Despite the enthusiasm of investigators, myocardial contrast echocardiography (MCE) has not attained routine clinical use and LV opacification during stress has been less widely adopted than the data would support. The purpose of this review is to facilitate an understanding of the involved imaging technologies that have made this technique more feasible for clinical practice, and to guide its introduction into the practice of the non-expert user. Two aspects of micro-bubbles are important – their gas content and the nature of their shell. Recently-approved micro-bubbles almost universally involve encapsulation of a high molecular weight gas, which improves the persistence of the bubble, optimising the number available in the left heart chambers. Air has a greater propensity to dissolve into solution and although currently unattractive because of loss of gas before arrival on the right side of the heart, better encapsulation may allow its resurgence – the benefit would be more rapid disappearance when the bubble bursts. The nature of the shell or surface modifying agent, which improves stability and prevents dissolution, may become important for new targeted imaging approaches.Even when optimal microbubble delivery to the myocardium is achieved with invasive coronary  or aortiMicro-bubbles oscillate (expand and contract) in the ultrasound field. The pattern and nature of their oscillation, and thus the nature of the backscatter signal, differs, depending on the acoustic power of the transmitted ultrasound field, which is expressed on modern ultrasound machines as the mechanical index (MI). In general echocardiography, the amplitude of returning backscatter depends on the nature of the insonated structure, and is represented by brightness on the formed image. Most backscatter returns at the same frequency as the transmitted ultrasound .very low mechanical index imaging (MI < 0.1), micro bubbles demonstrate linear oscillation, where the contraction and expansion of the micro bubble are equal. All returning micro bubble backscatter remains within the range of the frequency transmitted by the transducer  – as for surrounding structures , generates nonlinear oscillation of the micro bubble whereby expansion is greater than contraction. In addition to the usual backscatter of a particular amplitude within the range of the fundamental frequency, the bubbles also produce backscatter of (lesser) amplitude at harmonic frequencies . In. In42]. Like stress echo and nuclear perfusion imaging, MCE is also limited by the qualitative nature of the interpretation. Subtle differences in video intensity between vascular beds may not be visually evident, potentially reducing the sensitivity for the detection of stenosis. Quantitative methods may help to alleviate this limitation and possibly reduce intra-observer and inter-observer variability in assessment.The process of quantitative myocardial contrast echo was validated in open chest dogs using intermittent imaging, and the same destruction-replenishment approach is used for contemporary qualitative assessment . At a stplateau myocardial video intensity (A) represents the myocardial blood volume. The rate of rise of the slope (β) represents the mean myocardial red blood cell velocity and their product (A*β) represents myocardial blood flow. Wei demonstrated an excellent linear relationship between absolute myocardial blood flow measured with radiolabelled microspheres and myocardial contrast echo derived myocardial blood flow. While ECG gated intermittent triggered harmonic imaging was used to validate these measurements, both power Doppler and real time techniques have subsequently demonstrated similar results in animal experiments  where y is the video intensity at the pulsing interval or time t, A is the plateau video intensity and β represents the rate of rise of the slope. In this model the riments -46)..plateau More recently, Wei evaluated the ability of MCE to calculate flow reserves from these measurements in humans , using It is now well recognised that regional or global ventricular dysfunction does not necessarily imply irreversible necrosis. Hypokinetic, akinetic or dyskinetic, yet viable myocardium may be stunned or hibernating. Myocardial stunning occurs after a period of acute ischaemia, despite restoration of completely normal blood flow. The natural history of stunning is of spontaneous improvement in the viable myocardium over time. Hibernating myocardium is the term used to describe the presence of significant ventricular dysfunction in patients with chronic CAD, which recovers after revascularisation. Improvement in function of sufficient numbers of viable but hibernating segments is associated with symptomatic benefit and improved survival. Sadly, Radionuclide scanning, dobutamine echocardiography, MRI and PET scanning are currently available modalities, each with various advantages and disadvantages but similar efficacy for prediction of myocardial functional recovery after revascularization. MCE may also have an important role in this clinical setting. Viable myocardium is associated with preservation of the micro-vasculature, and as micro-bubbles act as pure intra-vascular tracers, the presence of myocardial perfusion by any MCE technique at rest implies viability  has been very low. There have been particular theoretical concerns raised about histologic abnormalities and cardiac marker elevation in animals with high MI imaging, and whiIn recent months the agent SonoVue (a phospho-lipid shell encapsulating sulphur hexafluoride gas), approved in Europe, was withdrawn from clinical use because of adverse events including fatalities related to idiosyncratic hypersensitivity reactions. At this stage, specific details about the dose of agent and imaging modality used in these cases is not available.Advances in micro-bubble development, combined with the development of contrast specific imaging modalities have enabled not only excellent LVO, but reliable qualitative and quantitative assessment of myocardial perfusion by ultrasound, following intravenous injections of micro-bubbles. Use of this technology during stress echo increases sensitivity and improves the non-invasive evaluation of CAD.Power Doppler 4CV at rest in normal subject.Click here for fileA4CV standard harmonic imagingClick here for fileContrast LVO with standard harmonic imagingClick here for fileReal time MCE with LVO and myocardial perfusion.Click here for fileContrast LVO with ideal machine settings to optimize image quality and frame rateClick here for file3-D non contrast imagingClick here for file3-D imaging with contrastClick here for fileReal time 3-D without contrastClick here for fileReal time 3-D with contrast.Click here for fileMr CC PLAX view restClick here for fileMr CC PLAX view stressClick here for fileMr CC PSSAX view restClick here for fileMr CC PSSAX view stressClick here for fileMr CC A4CV restClick here for fileMr CC A4CV stressClick here for fileMr CC A2CV restClick here for fileMr CC A2CV stressClick here for fileMr CC ALAX view restClick here for fileMr CC ALAX view stressClick here for fileMr CC contrast 4CV restClick here for fileMr CC contrast 4CV stressClick here for fileMr CC contrast 2CV restClick here for fileMr CC contrast 2CV stressClick here for fileApical HCM standard 4CVClick here for fileApical HCM contrast restClick here for fileMr JD Rest PSAXClick here for fileMr JD Rest A4CVClick here for fileMr JD Rest PLAXClick here for fileMr JD Rest A2CVClick here for fileMr JD Rest ALAX viewClick here for fileMr JD Rest contrast 4CVClick here for fileMr JD Rest contrast A2CVClick here for fileMr JD Stress PLAXClick here for fileMr JD Stress PSSAXClick here for fileMr JD Stress A4CVClick here for fileMr JD Stress A2CVClick here for fileMr JD Stress ALAX viewClick here for fileMr JD Stress contrast 4CVClick here for fileMr JD Stress contrast 2CVClick here for fileMr JD angiogram.Click here for fileMr T 4CV restClick here for fileMr T 4CV stressClick here for fileMr T 2CV restClick here for fileMr T 2CV stressClick here for fileMr T 2CV contrast restClick here for fileMr T 2CV contrast stressClick here for fileMr T cath LCAClick here for fileMr T cath RCAClick here for fileMr JD curve fits A4CVClick here for file


Faecal samples are frequently used to characterise the gut microbiota in health and disease, yet there is considerable debate about how representative faecal bacterial profiles are of the overall gut community. A particular concern is whether bacterial populations associated with the gut mucosa are properly represented in faecal samples, since these communities are considered critical in the aetiology of gastrointestinal diseases. In this study we compared the profiles of the faecal and mucosal microbiota from ten healthy volunteers using bacterial culturing (culturomics) and next-generation sequencing targeting the 16S ribosomal nucleic acid (rRNA) gene. Paired fresh rectal biopsies and faecal samples were processed under stringent anaerobic conditions to maintain the viability of the bacteria. Four different sample types were analysed: faecal (F), faecal homogenised (FHg), biopsy tissue (B) and biopsy wash (BW) samples. p = 0.972) but showed strong clustering of samples from individual donors. However, the rectal biopsy tissue (B) samples had a significantly altered bacterial signature with greater abundance of Proteobacteria and Acidobacteria compared to faecal (F) and faecal homogenised (FHg) samples. A total of 528 bacteria encompassing 92 distinct bacterial species were isolated and cultured from a subset of six volunteer samples (biopsy washes and faeces). This included isolation of 22 novel bacterial species. There was significant similarity between the bacterial species grown in anaerobic culture and those identified by 16S rRNA gene sequencing .There were no significant statistical differences in either bacterial richness or diversity between biopsy washes (BW) and faecal (F) or faecal homogenised (FHg) samples. Principal coordinates analysis of a Bray–Curtis distance matrix generated from sequence variant tables did not show distinct clustering between these samples (PERMANOVA; This study showed that the bacterial profiles of paired faecal and rectal biopsy wash samples were very similar, validating the use of faecal samples as a convenient surrogate for rectal biopsy-associated microbiota. Anaerobic bacterial culture results showed similar taxonomic patterns to the amplicon sequence analysis disproving the dogma that culture-based methods do not reflect findings of molecular assessments of gut bacterial composition.Video abstractThe online version contains supplementary material available at 10.1186/s40168-022-01354-4. The gut microbiota is a complex entity comprising of myriad species of bacteria, archaea, fungi and viruses that are critical in homeostasis and disease . There iFaecal samples have been commonly used as surrogate representatives of bacterial communities residing in the colon but there is debate on whether faecal samples accurately represent the mucosa-associated bacteria –12. MostThere has been a recent resurgence of culturing techniques with a specific focus on anaerobic conditions for collection and assessment of the gut bacterial species which has narrowed the gap with the more modern assessment of the enteric microbiome by next generation sequencing , 21. TheMost of the colonic bacterial species are strict anaerobes and there is a paucity of data that combines 16S rRNA gene assessment of faecal and mucosal samples collected and assessed under anaerobic conditions. Multiple studies have shown that the colonic microbiota is significantly altered after bowel preparation prior to colonoscopy, –26 whileThis current study on healthy volunteers is based on paired faecal and biopsy samples obtained from the rectum during flexible sigmoidoscopy (without prior bowel preparation) that were collected on the same day and transported and cultured in an anaerobic environment. This assessment removes the potential confounders affecting previous studies and provides accurate profiling of the anaerobic bacterial species residing loosely adherent to the mucosa and in the intestinal lumen of ‘healthy’ individuals. The study also underscores the importance of stringent anaerobic culture techniques in the assessment of the gut microbiota in addition to the 16S rRNA gene sequencing in this healthy cohort.Ten healthy subjects aged 27–43 years with normal BMI (defined as 18–25), and no history of any chronic diseases were recruited to the study. Details of exclusion criteria and individual biometric information can be found in Table 2 during the procedure) and placed immediately into anaerobic tissue transport medium  to preserve the viability of anaerobic bacteria. Samples were transported to the laboratory immediately in cool bags and were processed within 1–2 h of collection under stringent anaerobic conditions. A schematic of sample collection and processing is presented in Fig. Enrolled volunteers were invited to the Albyn Hospital, Aberdeen, Scotland where they underwent flexible sigmoidoscopy for collection of rectal biopsy samples. The volunteers did not receive any bowel preparation. Six mucosal pinch biopsy samples were collected from the rectum  of each volunteer anaerobically  .Additional file 5:Figure S1. Rarefaction plots for every sample for the alpha diversity metrics a) Observed Species, b) Chao, c) Shannon Index, d) Simpson Index and e) Good’s Coverage.Additional file 6:Figure S2. PCoA plots based upon Bray Curtis Diversity metrics for different volunteers showing inter-individual differences in the bacterial profile of both biopsy and faecal samples. Each volunteer is represented by a different colour, revealing the four linked samples.Additional file 7:Figure S3. PCoA plots based upon Bray Curtis Diversity metrics for different sample types.Additional file 8:Figure S4. Log relative abundance of taxa with significantly different abundance at the phylum level between biopsy tissue (red) and biopsy wash (blue) samples.Additional file 9:Figure S5. Log relative abundance of taxa with significantly different abundance at the genus level between biopsy tissue (red) and biopsy wash (blue) samples.Additional file 10:Figure S6. qPCR estimation of bacterial loads in the different sample types.Additional file 11:Table S5. Total viable counts of anaerobic bacteria enumerated on growth plates from biopsy wash (BW) and faecal (F) samples.Additional file 12:Table S6. Bacterial identification.Additional file 13:Figure S7. Detection of fermentation acids in media following growth of individual isolates in pure culture. Acid production split for biopsy wash (BW) and faecal (F) bacterial isolates. The upward arrow indicates fermentation acid production whilst the downward arrow represents consumption during bacterial growth in pure culture. Bacterial isolate numbers shown on the x-axis correspond to bacterial identities detailed in Additional file


Tuberculosis (TB) is a chronic granulomatous inflammation usually involving the lung parenchyma and hilar lymph nodes. Extra-pulmonary involvement is seen in ∼20% of all TB cases. Developing tuberculosis following treatment for another primary medical condition is a rare occurrence. Iatrogenic literally means illness caused by medical examination or treatment.Mycobacteria have been used to treat a few medical conditions and the therapeutic use has been validated extensively in literature. The mycobacteria used for therapeutic purposes are supposed to be either attenuated or non pathogenic strains. Growth and dissemination of this mycobacterium is a rare but serious possibility. Reactivation of latent mycobacterial infection following therapy is also a part of iatrogenic mycobacterial infection.We report a retrospective study investigating adverse events manifesting with development of iatrogenic tuberculosis. The data was obtained from a tertiary care centre over a period of 2 years. Diagnosis of tuberculosis was established based on clinical, radiological(chest X-Ray and High resolution CT scan), sputum smear microscopy and skin/tissue biopsy and Xpert MTB/RIF. Tuberculin skin test(TST) and Interferon gamma release assay (IGRA) were used as additional diagnostic tests.The search yielded 26 cases of iatrogenic tuberculosis, with a median age of 56.5 years. Most common cause was reactivation of latent tuberculosis due to use of anti-TNF alpha biologic agents(53.8%). Development of Tuberculosis verrucosa cutis following BCG inoculation for verruca vulgaris was noted in about 19.2% of cases and Tubercular abscess due to Mycobacterium w or BCG inoculation for Covid-19 was noted in 11.5% cases. Bacillus Calmette Guérin(BCG) induced balanitis secondary to therapy for Carcinoma urinary bladder was noted in 7.69%of cases.Bacillus Calmette-Guerin or BCG induced balanitis following use of intravesical immunotherapy for treating early-stage urinary bladder cancer and successful clearance of lesions post therapyTuberculosis Verrucosa Cutis following Immunotherapy for plantar wartsAll patients were managed successfully with anti tubercular therapy. These observations indicate that tuberculosis infection can develop in previously healthy individuals in endemic zones following biologic therapy of use of mycobacterial agents for other therapeutic indications.All Authors: No reported disclosures.


Plant Physiology initiated the Assistant Features Editor (AFE) program five years ago to help disseminate discoveries published in the journal and to train the next generation of editors and reviewers. Our AFEs are promising early-career scientists and they bring their passion for science to our journal, communicating to our readers each month some of the most exciting advances in research.News and Views articles, blog posts, and related material highlighting content of special interest in Plant Physiology. They have grown professionally and will build on their experience with the journal. Many of our previous AFEs have moved onto independent academic positions after completing their terms at Plant Physiology. We hope to call the AFEs to serve as regular members of the editorial board when they have become more established in their careers.The AFEs have added substantially to the plant science community and to the journal. Their contributions have expanded our content through https://plantae.org/2023-plant-physiology-assistant-features-editors/) who started last month and will work alongside our seasoned crew.The program is designed to rotate off a number of AFEs each year and to add new members at the beginning of each year. Sixteen of our AFEs stepped down from the editorial board this past month, and we would like to take this opportunity to thank them all for their contributions. We would also like to welcome the 19 new AFEs Jiawen Chen Joke De Jaeger-Braet Manuel Gonzalez-Fuente Henning Kirst Yee-Shan Ku Aida Maric Hannah McMillan Sebastian Moreno Dyoni Oliveira Lara Pereira Moona Rahikainen Janlo Robil Alaeddine Safi Maria-Angelica Sanclemente Henryk Straube Jiaqi Sun Kyle Swentowsky Ryo Yokoyama The new AFEs are joining those who started in January of 2022, listed below, who will stay on for one more year to continue writing News and Views, help with the transition, and mentor the new AFEs.Alexandra Burgess Amanda Cardoso Jian Chen Gustaf E. Degen Marieke Dubois Guadalupe Lucía Fernández-Milmanda Yana Kazachova Amy Lanctot Divya Mishra Míriam Osés-Ruiz .Yadukrishnan Premachandran José Manuel Ugalde Yajin Ye


Meta-analyses suggest that patients with schizophrenia show deficit in working memory – both verbal and visual – and are more distractible. Working memory disturbances are even regarded as the central deficit in schizophrenia by some researchers. Theta synchronization  is related to cognitive control and executive functioning during working memory encoding and retention.The main goal of the study was to gain more understanding of the nature of working memory deficit and attentional distractibility in schizophrenia.35 patients with schizophrenia and 39 matched controls were enrolled in our study. Participants performed a modified Sternberg working memory task that contained salient and non-salient distractor items in the retention period. A high-density 128 channel EEG was recorded during the task. Event-related theta (4-7 Hz) synchronization was analyzed during working memory encoding (learning) and retention (distractor filtering) in a later time window (350-550 ms).Patients with schizophrenia showed weaker working memory performance and increased attentional distractibility compared to the control group: patients had significantly lower hit rates (p < 0.0001) and higher distractor-related commission error rates (p < 0.0001). Theta synchronization was modulated by condition (learning < distractor) in both groups but it was modulated by salience only in controls .Our results suggest that patients with schizophrenia show diminished cognitive control compared to controls in response to salient distractors. Difficulties in cognitive control allocation may contribute to the behavioral results observed in this study.No significant relationships.


RSC Advances.The following article ‘Novel fatty chain-modified GLP-1R G-protein biased agonist exerts prolonged anti-diabetic effects through targeting receptor binding sites’ has been published in The Royal Society of Chemistry was contacted by a reader who raised concerns about scientific errors in this article, and that some of the content may have been reproduced without appropriate acknowledgement.The authors were contacted for comment but have not responded to these concerns.RSC Advances is publishing this Expression of Concern to alert readers to the concerns raised. An Expression of Concern will continue to be associated with the article until we receive conclusive evidence regarding the reliability of the reported data.Laura Fisher15/11/2022RSC AdvancesExecutive Editor,


Traumatic aortic regurgitation (AR) is a rare complication of blunt chest trauma. We described the case of a 35-year-old male who presented to our hospital with shortness of breath 7 years after sustaining blunt chest trauma associated with a motorcycle accident. Transthoracic and transesophageal echocardiogram detected severe AR with two separate jets. The patient was diagnosed with congestive heart failure due to severe AR, and surgical aortic valve replacement was performed. A large perforation of the right coronary cusp likely sustained during the initial blunt chest trauma injury was confirmed surgically. As AR caused by blunt chest trauma can gradually worsen, it is necessary to confirm if there is a history of trauma in patients with severe AR of unknown origin.


To determine the association between childhood involvement with social services and adult mental ill-health, using uptake of psychotropic medication as a proxy indicator.This longitudinal population-wide study linked primary care data on all children born 1985-1991 in Northern Ireland  to social services data (1985-2015) and psychotropic medication prescribing data (2010-2015). Multilevel logistic regression models explored psychotropic medication uptake  at ages 18-30 years given exposure to social services in childhood, clustered by GP practice. Additional analysis explored the sociodemographic characteristics and social care experiences  associated with medication uptake within social care subgroups.Over 1 in 10 adults (10.3%) were known to social services in childhood . During follow-up 58.5% of care experienced adults were in receipt of psychotropic medication compared to 26.9% of peers never known to social services. Care experienced adults were three to six times more likely to be in receipt of medication  than adults never known to social services. Adults deemed Not In Need in childhood (received no services) were at equivalent risk of psychotropic medication to those deemed In Need (received at-home care/support packages). Experiences before and during involvement with social services showed variable association with receipt of psychotropic medication in adulthood.Adults known to social services in childhood are more likely to receive psychotropic medication than peers never known, with number of referrals and placement type key predictors. Adults known as a Child in Need are equally as likely as those assessed as Not in Need, suggesting possible missed intervention opportunities.


A 63-year-old man known for mitral valve replacement (MVR) with a bi-leaflet mechanical valve (Open Pivot Medtronic 31) one year previously, presented with chest discomfort, a new murmur, and modestly increased inflammatory markers. He had been treated with warfarin with satisfactory home- and laboratory-monitored INR levels since the operation. In particular, he had several INR measurements in the preceding 3 months which had all been within the therapeutic range.Panels A and B; Videos 1 and 2). Blood cultures were negative including for fastidious microorganisms. Treatment with unfractionated heparin and antibiotics was given empirically for 2 weeks, and although inflammatory markers normalized, repeat TOE showed a progression to severe MVR obstruction with increased mass size now partially restricting also the anterolateral occluder . Persistent obstruction on transthoracic imaging was subsequently demonstrated and re-sternotomy surgery was therefore advised. Surgical inspection revealed a laminated thrombus on the posteromedial occluder of the MV prosthesis (Panels E and F).A transoesophageal echocardiogram (TOE) revealed a non-mobile mass adjacent to the posteromedial occluder causing restricted opening and partial obstruction of the MVR (Panel G). Unveiling pro-thrombotic mechanisms is paramount for secondary prevention: surgical reconstruction of the papillary muscle head was performed alongside redo MVR surgery.We report partial thrombosis and obstruction of a mechanical MVR with inherently low thrombogenicity profile despite demonstrably adequate anticoagulation. We hypothesize that the unusual anatomical interaction between a high posterior papillary muscle head, thickened chords, and the MVR led to locally turbulent flow and thrombus formation in the posteromedial region of the prosthesis  on the atrial side of the mechanical mitral valve with the partial opening of the posteromedial leaflet due to an obstructive mass. Panel B: Continuous wave Doppler across the MV showing increased gradients. Panel C: Three-dimensional zoom showing completely obstructed posteromedial occluder and partially restricted anterolateral occluder due to enlarging mass (*) on the atrial side of the MVR. Panel D: Continuous wave Doppler showing worsening mitral stenosis across the partially occluded mechanical mitral valve. Panels E and F: Surgical inspection of the excised MV prosthesis revealed a laminated thrombus on the atrial surface  and ventricular one (F). Panel G: Three-dimensional zoom and 2D transthoracic echocardiography (three-chamber) image showing complex interaction between high posterior papillary muscle head (PPM), thickened chords, and a very close MVR (distance = double arrow) which likely led to turbulent flow locally and thrombus formation in the posteromedial region of the prosthesis.


Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is increasingly being used as an alternative to percutaneous transhepatic biliary drainage (PTBD) after unsuccessful endoscopic retrograde pancreatography (ERCP). This technique has also been utilized for diagnosis of malignant biliary obstruction by providing biliary access for antegrade cholangioscopy with biopsies and brushings for cytology and fluorescent in situ hybridization (FISH). However, the potential impact of EUS-HG on surgical candidacy in cases with resectable disease remains unknown. We present three patients who underwent pancreaticoduodenectomy (Whipple procedure) for suspected distal malignant biliary obstruction following EUS-HG. Biliary drainage was achieved in all three patients preoperatively and a diagnosis of malignancy could be established in two of the three cases using this technique. There were no procedure-related complications. The HG metal stent was removed eight weeks post-operatively with cholangiogram showing a patent hepaticojejunostomy in all three patients. Mean length of follow-up after EUS-HG was 298 +/- 96 days. Our case series demonstrates that EUS-HG is an effective method to achieve biliary decompression in patients with an inaccessible papilla. The mature HG tract can subsequently be used to obtain a tissue diagnosis. Lastly, EUS-HG does not preclude patients from undergoing a curative Whipple procedure. In patients with malignant biliary obstruction, endoscopic retrograde pancreatography (ERCP) is the current standard of care for biliary decompression. However, ERCP is unsuccessful in 5-10% of cases due to surgically altered anatomy or tumor invasion causing ampullary distortion or gastric outlet obstruction ,3. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is emerging as a suitable alternative to PTBD in patients after failed attempt at ERCP. EUS-HG has been associated with similarly high technical and clinical success rates with fewer reinterventions when compared to PTBD . In addiIn this case series, we describe EUS-HG in three patients with suspected malignant biliary obstruction after unsuccessful ERCP. EUS-HG achieved biliary decompression and assisted with tissue diagnosis but did not preclude future surgical intervention.Procedure detailAll EUS procedures were performed by a single endosonographer using a linear echoendoscope . A dilated segment 3 biliary radicle was identified from the lesser curvature of the stomach and punctured with a 19-gauge fine needle aspiration (FNA) needle . Contrast was injected resulting in opacification of the biliary tree. A 0.025 inch in diameter and 450 cm in length straight tip VisiGlide 2 wire (Olympus) was advanced past the left hepatic duct into the distal bile duct and the small bowel. The HG tract was dilated using a 6 mm x 4 cm Hurricane biliary dilating balloon  followed by placement of an 8 mm x 80 mm fully covered, self-expandable, and non-foreshortening Gore Viabil biliary stent . The metal stent was anchored using a 7 Fr x 18 cm double pigtail plastic biliary stent with the proximal end in the stomach and the distal end past the ampulla and in the small bowel  scan demonstrated slightly increased intra- and extrahepatic biliary ductal dilation compared to imaging one year prior. On ERCP, narrowing of the duodenal sweep was visualized with abnormal appearing duodenal mucosa Figure . The duoEUS-HG was then performed according to the above description. Cholangiogram on follow-up ERCP two weeks after EUS-HG showed a 10 mm long stricture in the distal common bile duct (CBD). Cholangioscopy  was performed antegrade through the HG tract and a high-grade stricture was visualized in the distal CBD with evidence of neovascularization. SpyBite forceps (Boston Scientific) were unable to be advanced to the level of the stricture due to the acute angulation of the cholangioscope in the intrahepatic duct. Brushings were performed for cytology and FISH Figure .Cytology showed rare groups of highly atypical glandular cells, suspicious for adenocarcinoma. FISH was positive for malignancy of the pancreatobiliary tract. Patient then underwent successful pancreaticoduodenectomy (Whipple procedure) with simultaneous removal of plastic HG stent 55 days after EUS-HG. Surgical pathology confirmed extrahepatic cholangiocarcinoma  Figure .Follow-up ERCP was performed at eight weeks after the Whipple procedure. Cholangiogram through the HG tract showed a patent hepaticojejunostomy Figure . The HG metal stent was removed and was not replaced. He subsequently was treated with adjuvant chemotherapy and radiation. Patient has had follow-up for 405 days after EUS-HG and is doing well clinically. Case 2A 48-year-old female with history of obesity, chronic obstructive pulmonary disease (COPD), and prior cholecystectomy presented to hepatology clinic for evaluation of abnormal liver enzymes. Pertinent labs are noted in Table Two weeks post EUS-HG, patient returned for cholangiography and cholangioscopy through the HG tract. Cholangiography showed a high-grade stricture in the distal CBD with upstream ductal dilation Figure .Cholangioscopy with intraductal biopsies and brushings for cytology and FISH were performed and were suggestive of malignancy Figure . Patient eventually underwent successful Whipple procedure with surgical pathology examination confirming locally advanced pancreatic adenocarcinoma (T1cN2). The HG metal stent was removed eight weeks post-Whipple without need for replacement. She was started on adjuvant chemotherapy post-surgery and is clinically doing well after 269 days of follow-up. Case 3An 81-year-old female with history of COPD presented for evaluation of incidentally found abnormal liver enzymes. Labs are shown in Table Cold forceps biopsies of the mass later revealed an adenoma with no evidence of malignancy. On EUS, the common bile duct was dilated with extension of mass lesion into the distal CBD and pancreatic duct (PD) for more than 1 cm Figure .The patient underwent successful EUS-HG in the same session without complication. Cholangiogram showed a dilated CBD measuring 17 mm with a high-grade stricture in the distal CBD Figure . Given the size of the ampullary adenoma with extension into the distal CBD and PD, a decision was made to proceed with surgical management without the need for further diagnostic evaluation. She had a successful pylorus-preserving Whipple procedure 37 days after EUS-HG. Surgical pathology confirmed an ampullary tubulovillous adenoma with complete excision. After surgery, the HG metal stent was removed without necessitating replacement. Patient remains in good clinical condition after 219 days of follow-up. ERCP can be technically unfeasible in patients with surgically altered gastrointestinal anatomy or tumor invasion causing distortion of the ampulla or gastric outlet obstruction. Traditionally, these patients have been managed primarily with percutaneous drainage. While PTBD has proven efficacious at achieving biliary decompression, it is burdened by substantial risk for adverse events and negative impact on patient quality of life ,3,5. EUS-guided biliary drainage (EUS-BD) was first described in 2001 by Giovannini et al. as an endoscopic option for these patients . This teEUS-HG was first utilized for management of malignant biliary obstruction in 2003 . With thWhile the initial indication for EUS-HG was palliation of malignant biliary obstruction, its applications have since broadened to include treatment of benign biliary diseases. The HG tract can serve as a conduit for performing antegrade treatment of biliary lithiasis, benign strictures, and bile leaks . Stone rIn addition to assisting with antegrade therapies for benign biliary disease, the HG tract can also be used to aid in the diagnosis of suspected malignant biliary strictures. First, brushings can be performed with tissue sent for cytology and FISH. As reportedly previously, antegrade cholangioscopy can be also performed through the HG tract ,13-15. TWhile EUS-HG is now more widely used for biliary decompression in malignant obstruction, little is known about its potential impacts on surgery. A case series looking at EUS-CD for decompression as a bridge to surgery reported five cases of successful pylorus sparing Whipple procedure after EUS-CD . HoweverOur case series highlights the role of EUS-HG in suspected malignant biliary obstruction after unsuccessful ERCP. In each patient, successful biliary decompression was accomplished without adverse events. In two cases, cholangioscopy with biopsies and brushings for cytology and FISH helped in establishing a diagnosis of malignancy. In the third case, cold forceps biopsies demonstrated an ampullary adenoma with intraductal extension and hence diagnostic evaluation was not pursued. Lastly, EUS-HG did not impact surgical candidacy in any of the cases.EUS-HG is a safe and effective alternative to PTBD for biliary decompression when ERCP is not feasible. In cases of suspected malignant biliary obstruction, it also enables further diagnostic evaluation to be performed and does not preclude future surgical options.


Clinicians in mental healthcare have few objective tools to identify and analyse their patient’s care needs. Clinical decision aids are tools that can support this process.This study examines whether 1) clinicians working with a clinical decision aid (TREAT) discuss more of their patient’s care needs compared to usual treatment, and 2) agree on more evidence-based treatment decisions.Clinicians participated in consultations (n=166) with patients diagnosed with psychotic disorders from four Dutch mental healthcare institutions. Primary outcomes were measured with the modified Clinical Decision-making in Routine Care questionnaire and combined with psychiatric, physical and social wellbeing related care needs. A multilevel analysis compared discussed care needs and evidence-based treatment decisions between treatment as usual (TAU) before, TAU after and the TREAT-condition.First, a significant increase in discussed care needs for TREAT compared to both TAU conditions  was found. Next, a significant increase in evidence-based treatments decisions for care needs was observed for TREAT compared to both TAU conditions .TREAT improved the discussion about physical health issues and social wellbeing related topics. It also increased evidence-based treatment decisions for care needs which are sometimes overlooked and difficult to treat. Our findings suggest that TREAT makes sense of ROM data and improves guideline-informedcare.No significant relationships.


Community health workers (CHWs) play essential roles in implementing community-based behavioral lifestyle interventions. This qualitative analysis aimed to explore what program factors and CHW characteristics would help improve CHW performance in the Mobility and Vitality Lifestyle Program (MOVE UP), a community-based behavioral weight-management intervention for improving mobility among overweight or obese older adults. The MOVE UP program was implemented from January 2015 to June 2019 at 23 community-based sites in Pittsburgh, Pennsylvania. Trained and supported CHWs delivered 32 group sessions over 13 months. We collected data from semi-structured interviews with 21 CHWs and 14 community key informants (community site directors or coordinators); seven focus group discussions with participants from 9 sites, and 124 pieces of graduation advice provided by MOVE UP graduates for future participants; onsite CHW performance observation at 18 sites, and 124 meeting memos of support phone calls with CHWs. Interviews and focus groups were audio-recorded and transcribed verbatim. All data were thematically analyzed in a deductive approach, using the CHW generic logic model. Emerging themes were: Trained CHWs still require onsite support by experienced CHWs or training staff to deliver the first session; Participants need a Q&A session by specialists to address their questions beyond CHWs’ knowledge; Desirable CHW characteristics could increase CHWs’ relation and accessibility to participants, such as the same age group, similar weight loss experience, and living or working in the same community. These findings provide important insight as to recruiting and supporting CHWs in a community-based behavioral lifestyle intervention for older adults.


Food insecurity has been indicated to associate with more depressive symptoms. Supplemental Nutrition Assistance Program (SNAP) is an established anti-poverty government program that targets food insecurity. The goal of this study was to assess whether SNAP generosity, defined at the state level, impacts the relationship of food insecurity and depressive symptoms among older Americans. We linked state-level SNAP policy data to the individual-level data of older adults (aged 60+) from the longitudinal Health and Retirement Study . Our study baseline was survey year 2000. A state is considered SNAP generous when it eliminates income/assets limit from its SNAP eligibility criteria. All HRS participants reported their food insecurity status and depressive symptoms biennially. Participants were followed until 2018. We conducted state fixed-effect models adjusted for demographic and health measures. Results indicate household food insecurity was associated with higher risk of elevated depressive symptoms  from a fixed effect logistic model, and this effect was stronger when living in non-generous states compared with generous states though confidence intervals were too wide to be conclusive . The relative excess risk due to interaction (RERI) was 0.17 . Our study finding suggested that there is no to weak evidence that state-level SNAP generosity may alleviate or offset the risk of depressive symptoms associated with food-insecurity.


Inclusion of nanoparticles boosts thermal performance and is essential for thermal transport. The current investigation has been made to conduct research on heat mass transport in synovial material with the mixing of hybrid and tri-hybrid comprising variable viscosity past over a heated surface having constant density and a steady environment. The conservation laws have been considered in the presence of Lorentz force, heat generation/absorption, modified heat and mass fluxes together with chemical reaction. The mathematical model is developed in Cartesian coordinate in the form of coupled partial differential equation (PDEs). The derived PDEs are simplified by a boundary layer approach (BLA) and reduced PDEs have been converted into ordinary differential equation (ODEs) using scaling group Similarity transformation. The converted ODEs are highly nonlinear and have been solved numerically by finite elements scheme (FES). The used scheme is effective for nonlinear problem and can be frequently utilized to tackle nonlinear problems arising in mathematical physics. They have used FEM to know numerical results of model related to non-Fourier’s along with variable viscosity. Sohail et al.2 performed model of Sutterby fluid inserting suspension of nanomaterial along with thermal radiation past stretching surface in the presence of variable fluidic properties. They have used a numerical approach to conduct consequences. Nazir et al.3 conducted numerical impacts of Carreau–Yasuda martial in mass species and thermal energy inserting hybrid nanomaterial under the occurrence of thermal properties numerical implemented by finite element approach. Sohail et al.4 computed boundary layer flow regarding Carreau martial in heat energy in a disk considering bio-convection phenomena. They have implemented numerical method to investigate numerical results. Nazir et al.5 performed the thermal enhancement of ternary hybrid nanoparticles in Sisko martial involving heat generation over stretchable cylinder. They implemented FEM and include the tri-hybrid nanomaterial was significant the best performer to enhance heat energy. Imran et al.6 investigated the performance of shapes impacts into hybrid nanoparticles past flat frame considering solar collector. Imran et al.7 studied the impacts of thermal radiation and magnetic field including variable fluidic properties and slip conditions past a vertical heated frame. Danish et al.8 conducted numerical consequences of Williamson liquid inserting nanoparticles in the presence of thermal radiation and activation energy. Chen et al.9 discussed enhancement regarding heat energy in Maxwell liquid in the presence of titanium oxide and alumina oxide in rotating disks. Sohail et al.10 studied features of non-Newtonian liquid in heat energy using Joule heating and heat flux approach. Mebarek-Oudina et al.11 studied two heat energy sources in mixed convection phenomena in a trapezoidal cavity using moving walls. Chabani et al.12 investigate heat energy enhancement in triangular enclosure considering suspension regarding hybrid nanoparticles involving elliptic obstacle. Fares et al.13 investigated the performance of entropy generation in magnetized flow in the presence of Darcy–Forchheimer model using base liquid (silver and water) in a square enclosure. Abo-Dahab et al.14 securitized MHD features in Casson liquid considering nanoparticles involving dual behaviors of surface (suction and injection) past stretchable surface. Mebarek-Oudina et al.15 discussed applications of nanoparticles in heat energy mechanism using various enclosures. Dhif et al.16 investigated the performance of hybrid nanofluids in solar collectors in this study. Zamzari et al.17 studied mixed convection in a vertically heated channel to determine various aspects of entropy production. Using this method, multiple aspects of entropy production were examined to determine how they were affected. Li et al.18 determined the flow and thermal properties of a Darcy–Forchheimer fluid using a non-Fourier method and a Prandtl method. To achieve this objective, nanoparticles were incorporated into a Darcy–Forchheimer motion. Klazly et al.19 studied comparative consequences among non-Newtonian for single-phase and Newtonian for single-phase containing nanoparticles in the presence of two-phase models in backward-facing step. Klazly et al.20 developed empirical equation to visualize viscosity of nanofluid involving empirical and theoretical results. Bognár et al.21 investigated comparative consequences among fluid dynamics and similarity in Blasius flow considering nanoparticles. Thriveni and Mahanthesh22 discussed features based on convective heat transfer in hybrid nanofluid considering in two cylinders. Mackolil and Mahanthesh23 estimated thermal energy associated with Marangoni approach in hybrid nanofluid including sensitivity analysis. Mahanthesh24 discussed features regarding quadratic radiative flux containing nanoparticles in the presence of enhancement of kinematics regarding nanoparticles. Mahanthesh et al.25 performed new investigation based on quadratic Boussinesq approximation and quadratic radiation involving nanofluid. Shruthy and Mahanthesh26 computed Rayleigh-Bénard in rheology of Casson liquid inserting suspension of hybrid nanoparticles. Shalini and Mahanthesh27 discussed performance of dusty nanoparticles in Newtonian martial considering suspension of nanoparticles in the presence of coriolis force.Researchers got much attention on studying nanoparticles to boost thermal performance. Nanoparticles are immersed in different materials (base fluid) to improve thermal performance. Nanomaterial plays a vital role in the treatment of cancer therapy and is frequently used in industries in different physical processes. Several studies have been conducted on nanomaterial for thermal and mass transportation. For instance, Nazir et al.Comprehensive review on literature demonstrates that study on mass species and heat energy in the presence of Cattaneo-Christov heat flux model (CCHM) along with chemical reaction and heat absorption in synovial fluid is not investigated yet. Such complex model involving suspension of three types of nanoparticles considering two viscosity models is not studied yet. Additionally, hybrid nanomaterial and tri-hybrid nanomaterial are inserted in ethylene glycol. Present model is numerically solved by finite element method (FEM). Analysis is divided into five sections. Section one, section two, section three, section four and section five are based on literature review, mathematical procedure, numerical method and conclusions, etc.Model regarding mass and heat energy transport in synovial fluid is developed for constant density and steady flow past a stretching surface. Viscosity is considered as function temperature and concentration. Suspension of tri-hybrid nanoparticles into fluidic motion is made composite of silicon dioxide, titanium oxide and aluminum oxide in the presence of base liquid named ethylene glycol. Fluidic motion regarding various nanoparticles is produced with the help of wall velocity. Heat and energy solute particles are carried out using concept of non-Fourier’s law including heat generation/absorption and chemical reaction. Figure The concept of BLA (boundary layer approximations) are used to achieve system of PDEs areMomentum equation for Model-I which isMomentum equation for Model-II which isThe required BCs of current analysis areSimilarity variables are delivered asThe Correlations of hybrid nanoparticles and nanoparticles are used and Table A system in term of ODEs is derived asEquation  is reducSkin friction coefficients for two models in term of viscosity areConcentration rate and heat energy rate are Desired residuals are known as weighted and residuals are integrated over each elements regarding computational domain;The integration process is implemented for development of week form regarding residual equations and mesh free survey is shown through Table Stiffness elements are obtained via residual procedure called Galerkin approximations;Measure tolerance and error procedure. Table Numerical solution of dimensionless ODEs is achieved using finite element method (FEM) which is presented with the help of Fig. Comparative features in term of two viscosity models are studied over a 2D stretchable sheet. A non-Fourier’s approach is considered in energy as well as concentration equation. Heat source and chemical species are addressed. Additionally, suspension of various nanoparticles  is inserted in base fluid) termed as ethylene glycol. The productive complex biological model is numerically handled using a finite element approach. Detail reports and discussion are mentioned below.In the current subsection, acceleration into fluidic particles is measured in Figs. The comparative thermal features are estimated versus time relaxation, heat source parameters for model-I and model-II considering in Figs. Figures mentclasspt{minimamentclasspt{minimaImpacts of Sherwood number, heat transfer rate and skin friction coefficient are predicted versus variation in Weissenberg, heat source, magnetic and Schmidt numbers. These visualizations are recorded in Table Velocity profile is declined using higher numerical values of magnetic field intensity based on Lorentz force.Velocity profiles for model-I have less magnitudes rather than magnitudes for velocity profiles for model-II.External heat source brings enhancement into thermal energy and flow behavior.Cooling process thermal process can be achieved significantly by using mechanism of ternary hybrid nanofluid rather than mechanism of hybrid nanofluid.Production of mass species and thermal energy for case of model-II as compared for model-I.Mass diffusion decreases versus impacts of chemical reaction number and Schmidt number.Current development is applicable in biological field which is used in condyloid joints, hinge joints, pivot joints.Such complex analysis is applicable in biological field which is used in condyloid joints, hinge joints, pivot joints and shoulder joints.Comparison thermal aspects and solute aspects among model-I and model-II including tri-hybrid nanomaterial are observed past stretching frame. Heat energy and diffusion into mass species are carried out by non-Fourier’s approach. Additionally, heat source and chemical species are implemented. Such complex problem is developed and numerical tackled by finite element approach. Main finding of such complex problem are mentioned below.


The COVID-19 pandemic introduced many societal changes, including the need to use technology to communicate with healthcare providers. For many this was a new form of communication. This study examines (1) who older adults identified as healthcare providers and (2) reflected on how communications with formal healthcare providers changed during the pandemic. This data is a subset of a cross-sectional descriptive survey that was distributed electronically to a sample of community-dwelling older adults aged 65 years and older (N=323). Qualitative data was analyzed using thematic analysis. Quantitative data was analyzed using descriptive statistics. Participants averaged 72.7 years of age and 74.5% were retired. Just over ¼ of the sample identified nurses as part of their formal healthcare team; however, participants who identified nurses as formal healthcare providers had fewer negative themes regarding telehealth communication with healthcare providers compared to those who did not. They were also more likely to support in-person and technology driven communication models in the future. Telehealth remains an evolving form of primary healthcare that was utilized throughout the COVID-19 pandemic. Many older adults in our study considered it a resource that requires further optimization while others were staunch opponents to its continued employment in healthcare settings. Nurses are a vital part of our healthcare system and frequently interact with patients and families to coordinate care. Further research should examine how different scopes of nursing practice can support the implementation of telehealth to improve care delivery among community-dwelling older adults.


Mental health disorders have become one of the leading diagnoses causing sickness absence. Previous studies have examined the impact of single employment characteristics or working conditions on sickness absence. However, few studies have investigated the effect of a multidimensional construct of precarious employment on sickness absence. Therefore, this study aims to describe sickness absence due to common mental disorders (CMD) as a proxy for access to social security benefits among precarious and non-precarious workers with mental health problems.Cohort register-based study of the total Swedish population aged 27 to 61 years residing in Sweden in 2016 and having mental health problems defined as being prescribed Selective Serotonin Reuptake Inhibitors (SSRI) in 2017 . Individuals were classified as precariously employed or not based on a precarious employment score measured multidimensionally in 2016 . The outcome was the incidence of the first sickness absence episode due to CMD co-occurring with SSRI treatment in 2017. Logistic regression models will be performed.The following results are preliminary. Precariously employed treated with SSRI were 8,68% in 2017. The distribution of a first sickness absence episode due to common mental disorders was similar in precarious and non-precarious workers . Individuals directly employed (12.20%), with multiple jobs holding (14.62%), and low-medium income levels (14%) had higher sickness absence incidence due to common mental disorders. There were slight differences by gender.In these preliminary results, no differences were found between precarious and non-precarious workers with mental health problems in the distribution of sickness absence due to CMD. Further analysis will be conducted to investigate whether precarious employment is associated with sickness absences.Sickness absence due to common mental disorders is similarly distributed among precarious and non-precarious workers.Individuals with multiple jobs, low-income levels, and directly employed show higher sickness absence incidence due to common mental disorders.


Proactive coping helps to reduce stress “in advance” – by possible stressors’ anticipating . Does it helps to reduce distress in hazardous work environment with extremely high uncertainty level – like in healthcare professionals’ work at the beginning COVID-19 pandemic? Data showed the lover level of proactive coping in healthcare professionals in comparison with non-medical group . The acute issue is to investigate proactive coping among medical professionals with different stress level.Specialists of Moscow public dispensaries  were checked during pandemic breakout (April 2020) - in order to compare proactive coping and job stressors’ subjective evaluation in groups with high and low chronic states.The diagnostic set included: the job stress survey ; the proactive coping inventory ; the chronic stress and fatigues inventories .Cluster analysis by combination of stress-fatigue scores extracted equal 22% of professionals in risk subgroups. Surprisingly no proactive coping differences were found in nurses; among doctors preventive coping is significantly lower in risk subgroup . Revealed job stressors in risk groups for nurses are quite typical; but for doctors they are unusual: extreme workload , low coworkers support , lack of positive feedback .Despite the undeniable workload increase, well-to-do professionals perceived no high job stressors. In risk subgroup with lack of preventive coping, perceived stressors are likely connected with inability to predict strain increase and to minimize the impact of its negative effects .


A low-income country, Moldova is facing a rapidly growing burden of non-communicable diseases with a cardiovascular disease mortality rate of 202.2 per 100'000. Scarce resources require urgent preventative actions and involvement of communities and patients in the definition and design of locally relevant health promoting activities. Our intervention is a holistic, whole-of-community approach to foster local leadership in health promotion for the prevention of cardiovascular risks. The Healthy Life project to reduce the burden of non communicable diseases, funded by the Swiss Agency for Development and Cooperation (SDC), operates since 2016 in rural communities of Moldova. We present a 5-step model towards initiating Healthy Communities in Moldova based on 5 complementary steps:1. Raising awareness on cardiovascular risk factors through community education seminars tailored to audience needs2. Building multisectoral community coalitions for health between local elected leaders and community representatives around local health data and locally defined health priorities3. Fostering community leadership in defining local health solutions through health asset mapping exercises4. Community-led small projects based on identified needs and assets to improve local cardiovascular health5. Empowering chronic patients for healthy behavior change through community-based self-management workshopsThe Healthy Communities intervention was rolled out to 40 communities in 20 districts, reaching 1332 direct beneficiaries. Important learning emerged from social accountability mechanisms embedded in community coalitions which ensure regular, health-focused dialogue on community health. Using local assets to health problem solving is changing the perspective on the resourcefulness of community actors in health. Progress towards sustainability is achieved by local public authorities and community making a matching contribution to start-up funding to small projects.• Our Healthy Communities model proposes a strength-based vision of health promotion which empowers community coalitions to self-organize for the prevention of cardiovascular risk factors.• We promote bottom-up approaches that strengthen local health governance and community leadership into defining and addressing local health priorities.


Adolescents with major depressive disorder (MDD) often show reduced prefrontal functional connectivity with the subcortical regions than healthy controls (HC) . However, relatively little is known about longitudinal effects of antidepressant (AD) treatment on resting state functional connectivity (RSFC) in the prefrontal cortex (PFC).This study aimed to investigate abnormal PFC RSFC in MDD adolescents compared to HC and longitudinal effects of AD on PFC RSFC.This study included 59 adolescents with MDD and 43 HC. MDD adolescents were treated with escitalopram in an 8 week, open-label trial. The treatment outcome was assessed by Children’s Depression Rating Scale (CDRS-R) and patients showing at least a 40% improvement in CDRS-R scores from baseline to week 8 were defined as “responders”. Functional and T1 images collected before and after treatment were processed using AFNI and Freesurfer. Our seed was the lateral PFC . T-tests and repeated measures ANCOVAs, controlling for age and IQ, were conducted to examine abnormal PFC RSFC and longitudinal effects of AD on LPFC RSFC.Relative to HC, MDD showed increased LPFC RSFC with the posterior middle temporal gyrus (pMTG) and superior frontal cortex (SFG) involved in attentional networks. Responders showed greater changes in LPFC RSFC with the MTG and SFG after AD treatment compared to non-responders and HC .Our finding suggests that reduced LPFC RSFC with the pMTG and SFG reflecting decreased attentional network connectivity may serve as a biomarker to predict AD treatment outcome in adolescents with MDD.No significant relationships.


What do patients talk during a clinic evaluation? What do they report besides referring physical complaints? It is crucial to value ’hidden’ symbolic issues under a conversation between patient and his/her doctors and nurses. Elderly people are at increased risk of developing Chronic Obstructive Pulmonary Disease (COPD) that requires the management of associated emotions. In advanced stages, they need to use Long-term Home Oxygen Therapy (LTOT) as part of treatment. Patients perceive difficulties with its use, generating anguish.To explore meanings of emotional experiences as reported by patients regarding LTOT, seen in a public university outpatient service.Qualitative design. Semi-directed interviews with open-ended questions were carried out with seven elderly patients at Pulmonology Outpatient Clinic at General Hospital at University of Campinas, diagnosed with COPD and using LTOT in period 2019 to 2020. Data were analyzed using Content Analysis with the support of Webqda software. COREQ checklist was used.Three categories emerged from interviews: (1) Changes of self-image perception with great dissatisfaction in not recognizing their selves physically. (2) Sadness with social isolation and feelings of awkwardness regarding themselves. (3) Affective aspects bringing the need to re-mean old family supports.Simply listening to reports of emotional complaints implies only a description of a clinical condition of the psychic sphere. Elderly patients with COPD bring psychological representations of their clinical condition that call for a symbolic interpretation. If such patients become aware of hidden meanings, they can better manage their fears and other uncomfortable feelings.No significant relationships.


There have been numerous efforts to increase workforce participation among Medicaid beneficiaries in an effort to reduce program costs. We know little, however, about whether Medicaid beneficiaries with low workforce participation live in communities that support employment. The purpose of the current study was to determine if community disadvantage was associated with workforce participation among late middle-aged Medicaid beneficiaries, an age group that commonly faces difficulty entering the workforce. Participants were 1418 Medicaid beneficiaries ages 51-64 who participated in the 2016 wave of the Health and Retirement Study, a population-based study of community-dwelling adults aged >50. Community disadvantage was measured using the Social Vulnerability Index (SVI). We evaluated the association between community social vulnerability and reduced workforce participation (defined as working < 20 hours per week). We performed additional analyses to determine if the association between community disadvantage and reduced workforce participation was driven by any one of four subthemes of the SVI:(1) community socioeconomic status, (2) household composition/disability, (3) minority status & language and (4) housing type & transportation. Community disadvantages was associated with reduced workforce participation . Analyses by SVI theme showed that the association between community disadvantage and reduced workforce participation was largely driven by community socioeconomic status (SES). Those living in low SES communities were more likely to report reduced workforce participation than those living in high SES communities: . Policy interventions that focus on disadvantaged communities are likely needed to improve employment rates among late middle-aged Medicaid beneficiaries.


Homebound persons living with dementia (PWD) require healthcare services that proliferate with physical and cognitive changes over time. PWD often experience fragmented care that results in poor health outcomes and delayed healthcare access. The objective of the Virginia at Home Program (VaH), a recently initiated home-based primary care (HBPC) program, is to promote long-term sustainability and proliferation of HBPC. The study purpose was to examine the impact of VaH on the overall care and outcomes of homebound PWD and their families. We used quantitative and qualitative methods to describe the impact of VaH on patient care and outcomes over six months. We compared clinical outcomes  at baseline and six months using paired t-tests. We also conducted semi-structured phone interviews at baseline and six months with PWD-caregiver dyads. Thirty PWD-caregiver dyads enrolled. Of the 17 dyads that completed both visits, PWD’s physical function and caregiver’s burden decreased significantly over time (ps < .05). There was a significant improvement in PWD’s behavioral symptoms over the six-month period (p=.03). Three preliminary themes emerged from qualitative data: 1) participants established trusting relationships with the VaH team, 2) VaH supported caregivers in their caregiving responsibilities, and 3) participants met their pre-program goals through increased healthcare access. Findings suggest that the HBPC intervention improved care satisfaction and healthcare access and alleviated caregiver burden. Future studies should consider introducing HBPC programs in this hard-to-reach population to decrease acute care utilization and health care costs while improving care satisfaction and quality.


There are no current established guidelines for the role of antimicrobial suppression therapy in management of prosthetic joint infection (PJI). In 2013, the IDSA provided initial treatment guidelines for PJI but did not address suppressive therapy. The guidelines do not address suppressive therapy beyond the initial 4-6 weeks for non-staphylococcal infections nor do they address suppressive therapy after 3-6 months of treatment for Staphylococcal infections. Practitioners must delicately balance the risk of PJI recurrence and the negative effects of continued antibiotic therapy including toxicity and resistance. In this study, we surveyed Infectious Disease providers to better understand their antimicrobial suppression practice patterns in different clinical scenarios.We surveyed Infectious Disease providers across the United States from April 2022 to May 2022. We received 78 unique response from 31 different states. Basic demographic data was obtained. Providers presented six multiple choice clinical scenarios and were asked if they would start suppressive therapy and the duration of suppressive therapy.The preliminary data revealed that practice patterns vary greatly amongst providers in the management of antibiotic suppressive therapy in PJI. Of the 6 scenarios, only half had greater than 50% consensus . Scenario 1 involved a patient who underwent a single stage revision. It was of particular interest as 51.3% of providers indicated they would stop antimicrobial therapy and 48.7% indicated they would extend antimicrobial therapy with 25.6% electing for lifelong suppressive therapy.Practice patterns for antimicrobial suppression therapy in knee PJI varies significantly among providers. Even with IDSA guidelines addressing Staphylococcal PJI, the practice patterns among infectious diseases providers still varied greatly especially with regards to single stage revisions. Additional randomized controlled trials examining the best way to manage antimicrobial suppression in PJI would be helpful, and would allow for development of evidence-based guidelines. We also plan to survey orthopedic surgeons using the same clinical scenarios to see if there is a difference in management styles.All Authors: No reported disclosures.


Many people suffering from psychotic disorders report persistent auditory verbal hallucinations (‘voices’) despite pharmacological and psychological therapy. Interest is growing in approaches that emphasise the personal relationship between the patient and their voice(s). AVATAR therapy is one such approach that uses a digital representation (avatar) of a selected voice to facilitate a three-way discussion between patient, therapist and voice, the therapist speaking either as him/herself or in the digitally transformed voice of the avatar. Objectives: To describe AVATAR therapy and an ongoing multi-centre clinical trial. Methods: Encouraging findings from an earlier controlled trial (AVATAR1) comparing AVATAR therapy and supportive counselling informed our current multi-site cost-effectiveness trial of brief and extended versions of the therapy compared to treatment as usual (AVATAR2). Results: AVATAR1 delivered in 7 weekly sessions resulted in a reduction in the frequency, distress and power of voices that was significantly superior to supportive counselling. Clinical experience suggested that some participants improved in response to the early focus on anxiety while others seemed more responsive to later more formulation-driven approach. These findings led us to the current ongoing three arm clinical trial comprising a brief (6 session) focus on anxiety/assertiveness, an extended (12 session) formulation-driven approach both approaches compared to treatment as usual. Conclusion: Previous AVATAR studies suggest this is a therapy with considerable promise. It can be delivered through widely available laptop computers, usually in clinic but also remotely via existing commercial platforms. The current trial will address questions about dissemination, training and cost-effectiveness in NHS settings.The digital technology employed in AVATAR therapy is provided by licence for the trial from Avatar Therapy Ltd


As the pandemic continues to spread worldwide, many of healthcare facilities are exploring new methods to keep their patients safe from potential hospital-acquired infections (HAIs) during the pandemic. This study explored the attitudes about artificial intelligence (AI) among providers who utilized AI-based hand hygiene monitoring system (HHMS) at a rural medical center during the pandemic.A self-administered questionnaire was mailed to 48 healthcare providers at a rural medical center in north Texas, with a 75% percent response rate (n = 36). The survey collected information on providers attitudes about AI-based HHMS use. In addition, the study also examined the relationship between provider’s well-being and the level of satisfaction with the AI-based HHMS use. The lessons learned from this study will be used to determine important factors to consider when attempting to advance and expand AI technologies in rural healthcare settings.Results revealed that the integration of AI technology within the existing electronic health record (EHR) system remains a challenge for many providers. Plus, the lack of user-centered design approaches to incorporate the AI tool into existing workflows has reduced providers satisfaction about the new technology.The findings suggested that although AI technology has great promise to reduce the number of hospital-acquired infections (HAIs), successfully implement of an AI-based tool that meets the expectations of users requires significant levels of consolidation to ensure that it fits within the existing workflows and is accepted by users.• AI application indirectly affects the well-being of providers, particularly in rural healthcare settings.• A better AI application interface design that meets the expectations of providers is needed.


A fifteen-year-old male patient sustained a posteriorly dislocated right capital femoral Delbet type Ib epiphyseal fracture-separation and a right acetabular posterior column fracture after a low-energy trip and fall. The capital femoral epiphysis was closed reduced and fixed with cannulated screws on an urgent basis. He underwent acetabular osteosynthesis via a Kocher-Langenbeck approach two days thereafter. Twenty-two months after injury, he was weight-bearing on the right lower extremity without radiologic evidence of avascular necrosis or clinical evidence of pain or functional deficit.  Fracture-separation of the capital femoral epiphysis comprises only 8% of skeletally immature femoral neck fractures in the Delbet and Colonna classification. Prognosis is worse with ipsilateral hip dislocation due to the risk of avascular necrosis from disruption of the medial femoral circumflex artery. Urgent referral to a trauma center and treatment by appropriate specialists enables good long-term results after this uncommon traumatic injury pattern. Acetabular fractures in skeletally immature patients are relatively rare. In a review of over 7,000 patients in the German Pelvic Trauma Registry, only 153 patients were less than fourteen years old , of which only fifteen (9.8%) sustained acetabular fractures .Traumatic hip dislocations are more common than acetabular fractures in the pediatric population and often associated with sports activities or high-energy trauma; a case series of six patients from Turkey in 2014 included five posterior hip dislocations, one of which involved a transepiphyseal fracture . In a 19Delbet and Colonna classified fracture-separation of the capital femoral epiphysis as a rare lesion accounting for just eight percent of femoral neck fractures in skeletally immature patients  of the pelvis and right femur  showed aThe patient was taken urgently to the operating room on the day of presentation by a pediatric orthopaedist (R.C.) for closed manipulation and reduction using axial traction. Given the low energy mechanism and resultant posteroinferiorly displaced capital femoral epiphyseal fracture-separation, and the absence of any epiphyseal fragments remaining attached to the distal femoral neck fracture fragment, the displaced physeal fracture-separation was closed reduced with minimal manipulation. The reduced capital epiphysis was percutaneously stabilized with two 6.5 mm cannulated screws . The femThe patient then returned to the operating room on hospital day two for open reduction and internal fixation of the right acetabulum  via a KoAt the two-month follow-up, he was no longer following weight-bearing restrictions and he and his mother reported no pain or functional deficit. Radiographs  revealedOur report demonstrates that urgent reduction and pinning of an acute Delbet Ib displaced capital femoral epiphysis with concurrent reduction of the displaced hip joint, closely followed by osteosynthesis of the acetabulum, is a feasible treatment option for this uncommon traumatic injury pattern if referred in a timely fashion to a trauma center with an available specialist or specialists adept at caring for those injuries.Van Nortwick et al. performed a Ganz osteotomy to repair a posterior transphyseal SH III hip fracture-dislocation in a thirteen-year-old male; he had no osteonecrosis or functional limitations at two-year follow-up . MehlmanShaath et al. reported a case of a thirteen-year-old female who sustained a transphyseal SH I femoral neck fracture and posterior hip dislocation with ipsilateral transverse-posterior wall acetabular fracture; intraoperatively, several incarcerated articular fragments were removed from the hip joint and she underwent open reduction and internal fixation of the acetabulum and femoral neck . After tThese previous similar cases and our case demonstrate that timely surgical intervention with appropriate subspecialist consultation can provide excellent outcomes in complex pelvic and acetabular traumatic injuries. In particular, this case demonstrates that staged surgical intervention can lead to excellent long-term outcomes after a traumatic acetabular injury.Limitations of this case report include the inability to obtain close follow-up due to pandemic-related outpatient visit restrictions. However, this patient's case shows that pediatric patients can achieve good long-term results with return to all activities.


Frailty is a key hallmark of aging and exercise has been shown to delay aging effects. This study was initiated based on the hypothesis that voluntary wheel running (VWR) starting at 12 mo until 18 or 22 mo of age would benefit the female murine musculoskeletal system. Based on the final body weight, the mice were separated into high (HBW) and low body weight (LBW) subgroups. Beneficial effects of VWR were observed on soleus muscle mass and contractile force at both ages, although HBW led to greater increases at 22 mo. VWR increased fiber cross-sectional area by 20%, leading to more type I and fewer IIA fibers in soleus. HBW mice were resistant to age-related decline in Extensor digitorum longus (EDL) mass and contractile force. EDL in 18 mo HBW also showed 15% higher contractile force following VWR while muscle from 18 & 22 mo LBW responded to VWR with greater osteocyte protective factor secretion. Skeletal adaptation to VWR was also dependent on body weight, with HBW showing higher femoral cortical thickness and area under sedentary conditions. VWR maintained osteocyte dendrite number in HBW. VWR increased periosteal and endosteal circumferences in HBW, suggesting compensation for loss of material strength. Consistent with this, VWR maintained higher bone mechanical properties in 18mo LBW. In summary, VWR alters musculoskeletal parameters depending on body weight with HBW contributing to more muscle mass and strength to prevent sarcopenia while bone retains better mechanical properties in LBW but HBW contributes structural modification to prevent osteopenia.


Codetta is a Python program for predicting the genetic code table of an organism from nucleotide sequences. Codetta can analyze an arbitrary nucleotide sequence and needs no sequence annotation or taxonomic placement. The most likely amino acid decoding for each of the 64 codons is inferred from alignments of profile hidden Markov models of conserved proteins to the input sequence.http://eddylab.org/software/codetta/codetta2.tar.gz and at http://github.com/kshulgina/codetta.Codetta 2.0 is implemented as a Python 3 program for MacOS and Linux and is available from Bioinformatics online. Almost all of life uses the same decoding scheme; however, dozens of clades have evolved alternative genetic codes where the meaning of one or more codons is changed  and predicts the genetic code from coding regions with recognizable homology. For each codon, the best amino acid meaning is selected; thus, Codetta can detect canonical stop and sense codons with new amino acid meanings (i.e. stop-to-sense and sense-to-sense reassignments). Codetta does not predict termination codons and cannot detect sense-to-stop reassignments.Codetta performs three main steps, in order:Alignment. A preliminary six-frame standard genetic code translation of the input sequence is aligned to profile HMMs of conserved proteins using the HMMER hmmscan program  and 82 mitochondrial genomes with 18 alternative genetic codes affecting 14 different codons (27 Kb average genome size). For the mitochondrial comparison, we used a custom-built profile HMM database of mitochondrial proteins to demonstrate usage of the custom profiles feature; we also repeated the Codetta analysis with Pfam. Complete results and a breakdown of per-codon prediction accuracy are provided in -r option).Genetic code prediction requires high sensitivity to find rare codon reassignments but also a high positive predictive value (PPV) to avoid overwhelming predictions with errors. To assess how well Codetta and FACIL predict codon reassignments, we identified codon predictions that differed from the standard genetic code (predicted codon reassignments) and compared to the annotated genetic code to determine if they are correct . For theIn the mitochondrial test set, Codetta predicted three sense codon reassignments that we counted as errors in In btac802_Supplementary_DataClick here for additional data file.


Older Chinese Americans face many socioeconomic barriers including limited English proficiency, low educational levels, and limited access to care. These socioeconomic disadvantages not only contribute to an increased risk of developing dementia but also worsen inequitable access to effective strategies to promote cognitive health. Cognitive training is shown to be beneficial to maintain or enhance cognitive function. However, most prior interventions were tested exclusively in non-Hispanic Whites. To address this gap, we aim to adapt empirically supported cognitive training activities into a culturally and linguistically relevant mHealth cognitive training intervention. The adaptation process of the cognitive training includes focus groups (n=6/group) with older Chinese Americans (3 groups) and adult children (2 groups) to adapt cognitive training components to our target population. We will then organize an experience-based co-design workshop to further refine the intervention. Engaging end-users early will optimize the development of a culturally and linguistically relevant cognitive training intervention.


Although largely preventable, tooth decay  is among the most common health conditions worldwide and contributes to substantial dental treatment expenditures. While Fluoride Toothpaste (FT) is considered an essential strategy for oral health prevention, its market price has been shown to vary substantially across various settings. Against this background, the present study aimed to develop a decision analytical model to evaluate the cost-effectiveness of FT in various settings.Leaning on WHO CHOICE methodology, evidence scoping and an expert consensus were facilitated to extract model input parameters which were then fed into cost-effectiveness-analyses (CEA) for FT. The cost-effectiveness of the interventions was expressed as cost per Disability-Adjusted Life Year (DALY) averted.The CEA identified a high likelihood for FT to be a cost-efficient treatment strategy in settings with comparably low market prices for FT. FT was less likely to be a cost-efficient treatment strategy in settings with comparably high market prices for FT.The developed decision analytical model is suitable to inform policymakers about the extent to which FT represents good value-for-money under different market prices.• Fluoride toothpaste can provide high value for money as an oral health preventive strategy.• Policymakers need to ensure the affordability of fluoride toothpaste in order to harvest relevant efficiency gains.


In pairwise comparisons, postgraduate education was associated with more positive attitudes towards relapse risk (p = 0.004) when compared to diploma-educated respondents. No significant associations were observed between years of clinical experience and participant responses. Our findings highlight important aspects of clinician attitudes that could improve harm reduction education and integration into clinical practice.Stigma and other barriers limit harm reduction practice integration by clinicians within acute psychiatric settings. The objective of our study was to explore mental health clinician attitudes towards substance use and associations with clinical experience and education level. The Brief Substance Abuse Attitudes Survey was completed among a convenience sample of mental health clinicians in Vancouver, British Columbia. Five predefined attitude subgroups were evaluated. Respondents’ attitudes towards substance use were associated with level of education on questions from two (non-stereotyping [ North America is currently in the midst of an unprecedented opioid epidemic. The number of opioid-related deaths is rising steadily across Canada, with the highest mortality rate occurring in British Columbia . Many inIndividuals with both psychiatric and substance use issues are at increased risk for drug-related death , especiaGiven the disconnect between the scientific evidence for and the resistance to harm reduction among health care providers, it is critical to examine how clinician attitudes towards substance use influence the harm reduction best practices in psychiatric settings. The objective of our study was to explore mental health clinician attitudes towards substance use and associations with clinical experience and education level.n = 71) of mental health clinicians  between May and June 2022 at a tertiary care hospital in Vancouver, British Columbia. Participants were recruited via email based on internal distribution lists and informed consent was obtained electronically. Eligible participants were employed fulltime, parttime or casual within the hospital and had at least one year of experience in an acute psychiatric setting. The survey included socio-demographic questions  and the 25-item Brief Substance Abuse Attitudes Survey (BSAAS). The BSAAS [p values for multiple comparisons. Statistical analyses were performed using SAS version 9.4. Ethics approval was obtained from the Providence Health Care/University of British Columbia Review Board.We conducted an online cross-sectional survey among a convenience sample , were employed as nurses (48%), with bachelor’s (44%) or master’s (23%) level education and fewer than ten years of experience in their primary clinical role (71%) (Table p = 0.012) and treatment optimism (p = 0.008) (Table p = 0.004) when compared to diploma-educated respondents. In contrast, no pairwise effect was observed between education type with respect to propensity for hard drug use (p = 0.310) within the non-stereotyping subgroup. No significant associations were demonstrated between years of clinical experience and attitudes towards substance use  that could improve harm reduction education and integration into clinical practice.Prior research has identified that negative attitudes are consistently viewed as barriers to evidence-based harm reduction practices . Even thWe observed no associations between years of experience and clinician attitudes in our sample. This nonsignificant finding was in contrast to our hypothesis and existing literature which suggests that more experience and therefore increased contact with individuals who use substances fosters more positive attitudes ; howeverFurther research is required to understand elements of education and training that are associated with more positive attitudes towards and improved care for individuals who use substances. The limitations of this study include a low proportion of non-nursing providers, generalizability to other regions or settings and the cross-sectional survey design with assessments of attitudes at a single time-point.


To determine whether convolutional neural networks can detect morphological differences between images of microbiologically positive and negative corneal ulcers.A cross-sectional comparison of prospectively collected data consisting of bacterial and fungal cultures and smears from eyes with acute infectious keratitis at Aravind Eye Hospital. Two convolutional neural network architectures (DenseNet and MobileNet) were trained using images obtained from handheld cameras collected from culture-positive and negative images and smear-positive and -negative images. Each architecture was trained on two image sets: (1) one with labels assigned using only culture results and (2) one using culture and smear results. The outcome measure was area under the receiver operating characteristic curve for predicting whether an ulcer would be microbiologically positive or negative.There were 1970 images from 886 patients were included. None of the models were better than random chance at predicting positive microbiologic results .These two state-of-the-art deep convolutional neural network architectures could not reliably predict whether a corneal ulcer would be microbiologically positive or negative based on clinical photographs. This absence of detectable morphological differences informs the future development of computer vision models trained to predict the causative agent in infectious keratitis using corneal photography.These deep learning models were not able to identify morphological differences between microbiologically positive and negative corneal ulcers. This finding suggests that similar artificial intelligence models trained to identify the causative pathogen using only microbiologically positive cases may have potential to generalize well, including to cases with falsely negative microbiologic testing. After obtaining consent, eligible subjects underwent standard evaluation for corneal ulcer patients, including a detailed clinical history and slit lamp examination. All subjects then underwent external photography using a handheld Nikon D7100 camera with a 105-mm macro lens according to a standardized photography protocol, which has been successfully employed in several previous clinical trials.Subjects then underwent corneal scraping with heat sterilized Kimura spatulas according to the standard of care. Specimens were prepared for gram stain, KOH smear, bacterial culture on blood agar, and fungal culture on potato dextrose agar. Smear and culture results were determined by experienced microbiology technicians.This study adhered to the tenets of the Declaration of Helsinki and was approved by the internal review board at Oregon Health & Science University and Aravind Eye Hospital (project code RES2020050BAS). Informed consent was obtained from all participants. All cases of clinically diagnosed infectious keratitis were considered eligible for inclusion, as long as the external photographs and microbiologic specimens were obtained.,,Images were labeled according to their microbiologic results. Overall, both smears (Gram stain and KOH)https://github.com/tkredd2/MobileNet_to_predict_corneal_ulcer_culture_positivity), and all hyperparameters used to train the models are available in Subjects were allocated randomly into the training set (80%), validation set (10%), or test set (10%). Care was taken to ensure that all images associated with a particular subject were allocated to the same image set, to prevent label leakage. During training, image augmentation was performed to minimize overfitting using random flipping along the vertical axis and random rotation up to 20° in either direction. Images were then resized according to the standard input size for these deep CNNs (224 × 224 pixels) using the bilinear interpolation algorithm. Two model architectures were evaluated: MobileNetV2 and DenseNet201. These two architectures were previously found to have the highest performance among deep CNNs for distinguishing bacterial and fungal keratitis using this same imaging modality.There were 934 subjects with clinically diagnosed infectious keratitis recruited for this study. Forty-eight subjects were excluded from the analysis because of missing results on one or more microbiologic tests, resulting in 1970 images from 886 subjects in the final dataset. This included 444 ulcers of the right eye (50.2%) and 442 of the left eye (49.8%). There were 521 cases that were culture positive (59%) and 365 that were culture negative (41%). Among those that were culture positive, 164 demonstrated bacterial growth (32%), 374 demonstrated fungal growth (72%), and 17 (3%) grew both bacteria and fungi . Using the less restrictive definition of microbiologic positivity incorporating both culture and smear results, we found that 690 cases were culture and/or smear positive (78%) and 197 were culture and smear negative (22%). Among those that had positive results on either culture, gram stain, or KOH smear, 216 cases demonstrated the presence of bacteria (31%), 519 demonstrated fungi (75%), and 46 were polymicrobial (7%). The test set defined according to both culture and smear results consisted of 211 images; 28 (13%) culture and smear negative and 183 (87%) culture or smear positive. The validation set consisted of 200 images; 24 (12%) culture and smear negative and 176 (88%) culture or smear positive. The training set consisted of 1590 images; 176 (11%) culture and smear negative and 1414 (89%) culture or smear positive.Pseudomonas aeruginosa (34%), followed by Streptococcus pneumoniae (15%) and Nocardia species (11%). There were 374 cases (42%) that demonstrated fungal growth in culture. Fusarium was the most commonly identified fungal pathogen (28%), followed by Aspergillus (18%) and dematiaceous molds (18%).Gram stains demonstrated bacteria in 166 cases (19%), with the majority demonstrating gram-positive cocci or gram-negative bacilli . There wThe area under the receiving operating characteristic curve (AUC) for differentiating microbiologically positive and negative corneal ulcers was determined for each of the four CNNs. The AUC for the DenseNet trained using only culture results was 0.48  . The AUCThese results demonstrate that two different CNN model architectures did not identify morphological differences between clinical photographs of microbiologically positive and negative corneal ulcers, regardless of how microbiologic positivity is defined. This work has implications for the future development of diagnostic artificial intelligence models for infectious keratitis.–Prior studies have demonstrated that these computer vision model architectures are capable of recognizing meaningful morphological differences between bacterial and fungal keratitis in corneal photographs.Streptococcus pneumoniae, Pseudomonas aeruginosa, and Nocardia) and fungal species (Fusarium and Aspergillus) were the same between our study and this prior work.,The epidemiology of the etiologies for infectious keratitis included in this study is comparable to prior studies in South India. Lalitha et al.Acanthamoeba or viral keratitis) or sterile keratitis . However, all subjects with a suspected acanthamoeba-related ulcer undergo confocal microscopy at Aravind, which would exclude a large majority of potential cases. In addition, viral necrotizing keratitis is very rare and would be less likely to masquerade as a culture-negative case, and the clinical volume of infectious keratitis in South India is such that the diagnostic expertise of these cornea specialists is very high.Several potential limitations should be considered. First, the term culture-negative referred to images that did not have positive bacterial or fungal results, but it is possible that a few of these culture-negative cases included other infectious etiologies (e.g., Our results demonstrate that these state-of-the-art computer vision models were not able to differentiate between microbiologically positive and negative corneal ulcers based on external photographs, regardless of whether cultures or smears were used to determine the microbiologic status. These findings suggest that the CNNs used to distinguish the underlying etiology of infection in subjects with corneal ulcers may generalize well to microbiologically negative cases, even if they are trained using supervised learning with only microbiologically positive cases. Additional model evaluation studies in population-based samples are a necessary next step in the determination of whether these deep learning models may provide clinical benefit to patients with this potentially blinding condition.