Management of Severe Allergic-Like Contrast Media Reactions: Pitfalls and Strategies, From the AJR Special Series on Contrast Media.

Adverse reactions to contrast media are often high-acuity events that are uncommon potentially life-threatening. Nonetheless, these events are treatable, and radiologists may be called upon to manage a contrast media reaction. However, because these events are infrequent, they are prone to management errors. This article highlights common pitfalls and practical tips for the management of acute contrast media reactions in children and adults. Recognition of frequent management errors and implementation of the mitigation strategies presented can ameliorate risk and improve patient outcomes. These measures include proper training on reaction management and medication administration, the prompt use of IM epinephrine autoinjectors whenever a severe allergic-like reaction is suspected, the use of visual aids for quick reference in the setting of a reaction, and the recognition of adverse events that are not allergic-like reactions, which commonly require only supportive care.

Use of cine images in standard ultrasound imaging: a survey of sonologists.

PURPOSE: The aim of this study was to explore how sonologists utilize cine images in their routine practice. METHODS: A 10-question, multiple choice survey was distributed to members of the Society of Radiologists in Ultrasound. The survey queried respondent's routine inclusion of cines for ultrasound examinations in normal and abnormal studies in addition to questions related to respondent's practice type, geographic location, number of radiologists interpreting ultrasound examinations, and ultrasound imaging workflow. RESULTS: Sixty-five percent of respondents are in academic practice. Geographic location of practice, number of radiologists in the practice who interpret ultrasound, and whether the sonologist was on site where the examinations were performed was variable. Of respondents, 97% of used both static and cine images for abnormal/positive examinations and 82% used both for normal/negative studies. CONCLUSION: Nearly all respondents, who are mostly in academic practice, report using both static and cine images for all ultrasound examinations in their practice.

Fucosylation of HLA-DRB1 regulates CD4+ T cell-mediated anti-melanoma immunity and enhances immunotherapy efficacy.

Immunotherapy efficacy is limited in melanoma, and combinations of immunotherapies with other modalities have yielded limited improvements but also adverse events requiring cessation of treatment. In addition to ineffective patient stratification, efficacy is impaired by paucity of intratumoral immune cells (itICs); thus, effective strategies to safely increase itICs are needed. We report that dietary administration of L-fucose induces fucosylation and cell surface enrichment of the major histocompatibility complex (MHC)-II protein HLA-DRB1 in melanoma cells, triggering CD4+ T cell-mediated increases in itICs and anti-tumor immunity, enhancing immune checkpoint blockade responses. Melanoma fucosylation and fucosylated HLA-DRB1 associate with intratumoral T cell abundance and anti-programmed cell death protein 1 (PD1) responder status in patient melanoma specimens, suggesting the potential use of melanoma fucosylation as a strategy for stratifying patients for immunotherapies. Our findings demonstrate that fucosylation is a key mediator of anti-tumor immunity and, importantly, suggest that L-fucose is a powerful agent for safely increasing itICs and immunotherapy efficacy in melanoma.

Cancer in pregnancy: treatment effects.

PURPOSE: Pregnant patients present a unique challenge to cancer therapy. Due to the potential catastrophic implications related to teratogenic effects or pregnancy loss, oncologic management of this vulnerable patient group must be strategic and personalized. METHODS: This article will discuss the unique treatment approach to the pregnant cancer patient. This includes discussion of the role of imaging during staging, treatment, and follow-up with an emphasis on avoiding ionizing radiation when possible. RESULTS AND CONCLUSION: Specific considerations and modifications to standard cancer treatments, including surgery and systemic therapies such as chemotherapy, immunotherapy, targeted and hormone therapies are crucial components of providing oncologic care to minimize negative effects to the mother and developing fetus. Radiation and proton therapy are also options that may be employed in specific circumstances. Finally, this article will address the long-term treatment effects of these therapies on future fertility.

Gender and racial diversity among plenary session speakers at the Society of Abdominal Radiology Annual Meetings: a five-year assessment.

PURPOSE: To evaluate the gender and racial diversity of plenary session speakers in the annual meetings of Society of Abdominal Radiology (SAR) over 2016 to 2020. MATERIALS AND METHODS: The brochures of the SAR annual meetings were reviewed for plenary session speakers and titles. Publicly available institutional profiles and social media were reviewed by the investigator in order to infer gender and race. Gender assessments were men, women, transgender men, transgender women or gender non-binary. Race was classified as White, Black or African American, American Indians and Alaskan Natives, Asian, Native Hawaiian and Pacific Islander and Multiracial. Statistical analysis was performed using chi square and T-tests. RESULTS: Based on self-reported data, the SAR has 64% male and 36% female members. Over 2016-2020, plenary session speakers were more likely to be men [69.6% (183/263)] than women [30.4% (80/263)] (p-value = 0.0007). No speakers could be reliably identified as transgender, gender non-binary or gender expansive. In 2016, there were 24% women plenary speakers. This proportion was 28% in 2017, 33% in 2018 and 36% in 2019, and 30% in 2020. When assessing racial distribution, white speakers accounted for the majority of plenary speakers, ranging from 61 to 78%. Asians speakers accounted for 22 to 35%. There were no Black and African American, American Indian & Alaskan Native, Native Hawaiian & Pacific Islander plenary speakers (0%). Multiracial speakers were represented from 2018 to 2020, accounting for 2-4% speakers (p-value < 0.0001). CONCLUSIONS: Plenary speakers at SAR Annual Meetings from 2016-2020 were more likely to be men, but with the proportion of women presenters increasing over time. White speakers represented the majority of plenary session speakers, followed by Asians. No plenary session speakers were identified as Black or African American or Native Americans.

A Mathematical Model to Estimate Chemotherapy Concentration at the Tumor-Site and Predict Therapy Response in Colorectal Cancer Patients with Liver Metastases.

Chemotherapy remains a primary treatment for metastatic cancer, with tumor response being the benchmark outcome marker. However, therapeutic response in cancer is unpredictable due to heterogeneity in drug delivery from systemic circulation to solid tumors. In this proof-of-concept study, we evaluated chemotherapy concentration at the tumor-site and its association with therapy response by applying a mathematical model. By using pre-treatment imaging, clinical and biologic variables, and chemotherapy regimen to inform the model, we estimated tumor-site chemotherapy concentration in patients with colorectal cancer liver metastases, who received treatment prior to surgical hepatic resection with curative-intent. The differential response to therapy in resected specimens, measured with the gold-standard Tumor Regression Grade (TRG; from 1, complete response to 5, no response) was examined, relative to the model predicted systemic and tumor-site chemotherapy concentrations. We found that the average calculated plasma concentration of the cytotoxic drug was essentially equivalent across patients exhibiting different TRGs, while the estimated tumor-site chemotherapeutic concentration (eTSCC) showed a quadratic decline from TRG = 1 to TRG = 5 (p < 0.001). The eTSCC was significantly lower than the observed plasma concentration and dropped by a factor of ~5 between patients with complete response (TRG = 1) and those with no response (TRG = 5), while the plasma concentration remained stable across TRG groups. TRG variations were driven and predicted by differences in tumor perfusion and eTSCC. If confirmed in carefully planned prospective studies, these findings will form the basis of a paradigm shift in the care of patients with potentially curable colorectal cancer and liver metastases.

Representation of women among leadership and honorees within the Society of Abdominal Radiology, past and present.

PURPOSE: To evaluate gender diversity over time within the leadership and honorees of the Society of Abdominal Radiology with comparison to other radiologic societies. METHODS: This was a retrospective, observational study of the gender distribution of presidents and gold meal awardees within the Society of Abdominal Radiology (SAR) compared to three national radiology organizations: the American College of Radiology (ACR), the American Roentgen Ray Society (ARRS), and the Radiological Society of North America (RSNA). Data were collected from the inception of each society through 2020. Societies were directly contacted for president and Gold Medal awardee names when this information was not available on society websites. Differences in the proportion of female presidents and Gold Medal awardees before and after 2012, by society, were performed using χ2 test; 2012 was selected as a threshold year as this represented when SAR was created. RESULTS: The proportion of female past presidents was 5%, 9%, and 33% for the SGR, SUR, and SAR, respectively, and 5%, 4%, and 7% for the ACR, ARRS, and RSNA, respectively. The proportion of female Gold Medal awardees was 5%, 4%, and 10% for the SGR, SUR, and SAR, respectively, and 5%, 7%, and 7%, respectively, for ACR, ARRS, and RSNA. There was a statistically significant increase in the proportion of women presidents and honorees in all societies after 2012 compared to before 2012, but no significant difference between societies in either time period. CONCLUSION: A higher proportion of female presidents and honorees were demonstrated across all societies after 2012.

Sarcopenia and low muscle radiodensity associate with impaired FEV1 in allogeneic haematopoietic stem cell transplant recipients.

BACKGROUND: Quantification of skeletal muscle using computed tomography (CT) is accessible using cancer patients' standard oncologic images. Reduced muscle mass may be related to reduced respiratory muscle strength; however, the impact of this on lung functional parameters is not characterized in adult allogeneic haematopoietic stem cell transplant (alloHCT) recipients. METHODS: A consecutive retrospective series (n = 296) of patients who had alloHCT at a comprehensive cancer centre between March 2005 and April 2015 were included. Pre-transplant CT scans were used to quantify skeletal muscle and adipose tissue at the fourth thoracic (T4) and/or third lumbar (L3) level. Tumour and patient characteristics were recorded, including forced expiratory volume in 1 second (FEV1 ) by spirometry. Regression models were created to characterize predictive relationships. RESULTS: A total of 296 patients (♂n = 161; ♀n = 135) were included, all of whom had chest CT as part of standard care; a subset of these (n = 215, 72.6%) also had abdominal CT. Diagnoses were non-Hodgkins lymphoma (n = 165), acute myeloid leukaemia (n = 66), Hodgkin's disease (n = 14), acute lymphocytic leukaemia (n = 14), myelodysplastic syndromes (n = 18), and other (n = 19). In multivariable linear regression adjusted for sex (P < 0.0001), age (P < 0.0001), haematopoietic cell transplantation-specific co-morbidity index (P = 0.010), and parameters of pulmonary function testing (defined by spirometry, P < 0.0001), both T4 muscle index [ß 0.127 (95% confidence interval 0.019; 0.252), P < 0.0001] and T4 muscle radiodensity [ß 0.132 (95% confidence interval 0.087; 0.505), P = 0.006] were independently associated with FEV1 ; disease risk index (P = 0.877) and Karnofsky performance status (P = 0.548) were not associated with FEV1 . Similar conclusions were obtained when L3 muscle index and radiodensity were considered. Unlike T4, L3 muscle index values can be compared with published cut-off values for sarcopenia. Overall rates of sarcopenia were uniformly higher in the HCT population than in age-matched and sex-matched patients with solid tumours [alloHCT ♂64.7% vs. solid tumour ♂56.6% (P < 0.001); alloHCT ♀57.6% vs. solid tumour ♀36.0% (P < 0.001)]. Significant but moderate correlations (P < 0.001) were found for muscle area and radiodensity between L3 and T4, for both men and women; adipose tissue quantity also correlated significantly (P < 0.001) between L3 and T4 for both men and women. CONCLUSIONS: Lumbar or thoracic CT images are useful for body composition assessment in this population and reveal high rates of sarcopenia, similar to those reported in very elderly patients. Reduced muscle mass and radiodensity associate with impaired FEV1 even after adjustment for clinical covariables including co-morbidities, performance status, disease risk, and mild intrinsic pulmonary disease (chronic obstructive pulmonary disease) defined by spirometry.

Rare Abdominal Wall Metastasis following Curative Resection of Gastric Cancer: What Can Be Learned from the Use of Percutaneous Catheters?

In cancer care, tissue seeding after curative resections is a known potential complication, despite precautions taken during surgical treatment. We present an uncommon case of an abdominal wall metastasis along the tract of a surgical drain following gastrectomy for gastric adenocarcinoma. To our knowledge, this is the first case of such an occurrence in the setting of a negative staging peritoneal lavage. Aside from the rarity of such a recurrence, this instance highlights an opportunity to reevaluate best practices with regard to the extent of coverage of postoperative salvage radiotherapy. The oncologic patient provides many challenges and may require multiple catheters for drainage and at times infusion of nutrition or therapeutic agents. These foreign bodies should be scrutinized both clinically and radiographically, as they may create vulnerabilities in keeping malignant diseases contained and controlled. We provide a review of the literature with reasonable treatment options for the benefit of future patients.

The role of diagnostic imaging in the primary testicular cancer: initial staging, response assessment and surveillance.

Testicular cancers are a group of uncommon malignancies that account for less than 1% of new cancer cases per year in the United States and globally. The disease typically affects men between the ages of 20-44, and the overwhelming majority of tumors are germ cell in origin. Most cases of testicular cancer are organ confined at diagnosis and have a good overall prognosis. Testicular cancers are staged by the tumor, node, metastasis, serum markers (TNMS) classification set forth by the American Joint Commission on Cancer staging. Diagnostic imaging plays a crucial role in initial staging, specifically in assessing the primary tumor prior to orchiectomy and evaluating for regional and/or distant metastasis. Multimodality imaging is used for initial staging, with ultrasound and computed tomography (CT) most commonly utilized. Diagnostic imaging is also important in evaluating response in patients who initially present with metastatic disease as well as in patients who are undergoing surveillance. Typically, CT is used for response assessment and surveillance, with magnetic resonance imaging (MRI) and positron emission tomography (PET) serving as adjunct modalities. This article reviews the role of various diagnostic imaging modalities and how they are employed in the diagnosis, staging, response assessment and surveillance of primary testicular cancer.

Leiomyosarcoma of the Inferior Vena Cava with Hepatic and Pulmonary Metastases: Case Report.

Sarcomas are connective tissue tumors accounting for only 1% of all adult malignancies. Leiomyosarcoma (LMS) is a sarcoma arising from smooth muscle cells, and accounts for 10-20% of all sarcomas. A subtype of LMS are those originating from the smooth muscle of blood vessels. Leiomyosarcoma of the inferior vena cava is a sarcomatous tumor, with less than 350 cases described in the literature. It carries a poor prognosis, with 5- and 10-year survival rates of 31.4% and 7.4%, respectively. We present a case of a 46-year-old female with no significant past medical history presented to the emergency department with mild abdominal pain and distention, early satiety, and weight loss for three weeks, found to have unresectable metastatic leiomyosarcoma of the inferior vena cava.

Critical dialogical approach: A methodological direction for occupation-based social transformative work.

BACKGROUND: Calls for embracing the potential and responsibility of occupational therapy to address socio-political conditions that perpetuate occupational injustices have materialized in the literature. However, to reach beyond traditional frameworks informing practices, this social agenda requires the incorporation of diverse epistemological and methodological approaches to support action commensurate with social transformative goals. AIM: Our intent is to present a methodological approach that can help extend the ways of thinking or frameworks used in occupational therapy and science to support the ongoing development of practices with and for individuals and collectives affected by marginalizing conditions. METHOD: We describe the epistemological and theoretical underpinnings of a methodological approach drawing on Freire and Bakhtin's work. RESULTS: Integrating our shared experience taking part in an example study, we discuss the unique advantages of co-generating data using two methods aligned with this approach; dialogical interviews and critical reflexivity. DISCUSSION: Key considerations when employing this approach are presented, based on its proposed epistemological and theoretical stance and our shared experiences engaging in it. SIGNIFICANCE: A critical dialogical approach offers one way forward in expanding occupational therapy and science scholarship by promoting collaborative knowledge generation and examination of taken-for-granted understandings that shape individuals assumptions and actions.

Identification of nonalcoholic fatty liver disease following pancreatectomy for noninvasive intraductal papillary mucinous neoplasm.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) following pancreatectomy is a potential cause of long term morbidity in patients undergoing pancreatic resection with curative intent. Prior studies have reported an incidence of NAFLD up to 30% following pancreatectomy but the investigated cohorts were typically a mix of benign and malignant disease. Here we examined the incidence of NAFLD in a homogenous cohort of patients following pancreatectomy for benign intraductal papillary mucinous neoplasm (IPMN). METHODS: A retrospective review of patients who underwent pancreatic resection for IPMN from 2000 to 2016 was performed. Post pancreatectomy CT/MRI scans were obtained as standard surveillance. We investigated changes in the liver parenchymal density on post surgical imaging to estimate the frequency with which NAFLD occurred. Radiographic criteria for NAFLD included Hounsfield units less than 40 on CT or liver:spleen ratio <0.9 on CT or MRI. Fischer's exact test, Kruskal-Wallis test, and logistic regression were performed. RESULTS: Our study cohort included 109 patients who underwent pancreatectomy for nonmalignant intraductal papillary mucinous neoplasm with no evidence of NAFLD preoperatively and at least 6 months follow-up. Mean follow-up was 52 months (range 8-130/months). The incidence of postoperative NAFLD was 17/109 (15.6%). Most cases occurred within 12 months of pancreatectomy. On multivariate analysis, proximal pancreatectomy (pancreaticoduodenectomy) and development of atrophy of the pancreas remnant were significant risk factors for development of hepatic steatosis (p < 0.05). CONCLUSION: Patients undergoing pancreatectomy for benign disease have a significant risk of developing NAFLD but the frequency is lower than previously reported in cohorts that included individuals with malignant disease. Highest risk was observed in individuals who underwent pancreaticoduodenectomy or developed pancreatic atrophy. Further investigations to define the mechanisms that promote steatosis and interventions to prevent subsequent morbidity from NAFLD are warranted.

Hepatic Progression-free and Overall Survival After Regional Therapy to the Liver for Metastatic Melanoma.

OBJECTIVES: Regional therapy for metastatic melanoma to the liver represents an alternative to systemic therapy. Hepatic progression-free survival (HPFS), progression-free survival (PFS), and overall survival (OS) were evaluated. MATERIALS AND METHODS: A retrospective review of patients with liver metastases from cutaneous or uveal melanoma treated with yttrium-90 (Y90), chemoembolization (CE), or percutaneous hepatic perfusion (PHP) was conducted. RESULTS: Thirty patients (6 Y90, 10 PHP, 12 CE, 1 PHP then Y90, 1 CE then PHP) were included. Multivariate analysis showed improved HPFS for PHP versus Y90 (P=0.004), PHP versus CE (P=0.02) but not for CE versus Y90. PFS was also significantly different: Y90 (54 d), CE (52 d), PHP (245 d), P=0.03. PHP treatment and lower tumor burden were significant predictors of prolonged PFS on multivariate analysis. Median OS from time of treatment was longest, but not significant, for PHP at 608 days versus Y90 (295 d) and CE (265 d), P=0.24. Only PHP treatment versus Y90 and lower tumor burden had improved OS on multivariate analysis (P=0.03, 0.03, respectively). CONCLUSIONS: HPFS and PFS were significantly prolonged in patients treated with PHP versus CE or Y90. Median OS in PHP patients was over double that seen in Y90 or CE patients but was significant only between PHP and Y90.

Paratesticular Liposarcoma Masquerading as an Inguinal Hernia.

A man with left scrotal swelling felt to represent inguinal hernia underwent computed tomography scan for reported bleeding after prostate biopsy. Computed tomography scan revealed a 15-cm extratesticular left scrotal mass containing both fat and soft tissue components, raising concern for dedifferentiated liposarcoma. At surgery and pathology, the mass was separate from the left testis, epididymis, and spermatic cord. Histopathologic findings were consistent with paratesticular dedifferentiated liposarcoma.

Percutaneous hepatic perfusion with melphalan in uveal melanoma: A safe and effective treatment modality in an orphan disease.

BACKGROUND: Metastatic uveal melanoma (UM) carries a poor prognosis; liver is the most frequent and often solitary site of recurrence. Available systemic treatments have not improved outcomes. Melphalan percutaneous hepatic perfusion (M-PHP) allows selective intrahepatic delivery of high dose cytotoxic chemotherapy. METHODS: Retrospective analysis of outcomes data of UM patients receiving M-PHP at two institutions was performed. Tumor response and toxicity were evaluated using RECIST 1.1 and Common Terminology Criteria for Adverse Events (CTCAE) v4.03, respectively. RESULTS: A total of 51 patients received 134 M-PHP procedures (median of 2 M-PHPs). 25 (49%) achieved a partial (N = 22, 43.1%) or complete hepatic response (N = 3, 5.9%). In 17 (33.3%) additional patients, the disease stabilized for at least 3 months, for a hepatic disease control rate of 82.4%. After median follow-up of 367 days, median overall progression free (PFS) and hepatic progression free survival (hPFS) was 8.1 and 9.1 months, respectively and median overall survival was 15.3 months. There were no treatment related fatalities. Non-hematologic grade 3-4 events were seen in 19 (37.5%) patients and were mainly coagulopathic (N = 8) and cardiovascular (N = 9). CONCLUSIONS: M-PHP results in durable intrahepatic disease control and can form the basis for an integrated multimodality treatment approach in appropriately selected UM patients.

Magnetic Resonance Imaging of Neuroendocrine Tumor Hepatic Metastases: Does Hepatobiliary Phase Imaging Improve Lesion Conspicuity and Interobserver Agreement of Lesion Measurements?

OBJECTIVE: The aim of this study was to determine if magnetic resonance imaging (MRI) performed with hepatobiliary phase imaging results in higher lesion conspicuity and produces lesion measurements with higher interobserver agreement than other MRI sequences when imaging neuroendocrine hepatic metastases. METHODS: Patients who had MRIs with both gadoxetate disodium and gadopentetate dimeglumine contrast within a 6-month span were identified, and 23 hepatic lesions were selected. Three radiologists and 1 oncologist measured the greatest diameter of each lesion on the following sequences: T2 weighted, T1 weighted, postcontrast (dynamic, delayed, and hepatobiliary phase), and diffusion weighted. Signal intensity ratio (SIlesion/SIliver) and contrast-to-noise ratio ([SIlesion - SIliver]/noise) were calculated for all lesions on each sequence. The interobserver agreement of measurements on each sequence was calculated using concordance correlation coefficient. RESULTS: Diffusion-weighted sequences had the highest signal intensity ratio ranging from 147% to 187% (vs other sequences range of 19.6%-130%). One hepatobiliary sequence had the highest contrast-to-noise ratio with a value of 41 (vs other sequences range of 3.2-28.1). Lesion measurements on all sequences showed high-interobserver agreement, with hepatobiliary sequences showing some of the highest levels of agreement. CONCLUSIONS: Our results support the use of contrast agents with hepatobiliary excretion when imaging neuroendocrine tumors metastatic to liver.

Multimodal Imaging of Head and Neck Squamous Cell Carcinoma.

BACKGROUND: The role of imaging in the staging, treatment planning, and ongoing surveillance of patients with head and neck squamous cell carcinoma (HNSCC) continues to evolve. Changes in patient demographics, treatment paradigms, and technology present opportunities and challenges for the management of HNSCC. METHODS: The general indications and usage of standard and multimodal cross-sectional imaging in the evaluation and management of HNSCC are reviewed, with an emphasis on incorporating them into treatment pathways. Emerging imaging technologies and methods with a potential near-term impact on HNSCC are discussed. RESULTS: In general, the complex, multidisciplinary approach to the treatment of advanced HNSCC requires multimodal imaging for adequate treatment planning and follow up. Early-stage disease can often be managed with clinical and endoscopic examinations and a single, cross-sectional imaging modality (eg, computed tomography, magnetic resonance imaging). CONCLUSIONS: Although generalized treatment pathways and guidelines do exist, the literature is rapidly advancing and new radiotracers and evaluation methods are expected to alter both imaging and treatment recommendations in the years to come.

Symptoms, functioning and quality of life after treatment in a residential sub-acute mental health service in Australia.

The aim of this study was to assess clients' and service providers' perspectives on changes in mental health after an admission to a residential recovery-focused, sub-acute service, in Australia. Clients were either step-up clients, entering the service directly from the community, or step-down clients who were transitioning from an inpatient unit to home. During the 30-month period of data collection (August 2011 to January 2014) all clients (N = 102) were invited to participate in the longitudinal study and 41 clients consented to be involved (38% response rate). At admission and exit, participants completed the Behaviour and Symptom Identification Scale (Basis-32) and service providers completed the Life Skills Profile-16 and Health of the Nations Outcome Scales. Follow-up data 3 months after exit were available for 12 clients, including the Basis-32 and a self-report measure of quality of life (Assessment of Quality of Life 8-dimension). Both client groups reported positive improvements between admission and exit in the areas of relation to self and others, psychosis, daily living and presence of depression or anxiety symptoms. Service providers reported gains for clients in the areas of self-care, level of symptoms and presence of social problems. At 3 months, clients generally reported positive quality of life, although there was no significant change in symptoms and functioning. This study demonstrates that after an admission to a sub-acute service, step-up clients experience an improvement in their symptoms and functioning, have avoided a hospital admission and are well enough to return home. Step-down clients also experience further improvements in their symptoms and functioning, indicating that the service has assisted them in their transition to independent living after a hospital admission. Sub-acute residential units provide a continuation of care for inpatients preparing to return home, and people with a mental health problem living in the community who experience an escalation in symptoms and prefer an alternative to hospital.