Fall risk screening and balance rehabilitation in elderly: a missing healthcare intervention in Pakistani healthcare system.

Elderly are one of the fastest-growing population globally and require significant healthcare services due to age-related deterioration in physiological systems. Poor postural control due to aging results in impaired balance leading to increase in frequency of falls, poor quality of life, and rise in disability and mortality rates. In Pakistan, due to lack of awareness, and resources, fall prevention and screening programmes for the elderly are lacking. Regular fall risk screening utilizing balance assessment tools, integration of fall prevention programmes and balance rehabilitation approach as part of elderly healthcare services can serve as tools to lower the incidence of falls in the elderly population of Pakistan. Moreover, integration of latest technology as part of balance rehabilitation can also be considered. The review aims to highlight appropriate strategies for fall risk screening and balance rehabilitation in an effort to promote an important healthcare intervention for elderly in Pakistan.

Neurorehabilitation in time of COVID 19: A perspective from Pakistan.

A global public health emergency, the coronovirus disease-2019 pandemic has impacted every way of life, including neuro-rehabilitation, worldwide. Issues related to increased service demand in primary care, exhausted or insufficient healthcare facilities were significantly high in low and middle-income countries, like Pakistan, with already a struggling health infrastructure. This required major change in health service delivery and impacted rehabilitation care of vulnerable patients with neurological conditions and impairments. For the current review, relevant key words and their combinations were used for literature search, including 'COVID 19', 'SARS-CoV-2', 'Corona Virus', 'rehabilitation', 'physical rehabilitation', 'pandemic', 'NCOC', 'lockdown', 'health services', 'physical therapy', 'disability', 'access', 'tele-rehabilitation', 'research', 'human resource', 'healthcare', etc. The platforms searched were Google search, Google Scholar and PubMed. The idea was to highlight how the pandemic impacted neuro-rehabilitation care in countries like Pakistan throughout the pandemic duration and during the lockdowns.

Effects of high-intensity multi-modal exercise training (HIT-MMEX) on bone mineral density and muscle performance in postmenopausal women. A Pilot randomized controlled trial.

Objectives: To determine the effects of high-intensity multimodal exercise training on bone mineral density and muscle performance in postmenopausal women. METHODS: The two-armed, parallel, pilot randomised controlled trial was conducted from November 2020 to July 2021 at Riphah Rehabilitation Centre, Rawalpindi, Pakistan, and comprised women aged 45-70 having been in the post-menopause phase for at least 3 years, with body mass index <30, community ambulant and willing to have exercise therapy. The subjects were randomised into two equal groups. The experimental group A received supervised high-intensity resistance, weight-bearing, balance and mobility training twice weekly for 8 months. The control group B received low-to-moderate intensity exercises. Femoral neck and lumbar spine bone mineral density (g/cm2) were taken through a dual-energy X-ray absorptiometry scan. Muscle performance was measured using 1 repetition maximum for leg and trunk extensors, and 30 sec sit to stand test. Data was analysed using SPSS 21. RESULTS: Of the 101 women screened, 28(27.7%) were enrolled; 14(50%) in group A having mean age 53.36±6.28 years, and 14(50%) in group B having mean age 51.71±4.82 years (p>0.05). Group A showed significantly more improvement than group B both with respect to lumbar spine bone mineral density and muscle performance (p<0.05). CONCLUSIONS: Supervised high-intensity multimodal exercise training protocol had a positive effect on lumbar spine bone mineral density and muscle performance in postmenopausal women. Clinical Trial Number: NCT04653350, Link https://clinicaltrials.gov/ct2/show/NCT04653350.

Body composition profiling and obesity analysis of healthy adults: A cross-sectional study.

Obesity as depicted by changes in the body composition is considered a global epidemic of the 21st century, predisposing to cardiometabolic diseases. This analytical cross-sectional study evaluated body composition parameters in both genders and conducted an obesity analysis of healthy adult Pakistani population. Using non-probability purposive sampling technique, data was collected from 205 healthy adults (aged 18-45 years), who had not been participating in any structured exercise or dietary regime over the last six months. Body composition was assessed using bioelectrical impedance analyser. For data analysis, descriptive statistics, Mann-Whitney U-test and one-sample T-test were applied. The mean body mass index was 24.3±4.93 kg/m2. Body composition components which were significantly higher in males included soft lean mass, fat-free mass index, skeletal muscle mass index and bone mineral content, whereas females had significantly higher percentage of body fat (PBF), visceral fat area and fat mass index (p<0.05). For obesity analysis, the mean PBF (34.61±9.68%) of our sample was higher than White, Hispanics and European adults. Majority of healthy adults had greater body fat mass and lower skeletal muscle mass. The primary obesity index was significantly higher in Pakistani population compared to other ethnicities, with females exhibiting a higher trend towards obesity.

Effects of glucosamine and chondroitin sulfate supplementation in addition to resistance exercise training and manual therapy in patients with knee osteoarthritis: A randomized controlled trial.

OBJECTIVE: To determine the added benefits of short-term glucosamine and chondroitin sulfate supplementation in combination with manual therapy and resistance exercise training in the management of knee osteoarthritis. METHODS: A parallel-design, double-blind randomised controlled trial was conducted from January to September 2020 at the Foundation University Institute of Rehabilitation Sciences and Fauji Foundation Hospital, Rawalpindi, Pakistan, and comprised of knee osteoarthritis patients of either gender having radiological evidence of grade III or less on Kellgren classification. The subjects were randomly allocated to active comparator group A and experimental group B. Both the groups received manual therapy and resistance exercise training, while group B additionally received glucosamine and chondroitin sulfate supplementation for 4 weeks. Study outcomes included pain, function, quality of life, range of motion, strength, fall risk, skeletal muscle mass, visceral fat area, body fat, intracellular water ratio, and segmental lean and fat mass. Data was analysed using SPSS 21. RESULTS: Of the 24 subjects, there were 12(50%) in each of the two groups. Each groups had 9(75%) males and 3(25%) females. In terms knee osteoarthritis grade, there was no significant difference between the groups (p=1.00). No significant differences were observed in any of the outcome measures neither at 2 weeks, nor at 4 weeks post-intervention between the groups (p>0.05) except for percentage change in segmental lean mass of the right leg at 2nd week and of the left leg at 4th week (p<0.05). CONCLUSIONS: Manual therapy and resistance exercise training are effective in the management of knee osteoarthritis, however, glucosamine and chondroitin sulfate supplementation for 4 weeks showed no additional benefits. Clinical Trial Number: NCT04654871. https://www.clinicaltrials.gov/ct2/show/NCT04654871.

The UN Incheon strategy Implementation and the Pakistani quagmire; ground realities.

The Economic and Social Commission for Asia and the Pacific is the regional developmental arm of the United Nations. There are over 650 million persons with disabilities living in the region. In 2012, member countries, including Pakistan, launched the new decade of persons with disabilities from 2013 to 2022, adopting the Incheon Strategy to 'Make the Right Real', based on the Put Convention on the rights of Persons with Disabilities" and aimed at accelerating the disability inclusive development with 10 measurable goals and targets. The year 2017 marked the mid-point of that decade at which point member countries were to submit the Government Members Report on the Implementation of Incheon Strategy. The ambiguity in usage of terms, variable definition of disability, and use of impairment screens in population census of Pakistan has resulted in flawed data and underreporting of persons with disabilities. Pakistan provided data on only 13 of the 30 core indicators as part of its midpoint review. There is lack of awareness among ministries regarding the Incheon Strategy implementation.

Effects of structured exercise regime on lipid profile and renal function tests in gestational diabetes mellitus patients:A pilot study.

NOTE OF CONCERN: Article published in Journal of Pakistan Medical Association J Pak Med Assoc.February 2021, No. 2-A,Volume 72 Pages 505-507. This editorial expression of concern serves to notify readers that the Editorial Board has identified discernible weaknesses in the study design, statistical concerns and conclusion drawn regarding this previously published article, titled: "Effects of structured exercise regime on lipid profile and renal function tests in gestational diabetes mellitus patients-A pilot study" J Pak Med Assoc. Vol. 71, No. 2-A, February 2021pages 505-507. The Editorial Board has determined that : 1. The article did not discuss the feasibility of the pilot study, instead attempted to draw inference from the analytical outcomes, which does not allow readers to interpret the desired implications correctly. 2. The statistical methods applied were not at par and did not use the baseline data. The authors did not make full use of the data to add to the scientific weightage of the study, which could have been reported in the text. 3. The conclusion only points towards the positive impacts on serum markers for diabetes mellitus and renal functions. Considering the very small sample size used, this is an unjustified extrapolation. The authors did not attempt to mention the feasibility of the whole process, including participants' willingness, management, and resources that should have been assessed and reported to benefit the planning of the full-scale RCT. The editorial board of JPMA decided to publish this editorial expression of concern when we were made aware of deficiencies in the published article so that future researchers can plan their work on better scientific footings OBJECTIVE: To determine the effects of structured exercise regime on biochemical markers of patients of gestational diabetes mellitus during the third trimester. METHODS: The two-arm pilot study was conducted at the Fauji Foundation Hospital, Rawalpindi, Pakistan, from March to July 2019, and comprised women aged 20-40 years with gestational age >20 weeks who were diagnosed with gestational diabetes mellitus and who were able to do 6min walk test under severity level on the 0-10 Borg scale. The subjects were randomized into two groups using the sealed envelope method. The intervention group received 5 weeks of structured exercise programme. including aerobics, stabilisation and pelvic floor muscle training, while the control group only received postural education. Data was noted at baseline and after intervention, and was analysed using SPSS 20. RESULTS: Of the 16 subjects, there were 8(50%) in each of the two groups. The mean age was 31.5±4.17 years in the interventional group and it was 35.0±6.30 years in the control group. Serum low-density lipoprotein and serum creatinine showed significant differences between the groups (p<0.05), while the rest of markers were non-significant (p>0.05). CONCLUSIONS: Structured exercise regime was found to have a positive effect in reducing serum low-density lipoprotein and serum creatinine levels in gestational diabetes mellitus during the third trimester.

A Hospital based study on sudden sensorineural Hearing Loss: It's audiological characteristics and prevalence.

OBJECTIVES: To analyze the prevalence & characteristics of sudden sensorineural hearing loss. METHODS: This cross sectional study including n=377 cases of sensorineural hearing impairment, using non-probability convenience sampling, who fulfilled the selection criteria was conducted from 1st July 2019 to 31st October 2019. Study was conducted at Audiology section of ENT department, Lahore General Hospital, Pakistan. Sample included both genders, aged 17-70 years. Cases suffering from inflammatory or obstructive conditions of the external or middle ear and those who could not undergo pure tone audiometry were excluded from the study. Following consent for inclusion in study, data was collected using basic demographic and medical history sheet followed by Audiometric evaluation. Statistical Software for Social Sciences Version 20.0 was used for data analysis. RESULTS: The prevalence rate of sudden sensorineural hearing loss of 14(3.7%) being significantly more common in males 11(78%) than females 3(22%) (p=0.05) & age group 15-35 years (p=0.001). It is commonly of severe or profound degree with downward sloping audiogram (p<0.05), however it is not associated with vertigo (p=0.32), tinnitus (p=0.08) with no side predilection (p=0.27). CONCLUSION: We conclude that the prevalence of SSNHL is 3.7% being significantly more prevalent in males and those aged15-25 years. It is mostly characterized by severe to profound degree of hearing loss with downward sloping audiogram with no associated vertigo, tinnitus and side predilection.

Aphasia-Diagnostic Challenges and Trends: Speech-Language Pathologist's Perspective.

OBJECTIVES: To explore current aphasia assessment practices and barriers among Pakistani speech language pathologists. METHODS: Descriptive study design with qualitative parameters was used. Participants were identified using purposive sampling over a period of eight months from 1st December 2018 to 31st July 2019. Sample comprised of ten speech-language pathologists with least five years' experience of working with aphasic clients from four major cities of Pakistan including Islamabad, Karachi, Lahore and Peshawar. Study included in depth interviews using a self-structured interview guide with probe questions. Data recorded was transcribed and thematic analyses were drawn manually. RESULTS: Thematic analysis revealed that most Speech language pathologists rely heavily on informal assessment techniques. With no aphasia assessment tool available in Urdu language, no consensus as to the optimal evaluation strategy or tool for aphasia assessment was noted. However, need for such tool was highlighted by all participants. Hence, non-availability of standardized and culturally appropriate assessment tool in "Urdu" language turned out to be the major barrier in adopting formal assessment for aphasic clients, while time consumed in formal testing remained second most reported issue. CONCLUSION: There is a dire need of quick aphasia assessment tool in Urdu language with established psychometric properties and culturally appropriate norms.

Interprofessioal collaboration among Speech Language Pathologists and Nurses in Acute Care in Pakistan.

OBJECTIVE: To find out inter-professional collaboration among speech-language pathologists and nurses in acute care in Pakistan. METHODS: This was a cross sectional study which was conducted in all government and private hospitals of Islamabad and Rawalpindi having facility of ICUs after taking consent from authorities. The duration of study was six months from October 2018 to February 2019. A total number of 350 participants (200 nurses, 150 speech language pathologists) working in ICU of different private and government hospitals of Pakistan were included in the study. Standardized questionnaire of ": assessment of inter-professioal collaboration scale": (AITCS) was circulated to nurses and speech language pathologists (SLPS) working in ICU with its subscale's partnership, coordination, cooperation and shared decision making on a 5-point likert scale. Data was analyzed using SPSS version 21.Measure of mean was obtained by independent sample t-test. P- Value less than 0.05 was considered as significant. RESULTS: Statistical analysis showed measures of mean differences obtained by t-test revealed significant differences at p<0.001 level between partnership scores of SLPS and nurses. This reveals good partnership between two disciplines. Measures of mean differences obtained by t-test revealed significant differences at p<0.001 level between partnership scores of SLPS and nurses. Both do not value each other in cooperation. Measures of mean differences obtained by t-test showed significant differences at p<0.001 level amongst coordination scores of SLPS and nurses. Both have good coordination. Measures of mean differences obtained by t-test revealed significant differences at p<0.001 level amongst shared decision-making scores of SLPS and nurses. Both are involved in shared decision making. CONCLUSION: Results show significant difference in partnership, coordination, and shared decision making. There is no significant difference in cooperation.

Prevalence and associated risk factors among patients with overactive bladder syndrome in Pakistan.

OBJECTIVES: To determine the Prevalence and associated risk factors among patients with overactive bladder syndrome in Pakistan. METHODS: This was a community-based, face to face, cross sectional survey to calculate the prevalence and its associated risk factors. A sample of 1058 patients, women and men aged between 35 to 60 years having symptoms of overactive bladder was selected through convenience sampling from different cities of Pakistan during September to December 2020. Data was collected by using an Overactive Bladder Scoring System (OABSS) tool for prevalence and a developed questionnaire to rule out the risk factors. RESULTS: The prevalence was 27.4% (n=289) and it increased with age. The average ages for women and men were 44.60±7.88 and 46.14±7.69 years respectively. The OAB prevalence was the lowest among the participants aged 35-43 years 15.2% (n=55) while it was highest among those who were aged 53-60 years 49.6%, (n=127). The age, body mass index, diabetes mellitus, income, family history, parity and urinary tract infection were found to be significant associated risk factors for overactive bladder with p value <0.05. CONCLUSION: The overall prevalence of overactive bladder was 27.4% and it does not differ by gender, hypertension, pelvic surgery, smoking, constipation and sleep while it has significant association with age, body mass index, diabetes mellitus, income, parity and urinary tract infections.

Diffusion model comparison identifies distinct tumor sub-regions and tracks treatment response.

PURPOSE: MRI biomarkers of tumor response to treatment are typically obtained from parameters derived from a model applied to pre-treatment and post-treatment data. However, as tumors are spatially and temporally heterogeneous, different models may be necessary in different tumor regions, and model suitability may change over time. This work evaluates how the suitability of two diffusion-weighted (DW) MRI models varies spatially within tumors at the voxel level and in response to radiotherapy, potentially allowing inference of qualitatively different tumor microenvironments. METHODS: DW-MRI data were acquired in CT26 subcutaneous allografts before and after radiotherapy. Restricted and time-independent diffusion models were compared, with regions well-described by the former hypothesized to reflect cellular tissue, and those well-described by the latter expected to reflect necrosis or oedema. Technical and biological validation of the percentage of tissue described by the restricted diffusion microstructural model (termed %MM) was performed through simulations and histological comparison. RESULTS: Spatial and radiotherapy-related variation in model suitability was observed. %MM decreased from a mean of 64% at baseline to 44% 6 days post-radiotherapy in the treated group. %MM correlated negatively with the percentage of necrosis from histology, but overestimated it due to noise. Within MM regions, microstructural parameters were sensitive to radiotherapy-induced changes. CONCLUSIONS: There is spatial and radiotherapy-related variation in different models' suitability for describing diffusion in tumor tissue, suggesting the presence of different and changing tumor sub-regions. The biological and technical validation of the proposed %MM cancer imaging biomarker suggests it correlates with, but overestimates, the percentage of necrosis.

The effects of traditional massage on spasticity of children with cerebral palsy: a randomized controlled trial.

OBJECTIVE: To examine the effects of traditional massage on spasticity of children with cerebral palsy. METHODS: The randomised control trial was conducted at the National Institute of Rehabilitation Medicine, Islamabad, Pakistan, from September 2016 to August 2018, and comprised children with spastic cerebral palsy aged 2-10 years who were randomly allocated to control and intervention groups. Both the groups received routine physical therapy once daily, five times a week for three months. The intervention group additionally received traditional massage. Spasticity was evaluated using the Modified Ashworth Scale at baseline, and after 6th and 12th weeks of intervention. Data analysed using SPSS 20.. RESULTS: Of the 86 subjects enrolled, 75(87.2%) completed the study; 37(49.3%) in the control group with a mean age of 6.81±2.31 years, and 38(50.6%) in the intervention group with a mean age of 7.05±2.47 years. There were 25(68%) boys among the controls and 22(58%) in the intervention group. There was no statistically significant difference in baseline scores between the groups (p>0.05). At 6th week, reduction in scores was statistically significant in the right upper limb (p<0.05), and in the right lower limb (p<0.05) after the 12th week. CONCLUSIONS: Traditional massage was found to have significant effect on the right side compared to the routine physical therapy for reduction of spasticity in children with cerebral palsy.

Effects of structured exercise regime on Glycosylated Hemoglobin and C reactive protein in patients with Gestational Diabetes Mellitus - A randomized controlled trial.

OBJECTIVES: To evaluate the effects of structured exercise regime on Glycosylated hemoglobin and C reactive protein in patients with gestational diabetes mellitus. METHODS: This two arm parallel randomized controlled trial was conducted at Fauji Foundation Hospital, Rawalpindi from November 2018 till December 2019 on the 54 diagnosed gestational diabetes mellitus patients (Dropped out=4 Analyzed= 50) with age 20 to 40 years and gestational age from 20 to 36 weeks. Selection was done via convenient sampling technique and randomized into two groups (n=25) by sealed envelope method. Structured exercise regime group received combination of moderate intensity aerobics, stabilization and pelvic floor muscles exercises twice a week for 5 weeks (40 min per session) along with dietary and medical interventions while control group received only medical and dietary interventions with postural education. Demographics, glycosylated hemoglobin and C reactive protein were recorded at baseline then after 5 weeks of intervention. Analysis was done by SPSS 20. RESULTS: Mean age was 35.92 ± 5.24 years in control group while 34.36 ± 5.21 years in interventional group. Between group analysis for HbA1c showed no significant difference at base line (p >0.05) but showed significant difference (p <0.05) after five weeks' interventions. Similarly, for C reactive protein both groups showed no significant difference (p >0.05) at baseline but after five weeks of interventions showed significant difference (p<0.05). CONCLUSION: Structured exercise regime helps in reducing values of glycosylated hemoglobin and C reactive protein in patients with gestational diabetes mellitus.

Common balance measures and fall risk scores among older adults in Pakistan: Normative values and correlation.

The objective of this study was to assess the balance and fall risk among the community dwelling healthy older adults in Pakistan and to determine the correlation between balance measures and fall risk, for which a crosssectional correlation study was conducted at Foundation University Islamabad and Fauji Foundation Hospital from March 2016 to February 2017. A total of 77 individuals over 50 years were included via convenience sampling. I n di vi d u al s w i t h he a r i ng /v is ua l an d c o gn it ive impairments, infections, and orthopaedic and severe comorbid conditions were excluded. Data collection tools included Berg Balance Scale (BBS), Timed Up and Go (TUG) test, Functional Reach Test (FRT) and Fall Risk Score (FRS). Independent t-test and Bivariate Pearson Correlation (CI=95%, P<0.05) were used for analysis. Mean value of the BBS, FRS, TUG and FRT was 41.36±2.96, 3.40±1.47, 15.90±2.68 and 13.34±3.45 respectively. Age had a significant (p<0.05) positive correlation with FRS and negative correlation with BBS. A significant correlation (P<0.05) was found only between FRT & TUG and TUG & BBS.

Psychological Stress and Satisfaction with Life among Physical Therapy Students of Rawalpindi / Islamabad, Pakistan.

OBJECTIVE: To determine the occurrence of perceived stress and satisfaction with life as well as the association between the two among under graduate physical therapy students. METHODS: The cross-sectional study was conducted from January to July 2015 at Riphah International University, Isra University and Foundation University, Islamabad, Pakistan, and comprised Doctor of Physical Therapy students aged 17-23 years. Perceived Stress Scale and Satisfaction with Life Scale were used as tools to measure the outcomes. Data was analysed using S P SS 2 0.. RESULTS: Of the 306 students approached, 279(91%) responded. There were 39(14%) males and 240(86%) females with an overall mean age of 19.18±0.92 years. Mean stress and satisfaction with life scores were 21.35±5.76 and 24.49±5.77. Significant negative co-relation between the two scores was observed (p=0.001). There was no significant association of age with satisfaction with life (p=0.591) and perceived stress (p=0.283). A significant gender-based difference was observed in terms of perceived stress (p=0.037) and satisfaction with life ( (p=0.008), with females scoring higher. CONCLUSIONS: Male students were more satisfied with life compared to female students, and satisfaction with life decreased with an increase in stress.

Potential effects of traditional massage on spasticity and gross motor function in children with spastic cerebral palsy: A randomized controlled trial.

OBJECTIVE: To evaluate the effects of traditional massage (TM) on spasticity and gross motor function in children with cerebral palsy (CP). METHODS: This randomized control trial (RCT) was conducted with recruitment of 86 children (Dropped out= 11; Analyzed= 75) with spastic CP (diplegia) allocated randomly through sealed envelope method to intervention and control group with ages between 2-10 years from September 2016 to August 2018. Both groups received conventional physical therapy (CPT) once daily, five times a week for a period of three months. However, intervention group received TM additionally. Modified Ashworth Scale (MAS), Gross Motor Function Measure (GMFM-88) and Gross Motor Function Classification System (GMFCS) were used to evaluate spasticity and gross motor function at the beginning, after six and 12 weeks of intervention. Data were compared and analyzed through SPSS-20. RESULTS: Mean age in control and intervention group was 6.81±2.31 and 7.05±2.47 years respectively. No statistically significant differences in MAS, GMFM and GMFCS scores were found at base line. The children in intervention group showed statistically significant reduction in MAS scores in all four limbs after six and 12 weeks of intervention (p < 0.05) in comparison with the control group. However, GMFM scores and GMFCS levels did not change significantly in intervention group as compared to control group. CONCLUSION: It is concluded that TM can effectively reduce the spasticity, does not have harmful effects, so can be administered safely by mothers at home and making it suitable for the management of spastic CP. However, in order to achieve better gross motor function, it should be practiced in conjunction with CPT, functional skills and task oriented approaches.

Multi-level barriers & priorities accorded by policy makers for Neonatal Hearing Screening (NHS) in Pakistan: A thematic analysis.

OBJECTIVES: To explore the Barriers and Priorities accorded to neo-natal hearing screening at government health policy level. METHODS: This exploratory descriptive study design employed qualitative parameters with purposive sampling and was conducted at Capital Administration & Development Division (CADD) and Ministry of National Health Services, Regulations & Coordination (MoNHSR&C) from June 2015 to January 2017 over a period of 18 months. Sample included stakeholders concerned with healthcare planning and policy making in Pakistan. Research included in depth interviews using a self-structured interview guide from three policy makers' fulfilling the selection criteria. Data recorded was transcribed and thematic analyses drawn manually and verified using two separate coders. RESULTS: Outcomes from thematic analysis drawn were Planning, Funding, Governance, Awareness, Medical and technical capacity building, Policy development, Evaluation and Sustainability. Lack of financial resources allocation due to policies and legislation top the list of barriers. The lack of research and reliable data as to the number of persons suffering from hearing loss (HL) from birth and its economic cost to the state and individual remains a policy barrier. CONCLUSION: The barriers to NHS are lack of financial resource allocation by the federal government, and lack of research and reliable statistics about Hearing Impairment (HI) and its economic cost.

Data-driven mapping of hypoxia-related tumor heterogeneity using DCE-MRI and OE-MRI.

PURPOSE: Previous work has shown that combining dynamic contrast-enhanced (DCE)-MRI and oxygen-enhanced (OE)-MRI binary enhancement maps can identify tumor hypoxia. The current work proposes a novel, data-driven method for mapping tissue oxygenation and perfusion heterogeneity, based on clustering DCE/OE-MRI data. METHODS: DCE-MRI and OE-MRI were performed on nine U87 (glioblastoma) and seven Calu6 (non-small cell lung cancer) murine xenograft tumors. Area under the curve and principal component analysis features were calculated and clustered separately using Gaussian mixture modelling. Evaluation metrics were calculated to determine the optimum feature set and cluster number. Outputs were quantitatively compared with a previous non data-driven approach. RESULTS: The optimum method located six robustly identifiable clusters in the data, yielding tumor region maps with spatially contiguous regions in a rim-core structure, suggesting a biological basis. Mean within-cluster enhancement curves showed physiologically distinct, intuitive kinetics of enhancement. Regions of DCE/OE-MRI enhancement mismatch were located, and voxel categorization agreed well with the previous non data-driven approach (Cohen's kappa = 0.61, proportional agreement = 0.75). CONCLUSION: The proposed method locates similar regions to the previous published method of binarization of DCE/OE-MRI enhancement, but renders a finer segmentation of intra-tumoral oxygenation and perfusion. This could aid in understanding the tumor microenvironment and its heterogeneity. Magn Reson Med 79:2236-2245, 2018. © 2017 The Authors Magnetic Resonance in Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.