Treatment of rectosigmoid endometriosis by laparoscopic reverse submucosal dissection (LRSD): The Sydney partial thickness discoid excision technique.

BACKGROUND: Laparoscopic reverse submucosal dissection (LRSD) is a standardised surgical technique for removal of rectosigmoid endometriosis which optimises the anatomical dissection plane for excision of endometriotic nodules. AIM: This cohort study assesses the outcomes of the first cohort of women treated by LRSD, for deeply infiltrating rectosigmoid endometriosis. MATERIALS AND METHODS: Primary outcomes assessed were complication rate as defined by the Clavien-Dindo system, and completion of the planned LRSD. Secondary outcomes include mucosal breach, specimen margin involvement, length of hospital admission, and a comparison of pre-operative and post-operative pain, bowel function and quality of life surveys. These included the Endometriosis Health Profile Questionnaire (EHP-30), the Knowles-Eccersley-Scott Symptom Questionnaire (KESS) and the Wexner scale. RESULTS: Of 19 patients treated, one required a segmental resection. The median length of hospital admission was two days (range 1-5) and no post-operative complications occurred. Median pain visual analogue scales (scale 0-10) were higher prior to surgery (dysmenorrhoea 9.0, dyspareunia 7.5, dyschezia 9.0, pelvic pain 6.0) compared to post-surgical median scores (dysmenorrhoea 5.0, dyspareunia 4.0, dyschezia 2.0, pelvic pain 4.0) at a median of six months (range 4-32). Quality of life studies suggested improvement following surgery with pre-operative median EHP-30 and KESS scores (EHP-30: 85 (5-106), KESS score 9 (0-20)) higher than post-operative scores (EHP-30: 48.5 (0-80), KESS score: 3 (0-19)). CONCLUSION: This series highlights the feasibility of LRSD with low associated morbidity as a progression of partial thickness discoid excision (rectal shaving) for the treatment of rectosigmoid deep infiltrating endometriosis.

Active site serine-193 modulates activity of human aromatic amino acid decarboxylase.

Aromatic amino acid decarboxylase is a pyridoxal 5'-phosphate-dependent enzyme responsible for the synthesis of the neurotransmitters, dopamine and serotonin. Here, by a combination of bioinformatic predictions and analyses, phosphorylation assays, spectroscopic investigations and activity measurements, we determined that Ser-193, a conserved residue located at the active site, can be phosphorylated, increasing catalytic efficiency. In order to determine the molecular basis for this functional improvement, we determined the structural and kinetic properties of the site-directed variants S193A, S193D and S193E. While S193A retains 27% of the catalytic efficiency of wild-type, the two acidic side chain variants are impaired in catalysis with efficiencies of about 0.15% with respect to the wild-type. Thus, even if located at the active site, Ser-193 is not essential for enzyme activity. We advance the idea that this residue is fundamental for the correct architecture of the active site in terms of network of interactions triggering catalysis. This role has been compared with the properties of the Ser-194 of the highly homologous enzyme histidine decarboxylase whose catalytic loop is visible in the spatial structure, allowing us to propose the validation for the effect of the phosphorylation. The effect could be interesting for AADC deficiency, a rare monogenic disease, whose broad clinical phenotype could be also related to post translational AADC modifications.

Veterans' Experiences of Support in Managing Comorbid Sleep Apnea and Type 2 Diabetes.

BACKGROUND: Obstructive sleep apnea (OSA) is highly prevalent in patients with Type 2 diabetes, more so in veterans compared with nonveterans. Positive airway pressure is the recommended first-line treatment for OSA. However, adherence to both positive airway pressure and diabetes management regimens can be challenging for older adults. Support from family or friends may improve glucose control or sleep-apnea-related symptoms, yet the evidence is limited when both conditions coexist. OBJECTIVES: This study aimed to describe veterans' experiences of support from family and friends with managing comorbid sleep apnea and Type 2 diabetes. METHODS: We conducted a postal survey of older veterans with OSA and Type 2 diabetes from one healthcare system. Questions include demographic and health-related information, information about sleep apnea and diabetes treatment and education received, related support from family or a friend, perceived benefits of regular positive airway pressure device use on improving sleep health, and perceived benefits of education for family or a friend on sleep apnea and diabetes. Descriptive and bivariate analyses were performed. RESULTS: Of 145 respondents (mean age = 72 years), 43% reported receiving help for Type 2 diabetes from family or a friend. Almost two thirds of the respondents were currently using a positive airway pressure device, of whom 27% received support with device use from family or friends. About one third of veterans perceived family and friends receiving education on treating sleep apnea and diabetes to be very or extremely helpful. Such perceived benefit was higher among those who were married or identified as non-White. Veterans using a positive airway pressure device had lower hemoglobin A1c levels than nonusers. DISCUSSION: Veterans perceived that additional education for the individuals providing support would be beneficial. Future studies could address interventions to increase sleep apnea and Type 2 diabetes knowledge among families and friends of veterans with these comorbid conditions. In addition, patients' adherence to positive airway pressure may be enhanced by support from family and friends.

Superior Hypogastric Plexus Nerve Block in Minimally Invasive Gynecology: A Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the efficacy of a superior hypogastric plexus nerve block in reducing opioid requirements in the first 24 hours after minimally invasive gynecologic surgery. DESIGN: Patient-blinded randomized controlled trial. SETTING: Single-center academic institution (Sydney Women's Endosurgery Centre). Two surgeons administering the blocks in their own surgeries. PATIENTS: Patients undergoing either laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy for benign indications. INTERVENTIONS: Ropivacaine 10 mL (0.75%) infiltrated into the retroperitoneal space overlying the superior hypogastric plexus vs control of no block given at the completion of surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the total opioid use in the first 24 hours after surgery, measured in morphine milligram equivalents (MME). Standardized fentanyl patient-controlled analgesia was given to all patients in the trial. The secondary outcome was pain measured on a visual analog scale (1 to 10) at 1, 2, 6, 12, and 24 hours after surgery. Fifty patients out of 56 approached for the study participated in, and completed, the study (89.2%). The patients were randomized over a 5-month period, March 2020 to July 2020. A total of 27 patients were randomized to receive a nerve block, and 23 were randomized to the control. There was a difference of -21.8 MME in the block group compared with the no-block group (95% confidence interval [CI], -38.2 to -5.5; p = .008). This correlated to a 38% reduction in opioid use in the block group. The mean opioid use in the patients in the block group was 33.1 MME (95% CI, 24.2-41.9) and in those in the no-block group 54.9 MME (95% CI, 40.7-69.1). For the block group, opioid use ranged from 1.0 to 76.5 MME, with an interquartile range of 37 (14-51). For the control group, the range was 7.5 to 113.5 MME, with a higher interquartile range of 60 (28-88). Pairwise comparisons of the mean pain scores over the 24 hours showed a lower pain score with a nerve block of 1.8 (95% CI, 1.5-2.1) compared with a no-block score of 2.6 (95% CI, 2.3-2.9) No adverse effects of local anesthetic toxicity, nerve injury, or bowel/vascular injury were noted in any patient. CONCLUSION: A superior hypogastric plexus nerve block is a simple technique for reducing postoperative opioid requirements and pain in the first 24 hours after minimally invasive gynecologic surgery.

A Description of the Imaging Innovations for Placental Assessment in Response to Environmental Pollution Study.

OBJECTIVE: The aim of Placental Assessment in Response to Environmental Pollution Study (PARENTs) was to determine whether imaging of the placenta by novel multiparametric magnetic resonance imaging (MRI) techniques in early pregnancy could help predict adverse pregnancy outcomes (APOs) due to ischemic placental disease (IPD). Additionally, we sought to determine maternal characteristics and environmental risk factors that contribute to IPD and secondary APOs. STUDY DESIGN: Potential patients in their first trimester of pregnancy, who agreed to MRI of the placenta and measures of assessment of environmental pollution, were recruited into PARENTs, a prospective population-based cohort study. Participants were seen at three study visits during pregnancy and again at their delivery from 2015 to 2019. We collected data from interviews, chart abstractions, and imaging. Maternal biospecimens (serum, plasma, and urine) at antepartum study visits and delivery specimens (placenta, cord, and maternal blood) were collected, processed, and stored. The primary outcome was a composite of IPD, which included any of the following: placental abruption, hypertensive disease of pregnancy, fetal growth restriction, or a newborn of small for gestational age. RESULTS: In this pilot cohort, of the 190 patients who completed pregnancy to viable delivery, 50 (26%) developed IPD. Among demographic characteristics, having a history of prior IPD in multiparous women was associated with the development of IPD. In the multiple novel perfusion measurements taken of the in vivo placenta using MRI, decreased high placental blood flow (mL/100 g/min) in early pregnancy (between 14 and 16 weeks) was found to be significantly associated with the later development of IPD. CONCLUSION: Successful recruitment of the PARENTs prospective cohort demonstrated the feasibility and acceptability of the use of MRI in human pregnancy to study the placenta in vivo and at the same time collect environmental exposure data. Analysis is ongoing and we hope these methods will assist researchers in the design of prospective imaging studies of pregnancy. KEY POINTS: · MRI was acceptable and feasible for the study of the human placenta in vivo.. · Functional imaging of the placenta by MRI showed a significant decrease in high placental blood flow.. · Measures of environmental exposures are further being analyzed to predict IPD..

Rectal Shaving for Bowel Endometriosis by Laparoscopic Reverse Submucosal Dissection for Easier, Safer and More Complete Excision of Disease.

STUDY OBJECTIVE: To demonstratefull-thickness excision of the affected muscularis along the submucosal plane. DESIGN: Stepwise demonstration of LRSD technique with narrated video footage. SETTING: LRSD takes advantage of the submucosal layer of the bowel wall and uses it as an easier line of excision for rectal endometriosis compared with the very difficult traditional line of excision of irregular disease-muscularis interface. The expansion of the submucosal layer by the injection separates the affected muscularis away from the mucosa, making it safer to excise the lesion with less chance of entering the bowel lumen. Excision of disease is more complete with LRSD because the full-thickness excision of the muscularis layer includes the healthy deep muscularis, which will form the disease-free deep excision margin. INTERVENTION: This video will highlight anatomic and technical aspects of LRSD including the following key steps: 1. Mobilization of diseased bowel segment 2. Submucosal injection 3. Circumferential incision of the muscularis 4. Submucosal dissection along the submucosal plane 5. Bowel wall integrity test 6. Muscularis defect repair CONCLUSION: Rectal shaving by LRSD appears to be easier, safer, and more complete in excision of bowel endometriosis than the classical rectal shaving technique. This modification requires further evaluation to confirm its potential in the surgical management of rectosigmoid deep infiltrative endometriosis.

Extra-articular tibial deformity management in total knee replacement.

BACKGROUND: Presence of an extra-articular deformity in the femur or tibia poses a challenge to the surgeon undertaking knee replacement procedure. The conundrum is whether to correct the deformity beforehand, or accept the deformity and compensate for this through placement of the implant. MATERIAL AND METHODS: This is a retro-spective study comprising six patients who had a knee replacement in the presence of an extra-articular deformity of the tibia treated at our centre. All six had the knee replacement without correction of deformity. The data evaluated included clinical outcome, mechanical axis correction, type of implant, and the use of any software / computer guidance.The deformity was managed through planning of tibial resection without the need for pre-operative deformity correction. RESULTS: Mean age was 66.5 years. Mean coronal plane deformity in the tibia was 8.6 degrees. The hip- knee-ankle improved from a mean 12.6 degrees to 4 degrees. Mean Oxford knee score improved from a mean of 19 to 33.6. CONCLUSION: Planning the tibial resection on the basis of mechanical axis of tibia allows correction of alignment without the need for preoperative correction.Correction of the deformity may not be needed if the maximum tibial resection is less than 15 mm.

The management of the hospitalized ulcerative colitis patient: the medical-surgical conundrum.

PURPOSE OF REVIEW: In this review article, we address emerging evidence for the medical and surgical treatment of the hospitalized patient with ulcerative colitis. RECENT FINDINGS: Ulcerative colitis is a chronic inflammatory disease involving the colon and rectum. About one-fifth of patients will be hospitalized from ulcerative colitis, and about 20-30%, experiencing an acute flare will undergo colectomy. Because of the significant clinical consequences, patients hospitalized need prompt evaluation for potential complications, stratification of disease severity, and a multidisciplinary team approach to therapy, which involves both the gastroenterologist and surgeon. Although corticosteroids remain first-line therapy, second-line medical rescue options, primarily infliximab or cyclosporine, are considered within 3-5 days of presentation. In conjunction, an early surgical consultation to present the possibility of a staged proctocolectomy as one of the therapeutic options is equally important. SUMMARY: A coordinated multidisciplinary, individualized approach to treatment, involving the patient preferences throughout the process, is optimal in providing patient-centered effective care.

Transvaginal Ultrasound Can Accurately Predict the American Society of Reproductive Medicine Stage of Endometriosis Assigned at Laparoscopy.

STUDY OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal ultrasound in predicting a laparoscopic, surgically assigned, revised American Society of Reproductive Medicine (ASRM) endometriosis stage. DESIGN: A multicenter, retrospective, diagnostic accuracy study. SETTING: The patients visited 1 of 2 academic gynecologic ultrasound units and underwent laparoscopy led by 1 of 6 surgeons in metropolitan Sydney, Australia, between 2016 and 2018. PATIENTS: Patients with suspected endometriosis (n = 204). INTERVENTIONS: Ultrasound followed by laparoscopy. MEASUREMENTS AND MAIN RESULTS: Surgical cases were identified. The preoperative ultrasound report and surgical operative notes were each used to retrospectively assign an ASRM score and stage. The breakdown of surgical findings was as follows: ASRM 0 (i.e., no endometriosis), 24/204 (11.8%); ASRM 1, 110/204 (53.9%); ASRM 2, 22/204 (10.8%); ASRM 3, 16/204 (7.8%); ASRM 4, 32 204 (15.7%). The overall accuracy of ultrasound in predicting the surgical ASRM stage was as follows: ASRM 1, 53.4%; ASRM 2, 93.8%; ASRM 3, 89.7%; ASRM 4, 93.1%; grouped ASRM 0, 1, and 2, 94.6%; and grouped ASRM 3 and 4 of 94.6%. Ultrasound had better test performance in higher disease stages. When the ASRM stages were dichotomized, ultrasound had sensitivity and specificity of 94.9% and 93.8%, respectively, for ASRM 0, 1, and 2 and of 93.8% and 94.9%, respectively, for ASRM 3 and 4. CONCLUSION: Ultrasound has high accuracy in predicting the mild, moderate, and severe ASRM stages of endometriosis and can accurately differentiate between stages when ASRM stages are dichotomized (nil/minimal/mild vs moderate/severe). This can have major positive implications on patient triaging at centers of excellence in minimally invasive gynecology for advanced-stage endometriosis.

Shaving for Bowel Endometriosis.

STUDY OBJECTIVE: To demonstrate laparoscopic shaving of deeply infiltrative endometriosis affecting the rectosigmoid colon, with particular emphasis on the anatomic and technical aspects of the procedure. DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: Intestinal involvement in deep endometriosis is estimated to occur in 8% to 12% of patients, with 90% of occurrences being located in the colorectal segment. Deep endometriosis of the rectosigmoid is defined as endometriosis involving the muscular layer of the bowel wall, usually >5 mm deep, thus excluding superficial lesions that only affect the serosal layer. In cases in which medical therapy is unsatisfactory, rectosigmoid deep endometriosis can be surgically managed by 3 recognized surgical techniques: (1) rectal shaving, (2) disc excision, and (3) segmental resection. There are helpful recommendations for different approaches on the basis of the characteristics of the lesion, including the size, length, depth of invasion, involved rectal circumference, and number of lesions, among other factors [1]. Rectal shaving is well suited for smaller lesions, typically <3 cm, and involves "shaving" the lesion in the affected muscular layer of the bowel wall off the mucosa, ideally without entering the bowel lumen. It is associated with lower rates of perioperative complications and lower probability of long-term postoperative bladder and bowel dysfunctions [2]. INTERVENTIONS: This video demonstrates and highlights the anatomic and technical aspects of the following important steps of the rectal shaving procedure: (1) suspension of ovaries; (2) mobilization of the diseased segment of the rectum; (3) shaving of the lesions, with pertinent comments at different stages of nodule excision; (4) checking for the integrity of the bowel wall; and (5) suture of the muscularis defect after excision of the lesions from the muscularis layer of the bowel. CONCLUSION: Compared with other alternatives, shaving for bowel endometriosis is a more conservative procedure with lower rates of perioperative complications, and it is less likely to result in long-term bladder and bowel dysfunctions. Therefore, shaving is preferable and recommended for appropriate lesions.

Cytogenomic array detects a subset of myelodysplastic syndrome with increased risk that is invisible to conventional karyotype.

Conventional karyotyping is essential standard practice in the initial evaluation of myelodysplastic syndrome (MDS) and is the most impactful single component of the Revised International Prognostic Scoring System (IPSS-R). While single nucleotide polymorphism array (SNP-A) has demonstrated the ability to detect chromosomal defects with greater sensitivity than conventional karyotype, widespread adoption is limited by the unknown additional prognostic impact of SNP-A analysis. Here, we investigate the significance of additional SNP-A abnormalities in the setting of MDS and demonstrate differences in survival of patients with additional abnormalities, even those initially characterized as relatively lower risk either by cytogenetic score or IPSS-R. Our findings identify specific abnormalities, particularly KMT2A partial tandem duplication, that are invisible to conventional karyotype and potentially contribute to the poor prognosis of MDS patients. Furthermore, these results demonstrate the added value of SNP-A analysis in identifying patients who may benefit from more aggressive therapy, particularly those who would otherwise be classified into lower risk categories.

Diagnostic Accuracy and Reproducibility of Predicting Cul-de-Sac Obliteration by General Gynaecologists and Minimally Invasive Gynaecologic Surgeons.

OBJECTIVE: Knowledge of rectouterine cul-de-sac state and consistent classification among surgeons are important in the surgical management of women with endometriosis. The objective of this study was to determine the diagnostic accuracy and interobserver and intraobserver agreement among general gynaecologists (GGs) and minimally invasive gynaecologic surgeons (MIGSs) in the prediction of cul-de-sac obliteration at off-line analysis of laparoscopic videos. METHODS: Five GGs and five MIGSs viewed 33 prerecorded laparoscopic video sets off-line to determine cul-de-sac obliteration state (non-obliterated, partially obliterated, or completely obliterated) on two occasions (at least 7days apart). Diagnostic accuracy and interobserver and intraobserver agreement were evaluated. RESULTS: The interobserver agreements for all 10 observers for the description of cul-de-sac state ranged from fair to substantial agreement, with moderate overall agreement. MIGSs had slightly higher within-group interobserver agreement compared with GGs. MIGSs achieved overall almost perfect intraobserver agreement compared with substantial agreement for GGs. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for MIGSs classifying the cul-de-sac state were 83.9%, 88.5%, 88.5%, 89.2%, 92.0%, and 84.7%, respectively, whereas for GGs, they were 79.1%, 79.4%, 88.1%, 89.9%, and 76.1%, respectively. CONCLUSION: Diagnostic accuracy and interobserver and intraobserver agreement for cul-de-sac obliteration state classification is acceptable in both groups. MIGSs had greater diagnostic accuracy and exhibited high interobserver and intraobserver agreement, a finding suggesting that their advanced training makes them more reliable in cul-de-sac obliteration assessment. Partial cul-de-sac obliteration was the most commonly incorrectly diagnosed state, thus implying that partial obliteration is not well understood.

Heart Failure Self-care Associated With Brain Injury in Executive Control Regions.

BACKGROUND: Inadequate self-care is linked to poor health outcomes in heart failure (HF). Self-care depends on decision-making abilities, but links between self-care and brain injury to executive decision-making regulatory areas (prefrontal cortices) are unclear. OBJECTIVE: We investigated the relationships between HF self-care and status of prefrontal cortices. METHODS: Magnetic resonance imaging-based diffusion tensor imaging was performed in 21 patients with HF (age, 53.8 ± 7.9 years; 15 men; left ventricular ejection fraction, 25.1% ± 6.1%), and self-care and executive function were measured with the Self-care of Heart Failure Index (SCHFI) and Trail Making Test B. Using diffusion tensor imaging data, mean diffusivity (MD) maps were calculated and region-of-interest analyses were performed on the left and right prefrontal brain areas. Statistical analyses consisted of partial correlations (covariates, age, and gender). RESULTS: The mean ± SD SCHFI scores were 70.78 ± 11.37 for maintenance, 70 ± 17.32 for management, and 74.91 ± 15.76 for confidence. The mean ± SD Trail Making Test B score was 90.2 ± 73.3 seconds. The mean ± SD MD values (higher values indicate tissue injury) of the left and right prefrontal cortices were 1.46 ± 0.16 (×10 mm/s) and 1.44 ± 0.14 (×10 mm/s), respectively. Significant negative correlations emerged between prefrontal MD values and SCHFI maintenance (left/right, r = -0.64/-0.70; P < .003) and SCHFI management (r = -0.93/-0.86; P < .003). Significant positive correlations were observed between prefrontal MD values and Trail Making Test B (r = 0.71/0.74; P < .001). A nonsignificant correlation emerged between prefrontal MD values and SCHFI confidence scores. CONCLUSIONS: Brain tissue integrity in executive function regulatory regions is associated with HF self-care for maintenance and management. The findings indicate that protection and brain injury repair in executive control areas may improve HF self-care.

Utilization of the 21-Gene Recurrence Score in a Diverse Breast Cancer Patient Population: Development of a Clinicopathologic Model to Predict High-Risk Scores and Response to Neoadjuvant Chemotherapy.

INTRODUCTION: The 21-gene expression profile [Oncotype DX Recurrence Score (RS)] stratifies benefit from adjuvant chemotherapy in hormone receptor (HR)-positive, HER2/neu-negative, node-negative breast cancer. It is not routinely applied to predict neoadjuvant chemotherapy (NACT) response; data in diverse patient populations also are limited. We developed a statistical model based on standard clinicopathologic features to identify high-risk cases (RS > 30) and then evaluated ability of predicted high RS to predict for NACT downstaging. METHODS: Primary surgery patients with Oncotype DX RS testing 2012-2016 were identified from a prospectively-maintained database. A RS predictive model was created and applied to a dataset of comparable NACT patients. Response was defined as tumor size decrease ≥ 1 cm. RESULTS: Of 394 primary surgery patients-60.4% white American; 31.0% African American-RS distribution was similar for both groups. No single feature reliably identified high RS patients; however, a model accounting for age, HR expression, proliferative index (MIB1/Ki67), histology, and tumor size was generated, with receiver operator area under the curve 0.909. Fifty-six NACT patients were identified (25 African American). Of 21 cases with all relevant clinicopathology, 14 responded to NACT and the model generated high-risk RS in 14 (100%); conversely, of 16 cases generating high-risk RS, only 2 did not respond. CONCLUSIONS: Predictive modelling can identify high RS patients; this model also can identify patients likely to experience primary tumor downstaging with NACT. Until this model is validated in other datasets, we recommend that Oncotype-eligible patients undergo primary surgery with decisions regarding chemotherapy made in the adjuvant setting.

Asphyxia-activated corticocardiac signaling accelerates onset of cardiac arrest.

The mechanism by which the healthy heart and brain die rapidly in the absence of oxygen is not well understood. We performed continuous electrocardiography and electroencephalography in rats undergoing experimental asphyxia and analyzed cortical release of core neurotransmitters, changes in brain and heart electrical activity, and brain-heart connectivity. Asphyxia stimulates a robust and sustained increase of functional and effective cortical connectivity, an immediate increase in cortical release of a large set of neurotransmitters, and a delayed activation of corticocardiac functional and effective connectivity that persists until the onset of ventricular fibrillation. Blocking the brain's autonomic outflow significantly delayed terminal ventricular fibrillation and lengthened the duration of detectable cortical activities despite the continued absence of oxygen. These results demonstrate that asphyxia activates a brainstorm, which accelerates premature death of the heart and the brain.

Diagnostically relevant updates to the 2017 WHO classification of lymphoid neoplasms.

The recent 2017 WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues contains a number of updates under the category of lymphoid neoplasms. These changes include introduction of new entities, amended classification or terminology, and addition of newly discovered diagnostic and molecular features. In this review, we perform a focused, concise summary of selected lymphoid neoplasms and discuss changes in their classification. Rather than a comprehensive overview, we place specific emphasis on important and diagnostically relevant aspects of each entity that are novel or different from the previous WHO iteration and bring the practicing pathologist quickly up to speed with the updated classification.

Characterizing Beliefs about Stroke and Walking for Exercise among Seniors from Four Racial/Ethnic Minority Communities.

We described and compared seniors' stroke-related health beliefs among four racial/ethnic communities to inform a culturally-tailored stroke prevention walking intervention. Specific attention was paid to how seniors combined pathophysiology-based biomedical beliefs with non-biomedical beliefs. We conducted twelve language-concordant, structured focus groups with African American, Chinese American, Korean American, and Latino seniors aged 60 years and older with a history of hypertension (n = 132) to assess stroke-related health beliefs. Participants were asked their beliefs about stroke mechanism and prevention strategies in addition to questions corresponding to four constructs from the Health Belief Model: perceived susceptibility, perceived severity, and benefits and barriers to walking for exercise. Using thematic analysis, we iteratively reviewed and coded focus group transcripts to identify recurrent themes within and between racial/ethnic groups. Participants across all four racial/ethnic groups believed that blockages in brain arteries caused strokes. Factors believed to increase susceptibility to stroke were often similar to biomedical risk factors across racial/ethnic groups, but participants also endorsed non-biomedical factors such as strong emotions. The majority of participants perceived stroke as a serious condition requiring urgent medical attention, fearing paralysis or death, but few mentioned severe disability as a stroke consequence. Participants largely believed stroke to be preventable through physical activity, dietary changes, and medication adherence. Perceived benefits of walking for exercise included improved physical health, decreased bodily pain, and ease of participation. Perceived barriers to walking included limited mobility due to chronic medical conditions, increased bodily pain, and low motivation. While seniors' stroke-related health beliefs were often similar to biomedical beliefs across racial/ethnic groups, we also identified several non-biomedical beliefs that were shared across groups. These non-biomedical beliefs regarding perceived stroke susceptibility and severity may warrant further discussion in stroke education interventions. Patterns in non-biomedical beliefs that vary between groups may reflect cultural differences. Stroke education could potentially increase cultural relevancy and impact by addressing such differences in health beliefs as well as perceived benefits and barriers to walking for exercise that vary between different racial/ethnic groups.

Study protocol of "Worth the Walk": a randomized controlled trial of a stroke risk reduction walking intervention among racial/ethnic minority older adults with hypertension in community senior centers.

BACKGROUND: Stroke disproportionately kills and disables ethnic minority seniors. Up to 30 % of ischemic strokes in the U.S. can be attributed to physical inactivity, yet most Americans, especially older racial/ethnic minorities, fail to participate in regular physical activity. We are conducting a randomized controlled trial (RCT) to test a culturally-tailored community-based walking intervention designed to reduce stroke risk by increasing physical activity among African American, Latino, Chinese, and Korean seniors with hypertension. We hypothesize that the intervention will yield meaningful changes in seniors' walking levels and stroke risk with feasibility to sustain and scale up across the aging services network. METHODS/DESIGN: In this randomized single-blind wait-list control study, high-risk ethnic minority seniors are enrolled at senior centers, complete baseline data collection, and are randomly assigned to receive the intervention "Worth the Walk" immediately (N = 120, intervention group) or in 90 days upon completion of follow-up data collection (N = 120, control group). Trained case managers employed by the senior centers implement hour-long intervention sessions twice weekly for four consecutive weeks to the intervention group. Research staff blinded to participants' group assignment collect outcome data from both intervention and wait-list control participants 1 and 3-months after baseline data collection. Primary outcome measures are mean steps/day over 7 days, stroke knowledge, and self-efficacy for reducing stroke risk. Secondary and exploratory outcome measures include selected biological markers of health, healthcare seeking, and health-related quality of life. Outcomes will be compared between the two groups using standard analytic methods for randomized trials. We will conduct a formal process evaluation to assess barriers and facilitators to successful integration of Worth the Walk into the aging services network and to calculate estimated costs to sustain and scale up the intervention. Data collection is scheduled to be completed in December 2016. DISCUSSION: If this RCT demonstrates superior improvements in physical activity and stroke knowledge in the intervention group compared to the control group and is found to be sustainable and scalable, Worth the Walk could serve as a primary stroke prevention model for racial/ethnic communities across the nation. TRIAL REGISTRATION: ClinicalTrials.gov NCT02181062 ; registered on June 30, 2014.