A Systematic Review of the Impact of Placement Instability on Emotional and Behavioural Outcomes Among Children in Foster Care.

Foster care children are a highly vulnerable population and their experiences in care are considered crucial to their developmental and psychosocial wellbeing. Placement instability has been considered a possible risk factor for developmental difficulties due to its impact on the development of a reparative attachment relationship and sense of relational permanence. The current review synthesises the literature regarding the impact of placement instability on behavioural and mental health outcomes in foster care children. Three major databases and grey literature sources were searched for all relevant quantitative research published by July 2019. Titles and abstracts of 2419 articles were screened following searches, with full texts obtained for 51 studies and 14 included in the final review. All were subject to quality assessment by two independent reviewers. Results indicated that placement instability was a consistent predictor of externalising behaviour in children, although some evidence was counter-indicative in this regard. There was also evidence to suggest a relationship with internalising behaviours, and mental health difficulties, in particular PTSD symptoms. Methodological quality and design varied between studies which limited direct comparisons. Most notably, there was a lack of consensus on how to quantify and measure placement instability and many studies failed to control for potentially confounding care-related variables. The review highlights that instability seems to result in negative psychological outcomes, although the extent of this relationship remains unclear. The review's findings are discussed with reference to research and clinical implications.

Machine Learning and CT Texture Features in Ex-smokers with no CT Evidence of Emphysema and Mildly Abnormal Diffusing Capacity.

RATIONALE AND OBJECTIVES: Ex-smokers without spirometry or CT evidence of chronic obstructive pulmonary disease (COPD) but with mildly abnormal diffusing capacity of the lungs for carbon monoxide (DLCO) are at higher risk of developing COPD. It remains difficult to make clinical management decisions for such ex-smokers without other objective assessments consistent with COPD. Hence, our objective was to develop a machine-learning and CT texture-analysis pipeline to dichotomize ex-smokers with normal and abnormal DLCO (DLCO≥75%pred and DLCO<75%pred). MATERIALS AND METHODS: In this retrospective study, 71 ex-smokers (50-85yrs) without COPD underwent spirometry, plethysmography, thoracic CT, and 3He MRI to generate ventilation defect percent (VDP) and apparent diffusion coefficients (ADC). PyRadiomics was utilized to extract 496 CT texture-features; Boruta and principal component analysis were used for feature selection and various models were investigated for classification. Machine-learning classifiers were evaluated using area under the receiver operator characteristic curve (AUC), sensitivity, specificity, and F1-measure. RESULTS: Of 71 ex-smokers without COPD, 29 with mildly abnormal DLCO had significantly different MRI ADC (p < .001), residual-volume to total-lung-capacity ratio (p = .003), St. George's Respiratory Questionnaire (p = .029), and six-minute-walk distance (6MWD) (p < .001), but similar relative area of the lung < -950 Hounsfield-units (RA950) (p = .9) compared to 42 ex-smokers with normal DLCO. Logistic-regression machine-learning mixed-model trained on selected texture-features achieved the best classification accuracy of 87%. All clinical and imaging measurements were outperformed by high-high-pass filter high-gray-level-run-emphasis texture-feature (AUC=0.81), which correlated with DLCO (ρ = -0.29, p = .02), MRI ADC (ρ = 0.23, p = .048), and 6MWD (ρ = -0.25, p = .02). CONCLUSION: In ex-smokers with no CT evidence of emphysema, machine-learning models exclusively trained on CT texture-features accurately classified ex-smokers with abnormal diffusing capacity, outperforming conventional quantitative CT measurements.

Chest MRI and CT Predictors of 10-Year All-Cause Mortality in COPD.

Pulmonary imaging measurements using magnetic resonance imaging (MRI) and computed tomography (CT) have the potential to deepen our understanding of chronic obstructive pulmonary disease (COPD) by measuring airway and parenchymal pathologic information that cannot be provided by spirometry. Currently, MRI and CT measurements are not included in mortality risk predictions, diagnosis, or COPD staging. We evaluated baseline pulmonary function, MRI and CT measurements alongside imaging texture-features to predict 10-year all-cause mortality in ex-smokers with (n = 93; 31 females; 70 ± 9years) and without (n = 69; 29 females, 69 ± 9years) COPD. CT airway and vessel measurements, helium-3 (3He) MRI ventilation defect percent (VDP) and apparent diffusion coefficients (ADC) were quantified. MRI and CT texture-features were extracted using PyRadiomics (version2.2.0). Associations between 10-year all-cause mortality and all clinical and imaging measurements were evaluated using multivariable regression model odds-ratios. Machine-learning predictive models for 10-year all-cause mortality were evaluated using area-under-receiver-operator-characteristic-curve (AUC), sensitivity and specificity analyses. DLCO (%pred) (HR = 0.955, 95%CI: 0.934-0.976, p < 0.001), MRI ADC (HR = 1.843, 95%CI: 1.260-2.871, p < 0.001), and CT informational-measure-of-correlation (HR = 3.546, 95% CI: 1.660-7.573, p = 0.001) were the strongest predictors of 10-year mortality. A machine-learning model trained on clinical, imaging, and imaging textures was the best predictive model (AUC = 0.82, sensitivity = 83%, specificity = 84%) and outperformed the solely clinical model (AUC = 0.76, sensitivity = 77%, specificity = 79%). In ex-smokers, regardless of COPD status, addition of CT and MR imaging texture measurements to clinical models provided unique prognostic information of mortality risk that can allow for better clinical management.Clinical Trial Registration: www.clinicaltrials.gov NCT02279329.

Reduced Total Airway Count and Airway Wall Tapering after Three-Years in Ex-Smokers.

Computed tomography (CT) total-airway-count (TAC) and airway wall-thickness differ across chronic obstructive pulmonary disease (COPD) severities, but longitudinal insights are lacking. The aim of this study was to evaluate longitudinal CT airway measurements over three-years in ex-smokers. In this prospective convenience sample study, ex-smokers with (n = 50; 13 female; age = 70 ± 9 years; pack-years = 43 ± 26) and without (n = 40; 17 female; age = 69 ± 10 years; pack-years = 31 ± 17) COPD completed CT, 3He magnetic resonance imaging (MRI), and pulmonary function tests at baseline and three-year follow-up. CT TAC, airway wall-area (WA), lumen-area (LA), and wall-area percent (WA%) were generated. Emphysema was quantified as the relative-area-of-the-lung with attenuation < -950 Hounsfield-units (RA950). MRI ventilation-defect-percent (VDP) was also quantified. Differences over time were evaluated using paired-samples t tests. Multivariable prediction models using the backwards approach were generated. After three-years, forced-expiratory-volume in 1-second (FEV1) was not different in ex-smokers with (p = 0.4) and without (p = 0.5) COPD, whereas RA950 was (p < 0.001, p = 0.02, respectively). In ex-smokers without COPD, there was no change in TAC (p = 0.2); however, LA (p = 0.009) and WA% (p = 0.01) were significantly different. In ex-smokers with COPD, TAC (p < 0.001), WA (p = 0.04), LA (p < 0.001), and WA% (p < 0.001) were significantly different. In all ex-smokers, TAC was related to VDP (baseline: ρ = -0.30, p = 0.005; follow-up: ρ = -0.33, p = 0.002). In significant multivariable models, baseline airway wall-thickness was predictive of TAC worsening. After three-years, in the absence of FEV1 worsening, TAC diminished only in ex-smokers with COPD and airway walls were thinner in all ex-smokers. These longitudinal findings suggest that the evaluation of CT airway remodeling may be a useful clinical tool for predicting disease progression and managing COPD.Clinical trial registration: www.clinicaltrials.gov NCT02279329.

Undersampled Diffusion-Weighted 129Xe MRI Morphometry of Airspace Enlargement: Feasibility in Chronic Obstructive Pulmonary Disease.

Multi-b diffusion-weighted hyperpolarized gas MRI measures pulmonary airspace enlargement using apparent diffusion coefficients (ADC) and mean linear intercepts (Lm). Rapid single-breath acquisitions may facilitate clinical translation, and, hence, we aimed to develop single-breath three-dimensional multi-b diffusion-weighted 129Xe MRI using k-space undersampling. We evaluated multi-b (0, 12, 20, 30 s/cm2) diffusion-weighted 129Xe ADC/morphometry estimates using a fully sampled and retrospectively undersampled k-space with two acceleration-factors (AF = 2 and 3) in never-smokers and ex-smokers with chronic obstructive pulmonary disease (COPD) or alpha-one anti-trypsin deficiency (AATD). For the three sampling cases, mean ADC/Lm values were not significantly different (all p > 0.5); ADC/Lm values were significantly different for the COPD subgroup (0.08 cm2s-1/580 µm, AF = 3; all p < 0.001) as compared to never-smokers (0.05 cm2s-1/300 µm, AF = 3). For never-smokers, mean differences of 7%/7% and 10%/7% were observed between fully sampled and retrospectively undersampled (AF = 2/AF = 3) ADC and Lm values, respectively. For the COPD subgroup, mean differences of 3%/4% and 11%/10% were observed between fully sampled and retrospectively undersampled (AF = 2/AF = 3) ADC and Lm, respectively. There was no relationship between acceleration factor with ADC or Lm (p = 0.9); voxel-wise ADC/Lm measured using AF = 2 and AF = 3 were significantly and strongly related to fully-sampled values (all p < 0.0001). Multi-b diffusion-weighted 129Xe MRI is feasible using two different acceleration methods to measure pulmonary airspace enlargement using Lm and ADC in COPD participants and never-smokers.

'Nobody taught her how to be a mother': The lived experience of mothering without a mother.

Maternal grandmothers play a vital role in the transition to motherhood for their own daughters. The current study adds to this literature by investigating the lived experience of motherhood for women who lacked a meaningful relationship with their mothers. Ten mothers of children under 2 years of age participated in a semi-structured interview to explore their lived experiences of being a mother. Women were recruited from two parent-infant services in Northern Ireland. The interviews were analyzed using Interpretive Phenomenological Analysis (IPA). Three superordinate themes were identified: 'The Birth of a Mother', 'Mourning and Loss' and 'Ghosts in the Nursery'. The first theme captured the significant change of identity women experienced during their transition to motherhood. This identity change shed new light on their own experience of being mothered. The second theme captured the mourning and loss these women felt due to their relationship with their mother. Their lack of meaningful maternal relationships have left a hole impossible to fill. The final theme spoke to the intergenerational element of these mother's experience and their desire to break a cycle of maternal deprivation. The rich content from the interviews highlights the need for services to be aware of this struggle of motherhood.

Las abuelas maternas juegan un papel vital en la transición a la maternidad para sus propias hijas. El presente estudio contribuye a este campo de conocimientos escritos por medio de investigar la experiencia de maternidad vividas por mujeres a quienes les hace falta una significativa relación con sus madres. Diez madres de niños menores de dos años de edad participaron en una entrevista semiestructurada para explorar sus vividas experiencias de ser madre. A las mujeres se les reclutó de dos servicios progenitor-infante en Irlanda del Norte. Se analizaron las entrevistas usando el Análisis Fenomenológico Interpretativo (IPA). Se identificaron tres temas de nivel superior: 'El Nacimiento de una Madre,' 'Lamento y Pérdida' y 'Fantasmas en el Cuarto de la Niña.' El primer tema captó el significativo cambio de identidad que las mujeres experimentan durante su transición a la maternidad. El cambio de identidad arrojó una nueva luz en sus propias experiencias de ser criadas por una madre. El segundo tema captó la lamentación y la pérdida que estas mujeres sentían debido a su relación con sus madres. La falta de significativas relaciones maternas ha dejado un vacío imposible de llenar. El tema final tuvo que ver que el elemento intergeneracional de la experiencia de estas madres y su deseo de romper un ciclo de privación materna. El rico contenido de las entrevistas enfatiza la necesidad de servicios para estar conscientes de esta lucha sobre la maternidad.

Les grands-mères maternelles jouent un rôle vital dans la transition à la maternité de leurs propres filles. Cette étude s'ajoute aux recherches précédentes en enquêtant sur l'expérience vécue de la maternité pour les femmes n'ayant pas eu une relation importante avec leurs mères. Dix mères d'enfant de moins de deux ans ont participé à un entretien semi structuré afin d'explorer leurs expériences vécues du fait d'être maman. Ces femmes ont été recrutées dans deux services parent-bébé en Irlande du Nord. Ces entretiens ont été analysés en utilisant l'Analyse Interprétive Phénoménologique (en anglais Interpretive Phenomenological Analysis, soit IPA). Trois thèmes supérieurs ont été identifiés: 'La Naissance d'une Mère', "Deuil et Perte' et 'Fantômes dans la Chambre d'enfant'. Le premier thème a capture le changement d'identité important que les femmes ont vécu durant leurs transitions à la maternité. Ce changement d'identité a apporté un éclairage nouveau sur leur propre expérience d'avoir été maternées. Le second thème a capturé le deuil et la perte que ces femmes ont ressentis du fait de leur lien à leur mère. Leur manque de relations maternelles importantes a laissé un trou impossible à remplir. Le dernier thème fait référence à l'élément intergénérationnel de l'expérience de ces mères et leur désir de casser un cycle de privation maternelle. Ce contenu riche émanant des entretiens met en lumière la prise de connaissance nécessaire de ces difficultés de la maternité dont doivent faire preuve les services.

Bereaved mothers' experience of expressing and donating breast milk: An interpretative phenomenological study.

Perinatal loss is a devastating event for any mother. What is often overlooked is a mothers continued ability to lactate following the death of her child. Donor breast milk is a commodity highly sought after given its value for feeding sick babies resident in Neonatal Intensive Care Units. This study aimed to explore the lived experience of mothers who have expressed and donated their breast milk following the loss of their infant. Seven bereaved mothers who donated milk to the Human Milk Bank in Northern Ireland were recruited. These women took part in semistructured interviews, which explored their experiences of perinatal loss and the role that expression/donation played for them in their grief. Their accounts were analysed using a qualitative interpretative phenomenological analysis (IPA) method. After transcription and analysis, three superordinate themes emerged; (1) fulfilling the mother role; (2) the power of being able to 'Do'; (3) making good from the bad. The stories of these women reflect the independent and individual nature of grief. Each mother gained a great deal of comfort in having the ability to express milk. For some this created a physical connection to their child, for others, it created time alone to process what had happened and for all, it created a sense of autonomy and ownership in what was otherwise a very turbulent time in their lives.

Evaluation of the effects of three designs of oxygenators with integrated filters on clinical and haematological outcomes at an Australasian cardiothoracic unit.

INTRODUCTION: Cardiopulmonary bypass (CPB) machines have oxygenators with integrated filters and unique biocompatible coatings to combat systemic inflammatory response syndrome (SIRS) and mitigate coagulopathy. Contemporary oxygenators have undergone comparative studies; however, our study aimed to identify the most appropriate oxygenator for our regional Cardiothoracic unit in Australasia. METHODS: A prospective audit consecutively recruited one-hundred and fifty patients undergoing cardiac surgery at Waikato Hospital, New Zealand between the periods of 29th January 2018 and 31st July 2018. Fifty patients were recruited for each oxygenator arm: Sorin INSPIRE' (Group-S); Terumo CAPIOX'FX (Group-T); and Medtronic Affinity Fusion' (Group-M). The clinical outcomes were transfusions, chest drain output, reoperation and length of hospital stay (LOHS). Routine blood testing protocol included: haemoglobin, protein, albumin, white cell count (WCC), C-reactive protein (CRP), platelet count and coagulations tests including international normalized ratio (INR). RESULTS: Comparing Groups S, T and M there was no statistical difference in chest drain output (650 vs. 500 vs. 595 ml respectively, p = 0.45), transfusions (61 vs. 117 vs. 70 units, p = 0.67), reoperation (6 vs. 8 vs. 12%, p = 0.99) and LOHS (median 7.4 vs. 7.6 vs. 9.5 days, p = 0.42). Group-T had fewer SIRS cases but similar increase in CRP (p = 0.12) and WCC (p = 0.35). Group-M had a significant rise in post-op INR (p = 0.005) but no associated increase in chest drain output (p = 0.62). Group-S and -M required more 4%-albumin and Group-T had more transfusions. Only fresh frozen plasma (FFP) and red blood cell (RBC) transfusion had a significant relationship with LOHS (p < 0.05). CONCLUSION: Biochemically, there was slight difference among the oxygenators which did not translate into clinical difference in outcomes. The oxygenator design and perfusionist choice aided in our decision-making process.

Early diagnosis of surgically curable lung cancer is commonly serendipitous.

AIMS: Lung cancer is the largest cause of cancer death in New Zealand, accounting for 18.3% of cancer-related deaths.[[1,2]] There is limited literature on how patients with lung cancer clinically present in New Zealand. The aim of this cohort study was to identify the rate of incidentally diagnosed lung cancer in the Midland Region, the common symptomatology and route of diagnosis. METHODS: This retrospective cohort study included patients with lung cancer who underwent potentially curative thoracic surgery between January 2011 to June 2018 at Waikato Hospital, New Zealand. Symptoms or signs recorded were cough, dyspnoea, haemoptysis, lymphadenopathy, chest pain, hoarseness, fatigue, weight loss and finger clubbing. The lung cancer cases were grouped into incidental finding, symptomatic general practitioner, symptomatic emergency department and surveillance. RESULTS: Three hundred and ten patients with lung cancer had thoracic surgery with curative intent at Waikato Hospital. Two hundred and fourteen (69%) patients had symptoms which prompted presentation to a treating physician and 96 (31%) patients were asymptomatic. Incidental diagnosis was demonstrated in 121 (39.4%) patients. Of the patients diagnosed incidentally, 36.4% (n=44) had symptoms of lung cancer with the main symptoms including 45% with cough (n=20), 28% with dyspnoea (n=12) and 28% chest pain (n=12). CONCLUSIONS: In New Zealand, a large amount of lung cancer is still diagnosed incidentally with symptoms of cough, dyspnoea and chest pain. Further research into the development of a lung cancer screening program in New Zealand for a high-risk population is warranted.

Can We Better Differentiate Type A Dissections: Evaluating the Role of Aortic Ratios.

OBJECTIVES: Type A aortic dissection (ATAAD) is hypothesised as a progression of aneurysmal dilation, but 60% of patients in the International Registry of Acute Aortic Dissection (iRAD) registry had a maximum aortic diameter (MAD)<55 mm. We aim to demonstrate that size ratios and aortic wall stress, assessed using a simplified markers, are unique to aortic patients who have had adverse events (ATAAD) compared to those who have not (thoracic aortic aneurysm [TAA]). METHODS: A retrospective cohort analysis of patients who underwent aortic intervention at Waikato Hospital, New Zealand between 2015-2020, comparing dissection (ATAAD) to TAA patients. MAD; ratio of MAD to standardised-points within the aorta; and MAD-to-height collected from computed tomography (CT)-scans of all patients was undertaken. Receiver operating characteristic (ROC)-analysis to determine cut-off point for each marker was undertaken together with multivariable logistic regression comparing both cohorts, cross-validated by propensity-score matched analysis. RESULTS: Cohort of 215 patients, 78 (36.3%) ATAAD and 137 (63.7%) TAA; median age at intervention 63.3 years, 52 (24.2%) females, both cohorts matched for size. Using the entire cohort, the MAD: sinus of Valsalva (SoV) ratio>1.06 (cut-off value) had 4.5-times greater association with ATAAD (95%CI 1.46-13.8) and a 0.1-unit increased conferred 1.45-times greater association with ATAAD (95%CI 1.00-2.08). MAD>55 mm only seen in 33.3% of ATAAD (n=26/78), and not associated with ATAAD (OR 1.88, 95%CI 0.64-5.51). Compared to MAD, MAD:SoV ratio had greater sensitivity (33% vs 73%), lower number-needed-to-treat (17.9 vs 2.7) and superior discrimination (area under the curve [AUC] 0.54 vs 0.71). Findings were consistent with propensity score matched analysis. CONCLUSIONS: MAD:SoV ratio significantly correlates with ATAAD (4.5 times), with superior sensitivity, discrimination, and attributable-risk-percentage compared to MAD alone.

Pulmonary MRI and Cluster Analysis Help Identify Novel Asthma Phenotypes.

BACKGROUND: Outside eosinophilia, current clinical asthma phenotypes do not show strong relationships with disease pathogenesis or treatment responses. While chest x-ray computed tomography (CT) phenotypes have previously been explored, functional MRI measurements provide complementary phenotypic information. PURPOSE: To derive novel data-driven asthma phenotypic clusters using functional MRI airway biomarkers that better describe airway pathologies in patients. STUDY TYPE: Retrospective. POPULATION: A total of 45 patients with asthma who underwent post-bronchodilator 129 Xe MRI, volume-matched CT, spirometry and plethysmography within a 90-minute visit. FIELD STRENGTH/SEQUENCE: Three-dimensional gradient-recalled echo 129 Xe ventilation sequence at 3 T. ASSESSMENT: We measured MRI ventilation defect percent (VDP), CT airway wall-area percent (WA%), wall-thickness (WT, WT* [*normalized for age/sex/height]), lumen-area (LA), lumen-diameter (D, D*) and total airway count (TAC). Univariate relationships were utilized to select variables for k-means cluster analysis and phenotypic subgroup generation. Spirometry and plethysmography measurements were compared across imaging-based clusters. STATISTICAL TESTS: Spearman correlation (ρ), one-way analysis of variance (ANOVA) or Kruskal-Wallis tests with post hoc Bonferroni correction for multiple comparisons, significance level 0.05. RESULTS: Based on limited common variance (Kaiser-Meyer-Olkin-measure = 0.44), four unique clusters were generated using MRI VDP, TAC, WT* and D* (52 ± 14 years, 27 female). Imaging measurements were significantly different across clusters as was the forced expiratory volume in 1-second (FEV1 %pred ), residual volume/total lung capacity and airways resistance. Asthma-control (P = 0.9), quality-of-life scores (P = 0.7) and the proportions of severe-asthma (P = 0.4) were not significantly different. Cluster1 (n = 15/8 female) reflected mildly abnormal CT airway measurements and FEV1 with moderately abnormal VDP. Cluster2 (n = 12/12 female) reflected moderately abnormal TAC, WT and FEV1 . In Cluster3 and Cluster4 (n = 14/6 female, n = 4/1 female, respectively), there was severely reduced TAC, D and FEV1 , but Cluster4 also had significantly worse, severely abnormal VDP (7 ± 5% vs. 41 ± 12%). DATA CONCLUSION: We generated four proof-of-concept MRI-derived clusters of asthma with distinct structure-function pathologies. Cluster analysis of asthma using 129 Xe MRI in combination with CT biomarkers is feasible and may challenge currently used paradigms for asthma phenotyping and treatment decisions. EVIDENCE LEVEL: 3 TECHNICAL EFFICACY: Stage.

Exploring Adjustment and Parent-Infant Relations in Mothers of Premature Infants: Thematic Analysis Using a Multisensory Approach.

OBJECTIVE: The aim of the study was to explore mothers' experiences of having an infant born prematurely (28-32 weeks gestation). In particular, the study aimed to explore the developing parent-infant relationship 12-30 months since birth and the developing parental identity during hospitalization and discharge. METHODS: Twelve mothers, aged between 22 and 43, participated in the semi-structured interviews. The mean age of infants was 19 months. Interviews comprised open-ended questions and visual stimuli consisting of photographs brought by participants, word selection, and card sorting techniques. Data were analyzed using Braun and Clarke's thematic analysis (Braun & Clarke, 2013). RESULTS: Three themes arose from a clustering of 10 subthemes: (a) Emotional Impact, (b) Searching for Parent Identity, and (c) Moving Beyond Adversity. Participants expressed experiencing heightened emotional distress during the time of their infants' birth and hospitalization and initially not feeling like parents. Their parental identity strengthened as they became more involved in the care of their infant and began to accept the situation. Participants described parenting their premature infants differently compared with parents of full-term infants, and described adjusting to this difference over time. CONCLUSIONS: The findings highlight the emotional experience and adjustment of mothers of premature infants, from hospital and postdischarge. The need for psycho-educational interventions postdischarge and parent-partnered models during hospitalization is discussed. In addition, the study demonstrates the use of integrating visual stimuli in qualitative data collection procedures, to elicit further meaning and interaction from participants with the interview process.

Rapid On-site Evaluation (ROSE) in Capillary Pull Versus Suction Biopsy Technique With Endobronchial Ultrasound-transbronchial Needle Aspiration (EBUS-TBNA).

BACKGROUND: Suction and capillary pull are 2 biopsy techniques used in endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). Although these techniques have been shown to perform comparably in terms of overall diagnostic yield, we hypothesized that the capillary pull technique would be associated with improved rapid on-site evaluation (ROSE) adequacy rates thus allowing for a shorter procedure time. METHODS: One hundred eighteen patients undergoing EBUS-TBNA for any indication were randomized to suction or capillary pull techniques for the first biopsy pass; the technique used for all subsequent passes was based on operator preference and was not recorded. The first pass was subjected to ROSE and an adequacy assessment was given. ROSE slides were also scored for cellularity of diagnostic/lesional cells and blood contamination. The overall procedure time was also recorded. RESULTS: There were no significant differences between suction and capillary pull techniques in terms of ROSE adequacy rates. Cellularity of diagnostic/lesional cells and blood contamination scores were also comparable. There was no significant difference in procedure time for the 2 techniques. CONCLUSION: This study suggests no differences in ROSE outcomes between suction and capillary pull techniques in EBUS-TBNA. The technique used should therefore be left to the discretion of the operator.

Bronchial thermoplasty guided by hyperpolarised gas magnetic resonance imaging in adults with severe asthma: a 1-year pilot randomised trial.

Patient-specific localisation of ventilation defects using hyperpolarised gas magnetic resonance imaging (MRI) introduces the possibility of regionally targeted bronchial thermoplasty (BT) for the treatment of severe asthma. We aimed to demonstrate that BT guided by MRI to ventilation defects reduces the number of radiofrequency activations while resulting in improved asthma quality-of-life and control scores that are non-inferior to standard BT. In a 1-year pilot randomised controlled trial, 14 patients with severe asthma who were clinically eligible to receive BT underwent hyperpolarised gas MRI to characterise ventilation defects and were randomised to MRI-guided or standard BT. End-points were improved Asthma Quality of Life Questionnaire (AQLQ) and Asthma Control Questionnaire (ACQ) scores, the proportion of AQLQ and ACQ responders and the number of radiofrequency activations and bronchoscopy sessions. Participants who underwent MRI-guided BT received 53% fewer radiofrequency activations than those who had standard BT (p=0.003). At 12 months, the mean improvement from baseline was similar between the MRI-guided group (n=5) and the standard group (n=7) for AQLQ score (MRI-guided: 1.8, 95% CI 0.1-3.5, p=0.04; standard: 0.7, 95% CI -0.9-2.3, p=0.30) (p=0.25) and ACQ-5 score (MRI-guided: -1.4, 95% CI -2.6- -0.2, p=0.03; standard: -0.7, 95% CI -1.3-0.0, p=0.04) (p=0.17). A similar proportion of participants in both groups achieved a clinically relevant improvement in AQLQ score (MRI-guided: 80%; standard: 71%) and ACQ-5 score (MRI-guided: 80%; standard: 57%). Hyperpolarised gas MRI-guided BT reduced the number of radiofrequency activations, and resulted in asthma quality of life and control improvements at 12 months that were non-inferior to standard BT.

Cardiac surgery simulation: a low-cost feasible option in an Australasian setting.

BACKGROUND: Simulation training is a useful adjunct to surgical training and education (SET) in Cardiothoracic Surgery yet training opportunities outside the Royal Australasian College of Surgery or industry-sponsored workshops are rare due to high cost and limited training faculty, time, assessment tools or structured curricula. We describe our experience in establishing a low-cost cardiac simulation programme. METHODS: We created low-cost models using hospital facilities, hardware stores, abattoirs and donations from industry. Three workshops were conducted on coronary anastomoses, aortic and mitral valve replacement. RESULTS: Whole porcine hearts were sourced from local farms. Industry donations of obsolete stock were used for suture and valve material-stations constructed using ironing-board, 2-L buckets and kebab-skewers. Suture ring holders were fashioned from recycled cardboard or donated. All participants were asked to complete pre and post simulation self-assessment forms. Across three workshops, 45 participants (57.8% female) with a median age 27 (interquartile range 24-31) attended. Training level consisted of nurses (8, 17.8%), medical students (17, 37.8%), residents/house officers (6, 13.3%) and registrars (14, 31.1%). There were improvements in knowledge of anatomy (mean difference 18%; 95% confidence interval 12%-24%), imaging (16%; 10%-22%) and procedural components (34%; 28%-42%); and practical ability to describe steps (30%; 24%-38%), partially (32%; 26%-38%) or fully complete (32%; 28%-38%) the procedure. CONCLUSIONS: Simulation-based training in cardiac surgery is feasible in a hospital setting with low overhead costs. It can benefit participants at all training levels and has the potential to be implemented in training hospitals as an adjunct to the SET programme.

Ultra-short echo-time magnetic resonance imaging lung segmentation with under-Annotations and domain shift.

Ultra-short echo-time (UTE) magnetic resonance imaging (MRI) provides enhanced visualization of pulmonary structural and functional abnormalities and has shown promise in phenotyping lung disease. Here, we describe the development and evaluation of a lung segmentation approach to facilitate UTE MRI methods for patient-based imaging. The proposed approach employs a k-means algorithm in kernel space for pair-wise feature clustering and imposes image domain continuous regularization, coined as continuous kernel k-means (CKKM). The high-order CKKM algorithm was simplified through upper bound relaxation and solved within an iterative continuous max-flow framework. We combined the CKKM with U-net and atlas-based approaches and comprehensively evaluated the performance on 100 images from 25 patients with asthma and bronchial pulmonary dysplasia enrolled at Robarts Research Institute (Western University, London, Canada) and Centre Hospitalier Universitaire (Sainte-Justine, Montreal, Canada). For U-net, we trained the network five times on a mixture of five different images with under-annotations and applied the model to 64 images from the two centres. We also trained a U-net on five images with full and brush annotations from one centre, and tested the model on 32 images from the other centre. For an atlas-based approach, we employed three atlas images to segment 64 target images from the two centres through straightforward atlas registration and label fusion. We applied the CKKM algorithm to the baseline U-net and atlas outputs and refined the initial segmentation through multi-volume image fusion. The integration of CKKM substantially improved baseline results and yielded, with minimal computational cost, segmentation accuracy, and precision that were greater than some state-of-the-art deep learning models and similar to experienced observer manual segmentation. This suggests that deep learning and atlas-based approaches may be utilized to segment UTE MRI datasets using relatively small training datasets with under-annotations.

Reproducibility of Hyperpolarized 129Xe MRI Ventilation Defect Percent in Severe Asthma to Evaluate Clinical Trial Feasibility.

RATIONALE AND OBJECTIVES: 129Xe MRI has been developed to noninvasively visualize and quantify the functional consequence of airway obstruction in asthma. Its widespread application requires evidence of intersite reproducibility and agreement. Our objective was to evaluate reproducibility and agreement of 129Xe ventilation MRI measurements in severe asthmatics at two sites. MATERIALS AND METHODS: In seven adults with severe asthma, 129Xe ventilation MRI was acquired pre- and post-bronchodilator at two geographic sites within 24-hours. 129Xe MRI signal-to-noise ratio (SNR) was calculated and ventilation abnormalities were quantified as the whole-lung and slice-by-slice ventilation defect percent (VDP). Intraclass correlation coefficients (ICC) and Bland-Altman analysis were used to determine intersite 129Xe VDP reproducibility and agreement. RESULTS: Whole-lung and slice-by-slice 129Xe VDP measured at both sites were correlated and reproducible (pre-bronchodilator: whole-lung ICC = 0.90, p = 0.005, slice-by-slice ICC = 0.78, p < 0.0001; post-bronchodilator: whole-lung ICC = 0.94, p < 0.0001, slice-by-slice ICC = 0.83, p < 0.0001) notwithstanding intersite differences in the 129Xe-dose-equivalent-volume (101 ± 15 mL site 1, 49 ± 6 mL site 2, p < 0.0001), gas-mixture (129Xe/4He site 1; 129Xe/N2 site 2) and SNR (40 ± 19 site 1, 23 ± 5 site 2, p = 0.02). Qualitative 129Xe gas distribution differences were observed between sites and slice-by-slice 129Xe VDP, but not whole-lung 129Xe VDP, was significantly lower at site 1 (pre-bronchodilator VDP: whole-lung bias = -3%, p > 0.99, slice-by-slice bias = -3%, p = 0.0001; post-bronchodilator VDP: whole-lung bias = -2%, p = 0.59, slice-by-slice-bias = -2%, p = 0.0003). CONCLUSION: 129Xe MRI VDP at two different sites measured within 24-hours in the same severe asthmatics were correlated. Qualitative and quantitative intersite differences in 129Xe regional gas distribution and VDP point to site-specific variability that may be due to differences in gas-mixture composition or SNR.

CT Pulmonary Vessels and MRI Ventilation in Chronic Obstructive Pulmonary Disease: Relationship with worsening FEV1 in the TINCan cohort study.

RATIONALE AND OBJECTIVES: The relationships between computed tomography (CT) pulmonary vascularity and MRI ventilation is not well-understood in chronic obstructive pulmonary disease (COPD) patients. Our objective was to evaluate CT pulmonary vascular and MRI ventilation measurements in ex-smokers and to investigate their associations and how such measurements change over time. MATERIALS AND METHODS: Ninety ex-smokers (n = 41 without COPD 71 ± 10 years and n = 49 COPD 71 ± 8 years) provided written informed-consent to an ethics-board approved protocol and underwent imaging and pulmonary-function-tests twice, 31 ± 7 months apart. 3He MRI was acquired to generate ventilation-defect-percent (VDP). CT measurements of the relative area-of-the-lung with attenuation <-950 Hounsfield units (RA950), pulmonary vascular total-blood-volume (TBV) and percent of vessels with radius < one voxel (PV1) were evaluated. RESULTS: At baseline, there were significant differences in RA950 (p = 0.0001), VDP (p = 0.0001), total-blood-volume (p = 0.0001) and PV1 (p = 0.01) between ex-smokers and COPD participants as well as for VDP (p = 0.0001) in COPD participants with and without emphysema. The annual FEV1 change (-40 ± 93 mL/year) was not different among participant subgroups (p = 0.87), but the annual RA950 (p = 0.01) and PV1 (p = 0.007) changes were significantly different in participants with an accelerated annual FEV1 decline as compared to participants with a diminished annual FEV1 decline. There were significant but weak relationships for PV1 with FEV1%pred (p = 0.02), FEV1/FVC (p = 0.001), and log RA950 (p = 0.0001), but not VDP (p=0.20). The mean change in PV1 was also weakly but significantly related to the change in RA950 (p = 0.02). CONCLUSION: CT pulmonary vascular measurements were significantly different in ex-smokers and participants with COPD and related to RA950 but not VDP worsening over 2.5 years.