Occupational Therapy Practitioners' Implementation of Home Programs for Individuals Post Burn: An Initial Cross-Sectional Survey.

Occupational therapy practitioners who care for individuals post burn often prescribe home programs to facilitate continued progress toward occupational therapy goals. This study identified the components included in home programs, how practitioners create and prescribe home programs, and perceived supports and barriers to adherence in this population. Thirty-nine practitioners employed at American Burn Association-verified centers completed an online survey. Results suggest that home programs are primarily designed to address range of motion with less emphasis on function. The highest-ranked barriers to adherence were pain and lack of motivation while the highest-ranked supports were client motivation and family/caregiver support. Practitioners reported using handouts and demonstration frequently for delivery, with infrequent use of technology. Recommendations for incorporating evidence-based strategies into home program creation and administration are included.

Water in the terrestrial planet-forming zone of the PDS 70 disk.

Terrestrial and sub-Neptune planets are expected to form in the inner (less than 10 AU) regions of protoplanetary disks1. Water plays a key role in their formation2-4, although it is yet unclear whether water molecules are formed in situ or transported from the outer disk5,6. So far Spitzer Space Telescope observations have only provided water luminosity upper limits for dust-depleted inner disks7, similar to PDS 70, the first system with direct confirmation of protoplanet presence8,9. Here we report JWST observations of PDS 70, a benchmark target to search for water in a disk hosting a large (approximately 54 AU) planet-carved gap separating an inner and outer disk10,11. Our findings show water in the inner disk of PDS 70. This implies that potential terrestrial planets forming therein have access to a water reservoir. The column densities of water vapour suggest in-situ formation via a reaction sequence involving O, H2 and/or OH, and survival through water self-shielding5. This is also supported by the presence of CO2 emission, another molecule sensitive to ultraviolet photodissociation. Dust shielding, and replenishment of both gas and small dust from the outer disk, may also play a role in sustaining the water reservoir12. Our observations also reveal a strong variability of the mid-infrared spectral energy distribution, pointing to a change of inner disk geometry.

Measuring spatio-temporal couplings using modal spatio-spectral wavefront retrieval.

Knowledge of spatio-temporal couplings such as pulse-front tilt or curvature is important to determine the focused intensity of high-power lasers. Common techniques to diagnose these couplings are either qualitative or require hundreds of measurements. Here we present both a new algorithm for retrieving spatio-temporal couplings, as well as novel experimental implementations. Our method is based on the expression of the spatio-spectral phase in terms of a Zernike-Taylor basis, allowing us to directly quantify the coefficients for common spatio-temporal couplings. We take advantage of this method to perform quantitative measurements using a simple experimental setup, consisting of different bandpass filters in front of a Shack-Hartmann wavefront sensor. This fast acquisition of laser couplings using narrowband filters, abbreviated FALCON, is easy and cheap to implement in existing facilities. To this end, we present a measurement of spatio-temporal couplings at the ATLAS-3000 petawatt laser using our technique.

Breast cancer therapy in women under 35 years and between 50 and 69 years: influence of the observation period.

PURPOSE: In recent years, therapeutic strategies based on tumour biology have increased significantly. We aimed to provide an overview of the recent changes in patient characteristics, treatment procedures and survival factors for two groups of patients: women younger than 35 years and women between 50 and 69 years. METHODS: We used data from the population-based Cancer Registry Magdeburg. Subjects included women with non-metastatic breast cancer treated between 2000 and 2015. We compared between two observation periods: 2000-2007 and 2008-2015. RESULTS: There was an increase in patient survival from the first to the second observation period. Tumour characteristics and treatment modalities changed, especially in the group of older patients. The proportion of prognostically more favourable tumour subtypes, such as Luminal A, increased significantly. Between 2008 and 2015, there were more hormone receptor-positive, lymph-node-negative, human epidermal growth factor receptor-2 (HER2)-negative and well-differentiated tumours. Surgical methods were associated with significantly reduced radicality, while the rate of neoadjuvant therapy increased in both groups. There was a decrease in cyclophosphamide, methotrexate and 5-fluoruracil (CMF) and anthracycline therapies, but taxane-containing chemotherapy increased. While tamoxifen was used more frequently in younger patients in the later observation period, its use was reduced in older patients, superseded by aromatase inhibitors. Furthermore, the use of immune therapy increased. CONCLUSION: In both age groups, but primarily in older patients, there were significant changes in tumour biology and treatment options between the two observation periods. These changes have led to a continuous improvement in patient outcomes.

The role of collisional ionization in heavy ion acceleration by high intensity laser pulses.

We present here simulation results of the laser-driven acceleration of gold ions using the EPOCH code. Recently, an experiment reported the acceleration of gold ions up to 7 MeV/nucleon with a strong dependency of the charge-state distribution on target thickness and the detection of the highest charge states [Formula: see text]. Our simulations using a developmental branch of EPOCH (4.18-Ionization) show that collisional ionization is the most important cause of charge states beyond Z = 51 up to He-like Au.

Charge-state resolved laser acceleration of gold ions to beyond 7 MeV/u.

In the past years, the interest in the laser-driven acceleration of heavy ions in the mass range of [Formula: see text] has been increasing due to promising application ideas like the fission-fusion nuclear reaction mechanism, aiming at the production of neutron-rich isotopes relevant for the astrophysical r-process nucleosynthesis. In this paper, we report on the laser acceleration of gold ions to beyond 7 MeV/u, exceeding for the first time an important prerequisite for this nuclear reaction scheme. Moreover, the gold ion charge states have been detected with an unprecedented resolution, which enables the separation of individual charge states up to 4 MeV/u. The recorded charge-state distributions show a remarkable dependency on the target foil thickness and differ from simulations, lacking a straight-forward explanation by the established ionization models.

Healthcare utilisation and unmet health needs in children with intellectual disability: a propensity score matching approach using longitudinal cohort data.

BACKGROUND: Health disparities for children with intellectual disabilities can be challenging to measure due to many other factors that can impact health and healthcare use. The aim of the current study was to use longitudinal cohort data to compare children with intellectual disability (ID) in Ireland between 2006 and 2014 on healthcare utilisation and unmet need, at ages 9 and 13, using a propensity score matching (PSM) approach. METHODS: Using data from the Growing up in Ireland study, PSM was used to identify an appropriate control sample to compare with a sample of children with ID (n = 124). Participants were matched on variables that are known to influence healthcare utilisation to reduce the impact of confounding variables between groups so that differences between the groups can be estimated. Logistic regression was used to estimate effects at ages 9 and 13. RESULTS: Children with ID were no more likely to have visited a general practitioner or emergency department in the past 12 months than children without ID. They did have a greater likelihood of visiting a doctor in a hospital in the past 12 months and of having an overnight stay in hospital by age 9. Primary caregivers of children with ID were more likely to report unmet health needs at ages 9 and 13. CONCLUSIONS: This approach is a novel means of comparing healthcare use in this population by balancing the impact of other factors that may result in inequities, to which children with ID may be more vulnerable.

Geant4 Monte Carlo simulation study of the secondary radiation fields at the laser-driven ion source LION.

At the Center for Advanced Laser Applications (CALA), Garching, Germany, the LION (Laser-driven ION Acceleration) experiment is being commissioned, aiming at the production of laser-driven bunches of protons and light ions with multi-MeV energies and repetition frequency up to 1 Hz. A Geant4 Monte Carlo-based study of the secondary neutron and photon fields expected during LION's different commissioning phases is presented. Goal of this study is the characterization of the secondary radiation environment present inside and outside the LION cave. Three different primary proton spectra, taken from experimental results reported in the literature and representative of three different future stages of the LION's commissioning path are used. Together with protons, also electrons are emitted through laser-target interaction and are also responsible for the production of secondary radiation. For the electron component of the three source terms, a simplified exponential model is used. Moreover, in order to reduce the simulation complexity, a two-components simplified geometrical model of proton and electron sources is proposed. It has been found that the radiation environment inside the experimental cave is either dominated by photons or neutrons depending on the position in the room and the source term used. The higher the intensity of the source, the higher the neutron contribution to the total dose for all scored positions. Maximum neutron and photon ambient dose equivalent values normalized to 109 simulated incident primaries were calculated at the exit of the vacuum chamber, where values of about 85 nSv (109 primaries)-1 and 1.0 µSv (109 primaries)-1 were found.

Real-Time Electron Solvation Induced by Bursts of Laser-Accelerated Protons in Liquid Water.

Understanding the mechanisms of proton energy deposition in matter and subsequent damage formation is fundamental to radiation science. Here we exploit the picosecond (10^{-12} s) resolution of laser-driven accelerators to track ultrafast solvation dynamics for electrons due to proton radiolysis in liquid water (H_{2}O). Comparing these results with modeling that assumes initial conditions similar to those found in photolysis reveals that solvation time due to protons is extended by >20 ps. Supported by magnetohydrodynamic theory this indicates a highly dynamic phase in the immediate aftermath of the proton interaction that is not accounted for in current models.

Longitudinal associations between exposure to anesthesia and neurocognitive functioning in pediatric medulloblastoma.

AIM: To examine whether anesthesia exposure is associated with neurocognitive decline in pediatric medulloblastoma. METHODS: Patients were treated at St. Jude Children's Research Hospital and completed ≥2 protocol-directed neurocognitive assessments (n = 107) as part of a multisite clinical trial for pediatric medulloblastoma (NCT00085202). Patients received risk-adapted craniospinal photon irradiation, followed by four cycles of high-dose chemotherapy and stem cell rescue. Neurocognitive testing was completed at study baseline (after surgery and <2 weeks of starting radiation therapy) and annually for 5 years. Data on anesthesia exposure during treatment was abstracted from medical records. RESULTS: Patients were 10.2 years at diagnosis on average (SD = 4.5; 37% female, 73% average-risk). Mean cumulative anesthesia duration was 20.4 h (SD = 15.2; range 0.7-55.6 h). In the overall group, longer anesthesia duration was associated with greater declines in IQ (Estimate = -0.08, P < 0.001), attention (Estimate = -0.10, P < .001) and processing speed (Estimate = -0.13, P < 0.001). Similar results were shown in subgroups of patients who were <7 years at diagnosis (IQ = -0.14, P = 0.027; Attention = -0.25: P = 0.011), ≥7 years at diagnosis (Attention = -0.07, P = 0.039; Processing Speed = -0.08, P = 0.022), treated for high-risk disease (IQ = -0.09, P = 0.024; Attention = -0.11, P = 0.034; Processing Speed = -0.13, P = 0.001), or treated for average-risk disease (IQ = -0.05, P = .022; Attention = -0.08, P = 0.011; Processing Speed = -0.10, P < 0.001). CONCLUSION: Greater anesthesia exposure is a risk factor for clinically significant neurocognitive decline, in addition to factors of age at diagnosis and treatment risk arm. This result is notable as there are evidence-based strategies that can limit the need for anesthesia. Limiting anesthesia exposure, as feasible, may mitigate neurocognitive late effects, and thus, improve quality of life for survivors.

[Studies on Factors Influencing Influenza Vaccination Rates in Patients with Chronic Obstructive Pulmonary Disease]. / Untersuchungen zu Einflussfaktoren auf die Influenza-Impfraten bei Patienten mit chronisch obstruktiver Lungenerkrankung.

BACKGROUND : With low influenza vaccination rates among the chronically ill, approaches to increase these rates among risk patients with chronic obstructive pulmonary disease (COPD) are to be uncovered. METHODS : 120 COPD patients from Magdeburg filled out a questionnaire and were analyzed regarding the influenza vaccination status 2015/2016 or 2016/2017. Vaccinated and unvaccinated were compared in socio-epidemiological factors, the health belief model (HBM), self-efficacy (GESIS-ASKU), anxiety/depression (HADS-D) and disease processing (FKV-LIS). RESULTS : 62.5 % (n = 75) were vaccinated, 31.7 % (n = 38) unvaccinated, 5.8 % (n = 7) made no statement. In over or equal to 60-year-olds 76 % were vaccinated, in under 60-year-olds 42 % were vaccinated. 60 % (n = 72) knew to belong to a risk group. Unvaccinated indicated greater concern about side effects of the vaccination (p = .004) and drew a worse benefit-expense balance (p = .001). Unvaccinated were more often uncertain about the vaccination protection and the severity of influenza (p ≤ .001). Vaccinated were highly motivated to think about vaccination themselves and more often had a positive vaccination history (p = .001). COPD patients showed a lower self-efficacy than the reference group of the German general population (p = .000), vaccinated and unvaccinated did not differ (p = .418). No difference between vaccinated and unvaccinated was found in the processing of the disease and in depression and anxiety, but unvaccinated tended to give higher anxiety values. CONCLUSION : Measures should particularly target COPD patients under 60 years of age with a negative vaccination history and sensitize them as risk patients. Widespread uncertainties about the severity of influenza and vaccination protection should be addressed. It should be communicated that influenza vaccination does not lead to exacerbation. The vaccination recommendation should increasingly be made by pulmonologists.

Laser-driven x-ray and proton micro-source and application to simultaneous single-shot bi-modal radiographic imaging.

Radiographic imaging with x-rays and protons is an omnipresent tool in basic research and applications in industry, material science and medical diagnostics. The information contained in both modalities can often be valuable in principle, but difficult to access simultaneously. Laser-driven solid-density plasma-sources deliver both kinds of radiation, but mostly single modalities have been explored for applications. Their potential for bi-modal radiographic imaging has never been fully realized, due to problems in generating appropriate sources and separating image modalities. Here, we report on the generation of proton and x-ray micro-sources in laser-plasma interactions of the focused Texas Petawatt laser with solid-density, micrometer-sized tungsten needles. We apply them for bi-modal radiographic imaging of biological and technological objects in a single laser shot. Thereby, advantages of laser-driven sources could be enriched beyond their small footprint by embracing their additional unique properties, including the spectral bandwidth, small source size and multi-mode emission.

Beam characterization and feasibility study for a small animal irradiation platform at clinical proton therapy facilities.

A deeper understanding of biological mechanisms to promote more efficient treatment strategies in proton therapy demands advances in preclinical radiation research. However this is often limited by insufficient availability of adequate infrastructures for precision image guided small animal proton irradiation. The project SIRMIO aims at filling this gap by developing a portable image-guided research platform for small animal irradiation, to be used at clinical facilities and allowing for a precision similar to a clinical treatment, when scaled down to the small animal size. This work investigates the achievable dosimetric properties of different lowest energy clinical proton therapy beams, manipulated by a dedicated portable beamline including active focusing after initial beam energy degradation and collimation. By measuring the lateral beam size in air close to the beam nozzle exit and the laterally integrated depth dose in water, an analytical beam model based on the beam parameters of the clinical beam at the Rinecker Proton Therapy Center was created for the lowest available clinical beam energy. The same approach was then applied to estimate the lowest energy beam model of different proton therapy facilities, Paul Scherrer Institute, Centre Antoine Lacassagne, Trento Proton Therapy Centre and the Danish Centre for Particle Therapy, based on their available beam commissioning data. This comparison indicated similar beam properties for all investigated sites, with emittance values of a few tens of mm·mrad. Finally, starting from these beam models, we simulated propagation through a novel beamline designed to manipulate the beam energy and size for precise small animal irradiation, and evaluated the resulting dosimetric properties in water. For all investigated initial clinical beams, similar dosimetric results suitable for small animal irradiation were found. This work supports the feasibility of the proposed SIRMIO beamline, promising suitable beam characteristics to allow for precise preclinical irradiation at clinical treatment facilities.

[Operability and Pathological Response of Non-Small Cell Lung Cancer (NSCLC) after Neoadjuvant Therapy with Immune Checkpoint Inhibition]. / Operabilität und pathologisches Ansprechen des Lungenkarzinoms nach neoadjuvanter Therapie mit Immun-Checkpoint-Inhibitoren.

BACKGROUND: The blockade of immune escape mechanisms (e. g. PD1 /PD-L1) using immune checkpoint inhibition (ICI) can significantly prolong survival and induce remission in patients with advanced non-small cell lung cancer (NSCLC). Less is known about neoadjuvant ICI in patients with resectable (UICC stage III) or oligometastatic (UICC stage IVa) NSCLC. METHODS: Tissue biopsies from patients with advanced or oligometastatic NSCLC were screened for PD-L1 expression. In case of PD-L1-expression > 50 %, ECOG status of 0 or 1 and expected operability, patients received ICI. After about four weeks, patients underwent thoracic surgical resection. In all patients, a complete staging, including PET-CT, cMRI, and endobronchial ultrasound, was performed. The tolerability, the radiological and the histopathological tumor response as well as the surgical and oncological outcomes were analyzed. FINDINGS: Four patients (2 male, 2 female, age 56 - 78 years, n = 3 adenocarcinoma, n = 1 squamous cell carcinoma) with local advanced tumors received ICI before surgical resection. In three cases the mediastinal lymph nodes were positive. One patient had a single cerebral metastasis which was treated with radiotherapy. All four patients underwent therapy with two to six cycles of ICI (3â€Š× pembrolizumab, 1â€Š× atezolizumab) without any complication, and ICI did not delay the time of surgical resection. According to iRECIST, three patients showed partial response (PR), one patient had stable disease (SD). All tumors were completely resected. The thoracic surgical procedures proved to be technically unproblematic despite inflammatory changes. There were neither treatment-related deaths nor perioperative complications. In the resectates, complete pathological response (CPR, regression grade III ) and regression grade IIb were detected twice. The average time of follow-up was 12 (1 - 24) months. Patients with PPR developed distant metastasis after six months or a local recurrence after four months. The CPR patient is relapse free to date. CONCLUSION: In selected patients, neoadjuvant therapy with ICI is well tolerated and can induce a complete remission of the tumor. Treatment with ICI has no negative impact on the surgical procedure. Prognosis seems to be promising in CPR and limited in PPR.

Perspectives on the fellowship training in cardiac, thoracic, and vascular anesthesia and critical care in Europe from program directors and educational leads around europe

ABSTRACT:This article reviews fellowship training in adult cardiac, thoracic, and vascular anesthesia and critical care from the perspective of European program initiators and educational leaders in these subspecialties together with current training fellows. Currently, the European Association of Cardiothoracic Anaesthesiology (EACTA) network has 20 certified fellowship positions each year in 10 hosting centers within 7 European countries, with 2 positions outside Europe (São Paulo, Brazil). Since 2009, 42 fellows have completed the fellowship training. The aim of this article is to provide an overview of the rationale, requirements, and contributions of the fellows, in the context of the developmental progression of the EACTA fellowship in adult cardiac, thoracic, and vascular anesthesia and critical care from inception to present. A summary of the program structure, accreditation of host centers, requirements to join the program, teaching and assessment tools, certification, and training requirements in transesophageal electrocardiography is outlined. In addition, a description of the current state of EACTA fellowships across Europe, and a perspective for future steps and challenges to the educational program, is provided. (AU)

Sub-cycle dynamics in relativistic nanoplasma acceleration.

The interaction of light with nanometer-sized solids provides the means of focusing optical radiation to sub-wavelength spatial scales with associated electric field enhancements offering new opportunities for multifaceted applications. We utilize collective effects in nanoplasmas with sub-two-cycle light pulses of extreme intensity to extend the waveform-dependent electron acceleration regime into the relativistic realm, by using 106 times higher intensity than previous works to date. Through irradiation of nanometric tungsten needles, we obtain multi-MeV energy electron bunches, whose energy and direction can be steered by the combined effect of the induced near-field and the laser field. We identified a two-step mechanism for the electron acceleration: (i) ejection within a sub-half-optical-cycle into the near-field from the target at >TVm-1 acceleration fields, and (ii) subsequent acceleration in vacuum by the intense laser field. Our observations raise the prospect of isolating and controlling relativistic attosecond electron bunches, and pave the way for next generation electron and photon sources.

Laser Acceleration of Highly Energetic Carbon Ions Using a Double-Layer Target Composed of Slightly Underdense Plasma and Ultrathin Foil.

We report the experimental generation of highly energetic carbon ions up to 48 MeV per nucleon by shooting double-layer targets composed of well-controlled slightly underdense plasma and ultrathin foils with ultraintense femtosecond laser pulses. Particle-in-cell simulations reveal that carbon ions are ejected from the ultrathin foils due to radiation pressure and then accelerated in an enhanced sheath field established by the superponderomotive electron flow. Such a cascaded acceleration is especially suited for heavy ion acceleration with femtosecond laser pulses. The breakthrough of heavy ion energy up to many tens of MeV/u at a high repetition rate would be able to trigger significant advances in nuclear physics, high energy density physics, and medical physics.

[Lupus nephritis]. / Lupusnephritis.

Lupus nephritis (LN) is the most frequent and one of the most severe organ manifestations of systemic lupus erythematosus. The central pathogenetic mechanism is characterized by the loss of immune tolerance against autoantigens of the cell nucleus, which can lead to renal inflammation via the formation of nuclear autoantibodies. The clinical manifestations of LN encompass nephritic syndrome with the special form of rapidly progressive glomerulonephritis, nephrotic syndrome and thrombotic microangiopathy. The diagnostic procedures consist of renal function and urine analysis as well as the determination of serum autoantibody profiles and complement components. An early renal biopsy enables a differentiation between the prognostically different forms of LN. In addition to supportive measures, a differentiated immunosuppressive treatment is the main approach for prognostically unfavorable forms. Important components are corticosteroids, cyclophosphamide and mycophenolate mofetil for induction treatment. Currently investigated treatment principles include next generation calcineurin inhibitors and anti-B cell treatment.