A natural frameshift mutation in Campanula EIL2 correlates with ethylene insensitivity in flowers.

BACKGROUND: The phytohormone ethylene plays a central role in development and senescence of climacteric flowers. In ornamental plant production, ethylene sensitive plants are usually protected against negative effects of ethylene by application of chemical inhibitors. In Campanula, flowers are sensitive to even minute concentrations of ethylene. RESULTS: Monitoring flower longevity in three Campanula species revealed C. portenschlagiana (Cp) as ethylene sensitive, C. formanekiana (Cf) with intermediate sensitivity and C. medium (Cm) as ethylene insensitive. We identified key elements in ethylene signal transduction, specifically in Ethylene Response Sensor 2 (ERS2), Constitutive Triple Response 1 (CTR1) and Ethylene Insensitive 3- Like 1 and 2 (EIL1 and EIL2) homologous. Transcripts of ERS2, CTR1 and EIL1 were constitutively expressed in all species both throughout flower development and in response to ethylene. In contrast, EIL2 was found only in Cf and Cm. We identified a natural mutation in Cmeil2 causing a frameshift which resulted in difference in expression levels of EIL2, with more than 100-fold change between Cf and Cm in young flowers. CONCLUSIONS: This study shows that the naturally occurring 7 bp frameshift discovered in Cmeil2, a key gene in the ethylene signaling pathway, correlates with ethylene insensitivity in flowers. We suggest that transfer of the eil2 mutation to other plant species will provide a novel tool to engineer ethylene insensitive flowers.

Social support and non-participation in breast cancer screening: a Danish cohort study.

BACKGROUND: Social support may have an impact on screening participation. We studied the association between social support in 2006, defined as frequencies of contacts, instrumental support and emotional support and participation in breast cancer screening in 2008-09. METHODS: This population-based cohort study included 4512 women who had participated in a Health Survey in 2006 and who also were in the target group for the first round of organized breast cancer screening in the Central Denmark region in 2008-09. RESULTS: Women with infrequent contacts with friends and family in 2006 were more likely not to participate in screening in 2008-09 [prevalence ratio (PR) 1.69, 95% confidence interval (CI) 1.26-2.26, P-value < 0.001 and PR 1.56, 95% CI 1.21-2.20, P-value < 0.001, respectively] as were women who reported not to have someone to look after her home if she was away for some time and women who reported usually not or never having someone to turn to with personal concerns (PR 1.97, 95% CI 1.53-2.54, P-value < 0.001 and PR 1.42, 95% CI 1.14-1.77, P-value = 0.002, respectively). CONCLUSIONS: Low social support, indicated by items in each social support attribute, was associated with non-participation in breast cancer screening in 2008-09. Targeted social interventions may, therefore, have an impact on future screening behaviour, which calls for further research.

Self-assessed health, perceived stress and non-participation in breast cancer screening: A Danish cohort study.

OBJECTIVE: Population-based cancer screening is offered in many countries to detect early stages of cancer and reduce mortality. Screening efficiency and equality is susceptible due to a group of non-participants. We investigated associations between self-assessed health, perceived stress and subsequent non-participation in breast cancer screening. METHODS: This population-based cohort study included 4512 women who had participated in a Health Survey in 2006 and who were also the target group (aged 50-69 years) for the first organised breast cancer screening programme -3 years later in the Central Denmark Region in 2008-2009. RESULTS: A U-shaped association was observed for physical health assessment as women with the highest (PR=1.28, 95% CI: 1.06-1.55), and the lowest (PR=1.41, 95% CI: 1.18-1.68) physical health scores were less likely to participate in the programme than women with physical health scores in the middle range. Women with low mental health assessment were more likely not to participate than women with mental health scores in the middle range (PR=1.44, 95% CI: 1.22-1.69). Higher non-participation propensity was also observed for women with the highest perceived stress scores (PR=1.27, 95% CI: 1.07-1.51) compared with women scoring in the middle range. CONCLUSIONS: Women with highest and lowest self-assessed physical health, with lowest mental health or highest perceived stress were significantly more likely not to participate in breast cancer screening 2-3 years later than women who reported average health. Interventions targeting these groups may promote equal participation in future breast cancer screening programmes.

Symptom attributions in patients with colorectal cancer.

BACKGROUND: Symptoms of cancer may be interpreted differently by different patients before the diagnosis. This study investigated symptom attributions in Danish patients with colorectal cancer and the potential associations with symptom type, socio-demographic characteristics and patient interval. METHODS: Data were collected among incident colorectal cancer patients (n = 577, response rate 64.2 %), who were asked to think back on the time before their diagnosis when completing the questionnaire. The questionnaire comprised a Danish version of the revised Illness Perception Questionnaire (IPQ-R) with questions on 19 symptom attributions. These 19 attribitutions were categorised into five causal groups for statistical analyses. The patient interval (i.e. the time from the patient's first symptom experience to presentation to the healthcare system) was assessed in the same questionnaire. Data on socio-demographic characteristics were obtained by using nationwide registers from Statistics Denmark. RESULTS: Patients who experienced 'blood in stool' as the most important symptom were more likely to attribute this to cancer (PR(ad) 1.94, 95 % CI 1.46-2.58) and benign somatic causes (PR(ad) 1.36, 95 % CI 1.05-1.76), such as haemorrhoids, compared to patients who did not perceive this symptom as the most important. Socio-demographic characteristics were also associated with symptom attribution. Patients with higher educational levels were less likely to attribute their most important symptom to psychological causes (PR(ad) 0.57, 95 % CI 0.34-0.96) than patients with lower educational levels. Patients with rectal cancer attributed their most important symptom to a benign somatic cause more often than patients with colon cancer (PR(ad) 1.34, 95 % CI 1.02-1.77). [corrected]. CONCLUSIONS: Symptom attribution in patients was associated with aspects of socio-demography and with the symptom type perceived by the patient as the most important. No significant associations were found between symptom attributions and patient interval. These results have implications for general practice as symptom attributions may prompt patients to present symptoms in a certain way and thereby influence the general practitioner's assessment of presented symptoms.

Biomechanical evaluation of the side-cutting manoeuvre associated with ACL injury in young female handball players.

PURPOSE: The purpose of the study was to investigate the biomechanics of the knee and hip joint during handball-specific side-cutting on the dominant and non-dominant leg. Understanding the sports-specific biomechanics may improve prevention measures and post-injury treatment. METHODS: Twenty-four young female elite handball players performed 5 handball side-cutting manoeuvres on the dominant and non-dominant legs. The local maxima of the joint moments in each plane, during the initial 100 ms following foot contact, were collected. RESULTS: External knee moments of flexion, outward rotation and valgus-along with external hip moments of extension, abduction and internal rotation-were observed, coincidentally 30-40 ms after foot contact. No side-to-side asymmetries were found. The external moments observed support the injury mechanisms previously described in case studies of handball injuries. CONCLUSION: The results underline the importance of implementing preventive exercises that increase activity of medial hamstrings, to match the external outward rotating knee moments and knee valgus moments, and increase activity of hip external rotators to match the external hip inward-rotating moment. Furthermore, the results may yield further information to the graft selection decision before ACL surgery. LEVEL OF EVIDENCE: Diagnostic studies, Level II.

Effects of journey duration and temperature during pre-slaughter transport on behaviour of cull sows in lairage.

This observational field study investigated the effects of journey duration, temperature, and waiting duration before unloading on the behaviour of 562 cull sows during lairage from 23 commercial loads. Each load consisted of sows originating from more than one herd, thus experiencing variable pre-slaughter transport and management. In lairage, sows were mixed in groups of 25, involving animals from all journey durations (min-max: 0.8-8.4 h) and video monitored for 60 min. At first most sows were in upright position (approximately 80-90%), decreasing to 30-40% after 30 min. After 60 min, 42% of the sows had initiated aggression (min-max: 0-43 events/sow), 28% had been subjected to aggressive behaviour (min-max: 0-14 events/sow), and 36% s were observed drinking (min-max: 0-16 events/sow). Several significant interactions were found between journey duration, the average temperature in the vehicle and lairage pen (averages: 4.3-26.2 °C) and waiting duration before unloading (min-max: 3-25 min). For example, after short journeys, sows exposed to higher temperature carried out more aggressive behaviour, while a higher temperature after long journeys was associated with more lying and less drinking. This suggests that the sows prioritised lying behaviour over drinking and establishing a dominance hierarchy. We discuss how the results may be interpreted as behavioural signs of fatigue, but further studies, for example involving quantification of physiological and motivational indicators, are needed to clarify this. Irrespectively, the present findings suggest that a stay in a lairage pen, as part of the pre-slaughter logistic chain, involves challenges for the welfare of the cull sows.

Quantitative gene expression profiling of CD45+ and CD45- skeletal muscle-derived side population cells.

The skeletal muscle-derived side population (mSP) which highly excludes Hoechst 33342 is composed of CD45(+) and CD45(-) subpopulations; yet, rareness of mSP cells in general has complicated extensive quantitative analysis of gene expression profiles in primarily isolated mSP cells. Here, we describe the isolation of adult mouse normal skeletal muscle residing SPCD45(+) and SPCD45(-) cells from a parent mononuclear muscle-derived cell (MDC) population. Relative quantitative real time PCR (RT-PCR) of 64 genes revealed that mSPCD45(-) compared with mSPCD45(+) was enriched for cells expressing transcripts associated with endothelial cells, Notch signaling and myogenic precursors. By comparing the mRNA signatures of mSPs with those of adipose tissue-derived SP populations, a common endothelial component seemed to reside in both muscle and fat-derived SPCD45(-) entities. However, each SP subset was clearly specified by the tissue from which the cells originated suggesting that muscle SPs compared with adipose tissue SPs are predisposed towards differentiation into the myogenic lineage. Thus, our data support the previously suggested hypothesis that satellite cell precursors (or alternatively a satellite cell subpopulation) remain in the mSPCD45(-) fraction, and we show that these cells express high levels of many of the known myogenic precursor/stem cell related markers, including Pax7 and Myf5.

Identifying specific non-attending groups in breast cancer screening--population-based registry study of participation and socio-demography.

BACKGROUND: A population-based breast cancer screening programme was implemented in the Central Denmark Region in 2008-09. The objective of this registry-based study was to examine the association between socio-demographic characteristics and screening participation and to examine whether the group of non-participants can be regarded as a homogeneous group of women. METHOD: Participation status was obtained from a regional database for all women invited to the first screening round in the Central Denmark Region in 2008-2009 (n=149,234). Participation data was linked to registries containing socio-demographic information. Distance to screening site was calculated using ArcGIS. Participation was divided into 'participants' and 'non-participants', and non-participants were further stratified into 'active non-participants' and 'passive non-participants' based on whether the woman called and cancelled her participation or was a 'no-show'. RESULTS: The screening participation rate was 78.9%. In multivariate analyses, non-participation was associated with older age, immigrant status, low OECD-adjusted household income, high and low level education compared with middle level education, unemployment, being unmarried, distance to screening site >20 km, being a tenant and no access to a vehicle. Active and passive non-participants comprised two distinct groups with different socio-demographic characteristics, with passive non-participants being more socially deprived compared with active non-participants. CONCLUSION: Non-participation was associated with low social status e.g. low income, unemployment, no access to vehicle and status as tenant. Non-participants were also more likely than participants to be older, single, and of non-Danish origin. Compared to active non-participants, passive non-participants were characterized by e.g. lower income and lower educational level. Different interventions might be warranted to increase participation in the two non-participant groups.

The association between general practitioners' attitudes towards breast cancer screening and women's screening participation.

BACKGROUND: Breast cancer screening in Denmark is organised by the health services in the five regions. Although general practitioners (GPs) are not directly involved in the screening process, they are often the first point of contact to the health care system and thus play an important advisory role. No previous studies, in a health care setting like the Danish system, have investigated the association between GPs' attitudes towards breast cancer screening and women's participation in the screening programme. METHODS: Data on women's screening participation was obtained from the regional screening authorities. Data on GPs' attitudes towards breast cancer screening was taken from a previous survey among GPs in the Central Denmark Region. This study included women aged 50-69 years who were registered with a singlehanded GP who had participated in the survey. RESULTS: The survey involved 67 singlehanded GPs with a total of 13,288 women on their lists. Five GPs (7%) had a negative attitude towards breast cancer screening. Among registered women, 81% participated in the first screening round. Multivariate analyses revealed that women registered with a GP with a negative attitude towards breast cancer screening were 17% (95% CI: 2-34%) more likely to be non-participants compared with women registered with a GP with a positive attitude towards breast cancer screening. CONCLUSION: The GPs' attitudes may influence the participation rate even in a system where GPs are not directly involved in the screening process. However, further studies are needed to investigate this association.

Risk of deep vein thrombosis and pulmonary embolism after gynecological day surgery.

OBJECTIVE: To investigate the risk of venous thromboembolism (VTE) in Danish women operated within a day surgery setting and to evaluate whether the current use of thromboprophylaxis without using graduated elastic compression stockings (GCS) is an appropriate treatment to prevent VTE. STUDY DESIGN: A retrospective cohort study including women who underwent laparoscopic hysterectomy or vaginal prolapse operation for benign disease from January 2014 to December 2017 at the Gynecology Day Surgery Unit, Regional Hospital of Randers, Denmark. The primary outcome was VTE diagnosed within three months postoperatively. Only one dose of pharmacological thromboprophylaxis (PTP) was given to women stratified at high risk of VTE. None of the women used GCS. RESULTS: A total of 671 women were included. Vaginal prolapse operations were performed on 626 women, and laparoscopic hysterectomy on 45 women. PTP was used for only 220 (32.8%) of these women. A total of 346 (51.5%) women were stratified as at high risk of VTE according to the national recommendations. Only 218 (63%) of these women received PTP, while 128 women (37%) did not receive PTP. The incidence of VTE within three months postoperatively was 0%. Only 13 (1.9%) of the women were readmitted within 14 days postoperatively due to hemorrhaging or hematoma; six out of these 13 women (46%) received PTP postoperatively. Re-operation was performed in seven (1%) women due to hemorrhaging, and three out of the seven (42.9%) had PTP postoperatively. CONCLUSION: The risk of VTE in Danish women operated within a day surgery setting is probably very low since we found no cases of VTE in our setup. The beneficial effect of routine use of GCS and one dose of PTP postoperatively given to all women who had undergone MIS in a day surgery setting are questioned. One dose of PTP postoperatively without GCS can be considered to only women stratified as high-risk of VTE until there is more evidence whether these women actually need thromboprophylaxis postoperatively at all. PRECIS: The incidence of VTE in women undergoing laparoscopic hysterectomy or vaginal prolapse operation in a day surgery setting without using graduated elastic compression stockings is very low.

The gut hormone Allatostatin C/Somatostatin regulates food intake and metabolic homeostasis under nutrient stress.

The intestine is a central regulator of metabolic homeostasis. Dietary inputs are absorbed through the gut, which senses their nutritional value and relays hormonal information to other organs to coordinate systemic energy balance. However, the gut-derived hormones affecting metabolic and behavioral responses are poorly defined. Here we show that the endocrine cells of the Drosophila gut sense nutrient stress through a mechanism that involves the TOR pathway and in response secrete the peptide hormone allatostatin C, a Drosophila somatostatin homolog. Gut-derived allatostatin C induces secretion of glucagon-like adipokinetic hormone to coordinate food intake and energy mobilization. Loss of gut Allatostatin C or its receptor in the adipokinetic-hormone-producing cells impairs lipid and sugar mobilization during fasting, leading to hypoglycemia. Our findings illustrate a nutrient-responsive endocrine mechanism that maintains energy homeostasis under nutrient-stress conditions, a function that is essential to health and whose failure can lead to metabolic disorders.

Coping strategies and considerations regarding low anterior resection syndrome and quality of life among patients with rectal cancer; a qualitative interview study.

Introduction: Low anterior resection syndrome (LARS) is defined as disordered bowel function following rectal resection, which is detrimental to quality of life (QoL). A recent international consensus definition of LARS stresses the importance of focusing on both the symptoms and the consequences that the symptoms have for the individual patient as studies indicate that LARS has a negative impact on patients' QoL. However, an ongoing PROM study investigating late sequelae after rectal cancer finds that a minor proportion of patients scoring major LARS experience none or only little impact on quality of life. Aim: The aim of this study was to identify patients' considerations and coping strategies to establish why the burden caused by major LARS had little or no influence on their QoL. Materials and methods: This was a qualitative interview study based on 21 semi-structured individual telephone interviews with patients treated for rectal cancer. Data were analysed using a hermeneutic inspired thematic analysis. Results and conclusion: Three themes emerged from the analysis; Adapting new life situation, Altering life perception and the Importance of relationships. Major LARS and its consequences following rectal cancer may be managed or altered by adopting problem-focused and emotion-focused coping strategies. Maintaining a positive attitude and having a good network of family and friends constitute a surplus, allowing patients to cope with the need for changed behaviour and appreciate the life that they have been given. Accepting that major LARS and its consequences cause limitations in life allowed patients to change their normality threshold over time.

Monitoring neoadjuvant chemotherapy in breast cancer patients: improved MR assessment at 3 T?

PURPOSE: To investigate possible improvements in predicting the response to neoadjuvant chemotherapy (NAC) at 3 T for locally advanced breast cancer (LABC). MATERIALS AND METHODS: Dynamic contrast-enhanced magnetic resonance (DCE-MR) images acquired before and during NAC were retrospectively analyzed in 85 patients. Tumor volume and diameter, three volumes based on the shape of the enhancement curve, relative signal intensity, area under the curve, and the signal-to-noise ratio were extracted. Differences between responders and nonresponders at the same and between MR timepoints during treatment were evaluated. RESULTS: A higher signal-to-noise ratio was observed on 3 T images compared to 1.5 T, and 3 T revealed more significant findings related to response compared to 1.5 T. The DCE-MRI-derived volume parameters were the earliest predictors of response at both 1.5 and 3 T. CONCLUSION: Our results show that 3 T provides an improved assessment of the response to NAC in LABC patients, where the MR determined tumor volume reduction before the second cycle of NAC was the strongest and earliest predictor of a response.

Diffusion-weighted and dynamic contrast-enhanced MRI in evaluation of early treatment effects during neoadjuvant chemotherapy in breast cancer patients.

PURPOSE: To use dynamic contrast-enhanced (DCE) and diffusion-weighted (DW) MRI at 3 Tesla (T) for early evaluation of treatment effects in breast cancer patients undergoing neoadjuvant chemotherapy (NAC), and assess the reliability of DW-MRI. MATERIALS AND METHODS: DW- and DCE-MRI acquisitions of 15 breast cancer patients were performed before and after one cycle of NAC. MRI tumor diameter and volume, apparent diffusion coefficient (ADC) and kinetic parameters (K(trans), v(e)) were derived. The reliability of ADC before NAC was assessed. Changes in MRI parameters after NAC were analyzed, and logistic regression analysis was used to find the best predictors for pathologic response. RESULTS: The reliability for ADC values was high, with intraclass correlation coefficient of 0.84 (P = 0.001). After one cycle of NAC, MRI tumor diameter (8%, P = 0.005) and tumor volume (30%, P = 0.008) was reduced for all patients, while ADC mean values increased (0.12 mm(2)/s, P = 0.008). The best predictor for treatment response was a change in MRI tumor diameter with mean error rate of 0.167 (13% for responders, 5% for nonresponders, P = 0.291). CONCLUSION: Changes in MRI derived tumor diameter and ADC after only one cycle of NAC could provide a valuable tool for early evaluation of treatment effects in breast cancer patients.

A cross-sectional analysis of persistent low back pain, using correlations between lumbar stiffness, pressure pain threshold, and heat pain threshold.

INTRODUCTION: Little is known about the underlying biomechanical cause of low back pain (LBP). Recently, technological advances have made it possible to quantify biomechanical and neurophysiological measurements, potentially relevant factors in understanding LBP etiology. However, few studies have explored the relation between these factors. This study aims to quantify the correlation between biomechanical and neurophysiological outcomes in non-specific LBP and examine whether these correlations differ when considered regionally vs. segmentally. METHODS: This is a secondary cross-sectional analysis of 132 participants with persistent non-specific LBP. Biomechanical data included spinal stiffness (global stiffness) measured by a rolling indenter. Neurophysiological data included pain sensitivity (pressure pain threshold and heat pain threshold) measured by a pressure algometer and a thermode. Correlations were tested using Pearson's product-moment correlation or Spearman's rank correlation as appropriate. The association between these outcomes and the segmental level was tested using ANOVA with post-hoc Tukey corrected comparisons. RESULTS: A moderate positive correlation was found between spinal stiffness and pressure pain threshold, i.e., high degrees of stiffness were associated with high pressure pain thresholds. The correlation between spinal stiffness and heat pain threshold was poor and not statistically significant. Aside from a statistically significant minor association between the lower and the upper lumbar segments and stiffness, no other segmental relation was shown. CONCLUSIONS: The moderate correlation between spinal stiffness and mechanical pain sensitivity was the opposite of expected, meaning higher degrees of stiffness was associated with higher pressure pain thresholds. No clinically relevant segmental association existed.

Evaluation of the in vitro effects of local anesthetics on equine chondrocytes and fibroblast-like synoviocytes.

OBJECTIVE: To investigate the in vitro effects of clinically relevant concentrations of the local anesthetics (LAs) bupivacaine, lidocaine, lidocaine with preservative (LP), mepivacaine, and ropivacaine on equine chondrocyte and fibroblast-like synoviocyte (FLS) viability. SAMPLES: Chondrocytes and FLSs of the metacarpophalangeal joints of 4 healthy adult horses. PROCEDURES: Viability of chondrocytes and FLSs was determined with 3 assays: 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT), lactate dehydrogenase (LDH), and trypan blue (TB) exclusion (only FLS). Viability was assessed after 30- and 60-minute exposures to 0.0625%, 0.125%, and 0.25% bupivacaine; 0.25%, 0.5%, and 1% lidocaine; 0.25%, 0.5%, and 1% LP; 0.25%, 0.5%, and 1% mepivacaine; and 0.125%, 0.25%, and 0.5% ropivacaine. RESULTS: Viability of chondrocytes was significantly decreased with exposure to 0.25% bupivacaine, 1% lidocaine, 1% LP, 1% mepivacaine, and 0.25% ropivacaine. Viability of FLSs was significantly decreased with exposure to 0.25% bupivacaine, 1% mepivacaine, 1% LP, and 0.5% ropivacaine. CONCLUSIONS AND CLINICAL RELEVANCE: Clinically relevant concentrations of LAs had in vitro time- and concentration-dependent cytotoxicity for chondrocytes and FLSs isolated from the metacarpophalangeal joints of healthy horses. Bupivacaine was more toxic to chondrocytes than lidocaine, mepivacaine, and ropivacaine, whereas bupivacaine, LP, mepivacaine, and ropivacaine were more toxic to FLSs than preservative-free lidocaine. Several LAs may negatively affect chondrocyte and FLS viability.

Assessment of early docetaxel response in an experimental model of human breast cancer using DCE-MRI, ex vivo HR MAS, and in vivo 1H MRS.

The purpose of this study was to evaluate the use of dynamic contrast-enhanced (DCE) MRI, in vivo (1)H MRS and ex vivo high resolution magic angle spinning (HR MAS) MRS of tissue samples as methods to detect early treatment effects of docetaxel in a breast cancer xenograft model (MCF-7) in mice. MCF-7 cells were implanted subcutaneously in athymic mice and treated with docetaxel (20, 30, and 40 mg/kg) or saline six weeks later. DCE-MRI and in vivo (1)H MRS were performed on a 7 T MR system three days after treatment. The dynamic images were used as input for a two-compartment model, yielding the vascular parameters K(trans) and v(e). HR MAS MRS, histology, and immunohistochemical staining for proliferation (Ki-67), apoptosis (M30 cytodeath), and vascular/endothelial cells (CD31) were performed on excised tumor tissue. Both in vivo spectra and HR MAS spectra were used as input for multivariate analysis (principal component analysis (PCA) and partial least squares regression analysis (PLS)) to compare controls to treated tumors. Tumor growth was suppressed in docetaxel-treated mice compared to the controls. The anti-tumor effect led to an increase in K(trans) and v(e) values in all the treated groups. Furthermore, in vivo MRS and HR MAS MRS revealed a significant decrease in choline metabolite levels for the treated groups, in accordance with reduced proliferative index as seen on Ki-67 stained sections. In this study DCE-MRI, in vivo MRS and ex vivo HR MAS MRS have been used to demonstrate that docetaxel treatment of a human breast cancer xenograft model results in changes in the vascular dynamics and metabolic profile of the tumors. This indicates that these MR methods could be used to monitor intra-tumoral treatment effects.

[Drawing improves understanding of anatomy, operation planning and communication].

This review summarises the knowledge of drawing as a learning tool. Drawing is a skill, which can be used by doctors in communicating with their patients. It also seems, that drawing supplements traditional learning methods and improves learning and retention of knowledge. Drawing is used by some doctors for planning of operations and as a visual tool to explain procedures and improve communication with patients. New visual technologies like augmented reality, virtual reality and 3D printing seem promising when used for training surgical skills and anatomy or planning operations.

Vocational Rehabilitation in Mild Traumatic Brain Injury: Supporting Return to Work and Daily Life Functioning.

Persisting post-concussive symptoms are challenging to treat and may delay return-to-work (RTW). The aims of this study were to describe a multidisciplinary and holistic vocational rehabilitation (VR) program for individuals with mild traumatic brain injury (mTBI) and to explore course and predictors of employment outcome during VR. The VR program was described using the Standard Operating Procedures (SOPs) framework. Further, a retrospective, cohort study on individuals with mTBI receiving VR was conducted based on clinical records (n = 32; 22% males; mean age 43.2 years; 1.2 years since injury on average). The primary outcome was difference in hours at work per week from pre- to post-VR, and the secondary outcome was change in a three-level RTW-status. Time since injury, age, sex, and loss of consciousness were investigated as predictors of the outcomes. The VR intervention is individually tailored and targets patients' individual needs. Thus, it may combine a variety of methods based on a biopsychosocial theoretical model. During VR, hours at work, 17.0 ± 2.2, p < 0.001, and RTW-status, OR = 14.0, p < 0.001, improved significantly with 97% having returned to work after VR. Shorter length of time since injury and male sex were identified as predictors of a greater gain of working hours. Time since injury was the strongest predictor; double the time was associated with a reduction in effect by 4.2 ± 1.4 h after adjusting for working hours at start of VR. In sum, these results suggest that individuals facing persistent problems following mTBI may still improve employment outcomes and RTW after receiving this multidisciplinary and holistic VR intervention, even years after injury. While results are preliminary and subject to bias due to the lack of a control group, this study warrants further research into employment outcomes and VR following mTBI, including who may benefit the most from treatment.