There is a growing body of evidence that access to best practice perioperative care varies within our population. In this study, we use national‐level data to begin to address gaps in our understanding of regional variation in post‐operative outcomes within New Zealand.Using National Collections data, we examined all inpatient procedures in New Zealand public hospitals between 2005 and 2017 , and identified deaths within 30 days. We calculated crude and adjusted rates per 100 procedures for the 20 district health boards (DHBs), both for the total population and stratified by ethnicity (Māori/European). Odds ratios comparing the risk of post‐operative mortality between Māori and European patients were calculated using crude and adjusted Poisson regression models.We observed regional variations in post‐operative mortality outcomes. Māori, compared to European, patients experienced higher post‐operative mortality rates in several DHBs, with a trend to higher mortality in almost all DHBs. Regional variation in patterns of age, procedure, deprivation and comorbidity (in particular) largely drives regional variation in post‐operative mortality, although variation persists in some regions even after adjusting for these factors. Inequitable outcomes for Māori also persist in several regions despite adjustment for multiple factors, particularly in the elective setting.The persistence of variation and ethnic disparities in spite of adjustment for confounding and mediating factors suggests that multiple regions require additional resource and support to improve outcomes. Efforts to reduce variation and improve outcomes for patients will require both central planning and monitoring, as well as region‐specific intervention. In this study, we used national‐level data to begin to address gaps in our understanding of regional variation in post‐operative outcomes within New Zealand. After adjusting for confounding, we found regional variation in post‐operative mortality and in equity of outcomes between Māori and European patients. Regional variation in patterns of age, deprivation and comorbidity (in particular) helps to drive regional variation in post‐operative mortality, although variation persists in some regions even after adjusting for these factors. At the level of individual care, death shortly after surgery may occur despite timely, high‐quality care being provided. At the population level, patterns of deaths shortly after surgery may be used to indicate potential inadequacies in access to (and delivery of) high‐quality perioperative care.Within the context of publicly funded surgery in New Zealand, there is a growing body of evidence that access to best practice perioperative care varies – sometimes strikingly – within our population. Clear disparities in post‐operative outcomes have been identified for Māori patients relative to European patients,et al.et al.However, few studies have examined geographical variation in post‐operative outcomes within New Zealand. When recently examining variation in 30‐day mortality following hip fracture repair between regions, New Zealand's Perioperative Mortality Review Committee (POMRC) found that once rates were adjusted for age, gender, ethnicity, deprivation and comorbidity, there was no substantive difference between district health boards (DHBs).In the current study, we used national‐level data to begin to address gaps in our understanding of regional variation in post‐operative outcomes within New Zealand. We aimed to address the following questions: (i) to what extent does the rate of 30‐day post‐operative mortality differ between region of treatment in New Zealand?, (ii) to what extent can any variation be explained by differences in procedure‐ and patient‐related factors between regions? and finally (3) given what we understand about ethnic inequities in post‐operative mortality within New Zealand, do Māori and European patients experience similar regional variation in 30‐day post‐operative mortality?Our study cohort included all patients who underwent an inpatient procedure in a New Zealand public hospital between 1 January 2005 and 31 December 2017, as recorded on the National Minimum Dataset (NMDS).DHB of treatment was defined as the DHB in which the procedure took place, and was determined using the hospital facility code within the NMDS. Procedure specialty was determined by mapping procedures to the Australasian College of Health Informatics (ACHI) procedure code ‘block’, which is organized by anatomical specialty.Patient comorbidity was measured in two ways: using the ASA physical status score (to measure acute morbidity at the time of procedure) and the M3 index of multimorbidity (to measure long‐term condition morbidity in the build‐up to the procedure).Crude descriptive analysis was used to determine the number and rate (per 100 procedures) of death within 30 days of any procedure, stratified by DHB. When examining ethnicity‐specific rates of post‐operative mortality, we determined age‐standardized rates (per 100 procedures) using direct standardization methods,To examine the impact of the potential drivers of variation in rates of post‐operative mortality between regions, we calculated both crude and adjusted rates stratified by DHB using Poisson regression. Rates were calculated as the number of deaths within the 30‐day post‐operative period (including the date of the procedure), as a function of the total number of procedures that were performed over the follow‐up period as the denominator. Covariates (or ‘explanatory variables’) were added in a step‐by‐step manner to the Poisson models – starting with the crude (unadjusted) model that compared rates by DHB (first model), then iteratively adding age and sex as classic confounders (second model), then variables relating to the type of procedure being undertaken , a variable representing socioeconomic deprivation , then two variables representing chronic and acute comorbidity  and finally ethnicity (sixth model). We adjusted for ethnicity last, in order to ensure that the impact of comorbidity and deprivation was already accounted for within the model, given the differential burden of these factors between ethnicities.In addition to completing the above analysis for the total cohort, we also stratified our results by ethnicity, with a focus on Māori and European ethnic groups. Using crude and adjusted rates of post‐operative death for Māori and European patients, we calculated rate ratios between ethnic groups, stratified by DHB. We ran the same iterative models as for the total population (with the exception of ethnicity). We did not compare ethnic groups in those DHBs where fewer than 10 Māori patients died over the follow‐up period, in an effort to avoid over‐interpretation of imprecise data.Data management and analysis was completed in SAS v9.4 , Stata v16  and Microsoft Excel 2016 . Ethical approval for this study was sought and obtained from the University of Otago Human Ethics Committee , approval # HD18/085.The number of procedures and deaths are presented in Table Figures Ethnicity‐stratified data are presented in Table The relative risks of post‐operative mortality between Māori and European patients are shown in Figures To date, there has been limited research regarding regional variation in post‐operative outcomes in New Zealand. In this national study of all publicly funded inpatient procedures over a 13‐year period, we found rates of mortality following acute (2/100 procedures) and elective/waiting list (0.27/100 procedures) are in line with those observed in other regions including the USA.We found that some of the initially observed higher rates of post‐operative mortality in regions such as Auckland and Capital and Coast DHBs were explained by differences in both the type and risk of the procedure. This suggests that most of the excess risk identified in the age‐/sex‐adjusted models was likely due to these DHBs performing more higher‐risk procedures; for example, coronary artery bypass graft procedures are only performed within the five main centres (data not shown).Adjusting for deprivation had limited impact on the rates of 30‐day death within the majority of DHBs, and had little or no impact on disparities between Māori and European patients with the exception of Northland and Lakes DHBs. This highlights that it is entirely feasible that some covariates will modify the risk of post‐operative mortality in some regions, but not in others.Even after adjusting for the impact of differential patterning of age, sex, procedure type/severity and deprivation, comorbidity had possibly the strongest impact on both rates of 30‐day death in the total cohort Fig.  and dispOnce adjusted for the confounding impact of the younger age structure of the Māori population, we observed substantial disparities in post‐operative mortality between Māori and European patients across nearly all DHBs Fig. . While eIt is important to note that an absence of disparities (or of variation between DHBs in the rates of 30‐day death) following adjustment for covariates such as comorbidity does not translate to an absence of room for improvement within a given region; merely that the included covariates were, in many cases, able to explain the majority of this variation. Some of the key actions required to reduce the burden of comorbidity or increase the equitable distribution of care throughout the country need to occur centrally – including changes to how the health system is structured following the Health and Disability System Review,Upcoming changes to the structure of New Zealand's health system following the Health and Disability System ReviewThis study provides a national‐level overview of post‐operative mortality following publicly funded inpatient procedures within New Zealand. We used national routinely collected health records for all procedures performed in New Zealand over a 13‐year period, which enhanced the validity and generalizability of our findings. We note that this study relies on the accuracy of routinely collected health records, as reported by DHBs to the Ministry of Health. We also note that as this is a study of regional variation in post‐operative outcomes following a publicly funded procedure, and because of limitations in access to consistent and comprehensive privately funded surgical data at a national level, this study does not consider regional variation in outcomes following a privately funded procedure. We note that while we have included multiple explanatory factors within our analysis, there are likely to be other factors that could contribute to regional variation (as well as variation in ethnic disparity) that we cannot examine with the available data . Finally, we note that the current study grouped all procedures together, and that the extent of regional variation in post‐operative outcomes may differ between procedure types; further research is required to examine regional variation by surgical specialty.We found that there is both regional variation in post‐operative mortality after adjusting for multiple confounders , as well as regional variation in equity of outcomes between Māori and European patients. The persistence of variation and ethnic disparities in spite of adjustment for confounding and mediating factors (including procedure type and comorbidity) suggests that there is room for improvement in multiple regions. Efforts to reduce variation and improve outcomes for patients will require both central planning and monitoring, as well as region‐specific reflection and intervention.Jason K. Gurney: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; supervision; writing – original draft; writing – review and editing. Melissa McLeod: Conceptualization; investigation; writing – review and editing. James Stanley: Formal analysis; investigation; methodology; writing – review and editing. Bridget Robson: Investigation; writing – review and editing. Douglas Campbell: Investigation; writing – review and editing. Elizabeth Dennett: Investigation; writing – review and editing. Dick Ongley: Investigation; writing – review and editing. Juliet Rumball‐Smith: Investigation; writing – review and editing. Diana Sarfati: Investigation; writing – review and editing. Jonathan Koea: Conceptualization; investigation; writing – review and editing.None declared.Table S1. Crude and adjusted rate of 30‐day mortality (n/100) following (a) acute and (b) elective/waiting list procedures, iteratively adjusted for potential drivers of variation between district health boards  acute and (b) elective/waiting list procedures, by district health board (DHB), with iterative adjustment for modelled variables (i.e. tabulation of data presented in Fig. Click here for additional data file.


We report a difficult‐to‐diagnose case of Borrmann type IV gastric cancer with poor typical findings and marked colonic stenosis in a 47‐year‐old man and present a literature review. We report a difficult‐to‐diagnose case of Borrmann type IV gastric cancer with poor typical findings and marked colonic stenosis in a 47‐year‐old man and present a literature review. Advanced gastric cancer usually presents with epigastric or bleeding symptoms from the tumor such as black stools, hematemesis, and iron deficiency anemia. Advanced gastric cancer usually presents as an elevated lesion and is often detected on computed tomography (CT) or esophagogastroduodenoscopy (EGD). We report a difficult‐to‐diagnose case of Borrmann type IV gastric cancer with poor typical findings and marked colonic stenosis.A 47‐year‐old man with no past medical history presented with a complaint of colicky pain in the entire abdomen, fever, and watery stools that started about 1 month previously. He had a high fever (38.4°C) and tenderness in the lower abdomen. Laboratory examination on admission revealed signs of acute inflammatory response , hypoalbuminemia , and normal range of serum tumor markers . CT imaging Fig.  showed aGastric cancer is the third most common cause of cancer‐related death both globallyet al., colonic metastasis of gastric cancer is extremely rare. They also reported that the colonoscopic findings of the colonic metastasis were only wall thickening and swelling, unlike the classic appearance of primary colorectal cancer, which is contact bleeding or centrally ulcerated lesions in the colon.et al. reported most of the patients with gastric cancer with colonic metastasis had poorly differentiated adenocarcinoma.The initial cause of the transverse colon stenosis in this case was thought to be peritoneal dissemination and direct tumor invasion, based on the autopsy, but the possibility of colonic metastasis of gastric cancer was also raised. According to Su Our patient presented with marked transverse colon stenosis, no epigastric or bleeding symptoms, and normal serum tumor markers, which made the diagnosis difficult. Therefore, when an unexplained stenosis of the transverse colon is found, the possibility of Borrmann type IV gastric cancer should be considered in the diagnostic process.


Accessing the coronary arteries post‐transcatheter aortic valve replacement is a growing challenge. This is a case of a patient requiring percutaneous coronary intervention on a left circumflex artery after a TAVR valve‐in‐valve and a left main “chimney” stent, describing all the challenges met during the procedure. Accessing the coronary arteries post transcatheter aortic valve replacement is a growing challenge. This is a case of a patient requiring percutaneous coronary intervention on a left circumflex artery after a TAVR valve‐in‐valve and a left main “chimney” stent to prevent coronary occlusion were performed. This is leading to an increased number of TAVR procedures, going along with the spirit of the time for less invasive techniques. One of the concerns about TAVR is the ability to access the coronary arteries after the procedure,To raise the bar of complexity, in patients with low takeoff of the left main coronary artery and high risk of coronary artery occlusion, a stent is deployed in the ostium of the left main, protruding outside the perimeter of the TAVR valve into the aorta like a “chimney,” to ensure patency and prevent a catastrophic event.2This is a case of a 76 years old female patient, with past medical history of severe aortic stenosis, who initially underwent surgical aortic valve replacement with a bioprosthetic valve, which got degenerated and patient developed dyspnea with exertion. The surgical valve was stenotic, so a valve‐in‐valve TAVR with balloon‐expandable valve was performed. Due to low takeoff of the left main coronary artery, a drug‐eluting stent was deployed right after the TAVR valve deployment with the “chimney technique” in the ostium of the left main coronary artery. Two years after the TAVR procedure, she developed progressive angina with even mild exertion.3The differential diagnosis for this patient included but was not limited to prosthetic valve degeneration (stenosis or regurgitation), coronary artery disease (causing angina), or new native valvular disease (causing elevated pulmonary artery pressures).4Initial work up included a transthoracic echocardiogram that showed preserved left ventricular ejection fraction of 55%, a mean gradient of 16 mmHg across the aortic valve prosthesis, normal wall motion, and normal native valves function. A myocardial perfusion study was performed, which showed ischemia on the lateral and anterolateral wall of the left ventricle. A coronary angiogram was performed that showed 95% stenosis on the middle segment of the left circumflex artery, consistent with the findings of the myocardial perfusion scan , crossing through the side struts of the chimney stent and causing further deformation, leading to left main hypoperfusion and hemodynamic instability. Using a guide extension catheter protects the left main chimney stent by avoiding contact with all the necessary equipment for the percutaneous intervention. The balloon‐assisting technique was used to facilitate the passing of the guide extension through the left main chimney stent.These cases will become more common as TAVR is gaining momentum. The case reported above according to our knowledge is the first percutaneous intervention through a left main chimney stent and can be a helpful resource while optimizing the methods of securing coronary artery access post‐TAVR.6.1Importance of protecting the integrity of left main “chimney” stent while post‐dilating a TAVR valveImproving safety while performing PCI through a left main “chimney” stentUse of balloon‐assisted delivery of a guide extension catheter through a deformed stentThe author planned and performed the procedure, wrote the manuscript, and made all necessary revisions.Nothing to disclose.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Validation of quantitative MR measures for myelin imaging in the postmortem multiple sclerosis spinal cord.1 and T2 protocol to produce apparent proton density, T1, T2, myelin water, intracellular water, and free‐water fraction maps. After imaging, the cords were sectioned and stained with histological markers , which were quantitatively compared with the MR maps.Four fixed spinal cord samples were imaged first with a 3T clinical MR scanner to identify areas of interest for scanning, and then with a 7T small bore scanner using a multicomponent‐driven equilibrium single‐pulse observation of TExcellent correspondence was found between high‐resolution MR parameter maps and histology, particularly for apparent proton density MRI and myelin basic protein staining.High‐resolution quantitative MRI of the spinal cord provides biologically meaningful measures, and could be beneficial to diagnose and track multiple sclerosis lesions in the spinal cord. Formalin‐fixed spinal cords were placed on a Perspex frame and inserted into glass tubes. The formalin was drained and the tubes then filled with perfluoropolyether  to provide a susceptibility‐matched signal‐free background . Nine areas of interest were identified by a neurologist with > 20 years of experience in reading MRI of people with MS (KS) for scanning at 7 T. The thoracic level 1 was marked with a radiologically opaque marker tied to the nerve root; measurements of distance from the marker for each lesion were noted and used to inform positioning of the glass tube for subsequent 7T scanning.Qualitative structural MRI was performed on the whole cords at 3 T  using a 15‐element SENSE spine coil and a turbo spin‐echo sequence with the following parameters: TE = 16 ms, TR = 5000 ms, voxel size = 0.4 × 0.4 × 2.0 mmNext, the cords were scanned using a 7T preclinical scanner  and 39‐mm diameter quadrature transmit‐receive RF coil  designed for whole‐body rodent imaging. As the human spine is longer than the achievable FOV with this setup, for each area of interest the glass tubes were moved in or out of the RF coil as required to place the desired area at both the center of the RF coil and the isocenter of the magnet. We observed that the active area of the RF coil was longer than the linear region of the image encoding gradients. As the samples were long enough to protrude into this region, protons that were excited by the RF but not encoded by the gradients resulted in a “zipper artifact” in some images. This was minimized by careful rotation of the samples so that the artifacts did not intrude into areas required for analysis. In most samples, a small quantity of formalin remained after draining, which produced bright signal at the top of the sample tube. To avoid this wrapping into the tissue, the FOV was increased in the vertical direction.1 correction.3 for processing. The images were processed using the open‐source Quantitative Imaging Tools (QUIT) C++ toolboxhttp://github.com/spinicist/QUIT). T1 maps were generated using nonlinear least‐squares fitting to images with all flip angles,Spoiled gradient‐echo and balanced SSFP (with two RF phase cycles) sequences were acquired with the parameters given in Table 1 and T2 for each water component.1 and T2 of white matter (WM) in a healthy cord was used as a reference point for the myelin water T1 and T2; healthy gray‐matter (GM) relaxation times were used as reference points for the intracellular/extracellular water T1 and T2; and literature values were used for the free‐water fraction.Calculation of MWF from mcDESPOT requires the a priori specification of valid initial ranges of Thttp://mipav.cit.nih.gov/) was used to manually define regions of interest (ROIs) on aPD maps and transfer them to all other maps for ROI analysis.The MR parameter maps were then matched with histology using positional information (cord level and distance of the lesion from the marker) from the 3T whole‐cord scans, and checked against anatomical features (such as lesion shape and gray‐matter anatomy) in the histology and 7T images. MIPAV . Care was taken to cut the sections in a plane perpendicular to the anterior spinal artery. The sections were mounted on Superfrost1 slides  and left in a 608°C oven overnight.Serial sections of each block were stained for hematoxylin and eosin, phosphorylated neurofilaments  and myelin basic protein  following a modified protocol.2) cast randomly onto WML and nonlesional white matter (NLWM) on hematoxylin and eosin and SMI‐31 stained sections, respectively  and gray matter (GML). Cellularity and axonal counts were determined by counting the number of cells in four square ROIs , and 1 male control subject with no neurological disease, were used. The MS cords were from donors who died at the age of 67–87 years. Their disease duration had been 8–44 years. The MS cords had been fixed for 1127–1441 days. The control subject died at the age of 89 years. Duration of fixation of this cord was 1366 days.1 and T2 maps showed less contrast between lesion and healthy tissue than aPD, whereas the MWF produced high contrast, matching well with the myelin histology in the cords from people with MS. The IEWF map showed, as expected, the inverse of the MWF map (lower in myelinated areas and higher elsewhere). Surprisingly, the FWF map was nonzero in healthy tissue area, especially in the control cords, but decreased to zero in lesion areas. Cord MS454 had no gray‐matter areas that could definitely be determined as normal‐appearing gray matter. Myelin basic protein staining, aPD, MWF, IEWF, and FWF images only are shown together in Supporting Information Figure Figure Quantitative histology results and mean values of the MR parameters from the ROIs are given in Table p < 0.0001). Graphs of correlation (Pearson’s correlation) between histological and MR indices over all WML and NLWM in MS cords, and control WM in control cords  are shown in Figure p‐values found in Supporting Information Table p = .046), but not significant between axons and MWF in NLWM and control WM. This significance is likely due to the difference in nuclei between control data and NLWM rather than a correlation with MWF.Graphs of the MWF, IEWF, and FWF values in the NLWM, NLGM, and WM and GM lesion are shown in Supporting Information Figure 41 and T2 maps provide quantitative measures that correlate with quantitative histology measures.Our results show that with high‐resolution scanning at 7 T, good correspondence between quantitative MRI and histological metrics is observed. Apparent proton density maps show excellent contrast between healthy and pathological tissue, and T2. This may indicate infiltration by the fixative or may simply be due to bias in the fitting procedure.1 and T2.The MWF maps show clear differentiation between lesion and nonlesional tissue. The nonzero FWF in the healthy control cord is an unexpected finding, as fixed tissue has not been believed to contain water protons with a long T1 and T2 values, reducing the differences between the myelin and intracellular/extracellular compartments.Our samples were not rinsed of fixative before acquisition, as this could cause degradation of the tissue, and therefore contained formaldehyde. Formaldehyde causes known shortening of the TThe IEWF maps also show good definition between tissue types, with high values in lesional tissue. This implies more space in larger cells and between the cells in these areas. This has been postulated previously by Christiansen et al,1 and T2 maps showed comparatively low contrast. However, the aPD maps also showed excellent correspondence with histology, with increased values in lesion areas. It should be noted that because MWF and IEWF are defined as fractions, the aPD is effectively removed from the mcDESPOT measures; hence, the contrast in the aPD maps is orthogonal information to that in the mcDESPOT parameter maps. Our results imply that if, for example, only the MWF is considered, then an important additional source of information  will be missed.Despite the issues related to fitting the mcDESPOT model, the MWF and IEWF showed good contrast and anatomic correspondence to the histology images, whereas the single‐component T5High‐resolution quantitative MR parameter maps offer an alternative modality to histology for ex vivo quantitative assessment of MS spinal cord lesions. The MWF maps showed good contrast between lesional and non‐lesional tissue. Proton density, which reflects total water content, correlated significantly in MS lesions and offers additional information compared with the mcDESPOT parameter maps. The mcDESPOT model may benefit from the use of a Bayesian priors algorithm for more challenging conditions.GJB received honoraria for teaching from GE Healthcare at the time of this study. There are no other known conflicts of interest to disclose.FIGURE S1 Whole spinal cord secured in a glass tube and immersed in perfluoropolyether ready for scanningFIGURE S2 Example hematoxylin and eosin (H&E) stained section  with four square regions of interest (ROIs) positioned in the red outlined region ; gray matter is outlined in black. Zoomed section  shows detail in square ROI. Cellularity and axonal counts were determined by counting the number of cells in four square ROIs (size: 120 × 120 μm2) cast onto lesional and non‐lesional white matter on the H&E and SMI‐31 stained sectionsFIGURE S3 Expanded from Figure 2, showing only MBP, proton density (PD), myelin water fraction (MWF), intracellular/extracellular water fraction (IEWF), and free water fraction (FWF) to facilitate comparisonFIGURE S4 Box and whisker plots of all MR parameters in each tissue type. Red points are control samples, for which there are no lesional data. Differences in all parameters were present between nonlesional white matter (NLWM) and white‐matter lesion (WML). Center line is the mean with whiskers of 1 SDFIGURE S5 Graphs of correlation for MWF separated into individual white‐matter types expanded from Figure 2: WML and MLWM. Correlations with nuclei against MWF in WML and NLWM in multiple sclerosis (MS) cords and control white matter in control cords  and axons against MWF in WLM and NLWM in MS cords and control white matter in control cords . Control cord white‐matter data are shown by the red data points. The best fit line is shown with the 95% confidence intervalsFIGURE S6 Graphs of correlation for proton density separated into individual white‐matter types expanded from Figure 2: WML NLWM. Correlations with nuclei against proton density in WML and NLWM in MS cords and control white matter in control cords  and axons against proton density in WML and NLWM in MS cords and control white matter in control cords . Control cord white‐matter data are shown by the red data points. The best fit line is shown with the 95% confidence intervalsTABLE S1 Correlation coefficients for graphs shown in Figure 2Click here for additional data file.


A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need.We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models – individuals and hospital regions – were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 − 2013 and 2014 − 2017. The impact of several individual level explanatory factors  and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios.We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 − 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 − 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 − 2013, but only 5% in 2014 − 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially.Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.The online version contains supplementary material available at 10.1186/s12913-022-08305-7. A persistent research finding in industrialised countries has been regional variation in medical practices. In a recent systematic review, Corallo et al.  reportedA number of studies from different countries have focused on hip and/or knee arthroplasties and reported relatively large regional variations for their rates –11. In aThe sociodemographic composition of the region may have an effect on regional variation in these operations as there is evidence of an association between ageing of the population, previous heavy physical workload (e.g. work involving heavy lifting or farming) and the occurrence of hip and knee osteoarthrosis –20. In tThe aim of the current study was to examine (1) trends in regional variation in elective primary hip and knee arthroplasties and to analyse (2) how much of the variation can be explained by individual level factors including gender and age, comorbidities and socioeconomic position of the patients, or area level differences in population need, and (3) whether the effects of these factors have changed over time. Elective primary hip and knee operations are an interesting case for examining the reasons behind variation as there are no clear-cut criteria for need of these operations.The Finnish health-care system provides a good case for examining variations in joint arthroplasties as the system is universal in coverage and therefore, in general, supports equity in access to health care according to need. Municipalities provide public primary health care for the whole population through health centres. In addition, employers organize mandatory preventive occupational health care for their employees and can also organize curative primary care services. There are also private primary care services available for the population, but user fees can be a barrier to accessing them as private care is only partially reimbursed to patients . The pubWe obtained information on patients undergoing hip and knee arthroplasties for the total Finnish population aged ≥ 25 years in 2010 − 2017 from the routinely collected Finnish Care Register for Health Care maintained by the Finnish Institute of Health and Welfare (THL). To guarantee maximum coverage of the procedures we further complemented the hospital discharge register data using the Finnish Arthroplasty Register (FAR) maintained by the THL. Hospitalisations including these procedures from Care Register and FAR were combined if there was a maximum one-day gap separating the periods. A maximum of two primary procedures per person were examined. We formed annual cohorts for all individuals with primary hip or knee arthroplasty according to the NOMESCO Classification of Surgical Procedures . The totThe annual FOLK data set maintained by Statistics Finland was used to obtain individual level data for gender, age, municipality of residence, level of education, family net income per consumption unit using the OECD framework  and occuAs the geographic unit of analyses we used region of residence which was operationalised as hospital districts , responsible for organising public specialist services in the area . Each muAs we did not have a direct indicator of regional variation in need for these operations, we used the hospital district level musculoskeletal disorder index  as a proEthical approval for the study was received from the Research Ethics Committee of THL. Permissions to use register data from Care Register and FAR were sought from THL and permission to use the FOLK data from Statistics Finland. All linkages were performed by competent authorities using the personal identification codes unique to each individual in Finland. The data was pseudonymised before handing it over to the research team to be used through the remote access system of Statistics Finland.th and 97.5th percentiles as estimates for 95% credible intervals. We analysed the incidence of primary hip and knee arthroplasty separately in two consecutive time periods: 2010 − 2013 and 2014 − 2017 as the annual numbers of the procedures were not sufficiently high for the analyses.We built on analysis strategy presented by Falster et al.  and anal2) for hospital district which represents the baseline estimate for regional variation in the analysis. Subsequent models were compared to Model 0. We measured how each additional factor affected hospital district variance using the proportional change in variance (PCV) as a measure [By first analysing the age and gender adjusted model (Model 0) we acquired the estimate of variance , all individual level factors, i.e., female gender, older age, having no or one comorbidity, basic or secondary education, occupation as a farmer and having higher than the lowest quintile income were associated with higher IRR in 2010 − 2013. Having two or more comorbidities, higher education or low income decreased the likelihood of the operation. We performed additional analysis adding each of the individual level factors to Model 0 separately, and the results were similar to those presented in Table We then examined the effect of these variables in explaining regional differences in hip arthroplasties Table . In gendIn 2014 − 2017, individual level factors associated with hip arthroplasties were similar to those in 2010 − 2013. However, only higher level of education was statistically significantly associated to IRR of hip arthroplasties in the final model (Model 5). Farmers were more likely and those with lower income less likely to have undergone the operation. The lower the income the lower the likelihood of hip arthroplasty was. High area level musculoskeletal index did not have a statistically significant IRR that deviated from 1.00. When examining factors explaining regional variation  for knee arthroplasties suggested that all individual level factors were associated with IRR of the operation , we found relatively small regional heterogeneity in operation risks. This heterogeneity remained rather constant even after controlling for individual level sociodemographic factors and area level need.We found small and over time relatively stable regional variation in elective primary total hip arthroplasty in Finland 2010 − 2017, while in primary total knee arthroplasty the variation was larger and decreased slightly during the study period. In 2010 − 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasty, an effect that did not emerge in 2014 − 2017. The area-level musculoskeletal disorder index reflecting the need for care explained in total a further 44% of the variation in hip operations in 2010 − 2013, but only 5% in 2014 − 2017 – and respectively 22% and 25% in knee operations. Our results are in line with earlier studies from different countries reporting regional variation in these procedures [While our model for hip arthroplasty in 2010 − 2013 explained regional variation surprisingly well, PCVs in the operation in 2014 − 2017 remained rather low. This may result from changes in hospital district level procedure rates between the time periods as our set of explanatory variables was unable to capture a large part of variation in the latter period. In our study, comorbidity did not explain much regional variation in either hip or knee arthroplasty suggesting similar criteria concerning eligibility to be used in hospital districts across the country. However, socioeconomic position of the patients did have a role in explaining some regional differences in hip and in knee arthroplasties in the first period. These results are in line with earlier research from other countries , 8, 13 aRegional differences in need seem to play a further important part in regional differences as a high musculoskeletal disorder index in the district was an important explanatory factor for regional differences in both procedures throughout the study period. While the proportion of 65 + year-olds did seem to explain some of the variation, distance to the hospital, queueing times, having a university level hospital in the area, and/or numbers of orthopaedic surgeons did not seem to be as important. We used the musculoskeletal disorder index as a regional indicator of need as it fitted the models best. Similar results have also been reported in earlier studies concerning differences in need and supply of services , 4, 8. FA strength of our study was that we were able to use nationwide, representative register data covering all Finnish residents in 2010 − 2017. The data were collected from the nationwide Care Register for Health Care based on clinical diagnoses. The overall accuracy and coverage of the register has been reported to be good . HoweverWe acknowledge that the change in PCVs in hip arthroplasties over time limits the interpretation of the results: our hip arthroplasty models explained almost no variance in 2014 − 2017. This finding was similar when reanalysed with two-year periods. Our interpretation is that it occurred because of the low variances in the null models which meant that even minor changes in hip arthroplasty procedure rates could affect the explanatory power of models. Indeed, there were some changes in the distribution and order of hospital districts rates between 2010 − 2013 and 2014 − 2017. Moreover, the low variances were accompanied by relatively large uncertainty: the credible intervals for the variances overlapped between the time periods as well as between subsequent models.While we did not have direct information concerning individual need for these operations, we used the musculoskeletal disorder index as an indirect proxy for area level need allowing us to take regional differences in need for operations into account. Nevertheless, as current care guidelines rely on perceived functional limitations in addition to clinical severity of osteoarthritis, direct measurement of need is not possible in a total population approach. Further, we did not have information of obesity or exercise habits among the population as the registers used in this study do not record information on these, and thus we cannot evaluate their role in the decisions to operate. The index is based on numbers of working age population receiving disability pension due to musculoskeletal diseases in each of the study years and while it does not focus on disability pensions due to osteoarthritis of hip or knee only, it seems to represent regional differences in these diseases better than individual level indicators used in this study. The role of the referring primary care providers is a complex issue. As we did not have information of the health care sector of the referring primary care provider  it is not possible to assess the effect of private or occupational health care on access to these operations. On the one hand, all employed people in Finland have access to occupational health care, but its content tends to vary between industries and companies. A broader coverage for curative services tends to be available for employees in larger companies and white-collar workplaces. Moreover, supply of occupational health care is likely to be better in hospital districts containing more urban areas. On the other hand, those still in the workforce and thus having access to occupational health care tend to be younger and in better health. Use of private health care is likely to be associated with income level of the patients as its use is only partially reimbursed by the national health insurance system. There is also likely to be regional variation in supply of private services. Our results suggest that eligibility criteria in total hip and total knee arthroplasty are increasingly consistent between Finnish hospital districts – only some regional differences emerged in both operations across the country in 2010 − 2017. At the individual level, factors related to need  as well as socioeconomic factors (education and income) were associated with the likelihood of both operations. Our results further suggest that poorer access to both operations among those with lower income varies between hospital districts in both time periods. Regional differences in socioeconomic inequities in access to hip and knee arthroplasty would be an interesting question for further studies. However, the effect of individual socioeconomic position on regional differences was limited and decreased during the study period. Though two or more chronic comorbidities decreased the likelihood of total hip arthroplasty, this factor did not much affect regional variation in either operation. Contextual need related factors, measured in our study by regional musculoskeletal disease prevalence, seem to play an important role in regional differences in hip and knee arthroplasty. As the current regional equity in access to hip and knee arthroplasty appears promising, the next step should be to analyse regional equity in both quality and health outcomes of these operations. Another approach is to address the impact of individual level socioeconomic and health related factors which seems to associate with poor access to endoprosthesis surgery. This would be especially important in Finland where potential effects of policy actions including centralisation of specialised health care on regional and socioeconomic differences remain understudied.Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.Additional file 1. Hospital district variance (σ2) in elective primary total hip and knee arthroplasty in Finland for years 2010−2013 and 2014−2017, the proportion of variance explained (PCV) and Median Rate Ratio (MRR) when adding area-level variables one by one to both null model (M0) and the model with all individual variables (M4).Additional file 2. Individual and area-level factors added into the Models – the subsequent Models include also factors from previous ones.Additional file 3. Building of the two-level Poisson models for hip (THA) and knee (TKA) arthroplasty in two time periods.Additional file 4. Hospital district variation of elective total hip (THA) arthroplasties controlling for age and gender only (Models 4 and 5) in 2010-2013 and 2014-2017. Striped areas have incidence rate rations (IRR) over the country average.Additional file 5. Hospital district variation of elective total knee (TKA) arthroplasties controlling for age and gender only (Models 4 and 5) in 2010-2013 and 2014-2017. Striped areas have incidence rate rations (IRR) over the country average.


The majority of cancer patients with depressive symptoms does not perceive a need for psychological care. Reasons for this are still unclear. We examined the mediating role of cancer patients' perceptions of depressive symptoms in the relationship between depressive symptoms and perceived need for psychological care.For this cross‐sectional study, we recruited 127 Dutch cancer patients with moderate to severe levels of depressive symptoms  who did not receive professional psychological care. Depressive symptoms were measured with the PHQ‐9 questionnaire, by using three different depression score operationalizations. We used mediation analyses to test the mediating role of patients' illness perceptions  in the relation between depressive symptoms and need for care.B = 0.07, SE = 0.04, p < 0.02), meeting the DSM‐5 diagnosis  and having relatively more affective symptoms  on need for care through the identity perception.Whilst results did not show significant direct associations between depressive symptoms and perceived need for psychological care, we found positive indirect effects of severity (Including assessments of patients' recognition of depressive symptoms and their perceptions of depression treatment efficacy might improve depression screening in cancer patients by more accurately identifying those with a need for psychological care. Moreover, improving patients' knowledge and recognition of symptoms as being depressive symptoms might be a possible target point in increasing care needs and hereby optimizing the uptake of psychological care in cancer patients with depressive symptoms. Cancer patients might perceive depressive symptoms differently than patients in primary care due to overlap between depressive symptoms and symptoms related to cancer . Thus far, qualitative studies found that higher recognition of depressive symptoms and not considering symptoms as a normal part of life was related to higher need for psychological care in cardiovascular diseases,For patients with cancer type of depressive symptoms. When mainly experiencing somatic and few cognitive‐affective symptoms of depression, patients might attribute these symptoms to cancer and not to depression and thus not perceive a need for psychological support.Depressive symptoms are highly heterogeneous , and assessment of these symptoms in cancer patients can be difficult.The current study is the first to investigate whether perceptions of depressive symptoms explain an association between depressive symptoms and need for psychological care in cancer patients who currently do not receive psychological care for their elevated depressive symptoms. This leads to the following research questions: (1) To what extent are the three operationalizations of depressive symptoms related to need for psychological care?; (2) To what extent are the operationalizations of depressive symptoms related to perceptions of these symptoms?; (3) To what extent are perceptions of depressive symptoms related to need for psychological care?; and (4) Do perceptions of depressive symptoms mediate the relation between the operationalizations of depressive symptoms and need for psychological care?Although previous literature shows mixed results, based on a large body of evidence we expect that severity of depressive symptoms and meeting the DSM‐5 diagnosis of depression will not be related to need for psychological care.22.1The current study included baseline data from a longitudinal observational study within a larger project examining psychological care needs in cancer patients with depressive symptoms. Data were obtained using self‐report questionnaires. The study was approved by the Medical Ethical Committee of the University Medical Center Groningen (2017/064).2.2The target population comprised Dutch cancer patients who2.3, an international research agency with a respondent panel available for research (https://www.kantar.com/), carried out recruitment of respondents. Respondents in their database were contacted by e‐mail and asked if they had received any type of cancer diagnosis in the past 5 years. Respondents who did so were sent questionnaires to screen for further eligibility. Patients who fulfilled the criteria were instantly directed to the online questionnaires, after providing informed consent for study participation.Kantar Public2.42.4.1Socio‐demographic features included age, gender, educational level and marital status. Medical characteristics concerned time since cancer diagnosis, cancer type , currently receiving treatment (yes/no) and type of cancer treatment . Furthermore, information about history of depression and previous psychological help was collected. All variables were obtained with single self‐report questions.2.4.2The primary outcome was need for psychological care, and was measured with a single question: “Would you like to receive psychological help?” Answering options were “yes” and “no.”2.4.3not at all) to 3 (nearly every day). We used three operationalizations of depressive symptoms based on the PHQ‐9 scores.Depressive symptoms were measured using the PHQ‐9: a widely used and reliable self‐report questionnaire with good psychometric properties in cancer populations  factor: depressed mood, loss of interest, feeling worthless and suicidal ideation, with a Cronbach's alpha of 0.72.2.4.4not at all) to 3 (to a severe extent).We used items of the validated Brief Illness Perception Questionnaire—Dutch Language Version2.5Statistical analyses were performed in SPSS (version 26). Descriptive statistics were presented as means and standard deviations or counts and percentages. There were no missing data. Assumptions were checked using scatterplots and quantile‐quantile plots. The first three research questions were answered with correlation analyses. Only illness perceptions that significantly correlated with the operationalization of depressive symptoms and need for care were included in the mediation model. We corrected for multiple testing by dividing the alpha level of 0.05 by the total number of variables.Mediation analyses were conducted according to the Preacher and Hayes framework,33.1We approached 2549 patients, of which 2228 patients were screened for eligibility . However, all three operationalizations did significantly and positively relate to the need for psychological care via the identity dimension . Higher severity of depressive symptoms, being depressed according to the DSM‐5 criteria and experiencing a higher percentage of affective symptoms all led to a stronger identification of symptoms as being depressive symptoms. This in turn led to higher odds of perceiving a need for psychological care.None of the three operationalizations of depressive symptoms significantly related to the need for psychological care . Our results partly support this framework by showing that depressive symptoms were indeed associated with illness perceptions (particularly perceived consequences and identity). Future research could examine why other illness perceptions such as personal control and the perceived duration of symptoms were not strongly related to depressive symptoms or need for care. A second strength is that by considering different operationalizations of depression, we took into account depressive symptom heterogeneity and the somatic overlap of depression and cancer. Lastly, we used a personalized approach to measure illness perceptions based on the symptoms patients had indicated before.4.1A limitation of this study is that the cross‐sectional design did not allow us to make claims about the directionality of relationships. Although we based our hypothesized models on the well‐established CSM framework,4.2Although preliminary, the results of the current study have several clinical implications. First, the lack of a direct relation between depressive symptoms and need for psychological care shows that screening for merely depressive symptoms might not be effective in selecting patients who perceive a need for psychological support. Rather, including patients' identity and treatment control perceptions in screening might be more effective in identifying those with a need for care. Moreover, informing cancer patients about depression and possible treatment options might improve their recognition of depressive symptoms and knowledge regarding the beneficial effects of psychological treatment. This can be done through, for example, information campaigns or psycho‐education given by health care professionals during follow‐up medical appointments.5In conclusion, our study showed that the identification of symptoms as depressive symptoms and the perceived effectiveness of psychological treatments play a role in reporting a need for psychological care. Identification of depressive symptoms becomes more pronounced when patients have more severe symptoms, meet DSM‐5 criteria for depression, and experience relatively more affective symptoms.The authors have no potential conflicts of interest to report.Figure S1Click here for additional data file.


The synthesis of multicomponent polymer hybrids with nanometer precision is chemically challenging in the bottom‐up synthesis of complex nanostructures. Here, we leverage the fidelity of the DNA origami technique to install a multiple wavelength responsive photopolymerization system with nanometer resolution. By precisely immobilizing various photosensitizers on the origami template, which are only activated at their respective maximum wavelength, we can control sequential polymerization processes. In particular, the triggered photosensitizers generate reactive oxygen species that in turn initiate the polymerization of the catecholamines dopamine and norepinephrine. We imprint polymeric layers at designated positions on DNA origami, which modifies the polyanionic nature of the DNA objects, thus promoting their uptake into living cells while preserving their integrity. Our herein proposed method provides a rapid platform to access complex 3D nanostructures by customizing material and biological interfaces. DNA origami nanostructures have been decorated with photosensitive reaction centers that produce reactive oxygen species at their individual characteristic wavelengths. In this way, polymerization of the catecholamines dopamine and norepinephrine is induced and independent polymer patterning on the DNA origami template can be directed. In addition, the polymer rings alter the interaction of DNA origami objects and cell membranes, thereby promoting their cellular uptake. The spatial control and engineering of objects at nanometer resolution is imperative for the miniaturization of smart materials and devices. In both materials science and biomedicine, the demand for tools to construct multicomponent substructures across 3D space is required to expand the understanding of how surface patterns and object contours modulate interfacial forces. However, the construction of nanostructured surfaces on soft materials that can be freely customized is a bottleneck due to the lack of tools to precisely design them. This problem is further amplified for patterns that are much smaller than the wavelength of light, where top‐down approaches, such as lithography, reaches its limits. At this length scale, bottom‐up approaches based on self‐assembly provide the natural complementarity to top‐down strategies in the fabrication of patterned soft materials.Unlike the limitations posed by other systems based on synthetic polymers or peptides, DNA nanotechnology is equipped with the precision necessary to program nanostructured surfaces.In polymer chemistry and patterning, advances in radical and oxidative polymerization as well as the organization of polymer chains have demonstrated that the stringent conditions necessary for DNA origami can be made accessible to largely organic compounds.z‐direction. The formation of a polymer layer reduces the polyanionic nature of the DNA origami and can thereby facilitate its uptake into living cells, which can be imaged by fluorescence colocalization. Our approach will enable rapid and facile synthesis of multicomponent polymeric patterns with precise shapes and dimensions on DNA origami. Customizing the nano/bio‐interphase of DNA objects through surface modulation is crucial for various applications, for example, cellular uptake for therapeutic delivery.In this study, we control a series of photopolymerization reactions using multiple wavelengths to guide independent polymer patterns and fabricate layered structures on the DNA origami Figure . Previou1O2) was analyzed using an assay based on imidazole and p‐nitrosodimethylaniline (RNO).1O2, as reflected by the bleaching of RNO being 7 and 11 times faster, respectively . The initiation of polymerization using EY‐G4 and MB‐G4 on a tube DNA origami was subsequently attempted at their respective wavelengths . The tube DNA origami scaffold was designed with a central ring containing photosensitizer‐loaded G4 sequences. When using 10 mm dopamine in 100 mm buffer (pH 6.5), UV/Vis spectroscopy showed successful polymerization into polydopamine (pDA) after 3 h . The formation of intermediates including dopaminochrome (320 nm), oxidized oligomers (480 nm), and the eventual pDA (700 nm) could be monitored through their characteristic absorbances.To prepare 3D DNA origami tubes for photopolymerization, G‐quadruplex structures were arranged on the surface in distinct patterns. These catalytic centers can be tuned for wavelength selectivity by nominating the photosensitizer that will sit within the G‐quadruplex (5′‐GGG TA GGG C GGG TT GGG‐3′). As previously reported, the PPIX‐G4 complex produces ROS under irradiation with white light, which in turn trigger the oxidation and polymerization of dopamine. To suppress the well‐known self‐polymerization of dopamine and to control polymer formation, it is crucial to work in a slightly acidic environment (pH 6.5). Herein, we found that only blue light (410 nm) possesses sufficient energy to initiate the polymerization of dopamine . Excitation at the Q‐bands of PPIX‐G4 in the visible spectrum produced insufficient oxidized dopamine species to fuel polymerization. Wavelength specificity in the green and red region was accomplished by hosting EYWe subsequently investigated different patterns and the impact of the size of clustered G4 centers on the polymerization process. Firstly, we designed an origami tube with a diagonal G4 motif of similar density to the standard ring pattern . After polymerization, we could detect formation of pDA on the tubes, with varying observation perspective of the designated pattern. The lack of symmetry would mean that the orientation of the origami on the mica surface is subjected to inherent randomness and thus affects the imaging process. Hence, we consider ring patterns as the most reliable to provide robust characterization. In addition, we examined the correlation of polymer formation and the width of the ring system by direct comparison of the structures depicted in Figure z‐average values . Therefore, norepinephrine was introduced as a dopamine analogue to achieve well‐dispersible nanoobjects that also remain stable in complex media without aggregate formation. Norepinephrine also belongs to the catecholamine family and poly(norepinephrine) (pNE) reveals material‐independent modification capabilities similar to pDA but with an ultrasmooth surface morphology.16 Chemis Figure . MoreoveAdditionally, agarose gel electrophoresis (AGE) supplements the characterization of the origami tubes before and after polymerization of the pDA and pNE polymers .Based on the acquired reaction conditions and wavelength selectivities pertaining to DA and NE, sequential polymerization steps were performed to fabricate multicomponent nanostructures. The DNA origami tubes were loaded with MB‐G4s, and NE and DA were sequentially polymerized at 625 nm for 2 h each  by sequential irradiation at 625 nm and 525 nm for 3 h each. The generation of oxidized intermediates and pDA was verified by UV/Vis spectroscopy . Control experiments illustrated that the integrity of the DNA origami tube was not damaged by the prolonged irradiation and by the ROS produced by the photosensitizers .Next, we demonstrated wavelength orthogonality for a two‐step polymerization to achieve reaction selectivity. The dormancy of MB and EY at opposing wavelengths was first investigated. MB showed no generation of the oxidized species of DA when irradiated at 525 nm, and, likewise, EY was not active at 625 nm . To ensure that a consecutive activation of each photosensitizer can continuously trigger the polymerization of dopamine, the DNA origami tubes were loaded with ring patterns of EY‐G4 and MB‐G4 at each tubular end. Polymerization was initiated with DA  formed the first polymer ring, which could be visualized by AFM and UV/Vis spectroscopy  as the monomer to afford the final nanostructure where pNE and pDA each occupies a single ring. The oxidation profiles of both NE and DA in this dual component system showed consistent polymerization kinetics when compared to the single component system. Furthermore, by comparing the average polymer heights of each irradiation period, sequential ring formation can be tracked . In both the coupled and decoupled methods, we demonstrate that sophisticated and multicomponent 3D DNA‐polymer hybrids can be accessed easily.Additionally, the formation of these polymer patterns can be used as a tool to customize the surface chemistry of the DNA origami. Fundamentally, DNA origami structures are highly anionic due to the polyphosphate backbone and thus require divalent cations for stabilization.We therefore subjected our DNA structures, bare and polymer‐ringed origami, to cell medium conditions that are encountered when performing cell‐uptake studies. Comparatively, naked DNA structures exhibit a higher level of fragmentation than pNE‐origami when incubated at 37 °C for 24 h in cell medium .m, an efficient cellular uptake into A549 lung adenocarcinoma cells by pNE‐origami was observed by confocal laser scanning microscopy after 24 h incubation . However, significant aggregation was detected for pDA‐origami due to the well‐known adhesiveness of pDA. In agreement with the literature, Alexa‐647®‐labeled DNA origami alone do not show uptake into cells and neither does the Alexa‐647® oligonucleotide. To further characterize the stability of the internalized origami samples, another fluorophore, Alexa‐488®, was annealed onto the opposite end of the tube to facilitate co‐localization studies  that promote receptor‐mediated endocytosis.z‐direction. Furthermore, the polymer patterns altered the intrinsic polyanionic character of the DNA origami while preserving their integrity. By modulating the repulsive forces against the cellular membrane, these hybrid objects could be used for biological applications. In combination, this platform has provided a valuable tool to construct complex polymer‐origami architectures that enable the study of customized surface patterns in nanoscience and biomedicine.In summary, we have explored the patterned and layered growth of different polymers (pNE and pDA) on DNA origami using multiple wavelengths of light. The concept is facilitated by manipulating the interaction of G4s with different photosensitizers  such that their position on the DNA origami can be precisely located. As a consequence, the activity of each photocatalyst can be switched from active to dormant states, and vice versa. Moreover, the fabrication method is flexible so that the sequence of the photopolymerization reaction and/or annealing steps can be changed easily without affecting their efficiencies. The extent of polymer formation can be tracked easily by UV/Vis spectroscopy and AFM imaging, which facilitates structural customization in the The authors declare no conflict of interest.As a service to our authors and readers, this journal provides supporting information supplied by the authors. Such materials are peer reviewed and may be re‐organized for online delivery, but are not copy‐edited or typeset. Technical support issues arising from supporting information (other than missing files) should be addressed to the authors.Supporting InformationClick here for additional data file.