Inertial focusing is a microfluidic based separation and concentration technology that has expanded rapidly in the last few years. Throughput is high compared to other microfluidic approaches although sample volumes have typically remained in the millilitre range. Here we present a strategy for achieving rapid high volume processing with stacked and cascaded inertial focusing systems, allowing for separation and concentration of particles with a large size range, demonstrated here from 30 μm–300 μm. The system is based on curved channels, in a novel toroidal configuration and a stack of 20 devices has been shown to operate at 1 L/min. Recirculation allows for efficient removal of large particles whereas a cascading strategy enables sequential removal of particles down to a final stage where the target particle size can be concentrated. The demonstration of curved stacked channels operating in a cascaded manner allows for high throughput applications, potentially replacing filtration in applications such as environmental monitoring, industrial cleaning processes, biomedical and bioprocessing and many more. For example in environmental monitoring for pathogens such as et al.et al. also parallelized straight channels for a similar application achieving a higher filtration efficiency of 95% with 4 and 16 channel devices that could be operated at 4 mL/min81024As implied above parallelization is oft quoted as the solution to increase throughput, particularly in microfluidics. However, as highlighted in Table S1, there are much fewer examples of successful parallelization strategies in the literature, particularly for large particles separation using inertial focusing (>60 μm in diameter). Removing pathogenic bacteria from blood samples appears to be the application which has received most attention for parallelization in inertial focusing. Mach As Mach noted stacking could enable higher throughput since in-plane parallelization results in an expanded device footprint which can quickly become impractical and this strategy for inertial focusing was demonstrated in a prototype system developed by Parc  and in recent work by Warkiani21Recirculation or multiple passes within IF devices has been proposed previously for increasing purity and yield, having been described by the authors as operating devices in seriesvia imaging of particles within the device outlet channels and analyzing samples collected from the outlets using a laser diffraction particle size analyzer . All the designs presented a rectangular cross-section and utilized two outlets; the one closest to the inner wall being denoted the focused outlet since the focused particles, above a certain critical diameter are collected here. The critical diameter is function of the channel geometry and has been empirically estimated by a/Dh > 0.07a is the particle diameter and Dh is the hydraulic diameter of the channel .where This relationship, though purely empirical, may be useful for precisely targeting specific sizes of particles, provided that the channel design conforms to the ones produced for this work. Precise details for reproducing the spiral designs can be found in the SI.The use of a cascade of sequentially decremented scaled geometries reduces the consequent size of particles which can be focused at each stage. By choosing overlapping focusing size ranges, the efficient removal of particles large enough to clog the smaller geometries is ensured. The net effect is to fractionate and concentrate particle size ranges from a broad spectrum particle size distribution starting with the largest and working down to the smallest particle sizes. Each stage of the cascading strategy  has been2930i.e. those which focus in this device) are found in the expected focused outlet after ~2 recirculations in the 500 μm high spiral indicating a high degree of concentration/removal of the large particles. The 300 μm high spiral performed equally well, enriching the larger particles (>50 μm) 19-fold, and achieving 96% collection into the focused outlet. As detailed in In order to quantify the focusing performance a plot of the area under the curves shown in C, achieved by a single device layer is given by Equation 2The concentration factor, n is the number of outlets and r is the number of recirculations as defined in C = 0.0156) although this will be limited by the dead volume of the system. Since small particles remain unfocused the percentage recovered into the unfocused outlet after a certain number of recirculations is 1-C such that we could expect a recovery rate of 0.98 or 98% from 6 recirculations. Higher recoveries can be reached by increasing the number of recirculations r although issues of dead volume, and any particle loss within the system, act to reduce this number. Previous work by Warkiani et al.where t required for sample processing can be calculated using Equation 3The time V is the sample volume, f is the flow rate and R is total number of recirculations applied. Therefore using the stacked system which runs at 1 L/min, detailed in the next section, a sample of 100 L could be reduced to 1.5625 L after 6 recirculations in approximately 3.25 hours (193.75 mins).where The concentration effect was studied using 75–90 μm orange beads in the 200 μm high spiral design. Results, based on image processing of particle trajectories at the outlet as detailed in Two designs, the semi-circular and toroidal designs (last two rows in Table S3), were developed in order to enable the insertion of a manifold for stacking. These were designed to have the same length, and therefore ideally the same focusing behavior, as the spiral of corresponding channel height.The challenge with stacking spiral channels is that fluid delivery is from either the top or the bottom in a vertical array of devices, and therefore flow rates will vary between layers . Inertial focusing depends upon flow rate and if it is too low a focusing effect is not observed. Therefore, variation in flowrate could negatively impact upon the performance of a stacked set of channels. To overcome these issues a manifold approach to device stacking has been developed. The modular manifold was designed, inspired by a technique for ensuring highly uniform flow across an open linear sectionThe 20 layer stacked toroidal spirals device was tested with ~250 μm (blue) and ~45 μm (red) beads at a flow rate of 1 L/min. The focusing of particles into the outlet closest to the inner wall was clearly visible but to further quantify the performance of the system particle size distributions were measured using the laser diffraction particle size analyzer to compare the inlet sample with those collected from the outlets. A total of 7.05 L of sample was circulated until 2.51 L was remaining in the inlet reservoir (~1.7 recirculations). Here we show how a cascading and recirculating strategy can successfully separate and concentrate small particles from a mixture with a large range of particle sizes (2–300 μm) with enrichment factors of above 19, that could be improved by further recirculation steps. By sequentially removing the largest particles into a highly concentrated sample, the particle range is narrowed until the target particle size at which point this size is focussed and concentrated. This technique offers an alternative to filtration with the additional advantage that unlike traditional filtration processes which concentrate all particles above a given cut-off a relatively narrow size band of particles can be extracted from a complex mixture.We demonstrate larger scale inertial focusing than have been previously shown in the literature and observe at larger (>300 μm) channel heights that the critical size at which a particle becomes focussed is higher than predicted from the established empirical formula. A similar deviation is also observed at smaller channel heights, although in this case smaller particles than expected are focused. We propose a new relation between critical focusing particle diameter and channel height for spiral systems similar to those produced in this paper. This will assist in the design of such systems for other applications.Furthermore, we show the potential of stacking to increase the throughput of inertial focusing systems to industrially relevant sample volumes. In particular we have demonstrated a stack of 20 devices operating at 1 L/min, setting a new precedent for microfluidics throughput. This was achieved through the use of a novel toroidal inertial focusing design. The stacking approach presented enables even distribution of pressure and flow rates throughout the layers ensuring maintenance of performance and potentially enabling a larger number of devices to be integrated into a system. We believe this approach could be useful for environmental monitoring as well as industrial filtration applications and bioprocessing markets.2 laser cutter, tuned individually for each material thickness, to pattern device layers. PSA1589F adhesive transfer tape (18 μm thickness) was applied to both sides of the device layer material prior to patterning. Assembly was achieved by removing the tape backing and sandwiching between a ported layer and a substrate layer. Connections for the cascaded devices were achieved with generic 1/8″ bspt barbed tubing connectors and 2.4 mm ID tygon tubing. To run the spiral channels a 12-roller Watson-Marlow Peristaltic pump was used. The semi-circular device was also produced using this technique. A height of 200 μm was the maximum which could be manufactured due to constraints of the laser cutter workbed relative to the length of channel required to be directly comparable to a spiral of the same height.The single spiral devices used in the cascade  were allFor the devices with channel height of 30 μm manufacture was outsourced to the commercial company Epigem Ltd. From designs produced using AutoCAD Epigem manufactured the systems in Epoxy and PMMA. These devices were run using a WPI AL1000-220 syringe pump and 5 mL BD Lure Lock syringes. 50 μm devices were laser micro-machined and bonded using a hybrid solvent/plasticiser low temperature press bonding method.The stack of toroidal 500 μm high spirals  was prodFurther details regarding each designs tested in this work are available in the SI .The manifold, presented in A velocity field of the mid z-plane section was generated using the laminar flow solver on the geometry of the manifold imported from the AutoCAD 3D model at 1 L/min flow rate with 20 inlet sections of the same geometry as the 500 μm high device inlets.All of the beads above 5 μm were sourced from Cospheric LLC, with the exception of the turquoise and red beads which were obtained from Phosphorex. The beads of size 5 μm and below were sourced from Magsphere. All bead details are given in Table S4. Tween 20 (Sigma-Aldrich) was added to the sample to reduce aggregation of beads due to static build up on the polystyrene beads. A magnetic stirrer was used in the inlet reservoir to agitate the sample to prevent settling of the beads .Particle size measurements were obtained in triplicate using a laser diffraction particle size analyzer  to analyse the inlet samples and the subsequent samples collected from the outlets. Particle size distributions measured by the Mastersizer are expressed in volume percentage.cf.A high speed camera setup , mounted to an inverted microscope , was used to observe the evolution of concentration over time in a single layer system with a single bead size population. In the focussed outlet a batch of 100 photos was collected at 10 min intervals. Data was analysed in MATLAB and beads were detected based on intensity differences between background and particles using thresholds cf..How to cite this article: Miller, B. et al. Cascading and Parallelising Curvilinear Inertial Focusing Systems for High Volume, Wide Size Distribution, Separation and Concentration of Particles. Sci. Rep.6, 36386; doi: 10.1038/srep36386 (2016).Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


To support promotion, prevention and early intervention for mental illness school nurses need to be mental health literate.Three hundred and thirty-nine school nurses employed in government and private schools from three Emirates in the UAE were surveyed. A culturally adapted Mental Health Literacy questionnaire comprising three vignettes of fictional characters meeting diagnostic criteria for the target conditions along with the Kessler Psychological Distress Scale (K10) was administered to ascertain school nurses’ ability to correctly identify the conditions and to elicit beliefs about helpfulness of treatment interventions and of health care providers for these conditions.Less than 50% of the respondents correctly identified the disorders presented, while accurate identification of evidence-based interventions was also limited. Correlations between level of psychological distress and level of inaccurate survey responses was also revealed, respondents who correctly identified the correct diagnosis of the vignette and the most appropriate interventions were those who had a significantly lower K10 score.Low levels of mental health literacy amongst respondents in combination with potential religious and cultural factors as reported in the literature, highlight the need for curriculum enhancements for future health professionals and a targeted program of culturally appropriate professional development focused on mental health promotion for those in clinical practice. The level of psychological distress noted in this cohort also signals a need to ensure that appropriate supports are available for clinical staff employed in schools. The World Health Organisation reports mental illness, neurological and substance use disorders as a significant contributor to the global burden of disease and has identified an urgent need to accurately recognise illness and implement proven and cost-effective interventions.Mental health literacy assists the recognition, prevention or management of mental illnesses. Increasing research reports both on population wide and specific health care professionals’ level of mental health literacy in Western countries. However, there are no studies in the UAE reporting on either community or healthcare professionals’ level of mental health literacy.School nurses in the UAE are confronted with significant challenges as an increasing number of children with chronic and complex needs now attend mainstream schools in the UAE. To adequately care for the complex needs of school children, adequate levels of mental health literacy are required.To support promotion, prevention and early intervention for mental illness school nurses need to be mental health literate.Results reveal low levels of mental health literacy in school nurses in regard to recognition of and beliefs regarding the treatment of posttraumatic stress disorder, depression with suicidal thoughts and psychosis.Religious and cultural factors appeared to further impact on respondents’ mental health literacy.These findings highlight the need for curriculum enhancements for future nursing professionals and a targeted program of culturally appropriate professional development focused on mental health promotion for those in clinical practice in the UAE and other countries within the Gulf Cooperation Council (GCC).The levels of psychological distress in this cohort signals a need to ensure appropriate supports are available for nursing staff employed in schools, regular clinical supervision is encouraged and peer support is in place to promote early and appropriate help seeking.Possible screening of nurses in conjunction with ready access to programs designed to support mental well-being will also serve to develop and support the clinical workforce caring for children and adolescents in the school setting.In the rapidly developing country of the United Arab Emirates (UAE), approximately 35% of the total population are young people (aged 0–24 years) with close to 21% aged between 0 and 14 years [Central Intelligence Agency (CIA) 2016]. Similar to other countries comprising the Gulf Cooperation Council (GCC), the focus of health care for the entire population has until recently been primarily on physical health promotion and treatment. Epidemiological data reveals significant progress in decreasing deaths from a majority of communicable diseases and injuries leading to great gains in prolonging life. Consistent with a global trend, the impact of non-communicable diseases (NCDs) across all sections of the community in the UAE is significant and is estimated to account for 65% of total deaths in the country . NCDs coThe recent UAE Vision 2021 aspires to achieve prosperity for the citizens of the country with world-class medical care and reduction of health hazards through a growing awareness and prevention programs . The heaAs improvements in health care are achieved an increasing numbers of children with chronic conditions are now attending mainstream schools leading to significant nursing challenges. Further unique cultural and environmental factors contribute to the particular challenges experienced by school nurses in the UAE seeking to meet the needs of the children and adolescents in their care. While infant mortality rates in the UAE are low in comparison with many other Arab countries , family Children and adolescents living with chronic conditions face ongoing challenges such as repeated hospitalization, ongoing periods of poor health, decreased physical strength and skills or changes in appearance due to illness. These challenges have the potential to impede or delay the achievement of developmental, emotional and social milestones and also represent additional risk factors for the development of mental health problems , 17, 31.School nurses in the UAE recently identified the management of students with complex health-care needs as the highest priority area for research along with a number of other priorities including the psychological and behavioral well-being of students . If schoThe primary aim of this exploratory study was to investigate school nurses’ level of mental health literacy in relation to posttraumatic stress disorder, depression with suicidal thoughts and psychosis. The secondary aim was to identify participants’ capacity for problem identification and their treatment preferences for each problem. A further aim was to obtain a cross-sectional measure of non-specific psychological distress in the target population in order to test for potential associations between psychological distress and mental health literacy.The study employed a correlational cross-sectional design and was exploratory in nature as this was the first study of its kind in the UAE.The target population for this study was all school nurses employed in private and government preschools, primary, middle and secondary schools across the UAE. Participants were sought from the accessible population of school nurses in three of the seven Emirates in the UAE . The current structure of health services responsible for school nurses is complex with administering bodies differing from emirate to emirate. A paper-based survey was distributed to participants by the relevant organisation responsible for the management and oversight of school nurses in each of the three emirates involved in the study. School nurses employed in private schools not under the jurisdiction of emirate wide organisations were accessed via an educational meeting with surveys distributed to attendees. Data collection was undertaken between January and June, 2016. Based on available data and the number of surveys distributed, it is estimated that the response rate was approximately 60% in the Emirates of Sharjah and Ajman and 35% in the Emirate of Dubai (the most populous of the seven Emirates in the UAE).The questionnaire was presented in three parts, demographic data Table  followedAttitudes and beliefs concerning the nature and treatment of Posttraumatic stress disorder, depression with suicidal thoughts and psychosis were examined using a modified version of the mental health literacy questionnaire developed by Jorm and colleagues  and SlewThree case vignette were presented of fictional characters, the first (Miriam) suffering from posttraumatic stress disorder, the second (Abdul) experiencing depression with suicidal thoughts and the third (Saed) displaying symptoms indicative of psychosis. Each vignette was followed by a series of questions addressing the nature and treatment of the problem described, including problem recognition and beliefs about the likely helpfulness of various possible treatments and treatment providers.Miriam’s/Abdul’s/Saed’s main problem’? Participants were required to choose only one answer from a number of options that were listed in random order. For the PTSD vignette the options were ‘Fear’; ‘No real problem, just a phase’; ‘Depression’; ‘Weak character’; ‘Nervous breakdown’; ‘Post Traumatic Stress Disorder’; ‘Serious medical condition (e.g. brain tumour); ‘Stress’; ‘Not integrating well in the UAE/homesickness’; ‘Physical condition (e.g. migraine or back pain)’. For the depression with suicidal thoughts vignette the options were ‘Fear’; ‘No real problem, just a phase’; ‘Depression’; ‘Weak character’; ‘Nervous breakdown’; ‘Serious medical condition (e.g. brain tumour); ‘Stress’; ‘Physical condition (e.g. migraine or back pain)’; ‘Depression with suicidal thoughts’. For the psychosis vignette the options were ‘Physical condition (e.g. migraine or back pain)’; ‘Using forbidden drugs’; ‘Stress’; ‘Serious medical condition (e.g. brain tumour); ‘Psychosis’; ‘Nervous breakdown’; ‘Weak character’; ‘Depression’; ‘No real problem, just a phase’; ‘Anxiety’.Following the presentation of each vignette, participants were asked: ‘What would you say is one intervention within each category they believed would be most helpful for this person.Participant’s beliefs about helpfulness of various interventions for the problem described in each vignette were also assessed Tables , 3 and 4While the questionnaire was administered in English, the Australian developed vignettes were further adapted in consultation with academic colleagues to ensure each was culturally acceptable and valid for the UAE context. The format of each vignette was checked carefully to ensure that formal (i.e. DSM-V) diagnostic criteria for PTSD, depression with suicidal thoughts and psychosis were addressed. Care was also taken to avoid technical or medical jargon. The questionnaire was then piloted with ten final year Bachelor of Health Science (Nursing) students for cultural acceptability. Students represented the same cross-cultural backgrounds and languages spoken by the target population . No changes were required.To assess the general symptoms of anxiety and depression, the Kessler Psychological Distress Scale (K10)  was usedStatistical analysis was applied to test the effect of socio-demographic characteristics and the levels of the K10 on responses regarding problem recognition and beliefs about interventions. The tests were based on the research hypotheses and were determined prior to looking at the data.For categorical socio-demographic variables , the Chi square test of independence (p < 0.05) was applied to the hypothesis that responses regarding problem recognition and beliefs about interventions were independent of the socio-demographic variables.For numerical socio-demographic variables  and for the K10 score, the Kruskal–Wallis test (p < 0.05) was used to test the hypothesis that the variable was not significantly associated with responses regarding problem recognition and beliefs about interventions, because a normal distribution could not be assumed, particularly where numbers of responses for problem recognition and beliefs about interventions categories were small. Pairwise post hoc comparisons of significant socio-demographic characteristics were performed using Dunn’s procedure with a Bonferroni correction for multiple comparisons, to determine which response categories had significantly different values. Statistical analysis was carried out using R statistical analysis program version 3.2.2.Missing values for demographic variables are shown in Table A total of 324 school nurses and four medical officers participated in this study with all but three completing the Kessler 10 (K10), 54 answered three vignettes, two answered two vignettes and 170 answered one vignette. While the medical officers are included in the descriptive analysis, comparisons between the nursing and medical cohorts was not undertaken due to the small sample size (see Table In response to the question ‘What would you say is Mariam’s main problem?’ 43 respondents (39.1%) chose PTSD, and a further 33 (30.0%) chose “Depression”. An additional 23 respondents (20.9%) thought the character was suffering from “Fear” and collectively, these three responses accounted for 90.0% of all responses.Table With respect to medication, ‘anti-depressant medication’ was seen to be the most helpful medication (53.1%) while ‘relaxation medication’ was most commonly noted as helpful by over half the sample (57.7%).In terms of assistance from people, ‘psychologists’ and ‘psychiatrists’ were equally selected as the most important individuals to provide help (29.9%). The participants most frequently cited a ‘psychologist’ as being helpful (83%), followed by a ‘family member’ (80.8%) and ‘psychiatrist’ (75.5%).Respondents who correctly identified the PTSD vignette as describing a person with PTSD had a significantly lower K10 score (p = 0.018). Similarly, respondents with a lower K10 score were more likely to select a ‘psychologist’ (p = 0.014) whereas younger respondents were more likely to select a ‘family member’ as helpful treatment providers for Miriam (p = 0.01). Finally, respondents with a lower K10 score were more likely to select an ‘antidepressant’ as helpful for Miriam (p = 0.036).In response to the question ‘What would you say is Abdul’s main problem?’ 72 respondents (49.3%) chose ‘depression with suicidal thoughts’, and a further 51 (34.9%) chose ‘depression’. An additional 8 respondents (5.5%) thought the character was suffering from “Stress” and collectively, these three responses accounted for 89.7% of all responses.Table On examining the relationship between the participant’s characteristics and answers to vignettes questions, it was revealed that participants who chose the correct treatment, namely ‘anti-depressant medication’ were younger (p = 0.023) but had less nursing experience than other participants (p = 0.0047). Interestingly, those with higher K10 scores frequently selected ‘vitamins and minerals’ as a helpful medication for depression (p = 0.011).In response to the question ‘What would you say is Saed’s main problem?’ 32 respondents (38.6%) chose ‘psychosis’, and a further 21 (25.3%) chose ‘depression’. An additional 19 respondents (22.9%) thought the character was suffering from ‘anxiety’ and collectively, these three responses accounted for 86.7% of all responses.Table There were no significant associations between problem identification, and treatment preferences and participants characteristics.Ascertaining the knowledge and beliefs of school nurses regarding mental illness is integral to the development of targeted educational and mental health promotion initiatives. This is the first study that has systematically sought to examine mental health literacy in school nurses in the UAE. The findings reported focus on two aspects considered to be central to mental health literacy, knowledge of mental health disorders (ability to recognize a disorder) and beliefs about the helpfulness of treatments. Although the scenarios provided align with DSM-V, the diagnostic framework employed by mental health services in the UAE, the results revealed that a significant number of respondents  had difficulty identifying specific disorders accurately . At best only half of the respondents surveyed were able to identify a potentially lethal mental health disorder . This limited ability to recognize a mental health disorder may well result in a delay in timely access to much needed treatment. Similar research studies report that mental health professionals surveyed in Switzerland were largely able to recognize schizophrenia and depression , while pBeliefs regarding treatment for the specific mental disorders likewise differed from the recommended clinical practice guidelines as used by psychiatry in the UAE. Treatment preferences varied according to the vignette being presented. For example, when asked about the most helpful treatment activity to assist “Miriam” (PTSD vignette) 85.2% of the respondents thought that ‘Reading the Koran or Bible’, would be helpful and 84.4% selected ‘Getting information about the problem and available services’ as the most helpful activity for Abdul’s problem . For Saed’s problem (psychosis) 82.3% of respondents selected ‘Psychotherapy focusing on changing thoughts and behaviors’ (cognitive behavior therapy) as the most helpful treatment activity. These responses are in sharp contrast to the recommendations found in the clinical practice guidelines that inform psychiatric care in the UAE , 10, 19.In contrast, respondent’s selection of preferred medications tended to reflect the recommended treatment practices. For example, almost half of the respondents identified an “antidepressant’ as the most helpful medication for Abdul’s problem  and 38.6% of respondents noted that an antipsychotic would be helpful for the psychosis vignette. However, a concerning 39.1% thought that ‘Medication to help you relax’  would be helpful for Miriam’s problem of PTSD. Research evidence has demonstrated that the use of benzodiazepines in the treatment of PTSD is problematic and should be avoided as they can lead to significantly worsened outcomes .When asked about appropriate treatment providers, mental health professionals were most frequently selected for all clinical vignettes with psychiatrist preferred by 79.6 and 77.8% for the depression with suicidal thoughts and psychosis vignettes respectively. Interestingly, psychologists were the treatment providers most frequently selected by respondents as being helpful at 83% for the PTSD vignette. These same respondents also choose ‘reading religious texts’ and the use of benzodiazepines as helpful in the treatment of PTSD.Reflection on the outcome of correlations between the K10 scores and other variables (such as being able to select the right diagnosis) is an important aspect of this study. The most consistently noted factor influencing responses selected that can be considered indicative of lower mental health literacy was the level of psychological distress as reflected in the K10 score. For example, those with lower K10 scores tended to correctly identify Miriam problem as PTSD and were more likely to prefer psychologist and antidepressants as helpful treatment choices for the same vignette. With regards to Abdul’s problem  those with higher K10 scores  were more likely to select “Vitamins and Minerals” as a helpful medication, however those who were younger and had less clinical experience were more likely to selected an antidepressant as being helpful for Abdul. While it is acknowledged, that the findings from this cross-sectional use of the K-10 cannot be interpreted as unequivocal, the implications do require careful consideration. Findings suggest that respondents with higher levels of personal psychological distress selected responses that may delay recognition and appropriate treatment for people experiencing mental illnesses. In some vignettes (e.g. PTSD) the age of respondents (e.g. younger participants) with low psychological stress (K10 < 22) themselves were more sensitive to mental health problems and the associated stress than others who had higher stress levels. Respondents with lower scores on the K-10 (K10 < 22) reported less symptoms of mental health problems compared with others with high stress.The demographic profile of respondents reveals that a considerable number of the respondents originate from conflict ridden countries in the Middle East or North Africa or are separated from their families and beloved ones . Each of these will likely have left their home country looking for a better life and safety. Given that relocation and separation from home, culture and family are identified risk factors for increased levels of psychological distress, it could be argued that a potential impact of the elevated levels of psychological distress in these respondents may be a reduced capacity to detect the signs and symptoms of mental health problems among the children, adolescents and families with whom they interact , 26.Noteworthy was the impact of cultural and religious influences on respondents’ choices on treatments deemed most helpful, for example, for PTSD reading of religious texts was identified as the most helpful activity. This finding is consistent with previous research identifying the impact of religious and cultural influences on both healthcare professionals’ identification and management of mental health problems and on community members’ presentation of their illnesses and health seeking behaviors as reported in the national UAE literature , and intResearch designed to assess the attitudes of Arab Muslim female students in the UAE, Jordan and Israel towards mental health treatment and help seeking, reported that preferences varied from seeking help from professional treatment providers in times of need to using prayers and religious practices to manage their psychological distress . More reThese findings have implications for mental health promotion and education in the UAE and other countries within the GCC. Low levels of mental health literacy amongst these respondents in combination with religious and cultural factors highlight the need for curriculum enhancements for future health professionals and a targeted program of culturally appropriate professional development focused on mental health promotion for those in clinical practice. The levels of psychological distress noted in this cohort also signals a need to ensure that appropriate supports are available for clinical staff employed in schools, regular clinical supervision is encouraged and peer support is in place to promote early and appropriate help seeking. Possible screening of clinicians in conjunction with ready access to programs designed to support mental well-being will also serve to develop and support the clinical workforce caring for children and adolescents in the school setting.Limitations include the length of the survey. Each person was presented with the three scenarios, however, the time required to complete the full three surveys limited the number of completed surveys received. While healthcare professionals are generally fluent in English varying levels of English literacy amongst respondents may have influenced responses and limited funding and a small research team precluded the administration of the surveys by bilingual researchers. As this is the first study evaluating mental health literacy to date published in this region, no comparative data was available. Finally, the scenarios used in the survey while culturally adapted are adult-based rather than child or adolescent focused. Nevertheless, the low levels of mental health literacy identified in this sample are of concern given that respondents had completed tertiary level studies in their profession and could thus reasonably be expected to be able to recognize the three conditions covered in the survey and to identify evidence-based treatments.The focus of the healthcare system in the UAE has been directed towards improving physical health with beneficial impact, and yet much remains to be done in improving health literacy in general and mental health literacy in particular. Improved mental health literacy has the potential to increase early intervention, improve promotion of mental well-being and enable effective support of the community. This study focused on mental health literacy in health professionals providing care for children and adolescents , The low levels of mental health literacy in the school nursing healthcare workforce demonstrated in this study requires urgent attention.


The study was to explore the feasibility of improving cone‐beam CT (CBCT) number (corresponding to the Hounsfield units in computed tomography) consistency using a scatter‐correction algorithm, with the aim of using CBCT images for treatment planning with density correction. A scatter‐correction algorithm was applied to a Varian OBI CBCT and an Elekta XVI CBCT, and was evaluated for improving CBCT number consistency. CBCT numbers of phantom materials were compared between images with and without bolus, which introduced additional scatter, and with and without scatter‐correction processing. It was observed that CBCT numbers were different in the images with and without bolus in both CBCT studies, and the differences were reduced remarkably after scatter‐correction processing. Results showed that CBCT number consistency was significantly improved by use of the scatter‐correction algorithm.PACS number: 87.55‐x Studies applying CBCT images for treatment planning have been reported,,10 e and an Elekta XVI CBCT , respectively. The study was aimed to test the scatter‐correction algorithm on two imaging systems and was not aimed to compare the experiments between the systems. Each institution used available phantoms in the study.In the study of Varian OBI CBCT, a Catphan phantom  was scanned with and without a 3 cm bolus with a pelvis protocol . The 3 cm bolus was made of a few pieces of 1 cm thick bolus, which was used to introduce additional scatter and to test the robustness of the scatter correction algorithm on variant phantom or patient body. The CBCT numbers of phantom inserts on the images with and without the scatter correction were checked.In the study of Elekta XVI CBCT, a Gammex tissue characterization phantom  was used to examine CBCT number consistency, which was scanned with and without a bolus. The phantom, which is popularly used in clinics for creating CT‐ED conversion for treatment planning, has 16 insert materials with different densities varying from low density  to high density . CBCT numbers of the insert materials were measured on the CBCT images. Further, an anthropomorphic pelvis RANDO phantom (The Phantom Laboratory) was used to validate the scatter correction by evaluating dose calculation on the CBCT images of the phantom. A clinical prostate protocol was used in these CBCT scans . Bowtie filters were not used in the scans unless it is particularly mentioned.+borI=P+(1+a)S1(P). The form of S1(P) was derived based on the Klein‐Nishina formula.P0=I,Pk+1=Pk+c(I−Pk−S1−Sh),k=1,2,…, was used to estimate primary and scatter fluences from the projections. Here c is another parameter and was taken as unity in the iteration. More details about the iteration can be found in the published study.An algorithm based on the scatter‐correction method,16 wSh=aS1 to do the scatter correction. The functions of bowtie filter and antiscatter grid were modeled in the algorithm. To determine the value of a, BEAMnrc Monte Carlo simulation softwareSh=b, where b was optimally determined for each projection by searching the value b so that I−Pk−S1−Sh was minimized.For the Varian OBI system, antiscatter grids are employed before the photons arrive at the detector. During CBCT reconstruction, no further scatter correction was performed. Our scatter‐correction algorithm adopted Because Varian OBI system does not allow feeding back the processed projections into the acquisition‐reconstruction loop, an in‐house algorithm based on algebraic reconstruction technique (ART)2×10cm2 was applied to the Gammex phantom. The dose calculations were compared with a plan using CT images and clinical CT‐to‐ED conversion. The latter was used as the standard.In the study of Elekta XVI CBCT, the processed projection images were imported into the CBCT systems and volumetric images were reconstructed. CBCT numbers of the materials of the Gammex phantom were measured on the XVI and were compared with those of the images without scatter correction. A test based on the Gammex phantom was conducted to evaluate density‐corrected dose calculations using the CBCT‐to‐ED conversions generated from the images with and without scatter correction, respectively. Two CBCT‐to‐ED conversion files were generated from the nonbolused images (one set of images was processed with scatter‐correction and the other one was not). The CBCT‐to‐ED conversion generated from processed nonbolused images was applied to the processed bolused images, and the conversion generated from nonprocessed nonbolused images was applied to the nonprocessed bolused images. Single field treatment plans were generated in a CMS XiO treatment planning system , where an anterior beam of 6 MV with field size of 9×9cm2. Same beam arrangement and monitor units were applied to the CBCT plans which were based on the original CBCT images and the scatter‐correction processed images, respectively, and the CT plan. The CBCT‐to‐ED conversion generated from scatter‐correction processed images of the Gammex phantom was applied to the processed RANDO phantom images, and the conversion generated from nonprocessed images was applied to the nonprocessed RANDO phantom images. Clinical CT‐ED conversion was used in the CT plan dose calculation. The point doses and dose‐volume histograms (DVHs) were compared to check the effect of scatter correction on dose calculation.An experiment using the anthropomorphic pelvis RANDO phantom was conducted to further evaluate the scatter correction in the XVI CBCT. Four‐field pelvis treatment plans were generated using the CBCT images and CT images of the RANDO phantom, respectively. The size of each treatment field was It is shown from Further, the CBCT numbers obtained from the Elekta CBCT images with scatter‐correction processing were compared with those obtained from the images acquired with a bowtie filter. With a bowtie filter, the differences of CBCT numbers between nonbolused and bolused conditions were reduced because the bowtie filter hardens the kV beam and thus decreases the scatter‐primary ratio of photon fluences at the detector. The results showed that by using the scatter‐correction processing, the CBCT number consistency was significantly improved on both Varian OBI CBCT and Elekta XVI CBCT. Although the Varian OBI CBCT system has a 10:1 antiscatter grid to reduce scatter, the residual scatter still significantly affects CBCT number consistency. In our study of the Catphan phantom with bolus, the maximum scatter‐primary ratio was about 60%. It is indicated that scatter correction is necessary for CBCT applications, especially for treatment planning that requires density correction.Since it is software processing, scatter correction using the algorithm will have flexibility in the application to improve CBCT number consistency and image quality; scatter correction may be optimized under actual scanning conditions. When the scatter correction algorithm is applied together with a bowtie filter, scatter can be further reduced and the consistency of CBCT number can be improved.The feasibility study has showed that it is promising to apply the scatter‐correction algorithm to improve CBCT number consistency for treatment planning. We are improving the algorithm and will report patient study in the future.The preliminary study on the Varian OBI CBCT and Elekta XVI CBCT demonstrated that the CBCT number consistency was remarkably improved by using the scatter‐correction algorithm. We expect to conduct further study on the algorithm for additional improvement on the CBCT number consistency for clinical application.


Lung hernia is a rare condition defined as the external protrusion of lung tissue from the thorax, which usually occurs after trauma or thoracic surgery. A chest computed tomography while performing the Valsalva manoeuvre is useful for a definitive diagnosis. A 73‐year‐old man received positron emission tomography‐computed tomography (CT) screening to detect malignant disease, which revealed a hyper‐metabolic lesion in the right hilar lymph node. He underwent open thoracotomy for lymph node sampling, and the result was non‐specific lymphadenopathy. Twenty months after the thoracotomy, he had a cough and became aware of a protrusion from the intercostal space during coughing. Two years after the operation, the size of the protrusion increased, and a chest X‐ray revealed abnormalities, so he was referred to our hospital for examination and treatment. Physical examination showed skin protruding anterior laterally from the fourth right intercostal space during the Valsalva manoeuvre Fig. . Chest CLung hernia is a rare condition defined as external protrusion of lung tissue from the thorax and is caused by elevated intra‐thoracic pressure and defects or weakness in the thoracic wall. Most cases are acquired, usually from trauma or thoracic operation Appropriate written informed consent was obtained for publication of this case report and accompanying images.


Accelerating progress in women’s and children’s health requires scaling up efficacious interventions and measuring progress towards defined targets. However, determining what is effective in a particular setting and optimizing investments is challenging given the complexity of health systems and the diversity of contexts surrounding maternal, newborn, and child health and nutrition (MNCH&N) policies and programs in low– and middle–income countries (LMICs). There have been various global efforts to synthesize evidence  which have some influence on country-level priorities and plans –6. UltimPhoto: Two task team members in Tanzania. From the private collection of Rebecca Heidkamp.The National Evaluation Platform (NEP) is a systematic approach to identifying, compiling, and rigorously analyzing data from diverse sources , in order to evaluate the effectiveness of MNCH&N policies and programs. Country–led and country–owned, the NEP approach offers a set of core evaluation methods and tools to build national capacity for generating evidence–based answers to program and policy questions. NEP complements and reinforces other ongoing efforts to strengthen country monitoring and evaluation (M&E) systems and to promote data use.Journal of Global Health over the coming year.We present the history and rationale underlying NEP, describe core components and work streams supporting NEP implementation in four African countries, and introduce a collection of peer–reviewed articles about NEP to be published in the NEP design. Findings were published in 2016 [The NEP concept took root during an evaluation of the scale–up of Integrated Community Case Management (iCCM) programs in Malawi conducted by the National Statistics Office (NSO) and the Institute for International Programs at the Johns Hopkins Bloomberg School of Public Health (IIP–JHU) with financial support from the Government of Canada . The ori in 2016 .In the wake of the Malawi iCCM evaluation redesign, a group of experts in MNCH&N program evaluation published an article in the Lancet that proposed NEP as a departure from the status quo in large–scale effectiveness evaluations . RigorouIn contrast, the NEP approach articulated by Victora et al. aims to answer evaluation questions that are formulated based on MNCH&N program impact pathways developed using a common framework formulated by Bryce and others ,9. Data In late 2013, IIP–JHU received funding from Global Affairs Canada (GAC) to take NEP from a concept applied in a single evaluation in Malawi to a sustainable approach to rigorous evaluation by public sector MNCH&N stakeholders in four sub–Saharan African countries–Malawi, Mali, Mozambique and Tanzania. Country–level roll–out began in early 2014. By December 2017, IIP–JHU and government partners in each country aim to build systems and institutional capacity to carry out analyses and communicate NEP findings and to demonstrate that NEP outputs influence decision making by MNCH&N policy and program stakeholders. Activities are organized under three work streams which we highlight below: country–level operationalization; core technical development; and documentation, evaluation and communication.NEP Home Institution with several staff dedicated to NEP oversight and implementation, including data management and stakeholder coordination. A country–specific NEP High–level Advisory or Steering Committee is made up of senior leaders from MNCH&N stakeholder institutions in and outside government who guide NEP implementation by recommending or endorsing priority questions and serving as the first audience for NEP findings. The NEP Technical Task Team includes staff from each of the country’s NEP stakeholder institutions who work in M&E, program coordination or data analytics. The Task Team is the “engine” of NEP, with members working together to develop core evaluation skills, answer evaluation questions and ensure that their respective institutions support and utilize NEP. IIP–JHU has one full–time staff member in each country who coordinates technical assistance, capacity building, and networking. A diverse team of faculty based at Johns Hopkins University  support technical development and implementation along with several external partners including Health Alliance International  and 2Paths .Public sector institutions lead every aspect of NEP implementation. NEP brings together key government institutions involved in MNCH&N program evaluation, including those that make policies, implement programs, collect and report data, conduct research, and/or oversee budgets. Depending on the country this may include several units under the ministry of health, national statistical offices, multi–sectorial nutrition coordination bodies, ministries responsible for finance and local administration, public universities, and/or public health research institutes. Each country has a designated Stats Report tool helps address limitations in statistical expertise and capacity to use statistical software by allowing users to select, adapt and run core analysis, data management and data quality assessment functions programmed in R using a simple interface. IIP–JHU provides targeted mentorship and curriculum tailored to each country team’s existing capacity. The overall NEP curriculum is organized by eight core technical areas that comprise modules to introduce and apply relevant skills. These technical areas include: (1) general evaluation principles; (2) core data concepts; (3) data mapping; (4) data quality assessment; (5) data management; (6) data analysis; (7) new data collection; and (8) interpretation & reporting. Learning modules are designed to be customized and used by other groups wanting to adopt NEP methods.Country teams adopt a “cycle–based” approach to establishing core NEP systems and building capacity to carry out the evaluation work  describe and demonstrate core NEP design features including innovative methods and tools supporting data quality assessment, data management, data analysis, and capacity building; 2) present analyses produced by NEP country teams in response to locally–prioritized evaluation questions and identify how findings have been used by national MNCH&N stakeholders, and 3) assess whether the project has met high–level objectives including the potential for NEP to be sustained in current countries and successfully replicated and refined by other countries or sectors. Ultimately, we believe that sharing our outputs and overall experience in implementing NEP will encourage dialogue among academics, donors, and policymakers on the need to support governments in using data and developing evidence that guides their MNCH&N decision making.Over the coming year, the


Funding’ section.After publication of the original article  the authThe correct Funding information should therefore be the below :Fundingthe Spanish Government to SZ, by project (PrometeoII/2014/051) from the Generalitat Valenciana to SZ and by a MICINN project (AGL2011–28890) to AG. PM was supported by the University of Antofagasta grant MECE2 (ANT0806).Work supported by Aquagenomics project (CSD2007–0002) from


Dear Editor,,Journal of Applied Clinical Medical Physics may find our measurements of skin sparing for some modern couches useful when deciding on new couches. This data will supplement that of Higgins et al. who reported on a Sinmed BV couch.Over the last few years, medical LINAC manufacturers have started to offer couch tops or inserts designed for image‐guided radiation therapy (IGRT). These couch tops have a homogeneous construction, with a carbon fiber shell and no metal components. Although the use of these couches may offer some advantages in image quality, it can have a potentially serious impact on skin sparing.0.775cGy/MU and 0.842cGy/MU for 6 MV and 10 MV beams, respectively. It can be seen in Fig. We used a thin‐window parallel plate ion chamber (Capintec PS‐033) in solid water to measure the TPR in the build‐up region for 6 MV and 10 MV beams (10 by 10 cm field) with three different IGRT couches , with the regular tennis‐racket insert (Varian), and also with no couch in the beam. The results are shown in Fig. Although the loss of skin sparing is less important for multifield treatments, it might become an issue for AP‐PA or PA treatments that can comprise a significant fraction of treatments. For example, the use of a carbon fiber couch may increase the skin dose for a PA spine treatment from around 40% of prescription dose to 90–100% of the prescription dose, depending on the couch used. The skin dose for AP‐PA treatments may also increase to more than 90% of the prescription dose. Depending on the distribution of treatment sites and techniques and number of LINACs in their centers, physicists should consider including requirements on skin sparing in their couch specifications.


Participants performed a picture‐matching task that presented a recipient object and an action‐goal, and required the selection of the best tool object from among four candidates. Some trials allowed selection of the prototypical tool, whereas others forced selection of either a functionally substitutable or impossible tool. Statistical contrasts revealed significantly different activation between Proto and Sub conditions in frontal, parietal, and temporal lobes. The middle temporal gyrus (MTG) bilaterally, and the right posterior cingulate were more strongly activated by prototypical tool selection, and left inferior parietal lobule (IPL), intraparietal sulcus (IPS), middle frontal gyrus, and precuneus were more strongly activated when selecting substitutable objects. These findings are concordant with previous neuroimaging studies of tool use knowledge in demonstrating that activation of the MTG represents functional knowledge for conventional tool usage, and activation of the IPL/IPS supports action  knowledge representations. These results contribute to the literature that dissociates the roles of ventral and dorsal streams in tool‐related knowledge and behavior, and emphasize the role of the left hemisphere for processing goal‐directed object interactions.Tool selection is a cognitive process necessary for tool use, and may rely on distinct knowledge under different conditions. This  Tools are objects that facilitate interactions with other objects  in the service of goal‐directed behavior. Research suggests that tool‐related processing can be divided into two general domains of knowledge: action and function. Knowledge of an object's action‐related properties relate to how an object can be manually  manipulated, and is related to representations in a dorsal pathway through the parietal cortex  is a relatively easy and appropriate choice. However, when the prototypical tool is not available, an alternative object may be substituted if its structural properties sufficiently afford its use to alter the state of the recipient object in a similar manner as the prototypical tool. For instance: If a spoon is not available, but a carrot is available as a candidate from which to choose, the structural features of the carrot sufficiently afford the accomplishment of stirring coffee. As such, selecting a prototypical tool and deciding whether an alternative object is sufficiently substitutable for the prototypical tool require access to different types of tool‐related knowledge.Action and function knowledge are two dissociable domains of tool‐related knowledge. Action knowledge is related to how an object can be motorically manipulated, such as its graspability, and is associated with the structural properties of the visual object. For instance, if an object has a long‐axis, such as a screwdriver or carrot, this structural property provides action‐related information related to how the object can be grasped  preferentially activates the ventral pathway, and perceptual features of visual objects  preferentially activates the dorsal pathway  provided written informed consent and were paid 15€ for participation. A routine medical examination prior to participation screened for a history of neurological or psychiatric disorders, and contraindications to MRI scanning. The experimental procedure was approved by the local research ethics board and all protocols were carried out in accordance with the Declaration of Helsinki. Data from one participant were excluded because they reported falling asleep during the experiment.A total of 17 healthy right‐handed volunteers  would allow them to complete the specified action on the recipient object. Figure Proto), substitute (Sub), impossible (Imp). The three recipients were a coffee cup, a screw that was driven halfway into a plank of wood, and a small pile of dirt . There were 2 runs for each recipient object, and the order of the six runs was randomized across participants. Each Proto trial included a unique image of the prototypical tool; each Sub trial included a different sufficiently substitutable object with no repetitions. Distracter tools/objects  appeared with random repetition on Proto and Sub trials throughout the task, and also appeared on Imp trials, although no configuration of choice stimuli was repeated. For some trials, objects which were correct Sub responses in one condition appeared as distracters in another condition, and several objects were designated as correct Sub responses for two conditions .The task consisted of 108 total trials, with three different trial types, based on the available object that best accomplished the designated action: prototype . Functional BOLD images covered the whole‐brain volume and were acquired with an ascending‐interleaved single‐shot GE‐EPI sequence . In addition, a point‐spread function was collected to correct for image distortion of geometry and intensity caused by the high strength magnetic field  data were acquired with a 4 T Bruker MedSpec whole‐body MRI  with an 8‐channel head coil. High‐resolution anatomical images were acquired with a 3D T1‐weighted MPRAGE  performance, which was found to be 34%. Participants whose overall task performance was below this level were excluded from further analyses (N = 0).Mean response time (RT) and accuracy were calculated within participants for the https://surfer.nmr.mgh.harvard.edu/).Preprocessing and analyses of MRI data were completed, using AFNI and SUMA Cox . FunctioProto, Sub, Imp) using the onset of the choice assortment for each trial and convolving it with a canonical hemodynamic response function. Separate regressors for left‐ and right‐handed button presses were also included, as well as a regressor for error trials. Error trials were modeled separately to reduce both false‐positive and false‐negative activation clusters . A minimum statistic conjunction null (MSCN) analysis  that survived a minimum of 100 mm2 cluster area.A predictor time‐course was created for each of the three trial types , and was least accurate for the Sweep:Pile condition (85% at the threshold or greater than chance). Over the entire task, mean accuracy for Proto was significantly greater than Sub . Participants were able to correctly identify the prototypical tool for the specified action‐goal and recipient for more than 90% of trials, and they were able to choose the correct experimenter defined substitutable object for greater than 63% of trials.Figure Proto and Sub conditions. Proto trials were consistently the most rapid responses, with Imp trials consistently the slowest responses. Over the entire task, mean RT for Proto was faster than Sub , indicating that participants were able to identify the correct prototypical tool more rapidly than they were able to choose a substitutable object, which required on average 500 msec more to make a correct selection. The group mean and standard deviation for RT for the Imp condition was 1922.59 msec (±299.59 msec), which is significantly longer than group means for both Proto and Sub trials. This suggests that participants were indeed engaged with the problem presented on each Sub/Imp trial, and recognized after some deliberation on Imp trials that there was no correct response, and emitted a guess or random error response. In combination, these results show that participants were indeed processing the demands of the tool selection task, the Sub condition was more challenging than the Proto condition, and that participants were able to solve the task on a significant portion of the Sub trials.Figure Proto>Sub contrasts. Only one cluster in the left hemisphere with a peak single voxel t‐value at the MTG, and two clusters in the right hemisphere with peaks at the MTG and the posterior cingulate cortex (PCC), survived the threshold for whole brain correction. The clusters whose peaks were located at the MTG also extended into the superior temporal sulcus (STS) and the superior temporal gyrus (STG), showing that the anterior temporal cortex was more involved for prototypical tool selection than choosing a substitutable object. The graphs illustrate the sign of the relationship between activity in a particular cluster and the hemodynamic predictor time course. Proto trials showed a positive relationship of the predictor time course for each of the three clusters, whereas Sub and Imp trials showed a negative relationship. Figure Sub>Proto contrast. Four clusters in the left hemisphere demonstrated greater activation at the IPL, precuneus in posterior IPS, middle frontal gyrus (MFG), and supplementary motor area (SMA). No clusters survived the cluster threshold in the right hemisphere for the Sub>Proto contrast. In addition, the graphs indicate that these clusters show the opposite signed relationship to the predictor time courses for Proto, Sub and Imp trials as shown in Figure Sub and Imp trials showed a positive relationship, and Proto trials showed a negative relationship. This shows that Sub and Imp trials are engaging in similar neural resources, and that Proto trials recruit a different set of neural resources. Together, these results demonstrate that tool selection differently activates portions of the ventral and dorsal pathways dependent on whether the prototypical tool is available or not.Table Proto and Sub conditions. These results are shown with a less conservative single voxel threshold P < 0.005 and a minimum area of 100 mm2. Clusters that survive this threshold are sparse and are located in both hemispheres, including the insula, inferior occipital gyrus, cuneus, and lingual gyrus in the left hemisphere, and middle occipital gyrus, fusiform gyrus, insula and IPL in the right hemisphere. This suggests that Proto and Sub trials, although activating some common neural resources for visual processing, actually recruit disparate neural activity.Figure Proto versus Imp trials at the whole brain cluster corrected P < 0.05 (single voxel P < 0.001). The clusters that were more strongly activated for Imp trials  overlap with the same regions shown in Figure Sub and Imp trials engage similar neural resources in the left hemisphere. Although the clusters overlapped, the activation differences were much stronger for this contrast, the clusters were substantially larger , neural activity overlapping the frontal eye field emerged as a significant difference for only one side of the brain. This evidence supports the argument that eye movements do not account for differences in neural activation in our study, and further bolsters our claim that a left lateralized network is involved in the cognitive processes mediating substitutable tool selection. Eye tracking could be used in combination with the tool selection task to disentangle the processing of which visual features contribute to the decision that a particular object can substitute for a prototypical tool, as well as how the neural representation of semantic memory guides visual search for the prototypical tool.Because of the fact that the task can be conceptualized as a visual search and analysis of visual perceptual features, as described above, it is possible that task‐related differences in neural activity in the PFC  are in fact accounted for by eye movements. However, eye movements are synchronized across both eyes during a visual search task, thereby recruiting activation of the frontal eye fields Proto than Sub trials was more anterior (Brodamann area [BA] 21) to the canonical tool regions  in the posterior MTG/ITG. Activation of the posterior MTG/ITG  has been reported for numerous tool‐related perceptual and semantic processing studies, including selective visual processing for tools over animals, as well as naming pictures of tools and discriminating hand‐tool motion , PCC/precuneus, and lateral inferior parietal cortex, each bilaterally , suggest that the DMN per se was not differently deactivated between conditions, despite differences in RT and difficulty. Importantly, some DMN nodes have been implicated in semantic processing  of the visual stimulus need to be processed in order to choose a sufficient substitute. In sum, despite differences in RT, evidence advocates that resources specific to each task condition were identified by the contrasting neural activation rather than a confounding activation difference due to task difficulty.The RTs for Sub condition may also access additional resources that are not specific to tool‐related knowledge per se, such as working memory  or decision mechanisms. The experiment was designed to investigate whether decisions about the usability of an object as a tool would recruit similar or different neural activation than decisions about which tool is the prototypical tool for a specific purpose. This aim of the experiment was achieved in that we found that choosing a prototypical tool and deciding which object can be used as a tool to substitute for the prototypical tool when it is unavailable did indeed recruit different neural activation pathways. The activation during the Sub condition activated regions associated with tool‐specific motoric knowledge  in the dorsal processing stream, which unavoidably overlaps with the working memory system in the left hemisphere. We interpret this to indicate that tool‐related knowledge is activated, and being operated on by the working memory system in order to make a decision within the demands of the task. This is consistent with the design of the task in that a functionally substitutable object requires online processing of its motoric affordances  in conjunction with representations of the task goal and recipient object – which may require integration via the working memory system. Future research may aim to disentangle the neural activity associated with each of these component processes.The Proto and Sub tool selection differently activate the ventral and dorsal streams because they rely on function and action knowledge, respectively, other findings in the literature report finding tool‐related action knowledge represented in the ventral stream in the posterior MTG/ITG (Perini et al. While the evidence from this study supports the conclusion that Sub and Proto conditions. Further refinement of the tool‐selection task used in this experiment may lead to the development of a useful clinical assessment to dissociate these deficits, as well as for rehabilitation training, and further neuroimaging studies may reveal how the two brain systems of tool‐related knowledge interact during goal‐directed tool‐use behavior.The clinical neuropsychology literature concerning apraxia documents numerous deficits in various aspects of goal‐directed tool‐use behavior Heilman . PatientThis experiment employed a novel tool selection task to study the relative involvement of the ventral and dorsal streams when choosing an object to use as a tool for a specific purpose. Our findings demonstrate that tool selection may be mediated by either the ventral or dorsal pathway depending on whether it involves selection of the prototypical tool or a functional substitutable object for accomplishment of a specific action‐goal. Prototypical tool selection is related to activity in the ventral stream representing function tool‐related knowledge in the MTG and anterior temporal lobes, and suggests that it is a subdomain of rapidly accessible semantic knowledge. Choosing an alternative object to substitute requires the online perceptual analysis of the structural properties and motor affordances of the visual object, which is slower and more demanding than retrieving semantic knowledge for the prototypical tool, and is related to left lateralized activity in the dorsal stream representing action knowledge in the MFG, SMA, IPL and IPS. Additional neuroimaging research, in combination with eye tracking and other complementary methods, may elucidate how networks representing semantic function knowledge and motoric action knowledge interact during proper tool use.None declared.


HIV care do not take into account that the frequency of attendance is related to changes in treatment and health status. This study developed a new measure of engagement in care (EIC) incorporating clinical factors.Commonly used measures of engagement in HIV physicians to identify factors associated with the timing of patients' next scheduled appointments. These factors informed the development of an algorithm to classify each month of follow‐up as “in care” (on or before the time of the next expected attendance) or “out of care” (after the time of the next expected attendance). The EIC algorithm was applied to data from the UK Collaborative HIV Cohort (UK CHIC) study, a large clinical cohort study.We conducted semi‐structured interviews with eight AIDS diagnosis, treatment status, CD4 count and viral load). The resulting EIC algorithm was applied to 44 432 patients; 83.9% of the 3 021 224 person‐months were “in care”. Greater EIC was independently associated with older age, white ethnicity, HIV acquisition through sex between men, current use of antiretroviral therapy (ART), a higher nadir CD4 count, later calendar year and being seen at the clinic for the first time within the last year.The interviews indicated that time to next appointment varied depending on psychosocial and physical comorbidities, and clinical factors (time since diagnosis, HIV care incorporates a time‐updated measure of patients' treatment and health status. It adds to the options available for measuring this key performance indicator.This algorithm describing engagement in  The introduction of combination antiretroviral therapy (ART) has led to a dramatic reduction in HIV‐associated morbidity and mortality Engagement in out‐patient HIV care is therefore a key measure of quality performance for HIV service providers There is no gold standard measure of engagement in HIV out‐patient care. While each of the above measures has its own strengths and weaknesses The Retention and Engagement Across Care Services for HIV (REACH) study set out to better understand HIV out‐patient attendance in order to develop cost‐effective interventions to optimize engagement in care (EIC). Taking into account that the frequency of monitoring is dependent on treatment and health status, and as gaps between clinic visits may vary quite considerably within the current guidelines Exploratory, semi‐structured, face‐to‐face interviews were conducted with eight HIV physicians with a range of clinical experience selected from five HIV out‐patient clinics in inner and outer London where the prevalence of HIV is high The interviews, which were conducted by AH, took 25–30 min and were recorded verbatim. Physicians were asked to describe the factors that prompted the timing of the next scheduled appointment for the last ten patients that they had seen: specifically, they were asked when they had asked to see the patient again (number of weeks/months) and why. Interviews took place from November 2013 to February 2014 and the findings therefore reflect guidelines in place at the time spss statistics 22  to produce a cross‐tabulation of time to appointment by factor. The findings from this analysis informed the development of an algorithm to measure EIC that was refined iteratively to the precision required for programming.We conducted a content analysis sas 9.3 . UK CHIC collates routine data on HIV‐positive people, aged 16 years or older, who have attended some of the largest HIV clinics in the UK since 1 January 1996. For this analysis, we included all patients who attended a participating UK CHIC clinic on two or more occasions between 1 January 2000 and 31 December 2012. In the absence of complete data on clinic attendances, CD4 counts, viral loads, haemoglobin measurements and ART start or switch dates were used as markers of clinic attendance. Follow‐up for each person was considered to continue until the last recorded laboratory marker or clinic visit prior to (or on) 31 December 2012.The algorithm was applied to data from the UK Collaborative HIV Cohort (UK CHIC) study and analyses were performed using Individuals may often have repeat laboratory tests performed within a short time interval to confirm unexpected findings, and this may result in clusters of measurements around a single “index” date. For our analysis, we did not want to consider each of the measurements within a cluster as independent visits, as only the index visit would have been scheduled at the previous visit. Thus, we grouped attendances into “care episodes”, defined as months (period of 30.4 days since entry into the study) where at least one visit occurred. For each care episode, we then established the lowest CD4 count measured in that month , the highest HIV viral load  and the patient's treatment status, and used this information to establish a likely date of next scheduled visit using our algorithm , ethnic group , mode of HIV acquisition , whether currently on ART, nadir and current CD4 counts , participating clinic, calendar year  and time since entry in the study . Note that we did not consider follow‐up after the patient's last reported care date, and therefore this algorithm focuses on intermittent periods of disengagement rather than ultimate loss to follow‐up after the person's last clinic visit. Each patient‐month was then treated as a separate entry in a multivariable logistic regression model with the aim of identifying demographic and clinical factors associated with that month being “in care”. These models were fitted using A total of 73 patients were discussed in the physician interviews. One patient was not included in the analysis because their next appointment was dependent on awaited test results. The time of the next scheduled appointment was missing for another patient and not available for a further five patients who had not attended their last scheduled appointment at the time of the physician interviews.The time of the next scheduled appointment in the remaining 66 patients ranged from 1 week to 6 months, with a median of 3 months. While physicians were acting within the current guidelines, they described the reasons for this variation in the timing of the next scheduled appointment. Five factors were identified from the content analysis of the interview data as instrumental. These factors were summarized as “routine” where patients were stable and required routine follow‐up, “virological” where the next appointment was based on change in viral load , “treatment” where the next appointment was related to starting ART or changing an existing ART regimen, “psychosocial” where mental health or psychosocial issues were identified as instrumental, and “physical comorbidities” where a range of physical comorbidities were given as the key reason for the timing of the next appointment.One‐third of patients were described as stable and given routine follow‐up appointments 4–6 months after their last visit. Routine follow‐up for one pregnant woman was arranged for 3 months' time. Physicians talked about extending routine visits to every 6 months when patients were well and stable, both on treatment and in their psychosocial circumstances. Changes in viral load brought the next scheduled appointment forward to 1–2 months after the last. Patients who were starting or changing treatment were given a next appointment date between 2 and 12 weeks later, depending on the treatment start date and virological response or when treatment was planned to start. Follow‐up appointments of between 1 week and 4 months later were arranged depending on a range of psychosocial issues  and comorbidities: both of which required earlier follow‐up when patients were often otherwise stable on treatment.We used the data from the physician interviews on the timing of next appointments as the basis for developing the EIC algorithm. Although psychosocial wellbeing and comorbidities were key factors in determining the expected time between patient visits to the HIV clinic, data on these variables are not generally captured electronically and are not often available in routinely collected cohort data. Thus, we used clinical data  only to determine the patient's treatment and health status. This was used to estimate the expected time to the next scheduled care episode, in accordance with the data collected in the physician interviews Table . The EICAccording to the EIC algorithm, the shortest expected gap between care episodes was 2 months. This is to allow for the fact that clinic visits might occur at any point during the month or care episode into which they are grouped. If the patient was within 1 month of diagnosis, had an AIDS diagnosis, or started ART or changed ART at the initial care episode, the next care episode was expected within 2 months. If the patient was not on ART at the initial care episode, the next care episode was expected within 2–6 months, depending mainly on CD4 count. If the patient had started ART, it was expected within 2–6 months, depending on viral load. We used 6 months as the maximum time between visits, as described in the physician interviews. If more than one condition applied at the time of the initial care episode, the next care episode was expected within the least number of months associated with those conditions.Fig. A total of 44 432 patients from UK CHIC (2000–2012) were included in the following analysis. Women represented 27.8% of the sample. Half were white (53.3%), one‐third were black African (28.9%), 8.7% were of other ethnicity and 9.2% had unknown ethnicity. Around half had acquired HIV through sex between men (50.5%), with 39.1% acquiring HIV through sex between men and women, 3.0% through injecting drug use and the remaining 7.4% through other or unknown routes. Their median age at entry into the study was 36 years [interquartile range (IQR) 30–42 years] and the median date of follow‐up start was December 2004 (range January 2000 to October 2012). The median CD4 count at start of follow‐up was 355 (IQR 214–520) cells/μL; patients were followed for a median of 61 (range 2–156) months with a total follow‐up of 3 021 224 patient‐months.Overall, patients were engaged in care for 83.9% of the total follow‐up of patient‐months. Table We have developed an algorithm which provides a flexible new approach to measuring engagement in out‐patient HIV care. It is, to our knowledge, the first measure that adapts to the changing treatment and health status of the patient, reflecting the reality described to us by physicians and giving it strong face validity The algorithm provides a dichotomous measure for each month of follow‐up as to whether the patient is in care or out of care. Poor EIC during the first year after diagnosis is associated with a higher rate of mortality We found that patients were engaged in care for 83.9% of months over a follow‐up period of up to 12 years. Consistent with findings from an analysis of loss to follow‐up in the annual Survey of Prevalent HIV Infections Diagnosed in England, Wales and Northern Ireland The EIC algorithm was developed from interviews with physicians who indicated that the timing between appointments is dependent on a range of factors. The interviews clearly illustrate that there is no one‐size‐fits‐all when it comes to the timing of HIV clinic appointments. Patients stable on treatment were seen for routine care every 4 months which was extended to every 6 months, as appropriate for the individual under care, guided by the therapeutic relationship. We have used 6 months as the maximum time between routine visits in the algorithm, as described by physicians in accordance with the UK guidelines for routine monitoring The majority (90%) of people who are being seen for HIV care in the UK are on ART In common with other analyses of EIC using HIV cohort data, we have used laboratory data and ART start dates as surrogate markers of clinic visits. It is possible, therefore, that we may have missed some visits where no laboratory test was performed. Further analyses of data from the group of clinics that are able to provide more detailed information on attendances will allow us to validate this approach. We grouped visits into care episodes to negate the effect of repeated laboratory measurements within short time intervals.We censored the data at the last recorded visit and, while our measure does not therefore include any ongoing periods of loss to follow‐up, it would be possible to incorporate this into the algorithm. It should also be noted that any algorithm is clearly only an approximation to a far more complex clinical process and it is difficult in an observational cohort setting to incorporate other factors, such as social factors, that may lead to more regular scheduled visits. This is, however, likely to result in an under‐estimation of EIC rather than an over‐estimation. While our algorithm has these limitations, we have created a measure of engagement in HIV care that will benefit from the advantages of using these data EIC is a key quality performance measure for HIV service providers and it is important that it is captured in a way that reflects whether patients are attending as frequently as indicated by their clinical needs. We have presented a concept of how to measure engagement in HIV care by incorporating a time‐updated measure of patients' treatment and health status and a prototype of this measure that we have tested on HIV cohort data. The EIC algorithm adds to the options available for measuring engagement in HIV care, and assessing this key performance indicator.


Timely diagnosis and prompt initiation of treatment is essential in Lyme carditis to achieve favorable prognosis. Externalized permanent pacemaker with an active fixation lead as supportive pacing modality is a feasible option till complete resolution of conduction block with continued antibiotic therapy. Lyme carditis is an uncommon disease entity with potential complications of the conductive system such as advanced atrioventricular (AV) nodal block which can be life‐threatening if quick diagnosis and early therapy is not initiated. Here, we present an interesting case of a 26‐year‐old gentleman with Lyme carditis who was managed with emergent external pacemaker placement and antibiotic therapy.A 26‐year‐old gentleman with no significant past medical history had been on a fishing trip 3 weeks prior to presentation and reported a possible tick bite to his right second toe. This was followed by a mild erythematous rash and swelling on his toe that resolved within 2 days. Two weeks later, he started having episodic subjective fevers and chills and developed a well‐circumscribed macular rash on his left upper abdomen which gradually cleared within two to 3 days. He did not seek medical attention at any time.He presented to an outside emergency room with presyncope and worsening fatigue for 1–2 days prior to presentation. Initial telemetry monitor strips demonstrated 2:1 AV block alternating with complete heart block and a junctional escape rhythm in the range of 30 beats per minute (bpm)  was positive followed by confirmatory Western Blot for Ig M. A peripherally inserted central catheter (PICC) was placed due to his previous good response to IV ceftriaxone and infectious disease recommendations for 4 weeks of IV antibiotics due to high grade AV block. He was discharged home on the twelfth day with IV ceftriaxone therapy planned for a total of 4 weeks and backup externalized pacemaker in place.He was followed up in clinic 1 week postdischarge, and at that time on pacer interrogation, it was seen that he had not required any backup pacing and was maintaining normal sinus rhythm at 55–60 bpm. The external pacemaker was left in place. On the second follow‐up a week later, he was still maintaining normal sinus rhythm and had not required any pacing. The external pacemaker and active fixation lead were removed. An electrocardiogram (EKG) demonstrated complete resolution of AV block  test for Lyme antibodies is sensitive but not specific. In the first 6–8 weeks of clinical illness, serology can be negative as well. Presence of Ig M antibodies by Western Blot analysis is usually confirmatory The usual therapeutic regimens for Lyme carditis include ceftriaxone 2 g intravenously daily for 3–4 weeks or doxycycline 100 mg twice daily or amoxicillin 500 mg three times daily for 1 month In our case, the initial symptomatology along with the skin rash occurred at 2 weeks following the tick bite. Complete heart block occurred at 3 weeks. With appropriate treatment, complete resolution was achieved within 19 days. In addition, an externalized permanent pacemaker system utilizing a transvenous active fixation permanent pacing lead placement, enabled the patient to be ambulatory, and to be discharged home with pacing support while awaiting conduction recovery on the IV antibiotics. This case highlights the importance of timely diagnosis and prompt initiation of treatment to prevent morbidity and mortality and achieve favorable prognosis in this rare progressive disease with high dissemination potential. In this clinical scenario, we have safely documented the use of an externalized permanent pacemaker with transvenous access as supportive pacing modality until complete resolution of conduction block occurred.All authors have contributed to the manuscript content and have been a part of the actual case management.None declared.