Assisted partner notification (APN) safely and effectively increases partner awareness of HIV exposure, testing and case identification in community settings. Nonetheless, it has not been specifically developed or evaluated for use in prison settings where people with HIV often are diagnosed and may have difficulty contacting or otherwise notifying partners. We developed Impart, a prison‐based APN model, and evaluated its efficacy in Indonesia to increase partner notification and HIV testing.From January 2020 to January 2021, 55 incarcerated men with HIV were recruited as index participants from six jail and prison facilities in Jakarta in a two‐group randomized trial comparing the outcomes of self‐tell notification  versus Impart APN in increasing partner notification and HIV testing. Participants voluntarily provided names and contact information for sex and drug‐injection partners in the community with whom they had shared possible HIV exposure during the year prior to incarceration. Participants randomized to the self‐tell only condition were coached in how to notify their partners by phone, mail or during an in‐person visit within 6 weeks. Participants randomized to Impart APN could choose between self‐tell notification or anonymous APN by a two‐person team consisting of a nurse and outreach worker. We compared the proportion of partners in each group who were notified of exposure by the end of 6 weeks, subsequently tested and HIV diagnosed.n = 55) selected 117 partners for notification. Compared to self‐tell notification, Impart APN resulted in nearly a six‐fold increase in the odds of a named partner being notified of HIV exposure. Nearly two thirds of the partners notified through Impart APN (15/24) completed HIV testing within 6 weeks post notification compared to none of those whom participants had self‐notified. One‐third of the partners (5/15) who completed HIV testing post notification were diagnosed as HIV positive for the first time.Index participants (Voluntary APN can be successfully implemented with a prison population and within a prison setting despite the many barriers to HIV notification that incarceration presents. Our findings suggest that the Impart model holds considerable promise to increase partner notification, HIV testing and diagnosis among sex and drug‐injecting partners of HIV‐positive incarcerated men. Research demonstrating APN's effectiveness in successfully promoting HIV disclosure to partners, HIV testing, diagnosis and treatment referral has accumulated for over three decades. Two early U.S. studies showed that APN was feasible in notifying sex and needle‐sharing partners of people diagnosed with HIV , 4. SincIndonesia's incarcerated population is the eight largest globally, with more than a quarter million inmates . Also, pThis research helps to affirm and assist the use of APN in prisons and other criminal justice facilities by implementing and comparing the efficacy of the Impart model of APN that we developed for prison populations versus sole reliance on prison inmates to inform their partners themselves (standard of care). With Impart APN, incarcerated people with HIV voluntarily identify and provide names and contact information for partners in the community with whom they may have shared HIV exposure before incarceration. They then select which of these partners to notify themselves or to have informed anonymously by an Impart two‐person team consisting of a nurse and community healthcare worker. Our study examines the outcome of each form of notification on how many at‐risk partners in the community are notified, their gender and type of risk exposure, and HIV testing outcomes. Its findings respond to the need for research on the effectiveness of APN programmes .22.1The Impart model and the procedures for this research were designed or selected in full recognition of the special ethical challenges of protecting the rights and safety of prisoners as a particularly vulnerable research population . Informe2.2Our study population is comprised of HIV‐diagnosed men (index participants) receiving health services through HIV subspecialty clinics located within each jail and prison facility. A two‐group randomized trial was used to evaluate the effects of the prison‐based Impart APN model on partner notification and HIV testing outcomes. Index participants were allocated randomly to either to a self‐tell notification only standard of care condition or to Impart APN choice (active intervention) condition that allowed index participants to choose per partner between self‐tell or having an Impart team  notify the partner without revealing the identity of the index participant who named them. Approximately equal numbers of index participants were allocated to the intervention and control conditions per site, using block randomization to ensure balance in the two groups over time.Our primary outcome was partner notification within 6 weeks as reported by the index participant or APN notifier. As secondary outcomes, we compared the number of partners in either group who by the end of this period had completed HIV testing including those who subsequently were HIV diagnosed. With permission from index participants, “self‐tell partners” in both study arms were contacted at the end of 6 weeks to verify if they had been notified and to obtain their HIV testing results. Those who had yet to be notified were informed of possible HIV exposure and offered HIV testing.2.3From January 2020 to January 2021, we recruited 55 incarcerated men with HIV from six all‐male jail and prison facilities in Jakarta, Indonesia representing differing security levels, population sizes and inmate characteristics. Prison medical staff introduced the study to HIV‐positive inmates using a project‐prepared script before or after their regularly scheduled clinic visits. Those inmates who indicated possible interest in participating were invited to meet privately with a research team member for screening and to learn more about the study prior to being asked to give informed consent.n = 7), lack of time or interest (n = 3) and illness (n = 1). Of the 66, 55 (83%) consented to participate.To participate in the study, men had to be 18 years of age or older (by prison regulations), HIV positive (confirmed by HIV rapid test at enrolment), self‐reported as sexually active and/or injecting drugs during the year before incarceration, incarcerated within the last 3 years and more than 6 months away from their release date. Of the 241 inmates who were screened for possible participation, 175 were excluded from the study for having met one or more of its exclusion criteria. Of the 66 eligible inmates, 11 (15%) declined to participate due to feeling anxious or undecided about notifying partners  or the Impart APN choice model, using a numbered sealed envelope system to conceal allocation from research staff .2.52.5.1Participants randomized to self‐tell notification were assisted in developing a notification plan and coached in how to tell their at‐risk partners by the end of 6 weeks. They also were asked for permission to verify whom they had told or not when that period ended. Inmates could choose to tell their partner(s) by telephone, mail or in‐person during visitation at the jail/prison facility. They also could elect to have an HIV counsellor present during in‐person telling or by telephone to answer any clinical questions that the partner might have.2.5.2Participants randomized to the Impart arm could choose per partner between sell‐tell notification or having an Impart APN‐trained nurse and community outreach healthcare provider work as a team to locate and notify their partners without revealing the identity of who had named them. With the latter choice, Impart notifiers initially contacted named partners by telephone and identified themselves as research‐affiliated health workers with important information about their health that needed to be shared in person. Partners who agreed to meet were asked to choose a location. Notification by telephone was delivered only as a last resort when circumstances prevented in‐person notification or a partner insisted on learning the reason for the telephone call. To locate partners whose contact information was unknown or could not be reached by telephone, APN notifiers visited the partner's residence, known “hang‐out spots” or other address(es) as necessary to find them. Notifiers were instructed never to reveal why they were searching for the person but only to say that they had some important information for them. Once contact was made at a private location, partners were advised of their possible shared exposure to HIV. To protect the confidentiality of incarcerated index participants, APN notifiers were given no information about the index participant and thus could not reveal their names or provide identifying information during this meeting.2.5.3Partners notified by the Impart team were offered immediate HIV rapid testing using a fingerstick, combination antigen‐antibody test . Alterna2.5.4Socio‐demographic and health information were obtained from all HIV‐positive inmates enrolled as index participants prior to randomized group assignment. Using code numbers instead of personal identifiers, research staff recorded group assignment for each index participant, the number and characteristics of partners named  and Impart participants’ preference per partner for self‐tell versus APN notification. Although no compensation was given for agreeing to name or contact partners, all participants received a snack and basic toiletry kit as thanks for their time in being interviewed, even if they chose not to name or contact partners.Six weeks after the initial naming session, participants were reinterviewed about their notification experience. Participants in both arms who intended to inform one or more partners were asked to report on which (if any) they had informed. All self‐reported outcomes, including results from their verification, were entered into the project database to supplement information drawn from the logs that Impart notifiers kept recording the details and outcome of each successful and unsuccessful notification. After 6 weeks, APN was offered to notify any partner previously tried as self‐tell; however, those results are not reported here.2.5.5Our primary analysis compared the study's two groups (self‐tell only to Impart assignment) on primary and secondary outcomes using intention‐to‐treat (ITT). All partners selected for notification were included in the analysis irrespective of group allocation or notification method. Partner notification outcomes were examined using logistic regression with robust standard errors to account for clustering due to partners having a shared index participant. Partner gender and partner type were selected beforehand as covariates.n = 3) were treated as failed notifications. Sensitivity analyses (modified ITT and per protocol) compared outcomes for the two groups under different scenarios for missing data. To model a most‐conservative scenario for missing outcomes in the control group (modified ITT), we imputed successful notification outcomes  for two partners in the self‐tell notification (control) group and unsuccessful outcomes  for one partner in the Impart APN group. A complete case analysis excluded these same three participants. In an as‐treated analysis, we compared successful notifications among partners selected for Impart APN with those selected for self‐tell notification whether by randomization or by choice.For our primary analysis, partners with missing outcomes (33.1n = 17) also reported sharing injection equipment with a median of three drug‐injecting partners.As shown in Table 3.2All partners selected for notification were included in the analysis irrespective of group allocation or notification method. Figure n = 83/91) were female, whereas nearly all needle‐sharing partners (25/26) were male. Partner between‐group differences by gender and partner type were statistically significant (p<0.05).Partners ranged from 17 to 56 years of age (median of 28 years) and on average were younger than the index participants who named them. Most of those named (91/117) had been exposed through sex, including as spouses and regular sex partners, while 22% (26/117) had shared drug injection equipment. Most sex partners (3.3Table n = 8), or deceased (n = 3), had become incarcerated themselves (n = 4), refused to meet (n = 2), resided outside Jakarta (n = 3), and one partner was not notified because the index participant withdrew from the study and asked to stop the notification. Nearly two thirds of partners notified by Impart APN (15/24) had completed HIV testing within six weeks compared to none of those whom participants had personally notified. Meanwhile, nine partners notified by Impart APN chose not to test because they refused further contact after notification (n = 3), were anxious about receiving their test results (n = 2), had recently been tested (n = 2) or already had been diagnosed with HIV (n = 2). Among partners who completed HIV testing, 33% (5/15) were newly HIV diagnosed. No adverse events were observed or reported during notification or follow‐up among index participants and partners in either group, despite careful probing for such events by researchers.The remaining 21 partners were unable to be located (n = 117) predicting the odds of partner notification occurring through each of the two notification conditions of the study. Compared to partners in the self‐tell only condition, partners designated for notification by inmates assigned to the Impart model were nearly six times more likely to be notified of exposure , p<0.001). Similar effect estimates were obtained from a model that adjusted for partner gender and partner type .Table 4Our research demonstrates that voluntary APN can be implemented successfully and ethically within the organizational structure of a prison setting. The Impart model's positive effects in increasing partner notification remained significant in and after adjusting for partner sex and type and even when assuming best‐case scenarios for missing verification data in the control group. The use of clinically trained notifier teams equipped to offer immediate point‐of‐contact HIV testing was successful to increase HIV testing and find new cases.In general, the motivation to inform a partner of HIV exposure can be attributed to one or more factors, including self‐perception of ethical responsibility, concerns about the partner's health or to secure social support . For whaNo one approach to partner notification works best, and a combination of different approaches is needed . Index pImpart point‐of‐contact HIV testing also yielded a higher success rate than depending on an index person alone to encourage their partners to be tested. Of the 24 partners contacted in the Impart arm, 15 completed immediate point‐of‐contact HIV testing, of whom five were newly diagnosed and referred for treatment. Given that each partner contacted through APN was suspected or known to have been exposed to HIV, even partners who declined testing or who tested negative stood to benefit from notification counselling in HIV prevention.4.1Limitations of the study include relatively small sample size, short duration of follow‐up and possible bias due to incorrect self‐reporting of self‐tell outcomes. Nevertheless, to our knowledge, this research represents the first and largest study to develop and evaluate an APN model for use in prison settings. We are fully aware that fewer than half of the partners who index participants reported having personally told (7/17) could be confirmed. Yet, if all such reports of successful self‐tell notifications are indeed valid, the Impart choice model still proved three to four times more effective in successfully notifying at‐risk partners and generating HIV testing than self‐tell notification alone.5Our results confirm that the Impart APN model can be implemented successfully in jail and prison settings despite the many barriers to HIV notification that incarceration presents. With its trained team of notifiers, the model provides an effective means for HIV‐positive prisoners to inform HIV‐exposed partners whom they otherwise might not be able to reach or wish personally to tell. Although this study was conducted in Indonesia, the Impart model holds strong potential for successful implementation in other countries and with other incarcerated populations. It warrants further exploration.The authors declare no competing interests.All authors have contributed equally to the study's conceptualization and design. GJC obtained funding as Principal Investigator and wrote the initial manuscript with JL and AR. AW and AR supervised the research in Indonesia and analysed data with AS who planned the statistical analysis. VAE helped to develop the study's protocols and assessments and contributed with all authors to the interpretation of findings and revising the final manuscript.Research reported in this publication was supported by the National Institute of Mental Health of the National Institutes of Health under award number R34 MH115779 to GJC.Appendix 1. Multivariate models predicting partner notification from sensitivity analyses (n=117)Click here for additional data file.


Excluding the cases of early primary infection, the sensitivity values of the VCA IgM marker were comparable between the Liaison and Elecsys assays . Concerning the sera classified as past infection (n = 763), the Elecsys assay showed higher sensitivity values for the detection of the VCA and EBNA IgG markers in comparison with the Liaison assay . Overall, the Elecsys and Liaison assays showed similar performance. The interpretation of EBV serological profiles based on the clinical context may require serology follow up or further diagnostic approaches in challenging cases.Serological markers for Epstein–Barr virus (EBV) infection are commonly used to diagnose infectious mononucleosis and establish a serological status in pretransplant patients. This study prospectively assessed 1043 serum specimens sent to the laboratory for physician‐ordered EBV testing. The three markers—antiviral capsid antigen (VCA) immunoglobulin M (IgM), anti‐VCA immunoglobulin G (IgG), and anti‐Epstein–Barr nuclear antigen (EBNA) antibodies—were tested using the Elecsys and the Liaison immunoassays. Specimens with discrepant results between the two assays were assessed using further EBV diagnostic approaches to conclude on the EBV serological status. In spite of substantial agreement between the two assays (88%) and with the presumed EBV status (>92%), the results showed differences in the performance of the assays. Liaison VCA IgM appeared to be the most sensitive test for the detection of the 38 sera classified as early primary infection in comparison with the Elecsys assay (91.4% vs. 68.6%,  Primary infection is usually asymptomatic but can cause infectious mononucleosis (IM), occurring most often in young adults.EBV serology is mainly used for IM diagnosis and determination of the EBV status in the context of solid organ or hematopoietic stem cell transplantation. Its usefulness has also been explored in EBV‐associated malignancies, in particular in nasopharyngeal carcinoma with the anti‐EBV IgA‐specific antibody marker in combination with serum EBV DNA.Immunofluorescence assays (IFA) is considered the gold standard for EBV serology. Nevertheless, because performing and interpreting IFA is labor‐intensive and sometimes subjective, many laboratories use commercially available immunoassays based on enzyme‐linked immunosorbent assay (ELISA) or chemiluminescent methods. These assays showed good agreement with gold standard assays and are easier to perform. Diagnostic approaches based on IFA, heterophile testing, immunoblot analysis, and polymerase chain reaction (PCR) can be used to clarify some atypical serological results previously determined by immunoassays.This large prospective study aimed to evaluate the newly developed automated Elecsys EBV immunoassay in comparison with a widely used immunoassay in laboratories, the Liaison EBV immunoassay. Further diagnostic approaches for EBV diagnosis were performed when discrepant results were observed between the two assays. The independent evaluation of automated immunoassays is crucial to help biologists and clinicians in the interpretation of EBV serological status and the management of transplanted patients or patients suspected of IM.22.1The patients were included from May to August 2021 during the COVID‐19 pandemic in a city laboratory network (Biogroup) and tested for EBV serology according to the prescription of their general practitioner. Demographic and clinical data were collected if available . All included patients  were informed and gave their consent to participate in the study in accordance with the ethics committee (CPP Ouest 6‐2020‐A03128‐31).2.2Each patient's serum was tested consecutively for EBV serology with two commercial EBV immunoassays available at the Biogroup City Laboratory, Grenoble, France: the Elecsys EBV assay on the Cobas e801 analyzer (Roche Diagnostics) and the Liaison EBV assay on the Liaison XL analyser (Diasorin). The anti‐VCA IgM, anti‐VCA IgG, and anti‐EBNA IgG antibodies were analyzed with the two automated immunoassays in accordance with the manufacturers' instructions. The results were interpreted according to the cut‐offs described in the manufacturers' instructions . Further diagnostic approaches were performed if the interpretation of the EBV serological pattern differed between the Elecsys and Liaison assays , anti‐EBV IgM and IgG immunoblot assays , anti‐VCA IgM and IgG IFA (Euroimmun), heterophile antibody detection , and EBV PCR .The Vidas assay was performed for the majority of specimens with discrepant interpretation. If the Vidas assay was not contributive, an IgG or IgM immunoblot assay was performed to rule out the possibility of a false‐positive result in one or several markers. In cases of suspected primary infection not confirmed by previous testing, heterophile antibody testing was performed (considering that this test has a better sensitivity in patients >5 years of age). The IFA was the most frequently initiated to discriminate a primary infection with isolated anti‐VCA IgM antibodies from a seronegative status . EBV DNA detection in serum by PCR associated with isolated anti‐VCA IgM argued in favor of a primary infection. As PCR in serum is positive only 1 or 2 weeks after the onset of symptoms, a negative PCR result could not exclude a diagnosis of primary infection.2.4The expected EBV status was (i) the status obtained in the city laboratory when the results of the Elecsys and Liaison assays were concordant or (ii) the status established by the reference laboratory when the results of the two assays were discrepant. Serum with isolated anti‐VCA IgM antibodies in the Liaison or Elecsys assays was considered as early primary infection if the diagnosis of primary infection was confirmed by the reference laboratory. EBV status with an indeterminate profile  or that remained inconclusive despite the evaluation of the reference laboratory were excluded from the statistical analysis.Equivocal results obtained with one of the assays were considered as negative for sensitivity calculations and positive for specificity calculations. The sensitivity and the specificity of the different assays were compared using the exact binomial test. The clinical agreement between the Elecsys profiles, the Liaison profiles, and the expected EBV status was established in accordance with the criteria of the respective manufacturers and the following formula using 2 × 2 contingency tables: (True Positive + True Negative)/.33.1n = 62) the sera reclassified as concordant displayed a past infection pattern with presence of equivocal anti‐VCA IgM in one assay versus negative IgM antibodies in the other (combined with anti‐VCA and EBNA IgG positive in both assays). In 20% of cases (n = 19), the sera displayed an early primary infection pattern in one assay  and a primary infection profile in the other . Among the 130 sera requiring assessment at the reference laboratory, a total of 182 complementary analyses were performed including 106 Vidas assays with determination of the three markers , 32 IgG/IgM immunoblots, 21 tests for detection of heterophile antibodies, 17 IFA for detection of IgG/IgM anti‐VCA antibodies, and six PCR for EBV DNA detection. EBV serological statuses could be attributed to 122 sera out of 130 but the status of eight sera could not be resolved (lack of sample or sera remaining inconclusive despite expert assessment). In conclusion, the overall distribution of serological profiles included the following patterns: n = 77 primary infection (7%), n = 160 seronegative (16%), n = 763 past infection (73%), n = 19 transition phase (2%), n = 16 isolated anti‐VCA IgG (1%), and n = 8 inconclusive (<1%)  were discordant for at least one marker, but the interpretation of the serological pattern differed from one assay to another for only 130 sera (12%), according to the manufacturers' recommendations . Excluding from the calculation the sera classified as early primary infection (isolated anti‐VCA IgM) and considering only primary infection, the sensitivity values between the two assays for the detection of VCA IgM were not statistically different    (Table p < 0.001)  Table . The sen3.3p = 0.016), but the agreement with the EBV expected status was not statistically different between the two assays (p = 1). Considering the sera classified as past infection, the agreement with the EBV expected status was higher for the Elecsys assay  due to its better sensitivity to diagnose past infection . The details of the differences between the expected EBV status and the EBV serological profiles obtained with the Elecsys and Liaison assays are shown in Tables The interpretation of the EBV serological profiles obtained from the Elecsys and Liaison assays was based on the manufacturers' recommendations combining the results of all EBV markers  or the Vidas assay (n = 4) with detection of isolated of VCA IgM antibodies, whereas these sera were classified as seronegative (n = 5) or indeterminate (two sera with isolated VCA IgG at a low level) by the Elecsys assay. Of note, for three sera, the VCA IgM index determined by the Elecsys assay was very close to the cutoff (between 0.55 and 0.60).The diagnosis of IM is based on clinical manifestations including sore throat, fever, lymphadenopathy, and asthenia, in conjunction with laboratory tests results. Serology remains the method of choice for the diagnosis of IM. In the present study, Elecsys and Liaison assays concluded in the same EBV primary infection profile for 70 sera, whereas 21 sera required further analysis because the results of one assay were suggestive of a primary infection but the other was not. These sera required complementary testing including 63 EBV analysis by Vidas assays, 18 heterophile testing, 13 immunoblot tests, 10 IFA, six PCR, and review of medical records to conclude. Among these 21 discordant results, seven sera were classified as EBV primary infection, five as seronegative, two as isolated VCA IgG, one as past infection, and six remained inconclusive. Among these seven sera newly classified as primary infection, the majority was suspect of early primary infection by the Liaison assay  could be related to a primary infectionIn the clinical setting, the definitive interpretation of this pattern is often difficult and is based on clinical data  and the results of further EBV testing to clearly discriminate the possible end of a primary infection from a past infection with false IgM  or a serological reactivation profile. Our investigations showed that a transition phase pattern is commonly associated with a past infection. In accordance with our results, Klutts et al.EBV serology is also useful to determine the serological status in the context of transplantation to match the EBV status of the donor with that of the recipient and assess the risk of lymphoproliferative disorders.n = 30), presence of the three markers (n = 23), isolated EBNA IgG (n = 15), and seronegative status (n = 3). Isolated VCA and EBNA IgG patterns obtained with the Liaison assay were in line with a relative lack of sensitivity of VCA and EBNA IgG markers with this assay.n = 14), we classified four sera as seronegative, two sera as primary infection, three sera as confirmed isolated VCA IgG (using the immunoblot IgG test), two sera as past infection, and three sera remained inconclusive. All discrepant results with isolated VCA IgG with the Liaison assays were classified as past infection. An isolated EBNA IgG pattern with the Elecsys assay was very uncommon (n = 1). This serum classified as past infection by the immunoblot IgG analysis was found seronegative by the Liaison assay and displayed an isolated EBNA IgG pattern with the Vidas assay.In this setting, both assays showed an excellent specificity regarding seronegative status, but the study showed differences in the performance of the assays in clearly ascertaining the status of a past infection. Among the sera classified as past infection, the Liaison assay reported 10% discrepant profiles with the EBV status established by the reference laboratory. The most frequently discrepant profiles obtained with the Liaison assays were isolated IgG VCA . On the other hand, given the scarcity of seronegative donor, a false positive result can deprive a seronegative recipient from an organ essential for its survival. Ours results showed that this risk was relatively rare and similar with the two assays (2.5%–3%).This study has several limitations. The period of inclusion occurred during the COVID‐19 pandemic in a context of human contact prevention and social distancing measures, which may interfere with the recruitment of primary infection cases.In conclusion, this study showed the similar performance of the Elecsys and the Liaison assays to determine EBV serological status. The Elecsys assay showed an excellent sensitivity for the determination of VCA IgG and EBNA IgG markers in comparison with the Liaison assay. Nevertheless, the lack of sensitivity of the Liaison VCA and EBNA IgG markers is in most cases without clinical significance in a context of organ donation if the two markers are concomitantly performed. The Liaison VCA IgM marker was the most sensitive test for the diagnosis of early primary infection. In case of a suspected IM, serology follow‐up or further EBV testing should be carried out to avoid a false‐negative result of the VCA IgM marker at an early stage of infection. Given the differences in the performance of each single EBV marker in a given commercial assay, the use of more than one automated assay or further diagnostic approaches could be useful to resolve certain difficult profiles.Julien Lupo designed the study, analyzed the data and wrote the draft. Mansour Tsougaev performed manual testing, compiled the data and analyzed the data. Guillaume Chovelon and Stéphane Blachier obtained the patient's consent, supervised the Elecsys and Liaison immunoassays and compiled the data. Aurélie Truffot and Olivier Epaulard reviewed the manuscript. Corentin Leroy performed the statistical analysis. Joris Giai performed the statistical analysis and reviewed the manuscript. Raphaële Germi discussed the data and participated in the drafting. Patrice Morand analyzed the data and reviewed the manuscript All authors read and approved the entire content of the final manuscript.The authors declare no conflict of interest.Supplementary information.Click here for additional data file.


There were no apparent pregnancy‐associated delays in diagnosing and treating the cases. Three patients underwent induction chemotherapy during pregnancy, two of whom eventually delivered healthy babies. One of the five patients chose abortion before chemotherapy initiation. Two cases showing high‐risk features at the diagnosis (AML with an FLT3‐ITD mutation [n = 1] and relapsed ALL [n = 1]) eventually died despite consolidative allogeneic hematopoietic stem cell transplantation. Our results suggested that patients with pregnancy‐associated acute leukemia can be treated similarly to nonpregnant patients, although pregnancy imposes particular clinical challenges that should be resolved with multidisciplinary care.Leukemia may rarely develop in a woman during pregnancy, posing clinical challenges to the patient, fetus, family, and medical staff managing malignancy and pregnancy. We retrospectively analyzed cases of pregnancy‐associated leukemia consecutively diagnosed and treated at a local tertiary‐care hospital in Nagano, Japan, over the past 20 years. Five cases were identified among 377,000 pregnancies in the area , all involving acute leukemia (three acute myelogenous leukemia [AML] and two acute lymphoblastic leukemia [ALL]). The cases were diagnosed in the first trimester ( BRegardless of an acute or chronic nature, pregnancy‐associated leukemia frequently imposes particular clinical challenges on the patient, fetus, family, and multidisciplinary medical team helping manage the pregnancy, neonatal care, and malignancy , 10–13. Despite the above‐mentioned issues, a standard approach to addressing this clinical dilemma has not yet been established, partly due to the wide range of personal beliefs among patients . FurtherWe herein report the fetal and maternal outcomes as well as the dilemmas and their resolution in consecutive cases of pregnancy‐associated leukemias diagnosed and treated at a local tertiary‐care hospital the past 20 years. Our descriptions depict our perspective concerning rare but very challenging situations hemato‐oncologists may have to confront.22.1Patients with pregnancy‐associated leukemia who were referred to and treated at the Department of Hematology and/or Department of Gynecology and Obstetrics of Shinshu University Hospital in Nagano, Japan, between 2001 and 2022 were enrolled. There were 44 medical offices and hospitals offering obstetrics services in Nagano Prefecture as of 2014 . When a 2.2The indication and procedures for bone marrow biopsies were the same in pregnant women as in patients without pregnancy when a leukemia was suspected. The diagnosis and classification of leukemia were confirmed in accordance with the WHO Classification Tumours of Haematopoietic and Lymphoid Tissues, 4th edition 2017 . RadiogrAll patients were treated at the Department of Hematology, and their pregnancies were managed at the Department of Gynecology and Obstetrics of Shinshu University Hospital.2.3Vital statistics were obtained from a governmental database freely available online (e‐Stat), a portal site of official statistics of Japan managed by the Statistics Bureau . The dat2.4Leukemia patients who did not agree to be included in the present study were excluded from the cohort using an opt‐out method. This study was approved by the institutional review board of Shinshu University School of Medicine  and conducted in accordance with the Declaration of Helsinki.33.1We identified and enrolled five patients with pregnancy‐associated acute leukemia during the study period: three AMLs and two ALLs Table . There wAccording to the e‐Stat, there were 377,000 pregnancies in Nagano Prefecture, Japan, between 2001 and 2022, so we estimated the incidence of pregnancy‐associated acute leukemia to be 1.33/100,000 pregnancies, or 1 in 75,000 pregnancies in Nagano . Nagano 3.2Leukemia was diagnosed in the first trimester in one patient, second trimester in three patients, and third trimester in one patient Figure . The pat3.32. The two ALL patients eventually proceeded to allogeneic hematopoietic stem cell transplantation ; the patient who underwent transplantation during the first CR, remained alive at 24 months from the diagnosis of leukemia (UPN#3), while the other who received transplantation at the second CR, experienced a second ALL relapse 6 months after the transplant (UPN#5). One of the AML patients harboring an FLT‐ITD mutation received allo‐HSCT as postinduction therapy, but the disease relapsed 6 months after the transplant. Another patient with a RUNX1‐RUNX1T1 has been in molecular remission for 3 months since the completion of consolidation chemotherapy (UPN#2). Consolidative therapies are ongoing in the other patient with AML with an intermediate risk (UPN#1). With a median (range) time of observation of 21 (2–52) months, three are alive with CR, and two were dead from complications after second or third allo‐HSCT.The median (range) duration from the initial presentation to the diagnosis of leukemia was 7 0–28) days, and the median (range) duration from the diagnosis to the start of cytotoxic chemotherapy was 7 6‐12) days. Standard induction chemotherapy was eventually administered in all five patients; cytotoxic chemotherapy preceded delivery in three patients, while anti‐leukemic treatments followed an abortion in one patient and emergent Caesarean section in another  with pregnancy in our cohort, largely because the prefecture is located in less‐endemic area for HTLV‐1 , 26. It The small size and short observation period of our study hamper the drawing of any hard conclusions concerning the prognostic impact of pregnancy on the clinical course of leukemia. However, it may be worth mentioning that we did not note any significant delays in the diagnosis or initiation of treatment of leukemia due to pregnancy itself. In a previous study of malignant lymphoma during pregnancy, the start of chemotherapy was deferred in approximately 40% of cases . Our finShort‐term adverse effects were not observed in either of the two live‐born children who experienced intrauterine exposure to cytotoxic chemotherapies. Our results may confirm previous observations that standard treatment options should be offered to patients with pregnancy‐associated leukemia, as they would be in patients without pregnancy . HoweverIn summary, pregnancy‐associated acute leukemia was treated in the same manner as leukemia in patients without pregnancy. Multi‐disciplinary care is mandatory for patients in such challenging situations, but special clinical dilemmas should be resolved in sessions of supportive discussion with patients as well as among staff members throughout the treatment period.The authors received no specific funding for this work.The authors have no conflict of interest to be disclosed.Informed consent of participating patients was obtained using an opt‐out method. This study, including this opt‐out method, was approved by an institutional review board of Shinshu University School of Medicine, approval number 5756, approval date February 14th, 2023. And this study was conducted in accordance with the Declaration of Helsinki. The statement of IRB approval is described in the Method section.Supp InformationClick here for additional data file.


This retrospective cohort study aimed to evaluate the impact of the COVID‐19 pandemic on colorectal cancer care and mortality using a large cancer registry in Hiroshima Prefecture, Japan. The study aimed to estimate the all‐cause mortality rates within 1 year of diagnosis among colorectal cancer patients diagnosed during the pandemic period (2020 and 2021) compared to those diagnosed during the pre‐pandemic period (2018 and 2019).The day of diagnosis was set as Day 0 and Cox regression models were utilized to estimate crude hazard ratios (HRs) and adjusted HRs, accounting for age, sex, cancer stage, and treatment status. Two sensitivity analyses of overall survival were performed with different cutoffs of the pre‐pandemic/pandemic periods and year‐to‐year comparisons. Subgroup analyses were performed using likelihood ratio tests.A total of 15,085 colorectal cancer patients were included, with 6499 eligible for follow‐up. A median age of included patients was 72 years old, of which 59% were male. The distribution of cancer stages showed little variation between the pre‐pandemic and pandemic periods. With a median follow‐up of 177 days, the number of events was 316/3111  in the pre‐pandemic period, and 326/2746  in the pandemic period . The two sensitivity analyses and subgroup analyses consistently supported these findings.The study revealed an increased colorectal cancer mortality during the pandemic period, suggesting a continuous impact of the COVID‐19 pandemic on the known and unknown risk factors for colorectal cancer for several years. Further studies are necessary to mitigate the adverse effects on patient outcomes. This study first describes the mortality risk of colorectal cancer diagnosed during the COVID‐19 pandemic. Colorectal cancer patients diagnosed during the pandemic were 1.4 times higher mortality risk than those during pre‐pandemic. The prognostic impact of delaying diagnosis and treatment may persist in 2020 and 2021. The COVID‐19 pandemic has been associated with delays in new cancer diagnoses, diagnosis at more advanced stages, and delays in initiating effective treatment.In January 2020, the first case of COVID‐19 was diagnosed in Japan, and the Cabinet Office declared the State of Emergency in April 2020.In addition, cancer care and treatment changed, with treatment algorithms that differed from standard practice.The assessment of colorectal cancer, including histology by colonoscopy, is essential, especially in the early stages of the disease. Although the COVID‐19 pandemic resulted in isolation and a reluctance to seek medical care, few studies have examined the impact of the COVID‐19 pandemic on the diagnosis and prognosis of colorectal cancer using large databases.In this study, we compared the baseline characteristics of patients with newly diagnosed colorectal cancer during the pre‐pandemic and pandemic periods and the mortality risk after diagnosis in Hiroshima, Japan, using a large cancer registry.22.1This was a retrospective cohort study performed in Hiroshima Prefecture, Japan, which has a population of 2.81 million using cancer registry data.2.2All patients with newly diagnosed cancer during the study period whose ICD‐O‐3 site code indicated colorectal cancer Table  were eli2.3The primary endpoint was the occurrence of mortality from any cause, since the reason for death was not clear from the cancer registry. The follow‐up period was based on patient medical records at each hospital, which were extracted and used for the study. As cases diagnosed in 2021 only have a follow‐up period until the end of 2022, the maximum follow‐up period was set at 1 year for all cases. Cases were censored if the follow‐up period ended during the study period. Patients who were transferred between institutions were followed continuously, provided that they were transferred between the 15 study institutions.2.4In Japan, repeated outbreaks of COVID‐19 occurred throughout the 2020 and 2021 Figure . Unlike 2.5Data on age, sex, cancer stage, and treatment status were extracted. For the cancer stage, patients were registered based on the Union for International Cancer Control, eighth edition.2.6p‐value of less than 0.05 was interpreted as statistically significant.Analyses were conducted using Stata version 17 MP . First, we described the patient characteristics according to whether the cancer was diagnosed during the pandemic period (in 2020 and 2021) or the pre‐pandemic period (in 2018 and 2019). A two‐sided Survival analysis was conducted. The date of diagnosis was set as Day 0 in the analysis. In this study, we defined censoring as any patient who was lost to follow‐up due to a lack of medical records or who was still alive at the end of the 1‐year study period. All‐cause mortality was set as a censoring event. Kaplan–Meier curves were plotted for overall mortality, and the pandemic and pre‐pandemic periods were compared using the log‐rank test. Cox proportional hazards regression was utilized to estimate crude and adjusted HRs for the main analysis. The adjusted HRs were adjusted for sex, age, cancer stage, and treatment status. We assessed the assumption of proportional hazards for Cox regression analysis by examining the Schoenfeld residuals over time. Subgroup analyses were conducted for each category of sex, age, cancer stage, and treatment status, and the likelihood ratio test was utilized to assess whether adding interaction terms between the pandemic period and each subgroup affected the goodness of fit of the original models.In addition, we conducted two sensitivity analyses with different exposure periods: (1) setting the pandemic period from July 2019 to December 2021, and the pre‐pandemic period from January 2018 to June 2019, because colorectal cancer cases diagnosed in late 2019 were considered to have a higher probability of receiving cancer care during the COVID‐19 pandemic; and (2) a year‐to‐year comparison with 2018 was used as the reference period.3Figure Baseline characteristics Table  showed aThe Kaplan–Meier analysis to estimate the overall survival of patients with colorectal cancer is shown in Figure The results of the two sensitivity analyses exploring the impact of different cutoffs for defining the pre‐pandemic and pandemic periods on the association between the COVID‐19 pandemic and colorectal cancer mortality risk are shown in Table Subgroup analyses were performed to evaluate the potential interaction between the pandemic period and colorectal cancer mortality risk Figure . The sub4This large cohort study showed that the risk of death from colorectal cancer diagnosed during the COVID‐19 pandemic was approximately 1.4 times higher than the risk of death in the pre‐pandemic period. These results were consistent after adjustment for age, sex, stage, and treatment status categories, as well as the results of two sensitivity analyses. The adjusted HRs were smaller than the crude HRs, but the impact of the COVID‐19 pandemic on colorectal cancer mortality was still significant.In this study, we used a large cancer registry to document an increased mortality risk from colorectal cancer during the COVID‐19 pandemic. The 5‐year survival rate for colorectal cancer among patients diagnosed in 2009 and 2011 showed an improving trend from 69% to 71% in Japan.In this study, the risk of death was higher during the pandemic period, even after adjusting for known post‐diagnostic risk factors. Previous studies have identified the following post‐diagnostic risk factors: (1) advanced cancer at diagnosis, (2) a longer interval between diagnosis and starting treatment, and (3) changes in treatment options after diagnosis. A study using Italian National databases found an increased adjusted odds ratio of 1.07 for the risk of death in patients with advanced cancer stage at diagnosis.On the contrary, there are several factors not considered nor adjusted in this study including the time between cancer screening and medical examination, the direct impact of COVID‐19, the indirect effect of COVID‐19 pandemic, and changes in other risk factors, such as socioeconomic status (SES), comorbidities, and physical activities, smoking habits, and performance status.This study has several strengths. We used a general practice‐based database to cover all cases of colorectal cancer diagnosed at hospitals in Hiroshima Prefecture. This allowed us to analyze a large population at risk and to perform a survival analysis for the most important outcome, death. In addition, we set a 1‐year follow‐up period. Despite the shorter follow‐up period, our study showed a significant increase in mortality risk for colorectal cancer during the pandemic period compared with the pre‐pandemic period. This highlights the importance of conducting timely and efficient studies during pandemics to inform clinical practice and improve patient outcomes. Our study is unique in that it includes an analysis of endoscopic treatment and uses a large dataset to demonstrate the negative impact of the pandemic on the outcome of colorectal cancer, which has not been previously explored. This finding adds to the literature on the impact of the COVID‐19 pandemic on cancer outcomes.This study also has some limitations. First, there is a possibility of selection bias occurring in the groups that were followed up and those that were not Table . The folTo the best of our knowledge, this study represents the first comprehensive evaluation of the influence of the COVID‐19 pandemic on the survival outcomes of patients with colorectal cancer, encompassing endoscopic treatment, and utilizing a large dataset. The COVID‐19 pandemic was associated with increased mortality risk throughout 2020 and 2021. It is important to monitor cancer outcomes during and after the pandemic, and to identify possible disparities that may contribute to the increased mortality risk. This study did not identify all factors contributing to the mortality risk of colorectal cancer during the COVID‐19 pandemic; therefore, further studies are warranted to better understand the impact of COVID‐19 on cancer outcomes, and the system of care should be adapted to improve the outcomes of cancers worsened by the COVID‐19 pandemic.Daisuke Miyamori: Conceptualization (lead); data curation (lead); formal analysis (lead); funding acquisition (lead); investigation (lead); methodology ; project administration ; resources ; writing – original draft (lead). Tsukasa Kamitani: Methodology ; supervision ; writing – review and editing . Shuhei Yoshida: Methodology ; validation . Yuya Shigenobu: Validation . Kotaro Ikeda: Validation . Yuka Kikuchi: Validation . Saori Kashima: Investigation ; methodology ; software . Yosuke Yamamoto: Supervision ; writing – review and editing .This study received support from JSPS KAKENHI Grant Number JP21K17227.The authors declare no conflicts of interest related to this research. The authors of this study fulfill the authorship criteria set by the International Committee of Medical Journal Editors (ICMJE).The study protocol was approved from the Ethical Committee for Epidemiology of Hiroshima University (E2022‐0139) and was implemented according to the principles as outlined in the Declaration of Helsinki. Informed consent was waived because the authors received the data as anonymous status from the registry system.Figure S1:Click here for additional data file.Figure S2:Click here for additional data file.Figure S3:Click here for additional data file.Tables S1–S5.Click here for additional data file.


Mapping the topology of the visual system is critical for understanding how complex cognitive processes like reading can occur. We aim to describe the connectivity of the visual system to understand how the cerebrum accesses visual information in the lateral occipital lobe.Using meta‐analytic software focused on task‐based functional MRI studies, an activation likelihood estimation (ALE) of the visual network was created. Regions of interest corresponding to the cortical parcellation scheme previously published under the Human Connectome Project were co‐registered onto the ALE to identify the hub‐like regions of the visual network. Diffusion Spectrum Imaging‐based fiber tractography was performed to determine the structural connectivity of these regions with extraoccipital cortices.The fundus of the superior temporal sulcus (FST) and parietal area H (PH) were identified as hub‐like regions for the visual network. FST and PH demonstrated several areas of coactivation beyond the occipital lobe and visual network. Furthermore, these parcellations were highly interconnected with other cortical regions throughout extraoccipital cortices related to their nonvisual functional roles. A cortical model demonstrating connections to these hub‐like areas was created.FST and PH are two hub‐like areas that demonstrate extensive functional coactivation and structural connections to nonvisual cerebrum. Their structural interconnectedness with language cortices along with the abnormal activation of areas commonly located in the temporo‐occipital region in dyslexic individuals suggests possible important roles of FST and PH in the integration of information related to language and reading. Future studies should refine our model by examining the functional roles of these hub areas and their clinical significance.  For instance, the processes of speech and reading require integration of visual and nonvisual information, which is thought to occur within the lateral occipital lobe (LOL), and relay visual information to nonvisual parts of the cerebrum , in order to efficiently facilitate complex functions while minimizing metabolic costs  to understand how nonvisual areas access information in the LOL  on July 25, 2019 for all relevant task‐based fMRI studies related to the lateral occipital parcellations identified by the HCP authors ; (B) Subjects: Diagnosis = Normal. In total, we performed nine searches  and returned 394 papers related to the MNI images of the lateral occipital parcellations constructed in Connectome Workbench. All papers were reviewed for inclusion in this study based on the following inclusion criteria: (1) peer‐reviewed publication, (2) task‐based fMRI study related to the visual network and vision , (3) based on whole‐brain, voxel‐wise imaging, (4) including standardized coordinate‐based results in the Talairach or MNI coordinate space, and (5) including at least one healthy human control cohort. Only coordinates from healthy subjects were utilized in our analysis.We searched BrainMap Sleuth 2.4 (brainmap.org/taxonomy/paradigms.html)  meta‐analytic processing is performed on groups of coordinates to identify coactivation patterns and task‐dependent connectivity for a user‐defined ROI  to extract the relevant fMRI data from all 142 studies used in this analysis for creation of an ALE map. All Talairach coordinates identified during literature review were converted to the MNI coordinate space using SPM Conversion in Ginger ALE. We subsequently performed a Single Study analysis using Cluster‐Level Interference in the MNI coordinate space . The ALE coordinate data were displayed on an MNI‐normalized template brain using the Mango 4.0.1. A code was used to generate centroids according to the center coordinates and areas reported by Ginger ALE, identify HCP parcellations overlapping with this centroid, and calculate the percentage overlap between the centroid and HCP parcellation. Nonvisual parcellations with a percentage overlap greater than 10% were included in our analysis  using publicly available brain imaging from the HCP . The acquisition parameters for the HCP data are available within the HCP documentation. Tractography was performed individually with 50 adult subjects, chosen randomly using a random number generator. The inclusion and exclusion criteria for the HCP database have been described elsewhere . Grayordinate label parcellation fields were standardized to the three‐dimensional volumetric working spaces of DSI studio using the structural imaging data provided by HCP for each subject. Voxels within each ROI were automatically traced with a maximum angular threshold of 45°. When a voxel was approached with no tract direction or a direction greater than 45°, the tract was halted. Tracts with length shorter than 20 mm or longer than 800 mm were discarded. In some instances, exclusion ROIs were placed to exclude spurious tracts or tracts inconsistently represented across individuals.All fiber tractography was completed in DSI Studio , 6r , FOP4 , TPOJ1 , a24pr (anterior 24 prime), p32pr (posterior 32 prime), and STSdp  Figure .3.2Based off our observation that FST and PH demonstrated the greatest coactivation with extraoccipital areas outside of the lateral occipital ROIs, we performed deterministic tractography to test the structural connectivity between FST and PH and their coactivated areas.Area FST, located in the anterior portion of the LOL just posterior to MT gyrus, demonstrated a variety of structural connections to extravisual cerebrum mainly through long‐range superior longitudinal fasciculus (SLF) fibers and short local association fibers to the TPOJ1 Figure . We founArea PH, located in the anteroinferior LOL just lateral to the occipitotemporal sulcus, also demonstrated long‐range SLF connections to extravisual cerebrum as well as short local association fibers to lateral parietal regions Figure . ConnectOur findings of the connectivity of areas FST and PH support our previous greater characterizations of the structural connectivity of the lateral occipital cortex  and TPOJ1. FST also shows coactivation with two of the parcellations in the anterior cingulate gyrus, a24pr and p32pr, though structural connections were not consistently identified to these regions during fiber tracking analysis.The parcellations connected to FST in the anterior cingulate gyrus (a24pr and p32pr) and area FOP4 have been shown in previous studies to play a role in gestalt language retrieval , lateral parietal regions , and part of the lateral frontal lobe (6r). Area PH also shows coactivation with the motor division of the anterior cingulate gyrus (24dv and 24dd), part of the cognitive division of the anterior cingulate gyrus (p32pr), and a supplementary motor area (PEF), though structural connections were only identified with PEF.Previous studies conducted on the lateral parietal regions, PF and RI, and STSdp, as well as lateral frontal areas 8C and PEF, and the supplementary and cingulate eye field (SCEF), suggest these parcellations play an important role in the integration of motion, audiospatial, and visuospatial information to direct visual attention and oculomotor planning and saccadic control required in reading  and the cognitive portion of the anterior cingulate gyrus (p32pr), which have been linked to language processing and the integration of top‐down and bottom‐up processing of language (Amiez & Petrides, 4.4We provide evidence of critical hub regions within the LOL, connecting the visual system to nonvisual parts of the cerebrum. Previous studies investigating the integration of visual information indicated that MT and MST played the most significant role; however, these studies largely relied on macaques for data collection (Krubitzer & Kaas, It appears that FST and PH act as hubs in the lateral occipital network, collecting and relaying information from within the lateral visual system to extravisual parcellations responsible for various multinetwork functions, such as spatial, motor, and language functions. This supports the organization of the lateral occipital system as a small‐world network. Specifically, parcellations within the LOL display extensive internal communication, while areas FST and PH act as a bridge between the lateral visual and extravisual networks.These findings are indirectly supported by imaging studies that demonstrate abnormalities in multiple functional networks in individuals with dyslexia, including visual, attention, and cingulo‐opercular networks (Bailey et al., 4.5Although our study provided an extensive topographical model of the lateral visual system, it is not without its limitations. Coordinate‐based meta‐analyses allow the procuring of foci reported from numerous different experiments that can improve study power and the ability to generate hypotheses for further discussion. However, this type of analysis is also inherently limited by the quality of the data reported in available studies due to common heterogeneity in study designs and biases in selected studies. While numerous revisions of this method have been previously described, the ALE is subject to possible publication bias like most meta‐analyses and may require additional analyses to control for unreported information (Acar et al., Furthermore, we elucidated the hubs of the visual network that we identified in HCP nomenclature, which delineates 180 distinct cortical areas across two hemispheres allowing us to use complex computational algorithms to describe the neuroanatomical basis of the LOL with great precision (Glasser et al., We discussed the role of FST and PH in the context of langue and reading disorders while also excluding studies related to the behavioral paradigms including visual processing. These excluded studies may have further explained the role of the LOL in language‐related visuospatial processing and thus represent a limitation of our methods. However, it is important to note that the BrainMap database includes an intricate search software that allowed us to first screen all studies related to visual processing to identify cortical regions in the visual network and only then subsequently filter out studies solely focused on visual processing to better understand the nonvisual functions of possible hub areas identified (Laird et al., It is important to note that combined studies such as ours that utilize both structural tractography and functional coactivation maps together are able to better investigate connectomic information compared to either of these modalities alone, but are inherently limited by the quantitative limitations of tractographic analyses (Campbell & Pike, In conclusion, we identified two hub‐like regions of the LOL that form extensive connections with nonvisual cerebral areas. Elsewhere, abnormal activation of FST and PH has been described to illicit multinetwork disturbances that affect both visual and nonvisual functions, such as language and reading. FST and PH should be included in future studies as possible covariates to include in the modeling of the atypical mechanisms of language‐ and reading‐related multinetwork disturbances, such as in dyslexia. Further studies should refine our model with whole‐brain analyses in healthy individuals as well as in individuals with visuospatial disorders to better understand the implications of FST and PH as key hub areas for nonvisual cerebrum. Importantly, the current study demonstrates that ALE meta‐analytic software targeting functional data in large data sets can be applied to other cortical regions as well throughout the brain to determine possible hub areas, and subsequent structural tractography can be applied to understand how their structural interconnectedness may support their functional roles in integrating complex information across multiple brain networks.M. E. Sughrue is the Chief Medical Officer of Omniscient Neurotechnology, and no products related to this were discussed in this paper. The other authors declare no conflicts of interest.https://publons.com/publon/10.1002/brb3.2945.The peer review history for this article is available at


Overwhelmingly, older Australians  prefer to remain living in their own home rather than moving into residential care. To enable older Australians who require assistance to remain living at home, the Federal Government provides a wide range of community care services, the provision of which has increased substantially over the last 15 years. The importance of client preferences, prefaced by the introduction of consumer directed care across community aged care services, has gathered momentum in Australia following legislation in 2015. Older peoples' preferences differ in comparison to younger people with disability and those with mental health concerns. Older people focus more on the provision of services rather than the notion of independent living itself. This scoping review aimed to explore what aspects people aged 65 years and older consider to be important qualities of aged care services delivered in the community. A computerised search in MEDLINE, CINAHL, PubMed and PsychINFO and hand searches of the Cochrane database and Google Scholar were completed in May 2022. Sixty‐two articles met the selection criteria and were included in the review. Data were extracted using a fit‐for‐purpose protocol and analysed using the Miles and Huberman Model for thematic analysis. Results identified five themes representing quality domains that describe features that are important to clients: staff knowledge, respect for clients, a person‐centred approach, a collaborative partnership with clients and clear communication. When providers of community aged care services are planning to assess the quality of their services, these findings could be used to guide their evaluation. This will ensure that future services delivered accommodate the needs and preferences of clients who receive them. Quality measures are a pre‐requisite to improving the quality of care by enabling ongoing monitoring and comparing performance against a set of standards and/or measures.Many aged care service providers use satisfaction surveys to measure their clients' satisfaction.Very few aged care service providers develop satisfaction surveys in partnership with their clients, to ensure the views and opinions of features important to clients are included.The views and preferences of older community aged care service users regarding the provision of a quality service were identified through an international scoping literature review.A suite of quality domains that could be used by aged care providers to measure quality from the client's perspective when delivering services in the community.1Individual experience is considered one of the keys to quality in healthcare, along with safety and clinical outcomes. Providing feedback on the experience of clients and supporting the organisational team to address any identified problems, leading to improved quality, is the best way to support a service to meet its objectives , two separate systematic searches were undertaken, specifying the difference in age categories and population cohorts only. Filters were applied to the electronic searches including limiting the search to academic journals published between July 2000 and April 2022, age  and human. The year 2000 was selected as the commencement date as publications prior to this date would not reflect current Australian policies and practices. Duplicates were removed, and titles/abstracts were reviewed by one author (SS). Full texts were independently reviewed by three authors . Disagreement was resolved by consensus in the discussion. Full‐text articles were included if there was a reference to (a) either a client, patient or lived experience expert; (b) community aged care services or home care services and (c) quality measure or satisfaction or preference or participation Table . Data an2.1The first stage of data reduction was conducted according to step 1 of Miles and Huberman's model (1994) for thematic analysis  of the study, methods adopted and key measures used to obtain study outcomes , followed by the United Kingdom (n = 8), United States (n = 7), Sweden (n = 6) and Canada (n = 5). The remaining articles were published in the Netherlands (n = 3), Finland (n = 3) and Greece (n = 2) and one was from each Korea, Switzerland, Israel, Norway, Hong Kong and Scotland.The largest number of publications were from Australia  of the included studies were qualitative. The remaining studies were mixed methods  (n = 3), Discrete Choice Experiment and cross‐sectional (n = 1), randomised control trial (n = 1), non‐randomised control trial (n = 1) and discrete choice experiment (n = 3).The study population for most articles was similar, most often being older people living in the community, however, three articles focussed on support services for people living with dementia  client satisfaction, 2) client experience, 3) access and choice, 4) preference and expectations of care and 5) service quality. Definitions of these measures are summarised in Table  client e access a preferen service n = 24) explored client's perceptions and experiences and  explored satisfaction with the services they received. Four of the articles focused on other topics including understanding the needs and preferences of clients when seeking information about community services  they provide(ed), the way in which care should be delivered, and understanding clients' individual circumstances and problems .Thus, a unique aspect of this study was specifying evidence of the involvement of a client in a study as essential inclusion criteria. Additionally, the inclusion of ‘involvement of a client’ captured studies that described client's views, experiences and perspectives relating to a variety of important stages of a clients community aged care service experience including navigating the aged care system, understanding what care was available to them, getting through the assessment process that determined their eligibility for a service, negotiating how care was delivered to meet their specific needs, communicating with care staff and service providers and balancing both formal and informal care.A study by Jones et al. explored important dimensions of home care quality in 34 local authorities in England. The results of this study showed a clients' satisfaction with the services they received, and services delivered at suitable times were two performance indicators that reflected quality. In addition, this study showed the underlying constructs of home care quality were satisfaction and suitable times. This study also looked at the variance within the satisfaction ratings of dimensions of home care quality and suggested overall service quality had four aspects including service quality, positive carer quality, negative carer quality and outcome , it is difficult to say more about specific countries and their aged care systems (All countries have eight or less papers).Internationally, England and the United States have led the way in adopting person‐centred care, following significant policy reform. Both countries have mandated requirements for service providers to collect and publish data on patient experiences, which is attached to financial incentives for providers who achieve high measures , to feel empowered and have influence over the care and services they receive  that reported the preferences and experiences of older people living with cognitive impairment were identified and included in the review. Under‐representation of this client group makes it difficult to draw conclusions from the results that accurately reflect their perceptions regarding a quality aged care service. If their views are to be included in the development of these quality measures, further research to better understand their views is required. In addition, the number of articles that focussed on the perspectives and experiences of Aboriginal and Torres Strait Islander people when receiving community aged care services was limited (n = 5). Similarly, the number of articles that involved clients in the development of questionnaires and surveys used to understand a client's experience, satisfaction and preference were also limited. Thus, their opinions may not have been completely captured, resulting in a narrow representation of experiences and preferences that clients view as quality attributes of community aged care services. This shortcoming is currently being addressed through an increasing emphasis on the importance of including consumers in research activity that impacts them.Finally, a small number of articles (6The five quality domains identified in this review that reflect clients' views of important attributes of a quality community aged care service provide an opportunity for community aged care organisations to explore how these could be incorporated to provide clients with a high‐quality service. These quality domains could be used to inform the development of quality indicators to measure the quality of aged care services from a clients' perspective.Sandra Smith was responsible for undertaking the literature searching and preparing the initial draft of the manuscript. All authors assessed the articles against inclusion and exclusion criteria, proofread and revised the manuscript.None.


Cancer is the leading cause of mortality in people living with HIV (PWH) and is expected to account for a growing fraction of deaths as PWH age.In this literature review, we have compiled the most recent developments in cancer screening and screening performance in PWH, which are currently primarily implemented in well‐resourced settings. This includes an assessment of the associated benefits, harms, and cost‐effectiveness. The article also addresses unmet needs and potential strategies for tailored screening in the HIV population.Incidence and mortality due to screenable cancer are higher in PWH than in the general population, and diagnosis is frequently made at younger ages and/or at more advanced stages, the latter amenable to improved screening. Adequate evidence on the benefits of screening is lacking for most cancers in the HIV population, in whom standard practice may be suboptimal. While cancer surveillance has helped reduce mortality in the general population, and interest in risk‐based strategies is growing, implementation of screening programs in the HIV care settings remains low.Given the devastating consequences of a late diagnosis, enhancing early detection of cancer is essential for improving patient outcomes. There is an urgent need to extend the investigation in cancer screening performance to PWH, evaluating whether personalized measures according to individual risk could result in higher efficiency and improve patient outcomes. Observational studies have reported that ultrasounds are beneficial for early diagnosis and mortality reduction in people with viral cirrhosis.Most surveillance studies have been conducted in individuals with viral hepatitis, but the benefits and strategies of screening in patients with NAFLD‐related cirrhosis have yet to be elucidated.Table 3.2Professional society guidelines recommend screening for HCC in high‐risk individuals, with consensus for cirrhosis of any etiology and higher variability for other risk groupsScreening recommendations in PWH are in line with those of the general population.Table 3.3The poor performance observed with ultrasound will presumably be aggravated by the growing prevalence of NAFLD in PWH. Both awareness campaigns on the need for surveillance and research on alternative screening strategies are imperative. Shorter intervals between ultrasounds and/or screening in non‐cirrhotic advanced fibrosis remain to be explored in PWH. Using a Markov model, MRI was cost‐effective in a subgroup of HIV‐negative patients with compensated cirrhosis and annual HCC risk over 3%, identified via a scoring system.4Of all the NADCs, invasive anal cancer is the malignancy with the highest excess incidence and mortality.4.1The natural history of anal cancer can be modified by early treatment of high‐grade squamous intraepithelial lesion (HSIL), the necessary precursor of invasive carcinoma, to prevent progression to anal cancer.Despite the proven benefits, HRA has currently limited availability due to the scarcity of expert capacity and infrastructure. The procedure should therefore be reserved for people at the highest risk of cancer. Accurate screening tests for selecting the individuals with the highest pre‐HRA probability of bHSIL are particularly important to optimize the procedure. Although there is still no consensus, the most widely used screening test for referral to HRA is anal cytology; however, performance is suboptimal.Available screening tests to predict bHSIL are shown in Table Although the prevalence of bHSIL is up to 47% in men who have sex with men (MSM) with HIV,If early treatment of HSIL through HRA is not available, digital anal rectal examination (DARE) may allow early diagnosis of invasive carcinoma. Data on the benefits of DARE for early diagnosis of anal cancer are extremely limited. The size of the tumor is an important prognostic factor, and in one phase II clinical trial, the procedure was able to detect tumors of 3 mm or more.4.2To date, there is no international consensus on routine anal cancer screening. Due to the preponderance of anal cancer in PWH, some HIV management guidelines recommend screening with DARE, with or without anal cytology plus HRA if abnormal, usually in MSM/transgender women and in persons with HPV‐associated dysplasia,4.3The relevance of the results of the ANCHOR trial will directly impact cancer screening guidelines. Anal cancer screening with HRA should be incorporated as a routine procedure among the screenable cancers in people at risk. This implies a need for training in HRA on a large‐scale, ideally to infectious disease specialists, who are the physicians with the greatest involvement in PWH care. There is also a need for standardized protocols to select patients for HRA. A crucial step to optimize the procedure is to stratify people according to their anal cancer risk in order to identify the best candidates both for screening and treatment. Algorithms combining clinical/biological risk factors with biomarkers for bHSIL prediction and for bHSIL progression might be helpful for personalized anal cancer screening, warranting further research.5In women with HIV (WWH), the risk of developing cervical cancer is six‐fold that of the general population,5.1Treatment of precancerous lesions (HSIL) can prevent the development of invasive carcinoma and reduce mortality. Multiple observational studies and at least one RCT have shown that different screening strategies—even if performed only once in a lifetime—decrease mortality, reduce incidence of invasive cancer, and increase cure rates.5.2The American Society for Colposcopy and Cervical Pathology (ASCCP) 2019 guidelines provide specific screening recommendations for high‐risk groups such as WWH, and these recommendations have been adopted by other societies.5.3WWH are a high‐risk group, and guidelines recommend longer and more frequent screening than in the general population. The rate of false‐positives is high,6The incidence of colorectal cancer (CRC) seems to be similar in PWH and the general population6.1Screening can prevent CRC by diagnosing and treating premalignant adenomas or sessile serrated lesions in early stages through endoscopy. Screening tests can be divided into one‐step tests like colonoscopy, which is both diagnostic and therapeutic, and two‐step tests consisting of a stool‐based test or structural examination followed by colonoscopy if positive. Whereas genetic tests in stools and plasma hold promise Table , only th6.2The American College of Gastroenterology updated 2021 guidelines recommend colonoscopy every 10 years and annual fecal immunochemical testing as the primary screening modalities for CRC screening in average‐risk individuals aged 50 to 75 years.Table 6.3Despite having a similar frequency to the general population, CRC occurs at younger ages in PWH, which would support earlier initiation of screening. This would be of particular interest in MSM who have been severely immunosuppressed because of the increased risk for rectal squamous cancer.7Breast cancer incidence may be slightly lower in WWH compared to uninfected women.7.1Table 7.2Most scientific society guidelines recommend a biennial mammography for all women aged 50 to 74 years, extendable to some women aged 40 to 50 years based on individual patient characteristics.7.3Both the younger age and more advanced stage at diagnosis in WWH would support earlier initiation of screening, more frequent screening, or adapted screening with more sensitive procedures like ultrasound or MRI, particularly in higher‐risk subgroups. In view of the poorer prognosis of WWH, campaigns addressing the importance of breast cancer screening in WWH are desirable to raise awareness in both physicians and patients.8Studies comparing the incidence of prostate cancer in PWH versus the general population have shown discordant results, ranging from lower8.1Measurement of PSA blood levels is the standard procedure for prostate cancer screening. The results of a meta‐analysis concluded that PSA testing may have a modest effect in reducing prostate cancer mortality but not overall mortality, and it is associated with biopsy and cancer treatment‐related complications.8.2There are no specific recommendations for prostate cancer screening. The European Association of Urology (EAU) and the USPSTF guidelines advocate shared decision‐making after discussing the potential benefits and harms of screening with the patient. PSA would then be offered to men from 50 years of age or younger men at elevated risk of prostate cancer (EAU),8.3Prostate cancer is expected to be a leading NADC in the next decade as PWH become older. High‐level evidence is needed to determine the usefulness of prostate cancer screening to reduce mortality; alternative screening procedures such as ultrasound or MRI might also be explored to assess their potential advantages over PSA.Figure 9Cancer is the leading cause of mortality in PWH and is expected to account for a growing fraction of deaths as PWH age. Cancer screening has been shown to decrease cancer‐associated mortality in the general population and should be a priority in PWH. In this review, we have compiled the most recent developments in cancer screening and screening performance in PWH, which are currently primarily implemented in well‐resourced settings. This includes an assessment of the associated benefits, harms, and cost‐effectiveness. The article also addresses unmet needs and potential strategies for tailored screening in the HIV population. There is an urgent need to extend the investigation in cancer screening performance to PWH, evaluating whether personalized measures according to individual risk could result in higher efficiency and improve patient outcomes. Randomized intervention studies that assess earlier initiation, more frequent testing, and include the most recent advances in cancer screening are needed to generate high‐level evidence on cancer surveillance tailored to PWH, and to fill existing knowledge gaps.Mar Masiá: Conceptualization ; data curation (lead); writing – original draft (lead); writing – review and editing . Ana Gutiérrez Ortiz de la Tabla: Writing – review and editing . Félix Gutiérrez: Conceptualization ; funding acquisition (lead); writing – review and editing .This work was supported by the RD16/0025/0038 and CB21/13/00011 projects of the National Plan Research + Development + Innovation (R + D + I) and co‐financed by Instituto de Salud Carlos III—Subdirección General de Evaluación y Fondo Europeo de Desarrollo Regional  and the Conselleria de Innovación, Universidades, Ciencia y Sociedad Digital of the Generalitat Valenciana (grant AICO/2021/205).The authors declare that they have no conflict of interest.


Patients undergoing chemotherapy and radiotherapy are placed in an immunocompromised state worth consideration in the event of potential airway compromise, especially when superimposed on an airway‐obstructing tumor. We report a case of bacterial epiglottitis in a patient with active oropharyngeal cancer (OPC), who presented in such a way that an infectious etiology was not initially considered in the patient's care. To our knowledge, such a circumstance has not been reported in the literature.Haemophilus influenza and Pseudomonas aerugeniosa. Following antibiotic treatment, the patient recovered to the point in which he could then undergo concomitant chemoradiation. The patient later had a recurrence of P. aerugeniosa during their radiotherapy that was also treated with antibiotics. The patient experienced continued symptoms related to their OPC and underwent pharyngectomy. Despite the initial success of this procedure, the patient experienced tumor recurrence and succumbed to his disease.Here, we report a case of a 68‐year‐old male with advanced‐stage OPC who developed respiratory distress and underwent emergent tracheostomy. The patient was diagnosed postoperatively with This case underscores the importance of considering multiple etiologies concerning airway compromise, as the consequence of delayed cancer treatment may be loss of local cancer control. The patient's regional oncology clinic had concerns for airway compromise, and it was noted that the patient's radiotherapy had been delayed as the patient required dental clearance and could not lay flat without desaturation. The patient's initial physical exam revealed a visible mass raising concern for potential airway compromise. Computed tomography (CT) imaging of the neck was obtained Figure  showing On assessment by the otolaryngology service, the patient was noted as being lethargic; their mouth was open, and tongue was protruding, and the patient was using their abdominal, neck, and shoulder accessory muscles to breathe. Lung sounds were noted as diminished. It was also noted that the patient had a high‐flow nasal cannula in place set to 15 L. The patient aroused to verbal engagement but was difficult to understand due to their voice being raspy. Given the patient's known airway‐obstructing tumor with minimal area of airway patency, the otolaryngology service considered the patient to be a difficult airway and decided to perform an emergent tracheostomy in the operating room. No endoscopy was performed, as this assessment was considered likely to confirm suspicions that the patient's airway was minimally patent.P. aeruginosa and H. influenzae on culture. The patient required an urgent start of radiation due to tumor bleeding, with planned initial doses of 600 cGy delivered in two fractions to the head and neck, and 400 cGy delivered in two fractions to the supraclavicular regions. The patient's radiotherapy planning CT imaging reflected a diagnosis of epiglottitis contributing to airway obstruction , and later a respiratory panel taken on Day 5 of his hospital admission grew n Figure . He began Figure . The patDuring radiation follow‐up about 10 weeks after discharge, the patient reported increasing dysphagia and odynophagia along with chills and hoarseness. Follow‐up soft tissue neck CT revealed a mucosal mass at the left piriform sinus, at the inferior margin of the previously noted oropharyngeal mass  all increase the risk for infection in patients.Pharyngeal masses present a potentially difficult challenge for airway management. Complete airway obstruction resulting in loss of access to the airway could prove disastrous in an emergent situation. Common risks that pharyngeal masses pose to airway integrity include the risk of bleeding, local tumor invasion into supportive structures leading to airway obstruction, and from the bulk of the tumor directly. The literature describes a systematic approach in the management of patients with airway masses.4Literature suggests that early diagnosis permitting treatment of epiglottitis with IV antibiotics and corticosteroids decreases the need for airway intervention and as such would decrease the risks associated with tracheostomies.Michael Larkins: Investigation (lead); methodology (lead); project administration (lead); writing – original draft (lead); writing – review and editing (lead). David Meyer: Project administration (supporting); writing – original draft (supporting); writing – review and editing (supporting). Kenneth Lowery II: Project administration (supporting); writing – original draft (supporting). Rachel Speicher: Project administration (supporting); supervision (supporting); writing – review and editing (supporting). Brian Brodish: Project administration (supporting); supervision (supporting); writing – original draft (supporting); writing – review and editing (supporting). Andrew Ju: Conceptualization (lead); project administration (supporting); resources (lead); supervision (lead); writing – original draft (supporting); writing – review and editing (supporting).The authors received no financial support for the research, authorship, and/or publication of this article.The authors have stated explicitly that there are no conflicts of interest in connection with this article.Written informed consent was obtained from the patient for publication of case details, including imaging.


The magnetic resonance linear accelerator (MR‐Linac) offers a new treatment paradigm, providing improved visualisation of targets and organs at risk while allowing for daily adaptation of treatment plans in real time. Online MR‐guided adaptive treatment has reduced treatment uncertainties; however, the additional treatment time and resource requirements may be a concern. We present our experience of integrating an MR‐Linac into a busy department and provide recommendations for improved clinical and resource efficiency. Furthermore, we discuss potential future technological innovations that can further optimise clinical productivity in a busy department. The MR‐Linac introduces a novel approach to radiotherapy by combining improved visualisation capabilities with real‐time adaptation of treatment plans. While online MR‐guided adaptive treatment reduces uncertainties, it also raises concerns about increased treatment time and resource demands. This article shares insights from integrating an MR‐Linac into a busy department, offering recommendations for enhanced clinical and resource efficiency. Online magnetic resonance (MR)‐guided radiation therapy involves using a hybrid MR linear accelerator (MR‐Linac) to deliver radiotherapy treatment. It provides enhanced soft‐tissue visualisation and real‐time motion monitoring during treatment. Additional benefits include the ability to adapt plans based on daily anatomy, potentially reducing margins and improving accuracy. Early evidence indicates good patient tolerance with acceptable toxicity profile.We previously reported our initial 6 months of clinical operations highlighting the training requirements and nuances of treating using this technology.The MR‐Linac program at St Vincent's Sydney in GenesisCare Australia launched in July 2020, and while the initial clinical ramp‐up was gradual, significant improvements in treatment efficiency were achieved over the first year. For stereotactic treatments (dose per fraction 5–14 Gy), average treatment times reduced from 57 min in the first 6 months to 42 min in the next 6 months. Similarly, for long‐course treatments (>15 fractions), average treatment times reduced from 42 min in the first 6 months to 35 min in the next 6 months. These improvements have been sustained over time, despite the increasing treatment complexity, for example stereotactic body radiotherapy (SBRT) and new clinical indications. These efficiencies can be attributed to several factors including the increased confidence and experience of the dedicated multidisciplinary team, improvements in documentation and communication between the treating team and the implementation of a Wacom Cintiq tablet  to reduce online contouring time.The evidence supporting the benefits of MR‐guided adaptive radiotherapy (MRgART) compared with conventional radiotherapy is not yet mature.The Unity system provides two modes for online adaptive treatments: adapt‐to‐position (ATP) and adapt‐to‐shape (ATS) Fig. . The ATSThe ATP workflow involves a virtual isocentre shift and does not require recontouring. This approach is employed when a patient's anatomy is favourable and closely matches prior imaging. In our practice, for treatment involving more than five fractions, the first three to five fractions are treated with an ATS approach, and the resulting plans are used to create a plan library for the patient. Subsequent fractions are matched to the reference plan or an appropriate previous fraction. This approach requires manual selection of the most suitable plan and provides multiple options with different anatomical positions for that patient. This approach can speed up optimisation and shorten treatment times by eliminating the need for recontouring and is particularly useful in cases with stable anatomy of both target and OARs, such as oligometastatic lymph nodes.The ATS‐Lite workflow is a useful approach in situations where the target is stable and matches well to the reference scan or previous fractions, but the patient contours or nearby OARs vary in position. This is a modification of the ATS workflow, where only one or two contours are edited. If the change is not large, the system's deformable image registration algorithm can often accommodate these changes automatically and quickly, eliminating the need for manual recontouring. This reduces contouring time while still utilising the ability to accurately adapt to anatomical changes and optimise the plan. We have successfully used this approach in stereotactic liver treatments and head and neck cases. Other reports have also shown similar use of the ATS‐Lite workflow for head and neck cases.During the initial 2 years of treatment, our clinic adapted 94.4% of fractions using the ATS or ATS‐Lite workflow, with the remaining fractions adapted using the ATP workflow. The MR‐Linac system's flexibility enables us to interchangeably use the appropriate workflow based on the daily anatomy.Due to the adaptive nature of MR‐Linac treatments, the workflow in most centres requires the presence of the RO, especially during recontouring. To address this, we have developed a training and credentialing process that enables radiation therapists to contour patient anatomy, similar to practices implemented in other centres.The MR‐Linac has the potential to remove the need for simulation and reference imaging for radiotherapy planning. While previous trials investigating simulation‐free treatment have mainly focused on palliative scenarios using conformal treatment techniques,The delineation of target and OARs remains the most laborious and time‐consuming task and is a hindrance to adaptive radiotherapy in a busy department. Auto‐contouring methods have progressed over the last decade, with the most recent techniques involving AI approaches. Ongoing validation of AI‐based auto‐contouring tools has showed high contouring accuracy with less time and able to supplement clinicians with a quick solution.Other important technological innovations, which could be achieved with MR‐Linac, include volumetric modulated arc therapy (VMAT) and multi‐leaf collimator (MLC) tracking, dose accumulation and imaging biomarkers.While the unique characteristics and design of the Unity MR‐Linac offer many advantages, there are some treatment delivery improvements that can be made. The Unity MR‐Linac offers a 7 MV flattening‐filter free (FFF) beam to be used for static intensity‐modulated radiotherapy (IMRT). On a standard linac, VMAT reduces delivery times when combined with high‐dose‐rate FFF beams but currently not available on the MR‐Linac system for clinical use. A recent proof‐of‐concept study showed that VMAT is feasible on the Unity system for prostate SBRT.While the daily plan adaptation with MRgART offers personalised treatment approach, the accuracy of the assessment of the daily delivered dose would further improve through dose accumulation. If clinicians are able to review the deposited dose before each fraction, the plan of the day could be further personalised and optimised. Early studies showed that beam‐on MR‐Linac can be used for time‐resolved dose accumulation.Quantitative imaging biomarkers (QIBs) can provide measurable characteristics about the physiology of a tissue being imaged (e.g. tissue cell density). MR imaging‐derived QIBs are of particular interest in oncology due to the vast literature suggesting they can assist in predicting treatment outcomes and assessing treatment responses.The MR‐Linac's versatility in treating various anatomical sites makes it suitable for routine clinical use, unlike specialised machines such as CyberKnife and Gamma Knife. Based on our experience, new MR‐Linac centres should prioritise commonly treated anatomical sites. This includes sites where the soft‐tissue contrast using MRgART will allow safe high‐precision treatment with optimal sparing of healthy tissues, such as localised prostate cancer. Moving targets including pancreatic cancer, liver cancer and pelvic lymph nodes close to sensitive OARs will also benefit from MRgART with motion management approaches. These recommendations align with ESTRO's patient selection guidelines for MR‐Linac.The integration of an MR‐Linac into routine practice necessitates specific training and credentialing of staff to ensure safe and effective utilisation of the technology. We have developed a robust training and credentialing model encompassing essential areas including MR safety, MR image acquisition and optimisation for radiotherapy purposes, image interpretation and adaptive radiotherapy strategies.Our staffing model for the MR‐Linac is comparable to a standard linac, with a similar number of radiation therapists and radiation oncology medical physicists (ROMP) assigned per machine. This approach aligns with the position statement on MR‐Linac staffing model by the Australian Society of Medical Imaging and Radiation Therapy (ASMIRT).Treatment interruptions on the MR‐Linac are rare in our experience; therefore, dual planning (creating backup plans for standard linac) is unnecessary. In 2 years of operation, we encountered only one significant MR‐Linac breakdown, necessitating the creation of new plans for patients to transition to a standard linac. Additionally, our high volume of SBRT cases enables longer breaks between fractions compared with extended treatments.Despite superior image quality, MR‐Linac systems can still face limitations in visualising tumours affected by breathing artefact, particularly in the upper and mid abdomen. Abdominal compression is recommended to help reduce the breathing artefacts. Additionally, large tumours may be difficult to treat due to the limited field of view (22 cm) in the superior–inferior direction. Patient intolerance and MR safety also need to be considered. Although patients with cardiovascular implantable electronic devices can be treated,While adaptive radiotherapy offers a promising solution to high‐precision treatment, there are also some important limitations that should be acknowledged. Long‐term outcomes of MRgART remain uncertain. Furthermore, tumours frequently respond to radiotherapy and thus become smaller over the course of treatment; however, it is unclear if it is safe to adapt to these smaller volumes as the region originally occupied by the tumour might still contain microscopic disease.MR‐Linac offers an advanced form of radiotherapy delivery with the potential to reduce treatment toxicity and improve clinical outcomes. The system has introduced different adaptive workflows and processes which may be seen as a barrier to general implementation and use of the technology. However, workflow efficiencies can be achieved through many solutions including treatment workflow flexibility, simulation‐free treatment, AI solutions and technological innovations. Upskilling of staff is required, however, as with any new technology, experience and improved communication can facilitate its routine use. Moreover, aside from clinical efficiency, the MR‐Linac presents opportunities for greater personalisation of treatment that could potentially revolutionise radiotherapy treatments in the future.The authors declare no conflict of interest.