Inappropriate and wasteful use of health care resources is a common problem, constituting 10–34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging—in which the diagnostic test confers little to no clinical benefit—is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.Systematic review registration: PROSPERO: CRD42020208072.The online version contains supplementary material available at 10.1186/s12880-022-00798-2. The use of health care and health care expenditures are increasing in most countries . AccordiA scoping review was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) extension for scoping reviews . The proThe search was expanded through a snowballing technique of hand-searching the reference lists of articles included following full-text screening.The records were archived using Thomson Reuters EndNote X9.3.3 library and duplicates were removed. All remaining records were transferred to Rayyan QCRI  where tiThe inclusion and exclusion criteria are presented in Table Data of the included studies were extracted using a summary table consisting of the following variables: author and year, country, design/methods, population, clinical setting, medical condition, low-value practice, reason for being low-value, alternative to low-value practice, and extent of use (when applicable). EK, ERA, AMK, and BMH extracted data after a calibration meeting where 10 publications were discussed for quality assurance. Narrative synthesis of included articles was completed. Articles were first categorized by adult or pediatric, the imaging modality, type of radiological examination evaluated, and the anatomical area imaged.The electronic database search identified 39,986 records  and Europe (n = 78). In-hospital imaging was the most common clinical setting (> 65%). Fourteen different study designs were employed among the included studies; most studies were designed as retrospective chart reviews (n = 262), cohort studies (n = 39), and cross-sectional studies (n = 19). Three hundred and eight studies included adult patients, 60 studied pediatric populations, and 2 studies included both adults and children. The characteristics of the included articles are provided in Additional file Low-value diagnostic imaging in adults was evaluated in 264 studies. Across all imaging modalities, low-value use of computed tomography (CT), magnetic resonance imaging (MRI), and X-ray were most frequently reported.Outcomes measured for identifying low-value examinations varied across the studies and the most common were diagnostic yield (n = 213), and impact or change in treatment or management (n = 137). Importantly, the examinations defined as low-value were dependent on the clinical symptoms of patients e.g. a lumbar spine MRI is only valuable when the patient present with red flag symptoms.In the following sections, results are stratified by body areas , thoracic, musculoskeletal, abdominopelvic, vascular, whole body, breast, cardiac, and ear, nose, and throat, and neck imaging) and population type .Low-value imaging of the brain was explored in 49 studies –66. SpecFurther, low-value imaging examinations of the cervical spine was identified in eleven studies –77 incluThirty-eight studies reported chest X-rays to be low-value, while four studies reported on low-value use of chest CT –117. Of The most commonly reported low-value procedures in musculoskeletal imaging was for low back pain –130. TenThe second most common studied musculoskeletal low-value examination was MRI in knee pain without red flags, reported in eight studies , 141–147In abdominopelvic imaging, eighteen studies reported imaging with low-value in typical emergency or general medicine conditions –191. X-rThe two most reported low-value vascular imaging examinations were CTA of the chest in patients with low risk of pulmonary embolism (7 studies) and ultrasound in patients with low risk for deep venous thrombosis (5 studies). Negative result was demonstrated in 97% of examinations –221. FurWhole body imaging examinations were identified as low-value in trauma and oncology in six studies. Whole body scanning in trauma should be made only when clinically indicated –232. In In breast cancer follow-up, mammography or MRI of the breasts less than 1-year after treatment were described as low-value –262. FolStress imaging such as myocardial perfusion imaging (MPI) and echocardiography were described as low-value in low risk patients, and patients with more than one risk factor for cardiac disease , 265. In99 m-sestamibi scans are unnecessary as nodules are found during surgery [Post-operative thyroid cancer ultrasound was found to be low-value as 98% of the scans were negative  and the  surgery .X-ray and CT of the sinuses in acute rhinosinusitis did not change patient management .In patients with facial fractures, X-ray and CT was identified as low-value in five studies –282, as Imaging of templar bones was described as low-value in patients with chronic Eustachian tube dysfunction and pre-op for cochlear implants , 285. DeThe use of low-value imaging in pediatric patients was reported in 62 studies presented in Table The proportion of low-value examinations varied greatly in the 103 included studies reporting proportion. Seven studies explored low-value imaging in adults on an overarching level with several medical conditions and modalities, showing an overall rate of low-value imaging of 2–31% –352.The proportion of low-value imaging examinations in specific body areas differed from 4 to 100%  , 389. AbIn summary, through this scoping review, we found 84 different low-value imaging examinations performed among both adult and pediatric populations, for all imaging modalities, and body areas. Several of these examinations already have established referral criteria or have recommendations against them in the Choosing Wisely list, however this review show that these are still being used in clinical practice, and more examinations might need referral guidelines. The most commonly practices reported as low-value was head CT in several clinical queries  and varied between studies of the same examination. There is no obvious threshold in proportion for when to define examinations as low-value. Even though the examinations found in this review are low-value on a group level, certain patient sub-groups or individual patients could have clinical findings justifying the use of imaging. However, in several studies there were identified a rate of ≥ 90% inappropriate imaging examinations. This provides a reason for altering the utilization of these examinations in practice. We found this to be the case in: repeat head or routine trauma CT, echocardiography, MRI in hip, knee and upper extremity pain, CT/MRI in acute pancreatitis, and pre-op templar bone CT in cochlear implantation , 388.Our review found additional examinations that are potentially low-value to the examinations presented in the Choosing Wisely list , 390. AdThere are many ways to measure low-value imaging, including diagnostic yield, diagnostic accuracy, and impact/change in treatment or management, where diagnostic yield (n = 213) and change in patient management (n = 137) were most common. By applying the Fryback and Thornbury value model as stated by Brady et al. , measureThis scoping review has strengths and limitations in its methods. Although the search in databases was systematic and exhaustive, the cut-off was set at 2010, which excluded examinations identified as low-value imaging or adopted to clinical practice before 2010. Due to the large number of citations retrieved from the database searches, a wide range of inconclusive studies, studies identifying conditional low-value imaging, and articles reporting clinical practice guidelines were excluded. Hence, a wide range of supportive studies were excluded as the inclusion criteria were strict. Therefore, it is likely that there are several studies of low-value examinations that are not included in this review. Accordingly, the excluded studies in Additional file In this study, we provide a comprehensive list of low-value radiological examinations for both adults and children. Our overview reaches beyond earlier published lists and adds information on the quantity of low-value imaging utilization, which reportedly varied from 2 to 100% among included studies. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after chest interventions, fracture follow-up and cancer staging, or follow-up were the most frequently identified low-value imaging examinations. This overview can be of great value for clinicians, policymakers, and researchers for revising appropriateness criteria and planning de-implementation. Efforts should be made to reduce the extension and variation of inappropriate imaging which generates huge opportunity costs and is potentially harmful to patients.Additional file 1. Search strategy and hits.Additional file 2. Excluded studies.Additional file 3. Characteristics of the included studies.


Patients with post-COVID-19 syndrome have reported a wide array of symptoms that include autonomic dysfunction. It is hypothesized that this may be secondary to interruption of baroreflex pathways in the carotid arteries or nucleus tractus solitarius, however, confirming studies have yet to be performed. A limited number of studies have highlighted the presence of an exaggerated baroreflex response in patients with a post-COVID-19 syndrome that mirror other chronic autonomic dysfunction-related conditions. Coronavirus disease 2019 (COVID-19), is caused by the novel coronavirus SARS-CoV-2. Even though most of the infected patients present with mild symptoms or are asymptomatic, around 5% to 8% develop acute complications such as hypoxia and reduced lung compliance requiring non-invasive ventilation or mechanical ventilatory support [As the nature of the COVID-19 global pandemic has evolved, management of COVID-19 has shifted from acute care to management of long-term sequelae. Many physicians have reported patients presenting weeks or months after their initial diagnosis, with non-specific symptoms including fatigue, dyspnea, headache, chest and joint pain, and even orthostatic changes. The awareness of these symptoms has led to the creation of the novel diagnosis post-COVID-19 syndrome (PCS) .Although there are currently no established diagnostic criteria for PCS, the most commonly used criteria in the literature is COVID-19 symptoms persisting for more than 12 weeks from initial symptom onset . To dateA 49-year-old female with a past medical history of persistent headaches and COVID-19 pneumonia (diagnosed in September 2021) presented to the hospital in December 2021 for evaluation of multiple syncopal events. Blood pressure measurements upon admission were 110/76 seated, 98/76 standing, and 111/67 supine; oxygen saturation of 99% and temperature of 98.2 F. Cardiac workup including troponin T was negative and no arrhythmias were found on telemetry. The neurological evaluation included CT, lumbar puncture, and EEG, which were also negative for any pathology. An echocardiogram showed normal systolic function and no wall motion changes (Table Several months after hospitalization, she presented to the cardiology clinic due to ongoing symptoms of tachycardia, headaches, and near syncopal events. A full cardiovascular workup was ordered. Calcium scoring revealed a score of zero. Tilt table testing was negative. The patient was placed on a cardiac monitor for three weeks to detect arrhythmias and no significant ventricular or atrial arrhythmias were identified. A nuclear stress test was performed and showed no inducing ischemia or prior infarct.The patient was discharged from the hospital on topiramate 50mg and midodrine 5mg which were later discontinued on the initial visit to the cardiology clinic. At the two-month follow-up, the patient was prescribed metoprolol 25mg and instructed to titrate up to 50mg for symptomatic relief of tachycardia, diaphoresis, headaches, and near syncopal events. Additionally, she was suggested to try a whole-foods plant-based diet which she agreed to. The patient reported well-controlled blood pressures and no loss of consciousness during this time period.Subsequently, on a three-month follow-up, the patient reported complete resolution of her symptoms including chest pain, shortness of breath, lightheadedness, and dizziness. In addition, the patient reported that she had continued following a whole-foods plant-based diet. Metoprolol 50mg was discontinued and an 11-month follow-up was scheduled. The patient was advised to return sooner if any previous symptoms reappeared.An increasing amount of cardiovascular and neurological events have been identified following recovery from acute COVID-19 infection. Many cases in the medical literature now acknowledge PCS as a possible cause of these associations. One prospective cohort study of 1,733 patients estimated that up to 76% who had COVID-19 reported at least 1 persistent symptom at six-month follow-up .In this patient, the lack of diagnostic workup pointing towards another diagnosis leaves post-COVID-19 syndrome as a tentative diagnosis. Several studies have focused on dysautonomia as an underlying mechanism in PCS patients who present with orthostatic changes. Possible factors include hypovolemia, neurotropism, and inflammation which occur secondary to the initial COVID-19 infection.Currently, the management of POTS focuses on mostly conservative treatment options. These include increased fluid and salt intake, physical therapy, and avoidance of triggers, amongst other non-pharmaceutical options. In terms of pharmaceutical management for POTS, drugs that increase blood volume, counter tachycardia, or increase vasoconstriction have been experimented with .In this patient, the effectiveness of metoprolol in resolving her symptoms suggests sympathetic dysregulation as an underlying etiology of her symptoms. Although it is possible that her symptoms resolved over time, her lack of improvement at first follow-up post hospitalization and studies showing a long-term continuation of symptoms suggests that her autonomic dysfunction was persistent. Further studies should be conducted comparing treatment vs placebo in PCS patients with autonomic symptoms in order to better determine the efficacy of pharmacological treatment. In addition to her pharmaceutical intervention, this patient also agreed to switch to a whole-foods plant-based diet. Although no current studies exist regarding whole-foods plant-based diets and autonomic regulation, future research into whole-foods plant-based nutrition may be beneficial for those with PCS.The purpose of this case report is to add to the limited number of studies regarding the management of the post-COVID-19 syndrome. It establishes a precedent for the role that a whole-foods plant-based diet may play in the recovery of patients with PCS; however, its specific benefits are yet to be established.Patients with PCS have reported a large variety of symptoms that range from fatigue and dyspnea to orthostatic changes. For patients with sympathetic dysfunction, early recognition and treatment are important to improve their quality of life. As awareness and prevalence of PCS increases, future studies may explore other treatment options which may help to provide patients with relief. Additionally, future research into the precise pathophysiology of PCS may provide valuable insight into this condition and future treatments.


Depression is a common mental disorder affecting more than 264 million people worldwide. The first-line treatment for most cases of depression are selective serotonin reuptake inhibitors (SSRIs), such as sertraline, reboxetine and fluoxetine. Recently, it has been found that one-quarter of depressed patients have excessive activation of the immune system. This potentially warrants sub-categorisation of depressed patients into inflammatory and non-inflammatory subtypes. Such a sub-category of depression already exists for those not responding to various traditional antidepressants and is known as treatment-resistant depression. Those with treatment-resistant depression are far more likely to have raised inflammatory markers relative to those whose depression is treatment-responsive. Chronic, low-level inflammation seems to trigger depression via a multitude of mechanisms. These include kynurenine pathway and microglial cell activation, resulting in a reduction in hippocampal volume. Raised inflammatory cytokines also cause perturbations in monoaminergic signalling, which perhaps explains the preponderance of treatment resistance in those patients with inflammatory depression. Therefore, if treatment-resistant depression and inflammatory depression are semi-synonymous then it should follow that anti-inflammatory drugs will display high efficacy in both sub-types. Ketamine is a drug recently approved for use in depression in the USA and displays a particularly good response rate in those patients with treatment resistance. It has been suggested that the antidepressant efficacy of ketamine results from its anti-inflammatory effects. Ketamine seems to produce anti-inflammatory effects via polarisation of monocytes to M2 macrophages. Furthermore, another anti-inflammatory drug with potential use in treatment-resistant depression is Celecoxib. Celecoxib is a long-acting, selective COX-2 inhibitor. Early clinical trials show that Celecoxib has an adjuvant effect with traditional antidepressants in treatment-resistant patients. This paper highlights the importance of classifying depressed patients into inflammatory and non-inflammatory subtypes; and how this may lead to the development of more targeted treatments for treatment-resistant depression. Depression is a psychiatric disorder that affects mood, behaviour and overall health. The treatment for depression is a combination of counselling and pharmacotherapy. Depression treatment can be challenging due to drug side effects. Importantly, there is a group of depressed patients who do not respond adequately to multiple courses of appropriate pharmacotherapy, patients with treatment-resistant depression. Lack of response to antidepressants increases the risk of suicide, prolongs unnecessary suffering and is a large healthcare burden . This maA comprehensive literature shows that depression is linked to an activation of the immune system. The primary evidence for this comes from measures of immune cytokines. Cytokines associated with Th1 activation, including tumour necrosis factor (TNF)-α, interleukin (IL)-1β and IL-6, are raised in the cerebrospinal fluid and plasma of depressed patients. Furthermore, activated microglial cells are found in patients during a depressive episode, relative to healthy control , and othWorthy of inquiry is in which direction the relationship between inflammation and depression is causal. It is commonly known that depression-like behaviour can be induced in animals by the injection of lipopolysaccharide (LPS), which is highly pro-inflammatory . In addiFurther evidence for an immune system-depression link is provided by genomics data. Many genetic polymorphisms have been associated with depression but the existence of genetic roots for depression is somewhat perplexing. Through evolutionary history, depression would have increased one’s risk of death from suicide , 7. ThisN-methyl-d-aspartate (NMDA) receptors and activation of glutamate and reactive oxygen species release from microglial cells. The resultant excitotoxicity and oxidative stress cause tissue damage, particularly in the hippocampus. Reduced hippocampal volume is a well-characterised marker seen in the brains of depressed people [The primary mechanism proposed to mediate Th1 immune response-triggered depression is the activation of indoleamine 2,3-dioxygenase (IDO). IDO is an enzyme involved in tryptophan metabolism and is up-regulated and activated by Th1-associated cytokines, particularly IFNγ , 10. It d people –14. Furtd people .In addition to activation of the kynurenine pathway causing hippocampal neurotoxicity, inflammation also seems to attenuate hippocampal neurogenesis. IL-6, IL-1 and TNFα, for example, all suppress the neurotrophin, brain-derived neurotrophic factor (BDNF). BDNF is known to ameliorate depressive symptoms, in part by increasing hippocampal neurogenesis, which is consistently decreased in depressed individuals . Also, TDespite the link between inflammation and depression being incontrovertible, there is a large degree of heterogeneity between patients regarding inflammatory status. Around one-quarter of patients with depression have raised low-level inflammation . This suThe salience of an inflammatory depression subtype, appropriately targeted by immunosuppressives, is further supported by a number of other noteworthy facts from the literature. Firstly, depression that is co-morbid with previous childhood ill-treatment is associated with an increase in inflammation and is more often treatment-resistant . That isKetamine is a drug that has been used for many years as a fast-acting non-barbiturate general anaesthetic. It also has well-established use in hypotensive shock, reactive airway disease, analgesia and procedural sedation. It is primarily an NMDA receptor antagonist, but its pharmacodynamics are complex. It also shows interactions with opioid, cholinergic, purinergic and adrenergic receptors, as well as with ion channels not gated by endogenous ligands . More reKetamine has a remarkably high response rate in treatment-resistant depression (~65%) but the exact mechanisms underlying its antidepressant effects are unknown, particularly as other NMDA receptor antagonists possess non-comparable effects , 35. WhiLittle is known about ketamine’s immunomodulatory mechanism. It is likely to be the result of some direct effect on leucocytes . This isMicroglia also possess an M1 and M2 bifurcation in phenotype and LPS induces differentiation of microglia to an M1 type via activation of toll-like receptors, hence its neuroinflammatory effect . KetaminCelecoxib is a long-acting, selective cyclooxygenase-2 inhibitor. It is of similar potency to ibuprofen but is used in patients with mild to moderate pain and/or with arthritis, who cannot tolerate the gastrointestinal side effects of traditional non-steroidal anti-inflammatory drugs (NSAIDs). Celecoxib works by inhibiting pro-inflammatory protein synthesis . Downstradcy3, which codes for adenylate cyclase 3. Adenylate cyclase 3 plays an integral role in the signal transduction downstream of prostaglandin receptors, further providing evidence of a role for COX-2 inhibition in depression [Several studies had shown that Celecoxib is useful in treatment-resistant and inflammatory depression. Greater over-the-counter NSAID use is associated with reduced depression rates in the Danish population, suggesting NSAIDs may be antidepressant per se . FurtherMultiple clinical trials have been conducted using celecoxib in depressed individuals. In 2014, a meta-analysis of celecoxib trials was conducted . MonotheUnfortunately, there are contradictory results within the literature. For example, the only long-term trial of Celecoxib monotherapy in depression conducted to date, found no treatment effect , 63. ThiDepression is a complex condition. It is well accepted that inflammation can be a core feature of depression. Treatment-resistant depression is a subtype of depression, frequently characterised by enhancement of the Th1 cell-mediated and inflammatory immune responses. This subtype of depression could be amenable to improvement with the use of immunomodulatory drugs. Th1 dominance seems to cause treatment-resistant depression by causing reductions in hippocampal volume, mediated by IDO activation, microglial activation and reduction in neurogenesis, and perturbations in monoaminergic neurotransmission. Clinical trials of immunomodulators in depression thus far have been thwarted by the lack of an inflammatory depression subtype classification but have still shown promising results nonetheless.Ketamine is an exemplar of how effective a drug with immunomodulatory mechanisms can be in treatment-resistant depression. It seems to act via M2 polarisation of macrophages, which results in attenuation of the Th1 immune response. Celecoxib is a pharmacotherapy in earlier stages of development for treatment-resistant depression, which has shown exciting results. This is especially true when used as an ancillary to traditional antidepressants, notably increasing the response and remission rate. Further research is needed to elucidate the exact mechanism by which ketamine causes monocytes to differentiate into M2 macrophages and to what extent its efficacy in treatment-resistant depression is the result of immunomodulation. Moreover, future research should focus on confirming the efficacy, safety and tolerability of Celecoxib in long-term clinical trials in individuals with inflammatory depression.


Only age influenced the estimates of −0.85  and −1.29 , respectively. In acutely hospitalized older patients, there is an association between MCI and poorer nutritional status upon admission and four weeks after discharge. The association is partly explained by higher age.In acutely hospitalized older patients (≥65 years), the association between mild cognitive impairment (MCI) and malnutrition is poorly described. We hypothesized that (1) MCI is associated with nutritional status on admission and after discharge; (2) MCI is associated with a change in nutritional status; and (3) a potential association is partly explained by frailty, comorbidity, medication use, and age. We combined data from a randomized controlled trial (control group data) and a prospective cohort study . Nutritional status was assessed on admission and follow-up using the Mini Nutritional Assessment—Short Form. MCI or intact cognition (noMCI) was classified by three cognitive performance tests at follow-up. Data on frailty, comorbidity, medication use, and age were drawn from patient journals. MCI ( Worldwide, the population of older adults ≥65 years) is increasing . In 2018 years isBoth malnutrition and MCI are associated with readmission, mortality, and functional decline one year after hospitalization ,6,9,11. The presence of MCI in patients with malnutrition might explain the lack of effect of nutritional interventions that have been reported in recent studies in adults ≥65 with malnutrition during and after acute hospitalization ,16,17. SMoreover, frailty, comorbidity, and medication use have been linked to cognitive decline and/or nutritional status. A systematic review by Brigola et al. reports an association between frailty and cognitive function, especially memory , with a Therefore, our hypotheses are (1) that MCI is associated with poorer nutritional status on admission and after discharge in acutely hospitalized older patients; (2) that MCI is associated with a change in nutritional status from admission to 4 weeks after discharge in acutely hospitalized older patients; and (3) that a potential association between MCI and nutritional status is partly explained by age, frailty, comorbidity, and use of sedative medication.This study is a prospective observational cohort study using data from two studies: STAND-Cph, a randomized controlled trial registered at Clinical Trials.gov (NCT01964482); and FAM-Cph, a prospective cohort study registered at Clinical Trials.gov (NCT03052192). Data from the STAND-Cph control group and the FAM-Cph cohort collected at baseline and four weeks after discharge (4-week follow-up) were aggregated. Reporting of this study adheres to the ‘STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines’ using the checklist for cohort studies .Data from STAND-Cph were collected between September 2013 and September 2018 and data from FAM-Cph were collected between November 2016 and August 2017. Participants in both STAND-Cph  and FAM-Eligible participants were identified through the electronic patient journal. Participants in STAND-Cph and FAM-Cph were eligible if they were aged ≥65 years and admitted to the ED for an acute medical illness, and further, in FAM-Cph, were Caucasian. In STAND-Cph and FAM-Cph, eligible patients were excluded if they were: unable to understand and speak Danish, unable to cooperate, terminally ill or in isolation room stay, and further, in STAND-Cph, were transferred to another hospital or the intensive care unit, receiving treatment for cancer or unable to stand  and 4-week follow-up included descriptive variables and nutritional status. Further, at a 4-week follow-up, cognitive performance tests were completed and the results were used to characterize participants with or without MCI and further with MCI-subtypes within memory domains and/or non-memory domains . Data onThe Mini Nutritional Assessment—Short Form (MNA-SF) was used for the assessment of nutritional status at baseline and 4-week follow-up. MNA-SF is a nutritional screening tool that has been validated to identify patients ≥65 years in an acute setting who are at risk of malnutrition or malnourished . MNA-SF Mild Cognitive Impairment (MCI) is a condition where individuals show cognitive impairment greater than expected for age and educational level, with minimal impairment of one’s ability to perform activities of daily living ,34. In tHopkins Verbal Learning Test, Revised (HVLT-R) is a valid instrument for clinical and research-based neuropsychological assessment of older patients . HVLT-R The Symbol Digit Modalities Test (SDMT) is commonly used to measure attention . Good peThe Trail Making Test (TMT) is a neuropsychological instrument for detecting neurological disease and neuropsychological impairment . The TMTPerformance on HVLT-R total recall, HVLT-R delayed recall, HVLT-R recognition, DSST, TMT part A, and TMT part B were used to diagnose MCI. The scores from each test were converted into z-scores adjusted for age, based on normative data from healthy peers ,39,40,41Potential confounders were assessed at baseline.Frailty Index—Out of Reference (FI-OutRef) is an abbreviated form of the FI-Lab frailty index and reflects overall organism dysfunction due to deficiencies in numerous organ systems . FI-OutRCharlson Comorbidity Index (CCI) is an index based on weighted comorbidities used to measure disease burden with the ability to predict one-year mortality . CCI wasMedications marketed in Denmark potentially associated with cognitive decline were identified from the EU (7)-PIM list . These mFurther, age was considered a potential confounder.The descriptive variables used in this study were collected using semi-structured interviews and measurements at baseline and 4-week follow-up. The descriptive variables included demographics , anthropometry ), physical performance (hand grip strength (HGS), gait speed (GS)), social variables , and cognitive performance ). Education was grouped as: primary school = 0–9 years of school; secondary school = 10–11 years of school, graduate or skilled; and higher education = short, medium-cycle, or long-cycle higher education. Body weight was measured on a scale . BMI was calculated based on self-reported height and body weight. Physical performance was evaluated using hand grip strength measured by a hydraulic hand dynamometer   and habiData from FAM-Cph and STAND-Cph were entered directly in an electronic case report form (CRF) in the Research Electronic Data Capture (REDCap)  or written down on a paper CRF and double entered in REDCap to ensure data integrity and accuracy. To address data collection as a potential source of bias, clinical in-service training and supervision were provided by the same qualified person in both studies during data collection to enhance the quality of the measurements. Blood samples were routinely collected upon admission to the ED and the results from the blood samples were entered in Microsoft Excel before FI-OutRef was calculated  and percentage (%) for categorical variables. The prevalence of malnutrition and risk of malnutrition at baseline and 4-week follow-up based on MCI/noMCI are presented in a bar graph. Linear regression analyses were performed to examine the association between the independent variable for cognitive performance (MCI/noMCI) and the dependent variable for nutritional status (MNA-SF score). First, we calculated unadjusted estimates and confidence intervals (CI) for the difference in nutritional status (MNA-SF score) at baseline and 4-week follow-up between MCI and noMCI, and the difference in the change in MNA-SF score between baseline and 4-week follow-up between MCI and noMCI.This study is an explorative study based on data from the STAND-Cph trial and the FAM-Cph trial. Descriptive data are presented as mean and standard deviation (SD) for continuous variables and as frequency (n = 54) to access possible selection bias. Participants with missing MCI/noMCI were sampled to MCI or noMCI randomly with a weighted probability such that the distribution of MCI/noMCI would match that of the non-missing participants. A total of 10.000 of these samples were generated and unadjusted analyses were repeated for each sample giving a distribution of estimates to be compared with the estimates based only on non-missing MCI/noMCI participants.Additionally, adjusted models were fitted with age, and with age and one of either frailty, comorbidity, or medication, separately. Finally, a model including all possible confounders was fitted. In all the linear regression models, the independent variable (MCI/noMCI) and dependent variable (MNA-SF) had no missing values, but missing values for confounders were excluded from the analyses potentially giving a biased estimate. Further, we performed a sensitivity analysis that included participants who completed the baseline assessment and the 4-week follow-up assessment but who had not completed enough cognitive performance tests to be identified with MCI/noMCI .All analyses were performed as complete case analyses. The assumption of normal distribution was assessed by QQ-plots and statistical significance was determined at A total of 205 participants completed the baseline assessment, and 143 participants completed both baseline and 4-week follow-up assessments, with an assessment of MCI being feasible in 89 (62%) participants .n = 3), naMCI (n = 3), and mdMCI (n = 30). Additionally, frailty measures were missing for two participants. Compared to participants with noMCI, participants with MCI had a higher age (mean 81.8 years vs. 77.1 years), poorer performance in GS (mean 0.7 m/s vs. 0.9 m/s), poorer performance in 30 s STS test (mean 7.0 vs. 10.0), and more use of assistance with regards to purchases (46.3% vs. 17.0%); dressing ; and medication (43.9% vs. 4.3%) and laundry (48.8% vs. 12.8%) (MCI was present in 42/89 (47.2%) participants, and identification of MCI sub-types was feasible in 36/42 (85.7%) participants at the 4-week follow-up, with the following prevalence: aMCI (. 12.8%) . FurtherAt baseline, the prevalence of malnutrition was 10.6 % for participants without MCI and 31.0 % for participants with MCI. For risk of malnutrition, the corresponding prevalence was 51.1 % (noMCI) and 45.2 % (MCI) . At 4-weMCI compared to noMCI was associated with poorer nutritional status on admission for the unadjusted model with an average difference of −1.29 points  and the model adjusted for age, frailty, comorbidity, and medication with an average difference of −1.10 points  . All remMCI was not associated with a change in nutritional status (MNA-SF score) between baseline and 4-week follow-up (change) in any models and the model estimates did not change substantially when adjusting for possible confounders. The change in MNA-SF from baseline to 4-week follow-up for participants with MCI and noMCI is visualized in Because 54/143 participants did not complete enough cognitive performance tests to be identified with MCI/noMCI, it was not possible to include these in the analyses . ResultsTo our knowledge, this is the first study that has investigated the association between MCI and nutritional status in acutely hospitalized older patients. Our study found that MCI is associated with nutritional status upon hospitalization and four weeks after discharge in acutely hospitalized older patients with the strongest association four weeks after discharge. No association was found between MCI and change in nutritional status from hospitalization to four weeks after discharge. Age explained some of the associations at hospitalization and the 4-week follow-up, and frailty, comorbidity, and medication did not change the interpretation of these results.Having MCI might affect a person’s ability to receive and comply with dietary guidance because of impaired memory and/or processing speed . CompliaThe prevalence of malnutrition or risk of malnutrition 68.5%) in this study is similar to the prevalence of 60–70% reported in the literature ,5,62. Ad% in thisAfter adjusting for age, further individual adjustment for frailty, comorbidity, and medication affected the unadjusted MCI/noMCI estimates imperceptibly. This indicates that much of the potential confounding effect of frailty, comorbidity, and medication is confounded by age, as age expectedly will affect all three possible confounders. Therefore, individually, frailty, comorbidity, and medication explain only a small part of the association when age is accounted for. When accounting for all confounders simultaneously we see a larger change in the estimates suggesting that a larger part of the association can still be explained when accounting for all confounders. Further, different methods for the identification of frailty exist. In our study, we choose to assess frailty by using FI-OutRef, a cumulative deficits model of frailty. In an alternative approach, we could have assessed frailty using a phenotypic model as Fried’s criteria ,64. TherIn the absence of acute illness (at four-week follow-up) the total MNA-SF score increases by two points in all patients by the simple fact that the acute illness item on the MNA-SF is scored differently. This might explain why we did not find an association between MCI and the change in nutritional status between admission and four weeks after discharge. The influence of these two points might hide any minor changes otherwise existing between the two groups because the two points constitute a significant share of the total change in the MNA-SF score. Therefore, the MNA-SF might not be sensitive enough to identify a significant change in nutritional status in this setting and might explain why we only found an association at baseline and 4-week follow-up. However, MNA-SF is the only screening tool that is validated in both settings, and therefore an obvious choice of screening tool, when assessing change in nutritional status in a transitional setting.A strength of this study is that we used MCI identified at the 4-week follow-up for all analyses. Since the development of MCI from intact cognition rarely happens within a year  and the Our study has some limitations worth mentioning. With a difference in MNA-SF score ≥1  between MCI and noMCI, our results support a clinically relevant association between MCI and nutritional status in two models at baseline and all models at 4-week follow-up. The cut-off of ≥1 was chosen based on previously described considerations, but whether it is a reasonable cut-off should be investigated. With four weeks between the baseline and follow-up assessments of MNA-SF, the assessment at baseline will inevitably influence the assessment at the 4-week follow-up since questions in the MNA-SF refer to the patients’ experiences within the past three months. Moreover, questions in the MNA-SF are seeking self-reported answers, potentially resulting in reporting bias. Additionally, hydration, anticholinergic burden, and infection status upon assessment of cognitive function were not measured, which might bias the result of the cognitive performance tests negatively ,67. FurtMCI is associated with poorer nutritional status at hospitalization and four weeks after discharge in acutely hospitalized older patients, with the strongest association four weeks after discharge. Our study did not find an association between MCI and change in nutritional status from hospitalization to four weeks after discharge. Age explained some of the association at hospitalization and four weeks after discharge, while frailty, comorbidity, and medication did not change the interpretation of these results. The association found between MCI and poorer nutritional status emphasizes the importance of potentially alternating dietary counseling to accommodate the patient’s cognitive abilities when preventing and treating malnutrition in acutely hospitalized older patients. Whether such alternations will improve the effect of and compliance with nutritional interventions in this population is unknown and further research on the effect is needed.


To present an update of the available literature on external beam radiation therapy (EBRT) with or without brachytherapy (BT) compared to radical prostatectomy (RP) for patients with high-risk localised prostate cancer (PCa).2I statistic, respectively. We performed six meta-analyses for overall survival (OS) and cancer-specific survival (CSS).We conducted a systematic review and meta-analysis of the literature assessing the survival outcomes in patients with high-risk PCa who received EBRT with or without BT compared to RP as the first-line therapy with curative intent. We queried PubMed and Web of Science database in January 2021. Moreover, we used random or fixed-effects meta-analytical models in the presence or absence of heterogeneity per the A total of 27 studies were selected with 23 studies being eligible for both OS and CSS. EBRT alone had a significantly worse OS and CSS compared to RP . However, there was no difference in OS  and CSS  between EBRT plus BT compared to RP.While cancer control affected by EBRT alone seems inferior to RP in patients with high-risk PCa, BT additive to EBRT was not different from RP. These data support the need for BT in addition to EBRT as part of multimodal RT for high-risk PCa.Abbreviations: ADT: androgen-deprivation therapy; BT: brachytherapy; CSS: cancer-specific survival; HR: hazard ratio; MFS, metastatic-free survival; MOOSE: Meta-analyses of Observational Studies in Epidemiology; OR: odds ratio; OS: overall survival; PCa: prostate cancer; RR: relative risk; RP: radical prostatectomy; RCT: randomised controlled trials; (EB)RT:  radiation therapy High-risk non-metastatic disease  accounts for ~30% of newly diagnosed prostate cancer (PCa) ,2, depenIn the current and likely future, the absence of propensity designed RCTs comparing RP to RT for patients with high-risk PCa, meta-analyses may help a framework for clinical decision-making and patient counselling. To this end, we performed a systematic review and meta-analysis to summarise the results of available studies including the latest literature on this subject. We focussed on the additive value of BT in addition to EBRT.In this meta-analysis, we followed the Meta-analyses of Observational Studies in Epidemiology (MOOSE) statement guidelines that propose a checklist of items which provides a RCTs checklist . MoreoveThe question of this study was, ‘Do patients with high-risk PCa who receive EBRT with or without BT have a better survival outcome compared to those who receive RP?’. All current articles covering the study question were eligible for this systematic review. We selected studies that perform quantitative synthesis according to the similarity in Population, Interest, Context (PICO) elements to decrease the selection bias and heterogeneity. The inclusion criteria for the quantitative meta-analysis were original research articles that assessed survival outcomes and reported an estimated risk effect  for both patient and control groups. Exclusion criteria were BT usage alone as definitive therapy and lack of definition of high-risk PCa in the main or subgroup analysis.Consequently, the more comparable cohort studies according to the MOOSE guidelines were included in the analyses. Furthermore, the heterogeneity of the population was explored by detecting the source and country of databases. According to OS, we categorised studies’ outcomes, CSS, biochemical recurrence survival, and metastatic-free survival (MFS).We searched PubMed and the Web of Science for studies published before 1 January 2021. The search queries line and search strategies were ‘((Prostate OR prostatic) AND (cancer OR carcinoma) OR (Prostatic Neoplasms[Mesh])) AND external beam radiotherapy OR brachytherapy OR radiotherapy [Mesh]) AND ’ in PubMed and ‘((Prostate OR prostatic) AND (cancer OR carcinoma)) AND  AND ’ in the Web of Science.http://cccrg.cochrane.org/author-resources). We extracted the following data: first-author, type of article, year of publication, dates of the data collection or enrolment, cohort type, sample size, number of individuals on treatment, outcome, how the outcome was measured, type of effect statistic, effect statistic error measures, and effect statistic P value. There were no limitations in the articles’ data, so we did not need to contact any authors for additional details. Modified Newcastle-Ottawa Scale criteria were used to assess the quality of the included studies [The search results were restricted to English language articles. Two reviewers screened titles and abstracts independently; any disagreement about the articles’ eligibility was resolved by Delphi consensus with the co-authors. A data extraction sheet was developed based on the Cochrane Consumers and the Communication Review Group’s . Heterogeneity across the studies was appraised using P values, Q and 2I statistics [P value was <0.05. All analyses were carried out using Stata version 14 .Forest plots were used to assess the multivariable HRs. We summarised them to depict the relationship of our outcomes with the type of treatment . When HRs and atistics . In the After initial screening, 526 articles were available for assessment. The selection process for the systematic review is shown in Almost all of the studies in this review were cohort studies. Of the 27 included studies, regardless of the type of RT , 23 studies assessed OS and CSS. The quality assessment of the included studies according to the Newcastle-Ottawa scale is summarised in I2 = 84.5%, P < 0.001), so a random-effect model was used. The funnel plot was asymmetrical . In the second meta-analysis, 23 studies were again included. We found that patients with high-risk PCa who received RT (regardless of the type of RT) had significantly worse CSS than those treated with RP with a HR of 1.37 , so a random-effect model was used. The funnel plot was asymmetrical .In the first meta-analysis of OS, 23 were included. We found that patients with high-risk PCa who received RT (regardless of the type of RT) had significantly worse OS than those treated with RP with a HR of 1.27 , so a random-effect model was used. The funnel plot was slightly asymmetrical . In the second subgroup meta-analysis, 18 studies were included. We found that patients with high-risk PCa who received EBRT alone had significantly worse CSS than those treated with RP with a HR of 1.55 , so a random-effect model was used. The funnel plot was slightly asymmetrical .In the first subgroup meta-analysis, 15 studies were included. We found that patients with high-risk PCa who received EBRT alone (i.e. without a concomitant BT) had significantly worse OS than those treated with RP with a HR of 1.38 , so a random-effect model was used. The funnel plot was asymmetrical . In the fourth subgroup meta-analysis, seven studies were included. The HR of 0.69 (95% CI 0.45–1.06) suggested no difference in CSS between patients with high-risk PCa who received EBRT plus BT and those who underwent RP; however, statistical significance was not reached , so a random-effect model was used. The funnel plot was slightly asymmetrical . In the third subgroup meta-analysis, eight studies were included. The HR of 1.1 (95% CI 0.76–1.34) suggested that there was no difference in OS between patients with high-risk PCa who received EBRT plus BT compared to those who underwent RP . The eig reached . The sevThe present systematic review and meta-analyses assessed the comparative survival effectiveness of RT and RP as a definitive therapy with curative intent of PCa patients with high-risk features. Although we found that RT irrespective of RT type  resulted in significantly worse OS and CSS compared to RP, patients who underwent a EBRT plus BT combination had OS and CSS that were not inferior to RP. However, EBRT alone (i.e. without concomitant BT) was inferior to RP with regards to OS and CSS.While there is no direct, well designed comparison of RP vs RT as the first step in a multimodal therapeutic concept in concordance with our meta-analyses, cumulative data support the concept of combining maximal RT consisting of EBRT plus BT with androgen-deprivation therapy (ADT) as the first-line multimodal strategy for therapy of high-risk PCa ,17,19,29Today, RT as adjuvant or salvage strategy is supported as a part of a multimodal therapy after RP by major guidelines for patients with high-risk PCa based on data recruiting from several RCTs . HoweverThe main limitation of the present systematic review and meta-analysis was the lack of well-designed controlled trials. However, because of this lack, we believe that this systematic review and meta-analysis might help frame and equipoise decisions to guide patients’ counselling as part of the shared decision process . AnotherAccording to this systematic review and meta-analyses, patients with high-risk PCa who received EBRT alone (without a concomitant BT) as a first-line definitive therapy had worse OS and CSS than those who underwent RP. However, EBRT plus BT as a multimodal RT was not inferior to RP in high-risk PCa. These data support the need for a multimodal strategy to achieve optimal therapy in high-risk PCa. RT as a primary definitive strategy could be better when combined with EBRT and BT to achieve maximal radiation dose combined with ADT. The role, timing, indication of postoperative RT after RP, and the type and duration of ADT for each patient need assessment and evidence. Until then, we would postulate based on the findings of our present study an equipoise of EBRT with BT for local control as a part of multimodal flexible and dynamic treatment strategy tailored to each tumour in each patient.Click here for additional data file.


Nakajo-Nishimura is a rare autosomal recessive inherited autoinflammatory condition that has been described mainly in the Japanese population, but very similar syndromes, such as Candle syndrome, have been reported in Western populations. There is no gold standard treatment for this condition. This is a case report of a 12-year-old female who most likely has Nakajo-Nishimura syndrome.A 12-year-old female (born in 2010), from Batna (Algeria), was born of a first-degree consanguineous marriage, and the second of two children. She had no relevant past medical history. She was referred on account of dermatology symptoms, occurring very early in life, with papules and distal purplish erythema located in fingers and toes associated with an acrocyanosis. Subsequently, diffuse arthralgias appeared, exacerbated by cold, with a delay in walking, around the age of 3 years.th digit, and small erythematous lesions, without sclerosis or Raynaud's disease. There was no sign of synovitis or joint deformities. Hepatosplenomegaly with dental dysgenesis and delayed puberty were noted. The laboratory tests showed an inflammatory syndrome—ESR (Erythrocyte Sedimentation Rate) of 100 mm the first h, positive CRP (C-reactive protein), hyper alpha and gamma globulinaemia, and inflammatory anaemia with thrombocytopaenia. The genetic work-up is currently in progress.Clinical examination revealed a thread-like appearance of the fingers with shortening of the 5The treatment was Hydroxychloroquine and steroids. After the onset of a nephrotic syndrome, Mycophenolate mofetil (MMF) was added. The renal biopsy found a renal amyloidosis. The patient was in chronic renal failure stage 4 requiring hemodialysis.Extremely rare syndrome described in 30 patients in the literature and whose treatment remains symptomatic and does not prevent complications.None declared


There was little evidence concerning the association of community socioeconomic status (SES) and the cross-level interaction between community- and individual-level SES with depressive symptoms in China. This study aimed to investigate the association of community-level SES with depressive symptoms among Chinese middle-aged and older people and to examine whether individual-level SES moderates this relationship.Using data from the China Health and Retirement Longitudinal 2011–2018 Study, the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10) short form was used to measure depressive symptoms in 35,546 Chinese individuals aged 45 years and older. Community SES was calculated as a sum of z scores of the average years of schooling and household income per capita, which were derived by aggregating the individual measures to the community level. Two-level hierarchical linear regression was used.Community SES was negatively related to CES-D-10 scores (coef=-0.438). A 1-SD increase in individual SES was associated with lower CES-D-10 scores (coef=-0.490). The cross-level interaction on individual- and community-level SES was significantly associated with depressive symptoms, indicating that with the increase of individual-level SES, the effect of community-level SES on depression decreases. Stratified analyses observed robust associations of community SES with CES-D scores between urban and rural residents.This study showed that individuals who live in lower-SES communities had more severe depressive symptoms, particularly individuals with low SES. Additional attention should be given to the community socioeconomic context of middle-aged and older adults with lower SES, which may be helpful to reduce SES inequalities in depressive symptoms in China.The online version contains supplementary material available at 10.1186/s12888-022-03937-9. Depression is a global public health concern, imposing a high-level disease burden on individuals, families and societies . Major dSocioeconomic status (SES) has been found to be associated with a higher risk of depressive symptoms , 9, 10. A large number of studies have highlighted the importance of SES for health; however, in comparison to individual SES, the role of community SES has only recently been given the attention it deserves. And whether the relationship between area SES and health will be stronger or weaker depending on individual SES conflicts. The local social inequality model and the relative deprivation hypothesis indicate that the health of residents with lower SES is more likely to be better in lower SES areas than in higher SES areas , 20, 26.To date, the majority of these studies concerning the association between community-level or neighborhood-level SES and depressive symptoms were from developed countries , 26–31. Using a large-scale nationally representative longitudinal dataset, this study aimed to investigate the association of community-level SES and depressive symptoms among Chinese middle-aged and older people and to examine whether individual-level SES moderates this relationship. In addition, given the considerable socioeconomic disparities between urban and rural communities, we further explored whether these associations vary by urban/rural residence. Our study contributes to the world literature on this issue in the context of developing countries, and it would be of great benefit to identifying the priority populations and communities for the possible prevention of depressive symptoms, which may offer a sound rationale for improving the mental healthcare system in China.http://charls.pku.edu.cn/en.Four waves (2011–2018) of the China Health and Retirement Longitudinal Survey (CHARLS) were used in our study. CHARLS is a nationally representative longitudinal survey among Chinese community-dwelling people aged 45 or older . The surIndividuals who did not enroll in W2 (2522), W3 1621) and W4 (1577) were excluded. Then, we excluded 6375 cases without depressive symptom information, participants  without individual-level covariates and cases (1805) with missing community-level covariate information in waves 2011–2018. Participants younger than 45 years old were excluded, resulting in a final analytical sample of 35,546 observations in 2011–2018. Figure 621 and WThe 10-item short form of the Center for Epidemiologic Studies Depression scale (CES-D-10) was utilized as a measure of depressive symptoms , 35. TheObjective community-level information is not publicly available due to the data limitations of the Chinese census. Thus, according to previous studies, we derived community SES indicators by aggregating the individual-level SES measures to the community level , 38–41. Corresponding to community-level SES, individual SES was also measured by years of schooling and household income per capita. Similarly, years of schooling was obtained from the categorical variable educational attainment, which was also treated as a continuous variable . Z scores were calculated for each variable, and their sum was defined as individual-level SES , 14. TheAt the community level, the physical and social environments of communities were investigated in our study, as both of them have been found to be key determinants of older adults’ health , 42–44. At the individual level, control variables comprised age in years, sex , occupation , marital status (married/unmarried), residence , and activities of daily living (ADLs) (with impairment/without impairment), which were obtained from a self-reported questionnaire. Individuals with impaired ADLs were defined as those having difficulties in at least one of the ADL items including bathing, dressing, eating, getting in/out of bed, using the toilet, and controlling urination.Descriptive statistics were conducted to present community-level and individual-level characteristics and depressive symptom status according to various community- and individual-level SES. Two-level hierarchical linear regression models (HLMs) were undertaken to examine the independent relationships between community SES, individual SES, and their interaction and depressive symptoms. Three models were fitted, including the first model allowing for community-level SES and multiple demographic and socioeconomic covariates, the second model further adjusting for individual SES, and the third model adding the interaction term between community-level SES and individual-level SES. The interclass correlation coefficient (ICC) was provided for each model to represent the proportion of variance in depressive symptoms that could be explained by community-level social factors.p-value < 0.05 was considered statistically significant. All statistical analyses were performed using Stata V.14.0 .In our analytical sample, approximately 11% of participants due to missing data on depressive symptoms, 20% on individual income, and 5% on ADLs were excluded. To address the potential bias caused by sample exclusion, we conducted the analysis using multiple imputation methods by chained equations to replace missing values with five completed data sets . A p-valTable In terms of individual-level SES indicators, the average years of schooling and average per household income was 4.71 and 9489.10 yuan, respectively. Concerning community SES indicators, the average years of schooling was also 4.71, and per household income had an average of 9489.10 yuan.Compared with rural respondents, urban respondents were more likely to have higher individual SES and lower mean CES-D-10 scores and were more possibly to reside in higher SES communities. More details could be found in Table Table Table Furthermore, urban-rural differences in the association between community-level SES and depressive symptoms were not found in the stratified analyses of urban and rural residents. Among those in urban or rural communities, a similar pattern was found to that among the total population.The aim of this study was to examine the association of community-level SES and its interaction with individual-level SES with depressive symptoms and the urban-rural differences in these association among Chinese middle-aged and older people. Our results suggested that community-level SES was inversely associated with depressive symptoms, namely, individuals who live in higher-SES communities had lower depressive symptom scores. Moreover, the interaction between community-level SES and individual-level SES was significant in predicting depressive symptoms. Stratified analyses also observed that these associations between community SES and CES-D scores were robust in both urban and rural resident groups.Our study indicated that individuals living in higher SES communities experienced fewer depressive symptoms than their counterparts residing in lower SES communities among Chinese middle-aged and older adults. This result is in line with previous studies in the setting of the UK , the UniSeveral mechanisms may explain the negative relationship between community-level SES and depressive symptoms. For instance, the collective resources model proposes that all individuals, regardless of their SES, are expected to benefit from area-level resources in more advantaged areas, and individuals residing in deprived communities have fewer resources to gain health knowledge and worse availability and accessibility of health care services , 20, 26.A striking finding in this study was a significant interplay relationship between individual and community SES with depressive symptoms, indicating that with the increase of individual-level SES, the effect of community-level SES on depressive symptoms decreases. The fundamental cause theory suggests that the positive association between area SES and health was larger among lower-SES individuals than their higher-SES counterparts. Individuals with lower SES tend to be unable to access health-enhancing resources privately and be more dependent on services provided by the local communities, whereas higher-SES individuals are always able to access resources beneficial to their mental health . SpecifiA significant strength of this study is that we used a longitudinal, multistage national representative population-based survey to investigate the relationship between community SES and depressive symptoms. To the best of our knowledge, our study is the first to confirm the independent association of community SES and the interaction of community- and individual-level SES with depressive symptoms among middle-aged and older adults in mainland China. Nevertheless, several limitations of this study are noteworthy. First, some variables, such as the use of antidepressants and family history of mental disorders, were not considered due to the data restrictions. Second, we cannot investigate the internal mechanisms linking community SES to depressive symptoms due to missing information on some important mediator or moderator variables in the dataset, such as social cohesion and exposure to violence. Third, despite using a longitudinal survey dataset, this study cannot obtain causal relationships.This study showed that individuals who live in lower-SES communities had more severe depressive symptoms, particularly individuals with low SES, as those residing in low-SES communities had higher depressive symptom scores than other groups. This study helps to specify the priority communities that may compensate for individual disadvantages and the priority populations, such as individuals with lower SES residing in lower-SES communities, in the prevention of depressive symptoms, providing strong empirical evidence for promoting health equity in China. Additional attention should be given to the community socioeconomic context of middle-aged and older adults with lower SES, which may be helpful to reduce SES inequalities in depressive symptoms in China. Possible interventions, such as increased community organizations, improved community-based primary health care and the development of infrastructure, should be implemented, which could increase social cohesion, develop the community social welfare, promote physical activity and access to health services and improve the overall community-level SES. Besides, prevention, screening and early diagnosis of depressive symptoms for individuals with low-SES in low-SES communities are particularly needed in consideration of their double jeopardy health risks.Additional file 1.Additional file 2.


There is suggestive evidence linking hoarding with several problems in emotional regulation, and though this is shared with OCD patients, it may not correlate to the presence of obsessive symptoms.The present study aimed to examine self-reported deficits in emotion regulation (ER) and obsessiveness among individuals with hoarding disorder (HD) in comparison with others with obsessive compulsive disorder (OCD) and healthy controlsTwenty-two adult outpatients with HD, twenty-two with OCD and twenty-two age and gender matched healthy control (HC) participants completed the Emotion Regulation Questionnaire (ERQ) which measures respondents tendency to regulate their emotions in two ways: Cognitive Reappraisal and Expressive Suppression. They fulfilled as well the OCI-R which evaluates six groups of OCD symptoms: Washing, Checking, Ordering, Obsessing, Hoarding, and Neutralizing.The HD and OCD groups scored higher, (p 0.04), on Cognitive Reappraisal than did the HC group. There was no significant difference between groups in Expressive Suppression. HD and HC groups scored significantly lower, (p < 0.001), in OCI-R than OCD patients.Results suggest that OCD and HD are characterized by self-reported deficits in ER, but this relationship in HD patients is not solely attributable to obsessive symptoms.


Concussion is a common injury in children and adolescents. Current best practice guidelines indicate that recovery should be supervised through recurrent follow-up visits. A more detailed understanding of the system-level and individual factors that are associated with follow-up care is a critical step towards increasing evidence-based practice. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.A retrospective population-based cohort study was conducted using linked, province-wide administrative health data for all patients <18 years of age with a diagnosis of concussion, other specified injuries of the head, unspecified injury of head, or post-concussion syndrome (PCS) between April 1, 2004 and March 31, 2018 in Alberta, Canada. The association between predisposing, enabling, and need-based factors and the receipt of follow-up care within a defined episode of care (EOC) was analyzed using logistic regression models for the entire cohort and for EOC that began with a concussion diagnosis. Predisposing factors included age and sex. Enabling factors included the community type of patient residence, area-based socioeconomic status (SES), and visit year. Need-based factors included where the EOC began (outpatient vs. emergency settings) and history of previous concussion-related EOC.n = 25,461). Males and adolescents were more likely to receive follow-up care. Follow-up was less likely among patients who lived in remote communities or in areas of lower SES, while EOCs beginning in 2011 or later were more likely to involve follow-up care. Patients whose EOC began in outpatient settings, had more than one EOC, or a diagnosis of concussion were more likely to receive follow-up care.194,081 EOCs occurred during the study period but only 13% involved follow-up care , and when and where the index visit occurs. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do, is an important step in aligning practice with follow-up guidelines. Post-coThis study focused on identifying factors that facilitate or impede follow-up care for pediatric concussion. The Andersen Behavioural Model of Health Service Use guided analyses of individual and system-level factors that influence health service utilization of follow-up care after pediatric concussion –15. ThisTo identify individual and system-level factors that facilitated or impeded follow-up care for pediatric concussion, we used province-wide administrative health data to characterize health care utilization in episodes of care (EOC) that included vs. did not include follow-up care among children and youth following a concussion-related diagnosis in Alberta, Canada from 2004 to 2018. Due in part to universal taxpayer-funded physician and hospital health care services and the linkage of databases capturing all inpatient and outpatient services, Alberta's health administrative databases serve as a valuable population-based repository of all pediatric concussion-related diagnoses across the province. The objective of this study was to identify predisposing, enabling, and need-based factors associated with follow-up care after pediatric concussion.2.This study received ethics approval from the University of Calgary (REB17-1957_REN3), administrative approval from Alberta Health Services (AHS), and is reported according to STROBE guidelines . A retro2.1.We utilized the Centers for Disease Control and Prevention administrative data definition in place when the study commenced to identify concussion codes for inclusion . This deAn EOC definition was used to differentiate follow-up visits from new injuries in children and youth (children hereafter) with multiple concussion-related health care visits. Our definition was developed in conjunction with study clinicians and informed by previous population-based studies with similar approaches , 18. An Often, variables of interest cannot be abstracted from administrative health data. As such, the Andersen Behavioural Model of Health Service Use guided the selection of factors that may be associated with follow-up care in children and youth after a concussion. Predisposing factors included patient age and sex. Enabling factors consisted of the community type of the patient's residence as defined by Alberta Health Services (AHS) , the are2.2.Descriptive measures were used to summarize all predisposing, enabling, and need-based factors in EOC that included vs. did not include follow-up care. Those EOC that began with a diagnosis of concussion were also examined separately in a sub-analysis. The association between the factors identified  and follvia receiver operating characteristic (ROC) curves, the final model was calibrated by testing for specification error, and the Hosmer-Lemeshow test was used to assess goodness of fit. The linearity of log odds was evaluated for continuous variables. An α = 0.05 level was set a priori as the threshold for significance. Data were analyzed using Stata 15.1 (Multicollinearity was assessed using the variance inflation factor (VIF), model discrimination was evaluated ata 15.1 .3.Details regarding cohort creation are reported elsewhere . In brie3.1.n = 25,461), encompassing 36,494 visits (some EOC involved more than one follow-up visit) involving 23,499 children (some children had more than one EOC)  , 5. Follone EOC) , 4. Follone EOC) . Follow-one EOC) . The meaone EOC) . Over thone EOC) . Table 53.1.1.a priori were significantly associated with follow-up care in univariate models and included in the multivariable model. Crude odds ratios (OR), adjusted OR (aOR), and 95% confidence intervals (CI) are reported in All predisposing, enabling, and need-based factors identified 3.1.2.Males  and older children and adolescents  were more likely to receive follow-up care . Communi3.1.3.Among individuals diagnosed with concussion, males  and older children and adolescents  were more likely to receive follow-up care . Compare4.Even though we don't have clinical information to gauge need for follow-up care, clinical practice guidelines for concussion recommend all patients follow-up in outpatient settings 7–10 days after initial injury and diagnosis . While f4.1.Males were more likely to receive follow-up care than females, although as our previous report showed, the proportion of females receiving follow-up care increased more dramatically over the study period . While mAge was another important predisposing factor, with each additional year of age increasing the adjusted odds of follow-up by 10%. Rates of other head injury diagnoses  were higher among younger children, especially those under five years of age , 28, but4.2.While most children still were not receiving follow-up care at the end of the study period, the likelihood of follow up increased after 2011. Consistent with other studies , 37, thePatients from areas of lower SES also were less likely to receive follow up care, regardless of community type. Although Canada's health care system ensures access to care regardless of income, other geographic, socioeconomic, and cultural barriers still exist that prevent people from receiving or obtaining care –45. Addi4.3.Factors related to need include both perceived and evaluated (or objective and subjective) needs related to health service use , 15. HisEvaluated need in this context includes diagnosis and location of health service use, assuming that, on some level, more severe cases are receiving initial care in the ED . EOC that began with a non-concussion head injury diagnosis were less likely to involve follow-up care. This is not surprising given clinical practice guidelines relate specifically to concussion diagnoses. However, the finding does emphasize the importance of accurate diagnosis, as children and adolescents diagnosed with other head injuries will likely not receive the same management that they would if diagnosed with concussion, or their parents may not perceive a need for follow-up care. Clearer diagnostic standards are needed for concussion in young children, to increase the likelihood of appropriate follow-up care.Children with a concussion diagnosis whose first visit occurred in outpatient (PO) settings were more likely to have a follow up visit than those whose first visit was in the ED, which may reflect greater continuity of care with primary care physicians. While considerable gaps in knowledge and inconsistent application of clinical practice guidelines have been documented among both ED and primary-care physicians , 8, diff4.4.This study has several limitations. First, our findings may not generalize to jurisdictions beyond Alberta, Canada due to local factors that may be related to access to health care. In addition, the nature of administrative health data is such that its quality and validity are unknown . Becausen = 8,322) were missing a PDI quintile and so the impact is thought to be minimal. Finally, administrative health data provides limited or no information regarding mechanism or severity of injury and no data regarding clinical outcomes. Thus, future studies should explore the associations between SES, mechanism of injury, and follow-up care.Because administrative health databases do not contain socioeconomic information, the PDI was used to characterize area-based SES. The PDI is an area-based measure of material deprivation; in the absence of individual-level data, area-level aggregate data are considered a valid proxy  and the 5.Despite these limitations, our linkage of databases capturing all inpatient and outpatient services, robust case and EOC definitions, and 14 years of population-based data provides a basis for a better understanding of follow-up care among children and adolescents post-concussion. While follow-up care is not as routine as advised in clinical practice guidelines, it has increased over time. The rate of follow-up care is associated with patient age and sex and history of concussion-related EOC, where a patient lives (community type and area-based SES), and when and where the index visit occurred. Follow-up care is less frequent in non-metropolitan areas and in areas of lower SES, suggesting a need to increase access. Health care practitioners need guidance about how and when to use the concussion diagnosis with younger children to ensure they receive appropriate follow-up care post injury. A better understanding of which children are more likely to receive follow-up care, as well as how and when they do so, is an important step in aligning practice with follow-up guidelines.


Background and Objectives: Advanced non-small-cell lung cancer (NSCLC) has led to a high number of mortalities. Immunotherapy, as a first-line treatment in advanced NSCLC, currently has no clarity regarding its prognostic markers to assess the treatment outcome. This systematic review aimed to evaluate neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) as prognostic markers in advanced NSCLC patients treated with immunotherapy. Materials and Methods: This systematic review was conducted using the PRISMA guidelines, starting from screening for relevant studies from several databases. Each included cohort study was further assessed by using the Newcastle–Ottawa Quality Assessment Scale, and the available data were extracted for qualitative and quantitative synthesis in pooled and subgroup analysis. Results: A total of 1719 patients were included in this meta-analysis. Hazard ratio (HR) outcomes for progression-free survival (PFS) and overall survival (OS) for NLR and PLR showed significant results, supporting NLR and PLR as prognostic markers . Subgroup analysis with a cut-off value of 5 for NLR and 200 for PLR also demonstrated notable outcomes. Higher NLR and PLR levels are associated with poor prognostic. Conclusions: There is considerable evidence regarding both markers as prognostic markers in NSCLC patients treated with immunotherapy. However, further studies with more homogeneous baseline characteristics are required to confirm these findings. Lung cancer has become the leading cause of cancer-related mortality. According to the Global Cancer Observatory (GLOBOCAN), in 2020, there were approximately 2.2 million new cases of and 1.8 million deaths caused by lung cancer worldwide ,4.Out of all lung cancer patients, 40% of newly diagnosed patients are found in stage IV . AlthougAlthough many studies showed that NLR and PLR were significantly correlated with standard prognostic value in NSCLC treated with immunotherapy ,11,12,13The systematic review was conducted and reported using the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines see  18]..18].Screening processes based on eligibility, inclusion, and exclusion criteria were used to filter every research article obtained. The authors included prospective and retrospective cohort studies, randomized controlled trials, and case–control studies measuring NLR or PLR as a prognostic marker in advanced NSCLC treated with immunotherapy. Studies were considered to be excluded if they fulfilled any of the following criteria: (1) treatment with other than immunotherapy, (2) review articles or others; (3) animal studies; (4) inaccessible full-text articles; and (5) non-English articles.A literature search was conducted independently throughout several databases, including PubMed, Science Direct, EMBASE, EBSCO, and Cochrane. Any discrepancies were further discussed among the authors. The keywords used in each database were PubMed:  AND ((neutrophil-to-lymphocyte OR NLR) AND (platelet-to-lymphocyte ratio OR PLR)) EBSCOhost:  AND  AND (“Neutrophil-to-lympochyte ratio” OR “PLR”) Science Direct:  AND ((neutrophil-tolymphocyte OR NLR) AND (platelet-to-lymphocyte ration OR PLR)) Cochrane:  AND ((neutrophil-tolymphocyte OR NLR) AND (platelet-to-lymphocyte ration OR PLR)). Consequently, the results were removed for duplication and screened using the pre-determined eligibility criteria.All articles were independently reviewed based on a PRISMA flow diagram . A screeAll investigators extracted the available data from the included studies. The following data extracted from each study are shown in Each study was further assessed for its methodological quality by using the Newcastle–Ottawa Quality Assessment Scale (NOS), which appraised for three quality parameters: study selection, comparability of the population and determination of whether the exposure or outcome includes risk of bias . The stu2 or Q according to Cochrane, I2 and tau2) were also calculated to analyze data distribution.Hazard ratio on overall survival and progression-free disease was evaluated on each study and categorized based on the level of NLR and PLR (high or low). All extracted data were analyzed using RevMan ver 5.4.1. Summary data and related 95% confidence interval (CI) were then calculated by meta-analysis pooling on log[hazard ratio] and standard of error (SE). All results were then visualized into forest and funnel plots. The indexes of heterogeneity  and PLR (200). Subgroups were analyzed for hazard ratio on overall survival and progression-free disease as the previous pooled analysis.The literature search details are depicted on All included studies were cohort retrospective studies and published between 2017 and 2021. Meanwhile, the provided data were collected between 2013 and 2019. Out of 15 included studies, 7 studies were conducted in Asia ,29,32,33The summary of the outcome of each included study is listed in p < 0.0001]. However, a notable heterogeneity is found with an I2 value of 91%.  and high-NLR (H-NLR) as prognostic markers.  of 91%. . NLR usae of 37% . To invep < 0.00001] towards L-PLR, with homogeneity results of 0% I2 value  and OS  [Our study showed a significant correlation of H-NLR and H-PLR to shorter PFS and OS which is supported by most other meta-analyses. Xu et al. also showed similar results for PLR to PFS  . Wang et 0.0001) . Tan et  0.0001) .Most of the studies included in this review exhibited distinct cut-off values. Moreover, several factors are known to influence NLR and PLR, including age, gender, ethnic, environmental factors and lifestyle ,43,44. AVarious PLR cut-off values ranging from 150 to 262 were extracted from the included studies in this review. Our study showed that a PLR cut-off value of 200 is significantly associated with PFS and OS. A similar finding by Gu et al. suggested that a PLR cut-off value of 180 showed significant association with PFS and OS in Caucasians with NSCLC; however, no association was found with a such cut-off value in Asians . NonethePrognostic judgments are important to give information to patients about their future and potential outcomes so they can make decisions, either for their health, or others. If proven, these markers may also serve as clinical judgement for treatment failure, associated with worse prognosis. Therefore, it will provide a basis for medical professionals in making rational medical decisions, such as treatment change decision. Proposing NLR and PLR as novel prognostic markers for NSCLC patients treated with immunotherapy, this systematic review and meta-analysis can serve as a reference for prognostic guidelines in the future.There were some limitations in this study. First, we included studies with various cut-off values, causing a potential bias. Other factors from patients’ baseline characteristics, such as age, gender, and location of study, may also affect the results, shown by significant heterogeneity in a HR of NLR PFS outcomes. Despite the diversity of baseline characteristics, the studies included were retrospective studies, which are the best study design for prognostic analysis. Second, we do not use a failsafe to assess the impact of publication bias due to software limitations. Furthermore, the low risk of bias from the included studies is another strength of our research.To summarize, NLR and PLR are promising prognostic markers in NSCLC patients treated with immunotherapy, evident in remarkable PFS and OS hazard ratio outcomes. As stated in our limitations, no standardized cut-off value is available for NLR and PLR. Thus, we suggest making an identical cut-off value for worldwide usage, so more studies conducted with the same value can be made, resulting in a more accurate review in the future. We also recommend creating an updated systematic review and meta-analysis, using more homogeneous baseline characteristics and strengthening our current findings, including proving the definitive correlation of PLR as a prognostic marker.


Microhemorrhages have not been described in mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes syndrome (MELAS) on magnetic resonance imaging (MRI). Main symptoms and/or important findings: A MELAS-patient had a rapid succession of 3 stroke-like episodes with dysphasia, visual field deficits and paresis of the right arm. MRI showed a lesion with corticosubcortical vasogenic edema without reduced diffusion, conforming to a stroke-like MELAS-lesion. Microhemorrhages within MELAS-lesions were detected on MRI. The main diagnoses, therapeutic interventions, and outcomes: Microhemorrhages are an atypical imaging finding in MELAS. The patient was treated with L-arginine.Microhemorrhages can present on MRI in (sub)acute MELAS lesions and may reflect mitochondrial microangiopathy. Mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes syndrome (MELAS) is a rare genetic mitochondrial disease that may cause stroke-like episodes, epilepsy, recurrent headaches, and dementia . Typical2A 35-year-old male with a previously established diagnosis of MELAS with a point mutation at nucleotide 3243 mtDNA (A>G) presented with aphasia for two days, behavior changes for two months, and subtle loss of strength in the right arm on clinical examination.An immediate computed tomography (CT) and CT angiography  showed corticosubcortical hypodensity in the left temporoparietal operculum, and normal craniocervical arteries. The next day’s MRI  showed local corticosubcortical vasogenic edema without reduced diffusion, in keeping with a stroke-like MELAS lesion . TreatmeAfter three and seven weeks, two new stroke like-episodes occurred with similar imaging findings respectively in the left occipital region with right hemianopia, and in the left parietal region including the postcentral gyrus with right arm paresis and sensory deficits  and 3. NEventually, the patient left the hospital in good general health and underwent further rehabilitation.To our knowledge this is the first report of a case of juxtacortical microhemorrhages in MELAS lesions on MRI. As findings were subtle, these may not have been detected with conventional T2*-sequences that were more often used in the past. True hemorrhagic transformation of a MELAS lesion has been reported, but is rare 5. Our fi


Logo detection is one of the crucial branches in computer vision due to various real-world applications, such as automatic logo detection and recognition, intelligent transportation, and trademark infringement detection. Compared with traditional handcrafted-feature-based methods, deep learning-based convolutional neural networks (CNNs) can learn both low-level and high-level image features. Recent decades have witnessed the great feature representation capabilities of deep CNNs and their variants, which have been very good at discovering intricate structures in high-dimensional data and are thereby applicable to many domains including logo detection. However, logo detection remains challenging, as existing detection methods cannot solve well the problems of a multiscale and large aspect ratios. In this paper, we tackle these challenges by developing a novel long-range dependence involutional network (LDI-Net). Specifically, we designed a strategy that combines a new operator and a self-attention mechanism via rethinking the intrinsic principle of convolution called long-range dependence involution (LD involution) to alleviate the detection difficulties caused by large aspect ratios. We also introduce a multilevel representation neural architecture search (MRNAS) to detect multiscale logo objects by constructing a novel multipath topology. In addition, we implemented an adaptive RoI pooling module (ARM) to improve detection efficiency by addressing the problem of logo deformation. Comprehensive experiments on four benchmark logo datasets demonstrate the effectiveness and efficiency of the proposed approach. Feature extraction is the most fundamental problem in various image-related tasks. Recent years have witnessed the powerful feature representation capability of convolutional neural networks (CNNs) that makes them very good at extracting rich image features. This is because they have two inherent advantages, namely, sparse connectivity and weight sharing. The former changes the situation of full connectivity in traditional neural networks and enables local perception, while the latter allows for the number of parameters to be significantly reduced, thus allowing for CNNs to train light models with fewer parameters. These advantages enable CNNs to outperform the traditional manual feature method. Therefore, deep-learning-based CNNs are increasingly dominant in object detection tasks. As a special form of object detection, logo detection aims at finding all the logos in an image or a video and return their locations. Extracting effective features is a crucial step in logo detection, in which deep CNNs can help in discovering intricate structures in logo datasets.Logo detection plays an important role in various real-world applications, such as intelligent transportation ,2, tradeThe large aspect ratio of logos usually spans a large area in an image, as shown in Multiscale logo objects in an image. As seen in Compared with general object detection, the challenges of logo detection mainly come from two aspects:In this paper, we present a novel logo detection method called long-range dependence involutional Network (LDI-Net). We rethink the intrinsic principle of convolution, and propose long-range dependence involution (LD involution) and apply it to a region proposal network (RPN). Two major convolutional flaws are remedied by LD involution, since it has significant advantages in acquiring long-range interactions in spatial and channel dimensions. Meanwhile, it can preferentially extract significant visual information in space by creating particular involutional kernels for certain spatial locations. The construction of LD involution enables visual information and elements in the spatial domain to be reasonably allocated and sorted on the logo image to the greatest extent. The channel-sharing involutional kernel allows for us to use a larger K to satisfy the establishment and correlation of long-range information, and significantly reduces the redundancy of the model. For logo detection, a logo image with a very large aspect ratio is characterized by high requirements for long-distance information contact. LDI-Net improves the detection performance of logos with a large aspect ratio by employing a new operator and a self-attention mechanism. For the second issue, we suggest a multilevel representation neural architecture search (MRNAS) to detect multiscale logo objects. MRNAS introduces six heterogeneous information paths to construct a diverse multipath topology that combines semantic information and location representation, optimizing cross-level interaction between features. Additionally, we implemented an adaptable RoI pooling module (ARM) to improve detection efficiency and achieve adaptive feature learning for differently shaped objects. By adding additional offset and a modulation mechanism, the logo deformation problem caused by angles, occlusion, rotation, distortion, reflection, etc. L=LrpWe implemented To evaluate the effectiveness of the proposed LDI-Net, we completed comprehensive experimental validation on four datasets: large-scale dataset LogoDet-3K , medium-We implemented our method on the basis of the publicly available MMDetection toolbox , and useWe compared the proposed LDI-Net with several other one-stage and two-stage popular baselines, as reported in In We also set up different iterations to compare the proposed strategy and dynamic R-CNN in terms of convergence and accuracy. LogoDet-3K-1000 is a subdataset of LogoDet-3K that has a suitable number of images and categories. Experiments on this dataset helped in further evaluating our model. We used different strategies on LogoDet-3K-1000 and list the results in We provide experimental results on QMUL-OpenLogo to verify the effectiveness of LDI-Net. As shown in We also performed a comparison on FlickrLogos-32. In this section, we conduct comprehensive analysis of the effects of each LDI-Net component on four logo datasets. We compare the test and localization accuracy of each LDI-Net component with dynamic R-CNN, namely, LD involution, MRNAS, and ARM. We used dynamic R-CNN equipped with ResNet-50 and FPN as the baseline.LD involution is a targeted solution to the large aspect ratio problem. As shown in We applied the MRNAS module to solve multiscale problems and achieved good results. The MRNAS module performed well on two large logo detection datasets, i.e., LogoDet-3K and LogoDet-3K-1000. As shown in We provide some illustrative examples of logos with different scales from LogoDet-3K, as shown in We conducted ablation experiments for ARM on four datasets, and the experimental results demonstrate that ARM works better than the baselines. As shown in We selected a variety of deformed logos for different reasons to fully illustrate the functionality of ARM in a visualization experiment. After testing the components individually, we conducted experiments combining LD involution and MRNAS to further validate the model effects, as shown in In this paper, we proposed a logo detection model, long-range dependence involutional network (LDI-Net), to detect logos with large aspect ratios by adding a new operator and a self-attention mechanism. Meanwhile, MRNAS was proposed to construct a novel multipath topology to realize multiscale logo detection. ARM was also introduced to enhance the ability of the proposed model to handle logo deformation.So far, LDI-Net has worked well, but there are some limitations. Although multiscale logos can be completed well, there is still room for further improvement in the localization and classification of some small logos. Our method could also solve the problem of logo deformation caused by occlusion and rotation very well, but the deformations caused by reflection and distortion need to be studied more specifically. In future work, we will continue to conduct indepth research to solve the above problems. Further, we will address other challenges of logo detection, such as small, similar, and low-resolution logos.