On the Importance of Domain Awareness in Classifier Interpretations in Medical Imaging.

Translating the success of deep learning-based computer-assisted classification into clinical adaptation hinges on the ability to explain a prediction's causality. Post-hoc interpretability approaches, especially counterfactual techniques, have shown both technical and psychological potential. Nevertheless, currently dominant approaches utilize heuristic, unvalidated methodology. Thereby, they potentially operate the underlying networks outside their validated domain, adding doubt in the predictor's abilities instead of generating knowledge and trust. In this work, we investigate this out-of-distribution problem for medical image pathology classifiers and propose marginalization techniques and evaluation procedures to overcome it. Furthermore, we propose a complete domain-aware pipeline for radiology environments. Its validity is demonstrated on a synthetic and two publicly available image datasets. Specifically, we evaluate using the CBIS-DDSM/DDSM mammography collection and the Chest X-ray14 radiographs. Our solution shows, both quantitatively and qualitatively, a significant reduction of localization ambiguity and clearer conveying results.

Employing similarity to highlight differences: On the impact of anatomical assumptions in chest X-ray registration methods.

To facilitate both the detection and the interpretation of findings in chest X-rays, comparison with a previous image of the same patient is very valuable to radiologists. Today, the most common approach for deep learning methods to automatically inspect chest X-rays disregards the patient history and classifies only single images as normal or abnormal. Nevertheless, several methods for assisting in the task of comparison through image registration have been proposed in the past. However, as we illustrate, they tend to miss specific types of pathological changes like cardiomegaly and effusion. Due to assumptions on fixed anatomical structures or their measurements of registration quality, they produce unnaturally deformed warp fields impacting visualization of differences between moving and fixed images. We aim to overcome these limitations, through a new paradigm based on individual rib pair segmentation for anatomy penalized registration. Our method proves to be a natural way to limit the folding percentage of the warp field to 1/6 of the state of the art while increasing the overlap of ribs by more than 25%, implying difference images showing pathological changes overlooked by other methods. We develop an anatomically penalized convolutional multi-stage solution on the National Institutes of Health (NIH) data set, starting from less than 25 fully and 50 partly labeled training images, employing sequential instance memory segmentation with hole dropout, weak labeling, coarse-to-fine refinement and Gaussian mixture model histogram matching. We statistically evaluate the benefits of our method and highlight the limits of currently used metrics for registration of chest X-rays.

Multi-Task Fusion for Improving Mammography Screening Data Classification.

Machine learning and deep learning methods have become essential for computer-assisted prediction in medicine, with a growing number of applications also in the field of mammography. Typically these algorithms are trained for a specific task, e.g., the classification of lesions or the prediction of a mammogram's pathology status. To obtain a comprehensive view of a patient, models which were all trained for the same task(s) are subsequently ensembled or combined. In this work, we propose a pipeline approach, where we first train a set of individual, task-specific models and subsequently investigate the fusion thereof, which is in contrast to the standard model ensembling strategy. We fuse model predictions and high-level features from deep learning models with hybrid patient models to build stronger predictors on patient level. To this end, we propose a multi-branch deep learning model which efficiently fuses features across different tasks and mammograms to obtain a comprehensive patient-level prediction. We train and evaluate our full pipeline on public mammography data, i.e., DDSM and its curated version CBIS-DDSM, and report an AUC score of 0.962 for predicting the presence of any lesion and 0.791 for predicting the presence of malignant lesions on patient level. Overall, our fusion approaches improve AUC scores significantly by up to 0.04 compared to standard model ensembling. Moreover, by providing not only global patient-level predictions but also task-specific model results that are related to radiological features, our pipeline aims to closely support the reading workflow of radiologists.

"I Know That It's Something That's Creating a Bond": Fathers' Experiences of Participating in Baby Theater With Their Infants in South Africa.

In many African countries, particularly those with largely patriarchal societies like South Africa, promoting father-child interaction can pose a challenge. An informative medium that could potentially encourage active participation in pleasurable interactions between fathers and babies may prove to be an important way in which to stimulate fathers' awareness of their infants' abilities. A Cape Town based theater company created the first ever South African baby play for care-givers and their babies between the ages of 2 weeks to 12 months. The play is performed in a contained, relaxing space and offers carers and babies time to relate to each other in a pleasurable atmosphere, while specially trained actors model sensitive and responsive interactions. Baby Theater could be a way to encourage fathers' involvement with their infants, however, no research is currently available documenting fathers' perceptions about Baby Theater experience. Aim: To explore fathers' experience of participating in Baby Theater. Method: This qualitative study involved six fathers who, with their infants, participated in the Baby Theater production. A week later the fathers were divided into two focus groups to give them the opportunity to discuss their thoughts about the experience and to reflect on whether it had any subsequent impact on their interactions with their babies. The audiotaped, transcribed material was thematically analyzed using an interpretative phenomenological approach. Results: The fathers described the experience as educative and enjoyable. They reported that the program had a positive impact on the way they interacted with their infants and also positively influenced their relationship with them. Additionally, they reported feeling more confident about coping with their babies on their own, and appreciated the connection with the other fathers in the group. Cultural, societal, and gender issues were also considered. Conclusions: The subjective experience of the fathers was positive. Further research is needed to assess the lasting effects of the Baby Theater experience.

Pregnancy outcomes, early separation, and psychiatric relapse experienced by South African women with peripartum psychosis: a descriptive exploration.

The peripartum is associated with increased incidence of severe mental illness (SMI), a greater occurrence of psychotic symptoms and psychiatric admissions. This study aimed to describe the psychiatric, medical and psycho-social risk factors affecting South African mothers who experienced peripartum psychosis. Using a prospective, descriptive design, we conducted a detailed interview and supplementary information was collected by review of clinical records. The study examined the accounts of forty mothers who experienced peripartum psychosis between 6 and 18 months postpartum. Descriptive statistics for demographic and clinical variables were completed with SPSS for Windows, version 25. Pregnancies were predominantly unplanned and more than half of participants reported prenatal substance use. Medical or psychiatric problems during pregnancy were common and the majority of dyads experienced periods of early separation. Socio-demographic factors exacerbated the challenges this group of women at high risk face, in providing nurturing care to their infants. Results highlight the need for close follow-up for women with SMI, with particular attention to substance screening and psychosocial stressors. Integrated maternal and infant mental health services are recommended.

Mothering from the Inside Out: Adapting an evidence-based intervention for high-risk mothers in the Western Cape of South Africa.

During South Africa's first two decades as a democracy, the Western Cape Province has undergone radical changes to its healthcare system in an effort to address the extensive socioeconomic inequities that remain in the aftermath of the apartheid era. Although progress has been made, there is a clear need for interventions that support parents and children receiving health services in the public sector who are vulnerable to multiple psychosocial risks associated with extreme poverty. In this mixed-method study, we examined the feasibility and acceptability of adapting an evidence-based parenting intervention called Mothering from the Inside Out that was developed for mothers who are vulnerable to similar risks in the United States. Using qualitative methods, we documented the collaborative process that was guided by principles of community-based participatory research and examined themes in the Western Cape collaborators' perspectives about the feasibility and acceptability of the intervention. Using quantitative methods, we tested the preliminary efficacy of the adapted version of Mothering from the Inside Out for improving maternal reflective functioning and mother-child interactions. Although findings from both study components indicated preliminary promise, a number of obstacles and challenges at multiple levels underscore the need for (a) flexibility and contextual support for intervention research conducted in under-resourced communities, (b) clinical sensitivity to the unique experiences of parents rearing children in highly stressful, under-resourced environments, and (c) equal partnerships that allow the expertise of local providers to inform the design proposals of consulting investigators.

Revisiting the African origins of attachment research-50 years on from Ainsworth: A descriptive review.

Culture plays a significant role in the variations observed in the manifestation, expression, and meaning of attachment behaviors. Africa is home to multiple cultures, with distinct organizations of caregiving relationships underlying the development of attachment. This review aims to consolidate knowledge about African attachment by describing studies of infant attachment conducted in Africa since Mary Ainsworth's Ugandan findings in 1967. Electronic databases were searched with the terms "Africa" ("attachment" or "bond") and "infant." Nine studies that assessed infant attachment style with self-report or observation methods were included, but spanned only five countries. The Strange Situation Procedure was most frequently used. Most studies described dyads living in peri-urban or township areas. Multiple socioeconomic factors affecting living conditions were identified, including, unemployment, financial difficulties, limited education, poor housing, single parenthood, lack of partner support, substance abuse, and depression. Overall distributions of attachment classification proportions appear consistent with global attachment-classification patterns. Despite adverse conditions, secure attachment was relatively widespread, and some populations had low rates of avoidant attachment. Relatively high rates of disorganized attachment were found when the category was included. Africa remains an understudied continent regarding infant attachment. The continent's cultural diversity may hold important truths necessary for understanding the complex relationship between infant and attachment figure.

La cultura juega un papel significativo en las variaciones observadas en la manifestación, expresión y significado de los comportamientos de afectividad. África es hogar de múltiples culturas, con distintas organizaciones de relaciones de prestación de cuidados que resaltan el desarrollo de la afectividad. Esta revisión se propone consolidar el conocimiento acerca de la afectividad africana por medio de describir estudios de la afectividad infantil llevados a cabo en África desde los resultados que obtuvo Ainsworth en Uganda. Se buscó en los bancos de información electrónica los términos "África" ("afectividad" o "unión") e "infante." Se incluyeron nueve estudios que evaluaron el estilo de afectividad del infante con métodos de auto-reporte o de observación, pero se cubrió sólo cinco países. El Procedimiento de la Situación Extraña fue usado más frecuentemente. La mayoría de los estudios describieron díadas que vivían en áreas periurbanas o municipalidades. Se identificaron múltiples factores socio-económicos que afectan las condiciones de vida, incluyendo falta de empleo, dificultades financieras, limitada educación, pobres condiciones de vivienda, la soltería del progenitor, falta de apoyo de la pareja, abuso de sustancias y depresión. En general, las distribuciones de las proporciones de clasificación de la afectividad parecen consistentes con los patrones globales de afectividad. A pesar de las condiciones adversas, la afectividad segura estaba relativamente extendida, y algunos grupos de poblaciones tenían bajos puntajes con respecto a evitar la afectividad. Relativamente altos puntajes de afectividad desorganizada se encontraron cuando la categoría fue incluida. África se mantiene como un continente poco estudiado en lo que respecta a la afectividad del infante. La diversidad cultural del continente pudiera contener importantes verdades necesarias para comprender la compleja relación entre el infante y la figura de afectividad.

La culture joue un rôle important dans les variations observées dans la manifestation, l'expression et la signification des comportements d'attachement. L'Afrique est l'hôte et la mère de nombreuses cultures, avec des organisations distinctes de relation de soin sous-tendant le développement de l'attachement. Cette revue a pour but de consolider les connaissances sur l'attachement africain en décrivant des études de l'attachement du nourrisson faites en Afrique depuis les conclusions ougandiennes de Ainsworth. Les bases de données électroniques ont été sondées avec les termes "Afrique", ("attachement" ou "lien") et "nourrisson". Neuf études ayant évalué un style d'attachement du nourrisson au moyen d'une auto-évaluation et de méthodes d'observation ont été inclues mais elles ne portaient que sur seulement cinq pays africains. La Procédure de Situation Etrange était la plus souvent utilisée. La plupart des études ont décrit des dyades vivant dans des zones périurbaines ou dans des villes. Divers facteurs socio-économiques affectant les conditions de vie ont été identifiés, comme par exemple le chômage, les difficultés financières, l'éducation limitée, la pauvreté des logements, le manque de soutien du conjoint, la toxicomanie et la dépression. Les distributions générales des proportions de classification de l'attachement semblent s'aligner avec les patterns globaux de classification de l'attachement. En dépit de conditions adverses, l'attachement sécure était relativement répandu et certaines populations avaient des taux faibles quant à l'attachement d'évitement. Des taux relativement élevés d'attachement désorganisé ont été trouvés quand la catégorie était incluse. La diversité culturelle du continent africain pourrait tenir en elle des vérités importantes nécessaires à la compréhension de la relation complexe entre le nourrisson et la figure d'attachement.

THE WORLDWIDE BURDEN OF INFANT MENTAL AND EMOTIONAL DISORDER: REPORT OF THE TASK FORCE OF THE WORLD ASSOCIATION FOR INFANT MENTAL HEALTH.

Children worldwide experience mental and emotional disorders. Mental disorders occurring among young children, especially infants (birth -3 years), often go unrecognized. Prevalence rates are difficult to determine because of lack of awareness and difficulty assessing and diagnosing young children. Existing data, however, suggest that rates of disorders in young children are comparable to those of older children and adolescents (von Klitzing, Dohnert, Kroll, & Grube, ). The lack of widespread recognition of disorders of infancy is particularly concerning due to the unique positioning of infancy as foundational in the developmental process. Both the brain and behavior are in vulnerable states of development across the first 3 years of life, with potential for enduring deviations to occur in response to early trauma and deprivation. Intervention approaches for young children require sensitivity to their developmental needs within their families. The primacy of infancy as a time of unique foundational risks for disorder, the impact of trauma and violence on young children's development, the impact of family disruption on children's attachment, and existing literature on prevalence rates of early disorders are discussed. Finally, global priorities for addressing these disorders of infancy are highlighted to support prevention and intervention actions that may alleviate suffering among our youngest world citizens.

REFLECTIVE PRACTICE IN INFANT MENTAL HEALTH-A SOUTH AFRICAN PERSPECTIVE.

Reflective practice forms a pivotal part of mental health intervention in a setting where language and cultural differences require working together with a community counselor for language interpretation. Reflective practice in infant mental health began with Esther Bick's () infant observations and continued with Selma Fraiberg's () parent-infant psychotherapy. These two models formed the basis of the practice of infant mental health in a community in South Africa. A clinical example will highlight the importance of culturally informed observation that is then reflected upon. A qualitative study that examined the interaction among the participants in three clinical settings shows that a sustained partnership and tolerance for flexibility lie at the heart of good practice in intercultural settings. Object-relations theory offers an additional, in-depth understanding of the underlying psychic processes in reflective practice.

Physical therapy intervention in patients with non-cardiac chest pain following a recent cardiac event: A randomized controlled trial.

OBJECTIVES: To assess the effect of two different physical therapy interventions in patients with stable coronary heart disease and non-cardiac chest pain. METHODS: A randomized controlled trial was carried out at a university hospital in Norway. A total of 30 patients with known and stable coronary heart disease and self-reported persistent chest pain reproduced by palpation of intercostal trigger points were participating in the study. The intervention was deep friction massage and heat pack versus heat pack only. The primary outcome was pain intensity after the intervention period and 3 months after the last treatment session, measured by Visual Analogue Scale, 0 to 100. Secondary outcome was health-related quality of life. RESULTS: Treatment with deep friction massage and heat pack gave significant pain reduction compared to heat pack only (-17.6, 95% confidence interval: -30.5, -4.7; p < 0.01), and the reduction was persistent at 3 months' follow-up (-15.2, 95% confidence interval: -28.5, -1.8; p = 0.03). Health-related quality of life improved in all three domains in patients with no significant difference between groups. CONCLUSION: Deep friction massage combined with heat pack is an efficient treatment of musculoskeletal chest pain in patients with stable coronary heart disease.

Home-based versus hospital-based high-intensity interval training in cardiac rehabilitation: a randomized study.

BACKGROUND: High-intensity interval training (HIT) as exercise therapy is gradually implemented in cardiac rehabilitation as the cardiovascular benefits from exercise is intensity dependent. However, in previous studies, HIT has been performed with strict supervision. The aim of the study was to assess the feasibility and effectiveness of different modes of HIT in cardiac rehabilitation. DESIGN: a randomized clinical study. METHODS: Ninety participants with coronary artery disease (80 men/10 women, mean age 57 ± 8 years) were randomly assigned to one of three exercise modes: group exercise (GE), treadmill exercise (TE), or home-based exercise (HE). HIT was performed twice a week for 12 weeks with an exercise intensity of 85-95% of peak heart rate. The primary outcome measure was change in peak oxygen uptake (peak VO2). RESULTS: Eighty-three participants (92%) completed the intervention without any severe adverse events. Peak VO2 increased from 34.7 ± 7.3 to 39.0 ± 8.0 ml/kg/min, 32.7 ± 6.5 to 36.0 ± 6.2 ml/kg/min, and 34.4 ± 4.8 to 37.2 ± 5.2 ml/kg/min in TE, GE, and HE, respectively. Mean group difference for TE vs. HE was 1.6 ml/kg/min (95% confidence interval, CI, 0.7 to 3.1, p = 0.02), TE vs. GE 1.1 ml/kg/min (95% CI-0.5 to 2.5, p = 0.27), and GE vs. HE 0.6 ml/kg/min (95% CI -1.0 to 2.1, p = 1). However, on-treatment analysis showed no significant difference between groups. CONCLUSION: HIT was efficiently performed in three settings of cardiac rehabilitation, with respect to target exercise intensity, exercise attendance, and increase in peak VO2. Exercise mode was not essential for exercise capacity.

Infant-parent psychotherapy at primary care level: establishment of a service.

BACKGROUND: Access to infant and child psychiatric care in South Africa is limited. With focus on maternal and infant mental health, early identification and management of developmental, behavioural and psychosocial parent-child problems can be initiated. OBJECTIVES: To establish a mental health service for children aged 0 - 3 years, for delivery of infant-parent psychotherapy in a community setting. METHODS: The DC: 0-3R Classification for Mental Health and Development Disorders of Infancy and Early Childhood was used for diagnosis and standard multi-modal parent-infant psychotherapy methods for short-term interventions. RESULTS: A total of 179 infants and their maternal caregivers were seen. The primary referral symptom was faltering weight. The most frequent psychiatric diagnosis made was 'feeding disorder of caregiver-infant reciprocity'. Seventy two per cent of caregivers were exposed to more than 4 stress factors; 75% proved compliant with treatment with resultant improvement in the relationship between caregiver and child (78%) and in the age-appropriated functioning of the infant (76%). CONCLUSION: This study confirms that a psychotherapeutic service for infants and mothers can be established at a primary healthcare level. Infant-parent psychotherapy was effective and readily accepted by the community. This service offers a training model for mental health providers enabling early recognition of mental health problems in children and psychotherapeutic intervention.

Panel: What could be Jungian about Human Rights work?

The question of whether Jungian analysts should move beyond the consulting room to engage with mental health issues that pertain to the collective is the focus of this paper. Two narratives are presented: one from the view point of a psychiatrist in Occupied Palestine, the other from the conflicted situation which faces an Israeli analyst. Despite the strong ambivalence that is experienced on both sides, there is a willingness to meet and to take a standpoint without necessarily coming to a resolution. A third position is offered by describing experiences from the South African perspective. The African notion of Ubuntu is offered as a moral entry point that states that community goes beyond one's own; from this point of view, Jungian analysts can do no other than to act.