White matter integrity and functional connectivity of the default mode network in acute stroke are associated with cognitive outcome three months post-stroke.

BACKGROUND: Knowledge about factors that are associated with post-stroke cognitive outcome is important to identify patients with high risk for impairment. We therefore investigated the associations of white matter integrity and functional connectivity (FC) within the brain's default-mode network (DMN) in acute stroke patients with cognitive outcome three months post-stroke. METHODS: Patients aged between 18 and 85 years with an acute symptomatic MRI-proven unilateral ischemic middle cerebral artery infarction, who had received reperfusion therapy, were invited to participate in this longitudinal study. All patients underwent brain MRI within 24-72 h after symptom onset, and participated in a neuropsychological assessment three months post-stroke. We performed hierarchical regression analyses to explore the incremental value of baseline white matter integrity and FC beyond demographic, clinical, and macrostructural information for cognitive outcome. RESULTS: The study cohort comprised 34 patients (mean age: 64 ± 12 years, 35% female). The initial median National Institutes of Health Stroke Scale (NIHSS) score was 10, and significantly improved three months post-stroke to a median NIHSS = 1 (p < .001). Nonetheless, 50% of patients showed cognitive impairment three months post-stroke. FC of the non-lesioned anterior cingulate cortex of the affected hemisphere explained 15% of incremental variance for processing speed (p = .007), and fractional anisotropy of the non-lesioned cingulum of the affected hemisphere explained 13% of incremental variance for cognitive flexibility (p = .033). CONCLUSIONS: White matter integrity and functional MRI markers of the DMN in acute stroke explain incremental variance for post-stroke cognitive outcome beyond demographic, clinical, and macrostructural information.

Influence of a placebo tDCS treatment on cybersickness and EEG-neurofeedback success.

Virtual Reality (VR) serves as a modern and powerful tool within the domain of neurofeedback (NF). Users can learn how to alter their own brain activation with the help of NF, for example visual feedback. VR can help to make the training more engaging and motivating with its immersive nature. However, cybersickness (CS) poses a serious problem, as it negatively affects up to 80% of all VR users. Especially women seem to be affected. Some studies suggest positive effects of placebo interventions, so that less CS in the users can be detected. Hence, we investigated whether a transcranial direct current stimulation (tDCS) placebo intervention can influence CS symptoms in a VR-based NF training and whether CS affects NF performance. Additionally, we focused on possible sex differences in the development of CS and the NF success. For this purpose, we tested 41 healthy participants in an EEG-NF-training with sensorimotor rhythm (SMR, 12-15 Hz) upregulation and VR feedback. Half of the participants got a placebo tDCS stimulation in advance to the training and were told that the stimulation would prevent them from getting cybersick. The other half received no such treatment. Both groups underwent six NF runs to three minutes each where they were asked to follow a ball along a predefined path in the virtual environment by increasing their SMR. Results showed that women experienced significantly more CS than men regardless of whether they received a placebo intervention or not. Women were also not able to increase their SMR successfully over the six NF runs. Male participants were able to increase their SMR. Also, only participants in the non-placebo group were able to increase their SMR, not those from the placebo group. The tDCS placebo intervention had little to no effect on sickness symptoms in VR, however it hampered the ability to increase SMR power. Also, CS seems to be associated with a worse NF training outcome, especially in women. Strategies to reduce CS inducing factors in VR environments could help participants to benefit more from a VR-based NF training. This should be especially considered in vulnerable groups that are more prone to CS.

Training Master of Social Work Students in Brief Intervention for Unhealthy Alcohol Use: Results of a Validated Adherence Assessment.

BACKGROUND: Many social workers receive limited training in working with clients engaged in unhealthy substance use. As a result, national organizations and agencies such as the Council on Social Work Education and individual social work programs are beginning to address this need by incorporating training into higher education social work programs. The purpose of this study was to examine Master of Social Work (MSW) students' adherence to a brief intervention protocol for unhealthy alcohol use. METHODS: A total of 91 MSW students consented to the assessment of their digital, audio-recorded class assignment by independent raters. RESULTS: Although 90% of MSW student participants were found to be overall adherent to the protocol, gaps in training quality were also identified. CONCLUSIONS: Lessons learned for addressing the gaps are discussed, along with future directions for teaching and learning in social work related to substance use.

A review on the relation between grinding process and quality of ground meat.

This review is providing an overview of the actual and past research in the field of ground meat. The forces that are acting in the meat grinder are well understood. The higher the forces that are acting on the meat while grinding, the stronger the disintegration of the meat cells after the process. These forces can be calculated as energy transfer in meat grinders using specific mechanical energy (SME). The amount of non-intact cells (ANIC) can be used to describe the extent of disintegrated cells. Different methods are available to rate the quality of ground meat, which is mainly influenced by the raw material and processing. Over the past decades of industrialization, the landscape of ground meat production has changed. However, the effects of the process adjustments on the quality of ground meat are not yet sufficiently described in the literature.

Effects of virtual reality-based feedback on neurofeedback training performance-A sham-controlled study.

Electroencephalography-neurofeedback (EEG-NF) has become a valuable tool in the field of psychology, e.g., to improve cognitive function. Nevertheless, a large percentage of NF users seem to be unable to control their own brain activation. Therefore, the aim of this study was to examine whether a different kind of visual feedback could positively influence NF performance after one training session. Virtual reality (VR) seems to have beneficial training effects and has already been reported to increase motivational training aspects. In the present study, we tested 61 young healthy adults (mean age: 23.48 years; 28 female) to investigate, whether 3D VR-based NF training has a more beneficial effect on the sensorimotor rhythm (SMR, 12-15 Hz) power increase than a mere 2D conventional NF paradigm. In the 3D group, participants had to roll a ball along a predefined path in an immersive virtual environment, whereas the 2D group had to increase the height of a bar. Both paradigms were presented using VR goggles. Participants completed one baseline and six feedback runs with 3 min each, in which they should try to increase SMR power over Cz. Half of the participants received real feedback whereas the other half received sham feedback. Participants receiving 3D VR-based feedback showed a linear increase in SMR power over the feedback runs within one training session. This was the case for the real as well as for the sham 3D feedback group and might be related to more general VR-related effects. The 2D group receiving the conventional bar feedback showed no changes in SMR power over the feedback runs. The present study underlines that the visual feedback modality has differential effects on the NF training performance and that 3D VR-based feedback has advantages over conventional 2D feedback.

Relevance of Cognition and Emotion for Patient-Reported Quality of Life After Stroke in Working Age: An Observational Cohort Study.

Background: Patient-reported quality of life (QoL) may help to capture sequela of stroke more comprehensively. We aimed to investigate QoL in working age persons with ischemic stroke regarding impaired domains and identify factors associated with better QoL. Methods: We invited persons with stroke aged 18-55 years to participate in this prospective observational study. We assessed QoL and self-rated health using the EuroQol 5 Dimension questionnaire (EQ-5D) during hospital stay (baseline) and at 3-months follow-up (FU). Additionally, the National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), cognition (Montreal Cognitive assessment, MOCA), emotion (Hospital Anxiety and Depression Scale), and return to work were evaluated. We used hierarchical regression to identify predictors of QoL (self-rated health and QoL Index score) at FU. Results: We included 138 persons with stroke (mean age = 43.6 ± 10 years; 41% female; median admission NIHSS = 2), of whom 99 participated at FU. QoL Index and self-rated health were correlated with NIHSS, mRS, anxiety, and depression at both timepoints. Although 80% had favorable functional outcome at FU (mRS < 2), high proportions of these persons reported problems in the "Pain and/or Discomfort" (25.3%) and "Anxiety/Depression" (22.8%) dimensions. Only discharge NIHSS and baseline MOCA independently predicted self-rated health at FU. Female sex, higher discharge NIHSS, and higher baseline depression scores predicted worse QoL Index scores at FU. Conclusions: Three months post-stroke, working age persons with stroke frequently reported problems in dimensions not assessed by the routinely used mRS. Despite correlations between clinical scales and QoL, patient-reported outcomes and screening for cognition and emotion ensure a more comprehensive assessment of post-stroke consequences relevant for QoL.

Short-term fasting induced changes in HRV are associated with interoceptive accuracy: Evidence from two independent within-subjects studies.

Previous research suggested increased cardiac interoceptive accuracy after 24-h food-deprivation by means of the heartbeat tracking task. The present study investigated if 16-h of voluntary fasting shows similar effects and whether changes in interoceptive accuracy are accompanied by changes in autonomic function. In two independent within-subjects studies two measures of interoceptive accuracy, the heartbeat tracking task and the heartbeat discrimination task were applied. In study 1 (n = 24) and study 2 (n = 72) vagally-mediated HRV increases and heart rate decreases were observed. Stronger effects of fasting on vagally-mediated HRV went along with a higher interoceptive accuracy increase in the heartbeat tracking task. Furthermore, the fasting associated changes in interoceptive accuracy in both tasks were significantly associated, suggesting that these tasks are suitable to track changes in cardiac interoception. Taken together, fasting of 16-h might be suitable to increase participants' parasympathetic efference, thereby facilitating interoception.

MRI correlates of cognitive improvement after home-based EEG neurofeedback training in patients with multiple sclerosis: a pilot study.

OBJECTIVE: Neurofeedback training may improve cognitive function in patients with neurological disorders. However, the underlying cerebral mechanisms of such improvements are poorly understood. Therefore, we aimed to investigate MRI correlates of cognitive improvement after EEG-based neurofeedback training in patients with MS (pwMS). METHODS: Fourteen pwMS underwent ten neurofeedback training sessions within 3-4 weeks at home using a tele-rehabilitation system. Half of the pwMS (N = 7, responders) learned to self-regulate sensorimotor rhythm (SMR, 12-15 Hz) by visual feedback and improved cognitively after training, whereas the remainder (non-responders, n = 7) did not. Diffusion-tensor imaging and resting-state fMRI of the brain was performed before and after training. We analyzed fractional anisotropy (FA) and functional connectivity (FC) of the default-mode, sensorimotor (SMN) and salience network (SAL). RESULTS: At baseline, responders and non-responders were comparable regarding sex, age, education, disease duration, physical and cognitive impairment, and MRI parameters. After training, compared to non-responders, responders showed increased FA and FC within the SAL and SMN. Cognitive improvement correlated with increased FC in SAL and a correlation trend with increased FA was observed. CONCLUSIONS: This exploratory study suggests that successful neurofeedback training may not only lead to cognitive improvement, but also to increases in brain microstructure and functional connectivity.

Evaluation of a Newly Developed Smartphone App for Risk Factor Management in Young Patients With Ischemic Stroke: A Pilot Study.

Background: Efficient treatment of modifiable vascular risk factors decreases reoccurrence of ischemic stroke, which is of uttermost importance in younger patients. In this longitudinal pilot study, we thus assessed the effect of a newly developed smartphone app for risk factor management in such a cohort. Methods: The app conveys key facts about stroke, provides motivational support for a healthy lifestyle, and a reminder function for medication intake and blood pressure measurement. Between January 2019 and February 2020, we consecutively invited patients with ischemic stroke aged between 18 and 55 years to participate. Patients in the intervention group used the app between hospital discharge and 3-month follow-up. The control group received standard clinical care. Modifiable risk factors (physical activity, nutrition, alcohol consumption, smoking behavior, obesity, and hypertension) were assessed during the initial hospital stay and at a dedicated stroke outpatient department three months post-stroke. Results: The study cohort comprised 21 patients in the app intervention group (62% male; age = 41 ± 11 years; education = 12 ± 3 years) and 21 sex-, age- and education-matched control patients with a comparable stroke risk factor profile. Baseline stroke severity was comparable between groups (intervention: median NIHSS = 3; control: median NIHSS = 4; p = 0.604). Three months post-stroke, patients in the intervention group reported to be physically almost twice as active (13 ± 9 h/week) compared to controls (7 ± 5 h/week; p = 0.022). More intense app usage was strongly associated with higher physical activity (r = 0.60, p = 0.005) and lower consumption of unhealthy food (r = -0.51, p = 0.023). Smoking behavior (p = 0.001) and hypertension (p = 0.003) improved in all patients. Patients in the intervention group described better self-reported health-related quality of life three months post-stroke (p = 0.003). Conclusions: Specifically designed app interventions can be an easily to implement and cost-efficient approach to promote a healthier lifestyle in younger patients with a stroke.

Alcohol mixed with energy drinks: Expectancies of use and alcohol-related negative consequences among a young adult sample.

OBJECTIVE: Energy drinks are a popular mixer with alcohol among college-aged young adults. Few studies to date have examined the relationships between expectancies of alcohol mixed with energy drink (AmED) use, AmED use and AmED-related negative consequences. METHODS: Eighty college-aged young adults were surveyed regarding their alcohol and AmED use, related negative consequences and AmED expectancies. Associations were assessed using chi-square tests and Cramér's V. A simple mediational model also was used to explore the potential relationships between AmED expectancies, AmED use and AmED-related negative consequences. RESULTS: AmED use was associated with more types of related negative consequences than heavy alcohol use alone, and where AmED use and heavy alcohol use were mutually associated with a related negative consequence, the strength of association was stronger for AmED use. While several AmED-related negative consequences were associated with AmED expectancies, unwanted sexual contact and getting into a verbal argument were associated with the greatest number of expectancies. The mediational model identified a statistically significant indirect effect of AmED expectancies on AmED-related negative consequences mediated by AmED use. CONCLUSIONS: The study results contribute to the evidence that AmED use may confer additional risk for related negative consequences beyond heavy alcohol use and suggest that AmED expectancies may have a role in AmED use, which, in turn, is associated with AmED-related negative consequences. AmED expectancies may be targets for intervention to reduce AmED use considering the possible subsequent related negative consequences, especially those involving negative interpersonal experiences.

Fluorescence Lifetime Patterns of Retinal Pigment Epithelium Atrophy in Patients with Stargardt Disease and Age-Related Macular Degeneration.

PURPOSE: To investigate whether autofluorescence lifetime patterns within retinal pigment epithelium (RPE) atrophy differ between age-related macular degeneration (AMD) and Stargardt disease (STGD). METHODS: Mean retinal autofluorescence lifetimes were measured in a short and a long spectral channel (SSC: 498-560 nm; LSC: 560-720 nm). Mean retinal fluorescence lifetimes were analyzed with corresponding clinical features, fundus images, fundus autofluorescence intensity images, and optical coherence tomography. Mean fluorescence lifetime values of atrophic areas were compared between the two cohorts and within the same patient to adjacent nonatrophic regions. RESULTS: Mean fluorescence lifetimes within areas with RPE atrophy of 13 patients with STGD (mean age ± SEM 43.7 ± 5 years) and 30 patients with geographic atrophy (mean age: 78 ± 2 years) were analyzed and compared to age-matched healthy participants. The mean area of RPE atrophy in STGD and AMD was 6.6 ± 2.3 mm2 (range: 0.66-33.17 mm2) and 17.5 ± 3.8 mm2 (range: 0.58-50.02 mm2), respectively. In patients with AMD, atrophic areas revealed significantly longer mean fluorescence lifetime values as compared with patients with STGD (SSC: 997 ± 60 vs. 363 ± 26 ps; LSC: 880 ± 46 vs. 393 ± 23 ps; p < 0.0001). CONCLUSIONS: This study established that RPE atrophy in patients secondary to STGD and AMD display distinctive mean fluorescence lifetime characteristics. As retinal fluorescence lifetimes within areas of RPE atrophy were significantly longer in AMD patients, the analysis of specific lifetime patterns may provide additional insight into the disease processes and the pathogenetic mechanisms in the development of atrophic patches in AMD and STGD.

RETINAL FLECKS IN STARGARDT DISEASE REVEAL CHARACTERISTIC FLUORESCENCE LIFETIME TRANSITION OVER TIME.

PURPOSE: Stargardt disease is the most common inherited juvenile macular dystrophy and is characterized by yellowish flecks across the posterior pole. The purpose of this study was to investigate fluorescence lifetime changes of retinal flecks over time using fluorescence lifetime imaging ophthalmoscopy. METHODS: Longitudinal fluorescence lifetime data of 12 patients with Stargardt disease (mean age ± SEM, 42.25 ± 2.1 years; range, 28-58 years) were acquired using a fluorescence lifetime imaging ophthalmoscope based on a Heidelberg Engineering Spectralis system. Retinal autofluorescence was excited with a 470-nm laser. The emitted fluorescence was detected in two wavelength channels: a short spectral channel (498-560 nm) and a long spectral channel (560-720 nm). The mean retinal autofluorescence lifetimes were calculated and further analyzed with corresponding color fundus images, autofluorescence intensity images, and spectral domain optical coherence tomography. Patients were classified into three subtypes. RESULTS: All patients with Stargardt disease displayed characteristic autofluorescence lifetime patterns. Mean fluorescence lifetime values within areas of yellow flecks were significantly prolonged (long spectral channel 484 ps) compared with the surrounding tissue (long spectral channel 297 ps). In 91.6% of the eyes, flecks with short fluorescence lifetimes (long spectral channel 255 ps) were identified. Short lifetime flecks progressed to flecks with characteristic long lifetimes in 75.1% of eyes within a mean interval of 29.2 months (range 3-45 months). Between baseline and follow-up, the rate of newly developed short lifetime flecks (number/per year) based on subtypes was 2.62 in Group 1, 1.43 in Group 2, and 0.81 in Group 3. CONCLUSION: Recent onset flecks in Stargardt disease display short fluorescence lifetimes and convert into longer fluorescence lifetime flecks over time. This transition may represent a change in the composition of retinal deposits with accumulation of lipofuscin and retinoid by-products from the visual cycle. With emerging treatment options, these findings may prove useful to monitor disease progression and therapeutic effects.

Basic computer skills and computer preferences of inner-city hospitalized medical patients: implications for web-based alcohol screening and brief intervention.

Health care delivery is being transformed by the use of computer technology, and integrated physical health with mental and behavioral health care are national priorities. This study examined the basic computer skills and computer preferences of inner-city hospitalized medical patients in a design study of a web-based alcohol screening and brief intervention program prototype. Participants were 26 patients observed going through the program prototype using both a laptop computer and mouse, and an iPad. The majority of patients were able to do all the basic laptop and basic iPad skills to complete the program prototype, including older patients (aged 50 years or older) and patients with a high school degree or less. Patient computer preference was 3:1 for the use of an iPad versus a laptop computer, and the majority of patients preferred to complete a web-based versus an in-person brief intervention health program. Inner-city hospitalized medical patients appear able to complete and may be receptive to web-based alcohol screening and brief intervention programs.

Referral to treatment for hospitalized medical patients with an alcohol use disorder: A proof-of-concept brief intervention study.

Substance misuse intervention in healthcare settings is becoming a US national priority, especially in the dissemination and implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT). Yet, the referral to treatment component of SBIRT is understudied. This proof-of-concept investigation tested an enhanced coordinated hospital-community two session brief intervention designed to facilitate the referral to treatment of hospitalized medical patients with an alcohol use disorder. Participants (N = 9) attended the second session of the brief intervention held in the community in most cases (56%), while one out of three (33%) received some level of post-brief intervention alcohol and/or other drug treatment. Alcohol use and alcohol-related problems also statistically improved. Based, in part, on the results plus the widespread dissemination of SBIRT, next step investigations of brief interventions to help bridge hospitalized medical patients in need to community substance abuse treatment are warranted.

Family history density of substance use problems among undergraduate college students: Associations with heavy alcohol use and alcohol use disorder.

PURPOSE: A family history of alcoholism has been found associated with problematic alcohol use among college students, but less research has examined the effects of family history density of substance use problems in this population. This study examined the prevalence of family history density of substance use problems and its associations with heavy alcohol use, negative alcohol consequences, and alcohol use disorder in a college sample. METHODS: Based on a secondary analysis of a probability sample, data were analyzed from 606 undergraduate students. Family history density of substance use problems included both first and second degree biological relatives. Heavy alcohol use was the total number of days in which participants drank five/four or more drinks for men/women, negative alcohol consequences were derived from items commonly asked in college student surveys, and an alcohol use disorder was defined as meeting diagnostic criteria for alcohol abuse or dependence. Point prevalence estimated rates of family history density of substance use problems, and negative binomial, ANCOVA, and logistic regression models examined associations between family history density and the alcohol variables while adjusting for sociodemographic variables. RESULTS: Family history density of substance use problems was not significantly associated with total days of heavy alcohol use. Having a second degree, a first degree, or both a first and second degree relative(s) with a substance use problem, however, was significantly associated with experiencing negative alcohol consequences. In addition, having both a first and second degree relative(s) with a substance use problem significantly increased the odds of having an alcohol use disorder. CONCLUSIONS: Family history density of substance use problems may play a role in experiencing negative alcohol consequences and in having an alcohol use disorder among undergraduate college students and may be an important risk factor to assess by college health professionals.

Alcohol Use Disorder Treatment: The Association of Pretreatment Use and the Role of Drinking Goal.

BACKGROUND: In a recent study conducted in a family medicine setting, the medication acamprosate was found not to be efficacious in the treatment of alcohol dependence, but a drinking goal of abstinence was found to have positive effects on alcohol use outcomes. The purpose of this secondary analysis was to further understand which patients with an alcohol use disorder may be most successfully treated in a primary care setting. METHODS: The study was exploratory and used a trajectory-based approach based on data from the acamprosate treatment trial of 100 participants (recruited mostly by advertisement) who were randomly assigned to receive either acamprosate or a matching placebo. Post hoc trajectories of alcohol use before treatment were identified to examine whether trajectory classes and their interactions with treatment arm (acamprosate or placebo), pretreatment drinking goal (abstinence or a reduction), and time predicted alcohol use outcomes. RESULTS: Three distinct trajectory classes were identified: frequent drinkers, nearly daily drinkers, and consistent daily drinkers. Consistent daily drinkers with a goal of abstinence significantly improved over time on the primary outcome measure of percent days abstinent when compared with frequent and nearly daily drinkers. In addition, all participants with a goal of abstinence, regardless of trajectory class, significantly reduced their percentage of heavy drinking days over time. CONCLUSIONS: Patients with an alcohol use disorder who have a drinking goal of abstinence, in particular consistent daily drinkers, may maximally benefit from alcohol use disorder treatment, including the use of medication, in a primary care setting.

Changes in Physical Activity and Psychological Variables Following a Web-Based Motivational Interviewing Intervention: Pilot Study.

BACKGROUND: Web-based interventions for enhancing physical activity participation are in demand for application in health care settings. Recent research suggests Web-based interventions that are based on motivational interviewing are effective to increase physical activity. It is unclear whether motivational interviewing can influence targeted psychological variables such as perceived readiness, willingness, and ability to participate in physical activity. OBJECTIVE: The aims of this study were to determine whether there were changes in physical activity and psychological variables associated with readiness, willingness, and perceived ability to participate in physical activity following completion of a novel Web-based intervention. The goal of the motivational interviewing-based intervention was to increase physical activity. METHODS: Twenty-three underactive or inactive urban dwelling adults were recruited at a medical office for participation in a 4-session Web-based intervention lasting approximately 15 minutes per week. Sessions were based on principles of motivational interviewing. Assessment of physical activity was conducted using pedometers immediately prior to intervention participation (pre) and immediately post intervention (post1). Self-report assessments of physical activity and psychological variables were conducted using online surveys at pre, post1, and again at one month following intervention participation (post2). RESULTS: Comparisons of pre and post1 pedometer recordings revealed significant increases in steps per day (t22=2.09, P=.049). There were also significant changes in total physical activity energy expenditure per week (χ(2) 2=8.4, P=.02) and in moderate intensity physical activity energy expenditure per week (χ(2) 2=13.9, P<.001) over time following participation in the Web-based intervention. Significant changes in psychological variables following participation in the Web-based intervention included: (1) change in stage classification over time (χ(2) 2=21.5, P<.001), where the percentage of participants classified in the action or maintenance stages of change in physical activity increased over time (pre=25% [6/24], post1=71% [17/24], post2=68% [15/22]); (2) decreases in self-reported decisional balance cons (F2,42=12.76, P<.001); (3) increases in self-reported decisional balance pros (F2,42=16.19, P<.001); (4) increases in physical activity enjoyment (F2,20=3.85, P=.04); and (5) increases in self-efficacy (F2,42=3.30, P=.047). CONCLUSIONS: The Web-based intervention piloted in this study shows preliminary promise as a tool to promote physical activity in health care settings. Additional research is needed to test the effectiveness of motivational interviewing compared to a control condition and to refine content by considering mediation by psychological variables in a larger sample.

Q Fever Outbreak Among Travelers to Germany Who Received Live Cell Therapy--United States and Canada, 2014.

During September­November 2014, the New York State Department of Health (NYSDOH) was notified of five New York state residents who had tested seropositive for Coxiella burnetii, the causative agent of Q fever. All five patients had symptoms compatible with Q fever (e.g., fever, fatigue, chills, and headache) and a history of travel to Germany to receive a medical treatment called "live cell therapy" (sometimes called "fresh cell therapy") in May 2014. Live cell therapy is the practice of injecting processed cells from organs or fetuses of nonhuman animals (e.g., sheep) into human recipients. It is advertised to treat a variety of health conditions. This practice is unavailable in the United States; however, persons can travel to foreign locations to receive injections. Local health departments interviewed the patients, and NYSDOH notified CDC and posted a report on CDC's Epidemic Information Exchange to solicit additional cases. Clinical and exposure information for each patient was reported to the Robert Koch Institute in Germany, which forwarded the information to local health authorities. A Canada resident who also received live cell therapy in May 2014 was diagnosed with Q fever in July 2014. Clinicians should be aware of health risks, such as Q fever and other zoonotic diseases, among patients with a history of receiving treatment with live cell therapy products.