Youth voices from an informal settlement of Nairobi, Kenya: Engaging adolescent perspectives on violence to inform prevention.

We examined the experiences of violence and self-reported behavioural and community changes as a result of participation in a sexual assault prevention intervention in an informal settlement in Nairobi, Kenya. We conducted longitudinal qualitative in-depth interviews with 20 adolescent girls and 11 adolescent boys at baseline, 12, and 24 months. Analysis was thematic with two investigators coding and reaching consensus about the themes. Participants' ages ranged from 10 to 13 at baseline; girls' mean age was 11.9, boys' mean age was 11.6. Participants reported experiencing high levels of violence at all stages of the study. Most reported feeling more empowered to protect themselves and others from sexual assault because of the intervention. While participants had mixed responses about change in sexual assault incidence, most perceived an improvement in inter-gender relationships after the intervention. Participants at midline and endline cited acquaintances and friends as potential perpetrators of sexual violence more often than at baseline and were more open to reporting violent incidents. The very young adolescents in this setting perceived that this sexual assault prevention intervention led to improvements in gender relations, adolescent girls' empowerment and, recognition of harmful rape myths.Trial registration: ClinicalTrials.gov identifier: NCT02771132.

A Detailed Characterization of the Expert Problem-Solving Process in Science and Engineering: Guidance for Teaching and Assessment.

A primary goal of science and engineering (S&E) education is to produce good problem solvers, but how to best teach and measure the quality of problem solving remains unclear. The process is complex, multifaceted, and not fully characterized. Here, we present a detailed characterization of the S&E problem-solving process as a set of specific interlinked decisions. This framework of decisions is empirically grounded and describes the entire process. To develop this, we interviewed 52 successful scientists and engineers ("experts") spanning different disciplines, including biology and medicine. They described how they solved a typical but important problem in their work, and we analyzed the interviews in terms of decisions made. Surprisingly, we found that across all experts and fields, the solution process was framed around making a set of just 29 specific decisions. We also found that the process of making those discipline-general decisions (selecting between alternative actions) relied heavily on domain-specific predictive models that embodied the relevant disciplinary knowledge. This set of decisions provides a guide for the detailed measurement and teaching of S&E problem solving. This decision framework also provides a more specific, complete, and empirically based description of the "practices" of science.

Utilization of Multiparametric MRI of Prostate in Patients under Consideration for or Already in Active Surveillance: Correlation with Imaging Guided Target Biopsy.

This study sought to assess the value of multiparametric magnetic resonance image (mp-MRI) in patients with a prostate cancer (PCa) Gleason score of 6 or less under consideration for or already in active surveillance and to determine the rate of upgrading by target biopsy. Three hundred and fifty-four consecutive men with an initial transrectal ultrasound-guided (TRUS) biopsy-confirmed PCa Gleason score of 6 or less under clinical consideration for or already in active surveillance underwent mp-MRI and were retrospectively reviewed. One hundred and nineteen of 354 patients had cancer-suspicious regions (CSRs) at mp-MRI. Each CSR was assigned a Prostate Imaging Reporting and Data System (PI-RADS) score based on PI-RADS v2. One hundred and eight of 119 patients underwent confirmatory imaging-guided biopsy for CSRs. Pathology results including Gleason score (GS) and percentage of specimens positive for PCa were recorded. Associations between PI-RADS scores and findings at target biopsy were evaluated using logistic regression. At target biopsy, 81 of 108 patients had PCa (75%). Among them, 77 patients had upgrading (22%, 77 of 354 patients). One hundred and forty-six CSRs in 108 patients had PI-RADS 3 n = 28, 4 n = 66, and 5 n = 52. The upgraded rate for each category of CSR was for PI-RADS 3 (5 of 28, 18%), 4 (47 of 66, 71%) and 5 (49 of 52, 94%). Using logistic regression analysis, differences in PI-RADS scores from 3 to 5 are significantly associated with the probability of disease upgrade (20%, 73%, and 96% for PI-RADS score of 3, 4, and 5, respectively). Adding mp-MRI to patients under consideration for or already in active surveillance helps to identify undiagnosed PCa of a higher GS or higher volume resulting in upgrading in 22%.

Variability of the Positive Predictive Value of PI-RADS for Prostate MRI across 26 Centers: Experience of the Society of Abdominal Radiology Prostate Cancer Disease-focused Panel.

Background Prostate MRI is used widely in clinical care for guiding tissue sampling, active surveillance, and staging. The Prostate Imaging Reporting and Data System (PI-RADS) helps provide a standardized probabilistic approach for identifying clinically significant prostate cancer. Despite widespread use, the variability in performance of prostate MRI across practices remains unknown. Purpose To estimate the positive predictive value (PPV) of PI-RADS for the detection of high-grade prostate cancer across imaging centers. Materials and Methods This retrospective cross-sectional study was compliant with the HIPAA. Twenty-six centers with members in the Society of Abdominal Radiology Prostate Cancer Disease-focused Panel submitted data from men with suspected or biopsy-proven untreated prostate cancer. MRI scans were obtained between January 2015 and April 2018. This was followed with targeted biopsy. Only men with at least one MRI lesion assigned a PI-RADS score of 2-5 were included. Outcome was prostate cancer with Gleason score (GS) greater than or equal to 3+4 (International Society of Urological Pathology grade group ≥2). A mixed-model logistic regression with institution and individuals as random effects was used to estimate overall PPVs. The variability of observed PPV of PI-RADS across imaging centers was described by using the median and interquartile range. Results The authors evaluated 3449 men (mean age, 65 years ± 8 [standard deviation]) with 5082 lesions. Biopsy results showed 1698 cancers with GS greater than or equal to 3+4 (International Society of Urological Pathology grade group ≥2) in 2082 men. Across all centers, the estimated PPV was 35% (95% confidence interval [CI]: 27%, 43%) for a PI-RADS score greater than or equal to 3 and 49% (95% CI: 40%, 58%) for a PI-RADS score greater than or equal to 4. The interquartile ranges of PPV at these same PI-RADS score thresholds were 27%-44% and 27%-48%, respectively. Conclusion The positive predictive value of the Prostate Imaging and Reporting Data System was low and varied widely across centers. © RSNA, 2020 Online supplemental material is available for this article. See also the editorial by Milot in this issue.

Response to Neoadjuvant Treatment Is Influenced by Grade in Gastric Cancer.

Neoadjuvant therapy is commonly used in the management of gastric cancer. Primary tumor response to treatment correlates with prognosis. Published studies have compared efficacy of neoadjuvant therapy based on stage but not grade. The objective of this study was to determine the change in staging of gastric cancer after neoadjuvant therapy and resection based on grade. A retrospective analysis of gastric cancer patients treated at our institution between 2005 and 2017 was performed. Patient demographics, tumor characteristics, clinical and pathological stage, and microscopic treatment response were analyzed based on grade. Of the 269 patients identified during this period, 82 patients underwent definitive surgical resection, of which 38 patients received neoadjuvant therapy (low grade (grades 1 and 2), n = 17; high grade (grade 3), n = 18; and unknown grade, n = 3). Pathologic downstaging was observed in 52.9 per cent (9/17) of low-grade tumors compared with 22.2 per cent (4/18) of high-grade tumors. Majority of high-grade tumors (77.8%, 14/18) had either upstaging or unchanged stage. High-grade gastric cancers often lack response to neoadjuvant therapy. Novel targeted therapies based on biologic behavior should be evaluated and incorporated into neoadjuvant treatment. Neoadjuvant studies should stratify patients based on grade and report response by grade.

Sarcopenia predicts poor long-term survival in patients undergoing endovascular aortic aneurysm repair.

OBJECTIVE: Sarcopenia measured by decreased psoas muscle size has been used as a surrogate for frailty and correlates with adverse outcomes in both the short and long term after many major operations. Our aim was to evaluate this measure as a predictor of outcomes in patients undergoing endovascular aortic aneurysm repair (EVAR). METHODS: Once Institutional Review Board approval was obtained, all patients who underwent EVAR from December 2010 to March 2016 at a Veterans Affairs hospital were assessed for sarcopenia by total psoas muscle area (TPA) measured on axial computed tomography scan immediately inferior to the fourth lumbar (L4) superior end plate. Outcomes including length of stay and mortality were collected from the medical record. RESULTS: There were 135 patients who underwent EVAR at a median age of 70 years. Median aneurysm size was 5.5 cm. Length of stay was >2 days in 25% of patients (n = 33), with the most common reasons for delayed discharge including respiratory complications (8.9% [n = 12]) and urinary retention (4.0% [n = 9]). Low TPA was not associated with extended length of stay (P = .40). Patients with lowest tertile TPA had 42% 5-year survival compared with 93% survival observed for the remaining two-thirds of patients (P = .01). Multivariate analysis revealed increased likelihood of mortality at 5 years for patients in the lowest tertile for TPA (odds ratio, 3.9; 95% confidence interval, 1.2-12.9) as well as for patients with chronic kidney disease (odds ratio, 5.2; 95% confidence interval, 1.5-18.0). CONCLUSIONS: Preoperative sarcopenia does not appear to affect length of stay but does portend worse long-term survival. This simple preoperative measurement may help vascular surgeons tailor repair thresholds and avoid nonbeneficial procedures.

A Model Medical Student-Led Interprofessional QI Project on Lab Monitoring.

INTRODUCTION: Teaching quality improvement (QI) in undergraduate medical education to meet entrustable professional activities (EPA) requirements is a challenge. We describe a model where first-year medical students learn QI methods using online modules and then apply their knowledge by leading an interprofessional project in a clinical setting. This model project, set in an outpatient family medicine clinic, sought to improve patient compliance with the preventive care metric of annual serum potassium and creatinine monitoring for patients taking a diuretic, angiotensin-converting enzyme inhibitor (ACEI), or angiotensin receptor blocker (ARB) medication. METHODS: A first-year medical student joined an interprofessional team of one primary care physician and three pharmacy residents. The student led the team in reviewing patient charts to identify root causes and implementing a multifaceted strategy to improve patient outreach and refill policies. The effects of these interventions were monitored weekly using an electronic health record population health tool (Epic's Healthy Planet) over the course of 10 months. RESULTS: At baseline, 76.7% (477/622) of patients taking a diuretic and 79.4% (752/947) taking an ACEI or ARB were compliant with monitoring, approximately 10% below the Healthcare Effectiveness Data and Information Set (HEDIS) recommendations. Within 6 months, interventions resulted in both patient cohorts meeting the HEDIS metric with sustained success for the study duration of 10 months. CONCLUSION: This report demonstrates that a first-year medical student can make meaningful contributions to preventive care while gaining clinically relevant QI experience. Further evaluation is needed to determine generalizability and scalability of this model.

QRS fragmentation and sudden cardiac death in the obese and overweight.

BACKGROUND: Obesity has been associated with significantly greater risk of sudden cardiac death (SCD); however, identifying the obese patient at highest risk remains a challenge. We evaluated the association between QRS fragmentation on the 12-lead electrocardiogram and SCD, in obese/overweight subjects. METHODS AND RESULTS: In the ongoing prospective, community-based Oregon Sudden Unexpected Death Study (population approximately 1 million), we performed a case-control analysis, comparing obese/overweight SCD victims with obese/overweight controls from the same geographic region. Archived ECGs prior and unrelated to the SCD event were used for cases and all ECG measurements were assessed in blinded fashion. Fragmentation was defined as the presence of RSR' patterns and/or notching of the R/S wave in at least 2 contiguous leads. Analysis was limited to ECGs with QRS duration <120 ms. Overall prevalence of fragmentation was higher in cases (n=185; 64.9±13.8 years; 67.0% male) compared with controls (n=405; 64.9±11.0 years; 64.7% male) (34.6% versus 26.9%, P=0.06). Lateral fragmentation was significantly more frequent in cases (8.1% versus 2.5%; P<0. 01), with non-significant differences in anterior and inferior territories. Fragmentation in multiple territories (≥2) was also more likely to be observed in cases (9.7% versus 4.9%, P=0.02). In multivariable analysis with consideration of established SCD risk factors, lateral fragmentation was significantly associated with SCD (OR 2.84; 95% CI 1.01 to 8.02; P=0.05). CONCLUSION: QRS fragmentation, especially in the lateral territory is a potential risk marker for SCD independent of the ejection fraction, among obese/overweight subjects in the general population.

Medicolegal characteristics of cardiac catheterization litigation in the United States, 1985 to 2009.

There are few assessments of patterns of medicolegal cases involving cardiac catheterizations. This descriptive study reviews the patterns of liability and medical outcomes involving cardiac catheterization litigation from the LexisNexis Academic database and the Physician Insurers Association of America registry. From 1985 to 2009, the Physician Insurers Association of America registry documented 1,361 closed coronary angiography claims. The cardiovascular disease specialty was involved in 699 with other specialties involved in the remaining cases. Of the 1,361 closed claims, 301 (22%) resulted in payments to the plaintiff (average indemnity of $230,987). The most common alleged error was for improper performance (35.4%; average indemnity of $255,542). The alleged error with the highest average indemnity of $270,916 was errors in diagnosis. Not performing an indicated procedure had the highest ratio of paid to closed claims (41%) with an average indemnity of $246,988. In regard to the severity of injury, death was the most common outcome (44%). The highest ratio of paid to total closed claims (43%) was for grave injuries (highest average indemnity of $555,625). Of the 116 LexisNexis cases, litigation against physicians occurred in 90.5% of cases with judgments in favor of the patients in 29.5%. When death was the outcome (31% of cases), physicians were highly likely to be sued (97%) and the judgment was more likely in the plaintiffs' favor (44%). In conclusion, in litigation related to cardiac catheterizations, most cases are due to medical malpractice and physicians are sued in a high percentage of cases. Cardiologists should recognize these patterns of litigation as these may impact and improve processes of care.

Radiation safety among cardiology fellows.

Cardiology fellows can be exposed to high radiation levels during procedures. Proper radiation training and implementation of safety procedures is of critical importance in lowering physician health risks associated with radiation exposure. Participants were cardiology fellows in the United States (n = 2,545) who were contacted by e-mail to complete an anonymous survey regarding the knowledge and practice of radiation protection during catheterization laboratory procedures. An on-line survey engine, SurveyMonkey, was used to distribute and collect the results of the 10-question survey. The response rate was 10.5%. Of the 267 respondents, 82% had undergone formal radiation safety training. Only 58% of the fellows were aware of their hospital's pregnancy radiation policy and 60% knew how to contact the hospital's radiation safety officer. Although 52% of the fellows always wore a dosimeter, 81% did not know their level of radiation exposure in the previous year and only 74% of fellows knew the safe levels of radiation exposure. The fellows who had received formal training were more likely to be aware of their pregnancy policy, to know the contact information of their radiation safety officer, to be aware of the safe levels of radiation exposure, to use dosimeters and RadPad consistently, and to know their own level of radiation exposure in the previous year. In conclusion, cardiology fellows have not been adequately educated about radiation safety. A concerted effort directed at physician safety in the workplace from the regulatory committees overseeing cardiology fellowships should be encouraged.

mRNA decapping is promoted by an RNA-binding channel in Dcp2.

Cap hydrolysis by Dcp2 is a critical step in several eukaryotic mRNA decay pathways. Processing requires access to cap-proximal nucleotides and the coordinated assembly of a decapping mRNP, but the mechanism of substrate recognition and regulation by protein interactions have remained elusive. Using NMR spectroscopy and kinetic analyses, we show that yeast Dcp2 resolves interactions with the cap and RNA body using a bipartite surface that forms a channel intersecting the catalytic and regulatory Dcp1-binding domains. The interaction with cap is weak but specific and requires binding of the RNA body to a dynamic interface. The catalytic step is stimulated by Dcp1 and its interaction domain, likely through a substrate-induced conformational change. Thus, activation of the decapping mRNP is restricted by access to 5'-proximal nucleotides, a feature that could act as a checkpoint in mRNA metabolism.