[Value-based healthcare in mental health care: a practical example]. / Waardegedreven zorg in de ggz: een praktijkvoorbeeld.

BACKGROUND: To promote quality improvement in Dutch mental health care, it is imperative to line up methods of quality improvement with daily care practice. In value-based healthcare the joint vision of medical professionals and patients is leading in the design and execution of care improvements. AIM: To demonstrate the value of value-based care. METHOD: Description of a practical example of the application of value based healthcare in mental healthcare, including a practical example of value-based improvement of patient care. RESULTS: A multidisciplinary improvement team was formed, consisting of patients and employees who were involved in the depression care pathway. The team determined important outcomes of care from the patient’s perspective, and successfully executed several improvement initiatives. CONCLUSION: The bottom-up approach of value-based healthcare is in line with day-to-day care practice and provides opportunities for effectively improving the quality of mental health care.

The diagnostic accuracy of local staging in colon cancer based on computed tomography (CT): evaluating the role of extramural venous invasion and tumour deposits.

PURPOSE: The shift from adjuvant to neoadjuvant treatment in colon cancer demands the radiological selection of patients for systemic therapy. The aim of this study was to evaluate the accuracy of the CT-based TNM stage and high-risk features, including extramural venous invasion (EMVI) and tumour deposits, in the identification of patients with histopathological advanced disease, currently considered for neoadjuvant treatment (T3-4 disease). METHODS: All consecutive patients surgically treated for non-metastatic colon cancer between January 2018 and January 2020 in a referral centre for colorectal cancer were identified retrospectively. All tumours were staged on CT according to the TNM classification system. Additionally, the presence of EMVI and tumour deposits on CT was evaluated. The histopathological TNM classification was used as reference standard. RESULTS: A total of 176 patients were included. Histopathological T3-4 colon cancer was present in 85.0% of the patients with CT-detected T3-4 disease. Histopathological T3-4 colon cancer was present in 96.4% of the patients with CT-detected T3-4 colon cancer in the presence of both CT-detected EMVI and CT-detected tumour deposits. Histopathological T0-2 colon cancer was present in 50.8% of the patients with CT-detected T0-2 disease, and in 32.4% of the patients without CT-detected EMVI and tumour deposits. CONCLUSION: The diagnostic accuracy of CT-based staging was comparable with previous studies. The presence of high-risk features on CT increased the probability of histopathological T3-4 colon cancer. However, a substantial part of the patients without CT-detected EMVI and tumour deposits was diagnosed with histopathological T3-4 disease. Hence, more accurate selection criteria are required to correctly identify patients with locally advanced disease.

Exploring aspects of self-reported emotional mental imagery in patients with bipolar disorder.

BACKGROUND AND OBJECTIVES: CBT for patients with bipolar disorder has modest effects. Across disorders, mental imagery has been used to update CBT to increase effectiveness. In order to enhance CBT for bipolar disorder with imagery techniques, research is needed into emotional imagery quality and, related appraisals of imagery and their relationships with mood instability and subsequent behaviour in bipolar disorder. METHODS: Patients with bipolar disorder (n = 106), unipolar depression (n = 51), creative imagery prone participants (n = 53) and participants without a history of a mood disorder (n = 135) completed the Dutch Imagery Survey (DImS), an online imagery survey, adapted from the Imagery Interview, assessing self-reported emotional imagery aspects. Imagery quality, appraisals and their self-perceived effects on emotion and behaviour were compared between groups. As unexpected differences within the bipolar group appeared, these were additionally explored. RESULTS: Imagery appraisals but not imagery quality discriminated between the patient groups and non-patient groups Imagery was perceived as an emotional amplifier in all groups, but this was specifically apparent in bipolar manic and bipolar depressed groups. Only in the bipolar group imagery was experienced to amplify behavioural tendencies. LIMITATIONS: Results need to be replicated using a larger sample of patients with BD who are currently manic or depressed. CONCLUSIONS: Not only quality of imagery, but especially appraisals associated with imagery are differentiating between imagery prone people with and without mood disorder. Imagery amplifies emotion in all groups, but only in those patients with bipolar disorder currently manic or depressed did this influence behaviour.

Comparing the effectiveness of imagery focussed cognitive therapy to group psychoeducation for patients with bipolar disorder: A randomised trial.

BACKGROUND: Bipolar disorder is a severe, chronic mental disorder. Treatment options are limited, with pharmacological approaches continuing to dominate. However, relapse rates remain high. Several adjunctive psychosocial interventions, mostly psychoeducation (PE) and cognitive behavioural therapy (CBT), have been trialled, but treatment innovation is still needed. In the past, brief group PE has proven as beneficial as longer individual CBT in reducing levels of depression and increasing self-management strategies. We compared the relative effectiveness of group PE to an imagery focussed cognitive behavioural therapy (ImCT). STUDY DESIGN: This was a randomised parallel group study with both daily and weekly measures. A total of 62 adult patients were randomly allocated to either ImCT or group PE. Daily, weekly and pre-and post-intervention measures were used to assess impact on (i) mood instability, (ii) overall levels of depression, anxiety and mania, and (iii) general functioning, hopelessness and imagery characteristics. A four-week baseline and 16-week follow-up period were included. RESULTS: Mood instability reduced in both conditions after intervention. Levels of mania, depression and anxiety also reduced in both conditions, but on the daily measures, depression and anxiety significantly more so in the ImCT condition. Compared with the PE condition, the ImCT condition additionally showed increased level of functioning, reduced hopelessness, and a decrease in intrusive, problematic imagery. LIMITATIONS: These findings need to be replicated in a larger trial. CONCLUSIONS: Findings suggest that ImCT is a promising new avenue for management of bipolar disorder, an area in which treatment development is urgently needed.

INFEXIT: Implementing vaginal disinfection prior to cesarean section.

OBJECTIVE: To evaluate the rate of implementation after adding vaginal disinfection to the cesarean section protocol and its effect on post cesarean infections and hospital readmissions. STUDY DESIGN: This is an intervention study where two groups were compared. Women the year before (n = 1384) and one year following (n = 1246) the addition of vaginal disinfection, with povidone-iodine 1% prior to the cesarean section, to the protocol. Primary outcome was the rate of implementation. Secondary outcomes were the rates of endometritis, wound infection and postoperative fever. With the effect expressed in the number of hospital readmissions. RESULTS: The implementation rate was 85.6%. Intention-to-treat analysis showed endometritis rates of 2.0% versus 1.1% (p = 0.07). For women with preoperative ruptured membranes there was a significant decrease in endometritis, from 3.4% to 1.3% (p = 0.02). Per-protocol analysis showed endometritis rates of 2.0% to 1.0% (p = 0.05). Women with ruptured membranes, 3.4% versus 1.3% (p = 0.02), and women who were in the second stage of labor, 4.7% versus 0.0% (p = 0.01), had a significant decrease in endometritis. For wound infection and postoperative fever rates were similar. The decrease of infections had a significant effect on hospital readmissions, 27 versus 10 (p = 0.04). CONCLUSION: The implementation of this quality improvement measure shows to be adequate as the vast majority of women undergoing a cesarean received vaginal disinfection. Vaginal disinfection showed a declining trend of endometritis and postoperative fever and for women with broken membranes prior to cesarean section the decrease in endometritis was significant. These beneficial effects have led to a statistical and clinically relevant decrease in hospital readmissions and thus cost reduction.

Neoadjuvant FOLFOXIRI prior to chemoradiotherapy for high-risk ("ugly") locally advanced rectal cancer: study protocol of a single-arm, multicentre, open-label, phase II trial (MEND-IT).

BACKGROUND: The presence of mesorectal fascia (MRF) invasion, grade 4 extramural venous invasion (EMVI), tumour deposits (TD) or extensive or bilateral extramesorectal (lateral) lymph nodes (LLN) on MRI has been suggested to identify patients with indisputable, extensive locally advanced rectal cancer (LARC), at high risk of treatment failure. The aim of this study is to evaluate whether or not intensified chemotherapy prior to neoadjuvant chemoradiotherapy improves the complete response (CR) rate in these patients. METHODS: This multicentre, single-arm, open-label, phase II trial will include 128 patients with non-metastatic high-risk LARC (hr-LARC), fit for triplet chemotherapy. To ensure a study population with indisputable, unfavourable prognostic characteristics, hr-LARC is defined as LARC with on baseline MRI at least one of the following characteristics; MRF invasion, EMVI grade 4, enlarged bilateral or extensive LLN at high risk of an incomplete resection, or TD. Exclusion criteria are the presence of a homozygous DPD deficiency, distant metastases, any chemotherapy within the past 6 months, previous radiotherapy within the pelvic area precluding standard chemoradiotherapy, and any contraindication for the planned treatment. All patients will be planned for six two-weekly cycles of FOLFOXIRI (5-fluorouracil, leucovorin, oxaliplatin and irinotecan) prior to chemoradiotherapy (25 × 2 Gy or 28 × 1.8 Gy with concomitant capecitabine). A resection will be performed following radiological confirmation of resectable disease after the completion of chemoradiotherapy. A watch and wait strategy is allowed in case of a clinical complete response. The primary endpoint is the CR rate, described as a pathological CR or a sustained clinical CR one year after chemoradiotherapy. The main secondary objectives are long-term oncological outcomes, radiological and pathological response, the number of resections with clear margins, treatment-related toxicity, perioperative complications, health-related costs, and quality of life. DISCUSSION: This trial protocol describes the MEND-IT study. The MEND-IT study aims to evaluate the CR rate after intensified chemotherapy prior to concomitant chemoradiotherapy in a homogeneous group of patients with locally advanced rectal cancer and indisputably unfavourable characteristics, defined as hr-LARC, in order to improve their prognosis. TRIAL REGISTRATION: Clinicaltrials.gov: NCT04838496 , registered on 02-04-2021 Netherlands Trial Register: NL9790. PROTOCOL VERSION: Version 3 dd 11-4-2022.

Mind the gap: Patterns of red blood cell product usage in South Africa, 2014 - 2019.

BACKGROUND: A key component of any successful healthcare system is the availability of sufficient, safe blood products delivered in an equitable manner. South Africa (SA) has a two-tiered healthcare system with public and privately funded sectors. Blood utilisation data for both sectors are lacking. Evaluation of blood utilisation patterns in each healthcare sector will enable implementation of systems to bring about more equality. OBJECTIVES: To conduct a critical evaluation of red blood cell (RBC) product utilisation patterns at the South African National Blood Service (SANBS). METHODS: Operationally collected data from RBC requests submitted to SANBS blood banks for the period 1 January 2014 - 31 March 2019 were used to determine temporal RBC product utilisation patterns by healthcare sector. Demographic patterns were determined, and per capita RBC utilisation trends calculated. RESULTS: Of the 2 356 441 transfusion events, 65.9% occurred in the public and 34.1% in the private sector. Public sector patients were younger (median (interquartile range (IQR)) 33 (22 - 49) years) than in the private sector (median (IQR) 54 (37 - 68) years), and mainly female in both sectors (66.2% in the public sector and 53.4% in the private sector). Between 2014 and 2018, per capita RBC utilisation decreased from 11.9 to 11.0/1 000 population in the public sector, but increased from 34.8 to 38.2/1 000 population in the private sector. CONCLUSIONS: We confirmed distinctly different RBC utilisation patterns between the healthcare sectors in SA. Possible drivers for these differences may be healthcare access, differing patient populations and prescriber habits. Better understanding of these drivers may help inform equitable public health policy.

Improved response rate in patients with prognostically poor locally advanced rectal cancer after treatment with induction chemotherapy and chemoradiotherapy when compared with chemoradiotherapy alone: A matched case-control study.

INTRODUCTION: The addition of induction chemotherapy (ICT) to neoadjuvant chemoradiotherapy (CRT) has the potential to improve outcomes in patients with locally advanced rectal cancer (LARC). However, patient selection is essential to prevent overtreatment. This study compared the complete response (CR) rate after treatment with and without ICT of LARC patients with prognostically poor characteristics. METHODS: All LARC patients who were treated with neoadjuvant CRT, whether or not preceded by ICT, and who underwent surgery or were considered for a wait-and-see strategy between January 2016 and March 2020 in the Catharina Hospital Eindhoven, were retrospectively selected. LARC was defined as any T4 tumour, or a T2/T3 tumour with extramural venous invasion and/or tumour deposits and/or N2 lymph node status, and/or mesorectal fascia involvement (T3 tumours only). Case-control matching was performed based on the aforementioned characteristics. RESULTS: Of 242 patients, 178 (74%) received CRT (CRT-group) and 64 patients (26%) received ICT followed by CRT (ICT-group). In the ICT-group, 3 patients (5%) did not receive the minimum of three cycles. In addition, in this selected cohort, compliance with radiotherapy was 100% in the ICT-group and 97% in the CRT-group. The CR rate was 30% in the ICT-group and 15% in the CRT-group (p = 0.011). After case-control matching, the CR rate was 28% and 9%, respectively (p = 0.013). CONCLUSION: Treatment including ICT seemed well tolerated and resulted in a high CR rate. Hence, this treatment strategy may facilitate organ preservation and improve survival in LARC patients with prognostically poor characteristics.

Image qualities and mood variability: Evaluating the utility of an imagery survey for bipolar disorder.

OBJECTIVE: Imagery appears to play an important role in mood variability, a core symptom of patients suffering from bipolar disorder. The present study aimed to explore the validity and reliability of an online self-report measure of imagery, the Dutch Imagery Survey (DImS). The DImS is an adaptation of the Imagery interview used in research on imagery in mental disorders. The present study additionally explored the ability of the DImS to detect relationships between self-reported imagery and subsequent mood and subsequent behaviour. METHOD: 135 students completed the DImS and additional mental imagery and mood questionnaires. For re-test reliability, 42 students completed the survey again within two days. RESULTS: Internal consistencies and test-retest scores of the five scales of the DImS were reasonable. Imagery Quality correlated with Emotions, and to a lesser degree with Behaviour. Positive Appraisals correlated with Positive Emotions, Negative Appraisals with Negative Emotions, and Positive appraisals with Behaviour. Frequency of Imagery, Imagery Quality and Positive Appraisals correlated with elevated mood. Imagery Quality and Negative Appraisals correlated with low mood. The DImS took approximately 15 min to complete. LIMITATIONS: Re-test reliability was limited due to participants changing their dominant image. Results need to be replicated in a clinical sample. CONCLUSIONS: Psychometric findings with the DImS appeared reasonable and consistent and showed that, in line with other recent studies, imagery is related to current mood and to both self-perceived emotion and subsequent behaviour. These findings suggested that the DImS is suitable to study the role of imagery in bipolar mood variability.

A cognitive behavioural group therapy for bipolar disorder using daily mood monitoring.

BACKGROUND AND AIM: This study investigated the effects of group cognitive behavioural therapy (CBT) for patients with bipolar disorder. The development of CBT for this disorder is relatively under-explored. METHOD: Participants with bipolar I or II disorder were treated with group CBT in addition to treatment as usual. The effectiveness of the protocol was explored through sequence analysis of daily mood monitoring prior to, during and after the intervention. Also, a repeated measures design was used assessing symptomatology, dysfunctional attitudes, sense of mastery, psychosocial functioning, and quality of life at start and end of intervention, and at follow-up 2 and 12 months later. RESULTS: The results indicate that variation in mood states diminished over the course of the intervention. Also, there was a change from depressive states to more euthymic states. Greater number of reported lifetime depressive episodes was associated with greater diversity of mood states. There was an increase in overall psychosocial functioning and self-reported psychological health following the intervention. Improvement continued after treatment ended until follow-up at 2 months, and measured 1 year later, for outcomes representing depression, general psychosocial functioning and self-reported psychological health. Due to small sample size and the lack of a control group the results are preliminary. CONCLUSIONS: The results of this pilot study suggest that both offering CBT in group interventions and sequence analysis of time series data are helpful routes to further explore when improving standard CBT interventions for patients suffering from bipolar disorder.

Towards the future of blood transfusion - the South African National Blood Service's perspectives on cellular therapeutic services and products.

Blood transfusion services are the cornerstone of the healthcare delivery system, and need to stay abreast of advances in technology to ensure relevance to the needs of the country. In this review, we examine the current status of blood transfusion systems and discuss their possible future role in cellular therapies.

Towards the future of blood transfusion ­ the South African national blood service's perspectives on cellular therapeutic services and products

Blood transfusion services are the cornerstone of the healthcare delivery system, and need to stay abreast of advances in technology to ensure relevance to the needs of the country. In this review, we examine the current status of blood transfusion systems and discuss their possible future role in cellular therapies

Determination of early warning signs for photocatalytic degradation of titanium white oil paints by means of surface analysis.

Titanium white (TiO2) has been widely used as a pigment in the 20th century. However, its most photocatalytic form (anatase) can cause severe degradation of the oil paint in which it is contained. UV light initiates TiO2-photocatalyzed processes in the paint film, degrading the oil binder into volatile components resulting in chalking of the paint. This will eventually lead to severe changes in the appearance of a painting. To date, limited examples of degraded works of art containing titanium white are known due to the relatively short existence of the paintings in question and the slow progress of the degradation process. However, UV light will inevitably cause degradation of paint in works of art containing photocatalytic titanium white. In this work, a method to detect early warning signs of photocatalytic degradation of unvarnished oil paint is proposed, using atomic force microscopy (AFM) and X-ray photoelectron spectroscopy (XPS). Consequently, a four-stage degradation model was developed through in-depth study of TiO2-containing paint films in various stages of degradation. The XPS surface analysis proved very valuable for detecting early warning signs of paint degradation, whereas the AFM results provide additional confirmation and are in good agreement with bulk gloss reduction.

A cross-sectional study of peripartum blood transfusion in the Eastern Cape, South Africa.

BACKGROUND: Obstetric haemorrhage (OH) remains a major contributor to maternal morbidity and mortality. Blood transfusion is critical in OH management; yet, data on peripartum transfusion are lacking. A pilot study reported high rates of peripartum transfusion in a sample of South African (SA) hospitals, which was independently associated with HIV status. OBJECTIVES: To assess the incidence of peripartum transfusion in a sample of Eastern Cape, SA hospitals to evaluate generalisability of preceding study findings. METHODS: Hospital chart reviews were conducted of all deliveries at three large regional hospitals from February to June 2013. Additional clinical data were collected for patients who sustained OH and/or were transfused. RESULTS: A total of 7 234 women were enrolled in the study; 1 988 (27.5%) were HIV-positive. Of the 767 HIV-positive women with a CD4 count <350 cells/µL, 86.0% were on full antiretroviral therapy and 9.9% received drugs for prevention of mother-to-child transmission. The overall transfusion rate was 3.2%, with significant variability by hospital: Frere Hospital (1.5%), Dora Nginza Hospital (3.8%) and Cecilia Makiwane Hospital (4.6%). The number of red blood cell units per transfused patient and per delivery varied significantly by hospital. Bivariate analysis showed significant association between transfusion and HIV status. In a multivariate analysis, controlling for OH, age, mode of delivery, gestational age, parity and birthweight, this association (odds ratio 1.45; 95% confidence interval 0.78 - 2.71) was no longer significant. CONCLUSION: These findings confirm high rates of peripartum transfusion in SA. While this can be possibly ascribed to variability in practice and patient profile, variation in care and improvement in HIV treatment should be considered.

Protein intake and lean body mass preservation during energy intake restriction in overweight older adults.

BACKGROUND: Dietary-induced weight loss is generally accompanied by a decline in skeletal muscle mass. The loss of muscle mass leads to a decline in muscle strength and impairs physical performance. A high dietary protein intake has been suggested to allow muscle mass preservation during energy intake restriction. OBJECTIVE: To investigate the impact of increasing dietary protein intake on lean body mass, strength and physical performance during 12 weeks of energy intake restriction in overweight older adults. DESIGN: Sixty-one overweight and obese men and women (63±5 years) were randomly assigned to either a high protein diet (HP; 1.7 g kg(-1) per day; n=31) or normal protein diet (NP; 0.9 g kg(-1) per day; n=30) during a 12-week 25% energy intake restriction. During this controlled dietary intervention, 90% of the diet was provided by the university. At baseline and after the intervention, body weight, lean body mass (dual-energy X-ray absorptiometry), leg strength (1-repetition maximum), physical performance (Short Physical Performance Battery, 400 m) and habitual physical activity (actigraph) were assessed. RESULTS: Body weight declined in both groups with no differences between the HP and NP groups (-8.9±2.9 versus -9.1±3.4 kg, respectively; P=0.584). Lean body mass declined by 1.8±2.2 and 2.1±1.4 kg, respectively, with no significant differences between groups (P=0.213). Leg strength had decreased during the intervention by 8.8±14.0 and 8.9±12.8 kg, with no differences between groups (P=0.689). Physical performance as measured by 400 m walking speed improved in both groups, with no differences between groups (P=0.219). CONCLUSIONS: Increasing protein intake above habitual intake levels (0.9 g kg(-1) per day) does not preserve lean body mass, strength or physical performance during prolonged energy intake restriction in overweight older adults.

[Somatic disorders in outpatient psychiatry: the added value of a standard physical examination during the intake of outpatients]. / Somatiek in de ambulante psychiatrie: de toegevoegde waarde van een standaard lichamelijk onderzoek tijdens de ambulante intake.

BACKGROUND: It is well-known that psychiatric patients often suffer from severe somatic problems, such as diabetes mellitus and cardiovascular disease. Up till now, research has concentrated almost exclusively on the inpatient setting, but there is strong evidence that the correlation also exists in psychiatric patients who are outpatients. In the Netherlands there are, as yet, no clear recommendations regarding a standard form of somatic screening for the outpatient population. A pilot study performed by GGz Breburg has shown that somatic screening (without a physical examination) gave substantial additional value to treatment planning. AIM: To investigate the added value that a physical examination can provide when new psychiatric patients are screened for aspects of somatic concern (ASC). METHOD: Newly referred outpatients (n = 70) were screened somatically by means of a questionnaire and supplementary medical interview, and by laboratory tests and physical examination. If a somatic problem was found which had not been detected previously, the patient was referred back to to the general practitioner. RESULTS: At least one ASC was found in 81,4% of all patients. In 45,7% of all patients the asc had not been detected. 12% of all the newly discovered somatic problems were found exclusively via the physical examination. CONCLUSION: A physical examination provides substantial information and adds value to the somatic screening of psychiatric outpatients.

Satiety and energy intake after single and repeated exposure to gel-forming dietary fiber: post-ingestive effects.

BACKGROUND: Viscous or gel-forming dietary fibers can increase satiety by a more firm texture and increased eating time. Effects of viscous or gel-forming fibers on satiety by post-ingestive mechanisms such as gastric emptying, hormonal signals, nutrient absorption or fermentation are unclear. Moreover, it is unclear whether the effects persist after repeated exposure. OBJECTIVE: To investigate satiety and energy intake after single and repeated exposure to gelled fiber by post-ingestive mechanisms. DESIGN: In a two-arm crossover design, 32 subjects (24 female subjects, 21±2 y, BMI 21.8±1.9 kg m(-2)) consumed test foods once daily for 15 consecutive days, with 2 weeks of washout. Test foods were isocaloric (0.5 MJ, 200 g) with either 10 g gel-forming pectin or 3 g gelatin and 2 g starch, matched for texture and eating time. Hourly satiety ratings, ad libitum energy intake and body weight were measured on days 1 (single exposure) and 15 (repeated exposure). In addition, hourly breath hydrogen, fasting glucose, insulin, leptin and short-chain fatty acids were measured. RESULTS: Subjects rated hunger, desire to eat and prospective intake about 2% lower (P<0.015) and fullness higher (+1.4%; P=0.041) when they received pectin compared with control. This difference was similar after single and repeated exposure (P>0.64). After receiving pectin, energy intake was lower (-5.6%, P=0.012) and breath hydrogen was elevated (+12.6%, P=0.008) after single exposure, but not after repeated exposure. Fasting glucose concentrations were higher both after single and repeated exposure to pectin (+2.1%, P=0.019). Body weight and concentrations of insulin, leptin and short-chain fatty acids did not change during the study. CONCLUSIONS: Gelled pectin can increase satiety and reduce energy intake by post-ingestive mechanisms. Although the effects were small, the effects on satiety were consistent over time, whereas the effects on energy intake reduction were not.

The posterior parahippocampal gyrus is preferentially affected in age-related memory decline.

Atrophy in the medial temporal lobe is generally considered to be highly associated with age-related memory decline. Volume loss in the hippocampus and entorhinal cortex has extensively been investigated, but the posterior parts of the parahippocampal gyrus have received little attention. The present MRI study investigated whether volume differences in medial temporal lobe areas are differentially related to age-related memory decline. Thirty-nine subjects from a longitudinal study on cognitive aging (the Maastricht Aging Study) have been examined: 20 participants (mean age=67 years, range 52-80) with memory decline over a period of 12 years were matched to 19 participants without memory decline. Manual tracing was performed on 3T MR images to measure the volumes of the anterior, middle and posterior parts of the hippocampus and parahippocampal gyrus. A robust group difference and a significant association with memory decline were observed only in the posterior part of the parahippocampal gyrus. Our results may suggest that the posterior parahippocampal gyrus plays a key role in age-related memory decline.