Results of accuracy (0·85), sensitivity (0·94), specificity (0·77), positive predictive value (0·76) and negative predictive value (0·95) of GMS were also very high. Cohen’s κ for internal consistency of the GMS was 0·82. GMS proves to be a valid and reliable instrument for the detection of malnutrition in adult patients in acute-care hospitals.Despite the significant impact of malnutrition in hospitalised patients, it is often not identified by clinical staff in daily practice. To improve nutritional support in hospitals, standardised routine nutritional screening is essential. The Graz Malnutrition Screening (GMS) tool was developed for the purpose of malnutrition risk screening in a large hospital setting involving different departments. It was the aim of the present study to validate the GMS against Nutritional Risk Screening (NRS) and Mini Nutritional Assessment-short form (MNA-sf) in a randomised blinded manner. A total of 404 randomly selected patients admitted to the internal, surgical and orthopaedic wards of the University Hospital Graz were screened in a blinded manner by different raters. Concurrent validity was determined by comparing the GMS with the NRS and in older patients (70+ years) with the MNA-sf additionally. According to GMS, 31·9 or 28·5 % of the admitted patients were categorised as at ‘risk of malnutrition’ (depending on the rater). According to the reference standard of NRS, 24·5 % of the patients suffered from malnutrition. Pearson’s  The European Society for Clinical Nutrition and Metabolism (ESPEN) defines malnutrition as a state of nutrition in which a deficiency or excess  of energy, protein and other nutrients causes measurable adverse effects on tissue/body form  and function, as well as clinical outcome. The American Society on Parenteral and Enteral Nutrition (ASPEN) broadens the approach. According to the ASPEN guideline, malnutrition is defined as ‘an acute, sub-acute or chronic state of nutrition, in which varying degrees of over-nutrition or under-nutrition with or without inflammatory activity have led to a change in body composition and diminished function’.Malnutrition is highly prevalent in hospitalised patients, varying from 20 to 60 % upon admission. Prevalence estimation strongly depends on the underlying definition of malnutrition and pre-defined evaluation parameters–6. T. An International Consensus Guideline Committee has proposed an approach to diagnosing malnutrition in adults based on aetiology, thus integrating the present understanding of inflammatory responses to disease and trauma. At present, there are numerous screening tools for malnutrition in adults cited in the literature. The ESPEN as well as the ASPEN recommendations also include guidelines on how to evaluate malnutrition risk in the hospital setting. However, guidelines cannot account for every variation in circumstances. Hospitals therefore must always exercise professional judgement and look for applications feasible for their needs, based on internationally agreed core components within the definition of malnutrition. One of the major challenges in hospital-care settings is insufficient knowledge and low commitment among nurses and physicians regarding the topic of malnutrition, which results in an insufficient focus on nutritional aspects of care(–). Therefore, it is a great challenge to implement nutritional guidelines in hospitals(–).The goal of nutritional screening is to identify any specific nutrition risk(s). Indeed, the above-mentioned definitions are consistent with the Joint Commission on Accreditation of Healthcare Organisation’s interpretation of a ‘screen’ as an instrument used to determine whether additional information (from an assessment) is required to warrant an intervention9. An The Medical University of Graz (MUG) comprises forty clinical and non-clinical institutions. It is closely associated with the General Hospital Graz, which is among the largest hospitals in Europe and is a top-quality institution offering all fields of human medicine. The University Hospital Graz currently accommodates all medical disciplines within seventy organisational units and 1578 acute-care beds. Approximately 385 000 patients are being treated in the clinics annually. As for the specialty of internal medicine, approximately 70 % of the patients admitted to the wards are older than 65 years. In admitted patients older than 75 years, the sex ratio of female:male is approximately 2:1 with a further increasing tendency towards women with increasing age.. However, to address special needs of a big university hospital, the screening tool had to be adapted according to patients’ characteristics in the local setting. In terms of novelty, this malnutrition risk screening tool is based on electronic documentation and may be connected to any hospital IT platform. The Graz Malnutrition Screening (GMS) also has other advantages compared with currently available malnutrition risk screening tools. It has high user-friendliness and involves dietitians in an automated manner if malnutrition risk is detected in a patient who had been screened by the staff on the wards. GMS therefore assures the multi-professional approach and quality control. Using the GMS, we implemented effective governance via the establishment of a multi-disciplinary nutrition steering committee at each facility with representation from medical, food services, nursing, dietetic, pharmacy and speech pathology staff.It became essential to establish a malnutrition risk screening tool that addresses internationally recommended quality standards, is easy to handle in daily routine practice and that is highly sensitive in detection of individual malnutrition risk independent of sex, age or diagnosis at admission. Since 1997, a multi-disciplinary nutrition team, comprised of dietitians, medical doctors, pharmacists, nurses and staff from the local hospital management, stepped forward to implement a risk screening tool into the locally established hospital information technology (IT) platform (MEDOCS™) to improve compliance of healthcare professionals towards malnutrition risk screening on a routine basis. This screening instrument was primarily based on the tool of subjective global assessment (SGA), which initially had been dedicated and validated for surgical patients,21. . In addition, the GMS was compared with the Mini Nutritional Assessment-short form (MNA-sf), which is recommended for malnutrition risk screening for people older than 65 years.It was the aim of the current study to validate the GMS in a blinded randomised controlled trial against the gold standard of malnutrition risk screening in hospitals recommended by ESPEN, the Nutritional Risk Screening (NRS) tool22. In(–). It seems noteworthy that aged patients account for a large number of admissions at our university hospital. On the basis of recently developed knowledge regarding age as an independent risk factor for malnutrition and given local hospital challenges of acute medical care, it was decided that age >65 years is handled as an ‘independent risk factor’ in the screening tool accounting for 1 point on the scoring scale. The risk screening tool is designed so that a score of 3 or more signifies ‘risk of malnutrition’ , GMS by a trained dietitian using the GMS (listed as rater 2) and NRS and MNA-sf performed by a study dietitian (listed in legends of figures as rater 3). All screenings were performed in a blinded manner. Within the study cohort, data were collected by pencil and paper in the wards and transformed into the study data file collectively by a study nurse.Ethics approval was obtained from the independent Ethical Review Committee of the MUG. All patients admitted to the internal ward, the surgical ward or the orthopaedic ward between December 2013 and March 2014 were screened for study participation within the recruitment tool. Only patients able to provide informed consent were eligible for recruitment. Potential candidates for study participation were approached by the study team in a compliance talk and were also additionally provided written information. Patients confirmed their participation by signing an informed consent document. In the case where patients could not be met by the team – for example, due to procedures taken or length of stay – the electronic randomising programme provided substitute patients within the same age range.For measuring height to the nearest 0·5 cm, a stadiometer  fixed to the wall was used. Weight was measured to the nearest 0·1 kg using ward- or clinic-based medical, calibrated scales. The percentage of weight loss in the last 3 months and nutritional intake were documented from the patient’s history routinely. Acute and chronic diseases were scored and documented by physicians at the ward. To determine inter-rater reliability of the GMS, patients were screened by two dietitians in a blinded and independent manner. Within 4-h, both raters visited the same patient and conducted the GMS. For measuring concurrent validity of the GMS, the NRS was used as a gold standard. The MNA-sf was conducted additionally in patients older than 70 years by a study dietitian working in a blinded manner from the rest of the study team.κ and percentage agreement (PA). κ Values were interpreted derived from Landis & Koch. κ Values under 0·2 were defined as ‘slight agreement’, κ values between 0·21 and 0·4 were considered as ‘fair agreement’, κ values between 0·41 and 0·6 indicated ‘moderate’ and κ values between 0·61 and 0·80 a substantial agreement. κ Values>0·8 were considered as almost perfect agreement. Concurrent validity was determined matching the GMS and the NRS results of older patients (70+ years) with individual MNA-sf data using Pearson’s correlation. Furthermore, sensitivity, specificity, accuracy and positive/negative predictive values (PPV/NPV) were calculated. Internal consistency was estimated by calculation of Cronbach’s α.Statistical analysis was performed using SPSS version 21.0 for Windows (SPSS). The number of patients needed to be screened to reach the level of significance had been estimated by the local statistician for the end points described. The cut-off value to prove statistical significance had been estimated at 400 participants. Baseline characteristics were analysed using descriptive statistics. Inter-rater reliability was tested with Cohen’s is & Koch34. κ A total of 407 randomly selected patients, admitted to the internal medicine, surgical or orthopaedic wards were screened by the study team; three patients refused to participate. Finally, 404 patients were recruited and screened according to the protocol; 183 (45·3 %) participants were female and 221 (54·7 %) were male. Median patient age was 61 (18–93) years. A total of 128 patients were matched in age-group one (18–44 years), 143 in age-group two (45–69 years) and 133 in age-group three (70+ years). Risk of malnutrition in the overall cohort varied between age groups. There was an increasing prevalence of risk of malnutrition with age . No statr 0·78. The determination coefficient r2 was 0·61. Out of overall 404 patients, there were fifty disagreements between tools, with forty out of fifty subjects’ risk being overestimated by GMS (r2 was 0·71. Results for accuracy (0·85), sensitivity (0·94), specificity (0·77), PPV (0·76) and NPV (0·95) were also very high.d by GMS . Using dComparison of GMS and MNA-sf results indicated nineteen disagreements between the two tools with sixteen out of nineteen older patients’ risk underestimated by GMS compared with MNA . It shouκ Values, PA and standard error of measurement for the single items as well as for the total scale are shown in κ Values of the agreement between raters and reliability of single items within the GMS screening tool varied between 0·6 and 1·00. The κ value of the total scale was 0·82. PA was between 86·4 and 100 %, whereas PA of the total scale was 94·8 %; 100 % agreement was reached in the items BMI, severity of disease and age. Overall internal consistency Cronbach’s α was 0·57 with a range for the corrected item total.According to the GMS, 129 patients (31·9 %) and 115 patients (28·5 %), respectively, were classified as ‘at risk for malnutrition’. Numbers at risk for malnutrition detected by the NRS were slightly but not statistically significantly lower . Percent, thirty-three million people are at risk of under-nutrition in Europe. Furthermore, a quarter of patients in hospitals are at risk of under-nutrition or are already malnourished. Under-nutrition has negative effects on treatment outcomes by increasing morbidity and mortality. Nutritional care starts with systematic screening to identify ‘at risk’ patients and nutritional assessment and intervention planning to ensure that adequate nutritional support is provided at the right time. This approach is also reflected in a recently launched publication by the Action Group A3 of the European Partnership on Active and Healthy Aging of the European Commission. The nutritional impairment identified by screening should therefore be relevant to objectives and outcomes individually determined, and interventions may vary according to individual assessment and care planning – for example, age or type of illness. In hospitals, special focus has to be given to acute and chronic illnesses, anthropometry, nutritional habits and history as well as individual therapeutic goals.According to Ljungqvist & de Man35, th: anthropometric parameters, recent weight loss, individual food intake and its history and disease process and nutritional needs. The GMS tool addresses all the items recommended within the ESPEN Guideline for use in hospitals. Furthermore, the GMS was developed according to long-standing experience and local needs. Its novelty stems from the fact that it is very user-friendly and that it can be incorporated into any hospital IT platform, and therefore electronic patient record. It involves dietitians in an automated manner if malnutrition risk is detected in a patient screened by the staff on the wards. GMS therefore assures the multi-professional approach and quality control.The usefulness of malnutrition risk screening tools can be evaluated by a number of criteria. First, efficacy of a screening tool is of major importance. A hospital-based malnutrition risk screening tool should incorporate basic structural elements recommended by international scientific societies. ESPEN recommends four different variables to be included in a hospital nutrition screening tool40: anr values of 0·78 according to the NRS and even higher, 0·84 compared with the MNA-sf).To address the screening tool’s statistical efficacy in terms of validity and sensitivity, 404 age-matched patients admitted to the internal medicine, orthopaedic or general surgery ward of the Graz University Hospital were screened in a blinded, randomised manner using the GMS, the NRS and the MNA-sf, respectively. Referring to the validation data of the screening tools used in terms of ‘gold standards’, one can state that the GMS tool is at least as sensitive in detecting an individual’s risk of malnutrition in patients admitted to an internal, surgical or orthopaedic ward. The results of this study indicate a high validity of GMS compared with malnutrition screening tools recommended for hospital use (Pearson’s (–). Modification of SGA to distinct patient profiles in a large university hospital, specifically introducing ‘age’ as an independent risk factor, seems to raise the sensitivity of the GMS tool. Originally, the GMS had been designed for a general screening of all patients admitted to various hospital departments and wards. The sensitivity of the GMS tool seems to be comparable with the NRS, independent of patient age. According to data in our study, MNA-sf seemed to ‘overestimate’ risk of malnutrition when compared with NRS and GMS (independent of ward of admission and diseases). Young et al. argue in their publication that MNA-sf was designed to identify patients requiring further assessment with the MNA-long version, and highlighted the rather ‘poor performance’ of MNA-sf compared with SGA, pointing towards the different objectives of the MNA-sf and the SGA in that publication. This argument may also count for the comparison of the MNA-sf with the GMS in older patients in our study. However, differences in sensitivity between test systems did not reach the level of significance, at least in our study. Issues arising from this repetitive data from MNA-sf clearly include the question of feasibility of MNA-sf for the acute-care setting. Positive test scores for malnutrition risk screening highlight the need for further assessment of patients detected at risk. Although the MNA-sf was accurate, it identified a larger number of at-risk patients, as also reported by Raslan et al., and therefore should be chosen only where healthcare services have sufficient resources to provide nutritional assessment and intervention programmes for all patients detected to be ‘at risk for malnutrition’. Similar arguments were also made by other authors. Hospital management and clinicians should consider use of screening tools that are simple to implement and handle and tailor the screening and nutritional care process according to structures and resources available. Considered from these points of view, the GMS is a valid and easy-to-handle malnutrition risk screening tool, which may also be implemented in hospital IT systems.In patients older than 70 years, the detection rate for risk of malnutrition using the GMS was quite comparable with results obtained using the NRS. This provides evidence for good criterion-related validity. Furthermore, accuracy of the GMS and NRS was 0·88, whereas accuracy value of the GMS and MNA-sf was 0·85. This indicates that there is a very high agreement between the GMS and these pre-existing validated nutritional screening tools. These findings are quite promising as several groups showed a rather fair agreement between MNA-sf and other screening tools such as the SGA in different cohorts–42. κ values for the single items of the GMS ranged from 0·6 to 1·0, whereas the value of the total GMS scale was 0·82, which may be considered a highly sufficient reliability indicator for the test. Some items of the GMS scale showed higher inter-rater agreement values than others. Three items including BMI, severity of disease and age reached agreement of 1·0. These items are very ‘objective’ items, which vary only marginally or not at all as in the present sample. The measures of weight and height were performed in close time schedules between two raters. Data concerning changes in nutritional intake through loss of appetite, problems with chewing or swallowing or nausea/vomiting/diarrhoea were collected through interviewing patients. These subjective questions resulted in lower κ values from 0·60 to 0·63, which still reflects high agreement between the two raters. The blinded and randomised design of our study, including the activities of the various dietitians who carried out the interviews with the patients in the cohort of the GMS, underscores the effectiveness in terms of validity and reliability of the GMS as a malnutrition risk screening tool for daily practice in a large university hospital.Another factor influencing the efficacy of a screening test system is the reliability of the screening tool. In our study, we observed nearly ‘perfect’ results regarding equivalence and reliability of the GMS when compared with NRS and MNA-sf. Cohen’s . Up until now, these attitudes have not changed significantly. One reason for low acceptance of screening tools by professionals is lack of time. Nutritional screening is often seen as a time-consuming procedure with few consequences in a busy hospital. As effects of nutritional interventions are often not assessable during short periods of admission to acute care, NRS may be easily neglected. On the basis of the experience gained from several studies, there seems to be a scarcity of nutritional knowledge among hospital staff and a lack of dietitians who are routinely present at the wards. It is therefore essential to develop a malnutrition risk screening tool with high accuracy in the prediction of individual malnutrition risk that is also easy to handle, and may therefore be accepted by most of the hospital staff. It must be easy to integrate into locally pre-defined work flows of the various hospital departments and must link dietitians into the patient-care process to optimise translation of information between different medical and healthcare professions working in the hospital setting. The GMS addresses all these requirements and is today well accepted by hospital staff as can be seen by the high professional fulfilment of the staff in routine day-to-day patient record keeping.When introducing new tools into clinical practice, one also considers factors influencing effectiveness of test systems. It has been demonstrated long ago that awareness regarding malnutrition among hospital staff is rather low,44. (–). In our sample, malnutrition risk prevalence according to GMS was highest in age-group three (70+ years) with 41–45 % at risk compared with 26–29 % in age group two (45–70 years) and 19–22 % in age-group one (18–44 years). These data underline the importance of hospital risk screening tools for addressing malnutrition and the need to close inter-professional ‘gaps’ in the treatment plan and options in the acute-care setting. As a malnutrition screening tool refers only to the detection of ‘risk of malnutrition’ in patients admitted to the hospital, there is a great need for subsequent assessment and treatment. The use of risk screening alone does not necessarily result in improved outcomes unless there is a care pathway for malnourished patients or patients being at risk of malnutrition. For this reason, the Nutrition Team of the University Hospital Graz developed an associated clinical pathway to standardise nutritional care in malnourished patients. In this concept, electronic data of patients screened positive for risk of malnutrition are transferred to a dietitian through the computer system. The set-up and implementation system chosen for risk screening strongly influence acceptance by healthcare professionals. Nowadays, nurses and doctors are accustomed to documenting their work electronically. A screening tool that is efficiently implemented into the hospital IT platform, and therefore individual care plan, will raise the acceptance of hospital staff as compared with the pencil and paper format. It is therefore reasonable to expect that GMS will increase awareness of medical staff towards the challenge of malnutrition in hospitalised patients. Further studies will provide proof on that concept.Using the current test setting, we could show prevalence for the risk of malnutrition in patients admitted to our university hospital, which is comparable with recent publications. An overall prevalence rate of about 30 % according to the GMS and 25 % according to the NRS goes along with previous clinical studies on prevalence of malnutrition in hospital inpatients. Higher prevalence rates in internal wards are also described in a range of publications as well as the fact that prevalence of malnutrition increases with age–6. IIn conclusion, the GMS tool proves to be a valid and reliable instrument to detect risk of malnutrition in adult inpatients in acute-care hospitals. The GMS is easy to handle and provides reliable individual and overall results. GMS may be embedded in the hospital IT platform, and therefore provides short clinical pathways between different professions involved in the care process.


Early infant male circumcision (EIMC) conducted by nurse-midwives using the AccuCirc device proved safe, feasible, and acceptable to parents in Zimbabwe. The AccuCirc device has the potential to facilitate widespread scale-up of safe EIMC in sub-Saharan Africa. Early infant male circumcision (EIMC) conducted by nurse-midwives using the AccuCirc device proved safe, feasible, and acceptable to parents in Zimbabwe. The AccuCirc device has the potential to facilitate widespread scale-up of safe EIMC in sub-Saharan Africa. For prevention of HIV, early infant male circumcision (EIMC) needs to be scaled up in countries with high HIV prevalence. Routine EIMC will maintain the HIV prevention gains anticipated from current adult male circumcision initiatives. We present here the results of a field study of EIMC conducted in Zimbabwe.The study was observational and based on the World Health Organization (WHO) framework for clinical evaluation of male circumcision devices. We recruited parents of newborn male infants between August 2013 and July 2014 from 2 clinics. Nurse-midwives used the AccuCirc device to circumcise eligible infants. We followed participants for 14 days after EIMC. Outcome measures were EIMC safety, acceptability, and feasibility.We enrolled 500 male infants in the field study (uptake 11%). The infants were circumcised between 6 and 60 days postpartum. The procedure took a median of 17 minutes (interquartile range of 5 to 18 minutes). Mothers’ knowledge of male circumcision was extensive. Of the 498 mothers who completed the study questionnaire, 91% knew that male circumcision decreases the risk of HIV acquisition, and 83% correctly stated that this prevention is partial. Asked about their community’s perception of EIMC, 40% felt that EIMC will likely be viewed positively in their community; 13% said negatively; and 47% said the perception could be both ways. We observed 7 moderate or severe adverse events . All resolved without lasting effects. Nearly all mothers (99%) reported great satisfaction with the outcome, would recommend EIMC to other parents, and would circumcise their next sons.This first field study in sub-Saharan Africa of the AccuCirc device for EIMC demonstrated that EIMC conducted by nurse-midwives with this device is safe, feasible, and acceptable to parents. As the WHO “Framework for Clinical Evaluation of Devices for Male Circumcision”,In August and September 2013, doctors trained 4 study nurse-midwives over the course of 5 days to use the AccuCirc device. The trainers had previously performed circumcisions for the Zimbabwe EIMC comparative trial, described in detail elsewhere.Mothers and infants were enrolled between August 2013 and July 2014 at Edith Opperman and Mabvuku, 2 polyclinics in Harare, with 400 and 250 deliveries per month, respectively.We collected data on eligibility criteria from all mothers and infants. Maternal eligibility criteria were: (1) ability to attend follow-up appointments at the study clinic through 2 weeks postpartum, (2) readiness to provide a home address, and (3) written informed consent. Only infants ages 6 to 60 days were eligible. Although WHO guidelinesBefore enrollment, study staff performed a physical examination to exclude infants with abnormalities precluding circumcision. We referred to a specialist all 10 infants who were ineligible due to genital abnormalities. The 4 trained nurse-midwives (2 at each study clinic) performed all the circumcisions, assisted by 2 registered general nurses. To minimize bleeding, all infants received vitamin K (1 mg) an hour before the procedure. Additionally, all infants had approximately 1 gram of EMLA Cream  applied to the outer foreskin and shaft of the penis about 45 minutes before the procedure. Administration of vitamin K and the anesthetic is part of standard operating procedures for conducting EIMCs and not specific to the AccuCirc device.We assessed achievement of anesthetic effect by holding the foreskin using artery forceps. If there was no pain response from the infant, subsequent steps would commence. Otherwise, providers would wait until the EMLA Cream had achieved anesthetic effect . When the EMLA Cream had achieved anesthetic effect, the surgical area was cleaned with povidone-iodine. Physiologic adhesions between the foreskin and the glans were released by manual technique using the flexible foreskin probe that comes with the AccuCirc kit. The nurse-midwife then marked the circumcision site (around the corona) with a surgical pen that is also part of each AccuCirc kit. The pen mark helps to minimize excessive or insufficient skin removal.www.accucirc.com) and as recommended by the study previously conducted in Botswana.,,In addition to the flexible foreskin probe, the AccuCirc device consists of a shielding ring plus a single-action clamp  that contains a circular blade. It is available in 2 sizes: 1.1 cm and 1.3 cm (penile diameter).Follow-up appointments at the clinic took place at days 2, 7, and 14 after circumcision. At these visits, nurse-midwives asked parents about complications. The EIMC providers also conducted physical examinations of the infants, including inspection of the circumcision site. Seven days after the procedure we asked parents their views on the acceptability of circumcision.Outcome measures for the field study were (1) EIMC safety, (2) acceptability, and (3) feasibility. Safety was indicated by the number of moderate and severe adverse events (AEs). EIMC-related AEs were categorized as bleeding, infection, inadequate or excessive skin removal, or penile injury  . We reco,We asked parents to rate their satisfaction with and acceptability of the procedure on a numerical scale ranging from 0 (dissatisfaction) to 10 (very satisfied). Satisfaction was defined as a score between 6 and 10. We also asked parents to rate on a scale of 0 to 10 the likelihood that they would recommend EIMC to friends or relatives. A score of 0 was classified as “would not recommend” and 10 as “would definitely recommend.” Feasibility was defined as spending the least amount of effort on a procedure and gauged by the time that the nurse-midwives needed to perform EIMC using AccuCirc (timed using a stopwatch plus video recording of each procedure), and the ability of nurse-midwives to safely perform the procedure. We considered15 to 30 minutes a “feasible procedure time,” based on the typical time spent in previous studies of the AccuCirc device.We chose a sample size of 500 subjects, as specified by the WHO “Framework for Clinical Evaluation of Devices for Male Circumcision.”We used Stata 13  to perform statistical analyses. We summarized characteristics of parents and infants, including socio‐demographic characteristics, father’s reported circumcision status, and circumcision and HIV knowledge and attitudes. To evaluate the safety of the procedure, we calculated the proportion of procedures associated with AEs and the associated 95% CI. We calculated similar proportions and 95% CIs for the parental acceptability outcomes. To assess feasibility, we calculated the mean time for the procedure and an associated 95% CI.The Medical Research Council of Zimbabwe and the ethics committees of University College London and the London School of Hygiene and Tropical Medicine approved the study. We obtained written informed consent from the infant’s mother and verbal consent from the infant’s father (if available) before enrollment. After the procedure, mothers received a 20-liter plastic bucket, 2 bars of washing soap, a 100-ml bottle of Vaseline (for wound care), and 3 disposable diapers . At each scheduled clinic visit, mothers also received the equivalent of US$5 for bus fare.To enroll 500 infants in the field study, we approached 4,617 parents of newborn male infants. Thus, the uptake rate was 11% . Some 4,107 parents (89%) declined to participate. Reasons for refusal included fear of harm and sociocultural considerations.The median age of male infants at the time of circumcision was 22 days  . Eighty-Approximately 40% of fathers were reportedly circumcised. Among mothers whose partner was not circumcised, 80% would like their partner to be circumcised.Completing the procedure took a median of 17 minutes . Mild post-circumcision bleeding occurred in 49 male infants (10%). For 46 of these infants (94%), simple pressure stopped this bleeding. Three cases of bleeding could not be stopped by simple pressure. We classified these as moderate or severe procedure-related AEs; we detail these cases below.Completing the procedure took a median of 17 minutes.We observed 7 AEs  . These iModerate or severe adverse events occurred in 7 of 500 circumcisions.The 1 case of moderate bleeding required clamping of the bleeding vessel with forceps and an acetylated glucosamine dressing at the time of the procedure. The 2 cases of severe bleeding required hospitalization. In 1 case, the infant bled immediately post-circumcision. The bleeding was controlled with pressure but started again at home, and he was referred to a hospital. Three sutures were required to stem the bleeding. The other case of severe bleeding was in an infant who had a family history of hemophilia (unreported and undetected at the time of the procedure). The infant was given a blood transfusion (200 ml). He was hospitalized for 3 days.One male infant left the study 2 days after the procedure without any formal follow-up visits. This infant developed an acute respiratory infection after the procedure was performed and died 36 hours post-EIMC. The respiratory infection was due to an outbreak of severe bronchiolitis and was deemed unrelated to the EIMC procedure.All mothers who answered the question on satisfaction with EIMC (n = 498) reported being satisfied with the outcome (scores  =  6 to 10), with 491 (99%) reporting that they were very satisfied (scores  =  8 or greater). Nearly all mothers  said they would recommend EIMC to other parents and would circumcise their next newborn son . Among fathers who answered the question on satisfaction with EIMC, all 112 gave a score of 6 or greater. Nearly all the fathers would recommend the procedure to a friend  and would have a future son circumcised  . The mosWe have implemented the first field study in sub-Saharan Africa of EIMC conducted by nurse-midwives using the AccuCirc device. We found that the procedure is safe, feasible, and acceptable to parents who choose it for their infant sons.,,,,,,,Overall, the rate of AEs was low and similar to those reported in the 2 previous AccuCirc studies conducted in BotswanaSimilar AE rates for physicians and nurse-midwives suggest that it is safe and feasible to roll out EIMC using non-physician providers.Nonetheless, the fact that we encountered 2 cases of severe bleeding (including a case of unreported hemophilia) that required hospitalization for monitoring and management has important implications for EIMC planning and subsequent roll-out:Although EIMC can be offered at the lowest-level health facilities, there should be easily accessible backup services to deal with any life-threatening complications .Intensive screening and history-taking before the procedure are required in order to exclude any infants with a family history of bleeding disorder.Screening for other non-circumcision-related health issues is necessary to ensure that infants who are circumcised are clinically well.The infant mortality rate is high in sub-Saharan Africa. Recent Zimbabwe Demographic and Health Survey findings suggest that infant and neonatal mortality rates are 57 and 31 deaths per 1,000 live births, respectively.,,As in the Zimbabwe comparative trial,Actual uptake of the procedure—11%—was lower than previously suggested by hypothetical acceptability studies.,,,Sustained uptake and acceptability will depend greatly on perceptions of the safety and aesthetic aspects of EIMC.,Most women who sought EIMC for their sons were knowledgeable about male circumcision and its HIV-preventive benefits. Our findings corroborate those from previous studies on the hypothetical acceptability of VMMC and EIMC; these studies found that this knowledge is likely to be associated with uptake.-A few women  felt that EIMC will likely be viewed negatively in their community. Hypothetical acceptability studies have suggested that fear of their son’s future social exclusion, including ostracism, derision, and rejection, may discourage parents from opting for EIMC.Current initiatives that portray VMMC as a lifestyle choice likely are playing a critical role in changing community norms.-EIMC may provide a rare opportunity to reach fathers via health care facilities. In this study, for example, about one-third of fathers accompanied their sons to the EIMC clinic. Otherwise, men are known to be hard to reach via health services.It may be possible to use EIMC as a platform to strengthen other maternal and child health programs and to promote other health interventions to men.The sample size of this field study was guided by the WHO “Framework for Clinical Evaluation of Devices for Male Circumcision,”We circumcised 500 male infants in a field study of the AccuCirc device for EIMC in Zimbabwe. We found that EIMC can be safely and acceptably offered by nurse-midwives using the AccuCirc device. The AccuCirc device has the potential to facilitate widespread scale-up of safe EIMC in sub-Saharan Africa.


Microcirculatory dysfunction impairs tissue oxygenation during sepsis. We applied near-infrared spectroscopy (NIRS) to evaluate the tissue oxygen extraction rate in sepsis and its relationship with outcome.2 target) at admission to the ICU. Healthy volunteers (n = 27) were studied as controls. The slope of the desaturation curve was assessed separately for the first (StO2 down1) and the last part (StO2 down2) of the curve and the difference between, Down2 - Down1, was calculated.A prospective observational study; 14 septic patients underwent NIRS monitoring (thenar eminence) with a vascular occlusion test ; no difference was seen between ICU survivors (n = 7) and nonsurvivors (n = 7). StO2 Down2 was similar between healthy volunteers and ICU survivors, while it was higher in nonsurvivors . ICU nonsurvivors showed higher Down2 - Down1 as compared with ICU survivors (P < 0.01, Figure StO2 downslope did not show any difference between survivors and nonsurvivors. This may reflect a tissue hypometabolic status, which may be better elicited in the final part of the ischemic challenge.Tissue oxygen extraction was reduced in septic patients. Nonsurvivors showed a flattening in the last part of the desaturation curve during a VOT, while the first part of the StO


Aim: Regarding tuition fees  putative drawbacks like prolonged study duration have been suspected while benefits are not clearly proven. We investigated whether tuition fees (500 Euro per semester) affected the course of studies of Cologne medical students and asked for students’ stance over tuition fees.Methods: Of 1,324 students we analyzed the rate of those passing their first medical exam (“Physikum”) within minimum time and students’ discontinuation rate, respectively. Regression analysis tested for putative influences of tuition fees and demographic factors. In an additional online survey 400 students answered questions regarding the load by and their stance over tuition fees.Results: We find that fees did not affect rate of Cologne students passing their first medical exam within minimum time or students’ discontinuation rate. According to the online survey, at times of tuition fees significantly more students did not attend courses as scheduled. Time spent on earning money was significantly increased. 51% of students who had to pay tuition fees and 71% of those who never had to stated tuition fees to be not justified. More than two thirds of students did not recognize any lasting benefit from tuition fees.Conclusion: Tuition fees did not affect discontinuation rate or study duration of Cologne medical students. However, they obviously influenced the study course due to an increased need to pursue a sideline. Cologne medical students rather refused tuition fees and did not recognize their advantages in terms of enhanced quality of studies. In many but not all countries, students have to pay fees for their studies. While for example in the U.S.A. tuition fees are an inherent part of the educational system this is not the case in many European countries , 2]. In. In2]. IWe wanted to investigate whether tuition fees of rather moderate amount had an effect on course and success of medical studies. Furthermore, we conducted a prospective online survey to ask medical students about their stances over tuition fees and whether they have been burdened by this duty. In addition we wanted to test for putative effects of stance and/or (perceived) burden on students’ study course and putative effects of tuition fees on students’ study course and stance over these fees.In accordance with the German Medical Licensure Act (“Approbationsordnung”) the reformed medical curriculum in Cologne is divided into three parts and takes at least six years (12 semesters) in total, similar to regular medical curricula . The firAssessment results and study progress of medicals students at the University of Cologne are documented and administrated in the local campus management system. By analyzing data from subsequent cohorts, we calculated the rate of students finishing their preclinical studies in the minimum time period, and the number of students per cohort leaving the university (dropout rate) during their preclinical studies . Using ath 2013 to February 20th 2014. Some items were only presented to those students who stated that they had paid tuition fees in the past. A translated version of the applied questions is available as an online supplemental. Survey data were analysed descriptively or in comparison depending on whether only students who had to pay tuition fees or all students should answer the particular questions.By e-mail we invited all medical students enrolled at our Medical Faculty at the time of our study to attend a survey that was offered online via the e-learning platform ILIAS. The self-developed items aimed at students’ views on tuition fees and their impact on students’ course of studies [see attachment ]. Answers had to been given using a five-point Likert scale  or simply by affirmation (“yes”) or rejection (“no”). The survey was available online from December 17Data of eight cohorts (enrolment from winter term 2008/2009 until summer term 2012) were included into the analysis of course of studies, covering 1,324 students in total. Three cohorts paid 500 € per semester throughout their preclinical studies , three cohorts had paid tuition fees for three, two or one term, respectively . Two cohorts never had to pay tuition fees during their studies.The invitation to attend the online survey was sent via e-mail to all students regularly enrolled at our Medical Faculty at the time of our study .2 tests, Spearman correlations and a binary regression analysis we investigated how tuition fees, gender, age, nationality, and grade of general qualification for university entrance might have influenced course of study and dropout rates, respectively.Regarding course of studies and dropout rate we only analyzed the “preclinical” part of medical studies  since dropout rates are negligible during the clinical part of medical studies. As endpoints we defined “kept minimum time of four terms to finish preclinical studies“  and “left university during first two years of study” . Based on ChiAll data were collected and analyzed anonymously. The Ethics Committee of the University of Cologne raised no concerns regarding this study or the publication of the results (reference No. 15-377).The rate of students needing only the minimum study period in the preclinical phase did not differ significantly between the observed cohorts   or the three groups mentioned above , respectively . Regarding gender, nationality or age there was no difference between our sample and the entire population. Therefore, we consider our sample to be representative regarding these attributes. The online survey revealed that the percentage of students with parents having a university degree and students with parents without university degree was similar for tuition fee payers and non-payers (72%). When asked how tuition fees were paid, 40% of the respondents stated to have jobbed while studying and 17% to have taken out a loan to pay tuition fees. At times of tuition fees, 74% of the jobbers stated to have worked more than 11 hours per week, while after abrogation of tuition fees this fraction dropped to only 46%. Nearly half of the payers (44%) responded that working was one of the reasons for extending the standard study period. Less than a third of non-payers (28%) but approximately half of payers (49%) indicated to have switched (i.e. delayed or preponed) courses for at least one semester   stated that tuition fees in medical studies are not or rather not justified . Interestingly, 70% of the payers stated that the quality of the studies did not improve considerably at times tuition fees were raised. Only 29% of non-payers and 27% of payers thought that the study environment had effectively improved by tuition fees.In this study we find that tuition fees of 1,000 € per year did not affect proportion of Cologne medical students studying in minimum time nor fraction of students quitting their studies early. There was a moderate but statistically significant effect on how students organize their schedules (i.e. preponing or delaying courses). At times tuition fees were raised, students spent more time on earning money. The majority of students attending our survey had a rather negative attitude towards tuition fees. Interestingly, this was more common among students who did not have to pay tuition fees at all.In public and media it is often claimed that tuition fees would keep graduates with a low socio-economic background from enrolling in higher education. In fact, this seems not to be the case in Germany , 11], b, b11], bAdvocates of tuition fees often point to the quite high fraction of enrolled students with a low socio-economic background in the U.S.A. despite tuition fees being significantly higher than in Germany . HoweverAnother objection frequently raised is that students have to spend additional time on earning money to cover tuition fees and this has negative effects on successful graduation. Eventually, this might lead to a delay or even an abortion of their studies. In our study, hours worked per week indeed increased at time of tuition fees but this did neither affect duration of preclinical studies nor dropout rates. This might be explained by the finding that moderate tuition fees rather reduce leisure time than intensity of studies . Assuminhttp://kiss.uni-koeln.de], the office of the students’ council, and recreation rooms for students was largely funded by tuition fees. A one-week practical course for 5th year students offering amongst others a simulation ward and a student-to-staff ratio of 6 on average could only be initiated due to tuition fees – and since its implementation it ranks among the courses evaluated best by the students [Advocates of tuition fees argue that tuition fees would help to enhance quality of studies. To the authors’ knowledge there is no clear-cut evidence for this. In fact one should expect that the effect of tuition fees is inherently linked to the reason why these fees are demanded. For example, tuition fees might be used to compensate for increased expenditure necessary to maintain the status quo. Thus, one should not expect that tuition fees are inevitably associated with increased quality of studies. In Canada student-to-staff ratio as a frequently used measure of study quality rose by 20% although tuition fees continuously increased . In Colostudents . That deThe return rate in our online survey was only about 18%, though this is in an expected range regarding this kind of survey (e.g. ). AnotheTuition fees did not affect discontinuation rate or study duration of Cologne medical students. However, fees obviously influenced the study course due to an increased need to pursue a sideline. Abrogation of these fees  likely rules out many measures that aim at enhancing quality of medical studies (see above and for example ). To enhWe thank Mrs. Inka Meyer-Widynski for her help with data acquisition.The authors declare that they have no competing interests.


Conventional saturation pulses cannot be used for 7 Tesla ultra-high-resolution time-of-flight magnetic resonance angiography (TOF MRA) due to specific absorption rate (SAR) limitations. We overcome these limitations by utilizing low flip angle, variable rate selective excitation (VERSE) algorithm saturation pulses.Twenty-five neurosurgical patients  with different intracranial vascular pathologies were enrolled in this trial. All patients were examined with a 7 Tesla  whole body scanner system utilizing a dedicated 32-channel head coil. For venous saturation pulses a 35° flip angle was applied. Two neuroradiologists evaluated the delineation of arterial vessels in the Circle of Willis, delineation of vascular pathologies, presence of artifacts, vessel-tissue contrast and overall image quality of TOF MRA scans in consensus on a five-point scale. Normalized signal intensities in the confluence of venous sinuses, M1 segment of left middle cerebral artery and adjacent gray matter were measured and vessel-tissue contrasts were calculated.Ratings for the majority of patients ranged between good and excellent for most of the evaluated features. Venous saturation was sufficient for all cases with minor artifacts in arteriovenous malformations and arteriovenous fistulas. Quantitative signal intensity measurements showed high vessel-tissue contrast for confluence of venous sinuses, M1 segment of left middle cerebral artery and adjacent gray matter.The use of novel low flip angle VERSE algorithm pulses for saturation of venous vessels can overcome SAR limitations in 7 Tesla ultra-high-resolution TOF MRA. Our protocol is suitable for clinical application with excellent image quality for delineation of various intracranial vascular pathologies. In recent years, time-of-flight magnetic resonance angiography (TOF MRA) elmleeUltra-high-field magnetic resonance imaging (MRI) at 7 Tesla is currently being introduced in clinical application The study was conducted according to the principles expressed in the Declaration of Helsinki and was approved by the local university institutional review board (Ethik-Kommission der medizinischen Fakultät der Universität Duisburg-Essen). Written informed consent was obtained before each examination.This prospective study evaluated the diagnostic ability of high-resolution 7 Tesla TOF MRA for various intracranial vascular pathologies . The study group comprised of 25 neurosurgical patients . Inclusion criteria were: 1) single or multiple intracranial vascular pathologies, 2) age 18–80 years, 3) ability to give informed consent and 4) legal competence. Exclusion criteria were: 1) monitoring on intensive care or intermediate care unit 2) cardiac pacemakers or any other electronic implants, 3) metallic implants, 4) pregnancy or breast feeding period, 5) claustrophobia and 6) chronic or episodic vertigo.All images were acquired on a 7 Tesla whole-body MRI system  equipped with a 32-channel Rx/Tx head coil . The scanner has a gradient system of 45 mT/m maximum amplitude and a slew rate of 200 mT/m/ms.0 shimming was performed using a vendor-provided gradient echo sequence and an algorithm based on the work of Schar1 field mapping and local flip angle optimization. Following slice-selective excitation, two refocusing pulses sequentially generate a spin-echo and a stimulated echo. Transmitter adjustment volume was placed in the center of the brain leading to an average flip angle variation of less than 20% in the superior sagittal sinus. Spatial coverage of the TOF MRA slab and the saturation pulse is demonstrated on a sagittal localizer scan of a 40-year-old male patient suffering from a large right parietal AVM . The variable-rate selective excitation (VERSE) algorithm SAT = 35° instead of 90° which is normally used) to face SAR constraints The TOF MRA sequence is based on a 3D FLASH sequence with flow compensation and tilt-optimized non-saturated excitation (TONE) across the slab SAT, of the saturation pulses was set to nominally 35°  as suggested in our previously published paper Modified saturation pulses were used to suppress the venous system within the slab and above including the superior sagittal sinus. To reduce total measurement time, the RF pulse and the following spoiler gradient were made shorter (2.3 ms [chosen duration before VERSE was applied]/4 ms instead of 4 ms/11 ms). To reduce SAR of the RF pulses, the VERSE algorithm was used on the saturation pulses with a 30% cut-off threshold. The flip angle, αImage evaluation was performed in consensus by two experienced neuroradiologists on standard post-processing Picture Archiving and Communcation system workstations . Visual evaluation was performed on 3D image reconstructions and on the source images in axial orientation.For qualitative analysis the following features were evaluated, utilizing a five-point scale :Delineation arterial vessels in Circle of WillisDelineation of vascular pathologiesPresence of artifactsVessel tissue contrastOverall image quality1 inhomogeneities, inter-scan variability of signal intensities caused by e.g. different transmitter voltage, head size and other factors is successfully minimized ijdenbos . MINC is a medical imaging data format and associated set of tools and libraries developed at the Montreal Neurological Institute and freely available online (http://www.bic.mni.mcgill.ca/ServicesSoftware). After preprocessing quantitative signal intensity measurements were then performed by region-of-interest (ROI) analysis using the interactive display tool “fslview” . Vessel-tissue contrast ratio Prior to quantitative measurements, signal intensities of all scans were normalized. The image histogram of each subject was stretched, and shifted to match the baseline histogram of subject 1. Although this method does not correct for intra-subject BDifferences of continuous scaled variables were tested by Student's t-test. For every mean value the standard error of mean  using 35° flip angles for saturation pulses. Thirteen patients with a total of 19 intra-cranial unruptured aneurysms were enrolled in the study . Consensus ratings were excellent for delineation of Circle of Willis , excellent for vascular pathology delineation , excellent for vessel-tissue contrast , good for presence of artifacts  and excellent for overall image quality . The applied venous saturation pulses resulted in vessel-tissue contrast ratios as follows: mean VTCR_CoS = 0.45 ; VTCR_MCA = 0.667 .petzler-MartinFour patients with intracranial AVM were enrolled in the study . Consensus ratings were excellent for delineation of Circle of Willis , excellent for vascular pathology delineation , good for vessel-tissue contrast , good for presence of artifacts  and excellent for overall image quality . The applied venous saturation pulses resulted in vessel-tissue contrast ratios as follows: mean VTCR_CoS = 0.353 ; VTCR_MCA = 0.706 . Venous saturation was lower compared to other pathologies due to inherent features of AVMs, in particular the arterialized venous drainage. Decreasing volume of arterialized draining blood flowing through the saturation slab increases signal intensity. Patient 4 suffered of a right parietal parasagittal fistulous AVM. Signal intensity in the upper part of the sagittal sinus next to the outlet of the draining vein was equal to signal intensity of left middle cerebral artery M1 segment. In the confluence of venous sinuses signal intensity was lower than in the neighboring occipital gray matter . Consensus ratings were moderate for delineation of Circle of Willis , excellent for vascular pathology delineation , excellent for vessel-tissue contrast , good for presence of artifacts  and good for overall image quality . The inherent features of Moyamoya angiopathy with slim and sometimes completely blocked arteries in the Circle of Willis and complex collateral circulation especially in surgically treated patients resulted in only moderate ratings for delineation of the Circle of Willis. The applied venous saturation pulses resulted in vessel-tissue contrast ratios as follows: mean VTCR_CoS = 0.41 ; VTCR_MCA = 0.693 . Two patients with arteriovenous fistulas were enrolled in the study . Consensus ratings were excellent for delineation of Circle of Willis , moderate and good for vascular pathology delineation , moderate for vessel-tissue contrast , good for presence of artifacts  and good for overall image quality . The applied venous saturation pulses resulted in vessel-tissue contrast ratios as follows: mean VTCR_CoS = 0.131 ; VTCR_MCA = 0.678 . As in AVM patients venous saturation was lower compared to other pathologies due to inherent features of dural AVFs, in particular direct shunting of arterialized blood into the venous sinuses. High signal intensity of arterialized blood is similar to signal intensity of the left middle cerebral artery M1 segment. Signal intensity of venous sinuses decays the further away from the fistula point it is measured. The special features of dural AVF in 7 Tesla TOF MRA scans are exemplarily illustrated  in a 58-Time-of-flight MRA is a non-invasive imaging technique using FLASH gradient-echo magnetic resonance sequences to visualize the contrast between the high signal intensity of inflowing blood and saturated stationary tissue. TOF MRA utilizing 1.5 Tesla has been established as an excellent clinical diagnostic method for pre-operative and pre-interventional planning as well as for follow-up controls in cerebro-vascular pathologies, and has gained ground on the accepted gold standard, invasive digital subtraction angiography.oenninghoff et al. presented a high-resolution 7 Tesla TOF MRA protocol for clinical application including venous saturation pulses. To maintain SAR limitations, time-of-repetition (TR) had to be increased up to 57 ms, resulting in an increase in acquisition time to almost 15 minutes for comparable spatial coverage as the presented protocol. The previously suggested solution The increase of the magnetic field strength from 1.5 Tesla to 3 Tesla has been proven beneficial for clinical neuroimaging and feasible for ultra-high-field 7 Tesla MRI, facilitating a significant increase in spatial resolution The impairment of venous saturation at ultra-high field strength is mainly due to SAR limitations that prohibit the usage of venous saturation pulses within reasonable acquisition times.One proposed solution to overcome SAR limitations is to play out a regular 90° saturation pulse only every n-th readout of the k-space Only in patients with AVMs and AVF, venous saturation was reduced compared to other pathologies. This was presumably due to the inherent features of both pathologies, specifically the fast blood flow of venous drainage. In addition, only part of the AVMs were within the field of saturation pulses and consequently unsaturated blood was drained over the veins. Even though the venous saturation was reduced in these patients, the application of saturation pulses could still partially suppress the signal of draining veins with an overall good image quality.ognard1-weighted images. Future patients suffering of AVF will be examined with and without venous saturation pulses to further investigate the diagnostic potential of this effect.The high diagnostic relevance of saturation pulses in combination with ultra-high-resolution TOF MRA is exemplarily shown in the case of Subject 12 . The comConsensus ratings of two experienced readers ranged between good and excellent for the majority of patients and most of the evaluated features. In combination with short acquisition time and possibility to visualize the complete intracranial arterial vasculature with ultra-high resolution the presented TOF MRA protocol is suitable for clinical application.Clearly, this study is not free of limitations. The study group comprised of patients suffering from various intracranial vascular pathologies and therefore patient numbers for individual pathologies are small. Nevertheless, to the authors knowledge this is one of the largest neurosurgical patients cohorts scanned with TOF MRA at 7 Tesla, published in literature. Further investigations with larger patient cohorts of single pathologies should be the focus of future studies. Ultra-high-field imaging in patients who underwent treatment has been restricted so far, as Guglielmi detachable coils, aneurysm clips, most cranial fixation plates and other metallic implants are not certified for 7 Tesla MR imaging. Although preliminary results on implant safety in cerebral 7 Tesla MRI have been recently demonstrated In summary, this study presents the clinical application of the previously reported practical solution for saturation pulses in 7 Tesla ultra-high-resolution TOF MRA that maintains SAR levels within the accepted safety standards combined with short acquisition times


Research derived from the stress paradigm suggests that certain types of coping  are protective against problem-related drinking to deal with social stressors. Going beyond the typical focus in the coping literature, we hypothesize that stressors engendered by macrolevel social forces may require coping actions within the political realm in contrast to modes of coping focused outside of the political realm. A United States sample of 663 respondents completed a mail survey in 2010, including measures of stressful consequences of the Great Recession, drinking patterns and problems, modes of coping encompassed in the Brief COPE instrument, and politically oriented coping. Structural equation modeling examined whether modes of coping mediated the links between stressors and drinking outcomes. A substantial portion of the associations between stressors and drinking was explained by modes of coping. Politically oriented coping was protective against problem drinking for both genders. Future studies should further explore politically oriented coping in addition to modes of coping outside of the political realm when studying the relationships between macrolevel social stressors and deleterious drinking outcomes. Social scientists who explore factors mediating and moderating the relationships between social stressors and mental health, including drinking outcomes, have highlighted modes of coping , 2. ThesA key issue involving the effectiveness of alternative modes of coping with stressors derived from macrolevel social forces and protecting against deleterious drinking outcomes is the question of whether individual modes of coping outside of the political realm emphasized in the overall coping literature are most efficacious. Or, alternatively, do stressors engendered by macrolevel social forces require unique forms of coping, that encompass the political realm? With respect to coping strategies employed in the wake of the Great Recession, politically oriented coping strategies might be of particular relevance due to the impact of governmental decision-making on the state of the economy. Politically oriented coping strategies might include political activism oriented to altering economic policies or support for campaigns by politicians offering solutions to economically based hardships. Scholarly work on the Occupy Wall Street movement, for example, documents involvement by individuals sharing their own economic struggles  and collWhile sociologists have recently accorded greater attention to the prevalence and alcohol-related consequences of macrolevel stressors, they have yet to address the extent to which politically oriented modes of coping may be the most efficacious ways to address problems stemming from macrolevel social forces or events. Prior to the more recent focus on macrolevel stressors, Kaplan and Liu  embracedThe present study extends previous work by empirically addressing the extent to which politically oriented coping activities engaged in as a response to a macrolevel social stressor, the Great Recession, are protective against alcohol-related outcomes compared with coping strategies focused outside of the political realm. We hypothesize that politically oriented coping will be more protective against economic stressors linked with the Great Recession than nonpolitical modes of coping and will uniquely account for some portion of the associations between economy-related stressors and drinking outcomes.Further, we also examine whether politically oriented coping and coping outside of the political realm are more protective for men versus women in the face of macrolevel engendered stressors such as those involving the economic fallout from the Great Recession. There is consistent evidence that women are more likely to use support-based coping strategies  in response to stress in contrast to men and some indication that avoidant coping techniques are associated with greater alcohol consumption among men but not women , 20–22. Data were derived from a study conducted in the United States between June, 2010, and January, 2011, that was undertaken in order to understand life change consequences of the major downturn in the economy known as the Great Recession. Respondents were selected by a random digit dial (RDD) phone survey of the continental United States, and those who consented to participate in the study were mailed questionnaires. The phone screener was conducted using computerized assisted telephone interview (CATI) software. Eligibility criteria involved being aged 18 years or older and English-speaking. Eligible respondents were selected from the households using the Troldahl-Carter-Bryant method of respondent selection which involves the means to randomly select a respondent from all eligible household members . Respondn = 663) of the respondents completing the screening calls returned the questionnaire. The telephone screening cooperation rate and the mail survey response rate were each calculated using the conservative AAPOR response rate formula 3 [A total of 7,775 telephone screening calls were initially made. ormula 3 . The oveThe final sample obtained was weighted in two ways. Selection weights were calculated for each of the cases to weight for the different probability of selection for each case. Poststratification weights were calculated for the dataset to ensure that the distribution of sample cases on important demographic variables  conformed to the distribution of these variables in Census Bureau's 2008 United States Population Estimates. It should be noted that estimates of alcohol consumption for the present sample did appear to conform to national estimates preweighting. For example, the average number of drinks consumed in the past month on days when one drank for the present sample is 2.16, versus the estimated average of 2.10 reported by the Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System for 2010  (by gendP < 0.10) to use active coping strategies compared to those with a college degree or postcollege training. Given this discrepancy as well as the fact that education is generally protective against problem drinking, education is included as a control variable in all of the analyses presented.It should additionally be noted that the respondents included in this sample reported an overall higher level of education than the general population based on 2008 Census estimates. Analysis of variance revealed no significant variation by education in either the outcomes or support coping, avoidant coping, or politically oriented coping. Respondents with less than a high school degree are found to be marginally less likely . As with the current data, this index tends to approximate a continuous scale, and ample evidence supports its use as such  developed by Cahalan et al. . Frequen Mulford  for a reα = 0.74) [Our measure of problematic drinking is the 10-item BMAST ( = 0.74) , which i = 0.74) . It corr = 0.74) , 32. MorThe measure of economy-related stressors is the Life Change Consequences of the Great Recession (LCCGR) instrument . This co active coping, support coping, and avoidant coping. These measures of coping are derived from subscales of the Brief COPE instrument [α = 0.84) includes eight items measuring acceptance, positive reframing, and planning and taking action in response to the economic recession. Support coping (α = 0.81) includes four items measuring use of emotional and instrumental support . Avoidant coping (α = 0.75) includes 10 items measuring self-distraction, behavioral disengagement, self-denial, blame, and a tendency to vent about or make fun of the situation. All items were rated on a four-point Likert-type scale ranging from 0  to 3 (I did this a lot).Three dimensions of nonpolitical modes of coping are assessed:strument  and havestrument –36. Partα = 0.79) drawn from the summed responses  to four statements asking how often respondents, in response to the economic recession, have been (1) “engaging in political activities such as signing petitions, leading or participating in rallies or marches, or writing to political representatives;” (2) “organizing with others to challenge politicians currently in office;” (3) “voting in elections to support politicians who share your political beliefs;” and (4) “participating in groups trying to influence the policies of the government at the local, state, or national level.” The questions used to construct this index were derived from analyses of focus group transcripts  less than high school (n = 45); (2) high school graduate (n = 350); (3) college graduate (n = 110); and (4) postcollege training (n = 150). Race/ethnicity is a dummy variable including non-Hispanic Whites (n = 436), African Americans (n = 80), Hispanics (n = 91), Asians (n = 29), and individuals who identify as an “other” race/ethnicity (n = 17). In all analyses, non-Hispanic Whites serve as the reference category.After examining bivariate correlations in order to assess the basic patterns of association among key study variables, we performed structural equation modeling (SEM) using Mplus software  to examiFinally, because the associations between social stress and drinking are found to vary by gender , 39, we Additionally, the possibility that coping resources may vary by gender is not strongly supported by the pattern of correlations reported, with the exception that women reported significantly more emotional support than men. However, and consistent with previous research , women aThe hypothesized associations between economy-related stressors, coping strategies, and the alcohol-related outcomes are further elaborated upon in the structural equation model.β = 0.094, s.e. = 0.004, and P < 0.01) and a higher incidence of problematic drinking over the past year .Estimation of the first model , includiSEM analysis testing the second model, of the hypothesized associations between economy-related stressors, coping strategies, and the alcohol-related outcomes considered, is presented as This model demonstrates that economic stress is associated with higher levels of each of the coping resources considered. That is, greater economic strain appears to predict a greater propensity to use both maladaptive coping tactics  and adaptive coping tactics . Two of the coping resources considered are also associated with drinking patterns. Avoidant coping is associated with higher levels of past-month drinking and problematic drinking, whereas politically oriented coping is associated with less alcohol consumption and problematic drinking.Formal mediation tests next reveal that the effects of economy-related stressors on the alcohol-related outcomes assessed are partly explained by variation in avoidant coping and politically oriented coping. Significant indirect effects are found for the pathways from economy-related stress to both past-month drinking and problematic drinking. Of the total effect of economy-related stress on past-month drinking (0.071), 0.047 is accounted for by the indirect effect of economy-related stress through avoidant coping and −0.024 is explained by the indirect influence of politically oriented coping. A similar pattern emerges with respect to the relationship between economy-related stressors and problematic drinking. The indirect effects of avoidant coping account for 0.046 of the total effect of economic stressors on problematic drinking (0.098) and politically oriented coping explains −0.032. Taken together, these findings indicate that both adaptive and maladaptive coping strategies come to bear on drinking patterns associated with economic strain. On the one hand, economic strain appears to be associated with drinking more and more problematically, in the extent to which it is associated with a tendency to engage in avoidant coping strategies. But, then, again, economic strain is also associated with greater politically oriented coping, which is protective against alcohol use and misuse.β = −0.319, s.e. = 0.021, and P < 0.001), net of the remaining variables. Thus, the observation that economic strain is associated with greater problematic drinking in the extent to which it is associated with avoidant coping strategies appears to be more pronounced among men than among women.Moderation tests next determine whether the mediating effects of the coping strategies investigated vary by gender. No significant effects are observed for the pathway to past-month drinking patterns. However, the mediating effect of avoidant coping for the economy-related stressor problematic drinking association differs for men and women in this sample. This effect is displayed in The findings from this study support a broadened conceptualization of modes of coping in stress paradigm-oriented research to encompass politically oriented coping, in addition to modes of coping outside of the political realm which have predominated in studies of the coping-related moderators or mediators of the associations between social stressors and drinking outcomes. Moreover, given our focus on economic stressors deriving, at least in part, from the macrolevel social forces producing the Great Recession, we suggest that politically oriented coping is particularly salient as a mode of behavioral adaptation in relation to societally engendered stressors as opposed to stressors that are less affected by macrolevel social forces.While this study specifically addressed deleterious drinking consequences of the recent Great Recession, social scientists have also delineated broader social-structural and political forces occurring over the last three decades which have led to pervasive job insecurity across all sectors of the US workforce and the erosion in the standard of living for most of the population –43. ThesConsistent with our gender-linked hypothesis, our data showed that males and females did not differ either in the use of politically oriented coping or in the extent to which politically oriented coping was protective in relation to drinking outcomes. However, our data showed that male but not female avoidant coping significantly predicted problem drinking. Thus, with regard to nonpolitically oriented coping with economic stressors, males clearly utilized a coping mode that was maladaptive. This finding might be seen as congruent with early male socialization patterns which have been viewed as fostering men's sense of self-importance rather than connectedness in social relationships  insofar Our findings should be viewed within the context of the methodological limitations of this study. The politically oriented coping measure which we developed for this study represents an initial attempt to operationalize this concept. However, it is limited to 4 items in contrast to the much longer nonpolitically oriented coping instrument and does not differentiate politically oriented coping tactics into discrete modes, similar to the measurement of nonpolitically oriented coping. Although factor analysis supported the inclusion of the indicators of politically oriented coping as a single measure, additional work on the concept of politically oriented coping would be useful, with a differentiation between alternative types of politically oriented coping. First, the differentiation between individual modes of political action  and collective political activities  would be useful. Secondly, some types of collective coping could be viewed as relatively more adaptive versus maladaptive. For example, the Tea Party social movement was motivated by both economic and cultural concerns , 46. HowSecond, this study utilized cross-sectional data and, thus, likely provides only a snapshot of the complex processes linking economy-related stressors, coping strategies, and drinking outcomes. While our theoretical framework postulated that exposure to economic stressors coupled with particular modes of coping leads to problematic drinking, it is possible that problem drinking coupled with maladaptive coping might make one prone to experiencing economic stressors such as losing one's job. Moreover, we lack data regarding alcohol consumption prior to exposure to the stressors focused on in this study and the extent to which alcohol may have been used as a coping mechanism. Thus, further longitudinal studies are necessary to more clearly delineate the causal directions of the relationships between economic stressors, modes of coping, and drinking outcomes.Third, the study methodology encompassed random-digit-dialing for recruiting the sample, thus only reaching individuals with landline telephone numbers. Consequently, individuals relying on cell phones only, along with households without access to any telephone, were not included in this study. This potential noncoverage error is a source of concern because comparisons of our data with the US population revealed that the sample underrepresented African Americans, Latinos, and younger (<age 40) and less-educated (high school or less) persons. However, our data were weighted to reflect the demographics of the overall population, and we compared weighted and unweighted estimates of each of our dependent variables to determine if nonresponse and/or noncoverage may have introduced serious bias into one or more of them. In each instance, we found that the weighted values of each measure fell well within 1 SD of the unweighted values, suggesting that the distributions of our key measures were not appreciably influenced by the underrepresentation of particular demographic groups.Despite the noted limitations, this study extends prior research on the moderators and mediators of the social stressor-drinking outcome relationships to broaden notions of coping to include politically oriented coping. Future studies incorporating this mode of coping may more clearly elucidate the political dynamics involved in both the macrolevel production of social stressors and the deleterious alcohol-related consequences of these stressors. This line of research would also have implications for the treatment of alcohol-related problems. In particular, considerations of more adaptive modes of coping might go beyond recommending individual behaviors such as job seeking by unemployed individuals to also suggest politically oriented coping to collectively try to influence the social conditions such as unemployment levels that may give rise to the propensity to self-medicate distress through the use of alcohol.


A significant increase in MTRasym (3.5 ppm) of HGG was found when the length of saturation pulse became longer , but MTRasym (3.5 ppm) was not different among the saturation lengths in LGG. ΔMTRasym (3.5 ppm) increased with the length of saturation pulse in both LGG . In both LGG and HGG, APT-weighted contrast was enhanced with the use of longer saturation pulses.In this study, we evaluated the dependence of saturation pulse length on APT imaging of diffuse gliomas using a parallel transmission-based technique. Twenty-two patients with diffuse gliomas  were included in the study. APT imaging was conducted at 3T with a 2-channel parallel transmission scheme using three different saturation pulse lengths . The 2D fast spin-echo sequence was used for imaging. Z-spectrum was obtained at 25 frequency offsets from -6 to +6 ppm (step 0.5 ppm). A point-by-point B0 correction was performed with a B0 map. Magnetization transfer ratio (MTR CEST coexchange –4. The Cexchange .Amide proton transfer (APT) imaging is one of the endogenous CEST imaging methods developed by the group of Zhou and van Zijl et al. . APT imaSince CEST signal depends upon power and length of radio frequency (RF) saturation pulse, optimization is a key factor for sensitivity of CEST imaging. Many CEST research studies have been performed on animal MRI systems with small-sized bore and very different design of the RF power transmission chain , 11, 12.This study was approved by the institutional review board of Kyushu University Hospital , and written informed consent was obtained. Twenty-two adult patients with diffuse glioma  who underwent subsequent surgical resection were included in this prospective study. The number of patients of low-grade glioma was 9  and that of high-grade glioma was 13 . All tumors were located in the supratentorial region of the brain. The interval between MR imaging and surgery was shorter than 2 weeks in all patients.MR imaging was conducted on a 3T clinical scanner  equipped with second-order shims, using an 8-channel head coil for signal reception and 2-channel parallel RF transmission via the body coil. The alternation of the two transmission channels enables long quasi-continuous RF saturation beyond the 50% duty-cycle of a single RF amplifier . ParalleTwo-dimensional (2D) APT imaging was performed on a single slice delineating the maximum cross-section area of a tumor. We used a saturation pulse (B1 = 2μT) with various durations, 0.5, 1 and 2s that was determined by the number of applied 50ms sinc-gauss-sharped element, 10, 20 and 40, respectively. To obtain a Z-spectrum, imaging was repeated at 25 saturation frequency offsets from ω = −6 to +6 ppm with a step of 0.5 ppm as well as one far off-resonant frequency (ω = −1560 ppm) for signal normalization. The other imaging parameters were as follows: fast spin-echo readout with driven equilibrium refocusing; echo train length 128 (single shot FSE); repetition time (TR) = 5,000 ms; echo time (TE) = 6 ms; Matrix = 128 × 128 (reconstructed to 256 × 256); slice thickness = 5 mm, field of view = 230 × 230 mm; scan time = 2 min 20 s for one Z-spectrum. A B0 map for off-resonance correction was acquired separately using a 2D gradient-echo  with identical spatial resolution, and it was used for a point-by-point B0 correction. For reference, several standard MR images, including T1-weighted, T2-weighted, fluid attenuation inversion recovery (FLAIR), and contrast enhanced T1-weighted images were acquired. The APT images were performed before administration of gadolinium contrast agent in all patients since T1 shortening by gadolinium may alter APT-weighted signal.asym) equipped with a correction function for B0 inhomogeneity as previously demonstrated [Analysis of APT imaging was performed with the software program ImageJ . A dedicated plug-in was build to analyze the Z-spectra and asymmetry of magnetization transfer ratio .APT-weighted signal is the asymmetry of the Z-spectrum at 3.5 ppm calculated as MTR2, 72 pixels) independently by two trained neuroradiologists . Then one to five ROIs were placed depending on the lesion size in the solid component of a tumor and the best effort was given to avoid cystic, necrotic, or hemorrhagic components of the tumor with reference to conventional MR images. The same ROIs were used in the images for the three saturation pulse length in each patient. The average of the measurements in the ROIs was calculated to represent each tumor. The signal was also measured in a ROI placed in normal appearing white matter (NAWM).Signal intensity was measured in circular region-of-interests  criteria by established neuropathologists.asym (3.5 ppm) was measured in tumor as well as in NAWM. ΔMTRasym (3.5 ppm) was defined as the difference in MTRasym (3.5 ppm) between tumor and NAWM. The inter-observer agreement regarding the measurements for MTRasym (3.5 ppm) or ΔMTRasym (3.5 ppm) by the two observers was analyzed by calculating the intra-class correlation coefficient (ICC). ICCs are considered to be excellent if > 0.74. The measurements by the observer 1 were used for further statistical analyses when the ICC were excellent. In the patient groups of low-grade glioma  and high-grade glioma , MTRasym (3.5 ppm) of tumor and ΔMTRasym (3.5 ppm) were compared among the three saturation pulse lengths by one-way analysis of variance followed by Tukey’s multiple comparison test. MTRasym (3.5 ppm) of tumor and ΔMTRasym (3.5 ppm) were compared between LGG and HGG for each saturation pulse length by Student’s t-test. Statistical analyses were performed with a commercially available software package . P-values < .05 were considered significant.All values are expressed as mean ± standard deviation (SD). MTRasym (3.5ppm) with the 500 ms, 1s, and 2s saturations were 0.954, 0.949, and 0.956, respectively. The ICCs for the ΔMTRasym (3.5ppm) with the 500 ms, 1s, and 2s saturations were 0.908, 0.963, and 0.930, respectively. The inter-observer agreements were considered excellent in all measurements. The measurements of the MTRasym (3.5 ppm) ΔMTRasym (3.5 ppm) by the two observers were showed in The ICCs for the MTRThe Z-spectra of LGG (n = 9), HGG (n = 13), and corresponding NAWM  are shown in asym of tumor and NAWM and ΔMTRasym in the patients with LGG are shown in asym of LGG was decreased with the length of the saturation pulse at smaller frequency offsets (1–2 ppm), but almost comparable at around 3.5 ppm. MTRasym of corresponding NAWM was decreased with the length of saturation pulse in the entire frequency range. As a result, ΔMTRasym of LGG was increased with the length of saturation at larger frequency offsets (>2 ppm) including 3.5 ppm.MTRasym of tumor and NAWM and ΔMTRasym in the patients with HGG are shown in asym of HGG was decreased with the length of the saturation pulse in smaller frequency offsets (<2 ppm), but was increased at larger frequency offsets (>2 ppm) including 3.5 ppm. MTRasym of corresponding NAWM was decreased with the length of saturation pulse in the entire frequency range as consistent with the result in the patients with LGG . In particular, ΔMTRasym (3.5ppm) with the 2 s saturation reached maximum at approximately 3.5 ppm, which corresponds to the specific frequency of amide protons.MTRwith LGG . As a reasym (3.5ppm) and ΔMTRasym (3.5ppm) of LGG and HGG are shown in asym (3.5ppm) was not significantly different among the three saturation pulse lengths in LGG . On the other hand, MTRasym (3.5ppm) with the 1s  and 2 s  saturation was significantly higher than that with the 0.5 s (3.09 ± 0.54%) saturation in HGG. ΔMTRasym (3.5ppm) with the 1 s  and 2 s  saturation was significantly higher than that with the 0.5 s saturation (0.48 ± 0.56%) in LGG. ΔMTRasym (3.5ppm) of HGG significantly increased with the saturation pulse length . Both MTRasym (3.5ppm) and ΔMTRasym (3.5ppm) were significantly higher  in HGG than in LGG with all the three saturation pulse lengths. MTRasym and ΔMTRasym of brain tumors [The choice of appropriate imaging parameters, especially RF saturation pulse length and power, is crucial in APT imaging. Regarding saturation power, it was reported that the change in saturation power substantially affected MTRn tumors . In the asym (3.5ppm) was higher in HGG compared with LGG presumably reflecting abundant mobile proteins and peptides, which is consistent with previous study of Togao et al. [asym (3.5ppm) of HGG significantly increased with an extended length of the saturation pulse while that of LGG was almost unchanged with saturation pulse length. The Z-spectra of NAWM in both cases of HGG and LGG are almost identical in which the MTRasym (3.5 ppm) decreases with an extended length of the saturation pulse. Consequently, ΔMTRasym (3.5 ppm), which is a contrast in MTR asym (3.5ppm) between tumor and NAWM, increased with the length of saturation pulse in both LGG and HGG. According to the previous studies by Zhou et al. [asym (3.5 ppm) is affected not only by the APT effect but also by other factors as follows:asym (3.5 ppm) is the native or conventional MTR asymmetry at 3.5 ppm, APTR is the amide proton transfer ratio, K is the normalized proton exchange rate between the two proton pools, R1W is the relaxivity of water [asym (3.5 ppm) is composed of APTR and native MTR asymmetry. APTR depends primarily on mobile amide proton concentration and amide proton exchange rate that are related to tissue pH [asym (3.5 ppm) with longer saturation in HGG can be attributed to increase in APTR due to high concentrations of mobile proteins and peptides in tissue. We assume that a possible reason for the lack of this increase in LGG was the reduction of native MTR asymmetry and small increase in APTR due to lower concentrations of mobile proteins and peptides. The effect of the saturation pulse length acted like that of the saturation power level, as shown in asym (3.5ppm) was consistently decreasing with longer RF saturation. This reduction could result from larger MT and spill-over effects and decreased native MTR asymmetry caused by the longer saturation pulse. Subtracting MTRasym (3.5 ppm) in NAWM from that of tumor might cancel the decrease in native MTR asymmetry and thus lead to increase in ΔMTRasym (3.5 ppm) in LGG. In HGG, subtracting MTRasym (3.5 ppm) in NAWM from that of tumor might further contribute to the increase in ΔMTRasym (3.5 ppm). Thus, the long saturation pulses improve the sensitivity of APT imaging for detection of amide proton exchange in LGG as well as in HGG.Our present study demonstrated that the MTRo et al. . The MTRasym 3.ppm was hu et al. , MTRasymasym 3.ppm was hissue pH . The souissue pH , 18. TheIn the present study, time-interleaved parallel transmission-based APT imaging was conducted with a fast spin-echo sequence using driven-equilibrium refocusing. A previous study showed that fast spin-echo based APT imaging showed superior sensitivity compared to the gradient-echo sequence . In partThere are several limitations in the present study. The differences in recovery time could affect the CEST effect when TR was not long enough compared with tissue T1. The variation of recovery time  in our study does indeed lead to steady-state higher saturation levels for very long T1 tissue types. Assuming the longest T1 of 2 s, this effect may lead to 40%  higher steady-state saturation levels for saturation time of 2.0 s  as compared to a fully relaxed situation with very long TR (e.g. 20s). Thus, our fixed TR of 5 s approach favors the long saturation pulses for very long T1 species, because the steady-state saturation is enhanced with short recovery times. The effect is strongly reduced for shorter T1 values, e.g. for T1 of 1 s: 9% . Thus, the effect is insignificant at moderate T1 values. In the previous study with egg-white phantoms with T1 of 1639.3 ms, the effect of the difference in TR was evaluated using the exact same imaging scheme as the present study, however, no significant differences were found between the CEST effects obtained with different TRs . Optimalasym (3.5 ppm), which is the APT-weighted signal, of HGG when the length of saturation pulse became longer, but not in LGG. ΔMTRasym (3.5 ppm), which is the APT-weighted contrast, increased with the length of saturation pulse in both LGG and HGG. The long saturation pulse enabled by this method allows to detect sensitively low-concentrations of amide protons in diffuse gliomas.This study demonstrated the utility of long RF saturation pulses, which was enabled by the parallel transmission-based technique, in APT imaging of diffuse gliomas. It was shown that a significant increase in MTRS1 Table(DOCX)Click here for additional data file.