It is understudied how a patient's or psychotherapist's socioeconomic status (SES) might influence psychotherapeutic treatments. This project addressed this gap in research by investigating how ...doctoral therapists-in-training understood the impact of SES in their psychotherapeutic work. Reflexive thematic analysis with a phenomenological approach was used to analyze conversations with doctoral student therapists at a university clinic. Specific themes emerged concerning therapist self-worth, addressing patient SES, self-disclosing about one's SES, and working through SES fantasies. It was found that therapists-in-training routinely avoided conversations with patients related to SES. These findings suggest that doctoral training is not adequately preparing psychoanalytic psychotherapists to work with patients in lower SES positions. Limitations of the study and suggestions for future research are explored.
IMPORTANCE: Traumatic brain injury (TBI) is the leading cause of death and disability due to trauma. Early administration of tranexamic acid may benefit patients with TBI. OBJECTIVE: To determine ...whether tranexamic acid treatment initiated in the out-of-hospital setting within 2 hours of injury improves neurologic outcome in patients with moderate or severe TBI. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, double-blinded, randomized clinical trial at 20 trauma centers and 39 emergency medical services agencies in the US and Canada from May 2015 to November 2017. Eligible participants (N = 1280) included out-of-hospital patients with TBI aged 15 years or older with Glasgow Coma Scale score of 12 or less and systolic blood pressure of 90 mm Hg or higher. INTERVENTIONS: Three interventions were evaluated, with treatment initiated within 2 hours of TBI: out-of-hospital tranexamic acid (1 g) bolus and in-hospital tranexamic acid (1 g) 8-hour infusion (bolus maintenance group; n = 312), out-of-hospital tranexamic acid (2 g) bolus and in-hospital placebo 8-hour infusion (bolus only group; n = 345), and out-of-hospital placebo bolus and in-hospital placebo 8-hour infusion (placebo group; n = 309). MAIN OUTCOMES AND MEASURES: The primary outcome was favorable neurologic function at 6 months (Glasgow Outcome Scale-Extended score >4 moderate disability or good recovery) in the combined tranexamic acid group vs the placebo group. Asymmetric significance thresholds were set at 0.1 for benefit and 0.025 for harm. There were 18 secondary end points, of which 5 are reported in this article: 28-day mortality, 6-month Disability Rating Scale score (range, 0 no disability to 30 death), progression of intracranial hemorrhage, incidence of seizures, and incidence of thromboembolic events. RESULTS: Among 1063 participants, a study drug was not administered to 96 randomized participants and 1 participant was excluded, resulting in 966 participants in the analysis population (mean age, 42 years; 255 74% male participants; mean Glasgow Coma Scale score, 8). Of these participants, 819 (84.8%) were available for primary outcome analysis at 6-month follow-up. The primary outcome occurred in 65% of patients in the tranexamic acid groups vs 62% in the placebo group (difference, 3.5%; 90% 1-sided confidence limit for benefit, −0.9%; P = .16; 97.5% 1-sided confidence limit for harm, 10.2%; P = .84). There was no statistically significant difference in 28-day mortality between the tranexamic acid groups vs the placebo group (14% vs 17%; difference, −2.9% 95% CI, −7.9% to 2.1%; P = .26), 6-month Disability Rating Scale score (6.8 vs 7.6; difference, −0.9 95% CI, −2.5 to 0.7; P = .29), or progression of intracranial hemorrhage (16% vs 20%; difference, −5.4% 95% CI, −12.8% to 2.1%; P = .16). CONCLUSIONS AND RELEVANCE: Among patients with moderate to severe TBI, out-of-hospital tranexamic acid administration within 2 hours of injury compared with placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale-Extended. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01990768
Sarcopenia is associated with adverse clinical outcomes. CT-based skeletal muscle measurements for sarcopenia assessment are most commonly performed at the L3 vertebral level.
The purpose of this ...article is to compare the utility of fully automated deep learning CT-based muscle quantitation at the L1 versus L3 level for predicting future hip fractures and death.
This retrospective study included 9223 asymptomatic adults (mean age, 57 ± 8 SD years; 4071 men, 5152 women) who underwent unenhanced low-dose abdominal CT. A previously validated fully automated deep learning tool was used to assess muscle for myosteatosis (by mean attenuation) and myopenia (by cross-sectional area) at the L1 and L3 levels. Performance for predicting hip fractures and death was compared between L1 and L3 measures. Performance for predicting hip fractures and death was also evaluated using the established clinical risk scores from the fracture risk assessment tool (FRAX) and Framingham risk score (FRS), respectively.
Median clinical follow-up interval after CT was 8.8 years (interquartile range, 5.1-11.6 years), yielding hip fractures and death in 219 (2.4%) and 549 (6.0%) patients, respectively. L1-level and L3-level muscle attenuation measurements were not different in 2-, 5-, or 10-year AUC for hip fracture (
= .18-.98) or death (
= .19-.95). For hip fracture, 5-year AUCs for L1-level muscle attenuation, L3-level muscle attenuation, and FRAX score were 0.717, 0.709, and 0.708, respectively. For death, 5-year AUCs for L1-level muscle attenuation, L3-level muscle attenuation, and FRS were 0.737, 0.721, and 0.688, respectively. Lowest quartile hazard ratios (HRs) for hip fracture were 2.20 (L1 attenuation), 2.45 (L3 attenuation), and 2.53 (FRAX score), and for death were 3.25 (L1 attenuation), 3.58 (L3 attenuation), and 2.82 (FRS). CT-based muscle cross-sectional area measurements at L1 and L3 were less predictive for hip fracture and death (5-year AUC ≤ 0.571; HR ≤ 1.56).
Automated CT-based measurements of muscle attenuation for myosteatosis at the L1 level compare favorably with previously established L3-level measurements and clinical risk scores for predicting hip fracture and death. Assessment for myopenia was less predictive of outcomes at both levels.
Alternative use of the L1 rather than L3 level for CT-based muscle measurements allows sarcopenia assessment using both chest and abdominal CT scans, greatly increasing the potential yield of opportunistic CT screening.
Radiologic tests often contain rich imaging data not relevant to the clinical indication. Opportunistic screening refers to the practice of systematically leveraging these incidental imaging ...findings. Although opportunistic screening can apply to imaging modalities such as conventional radiography, US, and MRI, most attention to date has focused on body CT by using artificial intelligence (AI)-assisted methods. Body CT represents an ideal high-volume modality whereby a quantitative assessment of tissue composition (eg, bone, muscle, fat, and vascular calcium) can provide valuable risk stratification and help detect unsuspected presymptomatic disease. The emergence of "explainable" AI algorithms that fully automate these measurements could eventually lead to their routine clinical use. Potential barriers to widespread implementation of opportunistic CT screening include the need for buy-in from radiologists, referring providers, and patients. Standardization of acquiring and reporting measures is needed, in addition to expanded normative data according to age, sex, and race and ethnicity. Regulatory and reimbursement hurdles are not insurmountable but pose substantial challenges to commercialization and clinical use. Through demonstration of improved population health outcomes and cost-effectiveness, these opportunistic CT-based measures should be attractive to both payers and health care systems as value-based reimbursement models mature. If highly successful, opportunistic screening could eventually justify a practice of standalone "intended" CT screening.
Deep learning faces a significant challenge wherein the trained models often underperform when used with external test data sets. This issue has been attributed to spurious correlations between ...irrelevant features in the input data and corresponding labels. This study uses the classification of COVID-19 from chest x-ray radiographs as an example to demonstrate that the image contrast and sharpness, which are characteristics of a chest radiograph dependent on data acquisition systems and imaging parameters, can be intrinsic shortcuts that impair the model's generalizability. The study proposes training certified shortcut detective models that meet a set of qualification criteria which can then identify these intrinsic shortcuts in a curated data set.
In this article, I argue that the symmetry and mutuality of any therapeutic relationship must be variable and reactive to the patient's unique needs, which will almost certainly change over time ...between sessions, but also even within sessions. Invoking the work of Jacques Lacan, I suggest that attempts to define a priori how a treatment necessarily should work and look are imaginary, in that they seek to establish a harmony and order to a project that cannot sustain either. As such, I offer that psychoanalysis as a discipline should be deconstructed in this important way: the dismissal of constancy related to either symmetry or mutuality. I put these ideas in contrast and complement to Levenson's work on the deconstruction of narrative truth. In addition to discussing Levenson, I also discuss the imaginary described in Lacan's early seminars, and review the existing literature on symmetry and mutuality. Afterward, I provide case examples that illustrate how I apply symmetry and mutuality in my own work with patients, and conclude by discussing how Lacan informs my work in psychotherapy.
本文中, 我认为任何治疗关系的对称性和相互性必须是可变的,并且回应患者的独特需要, 这需要几乎肯定会随着时间而变化的,不仅在两次会谈之间,也在会谈之中。 援引雅克拉康的著作, 我提出尝试定义一个先验, 即一个治疗必须如何工作和看待是想象界的,在其中他们寻求对于一种无法承受的投射建立起一种和谐和秩序。 因此, 我提出, 精神分析作为一门学科, 应该以这样一种重要的方式被解构:不考虑与对称性或相互性有关的恒常性。 我将这些观点与Levenson关于叙事真理的解构的作品进行了对比和补充。 除了讨论Levenson, 我还讨论了拉康早期研讨会中描述的想象界,并回顾了现有的关于对称性和相互性的文献。 然后, 我提供了案例来说明, 我在与我的病人的工作中如何应用对称性和相互性, 并讨论总结了拉康如何启发了我的心理治疗工作。
OBJECTIVETo assess the diagnostic performance of post-contrast CT for predicting moderate hepatic steatosis in an older adult cohort undergoing a uniform CT protocol, utilizing hepatic and splenic ...attenuation values.MATERIALS AND METHODSA total of 1676 adults (mean age, 68.4 ± 10.2 years; 1045M/631F) underwent a CT urothelial protocol that included unenhanced, portal venous, and 10-min delayed phases through the liver and spleen. Automated hepatosplenic segmentation for attenuation values (in HU) was performed using a validated deep-learning tool. Unenhanced liver attenuation < 40.0 HU, corresponding to > 15% MRI-based proton density fat, served as the reference standard for moderate steatosis.RESULTSThe prevalence of moderate or severe steatosis was 12.9% (216/1676). The diagnostic performance of portal venous liver HU in predicting moderate hepatic steatosis (AUROC = 0.943) was significantly better than the liver-spleen HU difference (AUROC = 0.814) (p < 0.001). Portal venous phase liver thresholds of 80 and 90 HU had a sensitivity/specificity for moderate steatosis of 85.6%/89.6%, and 94.9%/74.7%, respectively, whereas a liver-spleen difference of -40 HU and -10 HU had a sensitivity/specificity of 43.5%/90.0% and 92.1%/52.5%, respectively. Furthermore, livers with moderate-severe steatosis demonstrated significantly less post-contrast enhancement (mean, 35.7 HU vs 47.3 HU; p < 0.001).CONCLUSIONModerate steatosis can be reliably diagnosed on standard portal venous phase CT using liver attenuation values alone. Consideration of splenic attenuation appears to add little value. Moderate steatosis not only has intrinsically lower pre-contrast liver attenuation values (< 40 HU), but also enhances less, typically resulting in post-contrast liver attenuation values of 80 HU or less.CLINICAL RELEVANCE STATEMENTModerate steatosis can be reliably diagnosed on post-contrast CT using liver attenuation values alone. Livers with at least moderate steatosis enhance less than those with mild or no steatosis, which combines with the lower intrinsic attenuation to improve detection.KEY POINTSThe liver-spleen attenuation difference is frequently utilized in routine practice but appears to have performance limitations. The liver-spleen attenuation difference is less effective than liver attenuation for moderate steatosis. Moderate and severe steatosis can be identified on standard portal venous phase CT using liver attenuation alone.
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