Premier Community Health

The current study examined the sociodemographic and psychosocial variables that predicted being at risk for low health literacy among a population of racially and ethnically diverse patients accessing primary care services at community-based clinics. Participants (N = 416) were aged 50-75 years, currently not up-to-date with colorectal cancer (CRC) screening, at average CRC risk, and enrolled in a randomized controlled trial (RCT) aimed at promoting CRC screening. Participants completed a baseline interview that assessed health literacy as measured by Rapid Estimate of Adult Literacy in Medicine-Revised, sociodemographic factors, and psychosocial variables (e.g., health beliefs) prior to randomization and receipt of an intervention. Thirty-six percent of the participants were found to be at risk for low health literacy. Sociodemographic and psychosocial variables were assessed as predictors of being at risk for low health literacy using logistic regression. In the final model, predictors were male gender, being from a racial/ethnic minority group, being unable to work, having higher social influence scores, and having higher religious belief scores. These findings suggest several patient characteristics that may be associated with low health literacy, and highlight the importance of supporting all patients through simplified and clear communications and information to improve understanding of CRC screening information.

The scope of a healthcare institution's infection prevention and control/healthcare epidemiology program (IPC/HE) should be driven by the size and complexity of the patient population served, that population's risk for healthcare-associated infection (HAI), and local, state, and national regulatory and accreditation requirements. Essential activities of all IPC/HE programs include but are not limited to the following: ∙ Surveillance.∙ Performance improvement to reduce HAI ∙ Acute event response, including outbreak investigation ∙ Education and training of both healthcare personnel and patients ∙ Reporting of HAI to the Centers for Disease Control and Prevention's National Healthcare Safety Network as well as entities required by law.

BACKGROUND: The objective of the current study was to improve colorectal cancer (CRC) screening uptake with the fecal immunochemical test (FIT). The current study investigated the differential impact of a multicomponent, targeted, low-literacy educational intervention compared with a standard, nontargeted educational intervention. METHODS: Patients aged 50 to 75 years who were of average CRC risk and not up-to-date with CRC screening were recruited from either a federally qualified health center or a primary care community health clinic. Patients were randomized to the intervention condition (targeted photonovella booklet/DVD plus FIT kit) or comparison condition (standard Centers for Disease Control and Prevention brochure plus FIT kit). The main outcome was screening with FIT within 180 days of delivery of the intervention. RESULTS: Of the 416 participants, 54% were female; the participants were racially and ethnically diverse (66% white, 10% Hispanic, and 28% African American), predominantly of low income, and insured (the majority had county health insurance). Overall, the FIT completion rate was 81%, with 78.1% of participants in the intervention versus 83.5% of those in the comparison condition completing FIT (P = .17). In multivariate analysis, having health insurance was found to be the primary factor predicting a lack of FIT screening (adjusted odds ratio, 2.10; 95% confidence interval, 1.04-4.26 [P = .04]). CONCLUSIONS: The multicomponent, targeted, low-literacy materials were not found to be significantly different or more effective in increasing FIT uptake compared with the nontargeted materials. Provision of a FIT test plus education may provide a key impetus to improve the completion of CRC screening. The type of educational material (targeted vs nontargeted) may matter less. The findings of the current study provide a unique opportunity for clinics to adopt FIT and to choose the type of patient education materials based on clinic, provider, and patient preferences. Cancer 2017;123:1390-1400. © 2016 American Cancer Society.

Depression often coexists with chronic illnesses and complicates the diagnosis and treatment of any patient who suffers from either of these health problems. Ethnicity, culture, stigma, and economics add to the difficulty of recognition and treatment of depression. In this Point of View article, possible solutions are addressed.

Author Affiliation: Nurse Researcher, Premier Health, Dayton, Ohio. The author reports no conflicts of interest. Correspondence: Patricia Anne O'Malley PhD, APRN-CNS, [email protected]. Note to the reader: This article reflects evidence available at the time of article preparation or approximately 6 months after the COVID-19 pandemic began. During this time, much evidence is emerging, which is fluid requiring more testing and analysis. This article provides a glimpse of the beginning of a possible future treatment pathway for a dangerous novel virus that has affected every area of clinical nurse specialist practice in the provision of care to COVID-10 patients.

Polyglandular autoimmune syndrome (PAS) is a rare disorder characterized by the autoimmune destruction of multiple endocrine glands. Type II PAS is the most common of the PAS subtypes and is characterized by Addison's disease, autoimmune thyroid disease, and type I diabetes mellitus. Disease manifestations are predominantly seen in young adulthood with an emerging endocrine disorder; however, a host of other autoimmune conditions can also be present before endocrine organ dysfunction. Due to the complex nature of presentation and management, an important consideration in patient care involves a multidisciplinary team with the addition of an endocrinologist. A 21-year-old African American woman with a medical history of PAS-II presented during three hospitalizations with adrenal crisis, diabetic ketoacidosis (DKA), and myxedema. The common theme across admissions entails a spectrum of adrenal dysfunction, including shock, as well as glucose and thyroid abnormalities. During her first hospitalization, the patient presented with hypotension, hyperglycemia, and hypothyroidism. She received aggressive IV fluid resuscitation, an insulin drip, electrolyte repletion, an up-titration of levothyroxine, and stress-dose corticosteroids. In the second hospitalization, she also had hypotension and electrolyte derangements, along with hypoglycemia and myxedema. She received glucose management, thyroid hormone replacement, and stress steroids again. The third hospitalization involved flu-like symptoms and a positive SARS-CoV-2 test. She was managed similarly for hypotension, hyponatremia, and hyperglycemia. In this case, she presented with non-gap metabolic acidosis and required a bicarbonate drip for a short period. She did not receive antibiotics across these three admissions. We present three hospitalizations where adrenal, pancreatic, and thyroid derangements were seen and managed. It is known that most general providers other than endocrinologists are not comfortable with the management of disease manifestations of PAS-II; therefore, we provide a case review to address the standard of care management and guidelines with further discussion. This patient's maintenance care was complicated by a lack of adherence to outpatient medications, leading to recurrent hospitalizations. We also endorse the importance of doctors pursuing endocrinology fellowships, especially due to the observed waning number of graduates. An endocrinologist's availability and involvement in the care of patients with complex endocrine issues lead to improved outcomes.

Cytomegalovirus (CMV) primarily affects immunocompromised individuals and can rarely involve the small bowel, causing deep ulcerations and microperforations. This is most commonly observed in patients with AIDS and CD4 counts below 50 cells/μL who are not receiving antiretroviral therapy (ART). Due to diagnostic challenges and the risk of severe complications, CMV gastrointestinal (GI) disease is associated with high morbidity and mortality. We report the case of a 38-year-old woman from Ecuador, four months postpartum with an unknown cause of infant demise, who presented with a 15-day history of abdominal pain, diarrhea, vomiting, and hypotension. Two exploratory laparotomies revealed multiple small bowel and colonic microperforations requiring bowel resections. CMV leads to both small bowel and colonic perforations primarily through a combination of direct viral cytopathic effects and ischemic injury secondary to vasculitis. Infectious evaluation revealed a new diagnosis of AIDS, and final surgical pathology was positive for CMV. The patient initially recovered from surgery and was started on appropriate systemic therapy, but ultimately left the hospital against medical advice and was noncompliant with ART. She was readmitted three days later with disseminated intravascular coagulation, GI bleeding, multi-organ failure, and disseminated toxoplasmosis. The patient ultimately passed away approximately 45 days after initial presentation. This case underscores the complexities of managing CMV GI disease. Early recognition of immunity status is crucial to broadening the differential to include opportunistic infections. Timely diagnosis and initiation of therapies with good patient compliance could significantly impact outcomes.

Background: About 47% of US adults have hypertension (HTN) per the 2017 guideline. Prevalence is worse in certain distributions of the country with top quartile in the Southeastern pocket. In a subset of patients who present with ST-segment elevated myocardial infarction (STEMI), the prevalence is 30-40%. An interesting further subset of patients are those who presented during COVID-19 pandemic. COVID-19 wreaked havoc on the world with its first confirmed case 9 January 2020. International followed by national transport became limited, followed by announcement of a pandemic. Quarantines and lockdowns were set in place, especially in March 2020, to prevent epidemiologic spread. Hypothesis: We were interested to observe if STEMI-alert patients during this period presented with worse background disease compared to years 2019 and 2021, years before and after COVID-lockdown and peak, including if the prevalence of HTN increased in the population. Methods: We evaluated 1001 adults who were STEMI-activated from 1 January 2019 to 31 December 2021 at 5 sites in Southwest Ohio. We obtained patient demographics and risk factors and performed multinomial logistic regression to compare years 2019 and 2021 to 2020. Statistical analysis was with SAS 9.4. Results. For 1001 STEMI-alert patients, 244 patients (72.6%) had HTN in 2019, 250 (78.9%) in 2020 and 261 (75.0%) in 2021. Overall prevalence over the three years was 755 (75.4%). Compared to 2020, 2019 prevalence was not significant (p=0.12) (OR 0.72) (CI 0.47,1.09). Neither was 2021 (p=0.25) (OR 0.78) (CI 0.51,1.19). Conclusion: STEMI-alert patients at our institution appeared to have higher overall prevalence of HTN than reported nationally by the Centers for Disease Control (CDC), 75.4% versus 40%. These may have self-selected for disease severity by STEMI-alert activation status. HTN may also be of higher prevalence in this region, be associated with poor disease detection or there may be patient compliance issues when antihypertensives are prescribed by a healthcare provider. HTN prevalence did not have statistical significance across the three observed years despite our hypothesis that patients would present with more background cardiac comorbidities such as HTN.

Abstract Poststroke depression (PSD) is a frequent complication affecting approximately 30% of stroke survivors in the first 24 months after stroke. PSD has been correlated with increases in hospital lengths of stay, hospital costs, increased morbidity and mortality, risk for recurrent stroke at one year, decreased functional outcome, cognitive function, and quality of life post-stroke. Depression among family caregivers of stroke survivors may also negatively influence stroke recovery and stroke survivor quality of life. This explanatory sequential mixed-method study ( n =32 dyads) sought to examine stroke disability, caregiver burden, rurality, prior history of depression, and depressive symptoms after stroke of stroke survivors and the perception of depressive symptoms after stroke from the perspectives of stroke survivors and their caregivers. Following quantitative data collection, 16 participants ( n =9 stroke survivors, n =7 caregivers) completed 1:1 semi-structured interview.Study findings noted a p -value of 0.0397 which suggests there is a significant mean difference in Beck Depression Inventory-Fast Screen (BDI-FS) scores between stroke caregivers who are a spouse/significant other and stroke caregivers who are a family member. There is also robust evidence to suggest a significant mean difference in Beck Depression Inventory-Fast Screen (BDI-FS) score between stroke caregivers who have a prior history of depression and stroke caregivers who do not ( p -value= 0.025). Thematic analysis of qualitative interviews corroborated these results with spouses and significant other caregivers and caregivers with prior history of depression noting increased depressive symptoms upon taking on stroke caregiver role.

BACKGROUND Lymphomatoid granulomatosis (LyG) is a rare lymphoproliferative disorder associated with Epstein-Barr virus (EBV) in which there is an infection of B cells and numerous reactive T cells. The lymphoproliferative disorder progresses to organ infiltration and resultant dysfunction of affected organs. Histologically, it is characterized by a triad of polymorphic lymphoid infiltrate, angiitis, and granulomatosis. The lungs are the most commonly involved sites for lymphomatoid granulomatosis, but other sites that can be involved include the liver, skin, and central nervous system. The signs and symptoms of LyG can vary, and can produce generalized symptoms such as cough, shortness of breath, and chest tightness, but can vary depending on the location of LyG. CASE REPORT We report a case of a 60-year-old man who presented with altered mental status. Cross-sectional imaging of the brain was negative for any acute intracranial process, but a fine-needle biopsy of a retroperitoneal lymph node revealed nodular polymorphous mononuclear infiltrates containing atypical large EBV-positive B cells with positive EBER and CD30, consistent with lymphomatoid granulomatosis. The patient was started on a regimen of brentuximab/bendamustine, and instructed to follow up with Oncology on an outpatient basis. CONCLUSIONS Treatment options for lymphomatoid granulomatosis are based on the disease grading. Lymphomatoid granulomatosis can be classified by using a grading system determined by the number of EBV-positive large B cell malignant cells, along with necrosis. The most effective treatment for lymphomatoid granulomatosis is unknown, but at this time treatment protocols are based on the grade of the disease. The clinical and histological features of lymphomatoid granulomatosis are discussed in this case report.

Proper identification of parathyroid tissue is a critical component in surgery involving the thyroid and parathyroid gland (PG). In recent years, near infrared autofluorescence (NIRAF) has been investigated as a non-invasive strategy to detect PG in parathyroidectomy and in PG preservation in thyroidectomy. There are currently two FDA approved NIRAF modalities, image-based and probe-based. The aim of this meta-analysis is to evaluate the efficacy of these two NIRAF modalities. PubMed, Scopus, and MEDLINE were utilized, with 238 studies analyzed via independent, blinded review. Studies from January 2000 to February 2023, Boolean phrase "parathyroid autofluorescence", written in English, and included results found within the body of the article were the inclusion criteria used. Conference abstracts, reviews, case reports, commentary, discussion and letter, non-English, animal studies, in vitro studies, contrast enhanced fluorescence, and NIRAF with use of indocyanine green, were the exclusion criteria used. Five studies were enrolled based on inclusion and exclusion criteria. The estimated overall accuracy of image-based methods is 0.96 (95% CI of (0.87, 0.99)), while the estimated overall accuracy of probe-based methods is 0.93 (95% CI of (0.92, 0.94)). With p=0.36, there is insufficient evidence to indicate a significant difference in overall accuracy, sensitivity and specificity between image-based methods and probe-based methods. Both imaging and probe-based detection modalities offer effective, noninvasive means for identifying parathyroid glands intraoperatively. Further studies comparing the efficacy of these two modalities are needed to further differentiate their clinical performance.

OBJECTIVE: Successful use of a novel percutaneous retrieval system (ŌNŌ retrieval system, ŌNŌCOR) to remove a significantly dislodged left atrial appendage occlusion device (Watchman FLX, Boston Scientific). KEY STEPS: First, a 17-F Bayliss VersaConnect and TruSteer catheter was advanced through a 20-F DrySeal sheath (Gore Medical). Then, the ŌNŌ retrieval system was advanced and positioned against the Watchman FLX device. Through this system, a 2.4-mm Raptor forceps (Steris) was advanced to grab one of the struts on the Watchman device. Slow traction on the Raptor forceps and simultaneous advancement of the ŌNŌ basket was performed to dislodge the Watchman device from the left atrial appendage. POTENTIAL PITFALLS: Device embolization, left atrial appendage avulsion, and pericardial effusion are some of the potential complications of the Watchman retrieval procedure. TAKE-HOME MESSAGE: Embolization of a left atrial appendage occlusion device is a rare but potentially devastating complication, and percutaneous retrieval with the ŌNŌ system may provide a safer alternative to surgical removal.

Introduction: Understanding clot composition and associated genomic, epigenomic, and proteomic signatures could provide insight into thrombus biology and etiology, and aid in prognosis in stroke. We report preliminary analysis of histology evaluations in subjects enrolled in the INSIGHT Registry, a multicentered ‘multi-omic’ analysis of thrombi associated with acute hemorrhagic and ischemic stroke this multi-omic clot collection registry. Our aim was to determine potential histology differences in thrombi as a consequence of infarct time (time from last known normal to thrombectomy). Material and Methods: Subjects age ≥18 years, treated frontline with the Penumbra System for thrombectomy are included in this analysis. Patient demographics, medical history, radiographic, and procedural information are collected in conjunction with extracted clot and concurrent extracranial arterial blood. Enrollment, data collection, and data monitoring are ongoing for the INSIGHT registry. While the protocol includes analysis for proteomics and transcriptomics, for this analysis we used automated histology. An MSB Trichrome stain was used to evaluate the tissue. Composition was determined by automated pixel analysis, with the values representing ratios of the overall clot. Results: Samples from 60 subjects who were enrolled from 10 sites between 02/2021 and 07/2021. Analysis of the thrombi successfully determined the relative portions of fibrin, red blood cells (RBCs), and platelets (PLT). The median percentage of fibrin in the thrombi was 44.0% (IQR 29.0 - 57.6; N=60). The median time interval from Last Known Well to recanalization was 4.0 hours (IQR 2.9-12.8 hours; N=55). There was no correlation between the time interval of stroke and the percent of fibrin in the thrombus (Pearson correlation coefficient -0.01, p 0.94). Conclusion: These preliminary results demonstrate a lack of relationship between time interval of the stroke and clot histology composition with relation to fibrin. Thrombus fibrin composition is likely more related to other factors, and not predominantly related to time. We are currently investigating potential relationships to demographics and co-morbidities.

Chronic subdural hematoma (cSDH) represents a relatively treatment-resistant pathologic process with a large impact on quality-adjusted life years. This risk is increased in the elderly, and the prevalence is expected to rise as the population ages. Expectant management and classical surgical treatment are associated with increased recurrence rate as well as complications. Middle meningeal artery (MMA) embolization is being utilized more frequently as adjunctive and primary treatment. It has demonstrated beneficial effects on recurrence and progression of cSDH. Here, we present the outcomes of this technique with different embolic agents in our patient population. IRB approval was obtained for this study. Retrospectively, all patients at a single institution who underwent endovascular MMA embolization with or without open surgical intervention for cSDH were included. Vulnerable populations were excluded. Demographic and medical data were collected at initial, 1-month, and 3-month time points if available and analyzed for differences with unpaired T-test, paired-T test, and chi-square test. Between 2020 and 2024, a total of 50 patients were treated with MMA embolization for cSDH. Mean age was 73 years. Majority were male. Most were on antithrombotic therapy. Of these, 34 had history of prior SDH, and 38 had history of head trauma. Of the 50 patients, 29 patients underwent combined open surgery and MMA embolization, while 21 underwent MMA embolization alone. The cSDH was bilateral in 23 patients and unilateral in 27 (13 right, 14 left) for a total of 73 cSDHs. Surgical evacuation was performed in 44 cSDHs. Liquid embolic agent (Onyx) was utilized for 32 patients, while particulate embolic agents (250-500 um) were utilized for 18 patients. Of the patients who had follow-up CTs at 1 month, there were 21 cSDHs treated with particles and 39 with Onyx. There was no significant difference in the proportions of patients undergoing surgery in addition to MMA embolization between the groups treated with Onyx and those treated with particle embolization. Additionally, there was no significant difference in the proportions of treated hemispheres with ≥ 50% reduction or ≥ 75% reduction between those treated with Onyx and those treated with particles. At our institution, there was no difference in reduction of cSDH with Onyx as compared to particle embolization. MMA embolization was associated with no recurrence or progression of cSDH at 3 months.

Abstract Date Presented 04/04/2025 The eHealth online intervention targeting cancer-related fatigue demonstrated a significant reduction in fatigue and improvement in quality of life and Canadian Occupational Performance Measure satisfaction scores. This provides preliminary support for using eHealth for treating cancer-related fatigue (CRF). Primary Author and Speaker: Anne Fleischer Additional Authors and Speakers: Mary Insala Fisher Contributing Authors: Caroline Frazee, Carrie Pickering, Emily Flohre, Samantha Wourms

Introduction: To detect coronary artery disease (CAD) in asymptomatic patients, noninvasive coronary artery calcium (CAC) computed tomography (CT) can be used in the decision to start statin or further lipid lowering management. The test is appropriate for adult patients 40-75 years old at 10-year atherosclerotic cardiovascular disease intermediate risk (7.5-20%) without diabetes mellitus and with low-density lipoprotein cholesterol 70-189 mg/dL. The study was to identify risk factor differences between self and provider-referred groups. We hypothesized that the provider-referred group would have greater risk factors. Methods: Patients who received CAC CT at seven southwest Ohio hospitals for the first 6 months of 2019 were self or provider-referred for CAC CT during a community campaign for persons who identified as having cardiovascular risk factors. Their background information and labs were obtained and compared to ascertain differences. Results: The analyses involved 2124 patients who received CAC CT. 163 were self and 1961 were provider-referred. With 30 demographic and clinical risk factors compared, peripheral vascular disease, higher triglyceride levels, higher LDL and beta blocker prescription were associated with higher odds for elevated CAC score in the self-referred group. There was no difference between white or black races. Conclusion: CAC CT testing can be used to clarify cardiovascular risk and to optimize medical therapy for both self and provider-referred groups. Self-referred patients seem to identify with similar or advanced awareness of risk factors for primary prevention concerns when a community initiative was issued. Therefore, community initiatives may have a public health benefit for primary prevention and early detection of cardiac risk. This is a study that may be repeated in other communities.

Between March 2020 to October 2021, COVID-19 accounted for 12.2% of deaths, about 350,000 people in the United States. The pandemic virus accounted for the third leading cause of death behind heart disease and cancer. Importantly heart disease deaths increased 4.1% in the first year of exposures from 2019 to 2020 which may reflect delay to pursue medical care due to COVID. Because of lockdown mandates it was suspected that chronic and incident diseases had poorer disease control and delayed diagnosis of primary conditions due to decreased contact within the medical system with the purpose of decreasing viral spread. We wished to collect background presentation differences in a specific cohort at risk, STEMI-activated patients, for years 2019 to 2021. 1001 adults were STEMI-activated January 2019 to December 2021. Patient demographics, risk factors, details of presentation and rationale for cath-lab activation were obtained. Average age 63.5 years old, BMI 30.2 kg/m2, and 68.8% males, which was not statistically significant. Hypertension, hyperlipidemia, diabetes, peripheral vascular disease, chronic lung disease, prior CABG, tobacco use, dialysis renal disease, history and newly diagnosed congestive heart failure were not significant between years. However cerebrovascular disease(CVA) was three times more prominent for patients presenting in 2019 compared to 2020. There were no differences in details of presentation for location of cardiac arrest (out-of-hospital, transfer, in-hospital). Rationale for cardiac cath was significant for new onset angina significant in 2019 and 2021. Worsening angina was significant in 2019. COVID-19 continues to affect many aspects of society and healthcare but how it has affected background disease control remains unclear. Patients in our sample were similar age, BMI and gender. Background risk factors were significant for CVA which was 1.87 times higher in 2019. New onset angina led to more caths in 2019 and 2021, and worsening angina was a significant complaint in 2019 compared to other years. There were not the amount of differences we expected suggesting that chronic diseases and new diagnoses remained at near the same level through years of pandemic consideration.

Background: This project describes one healthcare system’s journey to expand the outreach of the Primary Stroke Center. Premier Health (PH) is a hospital system based in Dayton Ohio that provides services for over 2,200 stroke patients annually. Premier Health consists of 5 community hospitals 3 of which are Joint Commission certified Primary Stroke Centers. The requirement for Stroke Specialized Physicians on-call 24 hours a day had become more difficult with expansion of services to respond to community needs. With a limited number of Stroke Physicians within system, it was not feasible for available Physician’s to cover the 50 mile radius. A Tele-Stroke Network was developed to provide lifesaving services as well as 24/7 coverage for stroke call. Program results include synergistic unity of best practices and improved patient outcomes with the majority of patients remaining in their community. Purpose: Implement a Tele-Stroke System to provide specialty coverage and favorable patient outcomes for a Primary Stroke Center that provides coverage for a large region in the Midwest. Methods: In 2013 a stroke telehealtlh Clinical Nurse Specialist role was added and became pivotal in facilitating the following outcomes: 1) Restructuring of the Stroke Alert Call Schedules across the system. 2) Streamlining Stroke Alert Process across the system and redesign of work flows 3) Development of standard system order sets to streamline care delivery. 4) Providing IT training to end users and physicians at five hospitals. Results: • 304 Tele-Stroke consults conducted since implementation. • 33% increase in the volume of patient’s receiving T-PA • Average of 20 minutes reduction in Door to Needle for 2 of the 5 hospitals • Post telemedicine implementation there was a reduction in transfers from spoke hospitals to hub. On average, 83 % of the PH Tele-Stroke patients were able to stay in their respective communities while receiving Primary Stroke Center Care via telemedicine. Conclusion: Telemedicine implementation with standardization of stroke alert processes and order sets, restructuring of physician scheduling and IT training for the Primary Stroke Team resulted in improved t-PA use, lower door to needle time and reduction in unnecessary transfers of patients.

Abstract PURPOSE Glioblastoma is the most aggressive adult brain tumor, with a median overall survival of approximately 15 months. It is important to build accurate prognostic models for glioblastoma patients to inform clinical management and trials. This study proposes a self-supervised learning-based approach with multimodal data integration for survival prediction and prognostic stratification of glioblastoma patients on the ReSPOND consortium. METHODS We curated a multi-parametric MRI dataset (T1, T1CE, T2, FLAIR) of 3,119 glioblastoma patients from 22 institutions across 3 continents. Masked autoencoder (MAE) was adapted to pretrain a Vision Transformer (ViT) encoder by reconstructing the masked image patches. The encoder was utilized for extracting patch embeddings for survival tasks, with cross-attention mechanism to incorporate the molecular and clinical information (age, sex, extent of resection, MGMT) to guide imaging feature aggregation. Imaging and clinical embeddings were fused through a multi-layer perceptron (MLP) for log-risk hazard estimation, optimized using Cox partial likelihood. Model performance and generalizability were assessed via k-fold cross-validation on the ReSPOND consortium and the leave-one-site-out validation was performed on 11 institutions comparing with CoxPH, DeepSurv and DeepHit. Prognostic risk stratification via Kaplan-Meier analysis divided the patients into low-, medium- and high-risk subgroups per site. RESULTS Multimodal data integration using the proposed framework achieved the highest C-index (0.674 ± 0.017) on the ReSPOND consortium. Integration of clinical information and MGMT consistently boosted the performance of the proposed model across sites (0.615 ± 0.046 vs. 0.662 ± 0.044). The imaging-based approaches, i.e., radiomics and convolutional neural network (CNN) features performed less robustly. The Kaplan-Meier curves and log-rank tests suggested the proposed framework achieved more separable prognostic subgroups. CONCLUSION The proposed self-supervised multimodal learning framework shows promise for survival prediction and prognostic risk stratification in glioblastoma. It highlights the challenge for clinical model deployment due to the data heterogeneity in multi-institutional cohort.

Background and Purpose: Intracranial aneurysms (IAs) with daughter sacs (DSs) have an increased risk for rupture yet the hemodynamic factors contributing to DS pathophysiology are still under-investigated. This study aimed to investigate hemodynamic factors in DS generation and rupture using anatomic and ablated IA models under various DS scenarios. Methods: 113 computational models of 43 patients with at least one IA containing a DS were built based on 3D rotational angiographical images using benchmarked model reconstruction procedures. Of these 43 patients, there were 19 ruptured (RIAs) and 26 unruptured IAs (UIAs). Ablated models representing the aneurysm before the DS formation were rebuilt by virtually ablating the blebs from the anatomic models. In-vitro validated computational fluid dynamics simulations were conducted for both anatomic IA and ablated IA models under physiologically pulsatile flow conditions. Wall shear stress (WSS) associated parameters were used to analyze the hemodynamic factor on the DS pathophysiology statistically. Results and Discussion: There was a statistically significant difference seen between RIAs and UIAs in hemodynamic performances at the entire aneurysmal sac region (P<0.01). Specifically, there was a significant difference in maximum instantaneous WSS (MIWSS), maximum instantaneous WSS gradient (MIWSSG), maximum time-averaged WSS (MTAWSS), and maximum time-averaged WSS (MTAWSSG) observed between RIAs and UIAs arising from the internal carotid artery, anterior cerebral artery, and middle cerebral artery. The difference in maximum oscillatory shear index (OSI) between RIAs and UIAs was not consistent at these aneurysmal locations. In addition, on the local DS bleb region, the hemodynamic comparisons between UIAs and RIAs were not consistent with the comparisons on the entire aneurysmal sac region. Future studies include the introduction of new parameters (i.e., instantaneous/time-averaged surface-averaged WSS, WSSG, and OSI) to investigate specific hemodynamic factors associated with DS and IA rupture. Hemodynamics between anatomic and ablated IA models will also be compared to determine its contributions on DS bleb inception. In conclusion, these findings are significant as they do suggest possible factors contributing to IA rupture. Continued research in this area will help develop a diagnostic tool to analyze IA rupture risk better than current available methods.