Optimal patient management protocols for metastatic castration-resistant prostate cancer (mCRPC) are poorly defined and even further complexified with new therapy approvals, such as radiopharmaceuticals. The prostate-specific membrane antigen (PSMA)–targeted agent ¹⁷⁷Lu vipivotide tetraxetan ([¹⁷⁷Lu]Lu-PSMA-617), approved after the phase III VISION study, presents physicians with additional aspects of patient management, including specific adverse event (AE) monitoring and management, as well as radiation safety. Drawing on our experience as VISION study investigators, here we provide guidance on best practices for delivering PSMA-targeted radiopharmaceutical therapy (RPT) to patients with mCRPC. After a comprehensive review of published evidence and guidelines on RPT management in prostate cancer, we identified educational gaps in managing the radiation safety and AEs associated with [¹⁷⁷Lu]Lu-PSMA-617. Our results showed that providing sufficient education on AEs (e.g., fatigue and dry mouth) and radiation safety principles is key to effective delivery and management of patient expectations. Patient counseling by health care professionals, across disciplines, is a cornerstone of optimal patient management during PSMA-targeted RPT. Multidisciplinary collaboration is crucial, and physicians must adhere to radiation safety protocols and counsel patients on radiation safety considerations. Treatment with [¹⁷⁷Lu]Lu-PSMA-617 is generally well tolerated; however, additional interventions may be required, such as dosing modification, medications, or transfusions. Urinary incontinence can be challenging in the context of radiation safety. Multidisciplinary collaboration between medical oncologists and nuclear medicine teams ensures that patients are monitored and managed safely and efficiently. In clinical practice, the benefit-to-risk ratio should always be evaluated on a case-by-case basis.

Multiple sclerosis (MS) is a chronic inflammatory demyelinating and neurodegenerative disease of the central nervous system (CNS), with a putative autoimmune origin and complex pathogenesis. Modification of the natural history of MS by reducing relapses and slowing disability accumulation was first attained in the 1990 s with the development of the first-generation disease-modifying therapies. Glatiramer acetate (GA), a copolymer of L-alanine, L-lysine, L-glutamic acid, and L-tyrosine, was discovered due to its ability to suppress the animal model of MS, experimental autoimmune encephalomyelitis. Extensive clinical trials and long-term assessments established the efficacy and the safety of GA. Furthermore, studies of the therapeutic processes induced by GA in animal models and in MS patients indicate that GA affects various levels of the innate and the adaptive immune response, generating deviation from proinflammatory to anti-inflammatory pathways. This includes competition for binding to antigen presenting cells; driving dendritic cells, monocytes, and B-cells toward anti-inflammatory responses; and stimulating T-helper 2 and T-regulatory cells. The immune cells stimulated by GA reach the CNS and secrete in situ anti-inflammatory cytokines alleviating the pathological processes. Furthermore, cumulative findings reveal that in addition to its immunomodulatory effect, GA promotes neuroprotective repair processes such as neurotrophic factors secretion, remyelination, and neurogenesis. This review aims to provide an overview of MS pathology diagnosis and treatment as well as the diverse mechanism of action of GA.

BACKGROUND AND PURPOSE:

Low-field 64 mT portable brain MRI has recently shown diagnostic promise for MS. This study aimed to evaluate the utility of portable MRI (pMRI) in assessing dissemination in space (DIS) in patients presenting with optic neuritis and determine whether deploying pMRI in the MS clinic can shorten the time from symptom onset to MRI.

BACKGROUND AND PURPOSE:

Neuronal ceroid lipofuscinoses are a group of neurodegenerative disorders. Recently, enzyme replacement therapy (ERT) was approved for neuronal ceroid lipofuscinosis type 2 (CLN2), a subtype of neuronal ceroid lipofuscinoses. The aim of this study was to quantify brain volume loss in CLN2 disease in patients on ERT in comparison with a natural history cohort using MRI.

BACKGROUND AND PURPOSE:

Gadolinium-based contrast agents are widely used for meningioma imaging; however, concerns exist regarding their side effects, cost, and environmental impact. At the standard gadolinium dose, most meningiomas show avid contrast enhancement, suggesting that administering a smaller dose may be feasible. The purpose of this study was to evaluate the impact of a lower gadolinium dose on the differentiation between meningiomas and adjacent intracranial tissues.

BACKGROUND AND PURPOSE:

Overuse of CT-based cerebrovascular imaging in the emergency department and inpatient settings, notably CTA of the head and neck for minor and nonfocal neurologic presentations, stresses imaging services and exposes patients to radiation and contrast. Furthermore, such CT-based imaging is often insufficient for definitive diagnosis, necessitating additional MR imaging. Recent advances in fast MRI may allow timely assessment and a reduced need for head and neck CTA in select populations.

BACKGROUND AND PURPOSE:

There has been a distinction made in the 2001 Canadian C-Spine Rule regarding patients 65 and older and younger than 65 years of age as far as indications for cervical spine CT scanning. We sought to determine if there are differences in the symptoms, mechanisms of injury, fracture locations, and types that are still relevant in 2024.

BACKGROUND AND PURPOSE:

Periprocedural intracranial hemorrhage is one of common complications after stent placement for symptomatic intracranial atherosclerotic stenosis. This study was conducted to demonstrate predictors and long-term outcomes of periprocedural intracranial hemorrhage after stent placement for symptomatic intracranial atherosclerotic stenosis.

BACKGROUND AND PURPOSE:

Reocclusion after treatment is a concern in endovascular therapy for isolated intracranial atherothrombotic stroke-related large-vessel occlusion (AT-LVO). However, the optimal endovascular therapy technique for AT-LVO has not yet been investigated. This study evaluated the optimal endovascular therapy technique for AT-LVO in a real-world setting.

BACKGROUND AND PURPOSE:

Prediction of aneurysm instability is crucial to guide treatment decisions and to select appropriate patients with unruptured intracranial aneurysms (IAs) for preventive treatment. High-resolution 4D MR flow imaging and 3D quantification of aneurysm morphology could offer insights and new imaging markers for aneurysm instability. In this cross-sectional study, we aim to identify 4D MR flow imaging markers for aneurysm instability by relating hemodynamics in the aneurysm sac to 3D morphologic proxy parameters for aneurysm instability.

Spinal CSF leak care has evolved during the past several years due to pivotal advances in its diagnosis and treatment. To the reader of the American Journal of Neuroradiology (AJNR), it has been impossible to miss the exponential increase in groundbreaking research on spinal CSF leaks and spontaneous intracranial hypotension (SIH). While many clinical specialties have contributed to these successes, the neuroradiologist has been instrumental in driving this transformation due to innovations in noninvasive imaging, novel myelographic techniques, and image-guided therapies. In this editorial, we will delve into the exciting advancements in spinal CSF leak diagnosis and treatment and celebrate the vital role of the neuroradiologist at the forefront of this revolution, with particular attention paid to CSF leak–related work published in the AJNR.

Rare genetic conditions are challenging for the primary care provider to manage without proper guidelines. This clinical review is designed to assist the pediatrician, family physician, or internist in the primary care setting to manage the complexities of 16p11.2 deletion syndrome. A multidisciplinary medical home with the primary care provider leading the care and armed with up-to-date guidelines will prove most helpful to the rare genetic patient population. A special focus on technology to fill gaps in deficits, review of case studies on novel medical treatments, and involvement with the educational system for advocacy with an emphasis on celebrating diversity will serve the rare genetic syndrome population well.

Inositol 1,4,5-triphosphate receptor type 1 (ITPR1) is an endoplasmic reticulum–bound intracellular inositol triphosphate receptor involved in the regulation of intracellular calcium. Pathogenic variants in ITPR1 are associated with spinocerebellar ataxia (SCA) types 15/16 and 29 and have recently been implicated in a facial microsomia syndrome. In this report, we present a family with three affected individuals found to have a heterozygous missense c.800C > T (predicted p.Thr267Met) who present clinically with a SCA29-like syndrome. All three individuals presented with varying degrees of ataxia, developmental delay, and apparent intellectual disability, as well as craniofacial involvement—an uncommon finding in patients with SCA29. The variant was identified using clinical exome sequencing and validated with Sanger sequencing. It is presumed to be inherited via parental germline mosaicism. We present our findings to provide additional evidence for germline mosaic inheritance of SCA29, as well as to expand the clinical phenotype of the syndrome.

Anorectal malformations (ARMs) constitute a group of congenital defects of the gastrointestinal and urogenital systems. They affect males and females, with an estimated worldwide prevalence of 1 in 5000 live births. These malformations are clinically heterogeneous and can be part of a syndromic presentation (syndromic ARM) or as a nonsyndromic entity (nonsyndromic ARM). Despite the well-recognized heritability of nonsyndromic ARM, the genetic etiology in most patients is unknown. In this study, we describe three siblings with diverse congenital anomalies of the genitourinary system, anemia, delayed milestones, and skeletal anomalies. Genome sequencing identified a novel, paternally inherited heterozygous Caudal type Homeobox 2 (CDX2) variant (c.722A > G (p.Glu241Gly)), that was present in all three affected siblings. The variant identified in this family is absent from population databases and predicted to be damaging by most in silico pathogenicity tools. So far, only two other reports implicate variants in CDX2 with ARMs. Remarkably, the individuals described in these studies had similar clinical phenotypes and genetic alterations in CDX2. CDX2 encodes a transcription factor and is considered the master regulator of gastrointestinal development. This variant maps to the homeobox domain of the encoded protein, which is critical for interaction with DNA targets. Our finding provides a potential molecular diagnosis for this family's condition and supports the role of CDX2 in anorectal anomalies. It also highlights the clinical heterogeneity and variable penetrance of ARM predisposition variants, another well-documented phenomenon. Finally, it underscores the diagnostic utility of genomic profiling of ARMs to identify the genetic etiology of these defects.

Affibody molecules are small (6-kDa) affinity proteins folded in a three-helical bundle and generated by directed evolution for specific binding to various target molecules. The most advanced affibody molecules are currently tested in the clinic, and data from more than 300 subjects show excellent activity and safety profiles. The generation of affibody molecules against a particular target starts with the generation of an affibody library, which can then be used for panning using multiple methods and selection systems. This protocol describes the molecular cloning of DNA-encoded affibody libraries to a display vector of choice, for either phage, Escherichia coli, or Staphylococcus carnosus display. The DNA library can come from different sources, such as error-prone polymerase chain reaction (PCR), molecular shuffling of mutations from previous selections, or, more commonly, from DNA synthesis using various methods. Restriction enzyme-based subcloning is the most common strategy for affibody libraries of higher diversity (e.g., >10⁷ variants) and is described here.

Sleep is important for survival, and the need for sleep is conserved across species. In the past two decades, the fruit fly Drosophila melanogaster has emerged as a promising system in which to study the genetic, neural, and physiological bases of sleep. Through significant advances in our understanding of the regulation of sleep in flies, the field is poised to address several open questions about sleep, such as how the need for sleep is encoded, how molecular regulators of sleep are situated within brain networks, and what the functions of sleep are. Here, we describe key findings, open questions, and commonly used methods that have been used to inform existing theories and develop new ways of thinking about the function, regulation, and adaptability of sleep behavior.

BackgroundAttention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder, for which there are effective pharmacological treatments that improve symptoms and reduce complications. Guidelines published by the National Institute for Health and Care Excellence recommend that primary care practitioners prescribe medication for adult ADHD under shared-care agreements with Adult Mental Health Services (AMHS). However, provision remains uneven, with some practitioners reporting a lack of support.AimThis study aimed to describe elements of support, and their availability/use, in primary care prescribing for adult ADHD medication in England to improve access for this underserved population and inform service improvement.Design and settingCross-sectional surveys were used to elicit data from commissioners, health professionals (HPs), and people with lived experience of ADHD (LE) across England about elements supporting pharmacological treatment of ADHD in primary care.MethodThree interlinked cross-sectional surveys were used to ask every integrated care board in England (commissioners), along with convenience samples of HPs and LEs, about prescribing rates, AMHS availability, wait times, and shared-care agreement protocols/policies for the pharmacological treatment of ADHD in primary care. Descriptive analyses, percentages, and confidence intervals were used to summarise responses by stakeholder group. Variations in reported provision and practice were explored and displayed visually using mapping software.ResultsData from 782 responders (42 commissioners, 331 HPs, 409 LEs) revealed differences in reported provision by stakeholder group, including for prescribing (95% of HPs versus 64% of LEs). In all, >40% of responders reported extended AMHS wait times of ≥2 years. There was some variability by NHS region – for example, London had the lowest reported extended wait time (25%), while East of England had the highest (55%).ConclusionElements supporting appropriate shared-care prescribing of ADHD medication via primary care are not universally available in England. Coordinated approaches are needed to address these gaps.

BackgroundMost people with type 2 diabetes receive treatment in primary care by GPs who are not specialised in diabetes. Thus, it is important to uncover the most essential information needs regarding type 2 diabetes in general practice.AimTo identify information needs related to type 2 diabetes for GPs.Design and settingSystematic review focused on literature relating to Western countries.MethodMEDLINE, Embase, PsycInfo and CINAHL were searched from inception to January 2024. Two researchers conducted the selection process, and citation searches were performed to identify any relevant articles missed by the database search. Quality appraisal was conducted with the Mixed Methods Appraisal Tool. Meaning units were coded individually, grouped into categories, and then studies were summarised within the context of these categories using narrative synthesis. An evidence map was created to highlight research gaps.ResultsThirty-nine included studies revealed eight main categories and 36 subcategories of information needs. Categories were organised into a comprehensive hierarchical model of information needs, suggesting ‘Knowledge of guidelines’ and ‘Reasons for referral’ as general information needs alongside more specific needs on ‘Medication’, ‘Management’, ‘Complications’, ‘Diagnosis’, ‘Risk factors’, and ‘Screening for diabetes’. The evidence map provides readers with the opportunity to explore the characteristics of the included studies in detail.ConclusionThis systematic review provides GPs, policymakers, and researchers with a hierarchical model of information and educational needs for GPs, and an evidence map showing gaps in the current literature. Information needs about clinical guidelines and reasons for referral to specialised care overlapped with needs for more specific information.

BackgroundBetween 2003 and 2018, incident prescriptions of beta-blockers for anxiety increased substantially, particularly for young adults. National Institute for Health and Care Excellence guidance for anxiety does not recommend beta-blockers, probably due to a lack of evidence to support such use. Recent reports have highlighted the potential risks of beta-blockers.AimTo understand when and why GPs prescribe beta-blockers for people with anxiety.Design and settingIn-depth interviews with 17 GPs in Bristol and the surrounding areas.MethodInterviews were held by telephone or video call. A topic guide was used to ensure consistency across interviews. Interviews were audio-recorded, transcribed verbatim, and analysed thematically.ResultsMany GPs viewed beta-blockers as ‘low risk’, particularly for young adults. Some GPs viewed beta-blockers as an alternative to benzodiazepines, acting quickly and not leading to dependence. GPs reflected that some patients appeared to want an ‘immediate fix’ to their symptoms, which GPs thought beta-blockers could potentially offer. This is salient in light of substantial waiting lists for talking therapies and delays in antidepressants taking effect. GPs described how some patients seemed more willing to try beta-blockers than antidepressants, as patients did not perceive them as ‘mental health drugs’ and therefore viewed them as potentially more acceptable and less stigmatising. Further, GPs viewed beta-blockers as ‘patient-led’, with patients managing their own dose and frequency, without GP input.ConclusionMany GPs believe that beta-blockers have a role to play in the management of anxiety. Given recent increases in the prescribing of these drugs in primary care, there is a need to assess their safety and effectiveness as a treatment for people with anxiety disorders.

We primary care clinicians, scholars, and leaders ascribe value to Barbara Starfield’s core tenets of primary care—the 4 Cs: first contact, comprehensiveness, coordination, and continuity. In today’s era of rapid technological advancements and dwindling resources, what are the implications for face-to-face interactions of patient-clinician relationships? We propose adding a 5th C: "Contiguity." Contiguity—or physical proximity and presence—is a key dimension that not only enables the necessary technical aspects of a physical exam but also authenticates the most human aspects of a relationship and occurs specifically when we are physically vulnerable and responsible for the other before us. This, in turn, may best enable us to bridge difference and nurture trust with our patients. We measure what we value and, thus, naming Contiguity as a core tenet assures that we will not lose sight of this keystone in a patient’s relationship with their personal physician.

The usual challenges of conducting primary care research, including randomized trials, have been exacerbated, and new ones identified, during the COVID-19 pandemic. HOMER (Home versus Office for Medication Enhanced Recovery; subsequently, Comparing Home, Office, and Telehealth Induction for Medication Enhanced Recovery) is a pragmatic, comparative-effectiveness research trial that aims to answer a key question from patients and clinicians: What is the best setting in which to start treatment with buprenorphine for opioid use disorder for this patient at this time? In this article, we describe the difficult journey to find the answer. The HOMER study began as a randomized trial comparing treatment outcomes in patients starting treatment with buprenorphine via induction at home (unobserved) vs in the office (observed, synchronous). The study aimed to enroll 1,000 participants from 100 diverse primary care practices associated with the State Networks of Colorado Ambulatory Practices and Partners and the American Academy of Family Physicians National Research Network. The research team faced unexpected challenges related to the COVID-19 pandemic and dramatic changes in the opioid epidemic. These challenges required changes to the study design, protocol, recruitment intensity, and funding conversations, as well as patience. As this is a participatory research study, we sought, documented, and responded to practice and patient requests for adaptations. Changes included adding a third study arm using telehealth induction (observed via telephone or video, synchronous) and switching to a comprehensive cohort design to answer meaningful patient-centered research questions. Using a narrative approach based on the Greek myth of Homer, we describe here the challenges and adaptations that have provided the opportunity for HOMER to thrive and find the way home. These clinical trial strategies may apply to other studies faced with similar cultural and extreme circumstances.

Patient expectations of receiving antibiotics for common symptoms can trigger unnecessary use. We conducted a survey (n = 564) between January 2020 to June 2021 in public and private primary care clinics in Texas to study the prevalence and predictors of patients’ antibiotic expectations for common symptoms/illnesses. We surveyed Black patients (33%) and Hispanic/Latine patients (47%), and over 93% expected to receive an antibiotic for at least 1 of the 5 pre-defined symptoms/illnesses. Public clinic patients were nearly twice as likely to expect antibiotics for sore throat, diarrhea, and cold/flu than private clinic patients. Lack of knowledge of potential risks of antibiotic use was associated with increased antibiotic expectations for diarrhea (odds ratio [OR] = 1.6; 95% CI, 1.1-2.4) and cold/flu symptoms (OR = 2.9; 95% CI, 2.0-4.4). Lower education and inadequate health literacy were predictors of antibiotic expectations for diarrhea. Future antibiotic stewardship interventions should tailor patient education materials to include information on antibiotic risks and guidance on appropriate antibiotic indications.

PURPOSE

We undertook a trial to test the efficacy of a technology-assisted health coaching intervention for weight management, called Goals for Eating and Moving (GEM), within primary care.

BACKGROUND

For many patients with post–COVID-19 condition (long COVID), primary care is the first point of interaction with the health care system. In principle, primary care is well situated to manage long COVID. Beyond expressions of disempowerment, however, the patient’s perspective regarding the quality of long COVID care is lacking. Therefore, this study aimed to analyze the expectations and experiences of primary care patients seeking treatment for long COVID.

The deadline to claim part of the $15 million Cash App settlement is November 18. Here's what to know.

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HARI SREENIVASAN: The desire of the Kurds along Iraq’s northern border to govern themselves is receiving more resistance from Iraq’s central government. Iraqi army forces are demanding Kurdish troops withdraw from oil fields and military bases around Kirkuk, a city in the Kurdistan region that voted for independence last month. Kirkuk also has 10% of Iraq’s known oil reserves. Washington Post’s Loveday Morris is in Baghdad covering this standoff joins me now via Skype. First of all the significance of this. Why is it so important?

LOVEDAY MORRIS: There’s been a longtime conflict between Baghdad and Kurdistan over these disputed territories. Most significant of which is Kirkuk because of the oil reserves. But the referendum last month has really sharpened these disputes because you have Baghdad opposing independence and so it feels like they have to restate its territorial claims these areas. So that’s why we’re seeing a lot of tension right now.

HARI SREENIVASAN: And just to give people a little bit of a brief timeline – Iraqi forces control this area for a while and then in June ISIS took over the area and now it’s kind of back in Kurdish hands?

LOVEDAY MORRIS: Right. So in June 2014 Iraq lost control of a lot of the areas and we have this huge collapse in the face of an ISIS offensive. Over 100,000 soldiers fled and Kurdish forces moved in some of these areas – some of them maybe took from ISIS and others just moved into into the vacuum. And so Iraqi forces have been in these areas since June 2014. And that’s their main demand that they return to the areas.

HARI SREENIVASAN: What’s the likelihood that this standoff right now turns violent? Into some sort of a civil war?

LOVEDAY MORRIS:: I think at this point both sides don’t want violence. Al-Abadi, the prime minister, is really trying to defuse the situation by saying there’s going to be no military attack. But at the same time there is this buildup of forces so that I think they are trying to, in a way, intimidate the Kurds to withdraw from some areas but they don’t want to see a fight per say. But in this really tense situation there can be a small spark and things can turn violent quite easily.

HARI SREENIVASAN: Thank you.

The post Iraqi, Kurdish forces in standoff, weeks after Kurdish vote for independence appeared first on PBS NewsHour.

U.S.-backed Syrian Democratic Forces announced Tuesday that they had captured the city of Raqqa from Islamic State militants.

“Everything is finished in Raqqa, our forces have taken full control of Raqqa,” SDF spokesman Talal Sello told AFP. A formal declaration would be announced after operations to clear any remaining sleeper cells and to remove landmines in the city were completed, Sello added.

The move is a major setback for the Islamic State which considered Raqqa the de-facto capital of its self-declared caliphate. It comes on the third anniversary of the global effort to defeat ISIS.

Raqqa was the first provincial capital to fall from government control in March 2013 after it was captured by a rebel army. The army included both Syrian opposition groups and more hard line  parties including al-Nusra and the Islamic State.

A civilian government  that was established in the city divided two months later, and less than a year later ISIS recaptured Raqqa and named the the capital of their caliphate.

About 900 civilians have been killed since the the start of the five-month operation, including 570 people in coalition air raids, according to the Syrian Network for Human Rights. The Britain-based Syrian Observatory for Human Rights put the civilian death toll at 1,130 people. American journalist James Foley was beheaded in the mountains south of the city.

SDF fighters pulled down the Islamic State’s black flag from the city’s National Hospital near the city’s stadium, according to a Reuters report.

Special presidential envoy for the Global Coalition to Defeat ISIS Brett McGurk said in August that the U.S. would attempt to perform a “stabilization” in Raqqa — including demining, removing rubble from major pathways to allow trucks and equipment through, and “basic electricity, sewage, water, the basic essentials to allow populations to come back to their home.”

It is not clear when the 300,000 civilians who have fled Raqqa since April during the operation will be able to return.

The post U.S.-backed Syrian forces recapture Raqqa from Islamic State group appeared first on PBS NewsHour.

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HARI SREENIVASAN: But first: The de facto capital of the Islamic State, Raqqa, in Syria fell yesterday to U.S.-backed forces.

However, the largest city the militants once held was Mosul in Iraq. They were ousted from it in July after a brutal 10-month-long fight that killed thousands.

Now a new major task: finding and destroying the ISIS mines, booby-traps and bombs that litter the city.

Special correspondent Marcia Biggs reports from Iraq.

MARCIA BIGGS, Special Correspondent: It was once a center of learning for over 6,000 students of technology, agriculture, and medicine.

Today, Mosul Technical Institute’s classrooms are burnt to the ground, laboratories reduced to rubble, and books charred and shredded. It’s one of the city’s five universities ravaged by the Islamic State and the battle to oust it.

Now that the battle is over, a new danger looms, the trail of land mines and booby-traps left by ISIS.

So this is the wire, and this is where it was buried.

CHRISTIAN, Team Leader, Janus Global Operations: Yes, they would cut the asphalt, and then they lay the wire in and put the main charge here.

MARCIA BIGGS: We spent the day with Christian, a team leader from Janus Global, a security and risk management firm hired by the U.S. government to sweep and clear major areas of unexploded ordnance and mines.

He’s not allowed to show his face or use his last name, for security reasons.

CHRISTIAN: There’s actually two more on that road before we get to the target building that have to be excavated and/or rendered safe.

MARCIA BIGGS: So, the first building you have to clear, you have got to get rid of the IEDs on the road to that building?

CHRISTIAN: Yes.

MARCIA BIGGS: It’s a long process.

CHRISTIAN: It is, but that’s what makes it interesting.

MARCIA BIGGS: The United States has sunk $30 million this year into clearing former ISIS territories all over Northern Iraq. Under this program, Janus has already cleared 727 buildings, removing 3,000 IEDs, which they say ISIS was producing on assembly lines at an industrial scale.

But State Department officials and experts say the number of unexploded ordnance in Mosul itself is unprecedented.

What’s your first line of attack, in terms of trying to clear Mosul?

CHRISTIAN: Our priority is more the community, rather than the individual, you know, infrastructure. You have got schools, power, sewer, water, so that the area can accept people back into it. And then, once this stabilization phase is over, we can move into the individual homes, so that they can be safer.

MARCIA BIGGS: Clearing Mosul is a process that they say could take years, even decades. So Janus is training local Iraqis to do the job, sending them out as a front-line search team, then investigating and removing any suspicious items themselves.

CHRISTIAN: We’re not going to be here the whole time, so when we — it’s our time to leave, they will have the capacity built from us, and the mentoring we have done, so that they can do it on their own.

MARCIA BIGGS: How are they doing?

CHRISTIAN: They’re — a lot of them are very apt to learn. They’re quick. They’re smart.

MARCIA BIGGS: Fawzi al Nabdi is the team leader for the Iraqi local partner. He’s cleared mines all over Iraq for the last six years.

CHRISTIAN: What you got?

FAWZI AL NABDI, Team Leader, Al Fahad Company (through interpreter): We are ready for this, because it’s my job and I love it. The Americans are here to complete our work and to help us. They have greater experience than we do. If we find any mines, we have to stop and they will investigate it and make a plan to remove it.

MARCIA BIGGS: But he says Mosul is the biggest project he has ever seen, and we’re told it could take at least a month to just get the campus cleared of mines. Only then can they start cleaning it up, so that students can resume classes, this itself a huge task.

ISIS fighters closed the university back in 2014, and used it as a military base. As coalition forces pounded ISIS targets, this seat of higher learning became a battleground.

Ghassan Alubaidy is the institute’s dean.

GHASSAN ALUBAIDY, Dean, Mosul Technical Institute (through interpreter): ISIS used our university to manufacture mines and bombs. For this reason, it was the target of airstrikes in the beginning. They struck the institute nine times, and they struck our workshops, too. Now we can’t use them.

MARCIA BIGGS: The former commander of coalition forces in Iraq, Lieutenant General Stephen Townsend, recently listed 81 locations where bombs were dropped, but had not yet exploded.

Facilities used to make weapons were often on the list of high-value targets for the coalition. So now those places are twice as likely to contain dangerous items.

So, this was once a workshop for electrical engineering students. You can still see the lab tables here. It was hit by an airstrike in 2015. Afterwards, members of the university staff found bomb-making instructions among the rubble. This was likely an ISIS bomb-making factory, and judging by the crater, a high-value target.

Despite the damage, Dean Alubaidy says he will hold classes this fall in alternate buildings, until the campus is ready. He’s expecting registration to be in the thousands, students who lost three years of education during the fighting and don’t want to lose another one.

GHASSAN ALUBAIDY (through interpreter): On our Facebook pages, we found a great number of students posting that they were full of encouragement to come back. For us, it was unbelievable. We couldn’t imagine it, to see how many students wanted to start again, how they were dreaming of the first day of classes, when they could sit in front of teachers again and start to live their lives again.

MARCIA BIGGS: Next door, Mosul University has already started classes. Students even volunteered to help in the cleanup.

But across the river, West Mosul was the site of ISIS’ last stand and bore the brunt of the battle. It’s densely packed Old City, with its flattened buildings, is a challenge for mine-sweeping.

FAWZI AL-NABDI (through interpreter): Most of the homes here were full of mines. And just here in front of us, a man with two kids came back to his home, and when he opened the door, the bomb killed him and his kids.

MARCIA BIGGS: Ahmed Younes fled back in early July with only the clothes on his back. Residents have been virtually banned from returning to his neighborhood on the outskirts of the Old City, but Ahmed said he got special permission, in order to retrieve some personal items.

AHMED YOUNES, Local Resident (through interpreter): We came on our own. We got permission to come, but they are not responsible if anything happens to us.

MARCIA BIGGS: Right now, there is no plan to begin clearing the Old City or even to determine how many mines there are. It is still out of bounds to anyone but the Iraqi security forces.

So the Janus team is focusing on progress in the rest of the city, building by building, bomb by bomb.

CHRISTIAN: Whoever made this device had a set goal. And to allow him to win, people get hurt. So you kind of compete against him to be better than him to take it out before it can do any harm.

MARCIA BIGGS: So, you feel like you’re winning the battle against ISIS?

CHRISTIAN: Yes, one IED at a time.

MARCIA BIGGS: For the PBS NewsHour, I’m Marcia Biggs in Mosul, Iraq.

HARI SREENIVASAN: Tune in later.

Frontline’s latest film, “Mosul,” was on the ground filming the fight as it unfolded street by street and house by house. That’s tonight on PBS.

The post The battle for Mosul is over, but this hidden ISIS danger could lurk for years appeared first on PBS NewsHour.

Paul Garrard has no plans to walk away but has urged Geoff Gerard to resign if he has lost his desire to fight.

ROLLING UPDATES:Malcolm Turnbull heads into tomorrow’s Liberal Party campaign launch with the economy and stability firmly front and centre.

LEADING Aboriginal academic Marcia Langton has blasted Bill Shorten over his claim Labor could sign a treaty with Indigenous Australians.

ROLLING UPDATES: Australia waited eight days for Malcolm Turnbull to claim election victory and now the PM and Bill Shorten have united in their push for online voting.

A Dundee ice hockey player has been jailed after being found guilty of raping a teenage girl in his car.

The Herald understands that former first minister Nicola Sturgeon has made no decisions on whether she will stand for election in 2026.

"I look forward to any contest, where of course it will be for branch members to select those they wish to represent them in Holyrood in the 2026 Scottish Parliament elections.”

"I hear journalists are wondering if I’ve put my name in for the Scottish Parliament. Big news re 2026 coming in the next hour…watch this space."

A former aid to Tony Blair has been criticised by the SNP after he said the Government "should do farmers what Thatcher did to the miners".

International numbers are on the up but not everything in tourism is rosy

3D Scotland are an innovative, Glasgow-based company who specialise in the design and manufacture of unique chess sets. Their sets have proved extremely popular as Christmas gifts, graduation gifts, fathers’ day gifts and everything in between.