Aliado - A design concept of AI for decision support in oncological liver surgery.

BACKGROUND: The interest in artificial intelligence (AI) is increasing. Systematic reviews suggest that there are many machine learning algorithms in surgery, however, only a minority of the studies integrate AI applications in clinical workflows. Our objective was to design and evaluate a concept to use different kinds of AI for decision support in oncological liver surgery along the treatment path. METHODS: In an exploratory co-creation between design experts, surgeons, and data scientists, pain points along the treatment path were identified. Potential designs for AI-assisted solutions were developed and iteratively refined. Finally, an evaluation of the design concept was performed with n = 20 surgeons to get feedback on the different functionalities and evaluate the usability with the System Usability Scale (SUS). Participating surgeons had a mean of 14.0 ± 5.0 years of experience after graduation. RESULTS: The design concept was named "Aliado". Five different scenarios were identified where AI could support surgeons. Mean score of SUS was 68.2 ( ± 13.6 SD). The highest valued functionalities were "individualized prediction of survival, short-term mortality and morbidity", and "individualized recommendation of surgical strategy". CONCLUSION: Aliado is a design prototype that shows how AI could be integrated into the clinical workflow. Even without a fleshed out user interface, the SUS already yielded borderline good results. Expert surgeons rated the functionalities favorably, and most of them expressed their willingness to work with a similar application in the future. Thus, Aliado can serve as a surgical vision of how an ideal AI-based assistance could look like.

Risky Business: Predator Chemical Cues Mediate Morphological Changes in Freshwater Snails.

Many prey organisms respond to the nonconsumptive effects of predators by altering their physiology, morphology, and behavior. These inducible defenses can create refuges for prey by decreasing the likelihood of consumption by predators. Some prey, as in marine mollusks, have been shown to alter their morphology in response to the presence of size-limited predation. To extend this work, we exposed pointed campeloma snails (Campeloma decisum) to chemical cues from a natural predator, the rusty crayfish (Faxonius rusticus), to better understand how snail morphology changes under the threat of predation. The total force needed to crush shells, total shell length, aperture width, and total weight, along with changes to these 3 body measurements, were recorded for each individual and used to quantify morphological changes as a function of risk. Snails exposed to crayfish chemical cues had shells that required significantly more force to crush their shells than controls (P = 0.023). Total shell length was greater in crayfish-exposed snails than in control snails (P = 0.012), and snails in the crayfish treatment also showed significantly more change in shell length than control snails (P = 0.007). Similarly, aperture width was significantly greater in exposed snails (P = 0.011). However, exposed snails exhibited significantly less change in aperture width than controls (P = 0.03). Finally, we found that snails exposed to crayfish weighed significantly more than snails in the control (P = 0.008). Thus, the results of this study show that morphology of gastropods is altered in the presence of predators, and this may be an antipredator tactic directly related to predation risk.

Performances of preoperative CT scan to predict the pTN stage for MSI/dMMR localized colon cancers.

BACKGROUND: Neoadjuvant immunotherapy emerges as a promising strategy for patients with localized colon cancer (CC) harboring microsatellite instability/mismatch repair deficiency (MSI/dMMR). The aim of this study is to evaluate the concordance between clinical cTN stage assessed by preoperative computed tomography (CT) scan and pTN stage of MSI/dMMR CC. PATIENTS AND METHODS: Consecutive patients diagnosed for localized MSI/dMMR CC and treated with upfront surgery between 2013 and 2022 in two French centers were eligible. Two independent radiologists, blinded to pathological findings, reviewed all preoperative CT scans and assessed cTN stage, with a third radiologist reviewing discordant cases. Radiological predictive diagnostic accuracy for pT4 and pN+ (N+ = N1 or N2) were calculated. RESULTS: One hundred and thirteen patients were included (right CCs = 79%). CT scan diagnostic performances for pT4 were sensitivity (Se) = 33.3%; specificity (Sp) = 94.0%; positive predictive value (PPV) = 66.7%; and negative predictive value (NPV) = 79.6% and for pN+ were Se = 70.3%; Sp = 59.2%; PPV = 45.6%; and NPV = 80.4%. When pT-pN were combined, 37.5% of tumors identified as cT4 and/or cN+ were actually pT1-3 and pN0, and 23.1% of the pT4 and pN+ population was not identified as such radiologically. CONCLUSION: The ability of preoperative CT scan to predict pT and pN stages is limited for localized MSI/dMMR CCs. Reassessing neoadjuvant strategies' benefit-risk balance in this population is needed.

Dynamic contrast enhanced MRI of the head and neck region using a VIBE sequence with Cartesian undersampling and compressed sensing.

OBJECTIVES: Compressed sensing allows for image reconstruction from sparsely sampled k-space data, which is particularly useful in dynamic contrast enhanced MRI (DCE-MRI). The aim of the study was to assess the diagnostic value of a volume-interpolated 3D T1-weighted spoiled gradient-echo sequence with variable density Cartesian undersampling and compressed sensing (CS) for head and neck MRI. METHODS: Seventy-one patients with clinical indications for head and neck MRI were included in this study. DCE-MRI was performed at 3 Tesla magnet using CS-VIBE (variable density undersampling, temporal resolution 3.4 s, slice thickness 1 mm). Image quality was compared to standard Cartesian VIBE. Three experienced readers independently evaluated image quality and lesion conspicuity on a 5-point Likert scale and determined the DCE-derived time intensity curve (TIC) types. RESULTS: CS-VIBE demonstrated higher image quality scores compared to standard VIBE with respect to overall image quality (4.3 ± 0.6 vs. 4.2 ± 0.7, p = 0.682), vessel contour (4.6 ± 0.4 vs. 4.4 ± 0.6, p < 0.001), muscle contour (4.4 ± 0.5 vs. 4.5 ± 0.6, p = 0.302), lesion conspicuity (4.5 ± 0.7 vs. 4.3 ± 0.9, p = 0.024) and showed improved fat saturation (4.8 ± 0.3 vs. 3.8 ± 0.4, p < 0.001) and movement artifacts were significantly reduced (4.6 ± 0.6 vs. 3.7 ± 0.7, p < 0.001). Standard VIBE outperformed CS-VIBE in the delineation of pharyngeal mucosa (4.2 ± 0.5 vs. 4.6 ± 0.6, p < 0.001). Lesion size in cases where a focal lesion was identified was similar for all readers for CS-VIBE and standard VIBE (p = 0.101). TIC curve assessment showed good interobserver agreement (k=0.717). CONCLUSION: CS-VIBE with variable density Cartesian undersampling allows for DCE-MRI of the head and neck region with diagnostic, high image quality and high temporal resolution.

Navigating the Future of Organisational Health Services Research in Germany and beyond: a Position Paper. / Die Zukunft der organisationsbezogenen Versorgungsforschung in Deutschland und darüber hinaus ­ ein Positionspapier.

BACKGROUND: Recent analyses have shown that in health services research in Germany, healthcare organisations are often considered primarily as a study setting, without fully taking their complex organisational nature into account, neither theoretically nor methodologically. Therefore, an initiative was launched to analyse the state of Organisational Health Services Research (OHSR) in Germany and to develop a strategic framework and road map to guide future efforts in the field. This paper summarizes positions that have been jointly developed by consulting experts from the interdisciplinary and international scientific community. METHODS: In July 2023, a scoping workshop over the course of three days was held with 32 (inter)national experts from different research fields centred around OHSR topics using interactive workshop methods. Participants discussed their perspectives on OHSR, analysed current challenges in OHSR in Germany and developed key positions for the field's development. RESULTS: The seven agreed-upon key positions addressed conceptual and strategic aspects. There was consensus that the field required the development of a research agenda that can guide future efforts. On a conceptual level, the need to address challenges in terms of interdisciplinarity, terminology, organisation(s) as research subjects, international comparative research and utilisation of organisational theory was recognized. On a strategic level, requirements with regard to teaching, promotion of interdisciplinary and international collaboration, suitable funding opportunities and participatory research were identified. CONCLUSIONS: This position paper seeks to serve as a framework to support further development of OHSR in Germany and as a guide for researchers and funding organisations on how to move OHSR forward. Some of the challenges discussed for German OHSR are equally present in other countries. Thus, this position paper can be used to initiate fruitful discussions in other countries.

A surgical activity model of laparoscopic cholecystectomy for co-operation with collaborative robots.

BACKGROUND: Laparoscopic cholecystectomy is a very frequent surgical procedure. However, in an ageing society, less surgical staff will need to perform surgery on patients. Collaborative surgical robots (cobots) could address surgical staff shortages and workload. To achieve context-awareness for surgeon-robot collaboration, the intraoperative action workflow recognition is a key challenge. METHODS: A surgical process model was developed for intraoperative surgical activities including actor, instrument, action and target in laparoscopic cholecystectomy (excluding camera guidance). These activities, as well as instrument presence and surgical phases were annotated in videos of laparoscopic cholecystectomy performed on human patients (n = 10) and on explanted porcine livers (n = 10). The machine learning algorithm Distilled-Swin was trained on our own annotated dataset and the CholecT45 dataset. The validation of the model was conducted using a fivefold cross-validation approach. RESULTS: In total, 22,351 activities were annotated with a cumulative duration of 24.9 h of video segments. The machine learning algorithm trained and validated on our own dataset scored a mean average precision (mAP) of 25.7% and a top K = 5 accuracy of 85.3%. With training and validation on our dataset and CholecT45, the algorithm scored a mAP of 37.9%. CONCLUSIONS: An activity model was developed and applied for the fine-granular annotation of laparoscopic cholecystectomies in two surgical settings. A machine recognition algorithm trained on our own annotated dataset and CholecT45 achieved a higher performance than training only on CholecT45 and can recognize frequently occurring activities well, but not infrequent activities. The analysis of an annotated dataset allowed for the quantification of the potential of collaborative surgical robots to address the workload of surgical staff. If collaborative surgical robots could grasp and hold tissue, up to 83.5% of the assistant's tissue interacting tasks (i.e. excluding camera guidance) could be performed by robots.

Current unmet needs in locally advanced (unresectable) or metastatic dedifferentiated liposarcoma, the relevance of progression-free survival as clinical endpoint, and expectations for future clinical trial design: an international Delphi consensus report.

BACKGROUND: Locally advanced (unresectable) or metastatic dedifferentiated liposarcoma (DDLPS) is a common presentation of liposarcoma. Despite established diagnostic and treatment guidelines for DDLPS, critical clinical gaps remain driven by diagnostic challenges, symptom burden and the lack of targeted, safe and effective treatments. The objective of this study was to gather expert opinions from Europe and the United States on the management, unmet needs and expectations for clinical trial design as well as the value of progression-free survival (PFS) in this disease. Other aims included raising awareness and educate key stakeholders across healthcare systems. MATERIALS AND METHODS: An international panel of 12 sarcoma key opinion leaders (KOLs) was recruited. The study consisted of two rounds of surveys with pre-defined statements. Experts scored each statement on a 9-point Likert scale. Consensus agreement was defined as ≥75% of experts scoring a statement with ≥7. Revised statements were discussed in a consensus meeting. RESULTS: Consensus was reached on 43 of 55 pre-defined statements across disease burden, treatment paradigm, unmet needs, value of PFS and its association with overall survival (OS), and cross-over trial design. Twelve statements were deprioritised or merged with other statements. There were no statements where experts disagreed. CONCLUSION: This study constitutes the first international Delphi panel on DDLPS. It aimed to explore KOL perception of the disease burden and unmet need in DDLPS, the value of PFS, and its potential translation to OS benefit, as well as the relevance of a cross-over trial design for DDLPS therapies. Results indicate an alignment across Europe and the United States regarding DDLPS management, unmet needs, and expectations for clinical trials. Raising awareness of critical clinical gaps in relation to DDLPS can contribute to improving patient outcomes and supporting the development of innovative treatments.

Memory changes in patients with hippocampal sclerosis submitted to surgery to treat mesial temporal lobe epilepsy.

PURPOSE: This study was performed with the purpose of analysing the relationship between epileptological and surgical variables and post-operative memory performance, following surgery for refractory mesial temporal lobe epilepsy (MTLE) due to hippocampal sclerosis (HS). METHODS: Logical memory (LM) and visual memory (VM) scores for immediate and late follow-up of 201 patients operated for MTLE/HS were reviewed. Scores were standardized with a control group of 54 healthy individuals matched for age and education. The Reliable Change Index (RCI) was calculated to verify individual memory changes for late LM and VM scores. A multiple linear regression analysis was carried out with the RCI, using LM and VM scores as well as the clinical variables. RESULTS: A total of 112 (56%) patients had right HS. The RCI of the right HS group demonstrated that 6 (7%) patients showed improvement while 5 (6%) patients showed decreased scores in late LM; for late VM, 7 (8%) patients presented improvement, and 2 (3%) patients showed poorer scores. RCI of the left HS group showed that 3 (3%) individuals showed improved scores, while scores of 5 (4%) patients worsened for late LM; for late VM, 3 (3%) patients presented higher scores and 6 (5%) showed lower scores. Left HS and advanced age at onset of the first epileptic seizure were predictors of late LM loss (p<.05). CONCLUSION: Left MTLE/HS and seizure onset at advanced ages were predictive factors for the worsening of late LM. We observed poorer baseline LM function in the left HS group and improvement of LM in some patients who had resection of the right MTL. Patients in the right HS group showed a higher percentage of reliable post-operative improvement for both VM and LM scores.

Luminescent lanthanide mixed N-phthaloylglycinate and terephthalate coordination polymers: Structural and optical properties.

A new class of lanthanide mixed-carboxylate ligands compounds with formula {[Ln2 (phthgly)4 (bdc)(H2 O)6 ]·(H2 O)4 }∞ , labelled as Ln3+ : Eu (1) and Gd (2) coordination polymers (CP) were synthesized under mild reaction conditions between lanthanide nitrate salts and a solution of N-phthaloylglycine (phthgly) and terephthalic (bdc) ligands. The (1) and (2) coordination polymers were formed by symmetric binuclear units, in which phthgly and bdc carboxylate ligands are coordinated to the lanthanide ions by different coordination modes. Surprisingly, all organic ligands participate in hydrogen bonding interactions, forming an extremally rigid crystalline structure. The red narrow emission bands from the 5 D0 →7 FJ transitions of the Eu3+ ion show a high colour purity. The intramolecular energy transfer process from L→Eu3+ ion has been discussed. The experimental intensity parameters (Ω2,4 ) reflect lower angular distortion and polarizability of the chemical environment around the metal ion compared with other Eu3+ compounds reported in the literature. This novel class of coordination polymer offers a more attractive platform for developing luminescent functional materials for different applications.

Brain Maturation Patterns on Normalized FLAIR MR Imaging in Children and Adolescents.

BACKGROUND AND PURPOSE: Signal analysis of FLAIR sequences is gaining momentum for studying neurodevelopment and brain maturation, but FLAIR intensity varies across scanners and needs to be normalized. This study aimed to establish normative values for standardized FLAIR intensity in the pediatric brain. MATERIALS AND METHODS: A new automated algorithm for signal normalization was used to standardize FLAIR intensity across scanners and subjects. Mean intensity was extracted from GM, WM, deep GM, and cortical GM regions. Regression curves were fitted across the pediatric age range, and ANOVA was used to investigate intensity differences across age groups. Correlations between intensity and regional volume were also examined. RESULTS: We analyzed 429 pediatric FLAIR sequences in children 2-19 years of age with a median age of 11.2 years, including 199 males and 230 females. WM intensity had a parabolic relationship with age, with significant differences between various age groups (P < .05). GM and cortical GM intensity increased over the pediatric age range, with significant differences between early childhood and adolescence (P < .05). There were no significant relationships between volume and intensity in early childhood, while there were significant positive and negative correlations (P < .05) in WM and GM, respectively, for increasing age groups. Only the oldest age group showed significant differences between males and females (P < .05). CONCLUSIONS: This work presents a FLAIR intensity standardization algorithm to normalize intensity across large data sets, which allows FLAIR intensity to be used to compare regions and individuals as a surrogate measure of the developing pediatric brain.

T2-FLAIR Mismatch Sign in Pediatric Low-Grade Glioma.

BACKGROUND AND PURPOSE: No qualitative imaging feature currently predicts molecular alterations of pediatric low-grade gliomas with high sensitivity or specificity. The T2-FLAIR mismatch sign predicts IDH-mutated 1p19q noncodeleted adult gliomas with high specificity. We aimed to assess the significance of the T2-FLAIR mismatch sign in pediatric low-grade gliomas. MATERIALS AND METHODS: Pretreatment MR images acquired between January 2001 and August 2018 in pediatric patients with pediatric low-grade gliomas were retrospectively identified. Inclusion criteria were the following: 1) 0-18 years of age, 2) availability of molecular information in histopathologically confirmed cases, and 3) availability of preoperative brain MR imaging with non-motion-degraded T2-weighted and FLAIR sequences. Spinal cord tumors were excluded. RESULTS: Three hundred forty-nine patients were included (187 boys; mean age, 8.7 [SD, 4.8] years; range, 0.5-17.7 years). KIAA1549-B-Raf proto-oncogene (BRAF) fusion and BRAF p.V600E mutation were the most common molecular markers (n = 148, 42%, and n = 73, 20.7%, respectively). The T2-FLAIR mismatch sign was present in 25 patients (7.2%). Of these, 9 were dysembryoplastic neuroepithelial tumors; 8, low-grade astrocytomas; 5, diffuse astrocytomas; 1, a pilocytic astrocytoma; 1, a glioneuronal tumor; and 1, an angiocentric glioma. None of the 25 T2-FLAIR mismatch pediatric low-grade gliomas were BRAF p.V600E-mutated. Fourteen of 25 pediatric low-grade gliomas with the T2-FLAIR mismatch sign had rare molecular alterations, while the molecular subtype was unknown for 11 tumors. CONCLUSIONS: The T2-FLAIR mismatch sign was not observed in the common molecular alterations, BRAF p.V600E-mutated and KIAA1549-BRAF fused pediatric low-grade gliomas, while it was encountered in pediatric low-grade gliomas with rare pediatric molecular alterations.

Ensuring privacy protection in the era of big laparoscopic video data: development and validation of an inside outside discrimination algorithm (IODA).

BACKGROUND: Laparoscopic videos are increasingly being used for surgical artificial intelligence (AI) and big data analysis. The purpose of this study was to ensure data privacy in video recordings of laparoscopic surgery by censoring extraabdominal parts. An inside-outside-discrimination algorithm (IODA) was developed to ensure privacy protection while maximizing the remaining video data. METHODS: IODAs neural network architecture was based on a pretrained AlexNet augmented with a long-short-term-memory. The data set for algorithm training and testing contained a total of 100 laparoscopic surgery videos of 23 different operations with a total video length of 207 h (124 min ± 100 min per video) resulting in 18,507,217 frames (185,965 ± 149,718 frames per video). Each video frame was tagged either as abdominal cavity, trocar, operation site, outside for cleaning, or translucent trocar. For algorithm testing, a stratified fivefold cross-validation was used. RESULTS: The distribution of annotated classes were abdominal cavity 81.39%, trocar 1.39%, outside operation site 16.07%, outside for cleaning 1.08%, and translucent trocar 0.07%. Algorithm training on binary or all five classes showed similar excellent results for classifying outside frames with a mean F1-score of 0.96 ± 0.01 and 0.97 ± 0.01, sensitivity of 0.97 ± 0.02 and 0.0.97 ± 0.01, and a false positive rate of 0.99 ± 0.01 and 0.99 ± 0.01, respectively. CONCLUSION: IODA is able to discriminate between inside and outside with a high certainty. In particular, only a few outside frames are misclassified as inside and therefore at risk for privacy breach. The anonymized videos can be used for multi-centric development of surgical AI, quality management or educational purposes. In contrast to expensive commercial solutions, IODA is made open source and can be improved by the scientific community.

Video-based learning of coping strategies for common errors improves laparoscopy training-a randomized study.

AIMS: The aim of this study was to investigate whether shifting the focus to solution orientation and developing coping strategies for common errors could increase the efficiency of laparoscopic training and influence learning motivation. The concept of coping has been particularly defined by the psychologist Richard Lazarus [Lazarus and Folkman in Stress, appraisal, and coping, Springer publishing company, New York, 1984]. Based on this model, we examined the use of observational learning with a coping model for its effectiveness as a basic teaching model in laparoscopic training. METHODS: 55 laparoscopically naive medical students learned a standardized laparoscopic knot tying technique with video-based instructions. The control group was only offered a mastery video that showed the ideal technique and was free from mistakes. The intervention group was instructed on active error analysis and watched freely selectable videos of common errors including solution strategies (coping model) in addition to the mastery videos. RESULTS: There was no statistically significant difference between the intervention and control groups for number of knot tying attempts until proficiency was reached (18.8 ± 5.5 vs. 21.3 ± 6.5, p = 0.142). However, there was a significantly higher fraction of knots achieving technical proficiency in the intervention group after first use of the coping model (0.7 ± 0.1 vs. 0.6 ± 0.2, p = 0.026). Additionally, the proportion of blinded attempts that met the criteria for technical proficiency was significantly higher for the intervention group at 60.9% vs. 38.0% in control group (p = 0.021). The motivational subscore "interest" of the validated score on current motivation (QCM) was significantly higher for the intervention group (p = 0.032), as well as subjective learning benefit (p = 0.002) and error awareness (p < 0.001). CONCLUSION: Using video-based learning of coping strategies for common errors improves learning motivation and understanding of the technique with a significant difference in its qualitative implementation in laparoscopy training. The ability to think in a solution-oriented, independent way is necessary in surgery in order to recognize and adequately deal with technical difficulties and complications.

Dynamic alpha factor prediction with operating data - a machine learning approach to model oxygen transfer dynamics in activated sludge.

Aeration is an energy-intensive process of aerobic biological wastewater treatment. An accurate model of oxygen transfer dynamics in activated sludge tanks would improve design and operation of aeration systems. Such a model should consider spatial and diurnal variation of α-factor as well as site-specific conditions that impact oxygen transfer. For this dynamic prediction a machine learning approach was used for the first time. The data-driven method was based on long-term ex-situ off-gas measurements with pilot-scale reactors (5.8 m height, 8.3 m3 vol) coupled to full-scale activated sludge tanks on the sites of two conventional and a two-stage activated sludge treatment plant. The ex-situ off-gas method allowed to quantify theoretical off-gas parameters in non-aerated zones and thus consider the whole activated sludge tank. We introduced the α0-factor to compare aerated and non-aerated zones under nonsteady-state conditions. Like the established α-factor for steady-state conditions, the α0-factor describes oxygen transfer inhibiting effects in activated sludge. α0-factor was lowest in upstream denitrification zones. This indicates an anoxic elimination of oxygen transfer inhibiting wastewater contaminants which improved oxygen transfer in subsequent aerobic zones. Random Forest models predicted α0-factor reliably in all examined activated sludge tanks even for stormwater events and seasonal variation. Model development only required online sensor data already available to operators. Our results suggest that machine learning models can dynamically predict α-factors in a variety of activated sludge processes, thus considering site-specific conditions in model training without manual calibration.

Nurse Preceptors' Experiences of an Online Strength-Based Nursing Course in Clinical Teaching.

Background: Online educational programs for nurse preceptors have been created based on various theoretical frameworks; however, no programs using a Strengths-Based Nursing (SBN) approach could be located. Purpose: This qualitative descriptive study explored the nurse preceptors' experiences in using a SBN approach to provide clinical teaching to nursing students after completing an online SBN clinical teaching course. Methods: Semi-structured interviews were conducted with six nurses. Data was thematically analyzed. Findings: Although their levels of familiarity with SBN varied, all preceptors acknowledged that using a SBN approach in clinical teaching benefits both students and educators. They reported that it empowered students and that it allowed them to discover their strengths. Getting to know their students helped the preceptors provide tailored learning experiences and feedback. Using the SBN approach simultaneously enhanced the preceptors' self-confidence and created opportunities for shared learning. Conclusion: Using a strengths' approach offers nurse preceptors a powerful tool to facilitate student learning and skills development in clinical practice.

Serious gaming and virtual reality in the multimodal training of laparoscopic inguinal hernia repair: a randomized crossover study.

BACKGROUND: The aim of this study was to assess the transferability of surgical skills for the laparoscopic hernia module between the serious game Touch Surgery™ (TS) and the virtual reality (VR) trainer Lap Mentor™. Furthermore, this study aimed to collect validity evidence and to discuss "sources of validity evidence" for the findings using the laparoscopic inguinal hernia module on TS. METHODS: In a randomized crossover study, medical students (n = 40) in their clinical years performed laparoscopic inguinal hernia modules on TS and the VR trainer. TS group started with "Laparoscopic Inguinal Hernia Module" on TS (phase 1: Preparation, phase 2: Port Placement and Hernia Repair), performed the module first in training, then in test mode until proficiency was reached. VR group started with "Inguinal Hernia Module" on the VR trainer (task 1: Anatomy Identification, task 2: Incision and Dissection) and also performed the module until proficiency. Once proficiency reached in the first modality, the groups performed the other training modality until reaching proficiency. Primary endpoint was the number of attempts needed to achieve proficiency for each group for each task/phase. RESULTS: Students starting with TS needed significantly less attempts to reach proficiency for task 1 on the VR trainer than students who started with the VR trainer (TS = 2.7 ± 0.6 vs. VR = 3.2 ± 0.7; p = 0.028). No significant differences for task 2 were observed between groups (TS = 2.3 ± 1.1 vs. VR = 2.1 ± 0.8; p = 0.524). For both phases on TS, no significant skill transfer from the VR trainer to TS was observed. Aspects of validity evidence for the module on TS were collected. CONCLUSION: The results show that TS brought additional benefit to improve performances on the VR trainer for task 1 but not for task 2. Skill transfer from the VR trainer to TS could not be shown. VR and TS should thus be used in combination with TS first in multimodal training to ensure optimal training conditions.

Secondary prevention in diabetic and nondiabetic coronary heart disease patients: Insights from the German subset of the hospital arm of the EUROASPIRE IV and V surveys.

BACKGROUND: Patients with coronary heart disease (CHD) with and without diabetes mellitus have an increased risk of recurrent events requiring multifactorial secondary prevention of cardiovascular risk factors. We compared prevalences of cardiovascular risk factors and its determinants including lifestyle, pharmacotherapy and diabetes mellitus among patients with chronic CHD examined within the fourth and fifth EUROASPIRE surveys (EA-IV, 2012-13; and EA-V, 2016-17) in Germany. METHODS: The EA initiative iteratively conducts European-wide multicenter surveys investigating the quality of secondary prevention in chronic CHD patients aged 18 to 79 years. The data collection in Germany was performed during a comprehensive baseline visit at study centers in Würzburg (EA-IV, EA-V), Halle (EA-V), and Tübingen (EA-V). RESULTS: 384 EA-V participants (median age 69.0 years, 81.3% male) and 536 EA-IV participants (median age 68.7 years, 82.3% male) were examined. Comparing EA-IV and EA-V, no relevant differences in risk factor prevalence and lifestyle changes were observed with the exception of lower LDL cholesterol levels in EA-V. Prevalence of unrecognized diabetes was significantly lower in EA-V as compared to EA-IV (11.8% vs. 19.6%) while the proportion of prediabetes was similarly high in the remaining population (62.1% vs. 61.0%). CONCLUSION: Between 2012 and 2017, a modest decrease in LDL cholesterol levels was observed, while no differences in blood pressure control and body weight were apparent in chronic CHD patients in Germany. Although the prevalence of unrecognized diabetes decreased in the later study period, the proportion of normoglycemic patients was low. As pharmacotherapy appeared fairly well implemented, stronger efforts towards lifestyle interventions, mental health programs and cardiac rehabilitation might help to improve risk factor profiles in chronic CHD patients.

The Evolution of Feeding Mechanics in the Danioninae, or Why Giant Danios Don't Suck Like Zebrafish.

By linking anatomical structure to mechanical performance we can improve our understanding of how selection shapes morphology. Here we examined the functional morphology of feeding in fishes of the subfamily Danioninae (order Cypriniformes) to determine aspects of cranial evolution connected with their trophic diversification. The Danioninae comprise three major lineages and each employs a different feeding strategy. We gathered data on skull form and function from species in each clade, then assessed their evolutionary dynamics using phylogenetic-comparative methods. Differences between clades are strongly associated with differences in jaw protrusion. The paedomorphic Danionella clade does not use jaw protrusion at all, members of the Danio clade use jaw protrusion for suction production and prey capture, and members of the sister clade to Danio (e.g., Devario and Microdevario) use jaw protrusion to retain prey after capture. The shape of the premaxillary bone is a major determinant of protrusion ability, and premaxilla morphology in each of these lineages is consistent with their protrusion strategies. Premaxilla shapes have evolved rapidly, which indicates that they have been subjected to strong selection. We compared premaxilla development in giant danio (Devario aequipinnatus) and zebrafish (Danio rerio) and discuss a developmental mechanism that could shift danionine fishes between the feeding strategies employed by these species and their respective clades. We also identified a highly integrated evolutionary module that has been an important factor in the evolution of trophic mechanics within the Danioninae.

Relationship between psychological characteristics, personality traits, and training on performance in a neonatal resuscitation scenario: A machine learning based analysis.

Background: In life-threatening emergency events, prompt decision-making and accurate reactions are essential for saving a human's life. Some of these skills can be improved by regular simulation trainings. However, besides these factors, individual characteristics may play a significant role in the patients' outcome after a resuscitation event. This study aimed to differentiate personality characteristics of team members who take responsibility for their actions, contextualizing the effect of training on resuscitation performance. Methods: Six hundred and two third-year medical students were asked to answer psychological and personality questionnaires. Fifty-five of them performed in a neonatal simulation resuscitation scenario. To assess participants' performances in the NLS scenario, we used a scenario-based designed NLS checklist. A machine learning design was utilized to better understand the interaction of psychological characteristics and training. The first model aimed to understand how to differentiate between people who take responsibility for their actions vs. those who do not. In a second model, the goal was to understand the relevance of training by contextualizing the effect of training to other important psychological and personality characteristics like locus of control, anxiety, emotion regulation, openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism. Results: No statistically significant differences were found for psychological characteristics between the training group and the no training group. However, as expected, differences were noted in favor of the training group for performance and within gender for psychological characteristics. When correcting for all these information in a model, anxiety and gender were the most important factors associated with taking responsibility for an action, while training was the only relevant factor in explaining performance during a neonatal resuscitation scenario. Conclusion: Training had a significantly stronger effect on performance in medical students in a neonatal resuscitation scenario than individual characteristics such as demographics, personality, and trait anxiety.