Do virtual patients prepare medical students for the real world? Development and application of a framework to compare a virtual patient collection with population data

Background: An important aspect of virtual patients (VPs), which are interactive computer-based patient scenarios, is authenticity. This includes design aspects, but also how a VP collection represents a patient population and how a patient is presented in a VP scenario. Therefore, our aim was to analyze VP scenarios integrated into the combined internal medicine and surgery curriculum at the University of Munich (LMU) and compare the results with data from the population in Germany. Method: We developed a coding framework with four main categories: patient data, patient representation, diagnoses, and setting. Based on the framework we analyzed 66 VP and compared the results with data from the German healthcare system. Results: Especially in the categories of patient data and patient representation, the VPs presented an unrealistic image of the real world;topics such as unemployment, disability, or migration background were almost non-existent. The diagnoses of the VPs and the onset of diseases were comparable with the healthcare data. Conclusions: An explanation for the lack of representativeness of the patient data and representation might be a trend to create VPs based on fictional patient stories with VP authors trying to minimize complexity and cognitive load for the students. We suggest raising awareness among VP authors concerning personalized representations of patients without overwhelming their students. Our framework can support educators to assess the authenticity and diversity of a VP collection

The pre-concept design of the DEMO tritium, matter injection and vacuum systems

In the Pre-Concept Design Phase of EU-DEMO, the work package TFV (Tritium – Matter Injection – Vacuum) has developed a tritium self-sufficient three-loop fuel cycle architecture. Driven by the need to reduce the tritium inventory in the systems to an absolute minimum, this requires the continual recirculation of gases in loops without storage, avoiding hold-ups of tritium in each process stage by giving preference to continuous over batch technologies, and immediate use of tritium extracted from tritium breeding blankets. In order to achieve this goal, a number of novel concepts and technologies had to be found and their principal feasibility to be shown. This paper starts from a functional analysis of the fuel cycle and introduces the results of a technology survey and ranking exercise which provided the prime technology candidates for all system blocks. The main boundary conditions for the TFV systems are described based on which the fuel cycle architecture was developed and the required operational windows of all subsystems were defined. To validate this, various R&D lines were established, selected results of which are reported, together with the key technology developments. Finally, an outlook towards the Concept Design Phase is given

Compositional diversity of rehabilitated tropical lands supports multiple ecosystem services and buffers uncertainties

High landscape diversity is assumed to increase the number and level of ecosystem services. However, the interactions between ecosystem service provision, disturbance and landscape composition are poorly understood. Here we present a novel approach to include uncertainty in the optimization of land allocation for improving the provision of multiple ecosystem services. We refer to the rehabilitation of abandoned agricultural lands in Ecuador including two types of both afforestation and pasture rehabilitation, together with a succession option. Our results show that high compositional landscape diversity supports multiple ecosystem services (multifunction effect). This implicitly provides a buffer against uncertainty. Our work shows that active integration of uncertainty is only important when optimizing single or highly correlated ecosystem services and that the multifunction effect on landscape diversity is stronger than the uncertainty effect. This is an important insight to support a land-use planning based on ecosystem services

Influence of solvent granularity on the effective interaction between charged colloidal suspensions

We study the effect of solvent granularity on the effective force between two charged colloidal particles by computer simulations of the primitive model of strongly asymmetric electrolytes with an explicitly added hard sphere solvent. Apart from molecular oscillating forces for nearly touching colloids which arise from solvent and counterion layering, the counterions are attracted towards the colloidal surfaces by solvent depletion providing a simple statistical description of hydration. This, in turn, has an important influence on the effective forces for larger distances which are considerably reduced as compared to the prediction based on the primitive model. When these forces are repulsive, the long-distance behaviour can be described by an effective Yukawa pair potential with a solvent-renormalized charge. As a function of colloidal volume fraction and added salt concentration, this solvent-renormalized charge behaves qualitatively similar to that obtained via the Poisson-Boltzmann cell model but there are quantitative differences. For divalent counterions and nano-sized colloids, on the other hand, the hydration may lead to overscreened colloids with mutual attraction while the primitive model yields repulsive forces. All these new effects can be accounted for through a solvent-averaged primitive model (SPM) which is obtained from the full model by integrating out the solvent degrees of freedom. The SPM was used to access larger colloidal particles without simulating the solvent explicitly.Comment: 14 pages, 16 craphic

Compositional diversity of rehabilitated tropical lands supports multiple ecosystem services and buffers uncertainties

High landscape diversity is assumed to increase the number and level of ecosystem services. However, the interactions between ecosystem service provision, disturbance and landscape composition are poorly understood. Here we present a novel approach to include uncertainty in the optimization of land allocation for improving the provision of multiple ecosystem services. We refer to the rehabilitation of abandoned agricultural lands in Ecuador including two types of both afforestation and pasture rehabilitation, together with a succession option. Our results show that high compositional landscape diversity supports multiple ecosystem services (multifunction effect). This implicitly provides a buffer against uncertainty. Our work shows that active integration of uncertainty is only important when optimizing single or highly correlated ecosystem services and that the multifunction effect on landscape diversity is stronger than the uncertainty effect. This is an important insight to support a land-use planning based on ecosystem services

AOSpine Consensus Paper on Nomenclature for Working-Channel Endoscopic Spinal Procedures

Study Design: International consensus paper on a unified nomenclature for full-endoscopic spine surgery. Objectives: Minimally invasive endoscopic spinal procedures have undergone rapid development during the past decade. Evolution of working-channel endoscopes and surgical instruments as well as innovation in surgical techniques have expanded the types of spinal pathology that can be addressed. However, there is in the literature a heterogeneous nomenclature defining approach corridors and procedures, and this lack of common language has hampered communication between endoscopic spine surgeons, patients, hospitals, and insurance providers. Methods: The current report summarizes the nomenclature reported for working-channel endoscopic procedures that address cervical, thoracic, and lumbar spinal pathology. Results: We propose a uniform system that defines the working-channel endoscope (full-endoscopic), approach corridor (anterior, posterior, interlaminar, transforaminal), spinal segment (cervical, thoracic, lumbar), and procedure performed (eg, discectomy, foraminotomy). We suggest the following nomenclature for the most common full-endoscopic procedures: posterior endoscopic cervical foraminotomy (PECF), transforaminal endoscopic thoracic discectomy (TETD), transforaminal endoscopic lumbar discectomy (TELD), transforaminal lumbar foraminotomy (TELF), interlaminar endoscopic lumbar discectomy (IELD), interlaminar endoscopic lateral recess decompression (IE-LRD), and lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD). Conclusions: We believe that it is critical to delineate a consensus nomenclature to facilitate uniformity of working-channel endoscopic procedures within academic scholarship. This will hopefully facilitate development, standardization of procedures, teaching, and widespread acceptance of full-endoscopic spinal procedures

Augmented Reality to Improve Surgical Workflow in Minimally Invasive Transforaminal Lumbar Interbody Fusion – A Feasibility Study With Case Series

Objective Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a highly reproducible procedure for the fusion of spinal segments. We recently introduced the concept of “total navigation” to improve workflow and eliminate fluoroscopy. Image-guided surgery incorporating augmented reality (AR) may further facilitate workflow. In this study, we developed and evaluated a protocol to integrate AR into the workflow of MIS-TLIF. Methods A case series of 10 patients was the basis for the evaluation of a protocol to facilitate tubular MIS-TLIF by the application of AR. Surgical TLIF landmarks were marked on a preoperative computed tomography (CT)-scan using dedicated software. This marked CT scan was fused intraoperatively with the low-dose navigation CT scan using elastic image fusion, and the markers were transferred to the intraoperative scan. Our experience with this workflow and the surgical outcomes were collected. Results Our AR protocol was safely implemented in all cases. The TLIF landmarks could be preoperatively planned and transferred to the intraoperative imaging. Of the 10 cases, 1 case had additionally a synovial cyst resection and in 2 cases an additional bony decompression was performed due to central stenosis. The average procedure time was 160.6±31.9 minutes. The AR implementation added 1.72±0.37 minutes to the overall procedure time. No complications occurred. Conclusion Our findings support the idea that total navigation with AR may further facilitate the workflow, especially in cases with more complex anatomy and for teaching and training purposes. More work is needed to simplify the software and make AR integration more user-friendly

Sirolimus-eluting stent fracture with thrombus, visualization by optical coherence tomography

FLRTs are broadly expressed proteins with the unique property of acting as homophilic cell adhesion molecules and as heterophilic repulsive ligands of Unc5/Netrin receptors. How these functions direct cell behavior and the molecular mechanisms involved remain largely unclear. Here we use X-ray crystallography to reveal the distinct structural bases for FLRT-mediated cell adhesion and repulsion in neurons. We apply this knowledge to elucidate FLRT functions during cortical development. We show that FLRTs regulate both the radial migration of pyramidal neurons, as well as their tangential spread. Mechanistically, radial migration is controlled by repulsive FLRT2-Unc5D interactions, while spatial organization in the tangential axis involves adhesive FLRT-FLRT interactions. Further, we show that the fundamental mechanisms of FLRT adhesion and repulsion are conserved between neurons and vascular endothelial cells. Our results reveal FLRTs as powerful guidance factors with structurally encoded repulsive and adhesive surfaces