Lebenswissenschaften und Ethik
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Exoskeletons were invented over 100 years ago but have only become popular in the last two decades, especially in the working industry as they can decrease work-related loads significantly. The most often used exoskeletons are for the lower back and shoulder since these are commonly affected body regions. All devices have in common that their purpose is to reduce internal loads of vulnerable body regions. Nevertheless, there is still little understanding on how biomechanical loading in the human body changes when exoskeletons are used. Therefore, further analyses are needed. A promising candidate for these are musculoskeletal models, which are based on an inverse dynamics approach and can calculate external parameters such as ground reaction forces or other interaction forces as well as internal parameters such as joint reaction forces or muscle activities. The various examples in the literature show that these models are increasingly used for assessing the biomechanical effects of exoskeletons on the human body. Furthermore, musculoskeletal models can calculate biomechanical loadings of humans with and without exoskeletons for all kinds of applications and allow an evaluation of their purpose.
Practical Relevance: This article highlights the possibilities of musculoskeletal models for assessing the design and efficiency of occupational exoskeletons. Several practical use cases are described along with distinct descriptions of common implications of musculoskeletal and exoskeleton modeling.
Aims
Congenital breast asymmetry represents a particular challenge to the classic techniques of plastic surgery given the young age of patients at presentation. This study reviews and compares the long-term results of traditional breast augmentation using silicone implants and the more innovative technique of lipografting.
Methods
To achieve this, we not only captured subjective parameters such as satisfaction with outcome and symmetry, but also objective parameters including breast vol-ume and anthropometric measurements. The objective examination was performed manually and by using the Vectra H2 photogrammetry scanning system.
Results
Differences between patients undergoing either implant augmentation or lipograft were revealed not to be significant with respect to patient satisfaction with surgical outcome (p= 0.55) and symmetry (p= 0.69). Furthermore, a breast symmetry of 93 % was reported in both groups. Likewise, no statistically significant volume difference between the left and right breasts was observed in both groups (p\0.41). However, lipograft patients needed on average 2.9 procedures to achieve the desired result, compared with 1.3 for implant augmentation. In contrast, patients treated with implant augmentation may require anumber of implant changes during their lifetime.
Conclusion
Both methods may be considered for patients presenting with congenital breast asymmetry.
Physical Education with Eduball Stimulates Non-Native Language Learning in Primary School Students
(2022)
Although the neuronal mechanisms of action and cognition are related, the division of intellectual and physical lessons is standard in schools. This is surprising, because numerous studies show that integrating physical education (PE) with teaching content stimulates critical skills. For example, several experiments indicate that Eduball-based PE (i.e., lessons in a sports hall during which students play team mini-games with educational balls with printed letters, numbers, and other signs) develops mathematical and language competencies. At the same time, the Eduball method does not slow down learners' physical development. However, we have little knowledge about the effects of such techniques on non-native language learning. Consequently, the absence of incorporating core academic subjects into PE in dual-language schools or during foreign language education is exceptionally high. Here, we replicated the Eduball experiment, but with the goal of testing this method for non-native language learning. Thus, the intervention occurred in a dual-language primary school and we evaluated second language (L2) learning. As before, we used the technique of parallel groups (experimental and control); in both groups, there were three 45-min PE classes per week. In the experimental class, two of them were held using Eduball. After a half-year experiment, children from the experimental group (one second-grade, N = 14) improved their non-native language skills significantly more than their peers from the control group (one second-grade, N = 12). These findings demonstrate that Eduball-type intervention stimulates non-native language learning in children. Hence, our report suggests that specific body training forms can support L2 learning.
In primary open-angle glaucoma (POAG), a neurodegenerative disease of the optic nerve (ON) and leading cause of blindness, the optic nerve head (ONH) undergoes marked structural extracellular matrix (ECM) changes, which contribute to its permanent deformation and to degeneration of ON axons. The remodeling process of the ECM causes changes in the biomechanical properties of the ONH and the peripapillary sclera, which is accompanied by an increased reactivity of the resident astrocytes. The molecular factors involved in the remodeling process belong to the Transforming growth factor (TGF)-β superfamily, especially TGF-β2. In previous publications we showed that TGF-β2 induced ECM alterations are mediated by Cellular Communication Network Factor (CCN)2/Connective Tissue Growth Factor (CTGF) and recently we showed that CCN2/CTGF is expressed by astrocytes of the ON under normal conditions. In this study we wanted to get a better understanding of the function of CCN2/CTGF under normal and pathologic conditions. To this end, we analyzed the glial lamina and peripapillary sclera of CCN2/CTGF overexpressing mice and studied the effect of CCN2/CTGF and increasing substratum stiffness on murine ON astrocytes in vitro. We observed enhanced astrocyte reactivity in the ONH, increased ECM protein synthesis in the peripapillary sclera and increased Ccn2/Ctgf expression in the ONH during the pathologic development in situ. CCN2/CTGF treatment of primary murine ON astrocytes induced a higher migration rate, and increase of ECM proteins including fibronectin, elastin and collagen type III. Furthermore, the astrocytes responded to stiffer substratum with increased glial fibrillary acidic protein, vimentin, actin and CCN2/CTGF synthesis. Finally, we observed the reinforced appearance of CCN2/CTGF in the lamina cribrosa of glaucomatous patients. We conclude that reactive changes in ONH astrocytes, induced by the altered biomechanical characteristics of the region, give rise to a self-amplifying process that includes increased TGF-β2/CCN2/CTGF signaling and leads to the synthesis of ECM molecules and cytoskeleton proteins, a process that in turn augments the stiffness at the ONH. Such a scenario may finally result in a vicious circle in the pathogenesis of POAG. The transgenic CTGF-overexpressing mouse model might be an optimal model to study the chronic pathological POAG changes in the ONH.
The early diagnosis of cancer in Barrett’s esophagus is crucial for improving the prognosis. However, identifying Barrett’s esophagus-related neoplasia (BERN) is challenging, even for experts [1]. Four-quadrant biopsies may improve the detection of neoplasia, but they can be associated with sampling errors. The application of artificial intelligence (AI) to the assessment of Barrett’s esophagus could improve the diagnosis of BERN, and this has been demonstrated in both preclinical and clinical studies [2] [3].
In this video demonstration, we show the accurate detection and delineation of BERN in two patients ([Video 1]). In part 1, the AI system detects a mucosal cancer about 20 mm in size and accurately delineates the lesion in both white-light and narrow-band imaging. In part 2, a small island of BERN with high-grade dysplasia is detected and delineated in white-light, narrow-band, and texture and color enhancement imaging. The video shows the results using a transparent overlay of the mucosal cancer in real time as well as a full segmentation preview. Additionally, the optical flow allows for the assessment of endoscope movement, something which is inversely related to the reliability of the AI prediction. We demonstrate that multimodal imaging can be applied to the AI-assisted detection and segmentation of even small focal lesions in real time.
In this study, we aimed to develop an artificial intelligence clinical decision support solution to mitigate operator-dependent limitations during complex endoscopic procedures such as endoscopic submucosal dissection and peroral endoscopic myotomy, for example, bleeding and perforation. A DeepLabv3-based model was trained to delineate vessels, tissue structures and instruments on endoscopic still images from such procedures. The mean cross-validated Intersection over Union and Dice Score were 63% and 76%, respectively. Applied to standardised video clips from third-space endoscopic procedures, the algorithm showed a mean vessel detection rate of 85% with a false-positive rate of 0.75/min. These performance statistics suggest a potential clinical benefit for procedure safety, time and also training.
Autologous lipotransfer is a promising method for tissue regeneration, because white adipose tissue contains a heterogeneous cell population, including mesenchymal stem cells, endothelial cells, immune cells, and adipocytes. In order to improve the outcome, adipose tissue can be processed before application. In this study, we investigated changes caused by mechanical processing.
Lipoaspirates were processed using sedimentation, first-time centrifugation, shear-force homogenization, and second-time centrifugation. The average adipocyte size, stromal vascular cell count, and adipocyte depot size were examined histologically at every processing step. In addition, the adipose derived stem cells (ADSCs) were isolated and differentiated osteogenically and adipogenically. While homogenization causes a disruption of adipocyte depots, the shape of the remaining adipocytes is not changed. On average, these adipocytes are smaller than the depot adipocytes, they are surrounded by the ECM, and therefore mechanically more stable. The volume loss of adipocyte depots leads to a significant enrichment of stromal vascular cells such as ADSCs. However, the mechanical processing does not change the potential of the ADSCs to differentiate adipogenically or steogenically. It thus appears that mechanically processed lipoaspirates are promising for the reparation of even mechanically stressed tissue as that found in nasolabial folds. The changes resulting from the processing correspond more to a filtration of mechanically less stable components than to a manipulation of the tissue.
Due to the various demands for lecturers, there is only a limited time to prepare lectures and lab courses. Therefore, it is necessary to invest the time target-oriented for optimal student learning success. A theoretic model is developed to structure course preparation work regarding scientific content, didactic preparation, and course presentation. Model parameters have to be chosen for each course depending on topic complexity, the lecturer’s prior knowledge, and the already available preparation from the prior semesters. With these parameters, a course preparation model for a complete semester is developed. Analytic models for different optimization strategies are introduced according to the overall goal of the lecturer. Numerical optimization is done to find the appropriate course preparation times to reach an optimal course preparation for high student learning success. It is seen that due to the different optimization strategies, the preparation time results vary and no single truth is given. But this optimization system gives hints on how to invest preparation time target-oriented for high student learning success.
The main focus of this paper is to describe the development and current state of policy, research and implementation of patient-centered care (PCC) and shared decision-making (SDM) in Germany. What is the current state in health policy? Since 2013, the Law on Patients' Rights has standardized all rights and responsibilities regarding medical care for patients in Germany. This comprises the right to informed decisions, comprehensive and comprehensible information, and decisions based on a clinician-patient partnership. In addition, reports and action plans such as the German Ethics Council's report on patient well-being, the National Health Literacy Action Plan, or the National Cancer Plan emphasize and foster PCC and SDM on a policy level. There are a number of public organizations in Germany that support PCC and SDM. How are patients and the public involved in health policy and research? Publishers and funding agencies increasingly demand patient and public involvement. Numerous initiatives and organizations are involved in publicizing ways to engage patients and the public. Also, an increasing number of public and research institutions have established patient advisory boards. How is PCC and SDM taught? Great progress has been made in introducing SDM into the curricula of medical schools and other health care providers' (HCPs) schools (e.g., nursing, physical therapy). What is the German research agenda? The German government and other public institutions have constantly funded research programs in which PCC and SDM are important topics. This yielded several large-scale funding initiatives and helped to develop SDM training programs for HCPs in different fields of health care and information materials. Recently, two implementation studies on SDM have been conducted. What is the current uptake of PCC and SDM in routine care, and what implementation efforts are underway? Compared to the last country report from 2017, PCC and SDM efforts in policy, research and education have been intensified. However, many steps are still needed to reliably implement SDM in routine care in Germany. Specifically, the further development and uptake of decision tools and countrywide SDM trainings for HCPs require further efforts. Nevertheless, an increasing number of decision support tools - primarily with support from health insurance funds and other public agencies - are to be implemented in routine care. Also, recent implementation efforts are promising. For example, reimbursement by health insurance companies of hospital-wide SDM implementation is being piloted. A necessary next step is to nationally coordinate the gathering and provision of the many PCC and SDM resources available.
BACKGROUND: Autologous fat grafting (AFG) has been established over the past two decades as an additive technique during and after breast reconstruction. Complete reconstruction of the breast mound with AFG alone represents an exceptional technique that has been published mostly in case reports or in studies with limited cases.The purpose of this study is to investigate the influence of three different techniques for breast reconstruction on the recovery of skin sensitivity at the reconstructed breast.
METHODS: The study included 30 patients after mastectomy following breast cancer. Three groups were examined: A) breast reconstruction by autologous fat grafting (AFG), B) breast reconstruction by deep inferior epigastric artery perforator flap (DIEP) and C) breast reconstruction by expander/implant (TE).Biometric data were compared; sensitivity tests were performed using Semmes-Weinstein monofilaments.The non-operated, healthy contralateral breasts of the patients were used as a reference.
RESULTS: While the traditional reconstruction techniques by microsurgical anastomosed perforator flap or expander/implant showed a strongly decreased or completely missing sensitivity of the skin, the tests after reconstruction by AFG represented high values of sensory recovery, which came close to the reference group of non-operated breasts.
CONCLUSION: To our knowledge, this is the first study to compare skin sensitivity after AFG-based reconstruction to established techniques for breast reconstruction. We could demonstrate in a limited group of patients, that breast reconstruction by autologous fat grafting can achieve higher values of skin sensitivity compared to traditional techniques.
Purpose
Lipofilling has been established as a standard technique for contour enhancement following breast reconstruction. However, there is a paucity in current literature regarding the use of this technique for complete reconstruction of the female breast as an alternative to conventional techniques, such as expander or flap-based procedures. In particular, the influence of pre-operative irradiation for successful reconstruction has rarely been examined in published studies. Here, the authors describe their experience with successful fat injection in pre-radiated breasts in comparison with non-pre-radiated patients.
Methods
In this retrospective study, we examined a total of 95 lipofilling treatments on 26 patients (28 breasts). All of them experienced mastectomy following breast cancer; local breast defects after partial resection of the gland were not included in this study. In total, 47 lipofilling procedures in 12 non-irradiated patients (14 breasts) and 48 procedures in 14 irradiated women (also 14 breasts) were performed. Per session, approximately 297 +/- 112 cc of adipose tissue was grafted in group A (no radiotherapy) and approximately 259 +/- 93 cc was grafted in group B (radiotherapy).
Results
Among the group of women without pre-operative radiation, 71% of breast reconstructions limited to lipofilling only showed constant engraftment of fat tissue with a successful reconstructive result, whereas only 21% of the patients with pre-radiated breasts showed complete reconstruction of the breast with a permanent fat in-growth.
Conclusion
Preoperative radiotherapy significantly impedes successful completion of breast reconstructions planned only by autologous fat transfer. Patients should be selected individually and carefully for complete breast reconstruction using lipofilling only.
Background:
Reliable, time- and cost-effective, and clinician-friendly diagnostic tools are cornerstones in facial palsy (FP) patient management. Different automated FP grading systems have been developed but revealed persisting downsides such as insufficient accuracy and cost-intensive hardware. We aimed to overcome these barriers and programmed an automated grading system for FP patients utilizing the House and Brackmann scale (HBS).
Methods:
Image datasets of 86 patients seen at the Department of Plastic, Hand, and Reconstructive Surgery at the University Hospital Regensburg, Germany, between June 2017 and May 2021, were used to train the neural network and evaluate its accuracy. Nine facial poses per patient were analyzed by the algorithm.
Results:
The algorithm showed an accuracy of 100%. Oversampling did not result in altered outcomes, while the direct form displayed superior accuracy levels when compared to the modular classification form (n = 86; 100% vs. 99%). The Early Fusion technique was linked to improved accuracy outcomes in comparison to the Late Fusion and sequential method (n = 86; 100% vs. 96% vs. 97%).
Conclusions:
Our automated FP grading system combines high-level accuracy with cost- and time-effectiveness. Our algorithm may accelerate the grading process in FP patients and facilitate the FP surgeon’s workflow.
Thinking like a Lawyer - Human Rights and Their Association with the Plastic Surgeon of Today
(2022)
Plastic surgeons are trained to perform a wide repertoire of surgeries-ranging from standard local procedures to highly specialized operations. Therefore, plastic surgeons treat a plethora of clinical presentations and address multiple patient needs. Their daily workflow is increasingly entwined with legal topics. The concrete legal
interpretation falls within the remit of legal experts.
However, by understanding the legal basics of selected surgical procedures, plastic surgeons may generate synergies in patient care and clinical practice. The legal situation is to be elucidated based on the German Basic Law (GBL) and the European Convention on Human Rights
(ECHR).
Accurate and reliable information about three-dimensional (3D) knee joint laxity can prevent misdiagnosis and avoid incorrect treatments. Nevertheless, knee laxity assessments presented in the literature suffer from significant drawbacks such as soft tissue artifacts, restricting the knee within the measurement, and the absence of quantitative knee ligament property information. In this study, we demonstrated the applicability of a novel methodology for measuring 3D knee laxity, combining robotics- and image-based technology. As such technology has never been applied to healthy living subjects, the aims of this study were to develop novel technology to measure 3D knee laxity in vivo and to provide proof-of-concept 3D knee laxity measurements. To measure tibiofemoral movements, four healthy subjects were placed on a custom-built arthrometer located inside a low dose biplanar X-ray system with an approximately 60 deg knee flexion angle. Anteroposterior and mediolateral translation as well as internal and external rotation loads were subsequently applied to the unconstrained leg, which was placed inside a pneumatic cast boot. Bone contours were segmented in the obtained X-rays, to which subject-specific bone geometries from magnetic resonance imaging (MRI) scans were registered. Afterward, tibiofemoral poses were computed. Measurements of primary and secondary laxity revealed considerable interpersonal differences. The method differs from those available by the ability to accurately track secondary laxity of the unrestricted knee and to apply coupled forces in multiple planes. Our methodology can provide reliable information for academic knee ligament research as well as for clinical diagnostics in the future.
Aims
Barrett´s esophagus related neoplasia (BERN) is difficult to detect and characterize during endoscopy, even for expert endoscopists. We aimed to assess the add-on effect of an Artificial Intelligence (AI) algorithm (Barrett-Ampel) as a decision support system (DSS) for non-expert endoscopists in the evaluation of Barrett’s esophagus (BE) and BERN.
Methods
Twelve videos with multimodal imaging white light (WL), narrow-band imaging (NBI), texture and color enhanced imaging (TXI) of histologically confirmed BE and BERN were assessed by expert and non-expert endoscopists. For each video, endoscopists were asked to identify the area of BERN and decide on the biopsy spot. Videos were assessed by the AI algorithm and regions of BERN were highlighted in real-time by a transparent overlay. Finally, endoscopists were shown the AI videos and asked to either confirm or change their initial decision based on the AI support.
Results
Barrett-Ampel correctly identified all areas of BERN, irrespective of the imaging modality (WL, NBI, TXI), but misinterpreted two inflammatory lesions (Accuracy=75%). Expert endoscopists had a similar performance (Accuracy=70,8%), while non-experts had an accuracy of 58.3%. When AI was implemented as a DSS, non-expert endoscopists improved their diagnostic accuracy to 75%.
Conclusions
AI may have the potential to support non-expert endoscopists in the assessment of videos of BE and BERN. Limitations of this study include the low number of videos used. Randomized clinical trials in a real-life setting should be performed to confirm these results.
Elbow stability is derived from a combination of muscular, ligamentous, and bony structures. After an elbow trauma the stability of the joint is an important decision criterion for the subsequent treatment. The decision regarding non-operative/operative care depends mostly on subjective assessments of medical experts. Therefore, the aim of this study is to use musculoskeletal simulations as an objective assessment tool to investigate the extent to which failure of different stabilizers affects the elbow stability and how these observations correspond to the assessment from clinical practice. A musculoskeletal elbow simulation model was developed for this aim. To investigate the stability of the elbow, varus/valgus moments were applied under 0°, 45°and 90° flexion while the respective cubital angle was analyzed. This was performed for nine different injury scenarios, which were also evaluated for stability by clinical experts. With the results, it can be determined by which injury pattern and under which flexion angle the elbow stability is impaired regarding varus/valgus moments. The scenario with a complete failure of the medial and lateral ligaments and a fracture of the radial head was identified as having the greatest instability. The study presented a numerical determination of elbow stability against varus/valgus moments regarding clinical injury patterns, as well as a comparison of the numerical outcome with experience gained in clinical practice. The numerical predictions agree well with the assessments of the clinical specialists. Thus, the results from musculoskeletal simulation can make an important contribution to a more objective assessment of the elbow stability.
At risk of reproductive disadvantage? Exploring fertility awareness among migrant women in Germany
(2022)
This study examined awareness about fertility among immigrant women and non-migrants in Germany. The social relevance of infertility and fertility treatment is increasing in Western countries due to continually low overall birth rates, a high rate of childlessness, and a gap between the desired and actual numbers of children. While there is growing interest in infertility and reproductive medicine in general, previous studies have rarely included immigrant or ethnic minorities in Europe. This study investigated whether knowledge on the age-related fertility decline (ARFD) varies between migrant groups and the majority group, and the role of education. Working hypotheses were drawn from theoretical considerations on frameworks of migrant assimilation. The analysis was based on data collected in a social science pilot study on reproductive medicine, representative of the general population (‘NeWiRe’ 2014–2015). The sample included 962 women aged 18–50 years living in Germany. Approximately 81% of the sample were immigrants who originated from Turkey, Poland, the Balkan countries or countries of the (post-Soviet) Commonwealth of Independent States. While rather poor overall, knowledge on ARFD was found to be significantly lower in the migrant groups compared with the majority group. This minority-group disadvantage cannot be explained by sociodemographic or cultural variables. Future research should include minority groups in empirical studies on awareness about fertility in order to better understand the causes of this disadvantage, and the potential reproductive needs of migrants.
Introduction:
Neointimal hyperplasia after percutaneous coronary intervention remains a major determinant of in-stent restenosis (ISR). The extent of mechanical vessel injury correlates with ISR. A new ex vivo porcine stent model was introduced and evaluated comparing different stent designs.
Methods:
Coronary arteries were prepared from pig hearts from the slaughterhouse and used for ex vivo implantations of coronary stents. One basic stent design in two configurations (dogbone, DB; non-dogbone, NDB) was used. Vascular injury was determined according to a modified injury score (IS).
Results:
Standardized experimental conditions ensured comparable vessel dimensions and overstretch data. DB stents caused more severe IS compared to NDB stents. The mean IS and the IS at the distal end of all stents were significantly reduced for NDB stents (ISMean, DB, 1.16 ±0.12; NDB, 1.02 ±0.12; p=0.018; ISDist, DB, 1.39 ±0.28; NDB, 1.13 ±0.24; p=0.03).
Discussion/Conclusion:
The introduced ex-vivo model allowed the evaluation of different stent designs exclude unfavorable stent designs.
The good availability and the large content of adult stem cells in adipose tissue has made it one of the most interesting tissues in regenerative medicine. Although lipofilling is one of the most frequent procedures in plastic surgery, the method still struggles with high absorption rates and volume losses of up to 70%. Therefore, many efforts have been made to optimize liposuction and to process the harvested tissue in order to increase fat graft retention. Because of their immunomodulatory properties, their cytokine secretory activity, and their differentiation potential, enrichment with adipose tissue-derived stem cells was identified as a promising tool to promote transplant survival. Here, we review the important parameters for lipofilling optimization. Finally, we present a new method for the enrichment of lipoaspirate with adipose tissue-derived stem cells and discuss the parameters that contribute to fat graft survival.
Celiac disease is an autoimmune disorder caused by gluten that results in an inflammatory response of the small intestine.We investigated whether celiac disease can be detected using endoscopic images through a deep learning approach. The results show that additional clinical parameters can improve the classification accuracy. In this work, we distinguished between healthy tissue and Marsh III, according to the Marsh score system. We first trained a baseline network to classify endoscopic images of the small bowel into these two classes and then augmented the approach with a multimodality component that took the antibody status into account.
The endoscopic features associated with eosinophilic esophagitis (EoE) may be missed during routine endoscopy. We aimed to develop and evaluate an Artificial Intelligence (AI) algorithm for detecting and quantifying the endoscopic features of EoE in white light images, supplemented by the EoE Endoscopic Reference Score (EREFS). An AI algorithm (AI-EoE) was constructed and trained to differentiate between EoE and normal esophagus using endoscopic white light images extracted from the database of the University Hospital Augsburg. In addition to binary classification, a second algorithm was trained with specific auxiliary branches for each EREFS feature (AI-EoE-EREFS). The AI algorithms were evaluated on an external data set from the University of North Carolina, Chapel Hill (UNC), and compared with the performance of human endoscopists with varying levels of experience. The overall sensitivity, specificity, and accuracy of AI-EoE were 0.93 for all measures, while the AUC was 0.986. With additional auxiliary branches for the EREFS categories, the AI algorithm (AI-EoEEREFS) performance improved to 0.96, 0.94, 0.95, and 0.992 for sensitivity, specificity, accuracy, and AUC, respectively. AI-EoE and AI-EoE-EREFS performed significantly better than endoscopy beginners and senior fellows on the same set of images. An AI algorithm can be trained to detect and quantify endoscopic features of EoE with excellent performance scores. The addition of the EREFS criteria improved the performance of the AI algorithm, which performed significantly better than endoscopists with a lower or medium experience level.
The present paper provides an overview on current developments of cash usage and issue of central bank digital currency (CBDC) in the euro area and proposes a possible design of a digital euro that allows for instant offline payments. Cash usage at the point-of-sale decreased perceptibly in the past years mainly due to the ongoing trend towards digitalization. However, we show that there are also indications that consumers were somewhat pushed into cashless payments by government regulations and supply-side restrictions by commercial banks. Nonetheless, overall demand for euro cash remained strong and even increased relative to GDP since the financial crisis in 2008. In this process, however, we observe a supply-driven shift towards lower banknote denominations. Central banks all over the world are intensively thinking about the potential issue of CBDC as a substitute or complement to cash. Based on some of its preferred characteristics, we propose a double pre-paid scheme combining central elements of TARGET Instant Payment Settlement and electronic money features enabling offline and online instant payments. Since anonymity is categorically discarded by the ECB and as cash has some special advantages from a consumer perspective, the digital euro will rather co-circulate with cash than replace it in transactions.
This paper focuses on the role of specific types of crisis (technological crisis, financial market crisis, natural disaster) and their effects on the demand for cash in an international context. As evidence from the last 30 years shows, demand for cash increases during periods of crisis, regardless of the nature of the crisis. The nature of the crisis does, however, determine whether small or large banknote denominations are affected more. This study finds that times of payment uncertainties are associated with increased demand for small denominations, probably reflecting an elevated demand for transaction balances. By contrast, in times of financial crisis or general economic uncertainty, the increased demand for cash is largely the result of consumers taking precautionary actions and building up non-transaction balances; for this reason, there is greater demand for large banknote denominations. This study finds that cash continues to play an important role in crisis management. Whether this function can also be fulfilled by a future central bank digital currency, however, remains to be seen.
Biomechanical analysis of the right elevated glenohumeral joint in violinists during legato-playing
(2022)
BACKGROUND:
Many statistics reveal that violin players suffer most often from musculoskeletal disorders compared to musicians of other instrument groups. A common phenomenon, especially observed in violin beginners, is the tendency to elevate the right shoulder during playing the violin. This can probably lead to serious disorders in long-term practice with repetitive movements.
OBJECTIVE:
For this reason, this study investigated the relationship between the right shoulder elevation and the force in the right glenohumeral joint during violin playing. It was hypothesized that the forces in the right glenohumeral joint are higher during playing with the right shoulder raised compared to playing in normal posture.
METHODS:
Motion capture data from four experienced violinists was recorded and processed by means of musculoskeletal simulation to get the force and elevation angle while playing with raised shoulder and in normal position.
RESULTS:
The results indicate that the absolute values of the resulting force, as well as the forces in the mediolateral, inferosuperior, and anteroposterior directions, are higher in playing the violin with the shoulder raised than in a normal posture.
CONCLUSIONS:
Elevating the right shoulder while playing the violin may pose a potential problem.
Clinical setting
Third space procedures such as endoscopic submucosal dissection (ESD) and peroral endoscopic myotomy (POEM) are complex minimally invasive techniques with an elevated risk for operator-dependent adverse events such as bleeding and perforation. This risk arises from accidental dissection into the muscle layer or through submucosal blood vessels as the submucosal cutting plane within the expanding resection site is not always apparent. Deep learning algorithms have shown considerable potential for the detection and characterization of gastrointestinal lesions. So-called AI – clinical decision support solutions (AI-CDSS) are commercially available for polyp detection during colonoscopy. Until now, these computer programs have concentrated on diagnostics whereas an AI-CDSS for interventional endoscopy has not yet been introduced. We aimed to develop an AI-CDSS („Smart ESD“) for real-time intra-procedural detection and delineation of blood vessels, tissue structures and endoscopic instruments during third-space endoscopic procedures.
Characteristics of Smart ESD
An AI-CDSS was invented that delineates blood vessels, tissue structures and endoscopic instruments during third-space endoscopy in real-time. The output can be displayed by an overlay over the endoscopic image with different modes of visualization, such as a color-coded semitransparent area overlay, or border tracing (demonstration video). Hereby the optimal layer for dissection can be visualized, which is close above or directly at the muscle layer, depending on the applied technique (ESD or POEM). Furthermore, relevant blood vessels (thickness> 1mm) are delineated. Spatial proximity between the electrosurgical knife and a blood vessel triggers a warning signal. By this guidance system, inadvertent dissection through blood vessels could be averted.
Technical specifications
A DeepLabv3+ neural network architecture with KSAC and a 101-layer ResNeSt backbone was used for the development of Smart ESD. It was trained and validated with 2565 annotated still images from 27 full length third-space endoscopic videos. The annotation classes were blood vessel, submucosal layer, muscle layer, electrosurgical knife and endoscopic instrument shaft. A test on a separate data set yielded an intersection over union (IoU) of 68%, a Dice Score of 80% and a pixel accuracy of 87%, demonstrating a high overlap between expert and AI segmentation. Further experiments on standardized video clips showed a mean vessel detection rate (VDR) of 85% with values of 92%, 70% and 95% for POEM, rectal ESD and esophageal ESD respectively. False positive measurements occurred 0.75 times per minute. 7 out of 9 vessels which caused intraprocedural bleeding were caught by the algorithm, as well as both vessels which required hemostasis via hemostatic forceps.
Future perspectives
Smart ESD performed well for vessel and tissue detection and delineation on still images, as well as on video clips. During a live demonstration in the endoscopy suite, clinical applicability of the innovation was examined. The lag time for processing of the live endoscopic image was too short to be visually detectable for the interventionist. Even though the algorithm could not be applied during actual dissection by the interventionist, Smart ESD appeared readily deployable during visual assessment by ESD experts. Therefore, we plan to conduct a clinical trial in order to obtain CE-certification of the algorithm. This new technology may improve procedural safety and speed, as well as training of modern minimally invasive endoscopic resection techniques.
ARTIFICIAL INTELLIGENCE (AI) – ASSISTED VESSEL AND TISSUE RECOGNITION IN THIRD-SPACE ENDOSCOPY
(2022)
Aims
Third-space endoscopy procedures such as endoscopic submucosal dissection (ESD) and peroral endoscopic myotomy (POEM) are complex interventions with elevated risk of operator-dependent adverse events, such as intra-procedural bleeding and perforation. We aimed to design an artificial intelligence clinical decision support solution (AI-CDSS, “Smart ESD”) for the detection and delineation of vessels, tissue structures, and instruments during third-space endoscopy procedures.
Methods
Twelve full-length third-space endoscopy videos were extracted from the Augsburg University Hospital database. 1686 frames were annotated for the following categories: Submucosal layer, blood vessels, electrosurgical knife and endoscopic instrument. A DeepLabv3+neural network with a 101-layer ResNet backbone was trained and validated internally. Finally, the ability of the AI system to detect visible vessels during ESD and POEM was determined on 24 separate video clips of 7 to 46 seconds duration and showing 33 predefined vessels. These video clips were also assessed by an expert in third-space endoscopy.
Results
Smart ESD showed a vessel detection rate (VDR) of 93.94%, while an average of 1.87 false positive signals were recorded per minute. VDR of the expert endoscopist was 90.1% with no false positive findings. On the internal validation data set using still images, the AI system demonstrated an Intersection over Union (IoU), mean Dice score and pixel accuracy of 63.47%, 76.18% and 86.61%, respectively.
Conclusions
This is the first AI-CDSS aiming to mitigate operator-dependent limitations during third-space endoscopy. Further clinical trials are underway to better understand the role of AI in such procedures.
In Germany, midwives are involved in extensive antenatal and postnatal care. As health professionals, they can play a key role in strengthening health literacy (HL) of parents on how to prevent chronic allergic diseases in their children. The objective of this study is to explore midwives’ perspectives regarding HL-sensitive counselling in early childhood allergy prevention (ECAP). Twenty-four qualitative semi-structured interviews were conducted with midwives, and data were analyzed using qualitative content analysis. Only a small number of study participants were aware of HL as a concept. However, most of these use screening and counselling strategies which consider individual information needs and which support parental HL. HL sensitivity in counselling is largely based on the midwives’ “gut feelings” and counselling experience, rather than on formal education. The midwives were largely aware of evidence-based ECAP recommendations; however, allergy prevention was not seen as a stand-alone topic but as part of their general counselling on infant feeding and hygiene. They found parents to be more open to receiving complex prevention information during antenatal counselling. In order to strengthen midwives’ roles in HL-sensitive ECAP counselling, their formal education should provide them with explicit HL knowledge and counselling skills. ECAP should be an inherent part of antenatal care.
BACKGROUND:
Due to their corrugated profile, dragonfly wings have special aerodynamic characteristics during flying and gliding. OBJECTIVE: The aim of this study was to create a realistic 3D model of a dragonfly wing captured with a high-resolution micro-CT. To represent geometry changes in span and chord length and their aerodynamic effects, numerical investigations are carried out at different wing positions. METHODS:
The forewing of a Camacinia gigantea was captured using a micro-CT. After the wing was adapted an error-free 3D model resulted. The wing was cut every 5 mm and 2D numerical analyses were conducted in Fluent® 2020 R2 (ANSYS, Inc., Canonsburg, PA, USA). RESULTS: The highest lift coefficient, as well as the highest lift-to-drag ratio, resulted at 0 mm and an angle of attack (AOA) of 5∘. At AOAs of 10∘ or 15∘, the flow around the wing stalled and a Kármán vortex street behind the wing becomes
CONCLUSIONS:
The velocity is higher on the upper side of the wing compared to the lower side. The pressure acts vice versa. Due to the recirculation zones that are formed in valleys of the corrugation pattern the wing resembles the form of an airfoil.
Cybersecurity and Ethics
(2022)
The text aims to demonstrate that establishing cybersecurity is not only a technical challenge, but that legal, economic, or organizational aspects also play at least as important a role. The provision of cybersecurity raises ethical questions, since cybersecurity can affect moral values such as autonomy, freedom, or privacy. If measurements necessary for the provision of cybersecurity shall be accepted, it is essential to find a balance between the different claims of all stakeholders involved. This aim is achieved through a detailed ethical analysis accompanied by an extensive literature study. As the most important result of this analysis, it becomes obvious that cybersecurity is in competition or even conflict with other values and interests, and that establishing cybersecurity always involves a trade-off. Not only can there be no 100 percent cybersecurity for technical reasons, but if other values and interests are to be considered, this inevitably leads to compromises in cybersecurity.
Vascular malformations (VMs) are a rare condition. They can be categorized into high-flow and low-flow VMs, which is a challenging task for radiologists. In this work, a very heterogeneous set of MRI images with only rough annotations are used for classification with a convolutional neural network. The main focus is to describe the challenging data set and strategies to deal with such data in terms of preprocessing, annotation usage and choice of the network architecture. We achieved a classification result of 89.47 % F1-score with a 3D ResNet 18.
We conceptualize the new phenomenon of the Fractional Chief InformationOfficer (CIO) as a part-time executive who usually works for more than one pri-marily small- to medium-sized enterprise (SME) and develop promising avenuesfor future research on Fractional CIOs. We conduct an empirical study by drawingon semi-structured interviews with 40 individuals from 10 different countries whooccupy a Fractional CIO role. We derive a definition for the Fractional CIO, dis-tinguish it from other forms of employment, and compare it with existing researchon CIO roles. Further, we find four salient engagement types of Fractional CIOsoffering value for SMEs in various situations: Strategic IT management, Restruc-turing, Rapid scaling, and Hands-on support. The results reveal similarities withexisting CIO roles as well as novel insights concerning the different engagementtypes. Lastly, we propose a research agenda for the Fractional CIO field, based onfour research themes derived from existing CIO research and insights from theinterviews.
Customized additively manufactured (laser powder bed fused (L-PBF)) stents could improve the treatment of complex lesions by enhancing stent-artery conformity. However, geometric irregularities inherent for L-PBF stents are expected to influence not only their mechanical behavior but also their interaction with the artery. In this study, the influence of geometrical irregularities on stent-artery interaction is evaluated within a numerical framework. Thus, computed arterial stresses induced by a reconstructed L-PBF stent model are compared to those induced by the intended stent model (also representing a stent geometry obtained from conventional manufacturing processes) and a modified CAD stent model that accounts for the increased strut thickness inherent for L-PBF stents. It was found that, similar to conventionally manufactured stents, arterial stresses are initially related to the basic stent design/topology, with the highest stresses occurring at the indentations of the stent struts. Compared to the stent CAD model, the L-PBF stent induces distinctly higher and more maximum volume stresses within the plaque and the arterial wall. In return, the modified CAD model overestimates the arterial stresses induced by the L-PBF stent due to its homogeneously increased strut thickness and thus its homogeneously increased geometric stiffness compared with the L-PBF stent. Therefore, the L-PBF-induced geometric irregularities must be explicitly considered when evaluating the L-PBF stent-induced stresses because the intended stent CAD model underestimates the arterial stresses, whereas the modified CAD model overestimates them. The arterial stresses induced by the L-PBF stent were still within the range of values reported for conventional stents in literature, suggesting that the use of L-PBF stents is conceivable in principle. However, because geometric irregularities, such as protruding features from the stent surface, could potentially damage the artery or lead to premature stent failure, further improvement of L-PBF stents is essential.