Search

Classification; Extracorporeal life support; Simulation training Classificació; Suport vital extracorpòri; Formació en simulació Clasificación; Soporte vital extracorpóreo; Formación en simulación High-volume extracorporeal membrane oxygenation (ECMO) centers generally have better outcomes than (new) low-volume ECMO centers, most likely achieved by a suitable exposure to ECMO cases. To achieve a higher level of training, simulation-based training (SBT) offers an additional option for education and extended clinical skills. SBT could also help to improve the interdisciplinary team interactions. However, the level of ECMO simulators and/or simulations (ECMO sims) techniques may vary in purpose. We present a structured and objective classification of ECMO sims based on the broad experience of users and the developer for the available ECMO sims as low-, mid-, or high-fidelity. This classification is based on overall ECMO sim fidelity, established by taking the median of the definition-based fidelity, component fidelity, and customization fidelity as determined by expert opinion. According to this new classification, only low- and mid-fidelity ECMO sims are currently available. This comparison method may be used in the future for the description of new developments in ECMO sims, making it possible for ECMO sim designers, users, and researchers to compare accordingly, and ultimately improve ECMO patient outcomes. This research was funded by the 2022 “Boost Your Research” Fund in the Priority Program SPP 2014 “Towards an Implantable Lung” by the DFG, the German Research Foundation, grant number 20003297 UKA.

With great interest we read the systematic review and meta-analysis by Osborne et al. on the effectiveness of high- and low-fidelity simulation-based medical education in teaching cardiac auscultation. We congratulate the authors for their efforts to provide a systematic review on simulation-based education. While the authors conclude that high-fidelity simulation has no benefit in improving cardiac auscultation knowledge or skills compared with low-fidelity simulation, we believe that this conclusion cannot be supported by the authors’ work.

Background: Population-based studies have consistently shown improved long-term outcomes with breast conserving surgery (BCS) plus radiotherapy (RT) vs. mastectomy in primarily operated breast cancer (BC) patients. However, the survival impact of type of local therapy following modern neoadjuvant systemic therapy (NST) is unclear. Methods: The population-based Swedish National Breast Cancer Register (NKBC), a prospectively collected population-based cohort, was used to identify female BC patients who were diagnosed from January, 2007 until December, 2017 and received NST in the Stockholm region. Patients were divided into BCS+RT and mastectomy groups, and the prognostic factors reflecting the response to NST like pathologic complete response (pCR) and Neo-bioscore calculated by pre/postoperative TNM stage, nuclear grade, and receptors status, were used for stratification. Disease-free survival (DFS), locoregional recurrence-free survival (LRFS), distant metastasis-free survival (DMFS) and overall survival (OS) were evaluated using inverse probability of treatment weighted (IPTW) Cox proportional hazards model, which enables covariates like age, St Gallen subtypes, cTNM and ypTNM stages to be balanced between the two groups. Results: Among 1,409 eligible women, 456 (32.4%) were treated with BCS+RT, and 953 (67.6%) with mastectomy. Overall, 87 (6.2%) local recurrences, 256 (18.2%) distant metastases, and 282 (20.0%) deaths occurred over a median follow-up of 61 months. Patients diagnosed during later years, younger patients, patients with earlier stage and higher-grade tumors were more likely to receive BCS+RT. After adjusting for age at diagnosis, Neo-bioscore, adjuvant chemotherapy and radiotherapy, significant improvements for BCS+RT compared with mastectomy were observed in DFS (weighted-multivariate hazard ratio (HR), 0.51; 95%CI, 0.28-0.93; median 5-year DFS: 79.1% vs 73.6%) and DMFS (HR, 0.44; 95%CI, 0.23-0.82; median 5-year DMFS: 83.7% vs 74.8%), but no difference was identified in LRFS (HR, 0.94; 95%CI, 0.29-3.07; median 5-year LRFS: 89.9% vs 92.0%) or OS (HR, 0.7; 95%CI, 0.34-1.45; median 5-year OS: 88.4% vs 81.2%). The DFS benefit was observed regardless of pCR status, but varied by Neo-bioscore. Patients with Neo-bioscore 4-7 treated with BCS+RT had better DFS (HR, 0.31; 95%CI, 0.12-0.81) compared with those undergoing mastectomy, whereas low-risk patients with Neo-bioscore 0-3 had similar DFS between the two groups. Both triple negative (N=252; HR for DFS, 0.26; 95%CI, 0.07-0.97) and HER2-positive (N=533; HR for DFS, 0.24, 95%CI, 0.09-0.68) BC patients benefited from BCS+RT, but not patients with luminal tumors (N=589; HR for DFS, 0.82, 95%CI, 0.31-2.18). Similarly, superior DFS with BCS+RT was also seen in patients with neoadjuvant anti-HER2 targeted therapy (N=505; HR, 0.19; 95%CI, 0.05-0.75) or neoadjuvant chemotherapy alone (N=594; HR, 0.47; 95%CI, 0.21-1.06), but not among those receiving neoadjuvant endocrine therapy (N=162; HR, 0.53; 95%CI, 0. 1-2.85). Conclusion: After adjusting for response to NST and other confounders, BCS+RT was associated with reduced risks of tumor recurrence or metastasis compared with mastectomy. This benefit was more pronounced in patients with high Neo-bioscore, indicating that Neo-bioscore rather than pCR status has the potential to tailor breast surgery after NST. Further studies with larger sample size or prospective randomized clinical trials are warranted to confirm our findings. Citation Format: Kang Wang, Aafke Duinmeijer, Alexios Matikas, Renske Altena, Hemming Johansson, Hanna Fredholm, Theodoros Foukakis. Long-term outcomes for breast conservation plus radiotherapy versus mastectomy in early breast cancer after neoadjuvant systemic therapy: Results from the Swedish national breast cancer register (NKBC) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-18-03.

Objectives: High-volume ECMO centers have better clinical outcomes than low-volume centers due to higher clinical exposure. Simulation-based training (SBT) can be an alternative for these centers to reach similar experience levels. SBT not only improves education of the individual caregiver but also improves multidisciplinary ECMO teams. However, ECMO simulators and/or simulations (Sims) differ on realism and functions, making each of these simulators useful for different purposes. Classifying Sims is often subjective and left to the individual user and/or creator. This scoping review aims to present a structured and objective way to classify available Sims. Methods: Physical and/or computational Sims with public information in English were screened for eligibility. Overall fidelity was established by taking the median of definition-based fidelity, derived from literature, and combining this with the median of our newly established component fidelity and customization fidelity. Component fidelity was based on the main elements of ECMO support while customization fidelity was based on main parameters to (re)create a unique patient, see table. Sims were subsequently classified as being low-, mid-, or high-fidelity. Results: Universal definitions for SBT were applied to Sims. According to our objective classification method, 10 (38%) low, 16 (62%) mid and no highfidelity Sims exist. Most (54%) Sims are lacking customization options for patient-specific modelling. Conclusions: Overall fidelity of available Sims were objectively classified based on definition-based, component, and customization fidelity. No high-fidelity Sims currently exists, urging for development of a high-fidelity simulator to improve ECMO-team training and improve patient outcomes. With our method, future Sims can be classified more objectively allowing for users and researchers to compare accordingly.

This paper studies the macroeconomic consequences of climate-induced reef degradation for Bonaire. Bonaire’s coral reefs progressively face the unavoidable reality of climate change, with its effects increasing in severity. Degradation of the island’s reef ecosystems may affect annual tourism arrivals as the reefs form one of the main attractions for visitors to Bonaire. Consequently, the industries that rely on tourist expenditures will suffer and thus the local economy. Coral reef-based tourism creates a unique opportunity to investigate the impacts of global warming on the macro¬economic performance of Bonaire. This paper employs the emission scenarios SSP1-1.9, SSP2-4.5, SSP3-7.0, and SSP5-8.5 of the AR6 IPCC 2021 to study the effects of coral reef degradation on the social carrying capacity of the coral reefs. Subsequently, the potential effects of reduced dive tourism and the induced effects of a change in tourism demand are translated into changes in sectoral outputs by employing input-output analysis. Coral reef degradation is expected under all scenarios, except the SSP1-1.9 scenario where a slight recovery of coral reefs is possible.This study finds a contraction in GDP between 25 USDm and 173 USDm by 2050 (between 2 to 18 percent of GDP in 2050), depending on the applied climate scenario. Moreover, a tourism income multiplier of 0.85x is found, which indicates a strong interlinkage between tourism income and the local economy, as from every dollar of tourism income 85% enters the local economy. This indicates that any losses in tourism demand will significantly result in macroeconomic damages for Bonaire. It can thus be expected that climate change will have a substantial impact on coral reefs as a vital tourism asset on Bonaire, with more extreme emission scenarios leading to stronger negative effects on the local economy.

This paper studies the macroeconomic consequences of climate-induced reef degradation for Bonaire. Bonaire’s coral reefs progressively face the unavoidable reality of climate change, with its effects increasing in severity. Degradation of the island’s reef ecosystems may affect annual tourism arrivals as the reefs form one of the main attractions for visitors to Bonaire. Consequently, the industries that rely on tourist expenditures will suffer and thus the local economy. Coral reef-based tourism creates a unique opportunity to investigate the impacts of global warming on the macro¬economic performance of Bonaire. This paper employs the emission scenarios SSP1-1.9, SSP2-4.5, SSP3-7.0, and SSP5-8.5 of the AR6 IPCC 2021 to study the effects of coral reef degradation on the social carrying capacity of the coral reefs. Subsequently, the potential effects of reduced dive tourism and the induced effects of a change in tourism demand are translated into changes in sectoral outputs by employing input-output analysis. Coral reef degradation is expected under all scenarios, except the SSP1-1.9 scenario where a slight recovery of coral reefs is possible. This study finds a contraction in GDP between 25 USDm and 173 USDm by 2050 (between 2 to 18 percent of GDP in 2050), depending on the applied climate scenario. Moreover, a tourism income multiplier of 0.85x is found, which indicates a strong interlinkage between tourism income and the local economy, as from every dollar of tourism income 85% enters the local economy. This indicates that any losses in tourism demand will significantly result in macroeconomic damages for Bonaire. It can thus be expected that climate change will have a substantial impact on coral reefs as a vital tourism asset on Bonaire, with more extreme emission scenarios leading to stronger negative effects on the local economy.

Small islands are particularly vulnerable to climate change because of their fragile ecosystems, small economies, and often extensive, low-lying coastal areas. Therefore, small islands, such as present in the Caribbean Netherlands, are expected to suffer excessively from rising temperatures, changes in precipitation, sea-level rise, coral bleaching, cyclones, droughts and floods. Despite this widespread conviction, scientific evidence of these effects in the Caribbean Netherlands is scarce, and as a result, limited adaptation strategies are developed or implemented by local and Dutch governments.In this study, an analysis is conducted assessing the impacts of climate change for the island of Bonaire. Given the uncertainty regarding the actual level of climate change in the future, four universally recognised scenarios are simulated, ranging from an optimistic scenario “SSP1-1.9” (corresponding to a mean temperature rise of 1.4°C at the end of the 21st century relative to pre-industrial levels), which assumes climate change will modestly increase relative to current levels, to a pessimistic scenario “SSP5-8.5” (corresponding to a mean temperature rise of 4.4°C at the end of the 21st century relative to pre-industrial levels), which suggests very high levels of climate change. Impacts are measured and reported at different moments in time, mainly looking at the years 2050 and 2150, representing short-term and long-term effects of climate change, respectively. A mix of methods from various scientific disciplines are used to estimate the impacts of climate change, including climate and flood models, ecological-economic models, as well as social-science methods such as social media analysis, participatory mapping and key-informant interviews. Although the sub-components of the study are systematically aligned and integrated, four topics can be distinguished: the estimation of the biophysical impacts, the modelling of economic effects, the identification of socio-cultural effects, and the exploration for potential adaptation options.

High mammographic density (MD) is associated with an increased risk of breast cancer, however the underlying mechanisms are largely unknown. This research aimed to identify microRNAs (miRNAs) that play a role in the development of extremely dense breast tissue. In the discovery phase, 754 human mature miRNAs were profiled in 21 extremely high MD- and 20 very low MD-derived nipple aspirate fluid (NAF) samples from healthy women. In the validation phase, candidate miRNAs were assessed in a cohort of 89 extremely high MD and 81 very low MD NAF samples from healthy women. Independent predictors of either extremely high MD or miRNA expression were identified by logistic regression and linear regression analysis, respectively. mRNA targets and pathways were identified through miRTarBase, TargetScan, and PANTHER pathway analysis. Statistical analysis identified four differentially expressed miRNAs during the discovery phase. During the validation, linear regression (p = 0.029; fold change = 2.10) and logistic regression (p = 0.048; odds ratio = 1.38) showed that hsa-miR-29c-5p was upregulated in extremely high MD-derived NAF. Identified candidate mRNA targets of hsa-miR-29c-5p are CFLAR, DNMT3A, and PTEN. Further validation and exploration of targets and downstream pathways of has-miR-29c-5p will provide better insight into the processes involved in the development of high MD and in the associated increased risk of breast cancer.

Closure to “Experimental study on the 3D-flow field of a free-surface vortex using stereo PIV” by ALEX DUINMEIJER, GOSSE OLDENZIEL and FRANCOIS CLEMENS, J. Hydraulic Res. 58(1), 2020, 105–119, http...

Experiments are conducted in a Ø600 mm tank to analyse the 3D motion of buoyant particles in the free-surface vortex flow. The experiments revealed two stages in the particle motion: stage 1 is the helical motion along the vortex air core and stage 2 is the axial motion inside the vortex core. The stage 1 motion is sensitive to the particle’s initial conditions by showing a chaotic behaviour and quantified by determining the largest Lyapunov exponent. Consequently, the predictability (forecast horizon) of the particle’s motion is limited. A motion parameter is proposed that indicates if a continuous downward motion along the air core occurs. The dynamics in the stage 2 motion is determined by the imbalance between the particle’s buoyancy force and fluid drag force. The drag appears to be determined by the Taylor column drag force as present in rotating fluids. Based on this force, a motion condition is proposed that indicates if axial motion inside the vortex core occurs.

Accumulation of fat, oil and grease (FOG) in the sumps of wastewater pumping stations is a common failure cause for these facilities. Floating solids are often not transported by the pump suction inlets and the individual solids can accumulate to stiff and thick FOG layers. The lack of data about the dynamics in FOG layer formation still hampers the design of effective measures towards its mitigation. In this article, we present a low-cost camera-based automated system for the observation of FOG layer dynamics in wastewater pumping stations at high-frequency (minutes) over extended time windows (months). Optical imagery is processed through a deep-learning computer vision routine that allows describing FOG layer dynamics (e.g. accumulation rate and changes in shape) and various hydraulic processes in the pump sump (e.g. the water level, surface flow velocity fields, vorticity, or circulation). Furthermore, the system can perform in-camera image processing, thus allowing the transfer of compressed-processed datasets when deployed in remote locations (Edge AI computing), which could be of great utility for the hydro-ecological monitoring community. In this study, the technology applied is illustrated with a dataset (six months, two-minute frequency) collected at a wastewater pumping station at the municipality of Rotterdam, The Netherlands. This monitoring system represents a source of information for the management of (waste)water pumping stations (e.g. detection of free-surface vortices and scheduling of sump cleaning operations) and facilitates the collection of standardized high-frequency FOG layer dynamics data for a detailed description of FOG build-up and transport processes.

This is an experimental and theoretical research on the motion of buoyant particles in the flow of a free-surface vortex at moderate to high particle Reynolds numbers.

The accumulation of FOG (Fat, Oil and Grease) deposits in sewer pumping stations results in an increase in maintenance costs, malfunctioning of pumps and, a potential increase of wastewater spills in receiving open water bodies. It is thought that a variety of parameters (e.g. geometry of the pump sump, pump operation, socioeconomic parameters of the catchment) influences the built-up of FOG. Based on a database containing data of 126 pumping stations located in five Dutch municipalities a statistical model was built. It is shown that 3 parameters are most significant in explaining the occurrence of FOG deposits: mean income of the population in a catchment, the amount of energy (kinetic and potential) per m3 per day and the density of restaurants, bars and hotels in a catchment. Further it is shown that there are significant differences between municipalities that can be traced back to the local ‘design paradigm’. For example, in Amsterdam, the design philosophy of discharging in the pump sump under the water surface (and hence maintaining a low level of turbulence in the pump sump) results in an increase of the probability of the formation of FOG.

Wastewater pumping stations can experience problems due the presence of floating particles of solidified fat and grease. To transport this debris, the ability of free-surface vortices as transport mechanism is investigated. An experimental set-up is developed where the behaviour of large particles (0.02 - 0.04 m) in the vortex flow are analysed. An 3D-particle tracking method based of 6 iPhone® cameras was used to record the position of the particles in the vortex. Based on the measured particle acceleration, the hydrodynamic forces on the particle are derived. This novel 3D-PTV method was found to generate consistent information on the movement of the particles in the vortex flow field.

This study examines the grammatical abilities of children and adolescents with Specific Language Impairment (SLI). There were two research goals. Firstly, the persistence of grammatical problems over time was examined by comparing a younger group of children with SLI and an older group of adolescents with SLI. Secondly, this study explored whether difficulties in the grammatical domain in SLI purely reflect a grammatical deficit or may partly stem from problems in the implementation of grammatical knowledge due to problems in information processing. In the grammatical production tasks, the complexity of the linguistic context was therefore varied to examine whether this would cause a (larger) decrease in scores in the SLI groups. In addition, the link between variability in performance and processing abilities was examined. On the basis of the outcomes this book makes two major claims. Firstly, grammatical problems in SLI are persistent into adolescence. For some grammatical aspects such as grammatical gender, fossilization seemed to take place before children reach adolescence. Other aspects (e.g. verb inflection), had clearly been acquired by adolescence but differences between SLI and typical development (TD) in the amount of errors still remained. Secondly, grammatical performance in SLI was affected by the linguistic context in which grammatical knowledge had to be implemented. Such effects were small or absent in the TD groups. The effect of context was related to the verbal processing abilities of the groups. Even when grammatical knowledge has been acquired, individuals with SLI are not always able to implement this knowledge in performance.

Sumps of wastewater pumping station can experience problems due the formation of (solid) floating layers of fat and scum as a result of insufficient current guidelines for sump design with respect to transport of floating debris. To complimentary the guidelines, the use of free-surface vortices is defined as a potential transport mechanism for floating debris. The transport ability and capacity of vortices is investigated in an experimental set-up and experimental data will be used to design and validate a theoretical vortex transport model describing the transport ability and capacity of a free-surface vortex. Two theoretical vortex models describing the vortex flow field are used as a base for the transport model. Experimental results show that both models needs adaptation to match experimental results. Furthermore, the experiments show that the ability to transport buoyant material is highly sensitive on the flow field in the vortex (core) and on the particle density. Particles can either get stuck in the vortex core with no or less transport or either translated around the core with efficient transport. Before designing and validating the vortex transport model, extensive future research is needed to capture the observed phenomena’s.