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Haptic feedback of gripping forces during robotassisted surgery can benefit the surgical outcome by means of reduced forces applied to the tissue. A custom-designed haptic user interface allows to control four degrees of freedom of the instrument’s endeffector and to display gripping forces. System-centered evaluation is performed to assess its capability of displaying feedback with high mechanical bandwidth. In addition, the perception of gripping forces is evaluated using task-centered methods. Two tasks were performed by ten participants to assess the perceived feedback regarding size and stiffness of grasped objects. Maximum feedback forces of 4.3N and a mechanical bandwidth of 73.5 Hz are achieved. Tests with participants showed promising results regarding the discrimination of size and stiffness of grasped objects.

This paper focuses on determining the cable tension required for a cable-driven endoscopic manipulator to reach a given position under an external load at the end effector. The aim is to restore the initial position of the end effector without an external force. A simulation was performed using MATLAB, where mathematical models and algorithms were used to calculate the required tension. The mathematical model, based on Optimized Motion Estimation Analysis, considers the joint stiffness and the influence of gravity, in addition to the cable tensions and external load. The algorithm minimizes the sum of moments to achieve a stable position. An optical tracking system was used to validate the simulation results against experimental data. The manipulator successfully compensated for an external load of 1.96N and returned to its initial position with adjusted cable tensions. The results showed that the manipulator was deformed by an external load, highlighting the need to adjust the cable tension for position compensation. The discrepancies between the experimental and simulation results were due to factors such as marker size, as well as joint imperfections due to manufacturing and friction effects. Nevertheless, the proposed method proved to be effective in compensating for external loads and restoring the manipulator to the desired position.

Concentric tube robots (CTR) have gained popularity in robotic research due to their potential for smaller instrument sizes, enhanced dexterity and reduced trauma. However, CTR control can be complex, with tip direction and curvature being kinematically coupled. To address this, a symmetric eccentric tube robot (ETR) is presented, where three identical pre-curved wires are arranged in parallel and constrained by an outer sheath. Instrument curvature is controlled by a single input angle. This study aims to demonstrate the suitability as manually actuated instrument. A model for curvature as a function of input angle is presented, and a prototype ETR with an outer diameter of 1 mm is assembled and evaluated. The results show that the ETR follows the expected shape, the curvature decreasing with the separation angle in an almost linear way that may be perceived as intuitive and predictable by the human user. However, some unsteady behavior (snapping) is observed, which may be addressed by preventing torsion of the wires through mechanical means. The simplified model neglecting the sheath stiffness provides precise enough predictions for the working space of a manual ETR. The findings suggest that manual ETRs have potential applications in superficial interventions, such as injections, arthroscopy, or ophthalmic surgery, where their curved section can be beneficial in comparison to current straight needles. Further research could explore interlocking mechanical designs to prevent torsion or modular setups for enhanced functionality.

Abstract We developed and validated the Influenza Severity Scale (ISS), a standardized risk assessment for influenza, to estimate and predict the probability of major clinical events in patients with laboratory-confirmed infection. Data from the Canadian Immunization Research Network’s Serious Outcomes Surveillance Network (2011/2012–2018/2019 influenza seasons) enabled the selecting of all laboratory-confirmed influenza patients. A machine learning-based approach then identified variables, generated weighted scores, and evaluated model performance. This study included 12,954 patients with laboratory-confirmed influenza infections. The optimal scale encompassed ten variables: demographic (age and sex), health history (smoking status, chronic pulmonary disease, diabetes mellitus, and influenza vaccination status), clinical presentation (cough, sputum production, and shortness of breath), and function (need for regular support for activities of daily living). As a continuous variable, the scale had an AU-ROC of 0.73 (95% CI, 0.71–0.74). Aggregated scores classified participants into three risk categories: low (ISS

Summary: Background: Translating findings from animal models to human disease is essential for dissecting disease mechanisms, developing and testing precise therapeutic strategies. The coronavirus disease 2019 (COVID-19) pandemic has highlighted this need, particularly for models showing disease severity-dependent immune responses. Methods: Single-cell transcriptomics (scRNAseq) is well poised to reveal similarities and differences between species at the molecular and cellular level with unprecedented resolution. However, computational methods enabling detailed matching are still scarce. Here, we provide a structured scRNAseq-based approach that we applied to scRNAseq from blood leukocytes originating from humans and hamsters affected with moderate or severe COVID-19. Findings: Integration of data from patients with COVID-19 with two hamster models that develop moderate (Syrian hamster, Mesocricetus auratus) or severe (Roborovski hamster, Phodopus roborovskii) disease revealed that most cellular states are shared across species. A neural network-based analysis using variational autoencoders quantified the overall transcriptomic similarity across species and severity levels, showing highest similarity between neutrophils of Roborovski hamsters and patients with severe COVID-19, while Syrian hamsters better matched patients with moderate disease, particularly in classical monocytes. We further used transcriptome-wide differential expression analysis to identify which disease stages and cell types display strongest transcriptional changes. Interpretation: Consistently, hamsters’ response to COVID-19 was most similar to humans in monocytes and neutrophils. Disease-linked pathways found in all species specifically related to interferon response or inhibition of viral replication. Analysis of candidate genes and signatures supported the results. Our structured neural network-supported workflow could be applied to other diseases, allowing better identification of suitable animal models with similar pathomechanisms across species. Funding: This work was supported by German Federal Ministry of Education and Research, (BMBF) grant IDs: 01ZX1304B, 01ZX1604B, 01ZX1906A, 01ZX1906B, 01KI2124, 01IS18026B and German Research Foundation (DFG) grant IDs: 14933180, 431232613.

Introduction Persons after stroke experience limitations in activities of daily living even in the chronic phase. Many patients who had a stroke report mobility limitations with loss of social roles such as reduced gait-related participation. International best-practice recommendations for patients who had a stroke include interprofessional diagnostics as a core element for goal setting and intervention planning to improve social participation. Interprofessional diagnostics has not yet been implemented in Germany.Methods and analysis The aim is to develop an interprofessional diagnostic toolkit. This will be done in a multi-step process: first, an integrative review is conducted to synthesise the literature. Second, the experiences regarding diagnostics and walking outside is captured in focus groups with persons after stroke, relatives and health professionals. Third, a toolkit for the interprofessional diagnostic process of gait-related-participation will be developed based on the results of the previous steps in a future workshop. Fourth, the results of each work package will be integrated into the iterative development process for evaluation and implementation. All steps will be performed in accordance with the respective reporting guidelines.Ethics and dissemination This study has been approved by the ethics committee at the Ludwig Maximilians University (LMU), Germany and is overseen by LMU-Medical Institutional Review Board. Written informed consent will be obtained from all participants. Results will be disseminated through knowledge exchange with stakeholders and in peer-reviewed journal publications, scientific conferences, formal and informal reports. Stakeholders, patients and providers will be involved in most steps of the development from the beginning, which will facilitate later implementation at a larger scale.Trial registration number German Register Clinical Trials/Deutsches Register Klinischer Studien DRKS00032389.

Abstract Background Proprotein convertase subtilisin/kexin type 9 (PCSK9) is a key player of lipid metabolism with higher plasma levels in women throughout their life. Statin treatment affects PCSK9 levels also showing evidence of sex-differential effects. It remains unclear whether these differences can be explained by genetics. Methods We performed genome-wide association meta-analyses (GWAS) of PCSK9 levels stratified for sex and statin treatment in six independent studies of Europeans (8936 women/11,080 men respectively 14,825 statin-free/5191 statin-treated individuals). Loci associated in one of the strata were tested for statin- and sex-interactions considering all independent signals per locus. Independent variants at the PCSK9 gene locus were then used in a stratified Mendelian Randomization analysis (cis-MR) of PCSK9 effects on low-density lipoprotein cholesterol (LDL-C) levels to detect differences of causal effects between the subgroups. Results We identified 11 loci associated with PCSK9 in at least one stratified subgroup (p

BackgroundThe COVID-19 pandemic caused graduate medical education (GME) programs to pivot to virtual interviews (VIs) for recruitment and selection. This systematic review synthesizes the rapidly expanding evidence base on VIs, providing insights into preferred formats, strengths, and weaknesses.MethodsPubMed/MEDLINE, Scopus, ERIC, PsycINFO, MedEdPublish, and Google Scholar were searched from 1 January 2012 to 21 February 2022. Two authors independently screened titles, abstracts, full texts, performed data extraction, and assessed risk of bias using the Medical Education Research Quality Instrument. Findings were reported according to Best Evidence in Medical Education guidance.ResultsOne hundred ten studies were included. The majority (97%) were from North America. Fourteen were conducted before COVID-19 and 96 during the pandemic. Studies involved both medical students applying to residencies (61%) and residents applying to fellowships (39%). Surgical specialties were more represented than other specialties. Applicants preferred VI days that lasted 4-6 h, with three to five individual interviews (15-20 min each), with virtual tours and opportunities to connect with current faculty and trainees. Satisfaction with VIs was high, though both applicants and programs found VIs inferior to in-person interviews for assessing 'fit.' Confidence in ranking applicants and programs was decreased. Stakeholders universally noted significant cost and time savings with VIs, as well as equity gains and reduced carbon footprint due to eliminating travel.ConclusionsThe use of VIs for GME recruitment and selection has accelerated rapidly. The findings of this review offer early insights that can guide future practice, policy, and research.

Flexible endoscopes are widely used for diagnostic and therapeutic procedures on internal organs and tissue surfaces. Accurate positioning of the endoscope tip is critical for obtaining clear images and avoiding tissue damage. Proximity sensors can provide information about the distance to the surrounding tissue, which can help align the endoscope tip and navigate along curved paths. This paper presents a method of proximity measurement using capacitive sensors with active shielding to determine the radial distance between an endoscope and surrounding tissue. The capacitive sensor consists of four copper foil electrodes attached to a 9.5 mm diameter ring. Two different active shielding designs were investigated and compared to reduce the sensing angle and minimize lateral effects. Capacitance was measured as a function of distance using a linear stage. A MATLAB script controlled the linear stage and calculated the distance from the measured capacitance. The results showed that advanced active shielding could be useful to reduce the sensing angle (angular space where capacitance sensor detects capacitance changes.). This method provides a cost-effective solution for radial distance measurement in endoscopy, essential for improving diagnostic and therapeutic procedures.

The global shortage of healthcare staff has led to high workloads and subsequent risks to patient well-being. One of the professions affected is that of the scrub nurse. Robotic scrub nurse systems have the potential to reduce workload and to assist in handling surgical instruments. Existing approaches mostly use two-finger grippers or electromagnetic grippers. However, it is assumed that a granular jamming gripper is more suitable for handling various surgical instruments, regardless of material and shape. A gripping unit based on a granular jamming gripper and attached to a robotic arm is presented. For evaluation, six surgical instruments were repeatedly gripped and transported. The granular jamming gripper was found to be suitable for picking up and transferring most instruments, however, handling very flat instruments turned out to be challenging.

Patients suffering from Wilson’s disease accumulate copper in their body. Copper load may become visible as Kayser-Fleischer (KF) rings - colorful copper-sulfur granules in the base of the cornea. Reoccurrence of KF rings in patients under anti-copper medication may be a sign for ineffective treatment. This work proposes a hand-held sensing system based on infrared reflectivity measurement of the cornea as a potential method for regular at-home progression monitoring. The intensity of the LEDs used is safe for operation on the human eye. As proof of concept, reflectivity was measured when placing the sensor onto samples of white paper that had copper tape of different sizes centered within the sensitive area. Further, reflectivity was determined for different solutions of copper sulfate in saline that were poured into adapter bowels fitting the sensor head, with Cu2+ concentrations of the samples deducted from literature. While the prototype system can be used to differentiate between two copper strips of 6 and 12 mm2 or larger, a different measuring principle would be needed to also determine the concentration of copper sulfate solutions. Since these two in-vitro models cannot fully represent the complex in-vivo molecular conditions of patients’ corneas, additional measurements on patients’ eyes are necessary to evaluate the potential of the proposed sensing system.

Musculoskeletal and nervous system injuries and strokes can influence the ankle in a way, that rehabilitation exercise is inevitable to regain a patient’s quality of life. However, increasing needs for physiotherapists and complex machinery for independent rehabilitation limit the patient’s possibility of experiencing proper care. One approach to address this issue is developing an affordable, safe, and cheap treatment solution. This paper presents a mechanically actuated ankle rehabilitation mechanism, which incorporates the use of the patients’ upper limbs to work on the ankle's range of motion. The mechanism consists of a Four-Bar linkage (FBL) to translate rotary motion into an oscillating angular displacement of the ankle. It provides the base for gamified ankle rehabilitation, acting as an input device for the game, controlled by the user; adopting the mechanism with the commercial games and required steps for designing a game for rehabilitation purposes.

The shortage of operating room technicians has led to a growing demand for automated systems in the OR to maintain the quality of care. Robotic scrub nurse (RSN) systems are increasingly being developed, which perform tasks such as handling instruments and documenting the surgery. While research has focused on detecting instruments in the hands of surgical staff or recognizing surgical phases, there is a lack of research on detecting instruments on the instrument tray. Therefore, this study proposes and evaluates two distinct methodologies for instrument detection on the OR table using the deep learning approaches YOLOv5 and Mask R-CNN. The performance of the two approaches has been evaluated on 18 YOLOv5 models and twelve Mask R-CNN models, mainly differing in model size. Two sets of instruments were used to assess generalizability of the models. The results show a mean average precision (mAP) score of 0.978 for YOLOv5 and 0.846 for Mask R-CNN on the test dataset comprising three classes. An mAP of 0.874 and 0.707 have been computed respectively for the test dataset including six classes. The study provides a comparison of the performance of two suitable approaches for instrument detection on the instrument tray in the OR to enhance the development of RSN systems.

Introduction: Application-related (hands-on) training and instruction is an essential component in the advanced education of physicians in residency. To teach and train required endoscopic examinations and interventions in a standardized manner, courses are offered by various societies. Within these courses the assistant endoscopists learn and train how to use the technical equipment and how to perform the examinations and related interventions. Similarly, for graduate biomedical engineering students with a job- or research-related interest in the field of endoand laparoscopy, an early involvement and practical introduction to the instrumentation and techniques - if possible already during their studies - can generate a fundamental understanding of the technical requirements as well needs of the physicians. Objective: As various such (hands-on) training-courses for flexible and rigid endoscopy specifically addressing young physicians, surgeons as well as engineers are offered by numerous institutes, this contribution tries do provide a structured overview on/over these possibilities. Material: Known cross-institutional courses in the field of endo- and laparoscopy currently offered in Germany in cooperation of physicians and engineers are listed and briefly described. Results: A total of n = 4 crossinstitutional courses for the introduction and training in flexible and rigid endoscopy have been identified. Discussion: The cross-institutional courses for physicians and technicians in the field of endo- and laparoscopy presented serve to provide a better understanding of the subject matter and the field of either discipline. Questions that arise in the field of endoscopy from physicians can be addressed at an early stage and, if necessary, worked on with little effort. Ideas for new instruments and even new interventions can arise and be pursued through an intensive exchange between technicians and physicians. Collaborations are established on a local basis which will foster national activities in this field and which allow to develop competencies relevant for the industrial sector of medical engineering.

BackgroundPeripheral Intravenous Cannulas (PIVCs) are frequently utilised in the Emergency Department (ED) for delivery of medication and phlebotomy. They are associated with complications and have an associated cost to departmental resources. A growing body of international research suggests many of the PIVCs inserted in the ED are unnecessary.MethodsThe objective of this study was to determine the rates of PIVC insertion and use. This was a prospective observational study conducted in one UK ED and one Italian ED. Adult ED patients with non-immediate triage categories were included over a period of three weeks in the UK ED in August 2016 and two weeks in the Italian ED in March and August 2017. Episodes of PIVC insertion and data on PIVC utilisation in adults were recorded. PIVC use was classified as necessary, unnecessary or unused. The proportion of unnecessary and unused PIVCs was calculated. PIVCs were defined as unnecessary if they were either used for phlebotomy only, or solely for IV fluids in patients that could have potentially been hydrated orally (determined against a priori defined criteria). PIVC classified as unused were not used for any purpose.ResultsA total of 1,618 patients were included amongst which 977 PIVCs were inserted. Of the 977 PIVCs, 413 (42%) were necessary, 536 (55%) were unnecessary, and 28 (3%) were unused. Of the unnecessary PIVCs, 473 (48%) were used solely for phlebotomy and 63 (6%) were used for IV fluids in patients that could drink.ConclusionsMore than half of PIVCs placed in the ED were unnecessary in this study. This suggests that clinical decision making about the benefits and risks of PIVC insertion is not being performed on an individual basis.

Blood sampling typically involves puncturing a superficial vein with a needle and then creating a vacuum (e. g., with a syringe) to transfer the blood from the venous system to the collection container. In some cases, the venous walls collapse due to excessive vacuum generated. In this work, a device is presented that prevents venous collapse and can be combined with any blood collection system available on the market. The mechanism of preventing venous collapse is based on a tubular segment interconnected between the needle and the syringe, which collapses at a lower vacuum pressure than the vein. The prototype was tested and evaluated using a test rig that simulates venous blood draw. The experiments proved the functionality of the device on a vein phantom.

Robotic assistance in rehabilitation procedures has gained increasing popularity for both scientists and patients. However, aside from the practicality and safety issues, the ability to motivate patients to pursue rehabilitation therapy is a hindrance and is still limiting the domestic usage of Ankle Rehabilitation Robotic Systems (ARRS). Most of the available ARRS are either applicable under clinical setups, or are dull to operate. New advancements have led to the fusion of virtual realities (VR) and augmented realities (AR) with ARRS. This paper presents a classification of contemporary ARRS based on their usability and practicality along with required modifications to make them befitting for domestic use. A systemic literature search is applied for these systems on Web of Science and PubMed databases and the search is confined to the last twelve years’ research from 2011 to 2022. Among the 219 found systems, 4 use VR, AR, or gamification. Generally, having the rehabilitation therapy equipped with novel interfaces, patients improve their motor function.

Congenital Central Hypoventilation Syndrome (CCHS) leads to insufficient breathing especially during sleep. While patients can be ventilated and monitored during the night, adolescents undergo changes in their biorhythm and lifestyle and are at higher risk to inadvertently fall asleep and stop breathing during the day. In this paper, we propose a prototype mobile wake-up device worn behind both ears that constantly measures oxygen saturation and heart rate noninvasively. If a dangerously low level of saturation is detected, it is assumed that the user fell asleep. To wake them, the device issues an acoustic and haptic alarm. The device settings are accessed via a smartphone app. To evaluate the sensor performance, a subject simultaneously wore the prototype behind his ears and a commercial finger pulse oximeter on his hand. Heart rate and blood oxygen saturation were taken for three measurements of few minutes each. Mean absolute error of oxygen saturation was less than 2 % for two data sets and 6.1 %for the third. It is assumed that during this measurement, the device lost contact to the skin. The heart rate measurement showed satisfactory agreement of < 4 % mean average error. In the future, the measurement quality will be improved by calibration and more reliable attachment to the ear and a user study will be conducted in order to evaluate the prototype usability.

In conventional laparoscopy, the field of view of the surgeon is limited. Angled laparoscopes enable the observation of surrounding structures, however, to change the viewing perspective on a specific object, permanent repositioning and rotation of the shaft is required. In this paper, a demonstrator of a steerable flexible laparoscope is presented, enabling the user to intuitively adjust the perspective onto an object by means of a single control element. The laparoscope provides a viewing angle of ± 50° at 50 mm working distance. In first tests, the presented laparoscope showed advantages regarding intuitiveness of the control, easier handling, and improved depth perception.

In current endoscopes, the estimation of the proximity to the surrounding tissue is based on the experience of the user. To provide precise proximity meassurement, a suitable sensor is needed. This paper presents a fiber optic proximity sensor that is inserted through the working channel of an endoscope. The impact of the fiber cutting angle at the distal end of the optical fiber is investigated. If the fiber is cut at a 3° angle to the optical axis, the measurement signal in axial direction can be increased by 126mV at the peak (measurement accuray 4.9 mV). A 45° fiber cutting angle allows radial measurement but with a weak measurement signal compared to an axial measurement. A distance between endoscope tip and intestine wall up to 15 mm can be measured. In conclusion, optical fibers can be used to insert a low-cost sensor through a working channel of an endoscope. By modifying the fiber cutting angle, an increased sensor signal can be obtained in the axial direction and a measurement in radial direction is possible.

This paper presents an exoskeleton for upper extremity rehabilitation of stroke patients. In order to make rehabilitation widely available, the goal is an inexpensive, portable, and easy-to-use therapy for paralysis of the arm. The exoskeleton is actuated by twisted string actuators (TSA). To reduce the length of the TSA a motor with hollow shaft was chosen, as this allows the string to run through the motor. The control of the exoskeleton is designed for predefined elbow flexion exercises. The start of the movement is triggered by a threshold value in the sEMG of the m. biceps brachii. To evaluate the controller, the exoskeleton performed a flexion movement (5° to 115°) in 2 s and then an extension back to 5° in the same time after a 1 s wait. To simulate different force requirements, additional weights up to 1500 g were attached. During both, the flexion and extension movement, that angle tracking error was sufficiently small and the steady state error was zero. The angular velocity of the elbow joint showed pronounced oscillations with increasing weights. The results show that TSAs can be used to actuate elbow exoskeletons. Thus lightweight, ergonomic, simple and small rehabilitation devices can now be built on this basis. The elasticity of the system must be considered in future work. sEMG must be further implemented to control more sophisticated functions of the rehabilitation device.

In this work, an electrode was developed to determine the dielectric properties of tissue phantoms using impedance measurements. For this purpose, a coaxial electrode design was selected as the most suitable electrode design. Three tissue phantoms (blood, fat, muscle) were prepared from distilled water, sodium chloride, 1,2-propanediol, agar, and gelatine, and then characterized. Measurements were performed using an impedance analyzer in a range between 1 kHz and 1 MHz. A comparison with literature values showed good correspondance of the permittivity values determined, thus proving the applicability of the electrode design. However, the conductivity values measured were different from literature values. In the future, alteration and minimization of the electrode can be done to further improve the characterization.

Sensor-integrated needles with impedance or other electrochemical sensors have gained increased attention in research. Their potential use is widespread and covers applications such as early disease diagnostics or needle guidance for needle-based interventions. However, fabrication and sensor integration are crucial parts of realizing functionalized needles. In this paper, a review of existing research on microscale sensor arrays on curved needle surfaces is presented. It focusses on medical needles excluding needle-type sensors. Especially, means of fabrications including flexible thin-film-based sensors or photolithography are discussed. Although they provide satisfactory results, no manufacturing method is yet ready for bulk production.

Minimally invasive procedures such as Natural Orifice Transluminal Endoscopic Surgery (NOTES) require powerful, small, and flexible instruments. A cable-driven instrument was developed, which is able to retract tissue to create sufficient space for an actual operation (e.g. cholecystectomy). In this paper, the work space of a developed instrument is presented. The work space is calculated using direct kinematics equations and verified by measurement using an electromagnetic (EM) tracking system. The angular orientation of the instrument can be up to 85° with a length of the active section of 60 mm. However, a longitudinal rotation up to 17° becomes apparent. This is due to the characteristics of the steel cable used for actuation. Nevertheless, the instrument reaches the intended work space. Further measurements are necessary to evaluate the instrument’s behavior under payload and whether this affects the work space.

During laparoscopic procedures, the surgeon's view of the situs, and thus her or his performance, is dependent on the skills of the camera assistant. The surgeon lacks control over his own field of view and there is a high potential for reducing mental load and workflow issues. In this paper, a research setup of a 360° laparoscopic imaging system is presented and evaluated. The system consists of a 360° camera and a head-mounted display, through which the surgeon can inspect the situs. In a user test, the system showed advantages over a conventional laparoscope regarding orientation in the situs, intuitiveness of operation, and faster task completion.

Contactless blood pressure monitoring displays a chance for detecting hypertension and increasing the awareness of cardiovascular diseases. Camera-based methods show high potential for replacing inconvenient cuff-based technology. Blood pressure estimation through pulse transit time (PTT) and other parameters obtained from photoplethysmography (PPG) signal present a promising alternative to conventional blood pressure measurement. In this paper, recent approaches for contactless blood pressure monitoring were reviewed. All of the articles implemented systems based on PPG, whereas most of them used PTT as measuring parameter. The results are reviewed and summarized while pinpointing key challenges and discussing expectations for future research.

Background The lack of standardised outcome assessments during hospitalisation and follow-up for acute COPD exacerbations has hampered scientific progress and clinical proficiency. The objective of the present study was to evaluate patients’ acceptance of selected outcome and experience measurements during hospitalisations for COPD exacerbations and follow-up. Methods An online survey was held amongst COPD patients in France, Belgium, The Netherlands, Germany and the UK. The European Lung Foundation COPD Patient Advisory Group was involved in the conceptualisation, development and dissemination of the survey. The survey was complementary to a previously obtained expert consensus. We assessed patients’ views and acceptance of selected patient-reported outcomes or experiences and corresponding measurement instruments (for dyspnoea, frequent productive cough, health status and hospitalisation experience), and of selected clinical investigations (blood draw, pulmonary function test, 6-min walk test, chest computed tomography, echocardiography). Findings 200 patients completed the survey. All selected outcomes and experiences were deemed important, and acceptance of their methods of assessment was high. The modified Medical Research Council scale and a numerical rating scale to address dyspnoea, the COPD Assessment Test for quality of life and frequent productive cough, and the Hospital Consumer Assessment of Healthcare Providers and Systems for hospital experiences were the instruments preferred by patients. Consensus on importance of blood draw and spirometry was higher compared with the other investigations. Interpretation The survey results endorse the use of the selected outcome and experience measurements during hospitalisations for COPD exacerbations. They can be used to optimise standardised and patient-centred care and facilitate multicentric data collection.

Objective The clinical spectrum of primary antibody deficiencies (PADs) and especially common variable immunodeficiency (CVID) includes various autoimmune disorders. We studied the prevalence and the features of articular rheumatic disease in a cohort of patient with PADs.Methods In this retrospective cohort study, complete clinical data of 268 patients with PADs, mainly consisting of patients with CVID, visiting the immunology outpatient clinic of a German tertiary hospital between 2018 and 2021 were collected. Those included case history, physical examination, laboratory as well as radiological findings.Results Inflammatory arthritis was diagnosed in 16.4% of studied patients and was significantly more common among patients with PAD-associated enteropathy (OR 13.39, p=0.0001), splenomegaly (OR 6.09, p=0.0001) or atopic diseases (OR 3.31, p=0.021). Given HLA-B27 status, the involvement of the axial skeleton and the presence of features, such as anterior uveitis, inflammatory bowel disease, psoriasis and/or dactylitis, 75% of studied patients fulfilled the Assessment of Spondyloarthritis International Society classification criteria.Conclusion PAD-associated arthritis frequently shares features with spondyloarthritis (SpA) and enteropathic arthritis. The latter may suggest the interconnected pathomechanisms of inflammatory arthritis in SpA and PADs.

Accurate measurement of interaction forces during robot-assisted surgery requires compact force sensing modalities in the surgical tools, thus might add considerable cost to the setup. Measuring the motor current to estimate gripping forces, is an advantageous approach since no expensive force sensor is needed. In this paper, a mechanical interface is presented, which allows actuating conventional articulated instruments for robot-assisted surgery. The interface features the estimation of static gripping forces at the instrument’s tip based on the motor current. The evaluation shows reproducible results, and the current-based approach seems to be a cost-efficient way to estimate gripping forces.

Background The 2022 ESC/ERS guidelines on pulmonary hypertension recommend noninvasive risk assessments based on three clinical variables during follow-up in patients with pulmonary arterial hypertension (PAH). We set out to test whether residual risk can be captured from routinely measured noninvasive clinical variables during follow-up in PAH. Methods We retrospectively studied 298 incident PAH patients from a German pulmonary hypertension centre who underwent routine noninvasive follow-up assessments including exercise testing, echocardiography, electrocardiography, pulmonary function testing and biochemistry. To select variables, we used least absolute shrinkage and selection operator (LASSO)-regularised Cox regression models. Outcome was defined as mortality or lung transplant after first follow-up assessment. Results 12 noninvasive variables that were associated with outcomes in a training sub-cohort (n=208) after correction for multiple testing entered LASSO modelling. A model combining seven variables discriminated 1-year (area under the curve (AUC) 0.83, 95% confidence interval (CI) 0.68–0.99, p=8.4×10−6) and 3-year (AUC 0.81, 95% CI 0.70–0.92, p=2.9×10−8) outcome status in a replication sub-cohort (n=90). The model's discriminatory ability was comparable to that of the guideline approach in the replication sub-cohort. From the individual model components, World Health Organization functional class, 6-min walking distance and the tricuspid annular plane systolic excursion to systolic pulmonary arterial pressure (TAPSE/sPAP) ratio were sensitive to treatment initiation. Addition of TAPSE/sPAP ratio to the guideline approach numerically increased its ability to discriminate outcome status. Conclusion Our real-world data suggest that residual risk can be captured by noninvasive clinical procedures during routine follow-up assessments in patients with PAH and highlights the potential use of echocardiographic imaging to refine risk assessment.

Vaccination campaigns played a crucial role in reducing the incidence of COVID-19. However, a scant number of studies evaluated the impact of vaccination on case fatality rates (CFRs), including in Brazil. Our study aimed to compare CFRs according to vaccination status among subjects living in Arapongas (Paraná State, Brazil), considering the age composition of the population. Several strategies adopted by the Arapongas City Hall to minimize the spread of the virus were also elaborated upon. We accessed the 2021 database of the Arapongas Municipal Health Department, in which a total of 16,437 confirmed cases and 425 deaths were reported. The CFR was calculated as the ratio between COVID-19 deaths and the number of confirmed cases. Differences in age composition between unvaccinated and fully vaccinated individuals were observed in our study. Considering that CFR is a crude indicator and is highly sensitive to the age composition of the population, we adopted the average age distribution of confirmed cases among the three vaccination statuses (unvaccinated, partially, and fully) as a standard age distribution. The age-standardized CFR for unvaccinated and fully vaccinated groups were 4.55% and 2.42%, respectively. Fully vaccinated individuals showed lower age-specific CFRs in all age groups above 60 years than unvaccinated populations. Our findings strengthen the role of vaccination as a critical measure for preventing deaths among infected people and is particularly important to the ongoing reassessment of public health interventions and policies.

Background Converging evidence from proteogenomic analyses prioritises thrombospondin-2 (TSP2) as a potential biomarker for idiopathic or heritable pulmonary arterial hypertension (PAH). We aimed to assess TSP2 levels in different forms of pulmonary hypertension (PH) and to define its clinical phenotype. Methods Absolute concentrations of TSP2 were quantified in plasma samples from a prospective single-centre cohort study including 196 patients with different forms of PH and 16 disease controls (suspected PH, but normal resting pulmonary haemodynamics). In an unbiased approach, TSP2 levels were related to 152 clinical variables. Results Concentrations of TSP2 were increased in patients with PH versus disease controls (p

Copernicia alba (Arecaceae) is a palm tree regionally known as carandá that forms large populations and produces abundant fruits, an important food source for the local fauna in Brazilian wetlands. The fruits present morphological variations regarding color, shape and dimensions. In this study fruits of different shapes were collected and processed following routine techniques in plant morphology, and biochemistry analysis of endosperm. (hemicellulose) The fruits isdark, of the berry type, with partially fibrous pericarp, rich in phenolic compounds; the ruminated seed coat also contains phenols; the endosperm, formed of cells with highly thickened, not lignified hemicellulosic walls, stores xyloses, proteins and lipids. The embryo is short and straight. Xylose is the leading sugar of xylan, which can be liberated by hydrolysis with specific enzymes, such as xylanases. This sugar is of interest in several industrial sectors, such as the production of biofuels and xylitol for foods. Excepting depth of seed rumination, C. alba fruits do not have relevant differences in anatomy and classes of substances detected. The fruit yield showed differences associated with its shape, indicating the best utilization. Considering fruit anatomical features and tissue composition, we highlight that the seeds of C. alba have the potential as a new functional food source.

Abstract The detection of a pathogenic variant in the BRCA1 or BRCA2 gene has medical and psychological consequences for both, affected mutation carriers and their relatives. A two-phase study with explanatory sequential mixed methods design examined the psychological impact of genetic testing and associated family communication processes. Analyzing a survey data of 79 carriers of a BRCA1 or BRCA2 mutation, the majority had general psychological distress independent of cancer diagnosis in the patients’ history. The point prevalence of depression was 16.9%. Contrary to their subjective perception, the respondents’ knowledge about those mutations was moderate. Despite the high rate of information transfer to relatives at risk (100%), their reported uptake of genetic testing was low (45.6%). Communication about the mutation detection was more frequent with female than with male relatives. In-depth focus group interviews revealed significant barriers to accessing genetic counseling including anxiety, uncertainty about the benefits of testing and about the own cancer risk, particularly among males. This study suggests that an adequate knowledge of the genetic background and psychological support is required to reduce emotional distress, to support familial communication and to facilitate genetic testing.

Abstract Accurately mapping individual tree species in densely forested environments is crucial to forest inventory. When considering only RGB images, this is a challenging task for many automatic photogrammetry processes. The main reason for that is the spectral similarity between species in RGB scenes, which can be a hindrance for most automatic methods. This paper presents a deep learning-based approach to detect an important multi-use species of palm trees (Mauritia flexuosa; i.e., Buriti) on aerial RGB imagery. In South-America, this palm tree is essential for many indigenous and local communities because of its characteristics. The species is also a valuable indicator of water resources, which comes as a benefit for mapping its location. The method is based on a Convolutional Neural Network (CNN) to identify and geolocate singular tree species in a high-complexity forest environment. The results returned a mean absolute error (MAE) of 0.75 trees and an F1-measure of 86.9%. These results are better than Faster R-CNN and RetinaNet methods considering equal experiment conditions. In conclusion, the method presented is efficient to deal with a high-density forest scenario and can accurately map the location of single species like the M. flexuosa palm tree and may be useful for future frameworks.

Localized impedance measurements at the needle tip identifying the present tissue type could aid clinicians in needle procedures. To assess the sensitivity field of a hollow, bipolar needle electrode, a 3D finite element approach using COMSOL Multiphysics was chosen. The simulated bipolar needle electrode consists of two hypodermic needles (17 G and 23 G) with an insulating layer of polytetrafluoroethylene (PTFE) in between. Impedance values were recorded while steadily increasing the insertion depth of the needle electrode in a layered tissue structure of skin (dermis), fat, and blood. Simulation results reveal a highly local sensitivity volume around the needle tip that can be approximated by half a tri-axial ellipsoid with elliptic radii of 0.735 mm, 2.886 mm, and 1.774 mm. A comparison with simulated and measured impedance values shows great correspondence.

To assist the insertion of a robot-aided endoscope during colonoscopy, a measuring system is required so that the endoscope tip can align automatically and thus find the curved pathway of the large intestine. To achieve this, a selfexpanding nitinol wire basket is used to sense the contour of the intestine. As the wire basket touches the wall, it is deflected towards the center of the intestine. The relative position of the wire basket within the camera image is captured, which describes the desired direction to follow the organ. To identify the wire basket in the image, the original RGB image stream is converted into the HSV (hue, saturation, value) color space. Thus, a binary image can be created, in which only the neongreen color portion of the wire basket is visible as a cross. The Hough Transformation is used to search for straight lines in the binary image. Once two lines are found, the intersection point can be calculated and thus its position in the image. The evaluation of the execution time of the algorithm on a live stream was 45 ± 31 ms on average. The algorithm robustly recognizes the wire basket even if it was not visible to the human eye in the original RGB image due to deficient lighting.

In robotic telemanipulation for minimally-invasive surgery, lack of haptic sensation and non-congruent movement of input device and manipulator are major drawbacks. Input devices based on cable-driven parallel mechanisms have the potential to be a stiff alternative to input devices based on rigid parallel or serial kinematics by offering low inertia and a scalable workspace. In this paper, the haptic user interface of a cable-driven input device and its technical specifications are presented and assessed. The haptic user interface allows to intuitively control the gripping movement of the manipulator’s end effector by providing a two-finger precision grasp. By design, the interface allows to command input angles between 0° and 45°. Furthermore, interaction forces from the manipulator’s end effector can be displayed to the user’s twofinger grasp in a range from 0 N to 6 N with a frequency bandwidth of 17 Hz.

Biopsies or surgical excisions for diagnosis should be taken for pulmonary lesions which show evidence of growth or are larger than 8 mm. This is usually performed by video-assisted thoracoscopic surgery. To improve the intraoperative localization of these lesions, we propose to add an ultra-wideband antenna directly on a thoracoscopic tool and locate the lesion through microwave imaging. Here the design of an antenna for such a goal is undertaken. Numerical simulations are used to quantify the influence of a fictional lung lesion on the signal recorded by a bowtie antenna of different lengths (2 to 6 cm) and widths (0.5 to 1.5 cm). It is found that the most important design parameter is the total length of the antenna. The width of the antenna, instead, affects only marginally the signals, but it has a limited effect for deeper lesions

A twisted string actuator (TSA) is a small, strong, lightweight, and low-cost gear, transforming rotation into a linear pulling movement. The TSA consists of two or more strings that are twisted along their common longitudinal axis. The helix formed in this process becomes shorter the further the bundle is twisted. A possible application is a tendon-based endoscopic robot. To control the movement of the endoscope, a precise contraction of the tendon is necessary. Since the strings of the TSA show an elastic behaviour, position feedback is needed to determine the exact movement of the TSA. In this paper, a TSA with a closed-loop position control by a low-cost displacement sensor is presented.

Teeth grinding is, due to its various impacts on the human body, a highly discussed issue in dentistry. It can damage the tooth structure or cause pain due to muscle tension. At the moment, there is neither a satisfactory diagnostic nor a comprehensive treatment option. This paper deals with the development of an app-controlled, small, portable sensor unit that can be used by patients to monitor their teeth grinding in everyday life. It also offers a treatment option due to an implemented biofeedback option. To achieve the most cost-effective device possible, only off-the-shelf electronics and no proprietary software were used. In initial tests, the measuring device showed high level of measurement accuracy when performing measurements without feedback at rest (f_score=-0.025...0).

Abstract Background CPD educators and CME providers would benefit from further insight regarding barriers and supports in obtaining CME, including sources of information about CME. To address this gap, we sought to explore challenges that clinicians encounter as they seek CME, and time and monetary support allotted for CME. Methods In August 2018, we surveyed licensed US clinicians (physicians, nurse practitioners, and physician assistants), sampling 100 respondents each of family medicine physicians, internal medicine and hospitalist physicians, medicine specialist physicians, nurse practitioners, and physician assistants (1895 invited, 500 [26.3%] responded). The Internet-based questionnaire addressed barriers to obtaining CME, sources of CME information, and time and monetary support for CME. Results The most often-selected barriers were expense (338/500 [68%]) and travel time (N = 286 [57%]). The source of information about CME activities most commonly selected was online search (N = 348 [70%]). Direct email, professional associations, direct mail, and journals were also each selected by > 50% of respondents. Most respondents reported receiving 1–6 days (N = 301 [60%]) and $1000–$5000 (n = 263 [53%]) per year to use in CME activities. Most (> 70%) also reported no change in time or monetary support over the past 24 months. We found few significant differences in responses across clinician type or age group. In open-ended responses, respondents suggested eight ways to enhance CME: optimize location, reduce cost, publicize effectively, offer more courses and content, allow flexibility, ensure accessibility, make content clinically relevant, and encourage application. Conclusions Clinicians report that expense and travel time are the biggest barriers to CME. Time and money support is limited, and not increasing. Online search and email are the most frequently-used sources of information about CME. Those who organize and market CME should explore options that reduce barriers of time and money, and creatively use online tools to publicize new offerings.

Abstract Pulmonary vein isolation (PVI) using cryoenergy is safe and efficient for treatment of atrial fibrillation (AF). Pre-existing upper gastrointestinal (GI) pathologies have been shown to increase the risk for AF. Therefore, this study aimed at assessing incidental pathologies of the upper GI tract in patients scheduled for PVI and to analyse the impact of patients’ characteristics on PVI safety outcome. In 71 AF patients, who participated in the MADE-PVI trial, oesophagogastroduodenoscopy and endosonography were prospectively performed directly before and the day after PVI to assess pre-existing upper GI pathologies and post-interventional occurrence of PVI-associated lesions. Subgroup analysis of the MADE-PVI trial identified clinically relevant incidental findings in 53 patients (74.6%) with age > 50 years being a significant risk factor. Pre-existing reflux oesophagitis increased risk for PVI-associated mediastinal oedema, while patients already treated with proton pump inhibitors (PPI) had significantly fewer mediastinal oedema. Our results suggest that AF patients with pre-existing reflux oesophagitis are at higher risk for PVI-associated mediastinal lesions, which is decreased in patients with constant PPI-treatment prior to PVI. Since PVI-associated mediastinal lesions are regarded as surrogate parameter for an increased risk of the fatal complication of an oesophago-atrial fistula, our findings hint at a beneficial effect of pre-interventional prophylactic PPI-treatment to reduce risk for PVI-associated complications. German Clinical Trials Register (DRKS00016006; date of registration: 17/12/2018).

Access to systems for robot-assisted surgery is limited due to high costs. To enable widespread use, numerous issues have to be addressed to improve and/or simplify their components. Current systems commonly use universal linkage-based input devices, and only a few applicationoriented and specialized designs are used. A versatile virtual reality controller is proposed as an alternative input device for the control of a seven degree of freedom articulated robotic arm. The real-time capabilities of the setup, replicating a system for robot-assisted teleoperated surgery, are investigated to assess suitability. Image-based assessment showed a considerable system latency of 81.7 ± 27.7 ms. However, due to its versatility, the virtual reality controller is a promising alternative to current input devices for research around medical telemanipulation systems.

Venepuncture is one of the most common invasive procedures performed worldwide, however, complications still occur. Currently, commercial single layer silicone phantoms used for venepuncture training do not accurately imitate the geometry and mechanical properties seen in the various patient groups. This paper presents the development of a realistic artificial venepuncture phantom. Three multilayered tissue phantoms are developed simulating venepuncture sites of paediatric, adult and geriatric patients. Silicone materials of different stiffnesses were selected to imitate the epidermis, dermis, subcutaneous fat, muscle and superficial veins. Singleaxis indentation tests were carried out on silicone samples and the multi-layered phantom inserts to characterize the material properties. The measured Young's moduli for the artificial dermis, fat and muscle show sufficient agreement with corresponding literature values. However, characterization of the complete phantom inserts showed stiffnesses four times larger than prior in-vivo studies. Future studies will work on developing a more comparable in-vivo study.

Many medical interventions in therapy and diagnostics require needle insertion into tissue. Common complications such as increased pain and formation of haematoma are caused by wrong needle positioning. It has been shown that pain experience and needle positioning can be improved by a reduction of insertion force, which can be achieved by vibrating the needle axially. An experimental setup has been designed to investigate the influences of different combinations of vibration frequencies (10, 100, and 200 Hz) and vibration amplitudes (20, 100, and 500 μm) during needle insertion into thin sheets of polyethylene terephthalate (PET). A customary 20 W loudspeaker was used to generate the vibration. The results indicate a maximum reduction of 73 % in puncture force and up to a 100 % reduction in shaft friction force. However, the additional vibration force generated by the vibration movement has to be high enough to generate positive effects in terms of force reduction.

Microscopy enables fast and effective diagnostics. However, in resource-limited regions microscopy is not accessible to everyone. Smartphone-based low-cost microscopes could be a powerful tool for diagnostic and educational purposes. In this paper, the imaging quality of a smartphone-based microscope with four different optical parameters is presented and a systematic overview of the resulting diagnostic applications is given. With the chosen configuration, aiming for a reasonable trade-off, an average resolution of 1.23 μm and a field of view of 1.12 mm2 was achieved. This enables a wide range of diagnostic applications such as the diagnosis of Malaria and other parasitic diseases.

Microscopy is an essential tool in research and science. However, it is relatively resource consuming regarding cost, time of usage, and consumable supplies. Current low-cost approaches provide good imaging quality but struggle in terms of versatility or applicability to varying setups. In this paper, a Compact Microscope Module for versatile application in custom-made setups or research projects is presented. As a first application and proof of concept, the use of the module in a High-Throughput Microscope for screening of samples in microtiter plates is shown. The Compact Microscope Module allows for simple and resource-efficient microscopy in various applications while still enabling relatively good imaging qualities.