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Damage-prone microscale products that need to be mass-assembled, such as surface mount devices, would benefit from being assembled in mid-air using acoustic forces. These forces can manipulate objects without contact, thereby circumventing damage. However, joining two objects together, which is a key step in assembly, is challenging to do acoustically because as the objects approach each other, the acoustic waves scattering off one object begins to greatly impact the position and orientation of the other object. Previous demonstrations of acoustic microassembly have demonstrated various techniques to overcome the acoustic scattering force, such as assembling, within a gel medium or using a robotic arm for object translation but there is still no way of achieving complex, configurable, 3-D assemblies in mid-air by purely using acoustic waves. To better maintain the object's orientation under a dominating acoustic scattering effect, we developed a new acoustic rotation algorithm called the two-segment phase gradient (TSPG) algorithm, which can rotate the object with an rms error of 12$^{\circ }$ under open-loop control while maintaining the object's centroid with an root mean squared error (RMSE) of 0.41 mm. Next, we demonstrate an alternative technique to overcome the acoustic scattering force by using the widely used single trap algorithm to cause one object to jump toward another object at a specified position and orientation. Finally, we demonstrate how the TSPG algorithm and single trap algorithm can be used to generate complex and configurable 2-D assemblies.

Objective: Non-invasive, pill-sized capsules can provide intestinal fluid sampling to easily retrieve site-specific gut microbiome samples for studies in nutrition and chronic diseases. However, capsules with both automatic sampling and active locomotion are uncommon due to limited onboard space. This paper presents a novel hybrid hydrogel-magnet actuated capsule featuring: i) pH-responsive hydrogels that will automatically trigger fluid sampling at an environmental pH of $>$ 6 and ii) active locomotion by an external rotating magnetic field. Method: Two capsule designs were fabricated (Design A: 31 $\mu$L sampling volume with dimensions 8 mm × 19 mm, Design B: 41 $\mu$L sampling volume with dimensions 8 mm × 21 mm). They were immersed in simulated gastric (pH = 1.2) and simulated intestinal fluid (pH = 6.8) to test for automatic intestinal fluid sampling. An external rotating magnetic field was applied to test for active locomotion. Finally, seal tests were performed to demonstrate sample contamination mitigation. Results: Preliminary experiments showed that sampling occurred quickly and automatically in simulated intestinal fluid at 6–15 hours, active locomotion via rotation, rolling, and tumbling were possible at magnetic field magnitudes $<$ 10 mT, oil piston seals were better at mitigating sample contamination than water piston seals, and minimum o-ring seal pressures limits of 1.95 and 1.69 kPa for Design A and B respectively were sufficient against intra-abdominal pressures. Significance: This work presents the ability to impart capsule multi-functionality in a compact manner without onboard electronics or external triggering for sampling.

The Enticing world belief factor—encompassing beliefs that the world is interesting, beautiful, abundant, and worth exploring—has been hypothesized to promote subjective well-being and several character strengths (e.g., curiosity). The present pre-registered longitudinal-experimental study tests a 9-day intervention aiming to increase Enticing world belief in 247 high school and university students (aged 14–35). Results show that the intervention increased Enticing world belief from pre to post. However, these changes did not persist at a 2-week follow-up. Although we did not find the predicted positive total effects of the intervention on optimism, life satisfaction, well-being, curiosity or love of learning from pre to post, we did find positive indirect effects on all of these variables via changes in Enticing world belief. We discuss inferential limitations regarding the observed effects as well as possible reasons for the lack of positive total effects on well-being measures and character strengths.

Surgery residents are at a higher-than-average risk of burnout syndrome, which is characterized by emotional exhaustion, depersonalization, and a sense of ineffectiveness. This risk of burnout can translate to increased stress and distress in trainees, poor performance, as well as worse patient outcomes. Therefore, developing and implementing burnout reduction strategies that are feasible, acceptable, and effective among surgical residents is paramount. Studies demonstrate that inherent mindfulness is associated with improved resiliency, reduced stress and burnout, as well as improved cognitive and motor skill performance. Fortunately, mindfulness is a skill that can be developed and maintained through targeted mindfulness-based interventions embedded within surgical education curriculum. Here, we present the data supporting the use of mindfulness as an integral part of burnout reduction efforts in surgical trainees as well as highlight evidence-based strategies for implementation in diverse surgical training environments.

The powder bed fusion of metals using a laser beam enables the additive manufacturing of thin-walled and topology-optimized geometries. These geometries feature structural transitions, where shrink lines form notches on the outer surface of the part and reduce the dimensional accuracy. The influence of shrink-line-shaped notches on the fatigue life has not been determined yet. This paper presents the impact of a shrink line on the fatigue resistance. A standardized specimen was prepared with a representative shrink line notch whose dimensions were varied. The resulting notch shape was optically measured and experimentally investigated concerning the fatigue properties and the fracture behavior. A position-dependent formation of the resulting shrink line notch during the manufacturing was identified. The shrink line dimensions demonstrated a significant influence on the fatigue resistance and the fracture mechanism. The results indicate that existing calculation methods can be applied for shrink line notches in the future.

When learning a motor skill it is helpful to get corrective feedback from an instructor. This will support the learner to execute the movement correctly. With modern technology, it is possible to provide this feedback via mixed reality. In most cases, this involves visual cues to help the user understand the corrective feedback. We analyzed recent research approaches utilizing visual cues for feedback in mixed reality. The scope of this article is visual feedback for motor skill learning, which involves physical therapy, exercise, rehabilitation etc. While some of the surveyed literature discusses therapeutic effects of the training, this article focuses on visualization techniques. We categorized the literature from a visualization standpoint, including visual cues, technology and characteristics of the feedback. This provided insights into how visual feedback in mixed reality is applied in the literature and how different aspects of the feedback are related. The insights obtained can help to better adjust future feedback systems to the target group and their needs. This article also provides a deeper understanding of the characteristics of the visual cues in general and promotes future, more detailed research on this topic.

Excessive choice of smaller-immediate rewards has been positively correlated with a host of negative health outcomes such as addiction, gambling, and overeating. Meta-analytic research suggests that stress is a contextual variable that can contribute to impulsive choice. The strength of the relationship between stress and impulsive decision making may be largely moderated by how these variables are measured. Despite clinical relevance, the relationship between daily stress and decision making is not well understood. The current investigation sought to further characterize the relationship between acute stress and impulsive decision making using the Daily Stress Inventory and the 27-item Monetary Choice Questionnaire. Results from 69 adults revealed a positive correlation between daily stressors and impulsive decision making. Future directions are discussed aimed at experimental evaluations of the effects of stress on impulsive decision making.

Several barriers may inhibit the growth of behavior analysis as a more integrated and collaborative field. Two such barriers are siloed environments that reinforce a basic-applied distinction, and a lack of translational research pathways. We describe the perils of silos, and elaborate on potential solutions to increase reciprocal relations among subfields in behavior analysis. We promote a five-tiered system to classify research in behavior analysis, and discuss literature on cultivating effective intra and cross-disciplinary collaborations, including using the framework of metacontingencies to understand collaborations. We also propose quantitative and qualitative measures to examine whether the potential solutions increase intra and interdisciplinary interactions. These measures include bibliometric (e.g., citations across fields), sociometric (e.g., social network analysis), and narrative analysis. We apply some of these measures to publications from 2011–2022 from the Journal of the Experimental Analysis of Behaviorand Journal of Applied Behavior Analysis, and argue that behavior analysis overall may benefit from a more collaborative approach.

Identifying barriers to compliance with mindfulness-based interventions (MBIs) during the perioperative period is paramount to the design and implementation of non-pharmacologic, opiate-sparing pain regimens. We prospectively investigated the acceptability and adherence patterns of an app-based MBI amongst surgical patients with chronic pain. Patients were provided a subscription code to a meditation app and encouraged to use the app an average of 10 minutes/day over a 6-week study period. Patients reported a high level of interest in using the app prior to enrollment. 71% used the app at least once, 30% for half the recommended time, and 8% for the recommended amount of time. 88% of respondents enjoyed using the app and agreed it improved mental health and stress levels. Surgical patients with pre-existing pain report a high level of interest in utilizing MBIs perioperatively. Identifying barriers to compliance represents an important area of future investigation.

Background: It is critical to ensure appropriate and consistent sleeve size and orientation during laparoscopic sleeve gastrectomy (LSG). Various devices are used to achieve this, including weighted rubber bougies, esophagogastroduodenoscopy (EGD), and suction calibration systems (SCS). Prior reports suggest that SCSs may decrease operative time and stapler load firings but are limited by single-surgeon experience and retrospective design. We performed the first randomized controlled trial comparing SCS against EGD in patients undergoing LSG to investigate whether the SCS decreases the number of stapler load firings. Methods: This was a randomized, non-blinded study from a single MBSAQIP-accredited academic center. Appropriate LSG candidates ≥ 18 years of age were randomized to EGD or SCS calibration. Exclusion criteria included prior gastric or bariatric surgery, detection of hiatal hernia before surgery, and intraoperative hiatal hernia repair. A randomized block design was employed controlling for body mass index, gender, and race. Seven surgeons employed a standardized LSG operative technique. The primary endpoint was the number of stapler load firings. Secondary endpoints were operative duration, reflux symptoms, and change in total body weight (TBW). Endpoints were analyzed via t-test. Results: A total of 125 LSG patients (84% female) underwent study enrollment, with an average age of 44 ± 12 years and average BMI of 49 ± 8 kg/m2. Overall, 117 patients were randomized to receive EGD (n= 59) or SCS (n= 58) calibration. No significant differences in baseline characteristics were identified. The mean number of stapler load firings for EGD and SCS groups were 5.43 ± 0.89 and 5.31 ± 0.81, respectively (p= 0.463). The mean operative times for EGD and SCS groups were 94.4 ± 36.5 and 93.1 ± 27.9 min, respectively (p= 0.83). There were no significant differences in post-operative reflux, TBW loss, or complications. Conclusion: Use of EGD and SCS resulted in a similar number of LSG stapler load firings and operative duration. Additional research is needed to compare LSG calibration devices in different patients and settings to optimize surgical technique.

AbstractBackground:Education of paediatric advanced practice providers takes a generalist approach which lacks in-depth exposure to subspecialties like paediatric cardiac intensive care. This translates into a knowledge gap related to congenital cardiac physiology and management for APPs transitioning to the paediatric cardiac ICU.Methods:A specialised interprofessional peer-reviewed curriculum was created and distributed through the Pediatric Cardiac Intensive Care Society. This curriculum includes a textbook which is complemented by a didactic and simulation review course. Course evaluations were collected following each course, and feedback from participants was incorporated into subsequent courses. Pediatric Cardiac Intensive Care Society partnered with the Pediatric Nursing Certification Board to develop a 200-question post-assessment (exam) bank.Results:From December 2017 to January 2022, 12 review courses were taught at various host sites (n = 314 participants). Feedback revealed that courses improved preparedness for practice, contributed to advanced practice provider empowerment, and emphasised the importance of professional networking. 97% of attendees agreed/strongly agreed that the course improved clinical knowledge, 97% agreed/strongly agreed that the course improved ability to care for patients, and 88% agreed/strongly agreed that the course improved confidence to practice. 49% of participants rated the course as extremely effective, 42% very effective, 6% moderately effective, and 3% as only slightly effective.Conclusions:A standardised subspecialty curriculum dedicated to advanced practice provider practice in cardiac intensive care was needed to improve knowledge, advance practice, and empower APPs managing critically ill patients in the cardiac ICU. The developed curriculum provides standardised learning, increasing advanced practice provider knowledge acquisition, and confidence to practice.

AbstractInternational comparative planning studies is a growing field of planning research that enjoys increasing recognition. In Europe in particular, various approaches have emerged over recent decades that can be considered established in the scholarly literature. However, a closer look at the literature reveals some weaknesses, particularly against the background of the methodological quality criteria of social science comparative research. For example, explanatory comparisons are rare in comparative planning studies. Often, case study research designs are chosen, while large N studies and qualitative comparative analysis (QCA) are still rarely used. This paper summarises these weaknesses and points out avenues for further development. English title: How can we best compare different planning systems?

A third‐grade educator and university researcher collaborated to develop an after‐school virtual book club curriculum for students during the pandemic. Third‐grade students were encouraged to explore social justice issues prevalent in their community first by reading relevant children's books, doing research, and collaborating to develop potential action plans to address the issues. The study examined the impact of the books, the identification with characters, and the benefit of small group pedagogy. Students were intrinsically motivated to read, research, and collaborate over social justice issues voluntarily given free choice, minimal guidance, and opportunities. The results showcased the importance of small group discussion with young children, the power of choice in research‐based activities, and the desire for students to have their voices heard in important matters.

The epidemiology of congenital heart disease (CHD) has changed in the past 50 years as a result of an increase in the prevalence and survival rate of CHD. In particular, mortality in patients with CHD has changed dramatically since the latter half of the twentieth century as a result of more timely diagnosis and the development of interventions for CHD that have prolonged life. As patients with CHD age, the disease burden shifts away from the heart and towards acquired cardiovascular and systemic complications. The societal costs of CHD are high, not just in terms of health-care utilization but also with regards to quality of life. Lifespan disease trajectories for populations with a high disease burden that is measured over prolonged time periods are becoming increasingly important to define long-term outcomes that can be improved. Quality improvement initiatives, including advanced physician training for adult CHD in the past 10 years, have begun to improve disease outcomes. As we seek to transform lifespan into healthspan, research efforts need to incorporate big data to allow high-value, patient-centred and artificial intelligence-enabled delivery of care. Such efforts will facilitate improved access to health care in remote areas and inform the horizontal integration of services needed to manage CHD for the prolonged duration of survival among adult patients.

There has been a growing interest in the use of complementary and alternative medicine in modern pain management strategies on behalf of both patients and clinicians. Nonpharmacologic modalities such as cryotherapy, acupuncture, music, and mind-body therapies have been shown to aid in symptom control and improve quality of life in patients suffering from acute and chronic pain, and there is a growing body of literature demonstrating their feasibility, acceptability, and efficacy in the perioperative period. Here, we provide a brief review of the current evidence supporting the use of complementary therapies within existing perioperative pain management strategies and highlight evidence-based protocols to facilitate implementation into modern surgical practice.

Background: Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations. Methods and procedures: An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student’s t-tests. Results: Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (P< 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4–80.8% post-implementation (P< 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes. Conclusion: Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.

Powder bed fusion of metals using a laser beam (PBF-LB/M) is a process that enables the fabrication of geometrically complex parts. In this process, a laser beam melts a metallic powder locally to build the desired geometry. The melt pool solidifies rapidly, which results in high cooling rates. These rates vary during the process in line with the geometric characteristics of the part, which leads to a non-uniform microstructure along with anisotropic mechanical properties. The unknown part characteristics prevent the process from being used in safety-critical applications. Thermographic in situ process monitoring provides information about the thermal field, enabling predictions of the resulting material properties. This study presents a novel methodology for the thermographic measurement of cooling rates during the PBF-LB/M process using a high-speed thermographic camera. The cooling rates occurring during the manufacturing of 316L tower-like specimens were measured. The cooling rate decreased with increasing build height, due to the heat accumulation in the parts. The microhardness profile of the parts was tested perpendicularly and parallel to the build direction. A significant decrease in hardness values was observed along the build height. The measured cooling rate was correlated to the microhardness profile of the specimens using a Hall–Petch type relationship. The results show a high level of reproducibility of the cooling rates between different specimens in the same build job as well as between subsequent build jobs. The presented methodology allows studying the effects of the geometry on the cooling rates and the resulting mechanical properties of 316L specimens.

Resistant hypertension is associated with increased cardiovascular risk. The endothelin pathway has been implicated in the pathogenesis of hypertension, but it is currently not targeted therapeutically, thereby leaving this relevant pathophysiological pathway unopposed with currently available drugs. The aim of the study was to assess the blood pressure lowering efficacy of the dual endothelin antagonist aprocitentan in patients with resistant hypertension.

IMPORTANCE: Breast cancer is the most common invasive subsequent malignant disease in childhood cancer survivors, though limited data exist on changes in breast cancer rates as primary cancer treatments have evolved. OBJECTIVE: To quantify the association between temporal changes in cancer treatment over 3 decades and subsequent breast cancer risk. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 5-year cancer survivors diagnosed when younger than 21 years between 1970 and 1999, with follow-up through December 5, 2020. EXPOSURES: Radiation and chemotherapy dose changes over time. MAIN OUTCOMES AND MEASURES: Breast cancer cumulative incidence rates and age-specific standardized incidence ratios (SIRs) compared across treatment decades (1970-1999). Piecewise exponential models estimated invasive breast cancer and ductal carcinoma in situ (DCIS) risk and associations with treatment exposures, adjusted for age at childhood cancer diagnosis and attained age. RESULTS: Among 11 550 female survivors (median age, 34.2 years; range 5.6-66.8 years), 489 developed 583 breast cancers: 427 invasive, 156 DCIS. Cumulative incidence was 8.1% (95% CI, 7.3%-9.0%) by age 45 years. An increased breast cancer risk (SIR, 6.6; 95% CI, 6.1-7.2) was observed for survivors compared with the age-sex-calendar-year-matched general population. Changes in therapy by decade included reduced rates of chest (34% in the 1970s, 22% in the 1980s, and 17% in the 1990s) and pelvic radiotherapy (26%, 17%, and 13% respectively) and increased rates of anthracycline chemotherapy exposures (30%, 51%, and 64%, respectively). Adjusting for age and age at diagnosis, the invasive breast cancer rate decreased 18% every 5 years of primary cancer diagnosis era (rate ratio [RR], 0.82; 95% CI, 0.74-0.90). When accounting for chest radiotherapy exposure, the decline attenuated to an 11% decrease every 5 years (RR, 0.89; 95% CI, 0.81-0.99). When additionally adjusted for anthracycline dose and pelvic radiotherapy, the decline every 5 years increased to 14% (RR, 0.86; 95% CI, 0.77-0.96). Although SIRs of DCIS generally increased over time, there were no statistically significant changes in incidence. CONCLUSIONS AND RELEVANCE: Invasive breast cancer rates in childhood cancer survivors have declined with time, especially in those younger than 40 years. This appears largely associated with the reduced use of chest radiation therapy, but was tempered by concurrent changes in other therapies.

Untethered magnetically actuated robots present significant advantages for biomedical applications by allowing power to be delivered wirelessly to remote, miniature robots through flesh and bone. Nevertheless, generating enough usable force to interact with their environment remains a challenge: Most millimeter-size magnetic robots achieve forces of much less than 0.1 N, which limits their medical applications. Therefore, a compact, millimeter-scale transmission is needed to amplify the output force. A novel microtransmission system is presented, composed of a driving magnet suspended between two twisted string actuators. An analytical model of the transmission is formulated to predict its behavior under both fixed load and fixed displacement configurations. Experimental measurements are used to validate the predicted maximum achievable force, to quantify the transmission performance over numerous cycles, to determine the effect of different string materials, and to determine the impact of hysteresis and viscoelasticity. Finally, the transmission is integrated into a 3 mm diameter surgical gripper prototype to demonstrate its effectiveness. With only a modest 20 mT of applied magnetic field, the gripper generates 1.09 N gripping force—a factor of 35 improvement in mechanical advantage and a factor of 62 improvement in gripping force compared to a similar size gripper using direct magnetic actuation. This microtransmission for miniature magnetic robots will enable high-strength untethered robots for minimally invasive surgical applications.

Databases for Congenital Heart Disease (CHD) are effective in delivering accessible datasets ready for statistical inference. Data collection hitherto has, however, been labour and time intensive and has required substantial financial support to ensure sustainability. We propose here creation and piloting of a semiautomated technique for data extraction from clinic letters to populate a clinical database.

There exists a robust amount of evidence supporting the broad application of mindfulness in a clinical environment. The evolution of mindfulness research is germane to modern surgical practice and education given its impact on patient outcomes, cognitive function, surgical skill, and mental health and wellbeing. “Mindfulness in surgical care, training, and practice” includes a series of articles that highlight the theoretical rationale behind mindfulness-based interventions (MBIs) for optimization of patient care and define its role in surgical education and practice. Furthermore, each article offers implementation strategies and best practices such that mindfulness-based interventions and curricula can be adapted to meet the unique needs of patients and providers existing within a diverse surgical environment. This series brings attention to the evolving archetype of surgical culture - one in which the wellbeing of individuals and communities is emphasized as fundamental to optimum patient care and outcomes.

AbstractBackground:Adults with systemic right ventricle have a significant risk for long-term complications such as arrhythmias or heart failure.Methods:A nationwide retrospective study based on the German National Register for Congenital Heart Disease was performed. Patients with transposition of the great arteries after atrial switch operation or congenitally corrected TGA were included.Results:Two hundred and eight-five patients with transposition of the great arteries after atrial switch operation and 95 patients with congenitally corrected transposition of the great arteries were included (mean age 33 years). Systolic function of the systemic ventricle was moderately or severely reduced in 25.5 % after atrial switch operation and in 35.1% in patients with congenitally corrected transposition. Regurgitation of the systemic atrioventricular valve was present in 39.5% and 43.2% of the cases, respectively. A significant percentage of patients also had a history for supraventricular or ventricular arrhythmias. However, polypharmacy of cardiovascular drugs was rare (4.5%) and 38.5 % of the patients did not take any cardiovascular medication. The amount of cardiovascular drugs taken was associated with NYHA class as well as systemic right ventricular dysfunction. Patients with congenitally corrected transposition were more likely to receive pharmacological treatment than patients after atrial switch operation.Conclusion:A significant portion of patients with systemic right ventricle suffer from a relevant systemic ventricular dysfunction, systemic atrioventricular valve regurgitation, and arrhythmias. Despite this, medication for heart failure treatment is not universally used in this cohort. This emphasises the need for randomised trials in patient with systemic right ventricle.

Die Patientengruppe der Erwachsenen mit angeborenen Herzfehlern (EMAH) ist mittlerweile bereits größer als die der Kinder mit angeborenen Herzfehlern. EMAH-Patienten weisen auch nach Reparaturoperationen oft komplexe pathophysiologische und anatomische Verhältnisse auf. Bei Komplikationen kann es sehr rasch zu Notfallsituationen auch bei ansonsten asymptomatischen oder nur wenig symptomatischen Patienten kommen. Gemessen an der Gesamtzahl der Patienten, die von Notärzten und in den Notaufnahmen versorgt werden, sind EMAH-Notfallsituationen nach wie vor sehr selten. Diese Übersicht soll die Notfallbetreuung von EMAH-Patienten erleichtern. Für ca. zwei Drittel aller Notfälle sind Rhythmusstörungen und akute Herzinsuffizienz verantwortlich. Rhythmusstörungen müssen in der Regel zügig terminiert werden, weil sie unbehandelt rasch zur kardialen Dekompensation führen können. Bei Scheitern der medikamentösen Therapie oder hämodynamischer Instabilität müssen EMAH-Patienten mit tachykarden Rhythmusstörungen rasch elektrisch kardiovertiert werden. Symptomatische Bradykardien können eine rasche Schrittmacherversorgung erforderlich machen. Aufgrund der komplexen Anatomie kann das Einschwemmen eines transvenösen Interim-Schrittmachers bei einzelnen Vitien unmöglich sein. Die akute kardiale Dekompensation bei EMAH ist oft durch ein akutes Rechtsherzversagen verursacht. Weitere relativ häufige Aufnahmegründe sind Infektionen, Synkopen, Thromboembolien und Aortendissektion. Der Herzpass der Patienten informiert über das vorliegende Vitium. Die umgehende Kontaktaufnahme mit dem behandelnden EMAH-Zentrum wird dringend empfohlen.

In recent years, there has been an increase in outbreaks of diseases that are preventable by vaccination. As vaccination involves behavior, behavior analysts are uniquely positioned to contribute solutions to this socially significant problem. The present article explores a behavior-analytic approach to understanding the function of the behavior of both people who have their children vaccinated and those who do not have their children vaccinated, and potential interventions to increase vaccination rates. An introduction to the problem is followed by a brief history of the antivaccination movement. In our analysis, a failure to vaccinate is conceptualized as a noncompliance response (i.e., medical nonadherence), and conditions giving rise to that noncompliance are evaluated. In this process, the roles of avoidance, the functional-altering impact of rule-governed behavior, relational frames, and countercontrol are considered. Potential solutions informed by applied behavior-analytic literature, including contingency management and behavioral safety, are discussed.

Kugellager sind Verbindungsglieder zwischen stillstehenden und bewegten Komponenten. Insbesondere im Bereich der Werkzeugmaschinen sind Kugellager hohen Belastungen ausgesetzt und sorgen bei einem Defekt zu hohen Ausfallkosten. Um diese Defekte schneller zu erkennen, kommt eine ultraschallbasierte Diagnosetechnologie am Kugellagerinnenring zum Einsatz. Der Applikationsort der Technologie setzt eine energetische Versorgung voraus, die keine begrenzte Lebensdauer besitzt. Mithilfe eines elektromagnetischen Energy Harvesters und eines Energiemanagements wird dieses Vorhaben realisiert. Aufgrund der begrenzt zur Verfügung stehenden Energie wird eine Low-Power-Diagnosetechnologie eingesetzt. Durch die Diagnosetechnologie ist die Werkzeugmaschine dazu in der Lage, automatisierte Entscheidungen hinsichtlich der Lagerwartung zu treffen. Somit können ungeplante und kostenintensive Anlagenstillstände vermieden werden.

ABSTRACTPeople with high dark triad levels, consisting of subclinical narcissism, Machiavellianism, and psychopathy, can have a destructive impact on their team members, subordinates, and the organisation. Recent research has even found that the higher the leadership position, the more dark triad traits were displayed. As coaching is often for people in (higher) leadership positions, the following study with 64 coaches investigated the dark triad traits among their clients and how this affected the coach as well as the coaching. The results show that the higher the client’s leadership level was, the higher their dark triad level was perceived and, thus, the more anxious and distressed the coaches were regarding the client, leading to less coaching success. Although the coaches did not name a definite strategy for dealing with such a client, the results showed that the higher their approach motivation was, the more successful the coaches was. The results depict the danger of high dark triad levels amongst coaching clients and its influences on the business coaching, implying theoretical and practical considerations.

Genetic testing for pediatric cancer predisposition syndromes (CPS) could augment newborn screening programs, but with uncertain benefits and costs.

Generative art is a domain in which artistic output is created via a procedure or heuristic that may result in digital and/or physical results. A generative artist will typically act as a domain expert by specifying the algorithms that will form the basis of the piece as well as defining and refining parameters that can impact the results, however such efforts can require a significant amount of time to generate the final output. This article presents and extends GenerativeGI, an evolutionary computation-based technique for creating generative art by automatically searching through combinations of artistic techniques and their accompanying parameters to produce outputs desirable by the designer. Generative art techniques and their respective parameters are encoded within a grammar that is then the target for genetic improvement. This grammar-based approach, combined with a many-objective evolutionary algorithm, enables the designer to efficiently search through a massive number of possible outputs that reflect their aesthetic preferences. We included a total of 15 generative art techniques and performed three separate empirical evaluations, each of which targets different aesthetic preferences and varying aspects of the search heuristic. Experimental results suggest that GenerativeGIcan produce outputs that are significantly more novel than those generated by random or single objective search. Furthermore, GenerativeGIproduces individuals with a larger number of relevant techniques used to generate their overall composition.

AbstractWe compare real and complex dynamics for automorphisms of rational surfaces that are obtained by lifting some quadratic birational maps of the plane. In particular, we show how to exploit the existence of an invariant cubic curve to understand how the real part of an automorphism acts on homology. We apply this understanding to give examples where the entropy of the full (complex) automorphism is the same as its real restriction. Conversely and by different methods, we exhibit different examples where the entropy is strictly decreased by restricting to the real part of the surface. Finally, we give an example of a rational surface automorphism with positive entropy whose periodic cycles are all real.

Dextro-transposition of the great arteries (D-TGA) has undergone a significant evolution in surgical repair, leading to survivors with vastly different postsurgical anatomy which in turn guides their long-term cardiovascular morbidity and mortality. Atrial switch repair survivors are limited by a right ventricle in the systemic position, arrhythmia and atrial baffles prone to obstruction or leak. Functional assessment of the systemic right ventricle is complex, requiring multimodality imaging to include specialised echocardiography and cross-sectional imaging (MRI and CT). In the current era, most neonates undergo the arterial switch operation with increasing understanding of near-term and long-term outcomes specific to their cardiac anatomy. Long-term observations of the Lecompte manoeuvre or coronary stenoses following transfer continue, with evolving understanding to improve surveillance. Ultimately, an understanding of postsurgical anatomy, specialised imaging techniques and interventional and electrophysiological procedures is essential to comprehensive care of D-TGA survivors.

ObjectivesData on the clinical outcome of patients with congenital heart disease (CHD) affected by severe viral pneumonia are limited. We analysed morbidity and mortality of viral pneumonia and evaluated the association between medical conditions, medication, vaccination and outcome specifically in patients with CHD requiring hospitalisation for viral pneumonia.MethodsBased on data from one of Germany’s largest health insurers, all cases of viral pneumonia requiring hospital admission (2005–2018) were studied. Mortality, and composites of death, transplantation, mechanical circulatory support, ventilation or extracorporeal lung support served as endpoints.ResultsOverall, 26 262 viral pneumonia cases occurred in 24 980 patients. Of these, 1180 cases occurred in patients with CHD. Compared with patients without CHD, mortality rate was elevated in patients with CHD. As a group, patients with CHD aged 20–59 years even exceeded mortality rates in patients without CHD aged >60 years. No mortality was observed in patients with CHD with simple defects <60 years of age without associated cardiovascular risk factors. On multivariable logistic regression analysis, age, CHD complexity, chromosomal anomalies, cardiac medication, use of immunosuppressants and absence of vaccination for influenza emerged as risk factors of adverse outcome.ConclusionsWe present timely data on morbidity and mortality of severe viral pneumonia requiring hospital admission in patients with CHD. Need for mechanical ventilation and risk of death in CHD increase early in life, reaching a level equivalent to non-CHD individuals >60 years of age. Our data suggest that except for patients with isolated simple defects, patients with CHD should be considered higher-risk individuals when faced with severe viral pneumonia.

Purpose: This study aims to investigate how university students' basic psychological needs (autonomy, competence and relatedness) determine whether coaching or training is more supportive for them. Design/methodology/approach: Real-life coaching (N1= 110) and training (N2= 176) processes with students as clients were examined, measuring the students' needs before the coaching/training, their need fulfilment after the coaching/training and their satisfaction and goal attainment/intrinsic motivation after the coaching/training. Findings: The results show that university students with a higher autonomy need had this need fulfilled to a greater extent through coaching, while university students with a higher competence need had this need fulfilled to a greater extent through training. Research limitations/implications: The research focused on university students and was conducted at German-speaking universities, so it is unclear to what extent the findings are transferable to other contexts. In addition, future research is needed to further compare other personal development tools, such as mentoring or consulting. Practical implications: The results depict the relevance of the most appropriate personal development tool (coaching or training) depending on students' needs. Furthermore, coaches should be autonomy-supportive, while trainers should be competence-supportive. Originality/value: Supporting students with the most appropriate personal development tool is essential for the effectiveness of this tool. Thus, the personal development tool used should reflect students' needs: students with a high autonomy need should receive coaching, while students with a high competence need should receive training.

AbstractBased on theoretical considerations on life cycles and multi-level models, this paper presents a new model to describe and analyze the development of regional governance processes on longer timescales. Additionally, elements of the path dependence debate and the resilience concept are included. Given this and a data base of over 1300 regional cooperations in Germany, a regional life and adaption cycle model is formulated, which systematically differentiates four development phases.The focus is laid on “tipping points”, that indicate the transition between two phases. Using the Altmark-region as an example, the model is filled with data and consequences for its interpretation are drawn. The model allows the flexible analysis of processes of change and adaptation in multi-level governance structure. External and internal impulses can be distinguished. For each “tipping point”, a specific adaptation cycle can be determined in the region, which describes the direction of the effects and the level of resilience reached.However, the new life cycle model has yet to be developed: The aspects of path dependency and resilience as well as the question of conditions for success are not yet sufficiently integrated. The typology of “tipping points” of phase changes should be specified. Therefore, further theoretical considerations and more detailed empirical research are necessary to improve the model.English Title: Development of a new model for the analysis of regional governance processes

IMPORTANCE: Advances in childhood and adolescent cancer treatment have been associated with increased rates of cure during the past 3 decades; however, improvement in adult life expectancy for these individuals has not yet been reported. OBJECTIVES: To project long-term survival and assess whether life expectancy will improve among adult survivors of childhood cancer who were treated in more recent decades. DESIGN, SETTING, AND PARTICIPANTS: A microsimulation model of competing mortality risks was developed using data from the Childhood Cancer Survivor Study on 5-year survivors of childhood cancer diagnosed between 1970 and 1999. The model included (1) late recurrence, (2) treatment-related late effects (health-related [subsequent cancers, cardiac events, pulmonary conditions, and other] and external causes), and (3) US background mortality rates. EXPOSURES: Treatment subgroups (no treatment or surgery only, chemotherapy alone, radiotherapy alone, and radiotherapy with chemotherapy) and individuals with acute lymphoblastic leukemia during childhood by era (1970-1979, 1980-1989, and 1990-1999). MAIN OUTCOMES AND MEASURES: Conditional life expectancy (defined as the number of years a 5-year survivor can expect to live), cumulative cause-specific mortality risk, and 10-year mortality risks conditional on attaining ages of 30, 40, 50, and 60 years. RESULTS: Among the hypothetical cohort of 5-year survivors of childhood cancer representative of the Childhood Cancer Survivor Study participants (44% female and 56% male; mean [SD] age at diagnosis, 7.3 [5.6] years), conditional life expectancy was 48.5 years (95% uncertainty interval [UI], 47.6-49.6 years) for 5-year survivors diagnosed in 1970-1979, 53.7 years (95% UI, 52.6-54.7 years) for those diagnosed in 1980-1989, and 57.1 years (95% UI, 55.9-58.1 years) for those diagnosed in 1990-1999. Compared with individuals without a history of cancer, these results represented a gap in life expectancy of 25% (95% UI, 24%-27%) (16.5 years [95% UI, 15.5-17.5 years]) for those diagnosed in 1970-1979, 19% (95% UI, 17%-20%) (12.3 years [95% UI, 11.3-13.4 years]) for those diagnosed in 1980-1989, and 14% (95% UI, 13%-16%) (9.2 years [95% UI, 8.3-10.4 years]) for those diagnosed in 1990-1999. During the 3 decades, the proportion of survivors treated with chemotherapy alone increased (from 18% in 1970-1979 to 54% in 1990-1999), and the life expectancy gap in this chemotherapy-alone group decreased from 11.0 years (95% UI, 9.0-13.1 years) to 6.0 years (95% UI, 4.5-7.6 years). In contrast, during the same time frame, only modest improvements in the gap in life expectancy were projected for survivors treated with radiotherapy (21.0 years [95% UI, 18.5-23.2 years] to 17.6 years [95% UI, 14.2-21.2 years]) or with radiotherapy and chemotherapy (17.9 years [95% UI, 16.7-19.2 years] to 14.8 years [95% UI, 13.1-16.7 years]). For the largest group of survivors by diagnosis—those with acute lymphoblastic leukemia—the gap in life expectancy decreased from 14.7 years (95% UI, 12.8-16.5 years) in 1970-1979 to 8.0 years (95% UI, 6.2-9.7 years). CONCLUSIONS AND RELEVANCE: Evolving treatment approaches are projected to be associated with improved life expectancy after treatment for pediatric cancer, in particular among those who received chemotherapy alone for their childhood cancer diagnosis. Despite improvements, survivors remain at risk for shorter lifespans, especially when radiotherapy was included as part of their childhood cancer treatment.

The application of statistical methods to comparatively framed questions about the molecular dynamics (MD) of proteins can potentially enable investigations of biomolecular function beyond the current sequence and structural methods in bioinformatics. However, the chaotic behavior in single MD trajectories requires statistical inference that is derived from large ensembles of simulations representing the comparative functional states of a protein under investigation. Meaningful interpretation of such complex forms of big data poses serious challenges to users of MD. Here, we announce Detecting Relative Outlier Impacts from Molecular Dynamic Simulation (DROIDS) 3.0, a method and software package for comparative protein dynamics that includes maxDemon 1.0, a multimethod machine learning application that trains on large ensemble comparisons of concerted protein motions in opposing functional states generated by DROIDS and deploys learned classifications of these states onto newly generated MD simulations. Local canonical correlations in learning patterns generated from independent, yet identically prepared, MD validation runs are used to identify regions of functionally conserved protein dynamics. The subsequent impacts of genetic and/or drug class variants on conserved dynamics can also be analyzed by deploying the classifiers on variant MD simulations and quantifying how often these altered protein systems display opposing functional states. Here, we present several case studies of complex changes in functional protein dynamics caused by temperature, genetic mutation, and binding interactions with nucleic acids and small molecules. We demonstrate that our machine learning algorithm can properly identify regions of functionally conserved dynamics in ubiquitin and TATA-binding protein (TBP). We quantify the impact of genetic variation in TBP and drug class variation targeting the ATP-binding region of Hsp90 on conserved dynamics. We identify regions of conserved dynamics in Hsp90 that connect the ATP binding pocket to other functional regions. We also demonstrate that dynamic impacts of various Hsp90 inhibitors rank accordingly with how closely they mimic natural ATP binding.

The systemic right ventricle (SRV), defined as the morphological right ventricle supporting the systemic circulation, is relatively common in congenital heart disease (CHD). Our review aimed at examining the current evidence, knowledge gaps and technical considerations regarding implantable cardiac electronic device therapy in patients with SRV. The risk of sinus node dysfunction (SND) after atrial switch repair and/or complete heart block in congenitally corrected transposition of great arteries requiring permanent pacing increases with age. Similar to acquired heart disease, indication for pacing includes symptomatic bradycardia, SND and high degree atrioventricular nodal block. Right ventricular dysfunction and heart failure also represent important complications in SRV patients. Cardiac resynchronisation therapy (CRT) has been proposed to improve systolic function in SRV patients, although indications for CRT are not well defined and its potential benefit remains uncertain. Amongst adult CHD, patients with SRV are at the highest risk for sudden cardiac death (SCD). Nevertheless, risk stratification for SCD is scarce in this cohort and implantable cardioverter-defibrillator indication is currently limited to secondary prevention. Vascular access and the incidence of device-related complications, such as infections, inappropriate shocks and device system failure, represent additional challenges to implantable cardiac electronic device therapy in patients with SRV. A multidisciplinary approach with tertiary expertise and future collaborative research are all paramount to further the care for this challenging nonetheless ever increasing cohort of patients.

ObjectiveTo describe the intervention spectrum, complexity, and safety outcomes of catheter-based interventions in a contemporary adult congenital heart disease (ACHD) tertiary cohort.MethodsAll patients over 16 years who underwent a catheter-based intervention for ACHD in our centre between 2000 and 2016 were included. Baseline demographics, clinical characteristics, indications for and complexity of intervention, procedural complications and early and mid-term mortality were analysed.ResultsOverall, 1644 catheter-based interventions were performed. Intervention complexity ranged from simple (67.5%) to intermediate (26.4%) and to high (6.1%). Commonly performed procedures were atrial septal defect (33.4%) and patent foramen ovale closure (26.1%) followed by coarctation of the aorta (11.1%) and pulmonary artery interventions (7.0%). Age at index intervention was 40±16 years, 758 (46.1%) patients were male, 73.2% in New York Heart Association (NYHA) class I, 20.2% in NYHA class II, whereas 6.6% in NYHA class III/IV. In-hospital mortality was 0.7%. Median postinterventional length of stay was 1 day. Complications occurred in 129 (7.9%) with major adverse events in 21 (1.3%). One-year postintervention survival rates were 98.7% (95% CI 98.2 to 99.2). Over the study period, there was a notable shift in intervention complexity, with a predominance of simple procedures performed in early years and more complex procedures in later years. Furthermore, the case mix during the study broadened (p<0.001) with new catheter-based interventions and a more individualised approach to therapy.ConclusionThis study shows an increasing complexity and expanding variability of ACHD catheter-based interventions, associated with low major complications, short hospital stays and low early and mid-term mortality. Ongoing investment in ACHD catheter interventions is warranted.

ObjectiveTo assess the utility of machine learning algorithms for automatically estimating prognosis in patients with repaired tetralogy of Fallot (ToF) using cardiac magnetic resonance (CMR).MethodsWe included 372 patients with ToF who had undergone CMR imaging as part of a nationwide prospective study. Cine loops were retrieved and subjected to automatic deep learning (DL)-based image analysis, trained on independent, local CMR data, to derive measures of cardiac dimensions and function. This information was combined with established clinical parameters and ECG markers of prognosis.ResultsOver a median follow-up period of 10 years, 23 patients experienced an endpoint of death/aborted cardiac arrest or documented ventricular tachycardia (defined as >3 documented consecutive ventricular beats). On univariate Cox analysis, various DL parameters, including right atrial median area (HR 1.11/cm², p=0.003) and right ventricular long-axis strain (HR 0.80/%, p=0.009) emerged as significant predictors of outcome. DL parameters were related to adverse outcome independently of left and right ventricular ejection fraction and peak oxygen uptake (p<0.05 for all). A composite score of enlarged right atrial area and depressed right ventricular longitudinal function identified a ToF subgroup at significantly increased risk of adverse outcome (HR 2.1/unit, p=0.007).ConclusionsWe present data on the utility of machine learning algorithms trained on external imaging datasets to automatically estimate prognosis in patients with ToF. Due to the automated analysis process these two-dimensional-based algorithms may serve as surrogates for labour-intensive manually attained imaging parameters in patients with ToF.

Activin A and follistatin exhibit immunomodulatory functions, thus affecting autoinflammatory processes as found in rheumatoid arthritis (RA). The impact of both proteins on the behavior of synovial fibroblasts (SF) in RA as well as in osteoarthritis (OA) is unknown. Immunohistochemical analyses of synovial tissue for expression of activin A and follistatin were performed. The influence of RASF overexpressing activin A on cartilage invasion in a SCID mouse model was examined. RASF and OASF were stimulated with either IL-1β or TNFα in combination with or solely with activin A, activin AB, or follistatin. Protein secretion was measured by ELISA and mRNA expression by RT-PCR. Smad signaling was confirmed by western blot. In human RA synovial tissue, the number of activin A-positive cells as well as its extracellular presence was higher than in the OA synovium. Single cells within the tissue expressed follistatin in RA and OA synovial tissue. In the SCID mouse model, activin A overexpression reduced RASF invasion. In human RASF, activin A was induced by IL-1β and TNFα. Activin A slightly increased IL-6 release by unstimulated RASF, but decreased protein and mRNA levels of follistatin. The observed decrease of cartilage invasion by RASF overexpressing activin A in the SCID mouse model appears to be mediated by an interaction between activin/follistatin and other local cells indirectly affecting RASF because activin A displayed certain pro-inflammatory effects on RASF. Activin A even inhibits production and release of follistatin in RASF and therefore prevents itself from being blocked by its inhibitory binding protein follistatin in the local inflammatory joint environment.

Eisenmenger syndrome is the most severe and extreme phenotype of pulmonary arterial hypertension associated with congenital heart disease. A large nonrestrictive systemic left-to-right shunt triggers the development of pulmonary vascular disease, progressive pulmonary arterial hypertension, and increasing pulmonary vascular resistance at the systemic level, which ultimately results in shunt reversal. Herein, we review the changing epidemiological patterns and pathophysiology of Eisenmenger syndrome. Multiorgan disease is an integral manifestation of Eisenmenger syndrome and includes involvement of the cardiac, hematological, neurological, respiratory, gastrointestinal, urinary, immunological, musculoskeletal, and endocrinological systems. Standardized practical guidelines for the assessment, management, risk stratification, and follow-up of this very fragile and vulnerable population are discussed. Multidisciplinary care is the best clinical practice. An approach to the prevention and management of a broad spectrum of complications is provided. Relevant therapeutic questions are discussed, including anticoagulation, noncardiac surgery, physical activity, transplantation, and advanced-care planning (palliative care). Advanced pulmonary arterial hypertension therapies are indicated in patients with Eisenmenger syndrome and World Health Organization functional class II or higher symptoms to improve functional capacity, quality of life, and—less well documented—survival. Specific recommendations regarding monotherapy or combination therapy are provided according to functional class and clinical response. The ultimate challenge for all care providers remains early detection and management of intracardiac and extracardiac shunts, considering that Eisenmenger syndrome is a preventable condition.

This paper compares facets of behavior analysis and intersectional feminist theory. We begin by describing the history of issues related to gender and sexuality in behavior analysis. Then, we explain how the goals of feminism and applied behavior analysis are aligned, with a focus on intersectional feminism. Intersectional feminism examines the influence of interacting variables (e.g., race, gender, and sexuality) that affect one’s experiences and behaviors, rather than focusing on a single factor, such as gender. Pragmatic behaviorism and intersectionality have many parallels, and by exploring them, researchers can generate more comprehensive explanations of behavior. With prevalent gender, race, and sexual orientation biases in contemporary society, it may be important for behavior analysts to be able to recognize these contingencies that have been previously overlooked. Describing the conceptual commonalities between these disciplines may be a stride towards inclusivity and advancement of the goals of each discipline.

A novel self-curing epoxy resin was synthesized using bio-oil. Bio-oil was produced by hydrothermal liquefaction of loblolly pine and utilized as a biopolyol in the synthesis of bio-oil-based epoxy resin (BOBER) for the first time. Hydroxyl groups in bio-oil were analyzed by quantitative 31P NMR. It was found that not only does the total hydroxyl number of bio-oil influence the yield and epoxy equivalent weight of BOBER, but also the distribution of hydroxyl groups within bio-oil (aliphatic, phenolic, and acidic OH) played an important role in the determination of the optimum amount of catalyst in the synthesis of BOBER. Differential scanning calorimetry analysis proved the self-curing phenomena of BOBER, and Fourier transform infrared spectroscopy suggested that etherification reaction was the dominate reaction during the self-curing. Glass transition temperature, cross-linking density, and the storage modulus of self-cured BOBER were calculated using a dynamic mechanical analyzer.