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BACKGROUND: Fenestrated endovascular aortic aneurysm repair (FEVAR) is used in pararenal abdominal aortic aneurysms to achieve a durable proximal seal. This study investigated the mid-term course of the proximal fenestrated stent graft (FSG) sealing zone on the first and latest available post-FEVAR computed tomographic angiography (CTA) scan in a single-center series.METHODS: In 61 elective FEVAR patients, the shortest length of circumferential apposition between the FSG and the aortic wall (shortest apposition length [SAL]) was retrospectively assessed on the first and last available postoperative CTA scans. Patient records were reviewed for FEVAR-related procedural details, complications, and reinterventions.RESULTS: The median (interquartile range) time between the FEVAR procedure and the first and last CTA scan was 35 (30-48) days and 2.6 (1.2-4.3) years, respectively. The median (interquartile range) SAL was 38 (29-48) mm, and 44 (34-59) mm on the first and last CTA scans, respectively. During follow-up, the SAL increased >5 mm in 32 patients (52%), and decreased >5 mm in six patients (10%). Reintervention was performed for a type 1a endoleak in one patient. Twelve other patients needed 17 reinterventions for other FEVAR-related complications.CONCLUSIONS: Good mid-term apposition of the FSG in the pararenal aorta was achieved post-FEVAR, and the occurrence of type 1a endoleaks was low. The number of reinterventions was substantial, however, but for reasons other than loss of proximal seal.

Introduction: Oncological outcome might be influenced by the type of resection in total mesorectal excision (TME) for rectal cancer. The aim was to see if non-restorative LAR would have worse oncological outcome. A comparison was made between non-restorative low anterior resection (NRLAR), restorative low anterior resection (RLAR) and abdominoperineal resection (APR). Materials and methods: This retrospective cohort included data from patients undergoing TME for rectal cancer between 2015 and 2017 in eleven Dutch hospitals. A comparison was made for each different type of procedure (APR, NRLAR or RLAR). Primary outcome was 3-year overall survival (OS). Secondary outcomes included 3-year disease-free survival (DFS) and 3-year local recurrence (LR) rate. Results: Of 998 patients 363 underwent APR, 132 NRLAR and 503 RLAR. Three-year OS was worse after NRLAR (78.2%) compared to APR (86.3%) and RLAR (92.2%, p < 0.001). This was confirmed in a multivariable Cox regression analysis (HR 1.85 (1.07, 3.19), p = 0.03). The 3-year DFS was also worse after NRLAR (60.3%), compared to APR (70.5%) and RLAR (80.1%, p < 0.001), HR 2.05 (1.42, 2.97), p < 0.001. The LR rate was 14.6% after NRLAR, 5.2% after APR and 4.8% after RLAR (p = 0.005), HR 3.22 (1.61, 6.47), p < 0.001. Conclusion: NRLAR might be associated with worse 3-year OS, DFS and LR rate compared to RLAR and APR.

Endovascular revascularization is the preferred treatment for peripheral arterial disease. Restenosis often occurs as a response to procedure-induced arterial damage. Reducing vascular injury during endovascular revascularization may improve its success rate. This study developed and validated an ex vivo flow model using porcine iliac arteries, obtained from a local abattoir. Twenty arteries (of 10 pigs) were equally allocated to two groups: a mock-treated control group and an endovascular intervention group. Arteries of both groups were perfused with porcine blood for 9 min, including 3 min of balloon angioplasty in the intervention group. Vessel injury was assessed by calculating the presence of endothelial cell denudation, vasomotor function, and histopathological analysis. MR imaging displayed balloon positioning and inflation. Endothelial cell staining showed 76% of denudation after ballooning compared to 6% in the control group (p < 0.001). This was confirmed by histopathological analysis, showing a significantly reduced endothelial nuclei count after ballooning compared to the controls (median: 22 vs. 37 nuclei/mm, p = 0.022). In the intervention group, vasoconstriction and endothelium-dependent relaxation were significantly reduced (p < 0.05).We present an ex vivo flow model to test the effects of endovascular therapy on the vessel’s wall morphology, endothelial denudation, and endothelial-dependent vasomotor function under physiological conditions. Additionally, it allows the future testing of human arterial tissue.

The gut microbiome has coevolved with its hosts over the years, forming a complex and symbiotic relationship. It is formed by what we do, what we eat, where we live, and with whom we live. The microbiome is known to influence our health by training our immune system and providing nutrients for the human body. However, when the microbiome becomes out of balance and dysbiosis occurs, the microorganisms within can cause or contribute to diseases. This major influencer on our health is studied intensively, but it is unfortunately often overlooked by the surgeon and in surgical practice. Because of that, there is not much literature about the microbiome and its influence on surgical patients or procedures. However, there is evidence that it plays a major role, showing that it needs to be a topic of interest for the surgeon. This review is written to show the surgeon the importance of the microbiome and why it should be taken into consideration when preparing or treating patients.

Recent developments in communication technologies, such as 5G, together with innovative computing paradigms, such as edge computing, provide further possibilities for the implementation of real-time networked control systems. However, privacy and cyber-security concerns arise when sharing private data between sensors, agents and a third-party computing facility. In this paper, a secure version of the distributed formation control is presented, analyzed and simulated, where gradient-based formation control law is implemented in the edge, with sensor and actuator information being secured by fully homomorphic encryption method based on learning with error (FHE-LWE) combined with a proposed mixed uniform-logarithmic quantizer (MULQ). The novel quantizer is shown to be suitable for realizing secure control systems with FHE-LWE where the critical real-time information can be quantized into a prescribed bounded space of plaintext while satisfying a sector bound condition whose lower and upper-bound can be made sufficiently close to an identity. An absolute stability analysis is presented, that shows the asymptotic stability of the closed-loop secure control system.

Contains fulltext : 288457.pdf (Publisher’s version ) (Closed access) OBJECTIVE: The Observing a Decade of Yearly Standardised Surveillance in EVAR patients with Ultrasound or CT Scan (ODYSSEUS) study was conducted to assess differences in outcomes of patients with continued or discontinued yearly follow up after endovascular abdominal aortic aneurysm repair (EVAR). Earlier results of this study showed that discontinued follow up was not associated with poor outcomes. Therefore, an incremental cost analysis and budget impact analysis of de-implementation of yearly imaging following EVAR was performed. METHODS: In total, 1 596 patients from the ODYSSEUS study were included. The expected cost savings were assessed if yearly imaging was reduced in patients with a post-operative computed tomography angiogram without abnormalities made around 30 days after EVAR. Costs were derived from the Dutch costs manual, benchmark cost prices, and literature review. Costs were expressed in euros (€) and displayed at 2019 prices. Sensitivity analysis was performed by varying costs. RESULTS: A difference of 24% in cost was found between patients with continued and discontinued imaging follow up. The cost per patient was €1 935 in the continued group vs. €1 603 per patient in the discontinued group at five years post-EVAR, with a mean difference of €332 (95% bias corrected and accelerated bootstrap confidence interval -741 to 114). De-implementation of yearly imaging would result in an annual nationwide cost saving of €678 471. Sensitivity analysis with variation in adherence rates, imaging, or secondary intervention costs resulted in a saving of at least €271 388 per year. CONCLUSION: This study provided an in depth analysis of hospital costs for post-EVAR patients in the Netherlands with a modest impact on the Dutch healthcare budget.

Objective: This study demonstrates intravascular micro-agent visualization by utilizing robotic ultrasound-based tracking and visual servoing in clinically-relevant scenarios. Methods: Visual servoing path is planned intraoperatively using a body surface point cloud acquired with a 3D camera and the vessel reconstructed from ultrasound (US) images, where both the camera and the US probe are attached to the robot end-effector. Developed machine vision algorithms are used for detection of micro-agents from minimal size of 250μm inside the vessel contour and tracking with error recovery. Finally, real-time positions of the micro-agents are used for servoing of the robot with the attached US probe. Constant contact between the US probe and the surface of the body is accomplished by means of impedance control. Results: Developed algorithms are tested in clinically relevant scenarios which include anthropomorphic phantom, biological tissue, simulation of physiological movement and simulation of fluid flow through the vessels. Breathing motion is compensated to keep constant contact between the US probe and the body surface, with minimal measured force of 2.02N. Anthropomorphic phantom vessels are segmented with an Intersection-Over-Union (IOU) score of 0.93±0.05, while micro-agent tracking is performed with up to 99.8% success rate at 28-36 frames per second. Path planning, tracking and visual servoing are realized over 80mm and 120mm long surface paths. Conclusion: Experiments performed using anthropomorphic surfaces, biological tissue, simulation of physiological movement and simulation of fluid flow through the vessels indicate that robust visualization and tracking of micro-agents involving human patients is an achievable goal.

During the COVID-19 pandemic, a 13.6 per cent reduction in the number of surgical procedures performed was observed in 2020. Despite great pressure on healthcare, the COVID-19 pandemic did not cause an increase in adverse surgical outcomes, and oncological surgery-related duration of hospital and ICU stay were significantly shorter.Background The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands. Methods A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates. Results Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001). Conclusion The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.Lay Summary COVID-19 has had a significant impact on healthcare worldwide. Hospital visits were reduced, operating facilities were used for COVID-19 care, and cancer screening programmes were cancelled. This study describes the impact of the COVID-19 pandemic on Dutch surgical healthcare in 2020. Patterns of care in terms of changed or delayed treatment are described for patients who had surgery in 2020, compared with those who had surgery in 2018-2019. The study found that mainly non-cancer surgical treatments were cancelled during months with high COVID-19 rates. Outcomes for patients undergoing surgery were similar but with fewer ICU admissions and shorter hospital stay. These data provide no insight into the burden endured by patients who had postponed or cancelled operations.

Establishing the predictive value of neck characteristics and real achieved sealing zone is essential to foster risk stratified procedure selection and imaging surveillance. This systematic review provides an overview of pre-operative aortic neck characteristics and post-operative real achieved sealing zone and their respective risk of type 1a endoleak and migration after endovascular aneurysm repair (EVAR).In agreement with PRISMA guidelines, MEDLINE, Embase, and Cochrane CENTRAL were searched. Data on neck characteristics, sealing zone, and EVAR outcome were extracted. Meta-analyses were performed to investigate the effect of neck diameter, angulation, and shape on type 1a endoleak (total, early ≤ 90 days, and late90 days) and migration in patients who underwent EVAR. A qualitative summary was also provided.Thirty-three studies were included. Patients with a larger neck diameter had an increased risk of total type 1a endoleak (nine studies: OR 3.32, 95% CI 2.38 - 4.63), early type 1a endoleak (six studies: OR 2.64, 95% CI 1.27 - 5.48), late type 1a endoleak (six studies: OR 3.26, 95% CI 2.12 - 5.03), and migration (seven studies: OR 2.88, 95% CI 1.32 - 6.26). An angulated neck increased the risk of total type 1a endoleak (seven studies: OR 4.27, 95% CI 1.55 - 11.78) and late type 1a endoleak (seven studies: OR 5.56, 95% CI 2.19 - 14.13). Neck shape was not associated with type 1a endoleak. Neck length and real achieved sealing zone on post-EVAR computed tomography were identified as risk factors for type 1a endoleak and migration through qualitative summary.There seems to be some consistent evidence that aortic neck diameter, angulation, and length are associated with the development of type 1a endoleak or migration. Real achieved sealing zone might be an important addition during follow up. However, a small number of studies, with serious limitations, could be included, and there was considerable variability in reporting patients and outcomes. A proposal for standardisation of aortic and EVAR data in future studies is provided.

Continuum manipulators coupled with magnetic actuation have great potential as steerable instruments for diverse surgical applications. They can be maneuvered inside the human body to reach difficult-to-access surgical sites with contactless actuation. This paper presents a new design of a compliant continuum manipulator of diameter 3 mm and length 70 mm, capable of spatial bending under magnetic actuation. A quasi-static model is developed to estimate the 3D motion of the manipulator. Experiments report an overall mean error in whole shape estimation of the manipulator between the model and the ground truth of 1.7 mm and 4.8 mm, when suspended vertically and horizontally from its base, respectively. Furthermore, fiber Bragg grating (FBG) sensors are integrated with the manipulator to enable shape sensing. Closed-loop control is demonstrated to trace different trajectories with the tip of the manipulator. A square trajectory and a straight line trajectory are generated with an average error in tip position of 4.1 mm between the desired and estimated positions. The potential of the manipulator as a steerable instrument is validated by maneuvering it inside phantoms of a bifurcating arterial system and a heart with visual guidance from a miniature camera.

The ability to edit an image using intuitive commands and primitives is a desired feature for any image editing software. In this paper, we combine recent results in medial axes with the well-established morphological tree representations to develop an interactive image editing tool that provides global and local image manipulation using high-level primitives. We propose a new way to render interactive morphological trees using icicle plots and introduce different ways of manipulating spline-based medial axis transforms for grayscale and colored image editing. Different applications of the tool, such as watermark removal, image deformation, dataset augmentation for machine learning, artistic illumination manipulation, image rearrangement, and clothing design, are described and showcased on examples.

PURPOSE: Upper extremity access (UEA) for antegrade cannulation of aortic side branches is a relevant part of endovascular treatment of complex aortic aneurysms and can be achieved using several techniques, sites, and sides. The purpose of this study was to evaluate different UEA strategies in a multicenter registry of complex endovascular aortic aneurysm repair (EVAR).METHODS: In six aortic centers in the Netherlands, all endovascular aortic procedures from 2006 to 2019 were retrospectively reviewed. Patients who received UEA during complex EVAR were included. The primary outcome was a composite end point of any access complication, excluding minor hematomas. Secondary outcomes were access characteristics, access complications considered individually, access reinterventions, and incidence of ischemic cerebrovascular events.RESULTS: A total of 417 patients underwent 437 UEA for 303 fenestrated/branched EVARs and 114 chimney EVARs. Twenty patients had bilateral, 295 left-sided, and 102 right-sided UEA. A total of 413 approaches were performed surgically and 24 percutaneously. Distal brachial access (DBA) was used in 89 cases, medial brachial access (MBA) in 149, proximal brachial access (PBA) in 140, and axillary access (AA) in 59 cases. No significant differences regarding the composite end point of access complications were seen (DBA: 11.3% vs MBA: 6.7% vs PBA: 13.6% vs AA: 10.2%; P = .29). Postoperative neuropathy occurred most after PBA (DBA: 1.1% vs MBA: 1.3% vs PBA: 9.3% vs AA: 5.1%; P = .003). There were no differences in cerebrovascular complications between access sides (right: 5.9% vs left: 4.1% vs bilateral: 5%; P = .75). Significantly more overall access complications were seen after a percutaneous approach (29.2% vs 6.8%; P = .002). In multivariate analysis, the risk for access complications after an open approach was decreased by male sex (odds ratio [OR]: 0.27; 95% confidence interval [CI]: 0.10-0.72; P = .009), whereas an increase in age per year (OR: 1.08; 95% CI: 1.004-1.179; P = .039) and diabetes mellitus type 2 (OR: 3.70; 95% CI: 1.20-11.41; P = .023) increased the risk.CONCLUSIONS: Between the four access localizations, there were no differences in overall access complications. Female sex, diabetes mellitus type 2, and aging increased the risk for access complications after a surgical approach. Furthermore, a percutaneous UEA resulted in higher complication rates than a surgical approach.

Background This study aimed to compare laparoscopic lavage and sigmoidectomy as treatment for perforated diverticulitis with purulent peritonitis during a 36 month follow-up of the LOLA trial. Methods Within the LOLA arm of the international, multicentre LADIES trial, patients with perforated diverticulitis with purulent peritonitis were randomised between laparoscopic lavage and sigmoidectomy. Outcomes were collected up to 36 months. The primary outcome of the present study was cumulative morbidity and mortality. Secondary outcomes included reoperations (including stoma reversals), stoma rates, and sigmoidectomy rates in the lavage group. Results Long-term follow-up was recorded in 77 of the 88 originally included patients, 39 were randomised to sigmoidectomy (51%) and 38 to laparoscopic lavage (49%). After 36 months, overall cumulative morbidity (sigmoidectomy 28/39 (72%) versus lavage 32/38 (84%), p = 0·272) and mortality (sigmoidectomy 7/39 (18%) versus lavage 6/38 (16%), p = 1·000) did not differ. The number of patients who underwent a reoperation was significantly lower for lavage compared to sigmoidectomy (sigmoidectomy 27/39 (69%) versus lavage 17/38 (45%), p = 0·039). After 36 months, patients alive with stoma in situ was lower in the lavage group (proportion calculated from the Kaplan–Meier life table, sigmoidectomy 17% vs lavage 11%, log-rank p = 0·0268). Eventually, 17 of 38 (45%) patients allocated to lavage underwent sigmoidectomy. Conclusion Long-term outcomes showed that laparoscopic lavage was associated with less patients who underwent reoperations and lower stoma rates in patients alive after 36 months compared to sigmoidectomy. No differences were found in terms of cumulative morbidity or mortality. Patient selection should be improved to reduce risk for short-term complications after which lavage could still be a valuable treatment option. Graphical abstract

We propose USTNet, a novel deep learning approach designed for learning shape-to-shape translation from unpaired domains in an unsupervised manner. The core of our approach lies in disentangled representation learning that factors out the discriminative features of 3D shapes into content and style codes. Given input shapes from multiple domains, USTNet disentangles their representation into style codes that contain distinctive traits across domains and content codes that contain domaininvariant traits. By fusing the style and content codes of the target and source shapes, our method enables us to synthesize new shapes that resemble the target style and retain the content features of source shapes. Based on the shared style space, our method facilitates shape interpolation by manipulating the style attributes from different domains. Furthermore, by extending the basic building blocks of our network from two-class to multi-class classification, we adapt USTNet to tackle multi-domain shape-to-shape translation. Experimental results show that our approach can generate realistic and natural translated shapes and that our method leads to improved quantitative evaluation metric results compared to 3DSNet. Codes are available at https://Haoran226.github.io/USTNet.

Knowledge about anatomical shape variations in the pelvis is mandatory for selection, fitting, positioning, and fixation in pelvic surgery. The current knowledge on pelvic shape variation mostly relies on point-to-point measurements on 2D X-ray images and computed tomography (CT) slices. Three-dimensional region-specific assessments of pelvic morphology are scarce. Our aim was to develop a statistical shape model of the hemipelvis to assess anatomical shape variations in the hemipelvis. CT scans of 200 patients (100 male and 100 female) were used to obtain segmentations. An iterative closest point algorithm was performed to register these 3D segmentations, so a principal component analysis (PCA) could be performed, and a statistical shape model (SSM) of the hemipelvis was developed. The first 15 principal components (PCs) described 90% of the total shape variation, and the reconstruction ability of this SSM resulted in a root mean square error of 1.58 (95% CI: 1.53–1.63) mm. In summary, an SSM of the hemipelvis was developed, which describes the shape variations in a Caucasian population and is able to reconstruct an aberrant hemipelvis. Principal component analyses demonstrated that, in a general population, anatomical shape variations were mostly related to differences in the size of the pelvis (e.g., PC1 describes 68% of the total shape variation, which is attributed to size). Differences between the male and female pelvis were most pronounced in the iliac wing and pubic rami regions. These regions are often subject to injuries. Future clinical applications of our newly developed SSM may be relevant for SSM-based semi-automatic virtual reconstruction of a fractured hemipelvis as part of preoperative planning. Lastly, for companies, using our SSM might be interesting in order to assess which sizes of pelvic implants should be produced to provide proper-fitting implants for most of the population.

We present a dynamical modeling of integrated (end-to-end) container terminal operations using finite state machine (FSM) framework where each state machine is represented by a discrete-event system (DES) formulation. The hybrid model incorporates the operations of quay cranes (QC), internal trucks (IT), and yard cranes (YC) and also the selection of storage positions in container yard (CY) and vessel bays. The QC and YC are connected by the IT in our models. As opposed to the commonly adapted modeling in container terminal operations, in which the entire information/inputs to the systems are known for a defined planning horizon, in this research we use real-time trucks, crane, and container storage operations information, which are always updated as the time evolves. The dynamical model shows that the predicted state variables closely follow the actual field data from a container terminal in Tanjung Priuk, Jakarta, Indonesia. Subsequently, using the integrated container terminal hybrid model, we proposed a model predictive algorithm (MPA) to obtain the near-optimal solution of the integrated terminal operations problem, namely the simultaneous allocation and scheduling of QC, IT, and YC, as well as selecting the storage location for the inbound and outbound containers in the CY and vessel. The numerical experiment based on the extensive Monte Carlo simulation and real dataset show that the MPA outperforms by 3-6% both of the policies currently implemented by the terminal operator and the state-of-the-art method from the current literature.

While it is widely used to represent hysteresis phenomena with unidirectional-oriented loops, we study in this article the use of Preisach operator for describing hysteresis behavior with multidirectional-oriented loops. This complex hysteresis behavior is commonly found in advanced materials, such as, shape-memory alloys or piezoelectric materials, that are used for high-precision sensor and actuator systems. We provide characterization of the Preisach operators exhibiting such input-output behaviors and we show the richness of the operators that are capable of producing intricate loops.

In recent decades, surgery for rectal cancer has evolved from an operation normally performed under poor vision with a lot of blood loss, relatively high morbidity, and mortality to a safer operation. Currently, minimally invasive rectal procedures are performed with limited blood loss, reduced morbidity, and minimal mortality. The main cause is better knowledge of anatomy and adhering to the principle of operating along embryological planes. Surgery has become surgery of compartments, more so than that of organs. So, rectal cancer surgery has evolved to mesorectal cancer surgery as propagated by Heald and others. The focus on the mesentery of the rectum has led to renewed attention to the anatomy of the fascia surrounding the rectum. Better magnification during laparoscopy and improved optimal three-dimensional (3D) vision during robot-assisted surgery have contributed to the refinement of total mesorectal excision (TME). In this chapter, we describe how to perform a robot-assisted TME with particular attention to the mesentery. Specific points of focus and problem solving are discussed.

Purpose Evidence regarding local recurrence rates in the initial cases after implementation of robot-assisted total mesorectal excision is limited. This study aims to describe local recurrence rates in four large Dutch centres during their initial cases. Methods Four large Dutch centres started with the implementation of robot-assisted total mesorectal excision in respectively 2011, 2012, 2015, and 2016. Patients who underwent robot-assisted total mesorectal excision with curative intent in an elective setting for rectal carcinoma defined according to the sigmoid take-off were included. Overall survival, disease-free survival, systemic recurrence, and local recurrence were assessed at 3 years postoperatively. Subsequently, outcomes between the initial 10 cases, cases 11–40, and the subsequent cases per surgeon were compared using Cox regression analysis. Results In total, 531 patients were included. Median follow-up time was 32 months (IQR: 19–50]. During the initial 10 cases, overall survival was 89.5%, disease-free survival was 73.1%, and local recurrence was 4.9%. During cases 11–40, this was 87.7%, 74.1%, and 6.6% respectively. Multivariable Cox regression did not reveal differences in local recurrence between the different case groups. Conclusion Local recurrence rate during the initial phases of implantation of robot-assisted total mesorectal procedures is low. Implementation of the robot-assisted technique can safely be performed, without additional cases of local recurrence during the initial cases, if performed by surgeons experienced in laparoscopic rectal cancer surgery.

We propose the use of curved triangles and mesh colours as a vector primitive for image vectorisation. We show that our representation has clear benefits for rendering performance, texture detail, as well as further editing of the resulting vector images. The proposed method focuses on efficiency, but it still leads to results that compare favourably with those from previous work. We show results over a variety of input images ranging from photos, drawings, paintings, all the way to designs and cartoons. We implemented several editing workflows facilitated by our representation: interactive user-guided vectorisation, and novel raster-style feature-aware brushing capabilities.

Arterial stenosis is a high-risk disease accompanied by large amounts of calcified deposits and plaques that develop inside the vasculature. These deposits should be reduced to improve blood flow. However, current methods used to reduce stenosis require externally-controlled actuation systems resulting in limited workspace or patient risks. This results in an unexplored preference regarding the revascularization strategy for symptomatic artery stenosis. In this paper, we propose a novel internally-actuated solution: a magnetic spring-loaded rotablation catheter. The catheter is developed to achieve stenosis-debulking capabilities by actuating drill bits using two internal electromagnetic coils and a magnetic reciprocating spring-loaded shaft. The state-space model of the catheter is validated by comparing the simulation results of the magnetic fields of the internal coils with the experimental results of a fabricated prototype. Contact forces of the catheter tip are measured experimentally, resulting in a maximum axial force of 2.63 N and a torque of 5.69 mN-m. Finally, we present interventions in which the catheter is inserted to a vascular target site and demonstrate plaque-specific treatment using different detachable actuator bits. Calcified deposits are debulked and visualized via ultrasound imaging. The catheter can reduce a stenosis cross-sectional area by up to 35%, indicating the potential for the treatment of calcified lesions, which could prevent restenosis.

Objective: It has been suggested that covered stents (CS) may lower restenosis rates compared with bare metal stents (BMS) after endovascular treatment of the common iliac artery. This trial aimed to provide additional evidence on the efficacy of CS vs. BMS in the common iliac artery. Methods: This multicentre, randomised, single blind controlled superiority trial compared balloon expandable CS and balloon expandable BMS for advanced atherosclerotic lesions in the common iliac artery; this was defined as a stenosis > 3 cm in length or occlusion. The primary end point was freedom from binary restenosis after two years of follow up. The study was conducted according to the principles of the Declaration of Helsinki (version: October 2008) and registered with the Dutch Trial register (NTR3381). Results: One hundred and seventy-four limbs were included between 2012 and 2019 with 87 limbs in each group. Six patients crossed over from the BMS group to the CS group but were analysed according to an intention to treat principle. Freedom from binary restenosis after two years of follow up was 84.7% (95% CI 76.7 – 92.7%) in the BMS group and 89.1% (95% CI 82.4 – 95.8%) in the CS group (p = .40). Freedom from occlusion was 95.0% (95% CI 90.3 – 95.7%) in the BMS group and 96.4% (95% CI 92.5 – 100%) in the CS group (p = .66). Freedom from target lesion revascularisation was 91.1% (95% CI 84.8 – 97.3%) and 95.2% (95% CI 90.7 –99.7%), respectively (p = .31). Technical success, complications, haemodynamic success, and clinical success were also comparable between both groups. Per-protocol analysis did not affect the outcomes of the study. Conclusion: No difference was found between balloon expandable CS and BMS for treating advanced atherosclerotic lesions of the common iliac artery.

Listening to familiar voices might improve intelligibility of target speech in multiple-talker situations. In addition to personally familiar voices, voice training—through implicit exposure or explicit learning of a previously unheard voice—can improve speech intelligibility. However, there is no consensus on which method is more effective. We investigated the effect of explicit and implicit voice training on speech-on-speech perception and listening effort (pupillometry), among normal hearing listeners. There was no significant difference in speech intelligibility performance between trained and untrained voices, with either voice training method. However, an interaction between voice training method and target-to-masker ratio (TMR) on accuracy scores showed that the benefit of increased TMR on accuracy scores was significantly larger when voice training was implicit compared to explicit. Pupillometry results showed that explicit voice training significantly reduced listening effort for most disadvantageous TMR (−6dB), but not for more advantageous TMRs (0 and + 6 dB), and not for implicitly trained voices. Our results may imply that explicit voice training is more effective than implicit voice training in reducing listening effort. Still, implicit voice training, perhaps via procedural learning, might be more beneficial on the performance level when TMR becomes more advantageous.

Magnetic actuation of minimally invasive medical tetherless devices holds great promise in several biomedical applications. However, there are still several challenges in noninvasive localization, both in terms of sensing detectable signals of these devices and estimating their states. In this work, a magnetic milli-roller is actuated in a viscous fluid under the influence of a rotating magnetic field. A Lyapunov-based nonlinear state observer is designed and implemented to estimate the position of the roller using a 2D array of Hall-effect sensors. We show that the local stability of the state observer yields convergence to one of the local equilibria, for pre-defined levels of sensor noise, initial conditions, and modeling errors. Performance is quantified using redundant measurements of the fields and we investigate the influence of the number of magnetic field measurements on the observability of the system. Open-loop actuation and state estimation are demonstrated and experimental results show that the localization of a 5 mm diameter roller along sinusoidal, circular and square trajectories achieve a steady-state mean absolute position error of 2.3mm, 1.67mm and 1.73mm, respectively.

Magnetically-actuated soft robots have potential for medical application but require further innovation on functionality and biocompatibility. In this letter, a multi-segmented snake-inspired soft robot with dissolvable and hiocompatible segments is designed. The actuation response under external magnetic field is investigated through simulations and experiments. A dissolve-controllable mixture of gelatin, glycerol and water (GGW) in a mass ratio of 1:5:6 is used to form the structure of the robot. The dissolution of GGW in water and mucus is tested. Magnetic cubes made of silicone rubber mixed with ferromagnetic particles are used to achieve snake-like motion under the influence of a rotating magnetic field. The motion of the robot is tested under different magnitudes and frequencies of the magnetic field. The ability of the robot to navigate obstacles, move over ground and under water as well as on the oil-coated surface, dissolve and release a drug is demonstrated through experiments. The combination of multi-segmented design and biocompatible and dissolvable materials illustrates the potential of such robots for medical applications.

Purpose Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but potentially lethal. Although the number of reports has increased over the past two decades, the true incidence and contemporary urologists’ experience and approach in clinical practice remains unknown. This research is conducted to provide insight in the incidence of AUF in The Netherlands, and the applied diagnostic tests and therapeutic approaches in modern practice. Methods A nationwide cross-sectional questionnaire analysis was performed by sending a survey to all registered Dutch urologists. Data collection included information on experience with patients with AUF; and their medical history, diagnostics, treatment, and follow-up, and were captured in a standardized template by two independent reviewers. Descriptive statistics were used. Results Response rate was 62% and 56 AUFs in 53 patients were reported between 2003 and 2018. The estimated incidence of AUF in The Netherlands in this time period is 3.5 AUFs per year. Hematuria was observed in all patients; 9% intermittent microhematuria, and 91% presenting with, or building up to massive hematuria. For the final diagnosis, angiography was the most efficient modality, confirming diagnosis in 58%. Treatment comprised predominantly endovascular intervention. Conclusion The diagnosis AUF should be considered in patients with persistent intermittent or massive hematuria.

Background Laparoscopic, robot-assisted, and transanal total mesorectal excision are the minimally invasive techniques used most for rectal cancer surgery. Because data regarding oncologic results are lacking, this study aimed to compare these three techniques while taking the learning curve into account. Methods This retrospective population-based study cohort included all patients between 2015 and 2017 who underwent a low anterior resection at 11 dedicated centers that had completed the learning curve of the specific technique. The primary outcome was overall survival (OS) during a 3-year follow-up period. The secondary outcomes were 3-year disease-free survival (DFS) and 3-year local recurrence rate. Statistical analysis was performed using Cox-regression. Results The 617 patients enrolled in the study included 252 who underwent a laparoscopic resection, 205 who underwent a robot-assisted resection, and 160 who underwent a transanal low anterior resection. The oncologic outcomes were equal between the three techniques. The 3-year OS rate was 90% for laparoscopic resection, 90.4% for robot-assisted resection, and 87.6% for transanal low anterior resection. The 3-year DFS rate was 77.8% for laparoscopic resection, 75.8% for robot-assisted resection, and 78.8% for transanal low anterior resection. The 3-year local recurrence rate was in 6.1% for laparoscopic resection, 6.4% for robot-assisted resection, and 5.7% for transanal procedures. Cox-regression did not show a significant difference between the techniques while taking confounders into account. Conclusion The oncologic results during the 3-year follow-up were good and comparable between laparoscopic, robot-assisted, and transanal total mesorectal technique at experienced centers. These techniques can be performed safely in experienced hands.

Purpose: Dose-escalated chemoradiation (CRT) for locally advanced rectal cancer did not result in higher complete response rates but initiated more tumor regression in the randomized RECTAL-BOOST trial (Clinicaltrials.gov NCT01951521). This study compared patient reported outcomes between patients who received dose-escalated CRT (5 × 3 gray boost + CRT) or standard CRT for 2 years after randomization.Methods and Materials: Patients with locally advanced rectal cancer who were participating in the RECTAL-BOOST trial filled out European Organisation for Research and Treatment of Cancer QLQ-C30 and CR29 questionnaires on quality of life (QoL) and symptoms at baseline, 3, 6, 12, 18, and 24 months after start of treatment. Between-group differences in functional QoL domains were estimated using a linear mixed-effects model and expressed as effect size (ES). Symptom scores were compared using Mann-Whitney U test.Results: Patients treated with dose–escalated CRT (boost group, n = 51) experienced a significantly stronger decline in global health at 3 and 6 months (ES –0.4 and ES –0.4), physical functioning at 6 months (ES –1.1), role functioning at 3 and 6 months (ES –0.8 and ES –0.6), and social functioning at 6 months (ES –0.6), compared with patients treated with standard CRT (control group, n = 64). The boost group reported significantly more fatigue at 3 and 6 months (83% vs 66% respectively 89% vs 76%), pain at 3 and 6 months (67% vs 36% respectively 80% vs 44%), and diarrhea at 3 months (45% vs 29%) compared with the control group. From 12 months onwards, QoL and symptoms were similar between groups, apart from more blood/mucus in stool in the boost group.Conclusions: In patients with locally advanced rectal cancer, dose-escalated CRT resulted in a transient deterioration in global health, physical, role, and social functioning and more pain, fatigue and diarrhea at 3 and 6 months after start of treatment compared with standard CRT. From 12 months onwards, the effect of dose-escalated CRT on QoL largely resolved.

Gradient meshes, an advanced vector graphics primitive, are widely used by designers for creating scalable vector graphics. Traditional variants require a regular rectangular topology, which is a severe design restriction. The more advanced subdivision gradient mesh allows for an arbitrary manifold topology and is based on subdivision techniques to define the resulting colour surface. This also allows the artists to manipulate the geometry and colours at various levels of subdivision. Recent advances allow for the interpolation of both geometry and colour, local detail following edits at coarser subdivision levels and sharp colour transitions. A shortcoming of all existing methods is their dependence on global refinement, which makes them unsuitable for real-time (commercial) design applications. We present a novel method that incorporates the idea of feature-adaptive subdivision and uses approximating patches suitable for hardware tessellation with real-time performance. Further novel features include multiple interaction mechanisms and self-intersection prevention during interactive design/editing.

Introduction: Type III endoleaks post-endovascular aortic aneurysm repair (EVAR) warrant treatment because they increase pressure within the aneurysm sac leading to increased rupture risk. The treatment may be difficult with regular endovascular devices. Endovascular aneurysm sealing (EVAS) might provide a treatment option for type III endoleaks, especially if located near the flow divider. This study aims to analyze clinical outcomes of EVAS for type III endoleaks after EVAR. Methods: This is an international, retrospective, observational cohort study including data from 8 European institutions. Results: A total of 20 patients were identified of which 80% had a type IIIb endoleak and the remainder (20%) a type IIIa endoleak. The median time between EVAR and EVAS was 49.5 months (28.5–89). Mean AAA diameter prior to EVAS revision was 76.6±19.9 mm. Technical success was achieved in 95%, 1 patient had technical failure due to a postoperative myocardial infarction resulting in death. Mean follow-up was 22.8±15.2 months. During follow-up 1 patient had a type Ia endoleak, and 1 patient had a new type IIIa endoleak at an untreated location. There were 5 patients with aneurysm growth. Five patients underwent AAA-related reinterventions indications being: growth with type II endoleak (n=3), type Ia endoleak (n=1), and iliac aneurysm (n=1). At 1-year follow-up, the freedom from clinical failure was 77.5%, freedom from all-cause mortality 94.7%, freedom from aneurysm-related mortality 95%, and freedom from aneurysm-related reinterventions 93.8%. Conclusion: The EVAS relining can be safely performed to treat type III endoleaks with an acceptable technical success rate, a low 30-day mortality rate and no secondary ruptures at short-term follow-up. The relatively low clinical success rates, related to reinterventions and AAA enlargement, highlight the need for prolonged follow-up.

We present the design and experimental validation of source seeking control algorithms for a unicycle mobile robot that is equipped with novel 3D-printed flexible graphene-based piezoresistive airflow sensors. Based solely on a local gradient measurement from the airflow sensors, we propose and analyze a projected gradient ascent algorithm to solve the source seeking problem. In the case of partial sensor failure, we propose a combination of Extremum-Seeking Control with our projected gradient ascent algorithm. For both control laws, we prove the asymptotic convergence of the robot to the source. Numerical simulations were performed to validate the algorithms and experimental validations are presented to demonstrate the efficacy of the proposed methods., Published in IEEE Transactions on Robotics

We present three classes of distributed formation controllers for achieving and maintaining the 2D/3D formation shape of manipulator end-effectors to cope with different scenarios due to availability of modeling parameters. We firstly present a distributed formation controller for manipulators whose system parameters are perfectly known. The formation control objective is achieved by assigning virtual springs between end-effectors and by adding damping terms at joints, which provides a clear physical interpretation of the proposed solution. Subsequently, we extend it to the case where manipulator kinematic and system parameters are not exactly known. An extra integrator and an adaptive estimator are introduced for gravitational compensation and stabilization, respectively. Simulation results with planar manipulators and with seven degree-of-freedom humanoid manipulator arms are presented to illustrate the effectiveness of the proposed approach., Comment: arXiv admin note: text overlap with arXiv:2103.14595

Background: Telemonitoring during the perioperative trajectory may improve patient outcomes and self-management. The aim of this study is to assess the feasibility of and patient’s experiences with telemonitoring before and after major abdominal surgery to inform future study design.Methods: Patients planned for elective major abdominal surgery wore a sensor and answered well-being questions on a tablet daily for at least 2 weeks preoperatively up to 30-days postoperatively. Feasibility was assessed by participation and completion rate, compliance per day, weekly satisfaction scores, and reasons for nonscheduled contact.Results: Twenty-three patients were included (participation rate of 54.5%) with a completion rate of 69.6%. Median compliance with the wearable sensor and well-being questions was respectively: 94.7% and 83.3% preoperatively at home; 100% and 66.7% postoperatively in-hospital; and 95.4% and 85.8% postoperatively at home. Median weekly satisfaction scores for both wearing the sensor and well-being questions were 5 (IQR, 4–5). Contact moments were related to absence of sensor data and technological issues (76.0%) or patient discomfort and insecurity (24.0%).Conclusions: In this study, telemonitoring showed high satisfaction and compliance during the perioperative trajectory. Future trial design regarding the effectiveness of telemonitoring requires embedding in clinical practice and support for patients, relatives, and healthcare personnel.

Medial descriptors have attracted increasing interest in image representation, simplification, and compression. Recently, such descriptors have been separately used to (a) increase the local quality of representing salient features in an image and (b) globally compress an entire image via a B-spline encoding. To date, the two desiderates, (a) high local quality and (b) high overall compression of images, have not been addressed by a single medial method. We achieve this integration by presenting Spatial Saliency Spline Dense Medial Descriptors (3S-DMD) for saliency-aware image simplification-and-compression. Our method significantly improves the trade-off between compression and image quality of earlier medial-based methods while keeping perceptually salient features. We also demonstrate the added-value of user-designed, as compared to automatically-computed, saliency maps. We show that our method achieves both higher compression and better quality than JPEG for a broad range of images and, for specific image types, yields higher compression and similar quality than JPEG 2000.

Objectives: Understanding speech in real life can be challenging and effortful, such as in multiple-talker listening conditions. Fundamental frequency (fo) and vocal-tract length (vtl) voice cues can help listeners segregate between talkers, enhancing speech perception in adverse listening conditions. Previous research showed lower sensitivity to fo and vtl voice cues when speech signal was degraded, such as in cochlear implant hearing and vocoder-listening compared to normal hearing, likely contributing to difficulties in understanding speech in adverse listening. Nevertheless, when multiple talkers are present, familiarity with a talker’s voice, via training or exposure, could provide a speech intelligibility benefit. In this study, the objective was to assess how an implicit short-term voice training could affect perceptual discrimination of voice cues (fo+vtl), measured in sensitivity and listening effort, with or without vocoder degradations.Design: Voice training was provided via listening to a recording of a book segment for approximately 30 min, and answering text-related questions, to ensure engagement. Just-noticeable differences (JNDs) for fo+vtl were measured with an odd-one-out task implemented as a 3-alternative forced-choice adaptive paradigm, while simultaneously collecting pupil data. The reference voice either belonged to the trained voice or an untrained voice. Effects of voice training (trained and untrained voice), vocoding (non-vocoded and vocoded), and item variability (fixed or variable consonant-vowel triplets presented across three items) on voice cue sensitivity (fo+vtl JNDs) and listening effort (pupillometry measurements) were analyzed.Results: Results showed that voice training did not have a significant effect on voice cue discrimination. As expected, fo+vtl JNDs were significantly larger for vocoded conditions than for non-vocoded conditions and with variable item presentations than fixed item presentations. Generalized additive mixed models analysis of pupil dilation over the time course of stimulus presentation showed that pupil dilation was significantly larger during fo+vtl discrimination while listening to untrained voices compared to trained voices, but only for vocoder-degraded speech. Peak pupil dilation was significantly larger for vocoded conditions compared to non-vocoded conditions and variable items increased the pupil baseline relative to fixed items, which could suggest a higher anticipated task difficulty.Conclusions: In this study, even though short voice training did not lead to improved sensitivity to small fo+vtl voice cue differences at the discrimination threshold level, voice training still resulted in reduced listening effort for discrimination among vocoded voice cues.

Various locomotion strategies employed by microorganisms are observed in complex biological environments. Spermatozoa assemble into bundles to improve their swimming efficiency compared to individual cells. However, the dynamic mechanisms for the formation of sperm bundles have not been fully characterized. In this study, we numerically and experimentally investigate the locomotion of spermatozoa during the transition from individual cells to bundles of two cells. Three consecutive dynamic behaviors are found across the course of the transition: hydrodynamic attraction/repulsion, alignment, and synchronization. The hydrodynamic attraction/repulsion depends on the relative orientation and distance between spermatozoa as well as their flagellar wave patterns and phase shift. Once the heads are attached, we find a stable equilibrium of the rotational hydrodynamics resulting in the alignment of the heads. The synchronization results from the combined influence of hydrodynamic and mechanical cell-to-cell interactions. Additionally, we find that the flagellar beat is regulated by the interactions during the bundle formation, whereby spermatozoa can synchronize their beats to enhance their swimming velocity.

Background The role of diverting ileostomy in total mesorectal excision (TME) for rectal cancer with primary anastomosis is debated. The aim of this study is to gain insight in the clinical consequences of a diverting ileostomy, with respect to stoma rate at one year and stoma-related morbidity. Methods Patients undergoing TME with primary anastomosis for rectal cancer between 2015 and 2017 in eleven participating hospitals were included. Retrospectively, two groups were compared: patients with or without diverting ileostomy construction during primary surgery. Primary endpoint was stoma rate at one year. Secondary endpoints were severity and rate of anastomotic leakage, overall morbidity rate within thirty days and stoma (reversal) related morbidity. Results In 353 out of 595 patients (59.3%) a diverting ileostomy was constructed during primary surgery. Stoma rate at one year was 9.9% in the non-ileostomy group and 18.7% in the ileostomy group (p = 0.003). After correction for confounders, multivariate analysis showed that the construction of a diverting ileostomy during primary surgery was an independent risk factor for stoma at one year (OR 2.563 (95%CI 1.424–4.611), p = 0.002). Anastomotic leakage rate was 17.8% in the non-ileostomy group and 17.2% in the ileostomy group (p = 0.913). Overall 30-days morbidity rate was 37.6% in the non-ileostomy group and 56.1% in the ileostomy group (p Conclusions The stoma rate at one year was higher in patients with ileostomy construction during primary surgery. The incidence and severity of anastomotic leakage were not reduced by construction of an ileostomy. The morbidity related to the presence and reversal of a diverting ileostomy was substantial.

To systematically review literature on nutritional intake, nutritional status and nutritional interventions, and to study their association with short- and long-term clinical outcomes in people with a major dysvascular lower limb amputation. PubMed, Ovid, CINAHL, and The Cochrane Library were searched. Studies were included if nutritional intake, nutritional status, or nutritional interventions in people with a major dysvascular lower limb amputation were analyzed. Of the 3038 unique papers identified, 30 studies were included. Methodological quality was moderate (1 study) or weak (29 studies). Limited information was available on nutritional intake (2 studies) and nutritional interventions (1 study). Nutritional intake and nutritional status were assessed by diverse methods. The percentage of people with a poor nutritional status ranged from 1% to 100%. In some studies, measures of poor nutritional status were associated with adverse short- and long-term clinical outcomes. The percentage of people with a poor nutritional status is inconclusive in the major dysvascular lower limb amputation population, because of the heterogeneity of the assessment methods used. Some included studies reported a negative association between poor nutritional status and clinical outcomes. However, these results should be interpreted with caution, because of the limited quality of the studies available. Studies high in methodological quality and high in hierarchy of evidence are needed.IMPLICATIONS FOR REHABILITATIONThe proportion of people with a poor nutritional status in the major dysvascular lower limb amputation population is inconclusive.Poor nutritional status seems to affect clinical outcomes negatively.More uniformity in assessment of malnutrition in the major dysvascular lower limb amputation population is needed. The proportion of people with a poor nutritional status in the major dysvascular lower limb amputation population is inconclusive. Poor nutritional status seems to affect clinical outcomes negatively. More uniformity in assessment of malnutrition in the major dysvascular lower limb amputation population is needed.

Purpose Currently used classification systems and measurement methods are insufficient to assess fracture displacement. In this study, a novel 3D measure for fracture displacement is introduced and associated with risk on conversion to total knee arthroplasty (TKA). Methods A multicenter cross-sectional study was performed including 997 patients treated for a tibial plateau fracture between 2003 and 2018. All patients were contacted for follow-up and 534 (54%) responded. For all patients, the 3D gap area was determined in order to quantify the degree of initial fracture displacement. A cut-off value was determined using ROC curves. Multivariate analysis was performed to assess the association of 3D gap area with conversion to TKA. Subgroups with increasing levels of 3D gap area were identified, and Kaplan–Meier survival curves were plotted to assess survivorship of the knee free from conversion to TKA. Results A total of 58 (11%) patients underwent conversation to TKA. An initial 3D gap area ≥ 550 mm2 was independently associated with conversion to TKA (HR 8.4; p = 0.001). Four prognostic groups with different ranges of the 3D gap area were identified: excellent (0–150 mm2), good (151–550 mm2), moderate (551–1000 mm2), and poor (> 1000 mm2). Native knee survival at 10-years follow-up was 96%, 95%, 76%, and 59%, respectively, in the excellent, good, moderate, and poor group. Conclusion A novel 3D measurement method was developed to quantify initial fracture displacement of tibial plateau fractures. 3D fracture assessment adds to current classification methods, identifies patients at risk for conversion to TKA at follow-up, and could be used for patient counselling about prognosis. Level of evidence Prognostic Level III.

While previous research investigating music emotion perception of cochlear implant (CI) users observed that temporal cues informing tempo largely convey emotional arousal (relaxing/stimulating), it remains unclear how other properties of the temporal content may contribute to the transmission of arousal features. Moreover, while detailed spectral information related to pitch and harmony in music — often not well perceived by CI users— reportedly conveys emotional valence (positive, negative), it remains unclear how the quality of spectral content contributes to valence perception. Therefore, the current study used vocoders to vary temporal and spectral content of music and tested music emotion categorization (joy, fear, serenity, sadness) in 23 normal-hearing participants. Vocoders were varied with two carriers (sinewave or noise; primarily modulating temporal information), and two filter orders (low or high; primarily modulating spectral information). Results indicated that emotion categorization was above-chance in vocoded excerpts but poorer than in a non-vocoded control condition. Among vocoded conditions, better temporal content (sinewave carriers) improved emotion categorization with a large effect while better spectral content (high filter order) improved it with a small effect. Arousal features were comparably transmitted in non-vocoded and vocoded conditions, indicating that lower temporal content successfully conveyed emotional arousal. Valence feature transmission steeply declined in vocoded conditions, revealing that valence perception was difficult for both lower and higher spectral content. The reliance on arousal information for emotion categorization of vocoded music suggests that efforts to refine temporal cues in the CI user signal may immediately benefit their music emotion perception.

Sperm cells undergo complex interactions with external environments, such as a solid-boundary, fluid flow, as well as other cells before arriving at the fertilization site. The interaction with the oviductal epithelium, as a site of sperm storage, is one type of cell-to-cell interaction that serves as a selection mechanism. Abnormal sperm cells with poor swimming performance, the major cause of male infertility, are filtered out by this selection mechanism. In this study, collinear bundles, consisting of two sperm cells, generate propulsive thrusts along opposite directions and allow to observe the influence of cell-to-cell interaction on flagellar wave-patterns. The developed elasto-hydrodynamic model demonstrates that steric and adhesive forces lead to highly symmetrical wave-pattern and reduce the bending amplitude of the propagating wave. It is measured that the free cells exhibit a mean flagellar curvature of 6.4 +/- 3.5 rad mm(-1) and a bending amplitude of 13.8 +/- 2.8 rad mm(-1). After forming the collinear bundle, the mean flagellar curvature and bending amplitude are decreased to 1.8 +/- 1.1 and 9.6 +/- 1.4 rad mm(-1), respectively. This study presents consistent theoretical and experimental results important for understanding the adaptive behavior of sperm cells to the external time-periodic force encountered during sperm-egg interaction.

In this work, we show the potential of the universal approximation property of neural networks in the design of interconnection and damping assignment passivity-based controllers (IDA-PBC) for stabilizing nonlinear underactuated mechanical systems of degree one. Towards this end, we reformulate the IDA-PBC design methodology as a neural supervised learning problem that approximates the solution of the partial differential matching equations, which fulfills the equilibrium assignment and stability conditions. The output of the neural learning process has clear physical and control-theoretic interpretations in terms of energy, passivity and Lyapunov stability. The proposed approach is numerically evaluated in two well-known underactuated systems: the inverted pendulum on a cart and inertial wheel pendulum, whose analytic IDA-PBC solutions are non-trivial to obtain.

In order to fabricate functional organoids and microtissues, a high cell density is generally required. As such, the placement of cell suspensions in molds or microwells to allow for cell concentration by sedimentation is the current standard for the production of organoids and microtissues. Even though molds offer some level of control over the shape of the resulting microtissue, this control is limited as microtissues tend to compact towards a sphere after sedimentation of the cells. 3D bioprinting on the other hand offers complete control over the shape of the resulting structure. Even though the printing of dense cell suspensions in the ink has been reported, extruding dense cellular suspensions is challenging and generally results in high shear stresses on the cells and a poor shape fidelity of the print. As such, additional materials such as hydrogels are added in the bioink to limit shear stresses, and to improve shape fidelity and resolution. The maximum cell concentration that can be incorporated in a hydrogel-based ink before the ink’s rheological properties are compromised, is significantly lower than the concentration in a tissue equivalent. Additionally, the hydrogel components often interfere with cellular self-assembly processes. To circumvent these limitations, we report a simple and inexpensive xanthan bath based embedded printing method to 3D print dense functional linear tissues using dilute particle suspensions consisting of cells, spheroids, hydrogel beads, or combinations thereof. Using this method, we demonstrated the self-organization of functional cardiac tissue fibers with a layer of epicardial cells surrounding a body of cardiomyocytes.

Objective: The aim of the Endurant for Challenging Anatomy: Global Experience (EAGLE) registry is to evaluate prospectively the technical and clinical success rate of a stentgraft used in patients with challenging neck anatomy outside the instructions for use (IFU) but within objective anatomical limits.Methods: This was a prospective, international, multicentre, observational study. From 1 February 2012 to 1 September 2017, patients with an abdominal aortic aneurysm with a challenging infrarenal neck that were deemed suitable for endovascular aneurysm repair were included prospectively at 23 European centres. Patients were distributed by anatomy into three groups: short neck (SN; infrarenal neck 5 – 10 mm in combination with suprarenal angulation [α] ≤ 45° and infrarenal angulation [β] ≤ 60°); medium neck (MN; infrarenal neck 10 – 15 mm with α ≤ 60° and β 60° – 75° or α 45°– 60° and β ≤ 75°; and long angulated neck (LN; infrarenal neck ≥ 15 mm with α ≤ 75° and β 75°– 90° or α 60°– 75° and β ≤ 90°. All computed tomography scans were reviewed by an independent core laboratory. Primary outcomes were technical and clinical success. Secondary endpoints were peri-operative major adverse events, all cause mortality, aneurysm related mortality, endoleaks, migration, and secondary intervention.Results: One hundred and fifty patients (81.3% male) were included (SN = 55, MN = 16, LN = 79). The median follow up was 36 ± 12.6 months. In the overall cohort, the technical success rate was 93.3%. Estimated freedom from aneurysm related death was 97.3% at three years. Freedom from secondary interventions was 84.7% at three years. Estimated clinical success was 96.0%, 90.8%, and 83.2% at 30 days, one year, and three years, respectively. Estimated freedom from all cause mortality, late type IA endoleak, and migration at three years was 75.1%, 93.7%, and 99.3%, respectively.Conclusion: The early and midterm results of the EAGLE registry show that endovascular repair with the Endurant stentgraft in selected patients with challenging infrarenal neck anatomy yields results in line with large “real world” registries. Long term results are awaited for more definitive conclusions.

We introduce an ML-driven approach that enables interactive example-based queries for similar behavior in ensembles of spatiotemporal scientific data. This addresses an important use case in the visual exploration of simulation and experimental data, where data is often large, unlabeled and has no meaningful similarity measures available. We exploit the fact that nearby locations often exhibit similar behavior and train a Siamese Neural Network in a self-supervised fashion, learning an expressive latent space for spatiotemporal behavior. This space can be used to find similar behavior with just a few user-provided examples. We evaluate this approach on several ensemble datasets and compare with multiple existing methods, showing both qualitative and quantitative results.

Optical microscopy techniques are a popular choice for visualizing micro-agents. They generate images with relatively high spatiotemporal resolution but do not reveal encoded information for distinguishing micro-agents and surroundings. This study presents multicolor fluorescence microscopy for rendering color-coded identification of mobile micro-agents and dynamic surroundings by spectral unmixing. We report multicolor microscopy performance by visualizing the attachment of single and cluster micro-agents to cancer spheroids formed with HeLa cells as a proof-of-concept for targeted drug delivery demonstration. A microfluidic chip is developed to immobilize a single spheroid for the attachment, provide a stable environment for multicolor microscopy, and create a 3D tumor model. In order to confirm that multicolor microscopy is able to visualize micro-agents in vascularized environments, in vitro vasculature network formed with endothelial cells and ex ovo chicken chorioallantoic membrane are employed as experimental models. Full visualization of our models is achieved by sequential excitation of the fluorophores in a round-robin manner and synchronous individual image acquisition from three-different spectrum bands. We experimentally demonstrate that multicolor microscopy spectrally decomposes micro-agents, organic bodies (cancer spheroids and vasculatures), and surrounding media utilizing fluorophores with well-separated spectrum characteristics and allows image acquisition with 1280 $$\times$$ × 1024 pixels up to 15 frames per second. Our results display that real-time multicolor microscopy provides increased understanding by color-coded visualization regarding the tracking of micro-agents, morphology of organic bodies, and clear distinction of surrounding media.

Aims Peripheral artery disease (PAD) is a global disease. Understanding variability in patient profiles and PAD-specific health status outcomes across health system countries can provide insights into improving PAD care. We compared these features between two high-income countries, the USA and The Netherlands. Methods and results Patients were identified from the patient-centred outcomes related to treatment practices in peripheral arterial disease: investigating trajectories study—a prospective, international registry of patients presenting to vascular specialty clinics for new onset, or exacerbation of PAD symptoms. PAD-specific health status was measured with the peripheral artery questionnaire. General linear mixed models for repeated measures were used to study baseline, 3, 6, and 12-month PAD-specific health status outcomes (peripheral artery questionnaire summary score) between the USA and The Netherlands. Out of a total of 1114 patients, 748 patients (67.1%) were from the USA and 366 (32.9%) from The Netherlands. US patients with PAD were older, with more financial barriers, higher cardiovascular risk factor burden, and lower referral rates for exercise treatment (P Conclusion Compared with the Dutch cohort, US patients had worse adjusted PAD-specific health status scores at all time point, improving less over time, despite treatment. Leveraging inter-country differences in care and outcomes could provide important insights into optimizing PAD outcomes. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT01419080? term=portrait&rank=1 NCT01419080.

For doctors and other medical professionals, the human body is the focus of their daily practice. A solid understanding of how it is built up, that is, the anatomy of the human body, is essential to ensure safe medical practice. Current anatomy education takes place either using text books or via dissecting human cadavers, with text books being the most traditional way to learn anatomy due to the cost of the alternatives. However, printed media offer only a 2D perception of a part of the human body. Although dissection of human cadavers can give a more direct observation and interaction with human bodies, it is extremely costly because of the need of preserving human bodies and maintaining dissection rooms. To solve this issue, we developed VeLight, a system with which students can learn anatomy based on CT datasets using a 3D Virtual Reality display (zSpace). VeLight offers simple and intuitive interactions, and allows teachers to design their own courses using their own material. The system offers an interactive, depth-perceptive learning experience and improves the learning process. We conducted an informal user study to validate the effectiveness of VeLight. The results show that participants were able to learn and remember how to work with VeLight very quickly. All participants reported enthusiasm for the potential of VeLight in the domain of medical education. Graphic Abstract: [Figure not available: see fulltext.]

Lay Summary Clinical decision-making in the treatment of patients with obstructed defaecation remains controversial and no international guidelines have been provided so far. This study reports a consensus among European opinion leaders on the management of obstructed defaecation in different possible clinical scenarios.Management of obstructed defaecation is challenging and remains controversial. No international guidelines have been published.