Science and the art of surgery should be anchored on evidence-based medicine. There is no room in the discipline of neurosurgery for “personal anecdotes/experience,” and the concept of “hero worship.” The construction of evidence-based medicine guidelines is essential in our continued improvement of care for neurosurgical patients. At the recent 17th World Congress of Neurosurgery in Bogotá, Colombia, held March 13-18, 2022, a prominent neurosurgeon stated, while moderating the talk I was giving on The Treatment of Large Acoustic Schwannomas with Gamma Knife Radiosurgery, that "statistics are not useful in neurosurgery". The reaction of the audience in attendance was one that made me uncomfortable. Certainly, for younger neurosurgeons or those in training, this kind of statement requires comment.A brief survey of publications in neurosurgery combining the terms "statistics AND neurosurgery" reveals 3,348 citations, and with no time limits, 35,680 citations. Obviously, statistics and the art and science (evidence-based medicine) of neurosurgery are not only relevant but essential. The disciplined science of evidence-based medicine applied to neurosurgery allows us to distinguish between the most efficacious management strategies including the diagnosis, assessment, and treatment of patients with neurosurgical diseases based on the academic rigor of studies in our literature on these topics. The compilation of evidenced-based medicine in topic-specific referred guidelines provides a chronicle of accepted strategies for assessment, diagnosis, treatment, and prognosis, ranking them according to scientific merit. Properly prepared and constructed evidence-based medicine guidelines allow practitioners to appreciate the variety of acceptable strategies they might employ for a given patient with a given pathology and identifies an area where little to no sound evidence exists, driving further research to fill these voids.Organized neurosurgery has done much in the past 25 years to use scientific evidence-derived data to guide clinical care. Our practitioners and neurosurgical societies have published over 250 evidence-based guidelines for virtually every neurosurgical subspecialty area in our profession. Class I medical evidence is derived from randomized, blinded clinical trials, properly designed, carried out, and completed. Class II medical evidence  is derived from properly designed and completed comparative studies or case-control studies. Class III medical evidence is derived from case series or poorly designed or carried out (flawed) attempts at Class I or Class II trials. Class IV medical evidence is derived from historical "the way I do it" assessment, diagnosis, or treatment proclamations. This may have been what the acclaimed neurosurgeon was speaking about in his dissertation in Bogota. While statistical facts apply to groups and populations of similar patients with similar pathology, statistics don't always apply to an individual patient due to other medical conditions, allergies, or pathology that an individual may have. Nonetheless, statistics and knowledge of evidence-based medical facts remain critically important in the contemporary, comprehensive care of our patients.Much of how we currently practice is based on Class III medical evidence, but year by year new studies of these issues bring important Class II medical evidence, sometimes Class I medical evidence to light. As more and more practitioners and residents in training learn the principles of evidence-based medicine and apply them to design studies to answer clinical questions, our field advances. At the institutional level, internal analysis of case series , while not as robust scientifically as evidence derived from randomized trials or properly designed comparative studies, can provide meaningful evidence on the incidence of a variety of different strategies to a similar pathology which can be used to help define the risk-benefit ratio and potential success of medical treatment or surgical intervention before that strategy is implemented. It can identify practitioners who perform less well or have inferior results compared to their peers allowing for physician education, training, and improvement. This kind of medical evidence can be useful when properly applied.The decision to intervene for a patient with a newly diagnosed condition is based on a variety of patient factors such as age, associated medical conditions, frailty indices, performance status, and patient desires, in addition to the specific nature of that patient’s neurosurgical pathology. Certainly, all of these factors should be considered and patient treatment decisions must indeed be individualized. Knowledge of the existing evidence-based medical science about the specific neurosurgical pathology to be treated expands the expertise of the neurosurgical practitioner and allows the treating surgeon to better stylize and individualize patient care. An example of how statistics and evidence-based medicine are helpful in guiding decisions for treatment is the recent international study on tuberculum sellae meningiomas, which in most institutional surgical series are rare tumors accounting for only 2% to 4% of all cases. The recruitment and collaborative collation of data from many institutions treating these tumors provide increased statistical power for the decision-making that guides the surgical approaches and treatment for patients with this pathology. An evidence-based statistical analysis suggests that for smaller tumors, an endoscopic endonasal approach for surgical removal provides better long-term tumor control than historical or individual surgeon preferences and practices.There are many excellent examples where statistical evidence-based medicine analyses of the literature provide the basis for guideline recommendations based on scientific merit for diagnosis, assessment, treatment, and prognosis in neurosurgery. Spinal neurosurgery is the most common form of neurosurgical intervention in contemporary neurosurgery practice. Evidence-based guidelines have been developed for Lumbar Spinal Fusion procedures on 20 topics related to lumbar spinal pathology. The Guidelines for the Management of Acute Traumatic Cervical Spine and Spinal Cord Injuries and the Guidelines for the Management of Cervical Myelopathy are two other comprehensive and contemporary evidence-based compendia on the diagnosis, assessment, management, and prognosis of these disorders that guide patient care based on existing scientific knowledge and "statistics". These focused, topic-specific guidelines and many others in neurosurgery have been carefully produced, vetted, refereed, and have been approved/adopted by our governing specialty societies, the American Association of Neurological Surgeons, and the Congress of Neurological Surgeons as official doctrine -3.We do not argue that individual patient decision-making is a complex process and must be individualized. However, the broad statement that "statistics are not useful in neurosurgery" grossly misrepresents 25 years of concerted effort to apply the science of evidence-based medicine to disease states and pathology within our specialty to improve the care offered by neurosurgeons and the outcomes of the patients we treat. There is no room in neurosurgery for "hero worshiping" and blind trust. We need to always validate our "feelings" and "memory."


With the rapid advancement of technology, digital literacy has become a key component in educators’ professional development. A wide range of assessment tools has been developed to measure teacher digital literacy; however, there has been no previous attempt to systematically synthesize and scrutinize those tools to improve evaluation of this ability among educators. The current study reviews literature on instruments that assess teacher digital literacy with the purposes of ascertaining the main aspects of it that recent researchers focus on in their evaluation, instrument types used for assessment, and the reliability and validity report, as well as the frameworks or models used to design assessment tools. The review selected 33 English-language publications in the field of educational technology from peer-reviewed journals indexed in the Education Resources Information Center (ERIC), Web of Science, and Scopus. The study period spanned from 2011 to 2022 with the objective of reviewing the tools used to assess teacher digital competence. The major findings demonstrate that scholars focus on digital competence in teachers’ use of educational technology, teaching and learning, professional development, and support for learners through digital competence. Other researchers emphasize the ability of educators to apply technology to the assessment of learner outcomes or to empower students in using technology to enhance learning. Additionally, self-evaluation instruments are common, whereas a few studies promote subjective evaluation in combination with objective assessment to provide a comprehensive understanding of teacher digital competence. The results form the basis for several recommendations for future research for the further examination of teacher digital literacy. There has been a great deal of effort to provide technologies in schools since the 1980s because educational computing has long been considered to prepare learners with essential digital skills for their future career. However, the issue of the integration of technology into an educational context positively facilitating the outcome of teaching and learning has been controversial because there has been a lack of evidence for the effectiveness of using technologies in education Elstad, . The conWhat aspects of digital literacy are presented in recent research on potential ways to assess teacher digital literacy?What types of instruments are used to assess digital literacy, and how are instrument reliability and validity reported?What frameworks or models are used to develop the instruments?With these guided research questions, the article will be followed by a theoretical background section where digital literacy and other related concepts, dimensions of digital literacy, models/frameworks for assessing educators’ digital literacy, approaches and types of instruments, and reliability and validity indicators for instruments are reviewed comprehensively. After that, we present the methodology with information on the coding process and study selection. In the Results and discussion section, the research questions will be answered and discussed in detail. In the final section, we will synthesize the main findings of the research and point out some limitations as well as making recommendations for future studies.The unprecedented growth of ICT in the digital era has spawned various terms to indicate the skills, competencies, abilities, or literacies related to the use of digital technologies. Apart from digital literacy, which was used by the European Commission , variousThe concept of digital literacy can be encapsulated using multiple means and perspectives. Although certain concepts of digital literacy have offered a panoramic vision, others have endeavored to dissect the terminology to understand what lies at the heart of it. Initially, the definitions seemed contradictory and were defined from different perspectives and in different contexts. A more comprehensive understanding of digital literacy was constituted out of a combination of such definitions. For example, digital literacy could be captured from the cognitive perspective through expansive definitions. For example, Gilster  proposedDigital literacy was also found in many studies on narrow-scope definitions of digital literacy, which mainly focus on operational technological tasks  are common in designing tools to assess digital literacy. Each approach has its strengths and weaknesses as regards validity. Scholars have thus advised combining the two approaches to guarantee instrument validity. Based on multiple frameworks and models, international and national organizations and researchers in specific contexts have designed and improved various tools to assess digital literacy. Assessment tools can measure information, technology, and digital information and are thus grouped from the perspective of assessment and item design or based on their objectives , Web of Science, and Scopus) and was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram Fig. . We condArticles were searched for with the following search terms in the title, keywords, and abstracts: “ICT competency” or “ICT literacy” or “digital literacy” or “information literacy” or “computer literacy” or “technology literacy” and “assessment.” The second to fifth listed here were included because they are subfields of ICT competency  were conducted to determine the level of digital competence among pre-service teachers, whereas 18 (55%) explored that of inservice teachers at primary and secondary schools, at universities, and in other areas  . Figure The studies selected used multiple instruments to examine different aspects based on various frameworks to identify the level of teacher digital competence. We categorized these aspects on the basis of the six main components of the DigCompEdu framework. The result demonstrates that among the aspects of digital literacy cited, the papers reviewed exhibited a trend of mainly focusing on exploring teacher competence in integrating digital resources (97%), teaching and learning (78%), improving professional development (78%), and facilitating learner digital competence 63%). The other two teacher competencies of assessment and empowering learners are less investigated . Figure %. The otOut of the 33 selected papers, ten investigated teacher competence within the six elements of digital literacy , and a combination of the two .In total, 28 papers used only self-assessment when exploring teacher digital competence. The reason for the popularity of self-assessment is that data collection from a large number of participants is convenient and economical. Additionally, self-assessment may be useful in eliciting teacher reflection on their knowledge, skills, and attitudes toward the use of educational technologies in teaching. However, the general limitation of these studies is that they only use self-assessment to evaluate competencies in the use of technology in teaching because the literature has demonstrated that certain groups of participants tend to overestimate or underestimate their competence compared with their actual level. This aspect may lead to inadequate knowledge and skills in the management of technologies and media in teaching.Thus, the use of self-assessment questionnaires may not achieve adequate reliability and internal validity because of the limitations noted above. For this reason, a few authors in recent years have tended to use more than one instrument by adding other objective tools for evaluation when assessing teacher digital literacy to reinforce the persuasiveness of the findings. For example, Nebot et al.  conducteIn terms of the reliability and validity of the assessment tools, critical to determining the efficacy of the research tools, 26 out of 33 papers (78%) reported reliability, 22 (66%) presented validity values, and 21 (63%) pointed out the levels of instrument reliability and validity. The results demonstrate that researchers generally describe the level of instrument reliability with Cronbach’s alpha (α) coefficient  used research tools designed and developed based on the DigCompEdu framework, which includes educators’ general and necessary competencies. Although the framework was designed for the educational context of European countries, it has been applied to other environments  from 2011 to 2022. The current study only includes papers that were searched for in these databases, and only papers published in English were selected. Hence, other articles on the topic may have been written in other languages but have been omitted. Future research may expand the search areas and review publications in other languages to depict the full picture of the assessment of teacher digital competence. The findings indicate that numerous studies have assessed teacher digital literacy using self-assessment tools. Thus, future research may develop and design other authentic and interactive tests to reflect teachers’ actual knowledge and skills in terms of technology integration. Additionally, a few papers used the mixed-method approach to evaluate target competencies. Therefore, further studies that combine quantitative and qualitative methods should be conducted to provide a comprehensive understanding of teacher digital competence in specific contexts. Additionally, subjective and objective evaluations should be incorporated into these tools to reflect the exact level at which teachers apply technology to education. Furthermore, the findings demonstrate that the percentage of papers that focus on examining teacher competence in terms of using educational technology for assessment and empowering learners remains low. Thus, the need emerges to focus on these two aspects of digital literacy when assessing teacher digital competence. Moreover, the results show that a large number of studies concentrate on evaluating teacher digital competence in primary and secondary schools. In this case, the context of technology integration among teachers in high school, higher education, and other educational contexts  warrants further exploration.


This review considers experimental findings on splenic repair, obtained in two types of small animal  models: splenic resections and autologous transplantations of splenic tissue. Resection experiments indicate that the spleen is able to regenerate, though not necessarily to the initial volume. The recovery lasts one month and preserves the architecture, albeit with an increase in the relative volume of lymphoid follicles. The renovated tissues, however, exhibit skewed functional profiles; notably, the decreased production of antibodies and the low cytotoxic activity of T cells, consistent with the decline of T-dependent zones and prolonged reduction in T cell numbers. Species–specific differences are evident as well, with the post-repair organ mass deficiency most pronounced in rabbit models. Autotransplantations of splenic material are of particular clinical interest, as the procedure can possibly mitigate the development of post-splenectomy syndrome. Under these conditions, regeneration lasts 1–2 months, depending on the species. The transplants effectively destroy senescent erythrocytes, assist in microbial clearance, and produce antibodies, thus averting sepsis and bacterial pneumonia. Meanwhile, cellular sources of splenic recovery in such models remain obscure, as well as the time required for T and B cell number reconstitution. The spleen is the largest lymphoid unpaired parenchymal organ of the abdominal cavity found in all vertebrates. The spleen is functionally and morphologically divided into the red and white pulp with a marginal (in rodents) or perifollicular zone (in humans) between them  1]. Blo. Blo1]. Total resection of the spleen is an option in a number of clinical situations including traumatic injury, thrombocytopenia, and severe portal hypertension . DespiteThe most common indications for splenectomy are a wide variety of diseases and conditions: raptured or enlarged spleen, blood disorders like idiopathic thrombocytopenic purpura and thalassemia, cancer , infection, etc. The study of spleen regeneration after splenectomy is often limited to patients and small laboratory animals, while for larger species, splenectomy has only been studied in the context of survival. Thus, it was shown that post-splenectomy, post-operative survival rate was 52% for dogs , 87.5% fThe first studies on mammalian spleen regeneration date back to the 19th century ,22. DediThe earliest known experimental studies on regeneration of the spleen after resections were carried out in the 19th century by Jean-Marie Philipeaux . In earlA bunch of experimental studies on regeneration of the spleen after resections was implemented by academic staff of the Laboratory of Growth and Development at the Scientific Research Institute of Human Morphology, Moscow, Russia. One series involved mice undergoing 50% splenectomy. The extent of regenerative outcomes considerably varied: after 1 month, most of the remnants grew significantly in length and volume, while preserving the architecture and showing no outgrowth at the wound surface. It should be noted that, even in cases of intensive regrowth, the organs never reached their initial size. Moreover, in a number of cases, the remnants progressively shrunk ,23,24.Resections of 90% of the splenic volume in mice produced functional spleen equivalents of loosely cubic shape in 38 days ,22. RegeIn addition to the morphological and cell lineage studies, the focus was expanded to the functional profiles of splenic lymphocytes, including the production of antibodies and participation in cellular immunity reactions. Following the resection and regrowth, splenic lymphocytes produced lower amounts of antibodies and showed weaker graft-versus-host reactions compared with the cells from intact spleens . The obsSpecies–specific differences in splenic regeneration are pronounced. Rabbits, by contrast with mice and rats, are incapable of splenic regrowth . The difTogether, these studies indicate that classical experiments on spleen resection unequivocally indicate its ability to regenerate, which is accompanied by the preservation of tissue architectonics and an increase in the size of lymphoid follicles. In the next section, we will turn to the analysis of heterotopic  transplantations of the spleen as a frequent model for studying regeneration.The orthotopic regeneration of the spleen is clinically unfeasible. At the same time, unattended splenectomies are fraught with delayed immunological complications . The proThe idea was born in connection with clinical cases of spontaneous splenic engraftment. In the aftermath of splenectomy, functionally active fragments of splenic lymphoid tissue may occasionally settle in the abdominal cavity, resembling accessory spleens. This phenomenon is known as ‘splenosis’ ,31.Studies on the heterotopic recovery of autologous splenic grafts in rodent models began in the early 20th century. Two major sites of heterotopic engraftment were abdominal  and subcutaneous. The course of regeneration for these two sites was similar and took about 1 month ,33. DataAn early series of such experiments was, oddly enough, performed on rabbits ,35, incaThese pioneering models were meticulously reproduced in other species of laboratory animals . In ratsConsistent with the previous findings on rabbits, in rat models, the engraftment was more robust in younger animals, with accelerated vascularization and re-innervation of the grafts, and higher numbers of Ki67+ cells and their distributions typical of the intact spleens in young rats ,41,42. IOver recent decades, these techniques were refined. The optimal site for peritoneal engraftments is the greater omentum, although autologous transplantations to the mesentery or the inside of abdominal wall work as well ,45,46. MSubcutaneous splenic grafts provide a major alternative, although the scenario is basically similar to the intraperitoneal splenic regeneration. In rats, the subcutaneous engraftments are finalized within 1–1.5 months p/t. Identical to the peritoneal grafts, the early phase is marked with necrosis. Subsequent morphological landmarks are blood vessel ingrowth (day 3) and accumulation of larger lymphocytes with dark nuclei in peripheral parts of the transplant (day 7). By day 14, the lymphocytes increase in number. By day 28, the transplant recovers characteristic splenic architecture with red and white pulp compartments . These oMost of the experiments indicate the universal capacity of autologous splenic grafts to regenerate at a variety of anatomical sites. At the same time, several studies argue that subcutaneous environments are less favorable due to the lower rates of angiogenesis and specify the greater omentum as the optimal site for the engraftment . Such coComprehensive functional assessment of the outcomes is important in connection with the clinical relevance of splenic autotransplantations. In this regard, hematopoietic status and resistance to particular infections and tumors in the aftermath of the intervention are chief indicators of its success or otherwise.Within 2 weeks p/t, the autografts begin to effectively sort erythrocytes, with the concomitant clearance of senescent erythrocytes from the blood ,52,53. TE. coli, as well as pneumococci .,78.77,78The spleen and the liver are anatomically connected via portal circulation and have shared responsibilities . Clinical experience shows that liver diseases often disrupt the normal splenic architecture ,78. At tApart from experimental models, a significant portion of the evidence on the potential splenic involvement was obtained in patients with liver cirrhosis. The disease is accompanied by excessive production of extracellular matrix by the activated stellate cells (Ito cells) of the liver ,85. The Il6, Il10, Tnfa, Hgf, and Nos2 expression in the liver [The impact of splenectomy on macrophage and lymphocyte populations of the liver in cirrhosis was emphasized in a number of studies. In a mouse model of concanavalin-induced hepatitis and cirrhosis, splenectomy promotes polarization of liver macrophages towards anti-inflammatory M2 phenotypes, which support the recovery . In micehe liver .The heavy-duty hepatosplenic circulation provides a permanent opportunity for the transportation of splenic monocytes/macrophages to the liver. On systemic scale, the spleen is viewed as a stock of monocytes to be released on demand for transportation and deployment at inflammatory foci. This is true for a number of murine models, including ischemic myocardial damage , ischemiMigration of monocytes from the spleen to the liver is disputable; for splenic lymphocytes, this route has been confirmed. In a murine model of cirrhosis, the spleen becomes progressively depleted of CD4+ (helper) T lymphocytes, with a simultaneous increase in the content of Th2 lymphocytes (thought to augment fibrosis) in the liver. Under these circumstances splenectomy restores the Th1/Th2 balance and alleviates the fibrosis . Apart fSplenectomy (splenectomized status) is also beneficial for regeneration of the liver after massive resections. The majority of studies emphasize the elevated rates of hepatocyte proliferation in splenectomized animals, although its mechanistic causes have to be specified. The variants include (1) resolution of portal hypertension; (2) mitigation of the damage to sinusoidal endothelium; (3) alleviation of the inflammatory side effects by inhibiting the synthesis of pro-inflammatory cytokines, as well as the rates of macrophage and neutrophil infiltration; and (4) hepatocyte apoptosis inhibition ,106.heme oxygenase-1 gene, considered beneficial for the repair [Splenectomy complementing 90% resections of the liver volume is accompanied by decreased expression of multiple acute phase markers in the liver remnant and increased expression of e repair . Physicae repair ,109,110.e repair ,112. Othe repair . A simile repair .On the other hand, some models question, and even disprove, the benefits of splenectomy for liver repair. For instance, Babaeva et al. observed the opposite, inhibitory effect of splenectomy on the compensatory growth of the liver after resections. The strength of the effect did not depend on the time lapse between the two interventions (splenectomy followed by liver resection); . At the Contemporary studies on the role of immunity in regeneration involve model animals depleted of particular lymphocyte populations. The data obtained in such models are often controversial, which reflects the complexity of the regulatory mechanisms. In mice depleted of T cells, resections of 70% liver volume have lower rates of necrotic complications than in ordinary mice . SimilarOther examples of lymphoid cell participation in repair processes include experiments with adoptive transfer of lymphocytes from actively regenerating organs to the orthotopic locations in non-operated syngeneic animals ,119. UpoThus, immune cells inside the liver, and some of those outside it, may influence repair processes within the organ or its remnant. The impact can be either activating or inhibiting; the latter is exerted by T killers, NK cells, and NKT cells. The stimulatory effect of splenectomy on the hepatic recovery after various types of damage, as well as the adoptive transfer of lymphocytes as the means for boosting liver repair, are subject to further investigation. Overall, these results indicate that the liver and spleen actively influence each other both at the level of cell migration and at the level of cytokine balance.The spleen has been traditionally regarded an accessory immune organ. However, this view is challenged by severe infectious and tumorigenic consequences of splenectomy. Apart from its prominent role in immunogenesis, the spleen appears to control hepatic repair, as has been confirmed in a number of experimental models. The spleen is also a depot of monocytes, wherefrom they migrate to damaged organs. The problem of splenic regeneration is of high clinical relevance; in this regard, the most important frontier is splenic autografts. The possibility of heterotopic autologous transplantation of splenic fragments has been comprehensively assessed in experimental models and a number of clinical trials. The autografts successfully restore the normal splenic architecture of red pulp and white pulp with the newly formed periarteriolar lymphoid sheaths and lymphoid follicles. The issues still waiting to be explored include the extent of functional recovery and stability of T and B lymphopoiesis, as well as cellular sources of de novo splenogenesis in heterotopic autografts.


Rare liver lesions and diseases have seldomly aroused major interest of researchers. For most guidelines, presumably similar clinical conditions are pooled without detailed investigations of singularities that they present.A multidisciplinary project aiming to establish evidence-based therapies for rare liver diseases has been founded. A series of systematic reviews and meta-analyses will be the starting point for a structured development of guidelines for rare conditions of the liver affecting pediatric and adult populations. The novel approach will be focusing on case reports and small patient series with distinct rare liver diseases without pooling several presumably acceptably similar conditions. Thus, a vital resource of information will be utilized, which has been largely neglected hitherto.Highly specific recommendations based on highest available evidence will therefore be developed for specific conditions, advancing the individualized medicine approach for the afflicted patients. Generating evidence for rare diseases based on clinical studies is, inevitably, difficult. As a consequence, the diagnostic and therapeutic approaches for many rare conditions rely primarily on individual experiences or guidelines developed for allegedly similar but more common diseases. Yet, the assumption of clinically relevant similarity is often unsubstantiated. This means that, frequently, current treatment recommendations for patients with rare diseases are based on the lowest level of scientific evidence . The hetReviewing the literature on various rare liver diseases, a considerable amount of case reports and small case series can be found. A few patient series from multi-institutional study registries tend to be the highest level of evidence available for most diseases, with virtually all data being retrospective. Long-term observational studies including large sample sizes are lacking, and randomized controlled trials are practically non-existent. Conducting such trials is hampered by the complexity of organizing multi-institutional and international studies, and, understandably, by the low number of eligible patients and necessity of a long study duration. So far, most studies have specifically excluded case reports and smaller series from their analyses. While there are some risks and obstacles to overcome when including case reports in reviews, they present a vital resource of information and can function as a base for generating evidence. Especially for very rare diseases, these reports are invaluable as many are only sufficiently described in case reports or series and are lacking true single entity cohort studies. Important data is lost when case reports and series are systematically ruled out. We argue that the dogma of categorically excluding smaller studies from systematic reviews and meta-analyses is unjustified. The informational benefit of these studies outweighs case report specific biases, provided certain methodological and statistical principles are applied. On the contrary, case reports often supply detailed data, and statistically robust results can be achieved, when larger number of induvial cases is accumulated and analyzed.Researchers from seven medical disciplines form the RELIVE consortium, including experienced physicians, senior and junior scientists in the fields of hepatobiliary surgery, hepatology, pediatric hepatology, pediatric surgery, oncology, infectious diseases, and radiology. Thus, diseases and research questions will be viewed from different angles, providing for comprehensive and objective study results.In light of the lack of evidence for rare liver diseases, we founded the RELIVE Initiative (RarE LIVEr Disease Initiative). The aim of RELIVE is to raise awareness of rare liver lesions and conditions and to launch a collective effort for a better understanding, diagnosis, and treatment of uncommon liver diseases. For the RELIVE Initiative, we define rare liver diseases as all conditions that affect no more than one person in 2000. The focus will be set on disease with a particular lack of evidence concerning diagnosis and treatment, with all kinds of liver conditions, be it hereditary cholestatic, metabolic hepatic diseases or benign and malign liver tumors of anatomical malformations. Researchers are motivated to write more reports and carry out studies on rare diseases despite the low number of cases. To generate higher evidence, we intend to launch a series of systematic reviews (SR) that will be predominantly based on small studies on specific lesions and afflictions of the liver in adult and pediatric populations. The applied systematic approach will be a major step towards an evidence-based treatment of rare liver tumors and diseases. Although SRs and meta-analyses of small studies bear the risk of several biases, they will nevertheless provide the highest level of evidence available. We are convinced that this will lead to a better understanding of rare liver diseases and their therapy. Based on the results of the SRs and pooled data analyses, a better comparative analysis between similar conditions or variants of tumors can be made. Furthermore, RELIVE will allow for the development of clinical recommendations and research questions for future studies. Other methods such as prospective trials and translational studies can later be initiated within the framework of the RELIVE Initiative.To ensure the highest study quality possible, a standardized systematic approach will be applied in all RELIVE systematic reviews. All systematic reviews and meta-analyses will be reported in accordance with the latest PRISMA guidelines , 4 and pBased on the RELIVE systematic reviews, robust recommendations on diagnostic and therapeutic approaches for rare liver diseases can be developed, solidified, or altered. Moreover, specific hypotheses can be derived, which can then be tested in future trials. The long-term goal of RELIVE is to engage the scientific community in developing targeted, evidence-based diagnostic and therapeutic guidelines for rare liver diseases and tumors.


All patients had undergone splenectomy before rituximab administration. Accessory spleen was detected in 5 of 15 patients (33.3%). Median age at diagnosis was significantly higher in patients with accessory spleen than those without accessory spleen (40 (range 25–68 years) and 26 (range 7–40 years), respectively; p = 0.049). There was a trend for older age at time of rituximab initiation in patients with accessory spleen compared to the other group (median 51 (range 43–75 years) and 42.5 (range 30–60 years), respectively; p = 0.066). Median follow-up duration was 96 months (range 40–98). We demonstrated a significant correlation between accessory spleen presence and older age. Accessory spleen presence correlated with higher platelet and WBC counts. We showed good inverse correlation between presence of accessory spleen and time to early response (ER) to rituximab while the rate of early response (ER), late response (LR), sustained response (SR) and overall response (OR) did not differ with respect to the presence of acessory spleen.No data exist for the association between the presence of accessory spleen after splenectomy and response to rituximab in immune thrombocytopenia (ITP). We investigated the relationship between accessory spleen presence and rituximab response in splenectomized ITP patients. Fifteen chronic refractory ITP patients were included. Four weekly doses of rituximab 375 mg/m Immune thrombocytopenic purpura (ITP) is an autoimmune disorder characterized by the premature destruction of platelets coated with IgG autoantibody by the reticuloendothelial system 1. Rituximab is a chimeric monoclonal antibody highly specific for the CD20 antigen that has the ability to deplete antibody-producing B lymphocytes. Rituximab has been administered in various autoimmune disorders including ITP ,4,5,6,7.2 was administered IV once weekly for 4 weeks between November 2007 and March 2008. Rituximab was offered to these patients as an off-label treatment following the approval of the Ministry of Health. Ethics approval was obtained from the local Institutional Review Committee and a signed informed consent was obtained from all participants. Spleen scintigraphy was performed for the investigation of accessory spleen. CR was defined as any platelet count of at least 100.000/mm3, partial response (PR) as any platelet count between 30 and 100.000/mm3 and no response (NR) as any platelet count less than 30.000/mm3, or the presence of bleeding [3, or the presence of bleeding and need of other therapy during follow-up. Time to response was defined as time from start of treatment until either CR or PR. Duration of response was defined as time from CR or PR until loss of CR or PR.We prospectively assessed the long-term follow-up data of median 96 months (range 40–98) of 15 patients diagnosed with chronic refractory ITP, all of whom had been treated with corticosteroids and splenectomy and various immunosuppressive agents including azathioprine, vincristine, danazol and mycophenolate mofetil. Exclusion criteria included the presence of severe infections, heart failure, pregnancy or chronic active hepatitis B infection. Rituximab 375 mg/mbleeding . Loss ofp < 0.05 were considered significant. The analysis of correlation between the presence of accessory spleen prior to rituximab and clinical and laboratory variables was performed according to Spearman’s rank correlation test.Statistical analysis was performed using the SPSS version 21 . Characteristics of patients were described as mean ± SD or median (range). Comparisons between groups were performed by chi-square test and Fisher’s exact test. The analysis of continuous variables among the groups was performed using the Mann–Whitney U test. Probability values of We prospectively analyzed 15 patients with chronic refractory ITP , who were treated with rituximab at the Division of Hematology of the Istanbul University Istanbul Medical Faculty. All patients had a history of splenectomy prior to the administration of rituximab. In 5 out of 15 patients (33.3%), accessory spleen was detected before the initiation of rituximab.Comparison of ITP patients according to the presence of accessory spleen prior to rituximab treatment.p = 0.049). Patients with accessory spleen showed a trend towards older age at initiation of rituximab compared to the other group (median 51 (range 43–75 years) and 42.5 (range 30–60 years), respectively; p = 0.066). The two groups showed no significant differences with respect to gender, actual age, age at time of splenectomy, hemoglobin level, WBC and platelet counts at diagnosis, initial response rate to corticosteroid therapy, number of previous therapies, interval between initial diagnosis and splenectomy, time from splenectomy to rituximab therapy and from diagnosis to initiation of rituximab, the rate of ER, LR, SR, loss of response, rate of OR to rituximab at 96th month, duration of ER and OR, time to response to rituximab of early and late responders and follow-up duration after rituximab therapy (p > 0.05). The frequency of comorbid diseases was higher in the presence of accessory spleen compared to the absence of accessory spleen, yet the difference showed no statistical significance . The presence of accessory spleen prior to rituximab showed moderate positive correlation with actual age, age at diagnosis, age at the time of rituximab therapy and at the time of splenectomy . There was a good inverse correlation between the presence of accessory spleen and the time to early response to rituximab (r = −0.645). There was mild inverse correlation between the presence of accessory spleen and the rate of loss of response to rituximab (r = −0.32). There was mild inverse correlation between the presence of accessory spleen and interval between initial diagnosis and the start of rituximab as well as time from initial diagnosis to splenectomy .Clinical and laboratory features of ITP patients according to the presence of accessory spleen were outlined in Rituximab is still commonly used off-label as a second or third-line option in many countries. In the evidence-based guideline by Neunert C. et al., rituximab is recommended as second or third-line therapy for relapsed or refractory disease after corticosteroids, IVIG, or splenectomy (grade 2C evidence) . In anotIn line with our observation, Marchese S. et al. reported that younger age poses risk for failure to radiologically identify accessory spleen and that the rate of detection of accessory spleen increases with older age . MarchesThe rate of ER was higher in our patients with accessory spleen compared to those with no accessory spleen, but this difference was not statistically significant . The rate of LR was lower in the accessory spleen group; this difference was not significant . In addition, no significant differences in terms of SR rate were observed between patients with and without accessory spleen . A total of 80% of patients without accessory spleen and 50% of patients with accessory spleen lost their response to rituximab; there was a mild inverse correlation between the presence of accessory spleen and the rate of loss of response to rituximab. To our knowledge, this is the first study to report the relationship between the presence of accessory spleen and response to rituximab in refractory İTP. Yet, our study population size is limited to make strong recommendations. Several studies investigated the association between response rate to rituximab and splenectomy ,7. In thIn our study, there was a good inverse correlation between the presence of accessory spleen and the time to ER to rituximab. In addition, there was a mild inverse correlation between the presence of accessory spleen and the rate of loss of response to rituximab. The current study is unique as it is the first study to provide clinical and laboratory characteristics as well as response rates to rituximab according to the presence of accessory spleen. Despite its limitations, our study provides novel, long-term, prospective, real-life follow-up data. In adults with refractory symptomatic ITP, multicenter studies with larger number of patients are required to confirm our findings and to determine the response to rituximab according to the presence of accessory spleen.


Mage = 49 mon; 98.3% Latino/Hispanic) and their parents and 47 teachers, drawn from the Migrant and Seasonal Head Start (MSHS) Study. Parents reported how often the target children engaged in language and literacy activities  with their family members. Teachers reported how often the target children engaged in classroom language and literacy activities . Children’s emergent literacy skills in English and Spanish were assessed by standard tests. After controlling for demographic variables, home and classroom language and literacy activities uniquely predicted children’s emergent literacy skills in Spanish, but not in English. Additionally, home and classroom activities compensated one another in supporting children’s English and Spanish emergent literacy development. That is, language and literacy activities in one context showed a stronger effect for children who experienced less frequent activities in the other context. Together, these findings shed light on ways to support MSFW children’s emergent literacy skills and reveal the importance of integrating and connecting home and school learning experiences.Children of migrant and seasonal farmworkers (MSFW) are among the most underprivileged, underserved groups in the United States. The current study examined how home and classroom language and literacy experiences uniquely and interactively contributed to MSFW children’s emergent literacy skills in English and Spanish. Participants were 255 Spanish-English dual language learning children ( In the United States, there are 2.5–3 million migrant and seasonal farmworkers MSFW; , most ofChildren’s emergent literacy skills, such as their knowledge of letters and words, phonological awareness, and print concepts, are important precursors of future reading skills and academic success . Most MSLanguage and literacy activities in both the home and classroom contexts offer children important opportunities to develop emergent literacy skills . HoweverAmple research has demonstrated the effect of home language and literacy experiences on children’s emergent literacy skills e.g., . In partBook-reading exposes children to language input that is diverse, complex, and cognitively demanding . Both cost and 2nd grades  during classroom language and literacy activities promoted MSHS children’s emergent literacy growth in English and Spanish .Most research has examined the effects of children’s home and classroom language and literacy experiences separately, without asking how these two components of children’s learning experiences uniquely contribute to the development of emergent literacy skills and whether they interact with one another. The bioecological model posits that children’s immediate contexts  are not independent. Rather, various developmental contexts interact with each other in their contribution to child outcomes . Similarst and 3rd grades  on the emergent literacy skills of children enrolled in MSHS programs and found that home literacy experiences was a stronger predictor than classroom literacy experiences . Howeverd grades .To date, no studies to our knowledge have examined the interaction between home and school language and literacy activities in relation to MSFW children’s emergent literacy skills. However, studies with other populations have suggested that home and classroom experiences may shape child development in a compensatory manner, such that rich, high-quality language and literacy experiences in one context may compensate the poor experiences in the other context . For exaIn contrast to the compensatory hypothesis, some studies found little evidence that children from more disadvantaged families would benefit more from high-quality classroom experiences . There iHow do home and classroom language and literacy activities uniquely contribute to MSHS children’s emergent literacy skills in English and Spanish? We hypothesized that frequencies of language and literacy activities in both the home and classroom settings would account for unique variances in MSHS children’s emergent literacy skills.Do home and classroom language and literacy activities interact with each other in their contributions to children’s English and Spanish literacy skills? If home and classroom activities benefit child development in a compensatory way, we would expect classroom language and literacy activities to show a stronger positive effect for children who experienced less frequent language and literacy activities at home, and vice versa. Alternatively, if home and classroom activities work in a complementary way, we would expect the effect of classroom activities to be stronger for those children who more frequently engaged in language and literacy activities at home.To better understand the unique and interactive effects of home and classroom literacy activities on MSHS children’s emergent literacy skills, we asked two research questions:via MSHS staff surveys, parent interviews, classroom observations, and direct child assessments.Participants were drawn from the Migrant and Seasonal Head Start (MSHS) Study , which aSD = 9.17) at the time of assessment. Almost all of them (98.3%) were identified by their parents as Latino/Hispanic. Most participating parents were mothers (88.9%) and had elementary to high school education levels (62.4%). About 82% of the parents reported using all Spanish or more Spanish than English with their children. The teachers’ education levels ranged from high school to graduate education  and 47 lead teachers. M = 2.87, SD = 0.71, Range = 1–4, Cronbach’s Alpha = 0.69).Parents were interviewed about how many days in the past week they themselves or someone in the family engaged in each of the four types of activities in any language with the target child: teaching the child letters, words, or numbers, reading or looking at books, singing songs, and telling stories . An average score across these 4 activities was calculated, with higher scores indicating more frequent language and literacy activities at home .Teachers were asked about how often children in their class engaged in each of the eight types of language and literacy activities in any language in a survey: learning the names of letters, writing children’s own names, learning about the conventions of print, retelling stories, listening to stories read by teachers, working on phonics, discussing new words, and practicing writing alphabets . An average score was calculated to indicate how frequently children engaged in these eight activities (Children’s emergent literacy skills in English and Spanish were assessed using the Letter-Word Identification (English) and Identificación de letras y palabras (Spanish) scales on the Woodcock-Muñoz Language Survey–Revised Normative Update . Across the sample, teachers used slightly more English than Spanish.A group of demographic variables were controlled for in the analyses. At the child/family level, we controlled for children’s age, gender, the total number of children living in the household, parental education, and parents’ relative language use with the child . According to the MSHS dataset, parental education was coded based on a scale, ranging from 1 (no school) to 25 . Multiple imputation was conducted in STATA 17.0 to handle missing values among the control variables  and classroom-level  factors, accounting for variation between classrooms. First, unconditional models were conducted to estimate the amount of variance explained by differences among individual children (Level 1) and classrooms (Level 2). Second, to examine the contributions of home and classroom language and literacy activities to children’s emergent literacy skills (Research Question 1), a set of two-level random intercept models were estimated, using home language and literacy activities as the key predictor at Level 1, and classroom language and literacy activities as the key predictor at Level 2. Models were estimated separately for English and Spanish literacy skills. Finally, to examine whether home and classroom activities interact with each other in their contributions to emergent literacy skills (Research Question 2), a cross-level interaction term between the home and classroom language and literacy activities was added to the models described above. When the interaction term was significant, we further estimated the conditional effects of classroom language and literacy activities, when the frequency of home language and literacy activities was set to be either low  or high . The nlcom command of STATA was used after model estimation to compute point estimates, standard errors, p values, and confidence intervals for different combinations of parameter estimates . In each model, covariates of the home and classroom contexts were included at Level 1  and Level 2  respectively.Because children and families were nested within classrooms, multilevel modeling was conducted using the range = 32–134 for English and 45–137 for Spanish), with an average standard score of 83.64 (SD = 12.84) for English emergent literacy and 94.79 (SD = 12.42) for Spanish emergent literacy, suggesting that overall children had better literacy skills in Spanish than in English (p < 0.001). Notably, the standard scores must be interpreted with caution, because the norm used was based on English-speaking and Spanish-speaking samples.Unconditional models suggested that 73.23% and 82.84% of the variances in English and Spanish emergent literacy skills could be attributed to the differences among individual children, respectively; whereas 26.77% and 17.16% of the variances in English and Spanish emergent literacy skills could be explained by the differences among classrooms, respectively. In the models below, we included a random intercept to account for between-classroom differences.b = 3.82, SE = 1.12, p < 0.001, 95% CI = ) and classroom , classroom language and literacy activities did not predict children’s English . Although the conditional effect was non-significant for children’s English literacy skills, the coefficient changed from negative to positive , the effect of home language and literacy activities was non-significant for English  and Spanish , home language and literacy activities significantly predicted their English  and Spanish . One possible explanation is that MSHS teachers might be primarily focusing on supporting children’s English language skills rather than their English literacy skills. Many MSHS children came to the program with very limited English proficiency , as most teachers reported using both English and Spanish during classroom activities. Supplementary analyses examining the interaction between classroom language and literacy activities and teachers’ instructional language(s) suggested that the effect of classroom activities did not vary by the language(s) teachers used  for this study can be found here: This is a secondary data analysis of an existing dataset. In the original study, written informed consent was obtained from the participating parents, teachers, and children’s legal guardians. The current study was approved by the Institutional Review Board at Rutgers University.RL contributed to conceptual framework, data analysis, and manuscript writing. LS contributed to conceptual framework and manuscript editing. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study evaluates the effectiveness and users’ experience of using live stream technology to conduct workplace observation assessments of trainee dental nurses. Information on the usability, accessibility, and general satisfaction of this technological technique were collected.This nationwide cross-sectional survey was conducted in Scotland and included one focus group and three online questionnaires with qualitative and quantitative questions. The quantitative responses were described using standard descriptive analysis, while the quantitative data were investigated using thematic analysis.Eighty-one trainee dental nurses, 35 clinicians and 19 assessors participated in this study. Live stream observation was generally well received by the trainee dental nurses and clinicians, who thought that it had helped increase their confidence to perform practical skills. The assessors also stated that overall satisfaction was high, and that live stream observation met their expectations for efficacy. However, several technical challenges, such as network issues were brought up by responders.This study provides evidence that workplace observation assessments can be performed in the future by using live stream technology. However, additional investigation and comparison will aid in determining the most effective way of using this approach and providing feedback to promote learning among dental trainees. The coronavirus disease-19 (COVID-19) pandemic resulted in global lockdown and created disruptions in educational delivery and assessment processes. Many educational activities including course completion examinations and certification were either postponed or cancelled. Of particular concern was the delivery of robust and timely observational assessment of practical skills , and it Dental Nurses are members of a group of Dental Care Professionals (DCPs) who play a vital role within a dental team and provide support and assistance in clinical and non-clinical aspects in providing high-quality patient care. All dental professionals must be registered with the General Dental Council (GDC) before they can work in the United Kingdom . It is aObservation of practice is a primary source of evidence and a fundamental principle of the Scottish Vocational Qualification (SVQ) in Dental Nursing qualification . The SVQEl-Kishawi et al. highlighted that evolving technologies and methods of assessment could enhance students’ learning environments and improve tutors’ assessment experiences . Some stTo ensure uninterrupted progress and reduce the impact of the COVID-19 pandemic restrictions on trainee dental nurses, NHS Education for Scotland’s (NES) DCP Workstream devised the process to align the Skills For Health COVID-19 supplementary guidelines for the assessment strategy. With reports that the use of real-time online assessment has good prospects , a proceHowever, very little is known about the use of technology in performing workplace assessment in dental education. It is important to consider whether it can be objectively measured and evaluate users’ perceptions of its usefulness and effectiveness, particularly in the post-pandemic era. This knowledge is key to integrating and sustaining the use of live stream technology in vocational dental education programmes which are actively seeking opportunities to embed technology-based education to improve their programme. Therefore, the focus of this study was to explore the views of trainee dental nurses, clinicians, and assessors to evaluate users’ experiences and satisfaction of using live stream technology to conduct workplace observational assessments.This was a national cross-sectional survey conducted in Scotland comprising three online questionnaire and one focus group.The study participants included all trainee dental nurses undertaking pre-registration training with NES, the clinicians they provided chairside support to and assessors who completed the live stream observation assessment process. The clinicians were dentists, dental therapists, and hygienists who work with the trainees in their practice, and the assessors were Dental Tutors employed by NES, who carry out the role of an Assessor.Evidence of candidates’ performance is drawn primarily from naturally occurring work activities that take place under normal working conditions in a normal work environment. This WBA requires an assessor to observe a trainee dental nurse while carrying out practical based tasks as defined in the qualification standards as they provide chairside support to a GDC registered dentist, hygienist, or therapist providing care to the patient. This is referred to as a Performance Criteria, and it describes the level of competency required for the SVQ in Dental Nursing qualification. This observation is conducted in the trainee’s own workplace, which could be a General Dental Practice, Public or Hospital Dental Service. Students pursuing the SVQ in Dental Nursing must be observed supporting the patient and the clinician as they provide chairside support during a variety of clinical dental procedures and duties within their role. The assessor records their performance and provides feedback on their findings. This provides evidence for the trainee’s portfolio to demonstrate achievement. Assessors must be competent in the area of practice to which the specific national occupational standards apply, according to the Scottish Qualifications Authority (SQA), and for the SVQ in Dental Nursing, assessors must hold a qualification recognised by the regulatory body for enrolment and maintain professional registration with the GDC as well as obtain an assessor qualification.https://www.microsoft.com), a workspace for real-time collaboration and communication was used during the assessment. Microsoft Teams is freely available for download, with secure connection, and features that allow multiple participants and screen sharing. The meeting link was shared with all participants, allowing them to connect, the assessor to observe, and interact during the practical observation. Before the observation, a test run was conducted to ensure connectivity and video/audio quality.Microsoft Teams Platform  preparation (seven questions), (2) access and usability (four questions), (3) equipment (two questions), (4) support and feedback (four questions for clinicians and five questions for trainees), and (5) expectation [performance/overall satisfaction] (two questions). Both questionnaires included open-ended questions for comments on the aforementioned measures. The assessor questionnaire included 3-items to collect information about expectations: [effectiveness/overall satisfaction] (two questions) and an open-ended question about effectively assessing trainee performance.Some of the closed-ended question items required a binary response (Yes/No). Most questions were based on a 3-point Likert scale with ‘3’ indicating never and ‘1’, all the time to statements in the access and usability domain; a 4-point Likert scale with ‘4’ indicating immediately and ‘1’, several days later to statements in the feedback domain; and a 5-point Likert scale with ‘5’ indicating strong agreement and ‘1’, strong disagreement to statements in the preparation, support and feedback, performance, effectiveness, and overall satisfaction domains, respectively.This was an online questionnaire survey hosted on Questback which is the NES approved online survey platform. This was distributed by email containing a secure link to the survey to the trainees and clinicians after completing the live stream observation assessment, whilst the assessors completed their questionnaires at the end of the observation assessment period. Data were collected from November 2020 for a period of two weeks to complete after the live stream observation assessment. In addition, invitations to participate in online focus groups via Microsoft Teams were circulated to all assessors employed by NES.Standard descriptive analyses were performed to describe the responses using the Statistical Package for the Social Sciences (SPSS) version 27 . For eacOut of 81 trainees that participated in the live stream observation, 45 completed the questionnaire with a response rate of 55.6%. Additionally,19 assessors participated in the live stream observation, although only 15 of them, together with 35 clinicians, completed the questionnaire. The response rate was 78.9% for assessors; however, it was not possible to calculate this for the clinicians as the total number involved in the trainee’s remote observation assessment is unknown. In line with the research question, the collected data provided information about the participants’ perspectives on the effectiveness and overall satisfaction of using live stream technology to conduct workplace observation competency assessment of trainee dental nurses. The internal consistency coefficient across all items for trainees, clinicians and assessors were 0.72, 0.82, and 0.81, respectively, Table Trainees agreed that they were prepared for the live stream observation , Table Clinicians agreed that their trainees were prepared for the live stream observation , Table Trainees agreed that the live stream observation was accessible and easy to use . Just under three quarters (73%) reported that they never had difficulties accessing suitable equipment to undertake the observation. Most (89%) reported that they were able to access the live stream with ease all the time to undertake the observation. In addition, more than half of the trainees (64%) reported that they had reliable connectivity all the time throughout the observation, and (69%) achieved clear view of the assessor to review their performance all the time, Table Clinicians agreed that the live stream observation was accessible and easy to use , Table For the equipment measure, the Spearman-Brown coefficient for both trainees (ρ = 0.36) and clinicians (ρ = 0.48) was <0.6, and therefore an overall measure was not calculated. For the type of IT equipment used for the observation, more than half of the trainees 62%) and around two-third (66%) of clinicians used smart phone while (16%) and (11%) used laptop. In addition, more than half (62%) of the trainees and around two-third (66%) of clinicians reported that they did not use additional equipment to hold or position their device to undertake the observation, while over a third 38% and just over a third (34%) used one to hold or position their device, Table % and aroOverall, trainees agreed that they were supported for the live stream observation , Table Overall, clinicians’ perspective towards feedback and support, was good, , Table Overall, trainees agreed that using the live stream observation met their expectations , Table Overall, clinicians agreed that using the live stream observation met their expectations , Table In response to the statement probing the assessors’ expectations about the effectiveness of assessing the trainees using the live stream observation, overall, assessors agreed that using the live stream observation met their expectations , Table Overall, 72 comments from trainees’, 49 comments from clinicians’ and 15 comments from assessors were obtained in response to the open-ended questions.The respondents  were asked to enter qualitative comments on relevant areas covered in the questionnaire. Responses for clinicians and trainees were coded into 5 domains  they were judged to best represent. Data corresponding to more than one domain were coded accordingly. Responses for assessors were related to effectively assessing using the live stream technology. Analysis of the data yielded distinct themes that represent the respondents’ experience of using the live stream technology.sense of responsibility, being organised, influence of time, and team collaboration. The participants described how important these themes were with regards to the type of support provided by their team and their preparedness for the observation.Both trainees and clinicians reported similar themes that enhanced their preparation for the live stream observation. Four distinct themes were identified that describe what it meant to participants to be prepared for the observation process. These four themes are The first theme, sense of responsibility was seen as imperative for respondents to use the live stream technology. Sense of responsibility means that the guidance document that provides the method of assessment and supports the vital preparation required for the observation was shared in advance. Here respondents expressed the significance of the guidance which they felt made a difference in the observation process.“I was given instructions and guidance from my tutor prior to my observations in order to prepare. My tutor also set time aside prior to the observation to ensure set up was ok, which also helped to ensure there was no disruption on the day.”One trainee reported, “I was guided by the trainees. They had done amazing well considering the situation. The girls have needed very little support as they have been committed and worked hard on their own initiative.”In addition, a clinician reported, Our trainee managed and organised herself outstandingly on this aspect. To be perfectly honest it was all sorted without any input from myself. Obviously, my support was there should she need it. That goes for other members of the clinical team. Our trainee always explained to myself what her plans were and how she carried them out.”“For the second theme, being organised, participants indicated that this was also important in preparing for the observation. For example, the usefulness of trainees being well organised before and during the livestream observation is demonstrated by one clinician:Influence of Time as the third theme was expressed as experiences of dichotomous relevance of time where perceived support needs for the observation required an immediate response but once responded to, time became unimportant, with the respondents feeling well prepared for the observation. Trainees repeatedly expressed that they were supported with additional time to prepare for the observation.“Sometimes it was hard to get observations within my workplace, but I got help around this when I needed to reach the deadlines.” Another trainee also touched on the step taken to obtain more time for the observation process: “Block the appointment for observations a bit longer than usual. It’s helps me enough time to setting up and finishing up.”One trainee expressed this as “My employer purchased a tripod to hold my phone during the observations. Our reception team contacted the patient’s involved and explained the process.” Another trainee responded that, “We set up mock trials in each surgery to find out where would be best to have the phone sitting.”The last theme related to preparation, team collaboration, was expressed as support that trainees received from their team and the supporting clinicians, to prepare them for the live stream observation process. Trainees commented on the support from the administrative team who contacted patients and from colleagues who supported them by identifying ways to increase visibility during the observation. There was a general agreement for both trainees and clinicians that full support was needed to ensure that the trainees were prepared, knew what was happening and what was expected of them:“We all work well as a team and feel the trainees were well supported.” Also: “Trainee had good support from head nurse, myself and from the associate they worked with. Between us we managed to find what would work best in terms of positioning, patient consent etc.” This suggests that team support is a key element for ensuring effective preparation for and improved outcomes from the live stream observation.Clinicians expressed the importance of teamwork in providing support to the trainees:suitable alternative, technical constraints, and visual issues.Three distinct themes were identified that informed what access and usability meant to the participants: “Great tool used to observe skills and it may be something to consider to continue using in foreseeable future because it is convenient and efficient.”Suitable alternative was a theme expressing that access and usability of the live stream technology worked well and live streaming is a flexible and significant tool that can be used to conduct workplace observation competency assessments. As one trainee said,“It was fine and enabled things to continue despite the current restrictions in clinical practice.”“[Trainee’s] observation went [well] she knew what was expected of her and the technology worked fine.”Similarly, clinicians also reported how useful it was for the trainees to continue their clinical practice during the pandemic.“I was very worried at the thought of the observation process when I started the course, but I think doing it via livestream actually made it less stressful and nerve wracking.”One of the positive aspects of using the live stream technology was that whilst some respondents did report feeling anxious or stressed beforehand, when they began to use it, they reported feeling less anxious than they would have been in a face-to-face scenario:Had no problems at any stage, felt confident all elements were able to be observed and assessed properly.” Another respondent emphasised that: “I was nervous in case there was a drop in signal which would interrupt observation but found that all assessments took place well without too many difficulties.” A third participant responded that: “There were no issues with technology.”“Technical constraints were described as the main challenge encountered and identified as a barrier to access and usability of the life stream technology. Network issues, data usage and battery draining were regarded as problematic, especially as they were outside of the assessor’s control. However, some respondents highlighted their confidence in and positive experiences in using the live stream:I’m not sure how reliable a static stream of working area allows for full observation and therefore full feedback in comparison to an assessor being present in the room.”“The last theme, visual issues, was expressed as not being able to have clear visibility of all aspects normally assessed within the observation process:During one of the observations my assessor didn’t have a clear view and made me aware of this which was sorted accordingly with the help of the clinician and assessor.”“However, some trainees highlighted how visibility issues were handled:portability.One theme related to the need for additional equipment to hold and position the device for clearer visibility was identified: I used a large tripod which helped with the clear view of the surgery for my assessor.”“For the portability theme, most respondents indicated using a tripod as a platform for maintaining the stability of their device during the live stream observation process.I have used a gooseneck phone holder. The phone holder is easy to secure on edge of table and it can be manipulated to what angle you want.”“However, respondents highlighted that other types of support, such as ring lights, phone cases, lab work trolleys and phone holders were used to support their devices during the process.process, visual support, educational value, technical support, and potential support if needed.Five themes informing support and feedback experiences included Because I was first student for observations, I didn’t get the document early enough before my observation, but I have been explained by my tutor verbally prior to my observation on the very same day.”“Process was expressed as clear communication support provided by the assessors during the live stream observation. It was expressed by one trainee as:Overall, our trainee has been given the highest standard of support. Where our trainee struggled, there was always an assessor there for guidance and support.”“Another clinician described this as an experience that left the trainee fully supported during the observation and seems to express this theme well.During one of the observations my assessor didn’t have a clear view and made me aware of this which was sorted accordingly with the help of the clinician and assessor.”“The theme of visual support was expressed by respondents as experiences of knowing when the assessor does not have clear visibility. In this case, they can quickly inform the trainees about the visual support to enhance visibility. This theme encompassed several attributes including trainees’ and clinicians’ ability to know what to do when visibility is reduced. One trainee shared her experience of increasing visibility during the observation process:At the start of the observation the link wouldn’t allow me to join, my assessor was able to support me in giving me more help to access the livestream.”“Educational value was a third theme in support and feedback experiences and was described as experiences of interpersonal interactions during the observation process. These were characterised by perceptions of beneficial support, good, helpful, and useful information, and feedback towards the trainees and clinicians by the assessor. These experiences were felt to enhance the individual’s competency. This theme included attributes such as feeling comfortable and confident, flexibility of the assessor, being able to freely contact the assessor, and feeling good about the observation process because they were supported. One trainee highlighted how an assessors’ support led to a successful observation:“I enjoyed the live stream observation because the feedback I received made me feel confident in the fact that I was doing my job well and I will make a good dental nurse.”Educational value was seen as significant to support and feedback in the live stream observation process, as expressed in the words of one of the trainees: I had problem with connecting my integrated camera and my tutor was telling me about her personal experience and how she sorted out that problem. I was very stressed about it and helped me out a lot to calm down.”“Technical support as a theme represented difficulties experienced due to technological interferences of internet connectivity and troubleshooting technology support provided by the assessor. Respondents shared many experiences of how they were supported during technology problems and how personal examples of the assessor made a difference. One trainee shared,I personally did not require technology support; however, our trainee was supported with any technical issues, and these were resolved.”“The last theme, potential support if needed, was expressed as being able to receive technological support if required but it was not needed. One clinician stated,negative and positive views for expectation. Negative views mean respondents experienced some challenges when using the live stream technology and were not satisfied. Positive views, on the other hand mean that respondents experienced some valued benefit when using the live stream technology and were satisfied.Two themes emerged for overall satisfaction with using the live stream technology: Some negative views of using the live stream technology were identified. Respondents voiced concerns about technical problems such as network issues causing frequent disruption in the observation flow; system issues such as high-data usage and fast draining of battery; and infrastructural problems such as less visibility where assessors struggle to see clearly, and less value in using the live stream technology appeared in the response for overall satisfaction. Respondents thought that some of the challenges were compounded by the type of workplace building such as old buildings with thicker walls that restricted internet flow.“… When connection wasn’t very good it became quite easy to get stressed to one ensure time keeping met while still trying to get good connection and also in case it got disconnected throughout.”A trainee noted, Arranging specific patients for the observation due to busy clinical lists was seen as a problem by clinicians, and the live observation was thought to be less useful.“Due to Covid, live stream was the only way of getting some form of observation, though there’s not much the assessor can adequately see to assess from a single, fixed vantage point. It was difficult to try to arrange specific patients in a row for the observations due to having a busy clinical list…I’m not convinced the live observation was useful in our nurse’s training.”A clinician shared, Some positive views of using the live stream technology included ease of using the live stream technology; how less stressful it was in comparison to face-to-face assessment; how well trainees coped; the ability to complete the observation on time; how confident trainees felt in being observed virtually; ease of contacting the assessor; and clear visibility. The predominant positive view reported by both trainees and clinicians was how the live stream technology worked well to ensure the assessment of trainees was performed during the pandemic.“It was good overall as was quite flexible.”One trainee shared: Live Streaming observation was positive in the way that due to the current circumstances I was still able to be observed in my work, there was a couple of times due to working in a hospital setting it required slightly more planning but overall, I was happy I was able to continue with my course and do my observations due to the circumstances.”Another trainee highlighted, “Overall fantastic”. “I think the process of live stream assessment generally worked well in this scenario.”“It was recommended that recording and compiling individual treatment would be much easier. Nevertheless, despite these concerns other respondents also expressed that the use of the live stream technology was an appropriate alternative. This is shown in some clinicians’ responses:efficiency, self-efficacy, clear visibility, cost-effectiveness, and reduced travel time. Factors inhibiting effectiveness were technical glitches , limited visibility, first time use of digital observation, and preferred method of observation (face-to-face/blended approach).To effectively assess performance using live stream technology, the factors which shaped the assessors’ perceptions have been investigated. In this case assessors were asked to comment on whether the live stream observations enabled them to effectively assess the performance of trainee dental nurses. Assessors’ perceptions of the effectiveness of using the live stream technology varied, and mixed responses were received. The findings have been grouped into two categories: factors aiding effectiveness and factors inhibiting effectiveness. Factors aiding effectiveness were Most candidates coped well, and you were able to see enough to note.” Another assessor expressed that he or she: “Was able to carry out effective observation of candidates performance during a range of clinical dental procedures.”Most assessors highlighted ‘some sort of [effective] strength’ associated with using the live stream technology. One assessor said, ““There are a lot of benefits no travel time or costs, if patient cancels no time wasted for assessor, candidate can set up an observation last minute with assessor.” Being a suitable alternative was also viewed as equally significant: “Live stream observations are certainly an obvious alternative to in-practice observations.” In addition, “Live stream observations have worked well. Initially there was some reluctance from practitioners and there has been slight issue with sound at times but apart from that all good.”The method used for the observation was felt to be all important. Another assessor emphasised on the tone of cost saving that: “For some yes, but others no, very much depended on view and WIFI connection.” Nevertheless, while some felt that there were some inhibiting factors of effectively assessing the trainees, others reserved criticism on the basis of unprecedented circumstances that could be resolved.It can be difficult to see everything and is connection dependant, but I set up the meeting before the appointment time so that I can observe the candidate setting up for the procedure and I ask them to pan round the surgery. This also gives me the opportunity to ask any questions therefore fewer questions at the end of the observation if the student does not have much time.”“However, several assessors questioned the effectiveness of using the live stream technology, discussing factors that inhibited its use. The difficulty of measuring effectiveness was raised with concerns of technical glitches, most assessors voiced concerns regarding WIFI connection, data usage, sound quality, and limited visibility. One assessor highlighted, “…What I was not able to capture, I questioned my student after the procedure or arranged for a TEAMS meeting when suitable for my candidate. Only once did I re-observe the procedure.”Another assessor expressed, “I feel nothing can beat a face-to-face observation, meeting with the student, the staff and looking at the environment and building relations.”Among factors related to the effectiveness of using the live stream technology, a preference for in person observation was a view held by some assessors, “It is very much depending on the student, ability to get a good view of the working area and how much you can actually hear, especially regarding communication with both the patient and the dentist. Still feel a blended approach is a must to fill in the blanks/make confident assessment decisions.”Another assessor emphasised, n = 4, 4 and 5 participants, respectively) exploring assessors’ thoughts and experiences of using the live stream observation with the following aims: first, to identify potential information not already identified in the survey; and second, to derive a meaningful assessment of user experience in live stream observation as a group. The analysis of the focus groups identified three core areas of reflections relevant to using the live stream technology for workplace assessment: Benefits ; Challenges ; Achievements .We conducted three focus groups  indicated that the live stream observation enabled their trainees to demonstrate their performance as a dental nurse. This contrasts with the report of  who highThe live stream observation therefore allowed the trainees to present to the assessors how their practical experiences at the practice had culminated into new insights, technological experiences, and new learning. In addition, all the trainees reported their overall satisfaction experience with using the live stream was good or excellent. Consequently, clinicians also expressed high levels of overall satisfaction with using the live stream technology. Furthermore, (86.7%) of assessors reported that they had a good or very good overall satisfaction experience with the live stream observation. This is a significant transformative outcome for technology-based workplace assessment in dentistry. Guze (2015) highlighted the transformative learning experiences associated with using technologies that engages the learner and allows learning that does not endanger the patient . It is aAcross the three groups, median overall satisfaction rates were higher for trainees and clinicians than assessors , which represents good to very good experience among respondents. In addition, the median effectiveness score for assessors was 4.0, which shows that the assessors agreed with effectively assessing the performance of the trainees using the live stream technology. These results suggest that trainees, clinicians, and assessors had a positive experience of using live stream observation for the workplace observation assessment, and its use had an effective impact on trainee performance outcome and achievement. Given the changing situation, as this method of assessment is increasingly used, the assessors will likely better understand its benefit to improving trainees’ performance outcomes and reflective learning and their satisfaction rate will reflect supporting learning effectiveness.However, a key challenge in using live streaming is the technology issue around internet stability which a concern for the trainees, clinicians, and assessors, as some were disconnected during the observation process. This may affect their abilities to be coordinated when performing the task during the observation process. Similarly, using live streaming can constitute physical barriers for trainees who may be perplexed by their requirements, structure, and navigation. Nevertheless, to combat this technology issues, before the observation, a guidance document on this method of assessment and support for vital preparation was sent to the trainees and during the assessment process, the assessors supported the trainees with a variety of troubleshooting techniques. The trainees, however, were positive about using live stream observation as a tool for their workplace assessment stating that the guidance document provided helped them prepare to use method for the assessment, allowed them to arrange a suitable time with their assessor and worked in a less stressful and nerve-wracking environment, even when visibility was reduced. This is because the assessors made them aware they didn’t have a clear view and advised on best position to enhance visibility, which made the observation process run smoothly.The limitation of the study is centred around the limited published data to support the use of live stream observation as a method of workplace-based assessment. As this study involves a small number of dental nurse trainees, the findings may not be a reflective of the personal experiences and viewpoints of all dental nurse trainees, clinicians, and assessors of other training providers. However, a key strength of the study is that it investigated views and experiences of using live stream observation from different perspectives and took a mixed methods approach to validate the findings. Moreover, this research indicates that this method was effective, and support from NES’s DCP workstream team significantly contributed to the successful implementation. It is hoped that this paper can support assessors in dentistry and other disciplines in the implementation of using technology to conduct workplace assessment. The findings from this study and further analysis will inform where continual improvements can be made to effectively support students and workplace teams in the organisation, and facilitation of remote workplace observation competency-based assessment via live video stream.Our main contribution in this paper is to investigate the views and experiences of using live streaming for workplace observation assessment to assess the overall satisfaction and effectiveness. Overall, it was found that satisfaction of using live streaming can be linked with the resolving technology issues and support received, but effectiveness is mixed. Our results, as well as the limitations of supporting data, point naturally to several directions for future work. However, sustaining this method and the future use of remote live observation will be dependent on the Skills for Health decision to maintain this as an assessment method with the assessment strategy for the SVQ in Dental Nursing qualification. Nevertheless, the use of remote live observation assessed a range of generic and practical trainee competencies that require a higher level of confidence in managing the technology used and carrying on with the assessment. It allowed for feedback and validation of the trainee learning experiences and was viewed as an efficient and effective way of assessing and providing feedback particularly in response to global pandemics such as the changing condition posed by the ongoing COVID-19 pandemic. Thus, it is a feasible option for assessing trainees based in areas with transport difficulty  without having to travel.NES has created a vision for Technology Enhanced Learning that will enable education by facilitating appropriate, high-quality Technology-Enhanced Learning for the Health and Social Care workforce now and in the future. The findings and learning from this project will be shared to support the integration and staff development of utilising the functionalities of various technologies within blended learning programmes as a robust assessment tool. Therefore, as the use of remote live observation continues to be developed, consideration should be given to incorporate features that enable acceptance and re-imbursement for high-speed internet/phone expenses. Further local research and comparisons will help to identify practical and efficient ways of using live streaming to conduct workplace-based assessment and give feedback to encourage learning among dental trainees. Nevertheless, the use of the live stream technology generally worked well for the purpose of the workplace-based competency assessment. What was learned from the experience with the COVID-19 pandemic is the need for flexibility concerning conducting the workplace-based assessment.