The current pipeline surface generation algorithm cannot get the angle information of the corner of complex pipeline surface, which leads to the poor accuracy of the algorithm, the slow speed of 3D point cloud intelligent mosaic, and the large number of effective points. Therefore, a CAD surface generation algorithm for complex pipeline model under the background of Industry 4.0 is designed, extracting and rendering the wireframe model and extracting background of the complex pipeline video. We obtain the angle information of the corner points of the complex pipeline surface, extract and match the feature of the dense point cloud, and construct the 3D point cloud data mosaic model. The pipe surface is generated by using double-nodal B-spline. The experimental results show that the precision and stability of the proposed method are high. In the early stage, the proposed method uses ISS feature extraction algorithm to extract feature of point cloud data, which improves the positioning accuracy effectively and enhances the 3D point cloud intelligent stitching speed. Industry 4.0 refers to the Industrial Revolution supported by the Internet and big data, which is the fourth Industrial Revolution derived from the information age. According to the requirements of Industry 4.0, the construction of the factory needs to move forward in the direction of intelligence, establish digital-physical system, make it participate in the purchase of materials, production, and marketing of products and other links, link all links into a whole, comprehensively improve the industrial production efficiency and the degree of product innovation, and then make the Industry get a greater level of progress on the original basis , 2. The Tubular engineering structure has the advantages of good mechanical properties and light weight. It is widely used in construction, vehicle engineering, biomedicine, chemical Industry, national defense and military, and other fields, for example, frame structures in buildings, lightweight engineering in the field of vehicles, vascular simulation in medicine, deep-sea drilling, pipeline robots, and other major equipment –5. In thReference  proposesHowever, the above methods can not obtain the included angle information of corner points of complex pipeline surface, resulting in poor accuracy of the algorithm, slow speed of 3D point cloud intelligent splicing, and more effective points of surface splicing. Therefore, the CAD surface generation algorithm of complex pipeline model under the background of Industry 4.0 is designed. The wireframe model of CAD surface of complex pipeline model is extracted and drawn, and the complex pipeline video is collected according to the model to extract the video background. Then the dense point cloud features of pipe surface are extracted and matched, and the 3D point cloud data stitching model is constructed. Finally, the pipe surface is generated by multiple node B-spline. Finally, experiments show that the algorithm has higher accuracy and stability and lower error rate and can meet the needs of CAD surface generation of complex pipeline model.Line frame model of geometric modeling system is the earliest technology used to describe object model, which plays an important role in the early development stage of products . It not U={0,0,0,0.5, 1,1, 1n}, and store the geometric information of each joint in the form of text file.The extracted wireframe structure is divided into multiple two joints and three joints, as shown in Figures TKF240 is selected as the acquisition module of the surveillance camera to complete the functions of the control exposure, image gain, and white balance of the complex pipeline video , 15. TheAs can be seen from In order to ensure the integrity of the video data of complex pipelines, it is necessary to use a video collector for complex pipelines to store the video data of complex pipelines. The 32-bit processor shall be used in the video monitoring system for complex pipelines oriented to Industry 4.0, and the video collector for complex pipelines shall also choose 32-bit processors. Considering that the video collector is larger than 8M to ensure the integrity of the video data of complex pipelines, the SCD985 chip is selected, and the single chip has a capacity of 16 × 16. Since the video data transmission of 32-bit is required in the motion video monitoring system, the 16-× 32 collector composed of two pieces shall be used.If the video image of complex pipeline captured by the monitor camera is displayed in the monitor terminal, it must be realized through the transmission interface of the monitor network. The Ethernet of Industry 4.0 is used to transmit the video image of complex pipeline. The monitoring terminal is used as the server and the video collector of complex pipeline as the client. Monitoring network transmission interface is the data interface connecting complex pipeline video controller and media access controller and can support the independent interface of complex pipeline video . In the The Monitor Network Transmission Interface allows monitoring applications to access registers. The Monitor Network Transmission Interface based on Industry 4.0 supports multiple input modes and supports complex pipe video images with a maximum input resolution of 8192 × 8192, monitoring network transmission interface with video data scaling and previewing video images and other functions, but also supporting the rotation and flipping functions. Complex piping video surveillance systems can capture complex piping video through the transmission interface of the surveillance network, and surveillance cameras with industrial 4.0 designs have super-high pixels of 3 million to meet the requirements of motion video resolution , 18.Based on the advantages of the Fourth Industrial Revolution, the paper integrates several video processing units in the hardware platform of the monitoring system, collects the image data of the complex pipeline video on the collection sensor, and completes the design of the video collector of the complex pipeline and develops the monitoring network transmission interface of the monitoring system by using Ethernet, completes the design of the monitoring network transmission interface by analyzing the performance and circuit interface of the monitoring network, and realizes the hardware design of the moving video monitoring system , 20.In the context of Industry 4.0, to extract the background of complex pipeline video, we must first determine the picture pixels in the complex pipeline video background. In the complex pipeline video collected by the collector, the value of each pixel follows a specific law. For complex pipeline video monitoring system, due to different monitoring scenes, the background of complex pipeline video usually presents single-mode characteristics , 22.Q={q1, q2, ⋯, qn}, the pixel values in the complex pipeline video together constitute a pixel set W={w1, w2, ⋯, wn}, so that μ is the mean value of pixel set μ and δ is the variance of pixel set W; when the complex pipeline video pixels in W conform to the normal distribution, there isSuppose that, for a complex pipeline video frame sequence ℵ and the complex pipeline video frames collected by the system are fi and , the extracted complex pipeline video background isWhen extracting the complex pipeline video background, the surveillance camera is usually static, and the extracted complex pipeline video background value is the mean value of the statistical value. Assuming that the extracted complex pipeline video background is α representing the speed of pixel update is introduced to control the proportion of complex pipeline video background. The updated complex pipeline video background extraction formula is as follows:In a complex pipeline video surveillance system, when the surveillance camera oscillates slightly, the captured complex pipeline video pixels will not follow the normal distribution, and the above method will cause the extracted complex pipeline video background confusion . Based oBecause it is difficult for the original complex pipeline video background extraction formula to obey the normal distribution, the complex pipeline video background extraction formula is updated by introducing the coefficient of update speed.In the process of reconstruction of complex pipeline surface, the included angle information of corner points of complex pipeline surface is firstly obtained by combining SUSAN corner detection theory, and corner features under contrast of dense point clouds of different pipeline surfaces are extracted , 25. Surg represents a fixed threshold value in the dense point cloud of the surface, and ℑ represents the minimum contrast of corner points that can detect the surface point cloud.In the complex pipe surface template area, the maximum and nonzero point is selected as the corner point, where ℑ of point cloud of different surfaces was extracted, which was expressed byIimax and Iimin, respectively, represent the maximum i gray values and the minimum i gray values in the point cloud of pipe surface.The gray value of complex pipeline surface was analyzed, and the adaptive threshold under contrast mi1， mj2) of the point cloud of the pipe surface is obtained by the correlation method. The two corners are centered on mi1 and mj2, respectively, and R is the neighborhood N(mi1) and N(mj2) of the radius of the pipe surface. Pipe surface point cloud matching points m1 and m2 are associated points, and pipe surface is 3 × 3. If F in the matrix is the module matrix of two pipe surface point clouds, and the surface point cloud module matrix vector mi, there areFirstly, the initial matching point , and the general form isa0, a1, a2, a3, a4 represent the rotation angle. The minimum value is obtained according to the least square principle, namely,Set the quadratic pipe surface equation composed of the Derive formula  so that Sequence splicingGlobal stitchingPoint cloud mosaic mainly refers to the use of arbitrary transformation to align the point cloud data in two groups of different regions, so that point clouds obtained from points in each region can be accurately matched and spliced –28. SeveOS − XSYSZSThe coordinate system of the topography sensor is Of − XfYfZfFrame coordinate system composed of rigid connection of topography sensor is Ow − XwYwZwThe world coordinate system is Three-dimensional topography measurement is mainly composed of control computers, industrial robots, and topography , 30. AmoP stands for any point within the set range, and the coordinate of this point in the topography sensor coordinate is Ps. Through transformation relation sfA, point cloud measurement data can be obtained and converted to the world coordinate system, and the corresponding relation can be obtained as follows:Any two coordinate systems between the above three coordinates can be converted, From the analysis formula, it can be seen that the point cloud data obtained by the robot driving the profilometric sensor at different measuring stations is converted to the world coordinate system, which is constructed on the laser transmitter . Becauses1 and target point cloud s2 to obtain the simplified model. The swarm intelligence optimization algorithm was used to optimize the evaluation function and obtain the transformation matrix. The obtained transformation matrix is applied to the initial point cloud s1 to realize the splicing with point cloud s2. The specific operation process is shown in Set up point sets corresponding to different point clouds, and determine the number of final feature points according to the size of data scaleStructured processing of point sets through the K-D tree method to accelerate the acquisition of the distance between point clouds g by using the target point set to quickly obtain K neighborhood points and calculate the distances between different point clouds and K neighborhood points, respectivelyA K-D tree is set up for all points in the source point set K neighborhood shall be counted, the point expansion matrix shall be established, and the corresponding feature vectors shall be calculatedThe regional point sets composed of each point and The eigenvalue is evaluated through the eigenpoint extraction algorithm, and the corresponding eigenpoints are extractedThe simplified model after extracting the feature points is regarded as a new initial model, and the swarm intelligence algorithm is used to determine the initial parameters and convergence conditionsInitialize the optimized individuals to ensure the corresponding spatial location of each search fieldWhen an iteration is completed, the current optimal solution and the global optimal solution shall be compared, the better optimal solution shall be set to all new optimal solutions, and step (7) shall be returned, and the above operation process shall be repeated until a required number of iterations are completedG, and obtaining a new point cloud is the point cloud after the completion of the mosaicComparing each variable of the final optimal solution with six parameters of the transformation matrix, the transformation matrix is applied to The swarm intelligence algorithm was used to solve the 3D point cloud data mosaic model : FeatureIn the process of generating pipeline surface, the free deformation technology is used to place the deformed part of the 3D model of pipeline surface parameters into a specific hexahedron space and assign fixed grid parameter coordinates to all points in the hexahedron and on the hexahedron boundary and promote the model to produce deformation effect by adjusting control points. The parametric optimization generation of pipeline surface is effectively realized , 35. Theri,j,k represents all marked pipe surface mesh control vertices, and the part of the pipe surface parameter 3D model to be modeled is placed in a specific hexahedron space based on Li,2 and Li,N+1; then all marked pipe surface mesh control vertices shall meet the following conditions:In the process of parametric optimization generation of pipe surface, it is assumed that i, N, and j represent the boundary of pipe surface mesh control vertices, and U, V, and W represent the coordinates of pipe surface mesh control vertices [Here, vertices .Q after deformation are calculated by using the following formula [In the process of generating pipe surface, the model is deformed by adjusting the control points, and the new coordinates of point  formula :(12)γu,vri,j,k represents the position of the new coordinates of the control vertex, and bi,j(u), bj,m(v), and bk,n(w) represent the basis function of the pipe surface, respectively, which completes the generation of the pipe surface.Here, The application effectiveness of the proposed algorithm is verified by the test object with a complex three-tube structure.W={1, 21/2, 1, 21/2, 1, 21/2, 1} and the node vector is V={0,0,0,1,1,1}. In this experiment, the three mutual components shown in According to the mutual formation mode of In order to prove the comprehensive effectiveness of the complex pipeline surface reconstruction method based on genetic algorithm, a simulation experiment is needed. In the process of complex pipeline surface reconstruction, firstly, the genetic parameters are given, the initial population size Num = 50, and the maximum number of iterations MAXGEN = 60. Binary coding is used for coding, and the coding accuracy is 0.01. The local pipeline surface to be reconstructed in the first group of reverse engineering is shown in The genetic algorithm is used for optimization to find the optimal position for the reconstruction and matching of complex pipeline surfaces. After the coordinate rotation operation, the coordinates of the obtained complex pipeline surfaces are transformed to realize the matching of local complex pipeline surfaces in reverse engineering. The reconstruction and matching effect pictures of local pipeline surfaces when the genetic algorithm is iterated 40 times are given, respectively, as shown in By analyzing Comparative experiments are carried out by using the automatic surface generation method based on CAD model proposed in , the autIt can be seen from Figures In order to further verify the advantages of the proposed method, the following experimental tests compare the three-dimensional point cloud intelligent splicing speed of four different methods. The specific experimental comparison results are shown in By analyzing the experimental data in The number of effective stitching points is also an important index to verify the comprehensive performance of each method. The higher the number of effective stitching points is, the more ideal stitching results will be obtained. By analyzing the experimental data in In order to optimize the surface reconstruction effect of complex pipeline, the CAD surface generation algorithm of complex pipeline model under the background of Industry 4.0 is designed. On the basis of extracting and matching the characteristics of dense point cloud of pipeline surface under different contrast of dense point cloud of pipeline surface, a three-dimensional point cloud data stitching model is constructed, and the pipeline surface generation algorithm is designed based on multiple node B-spline. The experimental results show that the proposed method has high accuracy and stability, effectively improves the positioning accuracy of surface point cloud data, and comprehensively enhances the intelligent splicing speed of 3D point cloud of the whole method.


YouTube is the second most popular search website worldwide to access health information online. This study was undertaken to assess the reliability and quality of information about myositis on YouTube and delineate attributes of useful videos using standard metrics.We conducted a thorough search on YouTube using 9 search terms related to myositis. The inclusion criteria were content related to myositis, English language and acceptable audio–video quality. Duplicates and advertisements were excluded from the analysis. Videos were classified as useful, not very useful or misleading and patient narratives. Reliability was determined using the mDISCERN criteria, quality using the Global Quality Scale (GQS) and JAMA system, using appropriate cut-offs .Out of a total of 900 videos, 453 were included for the analysis. Seventy-four per cent and 2% provided useful and not very useful information respectively, while 24% were patient narratives. Seventy-one per cent were intended specifically for patients while 69% were for healthcare providers and students.p = 0.024, p = 0.046).Noteworthily, useful and not very useful videos had similar total views though the number of likes and daily viewership were higher for useful videos (κ = 0.129). However, GQS emerged as a significant (p = 0.008) predictor of video usefulness in multivariate analysis.Nearly half (47%) of useful videos were by professional medical societies/patient support groups (PSGs) while not very useful ones were by nonmedical media (38%). Physician-predicted usefulness was discordant with score-based usefulness (A large majority of English YouTube videos on myositis provide useful information for patients. Physicians could signpost patients to high-quality useful videos as determined by GQS and sources like professional medical societies and PSGs.The online version contains supplementary material available at 10.1007/s10067-023-06522-x. In the digital era that we live, eight of ten users access health information on the internet . Of the The idiopathic inflammatory myopathies are not only rare but also complex conditions, which are often associated with comorbidities and complications of prolonged treatment . A typicWe undertook a cross-sectional review of the reliability and quality of YouTube videos on myositis using validated assessment tools  and the JAMA scoring system) , 8, 9. WThe results of this study will help determine the percentage of misinformation present about myositis on YouTube and identify the type, distribution and quality of content present, which will help physicians to direct patients to useful videos. Knowing the type and quality of content present will help plan future strategies for creating videos for supplementing patient and physician education, which may include the production of videos on the lesser prevalent content, and the debut of renowned healthcare providers on YouTube.In a cross-sectional design, we evaluated the quality of videos on YouTube® related to myositis after a thorough search using terms “Myositis”, “Idiopathic Inflammatory Myositis”, “Dermatomyositis”, “Polymyositis”, “Cancer Associated Myositis”, “Inclusion Body Myositis”, “Immune Mediated Necrotizing Myopathy”, “Juvenile Dermatomyositis” and “Overlap Idiopathic Inflammatory Myositis” sequentially in March 2021. Search terms were determined based on the type and classification of myositis. The internet browser was cleared of cookies and search history prior to the search which was carried out in the incognito mode to avoid bias from previous searches.The first ten pages, i.e. one-hundred videos per search term, were included in the evaluation, as viewers rarely go beyond this. We searched videos using the ‘relevance’ filter, which is the default setting on YouTube®, thus duplicating the search results of the common population and providing accurate results. The first 100 videos for each term were saved to a playlist for future analysis. Two authors (MJ and RG) conducted the search and evaluated the videos independently while LG resolved conflicts if any.We included videos that had primary content related to myositis, in English language, with acceptable audio–video quality, and were available on 13 March 2021. Multi-part videos were evaluated as a single entity. We excluded videos that did not relate to myositis, were repeats or duplicate or were advertisements. Of the 900 videos initially screened, 453 videos were included. The details are presented in Fig. The videos were classified as useful, not very useful or misleading, or patient narratives by two independent assessors, as defined in Table daily viewership rate was calculated in order to avoid bias that may result from the date of upload to YouTube®, using the formula: total view count/duration of availability. The total view count was noted during viewing of the video. The duration of availability was calculated by subtracting the date of upload from the date of viewing in days. Interaction index and viewing rate were calculated using the following: (number of likes-number of dislikes)/total number of views × 100% and (number of views/number of days since upload × 100%) respectively.A The reliability of the videos was determined using the modified DISCERN criteria, a scale for assessment of audio–video content Table  3]. It . It 3]. p-value of < 0.05 was considered significant. Inter-rater reliability was evaluated for mDISCERN, JAMA and GQS scores using intraclass correlation (ICC) estimates and their 95% confidence intervals based on a mean-rating (κ = 3), absolute-agreement, two-way mixed-effects model.Continuous variables are presented as mean (± standard deviation) or median (interquartile range) depending upon normality of data, and categorical variables are presented as counts and percentages. The results were analysed using the nonparametric Kruskal–Wallis test and the Pearson chi-squared test for continuous and categorical variables respectively. A No human subjects were involved in the conduct of this study. The study included a review of video content posted on YouTube® which falls under the category of open source distribution. The study was exempt from ethical review.A total of 900 videos were screened for inclusion in the study. Of these 372 duplicates, 25 videos presented in a language other than English and 50 that were considered irrelevant were excluded. A total of 453 videos were identified for further analysis. After detailed viewing, 108 were found to be patient narratives and experiences, and eight were identified as not very useful for patients and doctors.Of the analysed content, 191 (42%) videos were uploaded by a professional medical society or a patient support group (PSG). Furthermore, 79 (17%) were developed by group practice, physician and 62 (14%) by a hospital. While reviewing the videos, it was observed that 316 (70%) were presented by a speaker with formal medical training which included rheumatologists (16%) and neurologists (12%).p = 0.02) and the median number of views per day (p = 0046) or daily viewership were significantly higher for useful videos. The interaction index for useful videos was significantly higher (p = 0.01).The median number of views was 985  and the daily viewership was found to be 139 . The detailed baseline characteristics of the videos are presented in Table  to 2069.Among the included videos, 324 (71%) were developed for a target audience of patients, 313 (69%) for healthcare providers including students and 75 (17%) for caregivers. Videos contained information on the treatment , diagnosis of myositis , signs and symptoms  and miscellaneous information .Of the analysed videos, 74.3% (337/453) provided information that was considered useful and 1.7% (8/453) not very useful. It was found that content uploaded by non-medical media organizations was found not very useful videos . Content created by professional medical societies/patient support groups was considered useful . Content created by group practice or physician was also considered useful . As many as 310 (92%) videos were created by professionals who had undergone formal medical training. The detailed baseline characteristics of the videos, stratified by the source, are presented in Online Resource 2.reliability of the videos as assessed by the modified DISCERN criteria was higher for useful videos as compared to the not very useful videos , with a significant statistical difference (p ≤ 0.001). The useful videos also had higher scores for quality obtained by GQS  and JAMA  compared to the not very useful videos, and this was statistically significant . A comprehensive analysis of video characteristics by usefulness category is given in Table The p < 0.001 for all the three scoring systems). A detailed analysis of video characteristics by score based usefulness is given in Online Resource 3.The useful videos had higher scores for reliability and quality obtained by modified DISCERN , GQS  JAMA  compared to the misleading videos, and this was statistically significant  were categorized as useful and 9.0% (41/453) as not very useful videos, based on the aforementioned criteria. The Kappa values for p = 0.002) for predicting video usefulness.In order to identify the features of a video with useful content, we performed a multivariable binary logistic regression analysis. It was noted that the GQS scoring system is a statistically significant factor  and students (90%). Interestingly, the median views on the videos identified by our reviewers as useful were not significantly different from the not very useful ones. Indeed, those identified “not very useful videos” had higher number of median subscriptions as compared to “useful ones”. Most of the not very useful videos were produced by nonmedical media organizations and professional society/support groups, with patients being the primary intended audience. However, the quality and flow of the videos were generally poor, with many essential topics missing. One may postulate that the viewers can relate more closely and identify with the presenter in the videos developed by nonmedical individuals, making them more likely to subscribe to their channel. The disparity in the number of subscribers might also be because of the evident difference in the number of useful and not very useful videos. However, this might allow the spread of misinformation. This makes it important for health workers to direct patients towards appropriate content on the platform during clinical consults.n = 1) as per physician-decided usefulness. This disagreement between physician-decided and score-based usefulness  could be attributed to physician bias or objectivity in score-based systems. Although, poor agreement between the kappa values of mDISCERN, GQS, JAMA and physician-based usefulness  is likely due to the mutually exclusive nature of the scores judging different aspects of the videos, objective scores should be applied to all videos providing health care-related information. The GQS system, which takes into account the quality and flow of the video and the extent of relevant information covered, was found to better predict physician-identified video usefulness using a binary logistic regression analysis.As anticipated, non-medical organizations uploaded the highest proportion of not very useful videos (3/37) as per physician-determined usefulness. The score-based usefulness on the other hand stated that the highest number of not very useful videos came from “group practice/physician”  compared to only 13% (likes (useful-12: not very useful-1) and daily viewership (useful 95: not very useful (− 1136)), an indirect indicator of viewers’ acknowledgement of the quality.In the long run, accreditation metrics for validity and guidelines related to the uploading of factually correct and scientifically backed information may be needed. Other factors related to video characteristics such as duration, upload date, audio–video quality and credentials of the speaker also tend to affect people’s decision of choosing which videos to watch. Moreover, YouTube records a view when a user watches at least 30 s of a video. An average person takes longer than the above-mentioned time period to make a decision about the usefulness of a video. As expected, the videos classified as useful captured a higher number of While YouTube has become the second most popular social network and the third most trustworthy source of health-related information after physicians and government healthcare institutions, a further rise in usage of social media platforms is expected in the near future, especially in seeking health-related information , 11, 12.While several authors have found social media to be a source of misinformation like in COVID-19, rheumatoid arthritis, vaccines or drugs, we found that such was not the case with myositis, possibly owing to it being a niche area , 13, 14.Like many other, our study is also bound by certain limitations. Using a cross-sectional study design, we were unable to capture the dynamicity of a social media platform which gets updated continuously. Findings of other investigators may be at variance due to this dynamicity. Moreover, we only evaluated videos with English content. Evaluating other languages was beyond the scope of our current resources. Additionally, we included only the first one-hundred search results on a single social media platform. A broader inclusion of content as well as platforms is likely to reveal more comprehensive picture. However, we have reason to believe that our results are reasonably representative of a larger body of content across different platforms, and physicians should befriend social media while empowering patients to identify valid, reliable and effective content. Our study systematically evaluated video content available on YouTube and provides a reliable tool to predict usefulness for clinicians and patients. Including videos in languages other than English, reviewing the content available on other social media platforms and understanding the psychological and motivational factors influencing patients’ decision to subscribe to not very useful videos possibly by a thematic analysis may be the direction for future studies.The present study is one of its kind to study characteristics of information on sub-specialisms like myositis available on YouTube and report that the content is reliable with minimal misinformation. Nearly three quarters of the videos are from verifiable sources, and the results are quite reassuring. While it is challenging to eliminate misleading information easily available online on the internet, the present study also concludes that GQS system is a significant marker to identify reliable, valid and useful content on YouTube for myositis and possibly other medical subjects. Specialists should actively participate in the development of medically related videos using validated tools to disseminate appropriate health information.Supplementary file1 (PDF 31 KB)Supplementary file2 (PDF 36 KB)Supplementary file3 (PDF 40 KB)Below is the link to the electronic supplementary material.


Background: In restorative proctocolectomy with ileal J-pouch, perfusion assessment is vital to prevent complications such as anastomotic leak (AL). Indocyanine green near-infrared fluorescence (ICG-NIRF) is gaining popularity, while its interpretation and relevance remain subjective. This study aimed to evaluate a standardized ICG-NIRF imaging protocol combined with a novel, software-based assessment to detect areas of impaired perfusion and a possible correlation with AL of the pouch. Methods: In this prospective study, patients undergoing ileal J-pouch for ulcerative colitis at an inflammatory bowel disease (IBD) referral center were included. Intraoperatively, strictly standardized ICG-NIRF visualization was performed and video-recorded. Postoperatively, a specific software was utilized to determine the change in fluorescence intensity per second (i/s) for systematic regions of interest, generating perfusion-time curves and a pixel-to-pixel map. These were analysed in detail and correlated with clinical outcome . Results: Four out of 18 included patients developed AL of the ileal pouch-anal anastomosis (IPAA). In the AL group, the perfusion curves on the area adjacent to the IPAA (pouch apex) displayed considerably lower ingress/inflow  and egress/outflow  values than in the non-AL group ; egress: median = (−1.1); range = 3.9; interquartile range = 1.0 i/s). This was confirmed by further novel parameters of pouch perfusion  and pixel-to-pixel analysis. Conclusions: This study presents the feasibility of a novel methodology to precisely assess pouch perfusion with ICG-NIRF, identifying comparable, quantifiable, and objective parameters to potentially detect perfusion-associated complications in surgery in real-time. Restorative proctocolectomy (RPC) with the construction of an ileal J-pouch and ileal pouch-anal anastomosis (IPAA) has been established as the surgical procedure of choice for patients with medically refractory ulcerative colitis (UC) or familial adenomatous polyposis (FAP) and selected patients with Crohn’s colitis ,2,3. A tThe risk of AL is increased by an impaired blood flow to the pouch and IPAA ,19. ConsThis study aimed to evaluate a systematic approach of intraoperative ICG-NIRF imaging  combined with a software-based perfusion assessment for the detection of areas of impaired perfusion by correlation with postoperative outcome including AL of the pouch. We hypothesized that a dynamic depiction of fluorescence intensity over time would result in novel, quantifiable and objective indicators of pouch perfusion.This prospective cohort study (NCT04695184) was conducted from February 2019 to December 2020 at the Department of General and Visceral Surgery, Charité University Medicine Berlin, Campus Benjamin Franklin, a tertiary referral center for colorectal and inflammatory bowel disease (IBD) surgery. Study approval was given by the Charité University Hospital Ethics Committee  and all data were reported in conformity with the STROBE guidelines . Patients receiving RPC with an ileal J-pouch in either a two- or three-stage approach were included. In the two-stage approach, patients underwent proctocolectomy simultaneously with ileal J-pouch and protective ileostomy, followed by ileostomy reversal. Patients undergoing the three-stage approach received subtotal colectomy with end ileostomy in stage one, completion proctectomy with ileal J-pouch formation and loop ileostomy in stage two, and ileostomy reversal in stage three.Study inclusion required a diagnosis of medically refractory UC, indeterminate colitis (IC), Crohn´s colitis or familial adenomatous polyposis (FAP), age ≥ 18 years and an American Society of Anesthesiologists (ASA) physical status ≤ 3. Patients were excluded if they displayed a hypersensitivity to ICG or sodium iodide, iodine allergy, hyperthyroidism, thyroid nodules, a previously poorly tolerated injection of ICG, pregnancy or breastfeeding, a coexisting malignancy or liver dysfunction (with a Model End Score Liver Disease (MELD) score > 10).Informed consent for study participation was received at least 24 h prior to surgery.Following the standard surgical operating procedure of the tertiary IBD referral center, laparoscopic preparation was followed by fashioning of the J-pouch to a length of 14–16 centimetres (cm) by linear single-stapling. It was then ensured that the fashioned J-pouch had sufficient mobility to extracorporeally reach down to the symphysis pubis without tension, to enable tension-free IPAA. IPAA was achieved by circular mechanical double-stapling using an end-to-end anastomosis (EEA) 29 millimeter (mm) stapler. In cases where mucosectomy was required due to risk of malignancy, single-layer hand-sewn anastomosis was performed after completed mucosectomy. In cases where laparoscopic preparation was considered a risk for patient safety, open surgery was conducted.® Fluorescence Imaging Platform  at three consecutive, predefined measuring time points , protecting the IPAA while allowing manual air insufflation.At time point 1 (T1), prior to J-pouch formation, the terminal ileum was visualized to ensure adequate baseline perfusion. At time point 2 (T2), the J-pouch was visualized immediately after its formation by side-to-side stapled anastomosis. At time point 3 (T3), after trans-anal circular stapling, the completed ileal pouch-anal anastomosis (IPAA) was visualized. At time points 1 and 2, the Quest Spectrum of view B. At timAt each time point, the effect of surrounding light was minimized by turning off the operating room and surgical lights. Each visualization was video recorded for 120 s to enable postoperative analysis. Patient baseline, intraoperative clinical and technical imaging environment data were documented, as well as the timing between the measurements.Using the Quest Research SoftwareTM, the video recordings underwent a postoperative perfusion assessment by analysing the distribution of fluorescence intensity over time. To achieve this, 10 regions of interest (ROIs) were manually selected on each pouch visualization in a standardized, predefined order: 8 ROIs on the pouch body including the pouch appendage (blind end) as well as two ROIs at the pouch apex A,B. One www.r-project.org, the R foundation, Vienna, Austria; accessed on 1 December 2021). Additionally, a computed pixel-to-pixel analysis of fluorescence intensity over time was conducted for each video recording. In this assessment mode, the software utilized each pixel as an individual ROI, allowing an analysis for maximum ingress and maximum egress and its detailed depiction as a heat map.By depicting fluorescence intensity over time, a perfusion curve was generated for each ROI, resulting in an individual perfusion graph for each pouch. The shape and characteristics of each perfusion graph were analysed in R statistical software  were detected. Additionally, radiologic pouchography with contrast enema was performed 6–8 weeks after surgery.AL of the pouch as described within 30 postoperative days was defined as the primary end point. Baseline patient characteristics, 30-day postoperative morbidity and the imaging environment were defined as secondary end points, including sex, American Society of Anesthesiologists (ASA) physical status classification, underlying condition, disease category, preoperative immunosuppressive medication, type of surgery, two- or three-stage approach, hand-sewn ileal pouch-anal anastomosis (IPAA), intraoperative change of the anastomotic site, age at operation (years), body mass index (BMI) and the presence of autofluorescence in the imaging environment.We applied a novel assessment method investigating the correlation of novel perfusion indicators with clinical outcome, discriminating between cases of AL and no AL. No previous data investigating this specific correlation existed prior to study commencement to enable the prediction of a suitable sample size. Based on the results of this study, power analysis for sample size may be possible in future studies, taking into account the prevalence of AL.In total, 18 patients underwent ileal J-pouch with intraoperative ICG-NIRF visualization and video recording, follow-up, and statistical and perfusion assessment analysis . ReasonsThe software-based analysis resulted in a depiction of fluorescence intensity measured per pixel (i: intensity) over time in seconds (s) for the ROIs of each pouch, resulting in a rate of intensity change per second (i/s). A distinctive perfusion curve was generated for each ROI, allowing the differentiation between pouch body, pouch apex and pouch appendage. A general shape could be observed in most cases, which was similar and aligned synchronously with the other ROIs of the same pouch. A fluorescence ingress  phase was followed by an intensity peak and egress  phase A. egress). “Maximum intensity + 5 s” represented the time point 5 s after the maximum fluorescence intensity was reached. To calculate the slope for the egress phase (egress), the intensity value at the time point of maximum intensity (tmaxI) and the intensity value at the time point 5 s after the maximum intensity was reached (tmax+I5) were used (Formula (1)).Thus, recurring time points and characteristics of the perfusion curves were identified B: “IngreDifferences in the shapes of the perfusion graphs became evident by preliminary visual comparison. In the AL group, ROIs of the pouch apex (directly adjacent to the IPAA) predominantly showed weaker ingress, peak and egress as well as weaker overall fluorescence intensity when compared to the non-AL pouches B.The identified novel characteristics of the perfusion curve  were examined in depth for each pouch according to clinical outcome and ROI location on the pouch body or pouch apex . The corThe ingress of ROIs on the pouch body was similar in both AL  and non-AL cases . In contrast, the ingress of ROIs on the pouch apex was considerably lower in the AL group  than in the non-AL group , indicating an impaired inflow at the apex.The same distribution was evident for the maximum ingress, which represented the maximum positive slope of the perfusion curve.Concordantly, the egress of ROIs on the pouch body was similar in both AL –(−3.1)}; interquartile range = 0.7 {(−1.5)–(−2.2)} i/s) and non-AL cases }; interquartile range = 1.7 {(−0.7)–{{−2.4)} i/s). Contrarily, the ROIs on the pouch apex displayed considerably lower egress in cases of AL }; interquartile range = 0.5 {(−0.1)–(−0.6)}i/s) than in non-AL cases }; {0.0–(−0.7)}; interquartile range = 1.5 {(−0.5)–(−2.0)} i/s), indicating an impaired outflow at the apex. The maximum egress value of ROIs of the pouch body was again similar for both outcomes, while the ROIs of the pouch apex showed lower maximum egress values in cases of AL. In summary, ROIs on the pouch apex displayed lower ingress, maximum ingress, egress and maximum egress values in cases of AL, while ROIs on the pouch body showed no considerable difference. In non-AL cases, all parameters for both the pouch apex and pouch body had an overlapping range. Conversely, in cases of AL, there was a notable difference between pouch apex and pouch body. In the analysis of ingress versus egress , pouchesThe computed pixel-to-pixel analysis of the video recordings resulted in a parametric map for maximum ingress and maximum egress . The parIn the resulting parametric map, each pixel of the recording was analysed as an ROI for maximum ingress and maximum egress, respectively, resulting in an objective high-resolution map of each pouch. For clarity and to enable direct comparison, we have shown the parametric mapping for patient 1 (non-AL) and patient 2 (AL) from In maximum ingress mapping A, patienIn maximum egress mapping B, patienThe study presented here provides a novel, systematic methodology  to quantitatively assess anastomotic perfusion with ICG-NIRF and clinical outcome in ileal J-pouch surgery. Furthermore, this study describes a novel multi-step software-based assessment with objective indicators of pouch perfusion and areas of impaired perfusion, which are described for the first time in the medical literature.In studies investigating anastomotic perfusion with ICG-NIRF, the ICG dosage varies considerably, while the standardization of measuring time points, surrounding light, camera distance to target, device settings  are rarely ever mentioned ,24,33. HHowever, the combination of this systematic imaging approach combined with a novel software-based perfusion assessment resulted in quantifiable results. A graphic depiction of fluorescence intensity over time for defined ROIs resulted in perfusion graphs, which in turn were composed of perfusion curves following a reproducible pattern. So far, only a few clinical feasibility studies mention perfusion-time curves; however, none investigate the ileal J-pouch in a standardized manner or examine ingress and egress in detail ,40.For the first time in the medical literature, novel parameters of pouch perfusion were identified by examining the perfusion curves of the pouch apex and pouch body according to clinical outcome with regards to AL. The possible significance of the slope of the perfusion curve for AL in software-based assessment has previously been described, while ingress and egress have not . MaximumThe applied methodology resulted in perfusion graphs for each pouch consisting of repeatable, similar perfusion curves per ROI. Non-imaging related baseline patient and intraoperative factors did not show a statistical difference with regards to AL of the pouch, verifying high internal validity. The differences in the perfusion graphs of the AL and non-AL group are mechanistically comprehensible, as are the differences in ROIs of the pouch apex and pouch body. Impaired perfusion at the pouch apex is likely to contribute to AL of the IPAA. Interestingly, when ingress, maximum ingress, egress and maximum egress for all pouches (regardless of ROI location) were compared for regular outcome and AL, there was no considerable difference for cases of AL. However, when the differentiation was made between ROIs located on the pouch body and the pouch apex , there wThe novel, dynamic parameters of perfusion identified here represent the rate of inflow and outflow of blood at a region of surgical interest and are mechanistically comprehensible, enabling us to detect impaired perfusion not only due to reduced blood supply but also due to venous congestion. This is a feature that the widespread subjective real-time interpretation of ICG-NIRF has not been able to deliver. The relevance of this study is emphasized by the urgent need for objective and comparable intraoperative perfusion assessment and follow-up in ileal pouch surgery, which can only be achieved by systematic standardization of ICG-NIRF visualization and quantitative, software-based protocols such as those proposed here.Our study included a limited number of patients and can be improved, which we would like to address in the future by increasing the number of patients included, introducing randomization and blinded assessment to investigate statistical significance. The three time points of visualization had different degrees of relevance for predicting AL of the pouch. Time point T1  was designed to indicate baseline perfusion and to exclude an overall perfusion deficit, which was not the case in any patient. Time point T2 (J-pouch after fashioning) allowed visualization and assessment of the whole J-pouch, which is why it was given the highest priority for assessing pouch perfusion. Time point T3  had a high theoretical relevance to assess anastomotic perfusion locally at the IPAA. However, the intraluminal measurement was technically difficult to standardise in terms of the distance from the camera to the imaging site and reducing movement. Software-based assessment was not yet possible. This needs to be addressed in the future, when flexible ICG-NIRF endoscopes will offer additional intraluminal visualization possibilities. The parametric pixel-to-pixel mapping holds great promise for intraoperative real-time use, as it is highly accurate and removes further subjectivity and bias from the perfusion assessment . We have recently shown its feasibility for perfusion assessment in gracilis muscle interposition . HoweverRequiring less than one minute of computing time, the software-based perfusion assessment could have technically been performed intraoperatively in real-time; however, to increase patient safety, we decided to perform a retrospective analysis first to prove its feasibility before altering intraoperative decision making. To further investigate whether the novel parameters of perfusion identified here are indeed objective indicators of perfusion, larger, randomized and blinded trials are needed to investigate statistical significance.This study provides the feasibility of a methodology to objectively assess anastomotic perfusion with ICG-NIRF and clinical outcome in pouch surgery. By analysing and depicting fluorescence intensity over time dynamically, perfusion graphs could be characterized in detail and correlated with clinical outcome. Novel parameters of pouch perfusion such as ingress, maximum ingress, egress and maximum egress could be identified and confirmed by parametric pixel-to-pixel mapping. They have never been described before and have the potential to improve the objectivity and quantifiability of intraoperative perfusion assessment in the future in real-time, not only for pouch surgery, but also for intestinal surgery in general.


Crithmum maritimum L. effectively inhibits the growth of hepatocellular carcinoma (HCC) cells and we provide insights into the biological mechanisms involved. Here, we aimed to characterize the effect of ethyl acetate extract of Crithmum maritimum on the bioenergetic phenotype of HCC cells and if this is associated with the anti-tumour effect we previously described. Results show that Crithmum maritimum significantly increases cellular respiration and reduces lactic fermentation in HCC cells, and that this reduction of the fermentative glycolytic phenotype is linked to inhibition of HCC growth. These data provide new preclinical evidence supporting the role of Crithmum maritimum L. as a nutraceutical option to expand the therapeutic opportunities in the management of HCC.In the past few years, evidence has supported the role of plants as a valuable tool for the development of promising therapeutic support options for many diseases, including cancer. We recently discovered that the edible wild plant The online version contains supplementary material available at 10.1007/s11130-022-00986-z. The utilisation of plant extracts and plant-derived products for therapeutic purposes is now gaining new importance for many pathological affections, including cancer . HepatocCrithmum maritimum is known for a long time as an edible plant with general beneficial health effects, with antioxidant and antimicrobial properties . We . We Crity Figure  7]..CrithmumCrithmum maritimum in inhibiting HCC growth [Crithmum maritimum changes the bioenergetic phenotype of HCC cells, activating oxidative phosphorylation (OXPHOS) and decreasing lactic fermentation. These observations support the view that activation of aerobic oxidative metabolism is associated with a reduction of tumour growth.We have been the first to describe and characterize the activity of C growth , associaC growth . Here, wThe material and method section is reported in the Supplementary Material.Crithmum maritimum ethyl acetate extract effectively inhibits HCC cell growth [Crithmum maritimum ethyl acetate extract on HCC cell bioenergetic phenotype and if this is associated with its anti-tumour effect [Crithmum maritimum ethyl acetate extract in two HCC cell lines, HepG2 and Huh7. A 24 h treatment in the same conditions also determined a significant increase in basal respiration, ATP-dependent respiration and respiratory reserve, in both cell lines


In addition, classmates’ drinking behaviors, friends’ persuasion, and attending parties were risk factors for adolescents’ drinking behavior, while the propaganda and regulations of banning drinking in school were protective factors. The school environment, especially friends drinking, is associated with students’ drinking behavior. It is necessary to mobilize the strength of schools and peers to strengthen the prevention and control of adolescent drinking.Drinking alcohol during adolescence has short-term and long-term effects on physical and mental health. At this stage, teenagers are greatly influenced by their schoolmates and friends. We conducted a multicenter cross-sectional study to investigate the association between school environment factors and adolescents’ drinking behavior in China. Using multistage stratified cluster sampling, the study investigated 27,762 middle school students from six cities in China. The logistic regression model was used to explore the association between the school environment and adolescent alcohol drinking behaviors after adjusting for confounders, including gender, age, city, location, and smoking status. Compared with students with none of their close friends drinking, students with more than half of their close friends drinking were more likely to drink in a year (OR = 20.148, 95% CI: 17.722–22.905,  Alcohol consumption causes almost 3,000,000 deaths in the world per year. Drinking alcohol during adolescence has short-term and long-term effects on both physical and mental health . AdolescThe World Health Organization reports that 43.0% of people over 15 years old are currently drinking alcohol, and 12.5% have previously consumed alcohol worldwide. A study showed that 51.1% of teenagers had consumed alcohol in China . At presStudies have shown that the food environment is associated with adolescents’ eating behaviors, e.g., calorie/fat intake ,12,13,14Some studies have also attempted to describe the school environment factors that influence adolescent drinking behavior, such as peers’ drinking behavior ,24 and sWe conducted a cross-sectional study in Beijing, Shanghai, and Guangzhou in 2013 and conducted the same investigation in Jinan, Chengdu, and Harbin in 2014. In select cities, we considered the willingness and difficulty of carrying out and organizing actual work and tried our best to choose cities with different representativeness of geographical regions and levels of economic development. These regions were the following: Northeast: Harbin; North: Beijing; East: Shanghai, Jinan; Southwest: Chengdu; South: Guangzhou. Among them, Beijing and Shanghai are municipalities directly under the central government. The other four cities  are provincial capitals. In this study, a multistage stratified cluster sampling method was adopted. According to geographical location, administrative division, and class size, 4–6 urban districts were randomly selected from the above six cities by random number table. Middle and high schools were selected randomly from the selected urban districts. All students in all three grades in each school were selected for a questionnaire survey. For the graduate grade  class, which could not be investigated in schools, an extra second grade (junior two or senior two) class was included for compensation. The Ethics Committee of the Chinese Center for Disease Control and Prevention approved the study, and informed consent was sought from students, parents, and schools prior to implementation. The ethical approval number of the study is 2013-019. Moreover, the researchers informed the subjects that they had the right to leave the study at any time. Under the guidance of the investigator, participants completed the questionnaires. After completing all questions and answers, they were compensated with a mechanical pencil.Demographic characteristics were measured with a self-report questionnaire. Participants reported their gender, age, cities, and location via a general information questionnaire. Locations were divided into urban and suburban areas.The Youth Risk Behavior Survey Questionnaire  and GlobSchool environment variables associated with alcohol consumption in this study included learning about the dangers of drinking alcohol in class, learning about the dangers of drinking on the school radio, board newspaper and propaganda board, whether there was a prohibition of alcohol in school, seeing their classmate drinking, having friends who persuade them to drink, the proportion of friends always drinking, and frequency of attending parties. The proportion of friends who were always drinking was divided into three categories: none, ≤50%, and >50%. The frequency of attending parties included four options: almost none, less than 1 time per week, and ≥1 times per week. Questionnaire of school environment related to alcohol drinking is shown in SAS 9.4 and SPSS 25.0 were used for data cleaning and analysis. We used SAS to clean the data. When there was a logical error in the data, it was set as a missing value. For example, if someone reported an age above 20, the record was set as a missing value. Because this situation was rare in middle-aged students in China, we could not validate this record. Meanwhile, if participants did not report their drinking behaviors, gender, age, smoking status or any variables above, they were excluded from the analysis. SPSS 25.0 was used to perform logistic regression analysis.p < 0.05 was considered statistically significant.In this study, we set drinking behaviors as dependent variables , consumed alcohol within a year , and consumed alcohol within a month  than those whose friends did not drink alcohol. People with more than half of their friends who drank alcohol were 16.563 times more likely to have ever drank alcohol  and consumed alcohol within a year  within a month  than those with none of their friends drinking. In addition, classmate drinking, friends urging drinking, and attending parties are risk factors for drinking behavior. To some extent, the propaganda and regulations of banning drinking in school are also protective factors for teenagers not to drink.The school environment is closely related to adolescent drinking behavior. The logistic model shows the relationship between school environment variables and drinking behavior, as shown in p < 0.001; full adjustment: OR = 4.301, 95% CI: 3.779–4.896, p < 0.001). People with more than half of their friends who drank were more likely to get drunk than those with none of their friends . In addition, drinking by classmates, persuading friends to drink, and participating in parties were all risk factors for getting drunk (p < 0.001). Publicity on campus about the dangers of drinking was a protective factor for drunkenness (p < 0.001).The school environment is also closely related to individual drunken behavior. The association logistic model shows the relationship between school environment variables and adolescent drinking behavior, as shown in The study supports that school environment factors, including friends’ drinking behaviors and persuading, classmates’ drinking behaviors, and the frequency of attending parties, are related to adolescents’ drinking behaviors. This is consistent with other studies from other countries ,24,29. CSeveral theories may explain the effect of the school environment on adolescent drinking behavior. Social learning theory holds that people adjust their behavior according to normative or typical behaviors . For exaThe study also demonstrates that propaganda and regulations about the prohibition of drinking by schools are negatively correlated with adolescent drinking. Effective school propaganda on alcohol abstinence was a protective factor for adolescents in this study. However, there are currently inconsistencies in the influence of school environmental factors on drinking behaviors worldwide ,29,32. SAdolescent alcohol consumption has a significant impact on both physical and mental health at that time and in adulthood ,4. ThereMost previous studies on the food environment have focused on the effects on calorie intake and vegetable and fruit consumption. In this area, there is a lack of research on drinking behavior . AlthougThere are some limitations in this study. First, because of the limitation of data collection, some spatial school environmental factors and cause-and-effect relationships that exist between the existing situation, for example, stress from school, were not included . Second,Schools are common places for adolescent health behavior intervention . StudiesFurther studies are also needed to verify the results and explore the causal relationship. In addition, it is important to explore suitable school environment assessment tools for adolescent drinking in China. Based on these works, more targeted interventions should be implemented. Appropriate interventions and policies should be designed and implemented according to health-related school environmental indicators to positively impact adolescent drinking behavior.This study innovatively explored the relationship between the school food environment and adolescent drinking behavior in China and identified factors closely related to drinking behavior. Moreover, it is significant for the targeted prevention and control of adolescent drinking in China.


Malnutrition is a key global health challenge and a major contributor to childhood morbidity and mortality. In recent times, the contrasting coexistence of undernutrition including micronutrient deficiencies and overweight/obesity called double burden of malnutrition has been noted at individual, household or population level and/or at different times in life. The objective of this study was to examine individual, neighborhood and country level factors that are associated with the double burden of childhood malnutrition.We conducted multivariable multilevel logistic regression analyses on the most recent demographic and health datasets from surveys conducted between 2015 and 2020 in low- and middle-income countries. We analyzed data of 138,782 children (level 1) living in 13,788 communities (level 2) from 27 countries (level 3).The results of our analysis show variation in childhood malnutrition across the 27 countries from as low as 6.5% in Burundi to as high as 29.5% in Timor Leste. After adjusting for all level factors, we found that those who were wasted/overweight tended to have had an episode of diarrhea or fever in the last two weeks preceding the survey, were part of a multiple birth, were being breastfed at the time of the survey and born to mothers with more than one under 5-child resident in neighborhoods with high illiteracy and unemployment rates. The intra-neighbourhood and intra-country correlation coefficients were estimated using the intercept component variance; 44.3% and 21.0% of variance in odds of double burden of childhood malnutrition are consequent upon neighborhood and country level factors respectively.Evidence of geographical clustering in childhood malnutrition at community and country levels was found in our study with variability due to neighborhood level factors twice that of country level factors. Therefore, strategies in tackling the double burden of malnutrition must consider these shared drivers, contextual barriers and geographical clustering effects.The online version contains supplementary material available at 10.1186/s41256-022-00276-w. Malnutrition is a key global health challenge, it’s defined by the World Health Organization (WHO) as undernutrition which encompasses wasting, stunting and underweight; Micronutrient-related malnutrition; and overweight/Obesity . MalnutrGlobally, an estimated 22% (149.2 million) of children under-5 were reported to be stunted, and a further 6.7% (45.4 million) of children under-5 were wasted in 2020 . In addiIn recent times, with the changes in dietary patterns and consumption; population disease burden; and demographic structure and life expectancy; undernutrition including micronutrient deficiencies now coexist alongside overweight/obesity , 5. ThisThe major contributors of double burden of malnutrition have been categorized into three underlying factors: social and demographic; biological; environmental and behavioral , 6. In aChild growth is a standard indicator for measuring nutritional status. This is done using anthropometric measurement to ascertain changes in body composition. Amongst children under 5 years old, the gold standard indicators to determine malnutrition are stunting- child being too short for his or her age; wasting- child being too thin for his or her height; underweight- child being too thin for his or her age; and overweight- child being too heavy for his or her height. The stunting indicator measures a child’s height and his/her age compared against less than 2 Standard Deviation (SD) of the WHO child growth standards median, while the underweight indicator is estimated through the measurement of a child’s weight and age compared against less than 2 SD of the WHO Child growth standards median , 14, 15.Designing novel and integrated interventions which addresses the double burden of malnutrition requires an understanding of the shared drivers and contributors. We found significant number of literatures on the factors associated with wasting, undernutrition, stunting and overweight, however we found no extensive literature on the individual and contextual factors associated with the double burden of childhood malnutrition across countries. Multilevel regression analysis represents an ideal method of determining the shared factors and contributors associated with the double burden of malnutrition, their differences across levels and the magnitude of the clustering effects at these levels as well as cross level interactions . From thThis multilevel analysis was conducted using data from Demographic and Health Surveys (DHS) implemented by ICF International. These nationally representative cross-sectional household surveys provide data on maternal and child health, child survival, HIV/AIDS and other sexually transmitted infections (STIs), reproductive health and a whole range of healthcare areas, and are usually conducted every five years in each country. These surveys have been conducted in over 90 LMIC countries . The surThe double burden of malnutrition is defined by the coexistence of undernutrition and overweight and obesity, as well as diet-related noncommunicable diseases, within individuals, households, and populations, as well as across the lifecourse. In this study, we defined double burden of malnutrition at individual level. The outcome variable was derived from the WHO child growth standard Weight-for-Height . The WeiWe included both child and maternal individual level factors as control variables. The child individual level factors include age, sex, child birth type, diarrhea in the last two weeks preceding the survey, fever in the last two weeks preceding the survey and breastfeeding status. The maternal individual level factors include age, education, marital status, employment status, number of under five children, wealth index as constructed by the DHS and maternal health behavior. The maternal health behavior was constructed with principal component analysis of these three individual level factors: mother’s knowledge of Oral Rehydration Salts (ORS), place of delivery and entries in the immunization roster.Neighborhoods are defined as clusters of respondents in proximal households which serves as the primary sampling unit within the DHS dataset. These neighborhoods in the DHS datasets are stratified and selected with probability proportional to size, with households systematically sampled making it most suitable for intra and inter community analysis. The community level factors chosen include poverty level, neighborhood rurality, illiteracy and unemployment rates. Also included are unsafe sanitation, unimproved water source and limited access to health facility levels. All these were categorized into low or high with median value serving as the reference for the low and high groups.The country level variables included in our model were Human Development Index (HDI), Total Fertility rate (TFR) and Cereal Yield (kg per hectare) obtained from the Human Development Report and the World Bank Databank respectively , 19. TheWE conducted descriptive, univariable analysis of the variables with respondents’ distribution expressed as absolute number (percentages) and mean (SD) for categorical and continuous variables respectively. The analysis was adjusted for sample weight, stratification, and clustering.Multivariate multilevel logistic regression was used to analyze the individual, community and country level factors associated with childhood malnutrition of baby-mother pairs (level 1) living in a neighborhood (level 2) within a country (level 3). Five models were constructed: an empty model with no explanatory variable to determine the variance in odds of malnourishment between neighborhoods and countries. Model 2, 3 and 4 included individual-level, neighborhood-level and country-level variables only respectively. Model 5 included all individual-level, neighborhood-level and country-level variables.Odds ratio at 95% credible interval (CrI) was used to report the associations between the variables (fixed effects). Variance (random effects) was measured by intra-class correlation (ICC) and median odds ratio (MOR). ICC assesses the similarity between respondents in the same neighborhood and in the same country , 22. MORDescriptive analyses were performed using STATA 17, and multilevel models were fitted using the MLwinN programme, version 3.05 in STATA17 using the Bayesian Markov Chain Monte Carlo procedure which yields unbiased estimates with better properties –26. We eWe analyzed data of 138,782 children (level 1) living in 13,788 communities (level 2) from 27 countries (level 3) from DHS surveys that were conducted between 2015 and 2020. Across countries, the number of children ranged from 1082 in South Africa to 12,033 in Benin. The median number of neighborhoods was 466, with Senegal (214) and Nigeria (1378) having the least and the greatest number of neighborhoods respectively. Two thirds of the countries (18 of 27 countries) were in the Africa region and 22% (6 countries) from the Asia region. Americas, Europe and Oceania each had one country in the pooled dataset. More than half (15 of 27 countries) of the countries had low HDI, with 21 countries having a high TFR. With respect to cereal yield (Kg per hectare), 11 countries each were in the low and high categories respectively. Table The mean age of the children included in this study was 28 months, and males constituted half (50.6%) of the total study population ; and 20% reduced odds  among females compared to males. Children who had diarrhea and fever in the last two weeks preceding the survey had a 6%  and 8% %  increase in the odds of double burden of malnutrition respectively. In addition, children of multiple births had a 28%  increase in the odds of double burden of malnutrition, similar to the 21%  increase in odds of being malnourished among children who were currently being breastfed as at the time of the survey. Only mothers with primary 8%  and secondary 11%  education had decreased odds of having double burden of malnutrition. The odds of double burden of malnutrition increased with the number of under-5 children a mother had, with mothers having between 1 to 3 under-5 children and 4 and more under five children having an increased odd of malnourished children at 29%  and 32%  respectively. Conversely, there was an 8% reduction in the odds of malnutrition among mothers in employment .Compared to mother-children pairs resident in the poorest households, the odds of double burden of malnutrition decreased across three wealth index categories: poorer wealth index households 9% , middle wealth index households 14%  and richer wealth index households 12% . There was no statistically significant reduction in odds among pairs resident in the richest wealth index households. Similarly, only mothers in the second 8%  and third 12%  maternal health behavior quantiles had decreased odds of malnutrition compared with mothers in the first (poorest) maternal health behavior quantile. There was no statistically significant reduction in odds among mothers in the fourth and fifth (highest) quantiles of maternal health behavior.Mother-children pairs living in neighborhoods with a higher prevalence of illiteracy and unemployment had 10%  and 6%  increased odds of malnutrition respectively. Interestingly, those living in areas with high prevalence of poverty 8%  and unimproved sanitation 5%  had reduced odds of malnutrition. Pairs resident in countries with high HDI also had a 42% increase in odds of malnutrition .σ2 = 1.24, 95% CrI 1.09–1.42) in the empty model. The intra-neighbourhood and intra-country correlation coefficient estimated using the intercept component variance shows that 44.3% and 21.0% of variance in odds of malnutrition are consequent upon neighborhood and country level factors respectively. The importance of neighborhood and country contextual factors in malnutrition outcomes is further highlighted by the median odds ratio in Table Table The results of our analysis show variation in childhood malnutrition across the 27 countries with a low of 6.5% in Burundi to a high of 29.5% in Timor Leste. After adjusting for all level factors, we found that children who had an episode of diarrhea or fever in the last two weeks preceding the survey, were part of multiple birth, currently being breastfed were more likely to have double burden of malnutrition. In addition, mothers of children with more than one under 5-child, were resident in neighborhoods with high illiteracy and unemployment rates and were from countries with high HDI were more likely to have double burden of malnutrition children. Contrastingly, increasing age of child and being of the female sex reduced the likelihood of being malnourished. Similarly, mother of children with some form of education, were employed, improved health behavior and were relatively resident in well off households were less likely to have malnourished children. Curiously, neighborhoods with high levels of poverty and unimproved sanitation were less likely to have double burden of malnutrition children.Previous work on the double burden of malnutrition had found reduced odds of childhood malnutrition among female children similar to our findings . This ca ‘s findiPrevious studies have had similar findings on relatively well-off groups being strong risk factors for the double burden of malnutrition, similar to the community-level poverty and country HDI results of our study , 29, 37.While improved sanitation conditions has been touted in general health and wellbeing, and we found the chances of childhood malnutrition being lower in neighborhoods with unimproved sanitation . The stuEvidence of geographical clustering in childhood malnutrition at community and country levels was found in our study with a higher percentage of the variance attributable to neighborhood level factors (44.3%) compared to country level factors 21.0%). In essence, variability consequent upon neighborhood level factors was twice that of country level factors. Merlo et al. [.0%. In eA number of our results have also been observed in undernutrition and overnutrition only studies. A pooled analysis of factors associated with undernutrition across 35 low and middle income countries (LMICs) found that maternal education and household wealth index were significant predictors similar to ours . The finStudies which have examined childhood overnutrition have also highlighted similar association between maternal education, sex and child malnutrition as our study , 56. HowMost of our findings can be situated in the UNICEF Conceptual Framework on the Determinants of Maternal and Child Nutrition which recognizes the multifaceted burden of childhood malnutrition . These dThis study is an aggregation of nationally representative and generalizable DHS datasets from 27 countries across 5 continents. These are usually high-quality, high response rate datasets from DHS surveys which are conducted using a robust methodology with well documented data sources. These DHS surveys are carried out using standardized survey modules and implementations which allow for comparability across countries. However, these are cross sectional datasets thereby limiting our ability to attribute causality. Moreover, we lacked longitudinal data to assess the length of time respondents have been resident in the neighborhood and exposed to the communal contextual factors to attribute cumulative effects.The summary of our analyses shows that children who were wasted/overweight tended to have had an episode of diarrhea or fever in the last two weeks preceding the survey, were part of a multiple birth, were being breastfed at the time of the survey and born to mothers with more than one under 5-child resident in neighborhoods with high illiteracy and unemployment rates. Evidence of geographical clustering in childhood malnutrition at community and country levels was found in our study with variability due to neighborhood level factors twice that of country level factors. Therefore, strategies in tackling the double burden of malnutrition must consider these shared drivers, contextual barriers and geographical clustering effects.Additional file 1. Combined DHS Dataset for 27 Countries.


Private nonprofit colleges are increasingly using tuition resets, or a decrease in sticker price by at least 5%, to attract new students and counter declining demand. While discounting tuition with institutional aid is a common practice to get accepted students to matriculate and to increase affordability, a tuition reset is a more transparent approach that moves colleges away from a high aid/high tuition model. The authors find minimal evidence that these policies increase student enrollment in the long run, but that there may be short-term impacts. As expected, institutional aid decreases and varies directly with the size of the sticker price reduction. The average net price students pay decreases, but this effect may be driven by changes in the estimated non-tuition elements of the total cost of attendance. Finally, net tuition revenue appears unrelated to tuition resets. These findings call into question the efficacy of this practice. College prices have been increasing at steep rates. The published tuition price at private nonprofit four-year institutions has more than doubled in the past 30 years to an average sticker price of $37,650 in the 2020–2021 academic year   and College Scorecard from 2009 through 2018. We limit our sample to private nonprofit institutions offering a bachelor’s degree. These institutions are among the most expensive undergraduate institutions and the sector most likely to engage in tuition discounting practices  approach. DiD is used to estimate an effect of an exogenous change. We recognize that institutions actively opt into tuition reset policies and thus the policy shift is not truly exogenous. While we do not presuppose our DiD estimates to be causal, we do consider this the best approach to estimate the relationship between tuition reset policies and institutional outcomes.Reset is an indicator variable equal to one for treated units in the post-policy time period; Our primary estimation strategy is the two-way fixed-effects (TWFE) model:We also test for heterogeneous effects over time and by the size of the reset. In Eq. In Eq. The DiD model relies on an important assumption that the treatment and comparison groups are equal in expectations . One way to test this assumption is to examine the covariate-adjusted pre-treatment trends in the outcomes. In Eq. We also conduct multiple robustness checks on our models. First, we replace our outcomes of interest with outcomes expected to have no relationship with a tuition reset. The purpose of this is to examine the possibility of our main models estimating the effect of some unmeasured exogenous shift that confounds with the tuition reset policy. We use the amount of federal appropriations an institution receives as one alternative outcomes to test our models.Additionally, previous research suggests the TWFE model may be biased due to the staggered implementation across our treatment institutions , as seen in Table Our third research question concerns the combination of expected changes in enrollment with expected changes in student aid expenditures following a tuition reset. We seek to estimate how the average net price for undergraduates and net tuition revenue for institutions relate to tuition reset policies. We find evidence that the average net price decreases by roughly eight percent following a tuition reset. This effect seems to grow over time with point estimates in later years suggesting net price decreases by 12%. We also find that larger tuition resets result in larger reductions in net price. Using the approximate tails of the distribution of reset sizes in our study, a five percent reset is associated with a 1.4% decrease in net price and a 50% cut in sticker price is associated with 14% decrease in net price, assuming a linear relationship between effect and reset sizes. However, decreases in net prices for students are also accompanied by decreases in the non-tuition portion of a student’s total cost of attendance suggesting that the “savings” students experience may be attributable to the college estimating lower cost of living expenses  rather than a decrease in the net tuition price students pay. The magnitudes of these decreases in non-tuition COA expenses closely resemble those of the net price across Tables We also examined the effect of a tuition reset on net tuition revenue for institutions. The point estimate in Table As a falsification check, we estimate these models using an alternative outcome that is not expected to be related to a college implementing a tuition reset: total federal appropriations. We find no evidence of effects on unrelated outcomes, which provides additional support that the effects on our primary outcomes of interest are related to the tuition reset policy. We provide results of this falsification test in Table Table To further examine potential sources of bias in the TWFE estimates, we estimate cohort-specific effects following the approach of Cengiz et al. . BecauseThe mix of positive and negative estimated effects aligns with the lack of specificity in our main estimate of the relationship between tuition resets and enrollment. The cohort-specific estimates show some evidence that late adopters may see decreases in enrollment despite the fact that our time-trend estimates in Table Decreases in total aid appear to be consistent across cohorts, but per FTE aid decreases are concentrated among the earlier adopters. Decreases in the average net price are relatively consistent, although the earlier adopters may decrease their net price more than the later adopters. The 2013 cohort shows evidence that it fails the parallel trends assumption and also has the most extreme cohort-specific estimated effect. If we exclude this specific estimate, we still identify a negative relationship, but one that more closely mirrors the magnitude of effects on the non-tuition COA, thus supporting the idea that colleges may decrease net price through non-tuition levers. Additionally, the clustering among earlier cohorts may help explain the larger effect we find in our event study in the later years, which would consist solely of the initial institutions that reset tuition.The parallel trends for the per FTE net tuition revenue show some weaknesses for the 2013 and 2017 cohort. The cohort-specific estimates for these two groups are also roughly 0, compared to mostly negative estimates for other groups. While these two cohorts may play a role in upwardly biasing the TWFE estimate, or moderating the negative effect, we are still confident in our main finding that resets do not appear to be related to net tuition revenue given how large the standard errors are in our various estimation strategies.In Table Finally, we examine alternative definitions of a tuition reset. While Eq. To summarize, the falsification and robustness checks largely confirm our primary estimates that tuition resets appear to have minimal effects on enrollment in the long-run, to result in decreases in total and per FTE institutional aid, to be associated with lower average net prices and non-tuition COA estimates, and to have little impact on net tuition revenue per FTE. The main estimates do suggest that there may be a positive effect on enrollment in the first few years following the reset, but that the effect dissipates over time. We also show evidence that spending on institutional aid, the net price, and non-tuition COA decrease as the tuition reset increases.We do not find strong evidence that tuition reset policies are closely related to increases in long-term enrollment, although there is some evidence of a near-term growth. These effects are important considering the declining number of “traditional-aged” students Grawe, , who areSecond, students may perceive the reset as an indication of poor quality. Private institutions, which hold the highest sticker prices, may be a Veblen good; that is, a higher price may indicate a higher value to consumers Veblen, . In the Third, despite the reset, parents and students may continue to make errors in predicting cost and ultimately overestimate how expensive the institution will be. These errors may be minimized during the initial decrease in tuition, but erased as recency of the reset fades. This factor is particularly salient for low-income and racially minoritized students (Grodsky & Jones, Fourth, early effects on enrollment suggest a tuition reset may be an effective marketing tool in the short term. However, as sticker prices increase following the reset, that marketing ploy is unlikely to help. It is worth considering that long-term effects may not even be the goal or expectation given the general upward trajectory of tuition in the long run. Like other marketing tools, administrators may only expect a short-term effect. Additionally, the flexible conditional ATE presented in Table At private nonprofit colleges, discounting the sticker price is a longstanding and increasingly common practice (Ma et al., Behaunek and Gansemer-Topf  examinedThe combination of the decrease in sticker price and the decrease in institutional aid associated with a tuition reset policy combine to have an effect on the average net price students pay. Our findings show a negative impact on net price. Although colleges that reset tuition also decreased financial aid, this decrease does not appear to be enough to fully offset the drop in sticker price. This means colleges that reset tuition are, on average, less expensive than they previously were. However, the decrease in net price comes with a decrease in non-tuition COA. The price students pay include these non-tuition elements such as books, supplies, room, board, and transportation. Following a reset, institutions lower the expected cost of these expenses by five to eight percent. A tuition reset, however, is only a reduction of the published tuition price, not a change in the costs of transportation or books. We know that colleges typically accompany their reset with substantial marketing and publicity efforts (Lapovsky, This decrease in net price runs counter to larger trends among private nonprofit colleges. Despite increasing levels of discounting, colleges have maintained a relatively flat net price (Ma et al., Private nonprofit colleges have largely embraced the high aid/high tuition model, but a tuition reset may indicate a shift to a low aid/low tuition model where sticker price is closer to the actual net price paid. A tuition reset essentially redistributes institutional discounting evenly across students, rather than having enrollment managers award dollars to individual students on an ad hoc basis. Because merit-aid, which comprises a growing share of institutional discounts, is awarded disproportionately to wealthy and white students, a tuition reset may create a more egalitarian set of net prices across groups of students. It is important for future research to examine the potential equity impacts of such a shift away from the high aid/high tuition model, even if the average net tuition revenue remains flat.In this study we examine the relationship between tuition reset policies and enrollment, institutional aid expenditures, and net tuition prices. Our findings suggest that colleges behave in a revenue maximizing manner and reduce institutional aid as they cut sticker prices. We provide evidence that institutions with the largest tuition resets also cut aid by the largest amounts. Although colleges may be revenue maximizing in their strategies, tuition resets do not appear to have significant or sustained effects on enrollment and are unlikely to help counter flagging demand. Counter to expectations, net price decreases following a reset. However, this decrease is accompanied by a decrease in non-tuition COA which suggests colleges may reduce the expected costs of books, transportation, and other non-tuition expenses as an earnest recalibration of costs during the reset process or as an additional way to market lower prices to students. Importantly, net tuition revenue per FTE does not appear to decrease after a tuition reset, suggesting students are still facing similar tuition bills. We believe it is important for future research to discern between these approaches to better understand reset policies.This study is among the first to explore the effects of a tuition reset policy. Although we find minimal overall effects on enrollment, additional research on the promise of tuition reset policies to increase access for underserved groups of students is important. Additionally, we suggest future work examine student decision making in the face of a reset. While we used a five percent cutoff as our definition of a tuition reset to mirror previous research (Lapovsky,


The demographic characteristics of the two groups were comparable for age, sex, and cognitive style. The total procedure skill score, physical examination score, learner’s satisfaction score, and total cognitive load in the 360° VR video group were significantly higher than those in the 2D VR video group . This study suggested that a10-minute 360° VR video instruction helped undergraduate medical students perform fundamental H&P skills as effectively as 2D VR video. Furthermore, the 360° VR video might result in significantly better procedural metrics of physical examinations with higher learner satisfaction despite the higher cognitive load.Before caring for patients, video instruction is commonly used for undergraduate medical students, and 360° virtual reality (VR) videos have gained increasing interest in clinical medical education. Therefore, the effect of immersive 360° VR video learning compared with two-dimensional (2D) VR video learning in clinical skills acquisition should be evaluated. This randomized, intervention-controlled clinical trial was aimed to assess whether immersive 360° VR video improves undergraduate medical students' learning effectiveness and reduces the cognitive load in history taking and physical examination (H&P) training. From May 1 2018 to October 30 2018, 64 senior undergraduate medical students in a tertiary academic hospital were randomized to receive a 10-min immersive 360° (360° VR video group; The online version contains supplementary material available at 10.1007/s10055-022-00664-0. History taking and physical examination (H&P) are critical core competencies of undergraduate medical education (UME). Performing H&P can deepen the relationship between students and patients, direct clinical reasoning, and lead to further assessments for a differential diagnosis  from August 1 2017 to July 31 2020 at an academic teaching hospital . This study was approved by the Institutional Review Board of Chang Gung Medical Foundation (No: 201601821B0), and all procedures were conducted in compliance with the Declaration of Helsinki 1975. All the participants were informed about the study aims and provided written informed consent. The study followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines  contraindications for VR such as recent motion sickness, heart conditions, epileptic symptoms, and (2) refusing to participate. One of the authors (Lee LA) held information meetings about the study. All participants had been shown the practical aspects of using VR headsets and controllers and confirmed to have the essential ability to use the head-mounted display and controllers. Furthermore, the cognitive style of each learner was determined using the Group Embedded Figures Test (GEFT) , including essential knowledge and procedural skills of H&P according to the guidelines of the American Board of Otolaryngology Tsue , was maddeo Fig. . CoursewAfter randomization, all participants were given 10 min to watch their allocated VR video (either 360° or 2D) through a VR headset .In the 360° VR video group, the learners could watch and listen to the instructor’s demonstrations of H&P skills and the responses of a simulated patient and other medical staff from a first-person perspective at a time of their choosing Fig. e.In the 2D VR video group, the learners simply watched and listened to the instructor’s demonstrations and the responses of a simulated patient and other medical staff from a third-person perspective  to measure physical examination skills, the Mini-CEX to measure generic H&P skills, and the Cognitive Load Component (CLC) questionnaire to measure cognitive load.Each participant performed a real-patient H&P for a maximum of 20 min. Two separate investigators (Fang TJ & Lee LA), blinded to video group allocation, used a DOPS  assessed the participants’ competencies using a Mini-CEX rating form Table  Chang e. The MinThe CLC questionnaire includes six items that are used to measure intrinsic (task difficulty and complexity), extraneous , and germane  cognitive loads .Continuous data were reported as means (standard deviations [SD]) because all variables were normally distributed. Categorical variables were presented as numbers (percentages). A sample size of 32 participants per group was estimated using primary outcome effects  based on a priori study (360° VR video group = 90.2 [5.6] and 2D VR video group = 84.9 [5.1]) and an effect size of 0.99, type I error of 0.05, a power of 0.95, and 10–15% dropout rate. Sample size calculations were performed using G*Power 3.1.9.2 software . Differences between groups were analyzed using the unpaired Student’s t-test or Fisher’s exact test as appropriate. All Seventy volunteers expressed interest, among whom six were excluded Fig. . All of The mean DOPS-total score (88.4 [4.0]) in the 360° VR video group was significantly higher than that (85.8 [3.2]) in the 2D VR video group (effect size = 0.72) Table ; Fig. 3aThere was no significant difference in the mean Mini CEX-total score between the two groups Table . Among tThe total Fig. c and intTo our knowledge, this is the first clinical trial to report the outcomes of using VR technology to educate novice UME students on performing fundamental H&P skills. Although the 360° VR video triggered higher total and intrinsic cognitive loads than the 2D VR video, it helped the learners perform physical examinations more readily, appropriately, and safely with higher self-satisfaction. In addition, the 360° VR video review was as effective as the 2D VR video review in learning how to perform a generic H&P skill as evaluated by the Mini-CEX assessment, even though these two models differed in content and perspective.These findings support the use of 360° VR video to teach novice UME students essential H&P skills. Therefore, immersive 360° VR video with a higher field of view and degree of freedom is a cost-effective pedagogical tool by increasing learner attention, presence, skill enhancement, confident usability, performance, satisfaction, motivation, and engagement , while the 2D VR video learners can quickly focus on the relevant part of the scenario that the physician controls. In our preliminary study, the 360º VR learners watched the instructional scenes of physical examination with higher interest and engagement and longer secondary-task reaction time than the 2D VR video learners  360° videos, ergonomic VR software, and a high-end head-mounted display. After improving the quality of the 360° VR video, none of the pilot study subjects reported intolerable simulator sickness after experiencing a 10-min 360º VR video , whereas sex and cognitive style were not related to the DOPS-, Mini-CEX-, and CLC-total scores and subscales . Therefore, the older age of the UME students may have the more consulting experience to perform consulting skills better.Finally, age, sex, and cognitive style have been covariates of VR Supplementary file2 (DOCX 24 kb)Below is the link to the electronic supplementary material.