Cholec80-CVS, the first open dataset with video annotations of Strasberg’s Critical View of Safety (CVS) criteria. Our dataset contains CVS criteria annotations provided by skilled surgeons for all videos in the well-known Cholec80 open video dataset. We consider that Cholec80-CVS is the first step towards the creation of intelligent systems that can assist humans during laparoscopic cholecystectomy.Strasberg’s criteria to detect a critical view of safety is a widely known strategy to reduce bile duct injuries during laparoscopic cholecystectomy. In spite of its popularity and efficiency, recent studies have shown that human miss-identification errors have led to important bile duct injuries occurrence rates. Developing tools based on artificial intelligence that facilitate the identification of a critical view of safety in cholecystectomy surgeries can potentially minimize the risk of such injuries. With this goal in mind, we present  Strasberg and colleagues2 showed that most BDIs occur due to miss-identification of the bile duct and the cystic duct. This fact encouraged Strasberg to propose a method known as Critical View of Safety (CVS), which provides criteria to correctly identify cystic structures before the complete removal of the gallbladder. However, even though this identification method is commonly used and accepted for surgeons as an important attempt to reduce bile duct miss-identifications3, Way et al. showed that around 97% of the BDI occurrences were due to visual perceptual illusions and, in most of the cases of BDIs, surgeons did not even know what the problem was5. These findings encourage the development of technologies that aid surgeons to accurately identify the cystic structures during surgery and therefore to reduce BDI occurrence rates.Laparoscopic cholecystectomy is one of the most common surgeries performed in the world. For example, in the United States, around 20 million people suffer from gallbladder diseases that imply nearly 300,000 cholecystectomy surgeries per year. Despite being considered a low-risk surgery, bile duct injuries (BDIs) have occurred at a constant rate in the last 30 years8, surgery phase identification9 and anatomical structure localization10. Most of the current work leverage complex pre-trained convolutional neural network architectures and handcrafted databases annotated by experts in the medical field11. In particular, the automatic detection of CVS for BDI prevention has gained recent interest from several researchers. The work of Mascagni and colleagues12 aimed to detect critical views of safety on still images carefully annotated and selected by skilled surgeons. They used binary annotations of the occurrence of CVS criteria and anatomical segmentation annotations, and trained a deep neural network using both types of annotations to predict CVS occurrence. Tokuyasu et al.13 tackled the problem in an object detection setting by detecting four important anatomical landmarks: the common bile duct, the cystic duct, the lower edge of the left medial liver segment, and the Rouviere’s sulcus. The correct identification of these four landmarks has proven to help surgeons to avoid bile duct injuries. In this case, the authors used the fully-convolutional architecture YOLO and bounding box-like annotations. On the other hand, Madani et al.14 addressed the problem of identifying safe and dangerous zones of dissection as well as anatomical landmarks during laparoscopic cholecystectomy as a segmentation problem providing real-time intra-operative guidance.This type of technologies for automatic detection and identification are not new in the context of laparoscopic surgeries. For example, researchers have studied the problems of surgical instrument segmentation and tracking15, there are not publicly available datasets with annotations of the CVS criteria that can be used by researchers interested in addressing the problem of automatic CVS identification. Annotating videos based on CVS criteria on videos of laparoscopic cholecysectomy procedures is a challenging task that is time consuming and must be done only by skilled surgeons. In this data descriptor, we introduce Cholec80-CVS, the first open dataset with annotations based on CVS criteria on all the videos in the well-known Cholec80 video dataset11. Cholec80 is a popular open dataset that contains 80 video recordings of cholecystectomies performed by 13 surgeons and that has been widely used to study artificial intelligence-based models for real time analysis in surgeries.Despite the above mentioned studies and the effort of Mascagni and colleagues in proposing a reproducible method for objective video reporting of CVS in laparoscopic videos16. Strasberg’s method, known as Critical View of Safety, is based on three criteria: first, only two structures can be clearly seen connected to the gallbladder; second, the lower one third of the gallbladder is separated from the liver to expose the cystic plate; third, the hepatocystic triangle must be completely clear of tissue allowing proper visibility of all cystic structures.Strasberg originally proposed three main criteria over a given still image that allow the surgeon to determine if it is safe to proceed with the clipping and cutting process for gallbladder removal, and thus avoid bile duct injuries19, establishing it as one of the most popular benchmarks for research in laparoscopic cholecystectomy.Cholec80 dataset contains 80 high-quality videos of gallbladder laparoscopic surgeries. It was constructed by researchers from the research group CAMMA at University of Strasbourg, France. Videos in Cholec80 were recorded at 25 frames per second, and all videos were recorded for different patients, surgeons, and light conditions, facilitating the application of learning methods for surgery analysis. Additionally, each video was labeled frame by frame according to the surgical phase and the surgical instruments in the scene. Cholec80 has been widely used in recent research16 and latter used by Mascagni and colleagues15 to annotate Strasberg’s CVS on still images. However, we extended it by adding a new set of complementary rules to reduce the uncertainty during the annotation process.Our annotators strictly followed a scoring system to ensure the creation of a high quality dataset. This system was originally proposed by Sanford’s and Strasberg’spreparation and Calot’s triangle dissection phases. Our annotators carefully selected video segments where at least one of the non-zero Strasberg criteria was satisfied. Then, a score of one or two was assigned to the video segment following the scoring system proposed by Sanford16 and a complementary set of rules for each of the criteria proposed by our annotators as described in Tables For each video in Cholec80, we analyzed the We are aware that annotating time-lapses may induce noise, given that low quality frames can occur within an annotated video segment. For instance, brief occlusions and blurred or over exposed images may occur due to the abrupt camera movements that are common in laparoscopic cholecystectomy. However, we consider that Cholec80-CSV is the first step towards the creation of intelligent systems that can assist humans during surgeries. Therefore, it is crucial to model noisy input data to build robust systems in real scenarios.http://camma.u-strasbg.fr/datasets. On the other hand, our annotations are publicly available as a XLSX file20. Each row in this file details the initial and final frame of a video segment where our annotators detected any of the Strasberg’s criteria as well as the score assigned to it. All video segments that are not in the provided dataset are considered to have a 0 score for all criteria. Table Cholec80 Videos can be obtained from the University of Strasbourg’s research group CAMMA official web site Our annotators were highly skilled surgeons: one of them with a record of approximately 700 successful cholecystectomies performed, while the second has performed about 470 successful cholecystectomies. Each of the surgeons was paired with one surgical resident. Even though residents had prior experience in laparoscopic cholecystectomy, they also received additional training from the experienced surgeons. It consisted of weekly meetings before starting the annotation process. During these meetings, the annotators carefully studied the original set of rules proposed by Sanford and Strasberg to detect CVS. Additionally, the annotators proposed a complementary set of rules shown in Tables 15 where only the last 60 seconds before clipping and cutting phase were annotated, we analyzed the entire portion of the video prior the clipping and cutting phase. Figure In contrast to the methodology proposed by Mascagni15.It is evident the high imbalance between scores in the dataset. Given that most of the time a view of safety is achieved just for a couple of seconds before the gallbladder dissection, frames tagged with scores of two are very scarce. This behavior is consistent with the dynamics of a typical laparoscopic cholecystectomy and the methodology followed in the work of Mascagni and colleaguesFigure 20. Cholec80-CVS can be used for researchers to assess novel image classification architectures to automatically detect CVS criteria. We also encourage researchers to contribute to enriching the current dataset either by refining the current version or by adding new samples.To ease the use of Cholec80-CVS we provide public access to both the database and all the code related to this work. The database is publicly available in XLSX formatCholec80-CVS dataset has some important limitations. First, abrupt camera movements are very common, creating blurry low quality frames. Some of them may occur within the time-lapse annotated by the surgeons, producing noisy samples. Additionally, due to the nature of the surgery, in some frames a criteria may be briefly occluded by actions performed by the surgeon, but the frame will still be considered as a positive sample since it occurs within the annotated time-lapse. This behavior suggests possible research directions, for instance, implementing video analysis techniques. Analyzing multiple subsequent frames may reduce the negative impact of these noisy samples as well as reduce the probability of miss-classify images due to temporal occlusions.The second limitation of Cholec80-CVS is the high data imbalance due to the nature of the surgery. As it is shown in Fig.


This study compared stress and the benefits of video calling between individuals with autism spectrum disorder (ASD) proneness and diagnosis and those with typical developmental (TD). Study participants were recruited via the web, and 151 of the 252 participants who responded to a web-based questionnaire were included in the analysis . The results of the chi-square test suggest that the ASD group may prefer video calling more than the TD group. The results of the analysis using a qualitative methodology (KJ method) suggested that the ASD group was more likely than the TD group to perceive stress due to light stimuli emitted from the screen and the inability to concentrate on a conversation due to visual stimuli. The ASD group perceived the ability to cope with stressful stimuli by operating the device as an benefits of video calling. These findings suggest the importance of creating a communication environment that reduces stress and maximizes the benefits of video calling for people with ASD. Specific support measures include establishing rules in advance that allow the individual to turn the video off or switch to texting. Autism spectrum disorder (ASD) is a neurodevelopmental disorder whose main diagnostic features are impairments in reciprocal social communication and interpersonal interaction; limited and repetitive behaviors, interests, or modes of activity; and hypersensitivity to sensory stimuli . The corThe difficulties individuals with ASD may have in face-to-face communication can be alleviated by text-based communication over the Internet. Text-based communication, such as e-mail, is highly valued by individuals with ASD because it gives them additional time to think of their responses, there is no pressure for eye contact , 5, theyIn recent years, there has been a growing need for Internet communication using video calling mediums such as Skype. Video calling is an Internet-based technology that provides a synchronous experience of seeing another person and hearing their voice . Video cOnly a few studies have been conducted on video calling communication among individuals with ASD. Those studies suggest that individuals with ASD experience difficulties in video calling , 13. MorAlthough this study focuses on the negative aspects of video calling in individuals with ASD, video calling may have positive aspects for individuals with ASD. Zolyomi et al.  showed tIn this study, we examined the perceived stress of video communication among individuals with ASD proneness or diagnosis, and the benefits of video communication by considering the perceived benefits and preferences for video communication. The three research questions of this study are as follows: RQ1: Are there differences between individuals with ASD and TD in their preferences for video calling and face-to-face communication? RQ2: What differences exist in the perceived stress of video calling between individuals with ASD and TD? RQ3: What differences exist in the perceived benefits of video calling between individuals with ASD and TD?Qualitative analysis methods were used to examine the perceptions of stress and benefits mentioned in RQs 2 and 3. At present, it is unclear what aspects of stress and benefits are perceived by people with ASD proneness and diagnosis during video calling. Therefore, a qualitative study based on the subjective perceptions of the participants was conducted to clarify these aspects in an exploratory manner. In addition, to better clarify the stressors and benefits of video calling for individuals with ASD proneness and diagnosis, this study was conducted in comparison with individuals with TD. In qualitative research, attempts have been made to compare the results of analyses using comparison groups. Such attempts can show similarities and differences by comparing different groups and aspects of the phenomenon, highlighting areas in need of further support . TherefoThe purpose of this study was to qualitatively analyze open-ended responses obtained through an Internet-based questionnaire survey regarding communication form preferences, stress, and perceived benefits of video calling among individuals with ASD proneness or diagnosis, and those with TD. It also examines the kind of support needed to reduce stress and maximize the benefits of video calling in individuals with ASD.In this study, participants were recruited by sending an e-mail to ASD patient organizations and through Twitter, a social networking service. For recruitment by e-mail to ASD organizations, the URL and QR codes of a Google form containing the outline of this study and the questionnaire was sent through e-mail. For recruitment via Twitter, the second author’s account providing information was used to post an overview of the study and the URL of the dedicated web page.Those redirected to the web page from the URL were given a more detailed overview of the study. If they agreed to cooperate with the study after reading the study outline, they were instructed to go to Google Forms. Two Google Forms were created: one for individuals with ASD proneness or diagnosis and another for individuals with TD. Participants who accessed the web page through the URL selected one or the other by themselves. For both recruitment methods, before answering the questions, we explained that participation in the study was voluntary, that personal information would be kept confidential, that the results of the study might be used for academic purposes, and that no personally identifiable information would be made public in such cases. Only those who consented to participate in the study were allowed to answer the questionnaire.A total of 252 participant responses were obtained . Of these, we screened those eligible for analysis based on their scores on the Autism-Spectrum Quotient Japanese Version 16 , presendefinitely different,” “4: definitely similar”), and the cut-off point was 12.The Autism-Spectrum Quotient (AQ) is an instrument for rapidly quantifying where any given individual is situated on the continuum from autism to normality . In thisThe participants had to meet the following conditions to be included in the analysis: 1) those with an AQ-J-16 score above the cutoff and a diagnosis of ASD or ASD proneness and 2) those with an AQ-J-16 score below the cutoff and no diagnosis or proneness of any mental disorder, including ASD. Based on these conditions, 53 individuals whose AQ-J-16 scores were below the cutoff on the form for ASD proneness and diagnosis were excluded from the analysis even though they responded that they had ASD proneness or diagnosis.Two individuals who reported no ASD proneness or diagnosis even though their AQ-J-16 scores were above the cutoff were also excluded from the analysis. Two individuals with TD whose AQ-J-16 scores were above the cutoff were excluded from the analysis even though they answered that they did not have a proneness or diagnosis of a mental disorder, including ASD. In addition, 45 individuals who reported proneness or diagnosis of a mental disorder but whose AQ-J-16 scores were below the cut-off for individuals with TD were excluded from the analysis.Participants who met Condition 1 despite responding to the form for individuals with TD were treated as analysis participants with ASD proneness or diagnosis. Participants who met Condition 2 despite answering the form for ASD proneness and diagnosis, were treated as analysis participants for TD. As a result, one participant from the form for TD was considered an individual with ASD proneness and diagnosis, and two participants from the form for ASD proneness or diagnosis were considered individuals with TD.After screening, 76 individuals with ASD proneness and diagnosis  and 75 individuals with TD  were included in the analysis. The participants were divided into two groups: ASD and TD. A questionnaire was created using Google Forms. It consisted of demographic items such as age, sex, and mental disorder status of the participants; the AQ-J-16; items about preferences regarding the form of communication; and open-ended items about the stress and benefits of video calling. The same items were used for the ASD and TD groups. As the open-ended items were considered highly abstract, examples of responses were provided to reduce the difficulty of answering the questions. Before answering the open-ended item, the participants were asked, “Do you talk more often on one-on-one or multi-person video calling?” Based on the answers to this question, the participants were asked to think of situations in which they experienced more video calling.For the item assessing the preference of conversation format, we calculated the selection rates for video calling and face-to-face conversations in the ASD and TD groups, and conducted a chi-square test. In conducting the chi-square test, based on previous studies, we considered that people with ASD may be more influenced by sensory stimuli during video calling. Therefore, we hypothesized that the ASD group would be more likely than the TD group to choose face-to-face conversations and less likely to choose video calling. Chi-square tests were conducted using IBM SPSS Statistics version 28 for Windows.In this study, the open-ended responses obtained from the ASD and TD groups were analyzed using the KJ method developed by cultural anthropologist Jiro Kawakita , which iThe procedure for the analysis based on the KJ method in this study is as follows: first, we extracted meaningful cohesion (segments) from the open-ended responses. Segments were extracted such that each segment contained only one meaning. If more than one meaning was included, each segment was divided into another segment. Second, all extracted segments were examined multiple times, and segments with similar meanings were grouped into one category. Third, a summary that successfully expressed the common elements of all the segments belonging to each category was prepared. The summary was then used as the name of each category. Based on the category names, we then created higher-order categories by grouping categories highly similar to each other. These steps were repeated until no more categories were deemed similar.This study was approved by the Ethical Review Committee of Tottori University School of Medicine .2(2) = 10.79, p = .001). Therefore, a residual analysis was subsequently performed to examine the differences in selection rates between the groups in detail. The results of the residual analysis showed that the adjusted residual standardized values for each selection rate in the two groups exceeded ±1.96, indicating a significant difference in frequency. These results indicate that the selection rates of video calling in the ASD group and face-to-face conversations in the TD group were significantly higher than other selection rates, and the hypothesis that the ASD group would select face-to-face conversations more often was not supported.To determine the preferred communication mode (video or face-to-face conversation), we performed a chi-square independence test and residual analysis by calculating the selection rates of the two communication modes in the ASD and TD groups. The KJ-method analysis revealed 280 segments in the ASD group  and 290 segments in the TD group . The final number of categories was 125 for the ASD group  and 120 for the TD group . The categories ranged from the lowest-order first category, formed by combining segments, to the highest-order fourth category, formed by combining categories.This study investigated the perceived preference, stress, and benefits of video calling in communication between individuals with ASD proneness or diagnosis, and those with TD. We then compared individuals with ASD proneness or diagnosis and those with TD using the KJ method and other analytic methods.The results of the chi-square test showed a significant difference between the ASD and TD groups in their preferences for each form of communication. In other words, the ASD group was more likely to prefer video calling than the TD group. This result is in contrast with Morris et al. , who fouCurrently, owing to the prevalence of coronavirus disease 2019 (COVID-19), the use of remote tools, including video calling, is under recommendation, especially in Japan , those iStress in video calling in the ASD group was characterized by the categories of “Stimuli from the screen,” “Light from the screen,” and “Inability to concentrate on the conversation due to what is in front of the eyes.” Stress due to being influenced by visual stimuli was more characteristic in the ASD than the TD group. Stress due to “Attention and concentration problems” were found in both groups, but the ASD group had a higher level of this category. Therefore, it can be inferred that this topic was perceived as more stressful by the ASD group. In the ASD group, the subcategory of “Attention and concentration problems” included “Inability to concentrate on a conversation due to things in front of one’s eyes.” Therefore, visual stimuli may have affected the stress of not being able to concentrate in the ASD group.Stress related to “Audio” was also a common category in both groups. However, it accounted for 11.84% of the total segments in the TD group, whereas it accounted for 30.20% of the total segments in the ASD group. This may indicate that the ASD group was more likely to perceive stress related to the speech aspects. According to Zolyomi et al. , the strThese data indicate that individuals with ASD diagnoses and tendencies can have unique stressors in video calling, suggesting the need for support for stressors in video calling in individuals with ASD.Regarding the perceived benefits of video calling, analyzed qualitatively using the KJ method, “Benefits of not being face-to-face” and “Can make use of devices and applications” were the main common factors between the ASD and TD groups.However, an examination of the lower categories revealed that some of them were only found in the ASD group. For example, in the ASD group, among the subcategories included in the category “Benefits of not being face-to-face,” there was a category “Impact from stimuli are mitigated.” However, this category was not observed in the TD group. In addition, the ASD group’s category of “Can make use of devices and applications” included the category of “Can deal with problems in one’s own time using application functions.” This category is unique to the ASD group. Although the use of applications and device operation were commonly observed in TDs, the ASD group may have more actively used applications and device operation to cope with problems, including stress, and recognized the benefits in this respect.Individuals with ASD may have difficulty interacting with each other in face-to-face communication environments due to the influence of light stimuli . We fouIn addition, Morris et al.  showed tSupport during implementation in video calling environments has been considered in the medical context e.g., –23). Bis. Bis23])However, no studies have examined how to support individuals with ASD in video calling. In this study, the benefit of video calling was recognized in the ASD group as the ability to respond to load by operating the equipment. Therefore, it is important to support the creation of a comfortable communication environment for people with ASD. Specifically, it is to guarantee the opportunity to take coping actions through the functionality of the equipment or application. For example, it is possible to establish rules in advance that allow the user to, depending on the load generated, turn the screen off or switch to chatting as appropriate.In recent years, there have been attempts to apply video calling to remote assistance such as medical services , known aThe present study has some limitations. First, the ASD group in the present study included both those with a diagnosis and those with only proneness but no diagnosis; therefore, caution is needed in interpreting the results. Second, most participants in the ASD group in this study had comorbid mental disorders, such as ADHD, LD, and social anxiety. As video calling may cause experiences related to the characteristics of disorders such as social anxiety , cautionThe present study qualitatively compared preferences of communication mode and stress and benefits in video calling between individuals with ASD proneness or diagnosis and individuals with TD. The results indicated that the ASD group was more likely than the TD group to prefer to talk over video calling. The ASD group also showed stress due to light stimuli emitted from the screen and stress due to visual stimuli specific to video calling, such as the display of one’s face, which made it difficult to concentrate on the conversation. In contrast, the ASD group recognized the ability to cope with stressors by operating the device as a benefit. These results suggest the importance of creating a communication environment that reduces stress and maximizes benefits for individuals with ASD.S1 Dataset(XLSX)Click here for additional data file. 16 Jan 2023
 PONE-D-22-26680

 Stress and benefits of video calling for people with autism spectrum disorders

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You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: In methodology there was not mention about age limits. Age is an important indicator for coping any new application. In different age group person's ability to minimise stress at different level, like at early age group ASD people could cope early. Time of screen time also an important issue which author mentioned in limitation.**********  6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.If you choose “no”, your identity will remain anonymous but your review may still be made public.Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.  Reviewer #1: No**********https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  9 Mar 2023We thank the reviewers for their valuable comments that have greatly improved our paper.Comment:３．Have the authors made all data underlying the findings in their manuscript fully available?Response: We have added a Minimal Underlying dataset file to the Data Availability statement.Comment: In methodology there was not mention about age limits. Age is an important indicator for coping any new application. In different age group person's ability to minimise stress at different level, like at early age group ASD people could cope early. Time of screen time also an important issue which author mentioned in limitation.Response: Thank you for pointing this out. We have changed the following text in “Limitations” from : Third, the frequency of video calling may have confounded the results. In particular, the results of video calling fatigue may differ depending on the call frequency [11]. In the future, analyzing the differences in experience according to frequency of use would be desirable.to Third, the age of participants and frequency of video calling use may confounded the results of the study. Younger age is a factor that increases the frequency of video calling use [29], and furthermore, frequency of use affects fatigue on video calling [11]. Therefore, the confounding of participants’ age may create a bias in the frequency of video calling use and change the perception of stress in video calling. In the future, analyzing the differences in experience according to age and frequency of video calling use.Ｗe have also added the following reference.29. Brown G, Greenfield PM. Staying connected during stay-at-home: Communication with family and friends and its association with well-being. Hum Behav Emerging Technol. 2021;3(1): 147-156. doi: 10.1002/hbe2.246.We wish to thank the Reviewer again for his or her valuable comments.Attachmentrebuttal letter0308.docxSubmitted filename: Click here for additional data file. 12 Mar 2023Stress and benefits of video calling for people with autism spectrum disordersPONE-D-22-26680R1Dear Dr. Inoue,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. 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For more information, please contact Kind regards,Santiago Gascón, PhDAcademic EditorPLOS ONEAdditional Editor Comments :Reviewers' comments: 11 Apr 2023PONE-D-22-26680R1 Stress and benefits of video calling for people with autism spectrum disorders Dear Dr. Inoue:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. 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We investigated whether and how social power affects the representation of peri-personal space (PPS). We applied a multisensory interaction task to assess PPS representation and the Personal Sense of Power Scale to assess participants’ feelings of power over others’ behaviors and over others’ opinions. In Study 1, we probed PPS representation in a virtual social context. Participants with a higher sense of power showed a less defined differentiation between the close and far space as compared to participants with a lower sense of power. This effect was replicated in Study 2 when participants performed the task in a non-social context (with no person in the scene), but only after they were reminded of an episode of power. Thus, social power—the perception of power over others’ behavior—affects the multisensory representation of the self in space by blurring the differentiation between one’s own PPS and the space of others.The online version contains supplementary material available at 10.1007/s00221-023-06719-1. Thirty feet is the distance that is automatically set around important public figures Hall , p.124. This quote—taken from Hall’s seminal work on how people use space—suggests that people tend to keep further distance from powerful and high-status people. This behavior is generally interpreted as a sign of respect toward individuals in positions of power and authority, and as an indication that power affects self-representation in space. Powerful individuals are believed to “occupy more space” as if feeling powerful would magnify the spatial extension of the self in the area immediately surrounding the body—i.e., the peri-personal space. In the present research, we rely on the concept of peri-personal space (PPS) developed in neuroscience to empirically test the validity of this idea.It is not just anecdotal evidence, but also a scientific fact, that people treat the area immediately surrounding the body—i.e., the peri-personal space—as if it were a spatial extension of the self  and its shape .Concurrent available evidence supports this hypothesis. People, depending on individual differences, approach the world differently and this could also influence PPS representation, as this is ultimately a sensory–motor interface mediating individual–environment interaction Serino . LiteratOther findings in the same line of research suggest that psychological dispositions can also account for when and why PPS representation dynamically adjusts to the context. For instance, only when a threatening stimulus is present , PPS representation extends  and non-social  context. In the further sections of the paper, we will first introduce the notion of the personal sense of power, relying mainly on research in social psychology, and then introduce possible hypotheses on how, when, and why feeling powerful would affect individuals’ PPS representation.Power is a ubiquitous characteristic of the social and relational world. Power can be defined as the potential to influence others in psychologically meaningful ways , while studies that examine the role of non-clinical individual characteristics are needed. Second, it contributes to the ongoing debate on the nature and functions of the PPS representation. Studies have shown that multisensory representation of PPS is immediately translated into potential motor responses  at the University of Trento, Italy, who (1) participated in a larger project on PPS representation between November 2016 and April 2017 in our laboratory and (2) completed questionnaire measures and tasks relevant for the study (see the procedure) as a first task, that is, before receiving any other eventual experimental manipulation . Course credits were offered to volunteers and informed consent was obtained from all of them.We analyzed the data of 84 right-handed students , a new augmented-reality technology developed at the Laboratory of Cognitive Neuroscience at the École Polytechnique Fédérale de Lausanne. This technology allowed us to integrate a pre-recorded real scene  with a virtual element, a cube, and to administer the PPS task. The scales were presented, and responses were registered with the aid of online survey software.The PPS task was administered with the aid of a virtual reality headset  and the RealiSM software  by a laboratory session. In the online questionnaire, participants responded to a series of questions and some scales including the Personal Sense of Power Scale and the Core Self-Evaluations Scale . Given that sense of power is generally related to self-esteem . This scale was developed by Judge and colleagues  stood at a far location, at a distance of approximately 1.5 m. After 700 ms from the appearance of the actress, a tridimensional brown virtual cube (0.2 m × 0.2 m × 0.2 m) appeared, at the level of her neck. Then the cube started to move approaching the participant with a speed of 0.75 m/s, it moved for 2600 ms and then remained still for 400 ms at the end of its trajectory. The face of the actress was always visible. Together with the visual stimulus, a tactile stimulation—clearly above the perceptual threshold and lasting 350 ms—was delivered via a single vibro-tactile device that the participant held in his/her left hand for the duration of the task. Importantly, the tactile stimulation was given at six different temporal delays from the appearance of the cube  and thus perceived by the participant when the virtual object was placed at six distances from her/him (D1–D6)  reaction times (RTs) were submitted to a series of repeated-measure ANOVAs with Distance (D1–D6) as the within-subject factor and Power (powerless vs. powerful) as a between-subjects factor. To perform these analyses the two indices of the personal sense of power  were transformed into categorical variables—using a median split criterion  – and contrast-coded variables (Power: powerless vs. powerful) were created. When the assumption of sphericity was violated as assessed by Mauchly’s test of sphericity, the Greenhouse–Geisser correction was applied. Post hoc comparisons were performed to investigate significant main and interaction effects.To better characterize the spatial boundary of PPS and the near–far differentiation, similarly to what has been done previously in literature, the RTs for the six distances were fitted with a sigmoidal  and the far (and close to the other person) space.The slope In line with previous studies, using the same visuo-tactile interaction task  = 90.92, p < 0.001, η2 = 0.204]. This confirms that an approaching visual stimulus speeded up tactile processing when the former was within a given distance from the body . Importantly, this effect was qualified by the two-way interaction  . This suggests that the difference between the participants who felt powerful (vs. powerless) on others’ behaviors evidenced by the ANOVA lies in global properties of the PPS response curve, rather than a difference at a single distance. Thus, the effect can be better investigated through the fitting parameters.The Distance × Power ANOVA testing the effect of the perception of one’s own power over others’ behavior yielded a significant main effect of Distance   was negative, indicating that the more the capacity to influence others behavior, the less steep the RTs curve becomes  = 4.9, p = 0.01] and the coefficient for self-esteem was positive, although it did not reach the conventional value of statistical significance . Nevertheless, the coefficient associated to power over others’ behavior was still significant . Finally, no significant results emerged from the analyses on the central point of the sigmoidal fitting as the dependent variable. This excludes a more extended PPS representation for powerful individuals.Given that powerful people are also higher in self-esteem, we ran an additional regression analysis including the self-esteem score as a covariate. The model was significant , but no interactions (p = 0.63). Regressions on the slope  and the central points  yielded similar non-statistically significant results.When we entered in the analysis the other index of personal sense of power that is the perception of one’s own power over others’ opinions, the ANOVA showed only the main effect of Distance , thus showing the predicted facilitation effect.First, results from the ANOVA indicated that responses speeded as the stimuli approached , thus highlighting that this facilitation effect varied in function of the session and the reminder of the powerful vs. powerless episode. No other significant effects emerged from this analysis. Namely, since the type of reminder did not show any significant effect , we excluded this factor from further analyses. Indeed, a three-way (Power × Session × Distance) ANOVA still showed a significant Power × Session × Distance interaction .More interestingly, a significant three-way interaction Power (over others’ behavior) × Session × Distance emerged, .To better understand the interaction, baseline-corrected RTs to the first and the second PPS task were entered separately in two Power × Distance ANOVAs. In the first PPS session, Power over others’ behavior did not play a role, as only a main effect of Distance emerged , was qualified by the significant Power × Distance interaction,  . As in Study 1, we focused thus on the fitting analysis for the interpretation of the effects. As the ANOVA revealed a three-way interaction, we relied on the following linear mixed model:In the second PPS assessment (after participants were asked to remind an episode related to Power), the effect of Distance,  and the interaction between Session and POB was significant , meaning that the relation between POB and PPS slope was modulated by the reminder. To characterize the interaction, we performed two linear regressions for the pre- and post-reminder parameters of the RTs curve separately, by fitting the same model as for Study 1:Worthy of note, the equation includes as predictors the individual score on Power over others’ behavior (POB), the Session (before vs. after the reminder) of the task where the PPS parameters were extracted, and the interaction between these two terms. To assess the significance of the mixed models, we performed likelihood ratio tests against a null model including just the individual intercepts for each participant. The model was significant  and the coefficient estimate was negative : higher POB values corresponded to a flatter slope of the curve representing individuals’ PPS representation  = 30.67, p < 0.001, η2 = 0.11] with Greenhouse–Geisser correction, and a marginally significant the three-way interaction Power × Session × Distance, . . A linear mixed model including POO and the interaction term as predictors was only marginally significant .When we analyzed the other facet of the personal sense of power that is the perception of one’s own power over others’ opinion (POO), the ANOVA yielded only a main effect of Distance [To sum up, in Study 2 we investigated the role of the personal sense of power over others’ behavior and of power others’ opinion on PPS representation in a non-social context. Across the ANOVA and the regression, and similarly to Study 1, we found that the perception of one’s own power over others’ behavior is associated with a less sharp differentiation, in terms of multisensory processing, of PPS and extra-personal space representation in a non-social context, but only after participants were asked to remind an episode of power. This result suggests that personal sense of power over others’ behavior does not affect PPS representation tout-court, but only whenever cognitively accessible or contextually relevant.where the transition between the representation of the peri-personal and the extra-personal space occurs, the PPS boundary) and its shape .Does feeling powerful affect self-representation in space? To address this question, in the present research we took advantage of the concept of PPS to investigate whether (Study 1) and when (Study 2) the personal sense of power affects the individual multisensory representation of space. In both studies, we relied on a visual–tactile interaction task to gauge PPS representation and on a self-report scale to assess participants’ personal sense of power in two different domains: others’ behaviors and others’ opinions. We focused our analysis on investigating the modulation of power on the PPS representation both in terms of its spatial extent  as power increased. In Study 2, we further investigated the role of the personal sense of power by assessing participants’ PPS representation in a non-social context . We found that recalling an episode related to power—aimed at making the personal sense of power temporarily cognitively accessible—strengthened the negative correlation between feeling powerful over others’ behavior and the PPS slope. This suggests that, even when no other person is present during the assessment, a reduced near–far differentiation emerged—with an increased amount of multisensory processing allocated to the far space—when the participant’s sense of power is made accessibleTaken together, the present findings suggest a positive answer to our initial question. Feeling powerful over others’ behavior modulates multisensory self-representation in space. The area surrounding the body and mapped as part of the self is not systematically more extended, as we found no effect on the central point, the index normally considered a hallmark of PPS extent. However, this area is represented, in terms of multisensory processing, as less differentiated from that of the far space in powerful individuals. This conclusion is supported by a significant relationship between the slope of the PPS function and sense of power. Difference between slopes has been sometimes interpreted as differences in PPS size , with the median value at the midpoint of the scale (neither agree nor disagree). The index of power over others’ behavior likely best captured a significant variation among participants’ personal sense of power ; this could have contributed to the present results. In addition to these empirical considerations, also conceptual differences could underlie the effect we found. Previous research has shown that, although both indices are related to a dominant personality, only the perception of having power over others’ behavior is linked with the motivation to lead  they show that the shape of PPS representation maps also onto a personal sense of power over others’ behavior—a psychological characteristic different from those previously investigated in the context of PPS; (2) they provide some new insights on how and when individual differences contribute to PPS representation; (3) they offer further evidence on the role of PPS representation in social interactions.Previous studies have shown that the extent of PPS representation is linked to traits like anxiety . These findings echo other studies showing modulation of PPS representation as depending on individual differences (phobias), only in relevant contexts Below is the link to the electronic supplementary material.


Pulmonary hypertension (PH) is a common complication of combined pulmonary fibrosis and emphysema (CPFE). Whether the incidence of PH is increased in CPFE compared with pure pulmonary fibrosis or emphysema remains unclear. This meta-analysis aimed to evaluate the risk of PH in patients with CPFE compared to those with IPF or COPD/emphysema.We searched the PubMed, Embase, Cochrane Library, and CNKI databases for relevant studies focusing on the incidence of PH in patients with CPFE and IPF or emphysema. Pooled odds ratios (ORs) and standard mean differences (SMD) with 95% confidence intervals (95% CIs) were used to evaluate the differences in the clinical characteristics presence and severity of PH between patients with CPFE, IPF, or emphysema. The survival impact of PH in patients with CPFE was assessed using hazard ratios (HRs).P < 0.01; SMD: 0.86; 95% CI: 0.52-1.19; P < 0.01) or emphysema . In addition, the patients with CPFE combined with PH had a poor prognosis than patients with CPFE without PH .A total of 13 eligible studies were included in the meta-analysis, involving 560, 720, and 316 patients with CPFE, IPF, and emphysema, respectively. Patients with CPFE had an increased PH risk with a higher frequency of pulmonary hypertension and higher estimated systolic pulmonary artery pressure (esPAP), compared with those with IPF (OR: 2.66; 95% CI: 1.55-4.57; Our meta-analysis showed that patients with CPFE were associated with a significantly higher risk of PH compared with those with IPF or emphysema alone. The presence of PH was a poor predictor of mortality.The online version contains supplementary material available at 10.1186/s12890-023-02425-4. The concept of combined fibrosis and emphysema was first proposed by Mallory in 1984. It is characterized by predominant emphysema in the upper lobes and pulmonary fibrosis in the lower lobes . BesidesChronic pulmonary diseases, including obstructive pulmonary disease (COPD) and IPF, were associated with a high incidence of pulmonary hypertension (PH), and the patients with CPFE were particularly prone to the development of PH . HoweverThe presence of PH was associated with worse survival in patients with IPF and COPD . PreviouThe purpose of this study was to determine the risk of PH among patients with CPFE, IPF, or pure emphysema. In addition, we aimed to assess the effect of the presence of PH on mortality in patients with CPFE.Our systematic meta-analysis was based on the PRISMA guidelines. Literature searches were conducted in electronic databases, including PubMed, Embase, CNKI, and Cochrane Library from inception to August 1, 2022, with the keywords “combined pulmonary fibrosis and emphysema” and “pulmonary hypertension.” The specific search strategies are illustrated in Supplementary File The inclusion criteria for this study were as follows: (I) studies evaluating CPFE versus non-CPFE ; (II) the diagnosis of CPFE as defined by Cottin et al. ; (III) PTwo investigators (NHQ and LT) worked independently to extract data and assess the quality of the selected studies, with a third reviewer (WYY) to discuss and settle divergence. The following items were recorded: study characteristics , patient characteristics , and the presence of PH or esPAP. Newcastle–Ottawa Scale (NOS) was applied to assess the methodological quality of the eligible studies, with a score of 7 − 9 indicating high quality .χ2 test and I2 statistic. If the I2 was > 50%, the random-effects model was applied; otherwise, the fixed-effects model was adopted. The subgroup analysis was further performed to explore the source of heterogeneity.The pooled OR and SMD were calculated to compare the possibility and severity of PH in patients with and without CPFE. Potential heterogeneity was measured using the P value < 0.05 indicated a statistically significant difference. Statistical analysis was conducted using the R software (version 4.1.1).Funnel plots were used as a form of qualitative analysis to evaluate the publication bias. A The flow chart of the selection process is illustrated in Fig. The basic characteristics of the included studies are listed in Table P < 0.01), more ever-smokers , and longer smoking history  compared with patients with IPF. However, no significant differences were observed in sex, and number of smokers between patients with CPFE and those with emphysema.We then explored the clinical differences between patients with and without CPFE. The results are summarized in Tables P < 0.01) and those with emphysema . Besides, patients with CPFE presented with a TLC higher than the TLC of patients with IPF  but lower than the TLC of patients with emphysema , and an FEV1/FVC lower than the FEV1/FVC of patients with IPF  but higher than the FEV1/FVC of patients with emphysema .With regard to the pulmonary function tests, the pooled data showed that DLCO was lower in patients with CPFE compared with those with IPF . Besides, the pooled SMD of esPAP was also higher in patients with CPFE .The results of the meta-analysis on the PH risk are presented in Fig. P < 0.01) and 40 − 50 mm Hg .Despite the low heterogeneity, subgroup analysis was performed according to the different thresholds of esPAP for PH diagnosis, as presented in Fig. P < 0.01). In addition, the extent of PH indicated by esPAP was also higher in patients with CPFE  than in those with emphysema alone.We further estimated the difference in the PH risk of patients with CPFE and those with pure pulmonary emphysema. As indicated by forest plots in Fig. P< 0.01) than patients with CPFE without PH [To disclose the effect of PH on survival in patients with CPFE, we recorded the HR of PH by repeating the selection and extraction process. The selection criteria and the analysis methods are shown in supplementary files  at rest and were more likely to manifest dyspnea and exercise limitation, as prior studies suggested [It was reported that the combination of pulmonary fibrosis and emphysema resulted in different pulmonary function tests (PFT) in patients with either pure emphysema or pure IPF , 19. IPFuggested , 24.Secondary pulmonary arterial hypertension is defined as a mean pulmonary artery pressure (mPAP) ≥ 20 mm Hg, a pulmonary artery wedge pressure (PAWP) ≤ 15 mm Hg, and pulmonary vascular resistance (PVR) > 2 units at rest, evaluated by right heart catheterization (RHC) . HoweverSeveral reasons might explain the increased risk of PH in patients with CPFE. First, it was assumed that the underlying parenchymal remodeling process caused some natural loss of overall vascular cross-sectional area and thus an increase in PVR . Given tWith regard to histological vasculopathy in patients with CPFE, previous studies showed nonspecific, broad, and heterogeneous pulmonary vascular changes. The pathology involved the remodeling of arteries/arterioles, veins/venules, and capillaries, regardless of background lung parenchymal lesions. Compared with IPF or emphysema alone, the vascular changes and the Heath-Edwards grading  were more severe in patients with CPFE. It was correlated with the increased risk of PH in patients with CPFE. Besides, the changes in the arteries/arterioles were the most obvious, suggesting that they played a major role in the development of PH. Plexiform lesions were rarely observed, and arteriopathy was not homogeneous, indicating that it did not belong to the vasculopathy type of idiopathic pulmonary arterial hypertension , 39.Though the severity of PH and vascular remodeling was increased in patients with CPFE, it’s difficult to compare the association between PH with pulmonary emphysema or fibrosis. The prevalence of fibrosis and emphysema in PH-CLD was variable and contradictory across articles , 40. MorOur meta-analysis demonstrated that the presence of PH, evaluated mainly by echocardiography, was a significantly poor prognostic factor in the CPFE population. Previous studies using PVR or RVSP to assess PH also confirmed that the presence of PH had an adverse impact on survival in patients suffering from CPFE, with HR ranging from 1.01 to 10.29 , 45, 46.Although the presence of PH is a poor prognostic factor, the natural course of PH associated with CPFE remains to be fully explored. Generally, group 3 PH is chronic and progressive, but its course can be influenced by severity of underlying lung disease. For example, in IPF patients with mild-to-moderate restriction, the rate of the change of mPAP was 0.4 mm Hg/year . But in Our meta-analysis had several limitations. First, the official diagnostic criteria of CPFE were not established, and the diagnosis for CPFE usually included different types and extents of pulmonary fibrosis and emphysema in previous studies. Although we restricted the fibrosis pattern to IPF in the selected studies, the unstandardized criteria of CPFE might contribute to undue diagnosis or less sensitivity for patients with CPFE. Second, the emphysema group actually included patients diagnosed with COPD and patients without PFT, although they all had lung emphysema appearance on computed tomography. It could cause heterogeneity in the population with pulmonary emphysema. Third, most of the included studies had a retrospective collection of data, increasing the possibility that our analysis could be subject to selection bias. Finally, it was possible that the inclusion of studies with a small size of the population might have resulted in statistical bias.In conclusion, our meta-analysis revealed a significantly increased risk of PH in patients with CPFE compared with those with IPF or emphysema alone. Also, the presence of PH was a significant predictor of mortality. However, due to the limitations in this study, multi-center or prospective studies with a clear definition of CPFE should be conducted in the future to further explore the risk of PH and its impact on survival in patients with CPFE.Additional file 1: Supplementary Table 1. Search criterion for the analysis of the risk of PH in patients with CPFE.Additional file 2: Supplementary Table 2. Selecting criterion for the analysis of the effect of PH on survival in CPFE patients.Additional file 3: Supplementary File 3. Flow diagram for the analysis of the effect of PH on survival in CPFE patients.Additional file 4: Supplementary Table 4. Basic characteristics in analysis of the effect of PH on survival in CPFE patients.Additional file 5: Supplementary Figure 1. Sensitivity Analysis of combined OR between CPFE patients and IPF.


Physically-demanding occupations may increase rotator cuff disease (RCD) risk and need for surgery. We linked a job-exposure matrix (JEM) to the UK Biobank cohort study to measure physical occupational exposures and estimate associations with RCD surgery.Jobs and UK Standard Occupational Classification (SOC) codes were recorded during the UK Biobank verbal interview. Lifetime job histories were captured through a web-based survey. UK SOC codes were linked to a JEM based on the US O*NET database. O*NET-based scores  were assigned to jobs. RCD surgeries were identified through linked national hospital inpatient records. Multivariable Cox regression was used to calculate hazard ratios (HR) as estimates of associations with RCD surgery. Among those with lifetime job histories, associations were estimated for duration of time with greatest exposure (top quartile of exposure).Of 277 808 people reporting jobs, 1997 (0.7%) had an inpatient RCD surgery. After adjusting for age, sex, race, education, area deprivation, and body mass index, all O*NET variables considered were associated with RCD surgery . A total of 100 929 people reported lifetime job histories, in which greater exposures were significantly associated with RCD surgery after >10 years of work .Workplace physical demands are an important risk factor for RCD surgery, particularly for workers with more than a decade of exposure. Injury to the shoulder can be a substantial source of occupational disability, with shoulder pain impacting 18–26% of adults in prevalence surveys –6. Age iOccupations that require great upper extremity physical demands put individuals’ joints at greater risk of mechanical stresses that may lead to RCD. While evidence has accumulated demonstrating that occupational upper extremity loads are associated with risk of shoulder disorders generally –14, few Our study population was derived from the UK Biobank, a prospective cohort of half a million people registered with the National Health Service . BetweenFor participants who were employed at enrollment, trained UK Biobank staff collected information on current job title during a verbal interview and coded each job according to the UK Standard Occupational Classification (SOC) System 2000 . Betweenth revision (ICD-10) and procedures are coded using the Office of Population Censuses and Surveys Classification, 4th revision. Our case definition for RCD surgery cases required both: (i) a diagnosis with an ICD-10 code of M75.1 or S46.0 made at a visit with a physician specializing in trauma/orthopedics, and (ii) a surgical procedure consistent with RCD treatment . RCD surgical procedures included arthroscopic or open soft tissue procedures such as rotator cuff repair or sub-acromial decompression as well as joint arthroplasty when paired with a procedure code specific to rotator cuff pathology.National Health Service Hospital Episode Statistics (HES) records are linked to the UK Biobank providing information on diagnoses and procedures during hospital admissions between 2006 and 2020 (this included same-day and overnight admissions). HES records are coded using the International Classification of Diseases, 10As we were interested in incident symptomatic RCD, we excluded from analyses people reporting either tendonitis or ≥3 months of neck/shoulder pain at their baseline UK Biobank assessment visit, and people with a RCD diagnosis (ICD-10 of M75.1 or S46.0) from linked HES records prior to their UK Biobank enrollment date (based on data available back to 2006). Follow-up time for an incident RCD surgery started the date of an individual’s baseline assessment visit and ended at the first of: RCD surgery, death, loss-to-follow-up, or 31 December 2020 . As follow-up is obtained through linkage to hospital records, loss-to-follow-up only occurs when participants have reportedly left the country which has occurred in <0.03% of the population.Initial analyses focused on estimating associations between characteristics of participants’ jobs reported at the baseline assessment visit and risk of incident RCD surgery. For this aim, we included people who reported a current job title at their baseline interview. A fraction of the population was retired, unemployed or had no job to report and were excluded. Additionally, we excluded people whose job code could not be linked to the O*NET job exposure matrix, specifically those with military jobs or non-specific job codes . We then described distributions of each O*NET variable within the remaining population. Associations between each occupational exposure captured by O*NET and risk of RCD surgery were estimated using Cox regression adjusting for age at enrollment, sex, race, Townsend Deprivation Index , education, and body mass index (BMI)  . ParticiImmediate occupational effects on frequency of RCD surgery may be more likely to reflect differences in treatment-seeking behavior than differences in disease risk. To better isolate longer-term effects on disease risk we conducted sensitivity analyses with two-year, four-year, and ten-year time lags in which we only included RCD surgeries occurring two (and four and ten) years after the job title was reported at the baseline interview. Many of our O*NET measures were correlated with each other and with self-reported exposure to heavy physical work. To determine whether the O*NET variables were contributing uniquely predictive information, we also evaluated models that included the UK Biobank self-reported measure of heavy physical work.Our second set of analyses focused on estimating associations between lifetime job histories and risk of RCD surgery. For this aim, we included people for whom a lifetime job history was available . We excluded people who had any job codes in their job history that could not be linked to the O*NET job exposure matrix (military occupations and non-specific jobs). While people could have job histories up until 2015, we only included time spent in jobs prior to their baseline visit so as not to include time occurring after a RCD surgery.To calculate exposure duration across time we dichotomized the O*NET scores by creating whole number thresholds that identified people in approximately the top quartile of exposure for each variable as based on the distributions for jobs reported at baseline. For example, for the ‘Handling & Moving Objects’ measure, which has a score range of 0–7, time in a job with a score ≥4.0 was considered exposed. For our calculation of exposure duration, a job with work-weeks >30 hours was counted as full-time and the number of years in that job were summed to get a total number of exposed-years. A job with work-weeks of ≤30 hours counted as part-time and the number of years in that job were summed and divided by two to get a total number of exposed-years. We allowed a maximum of one exposure-year to be accumulated during any one calendar year, even if an individual reported working multiple jobs concurrently. Lifetime exposures for all variables were categorized as 0, 1–10, 11–20, 21–40, and ≥41 years. Associations with risk of RCD surgery were estimated using Cox regression, adjusting for age at enrollment, sex, race, TDI, education, and BMI.We excluded 78 855 people reporting chronic neck/shoulder pain at baseline, 1500 people with a hospital-based RCD diagnosis prior to enrollment, and 281 people with self-reported tendonitis at their baseline UK Biobank visit, leaving 421 850 people without evidence of prevalent symptomatic disease . Of thesDistributions of physical exposures were evaluated based on O*NET scores linked to job titles. Scores for O*NET variables of ‘static strength’, ‘dynamic strength’, ‘cramped work space, awkward positions’, and ‘exposure to whole body vibration’ were notably right-skewed, with most people employed in jobs with low exposure . The mosFor analyses estimating the association of work exposures with RCD surgery we limited the population to the 240 433 people with O*NET scores, information on self-reported exposure to physical work, and information on potential confounders  . Among tIn sensitivity analyses, we found similar results when we evaluated associations between O*NET measures and RCD surgery after implementing 2-, 4-, and 10-year lags (supplementary table S2).When associations between O*NET variables and RCD surgery were evaluated in multivariable models that included self-reported manual labor, statistically significant associations remained for general physical activities, exposure to cramped work space or awkward positions, and exposure to whole body vibration  for 11–20 versus 0 years=2.06, 95% CI1.39– 3.04), performance of general physical activities , and exposure to whole body vibration .Among those reporting lifetime job history, we evaluated associations between time with a great exposure level (top quartile) and risk of RCD surgery for each O*NET measure after adjusting for age, sex, race, TDI, education, and BMI. A greater duration of time in jobs frequently requiring repetitive motions was not associated with RCD surgery risk. For all other O*NET variables evaluated, ≤10 years of exposure was not associated with a significant increase in RCD surgery risk, but >10 years of exposure was consistently associated with increased RCD surgery risk . Risk waThe need to better understand risk factors for symptomatic RCD requiring surgery cannot be understated. RCD is the most common cause of shoulder pain and a significant driver of time lost from work. A better understanding of occupational exposures can identify high risk groups and potentially guide preventative strategies. This large, population-based cohort study provided the opportunity for a unique, prospective examination of the associations between occupational exposures and surgical treatment for RCD. Our use of a JEM for estimating occupational exposures avoids the recall bias associated with self-report. This study demonstrated that, for all estimates of physical occupational exposures examined, there were significant associations between greater physical exposure and increased risk of rotator cuff surgery. All physical occupational exposures were positively correlated with one another to some degree, thus associations may reflect a combined effect of these exposures. Our O* NET JEM provided novel physical exposures of importance, not captured by the self-reported UK Biobank data, such as exposure to whole body vibration and exposure to cramped work space or awkward positions. Importantly, use of a JEM also provided estimates of exposures unaffected by participants’ disease status , 30. WheOnly a few prior studies have assessed associations between occupational exposures and RCD identified through radiographic or clinical examination. These studies have identified several risk factors, including arm elevation, heavy lifting, and use of handheld vibrating tools , 17–20. Several studies from Denmark have also used a JEM to assess occupational shoulder burdens associated with surgery for shoulder impingement syndrome  , 32, 33.One strength of our study was its assessment of associations between lifetime occupational exposures and RCD surgery. As participants in the UK Biobank represent an older population (40–69 years of age at enrollment), we would expect most rotator cuff tears in this population to have a degenerative component. For degenerative RCD, the accumulation of occupational exposures over time may be particularly important. In line with this hypothesis, it was only among people with over a decade of exposure to greater levels of physical demands that we observed significantly increased rates of RCD surgery. However, effects appeared to weaken among people with >40 years of exposure. This is likely due to a healthy worker survivor effect, in which people who are most susceptible to the adverse effects of heavy physical work are unlikely to remain in these occupations for many decades. Thus, workers with >40 years of exposure to physically demanding work may represent a select subgroup of people who are more resistant to the development of RCD. Similar patterns have been observed in occupational studies of carpal tunnel syndrome and lung cancer, in which the highest exposed workers did not have the highest rates of disease –37.Our linkage with the O*NET JEM allows the use of unique and validated occupational measures not previously available in UK Biobank . This inOur study had several limitations. First, jobs with the greatest physical demands may be difficult to perform with significant shoulder pain, leading to increased pursuit of surgical treatment. However, the associations we observed with job title at baseline were not attenuated in lagged analyses and associations with job exposure duration were strongest in those with more than a decade of exposure, indicating that our findings are not purely an artifact of acute treatment-seeking behaviors. Second, we lacked some specific exposure measures of importance for the rotator cuff. In particular, we could not capture prolonged arm elevation, which is one of the most consistently identified occupational risk factors for RCD and shoulder pain more broadly . Third, In this large general population sample of the UK we observed numerous consistent associations between physical work exposures and RCD serious enough to require surgery. These associations were observed for a self-reported measure of heavy physical work, which captures variation at the individual level, and for several JEM-estimated physical work exposures, which are less likely to be influenced by reporting bias. Our results provide evidence that surgery for RCD may be considered as a potentially compensable occupational condition , particu


Difficult peripheral venous access, especially in obese people, is challenging for novices. We conducted a randomized cross-over study to examine whether near-infrared venous imaging or ultrasound guidance is more useful for novice operators to obtain difficult peripheral venous access.Medical students were recruited as participants. After receiving basic training using commercial simulators, participants were randomly assigned to obtain simulated venous access using a difficult venous access simulator with near-infrared venous imaging or ultrasound guidance in a randomized cross-over design. A difficult venous access simulator was newly developed with deep and narrow vessels to simulate an obese patient. The primary outcome measure of the study was the first-time success rate (%), and the secondary outcome measures included procedure time (seconds) and the number of 3 consecutive successful attempts, to represent proficiency with the procedure. Pearson chi-square test, the Wilcoxon signed-rank test, and generalized estimating equations were used for statistical analysis.P = .64). The duration of the procedure for the first attempt was significantly shorter using near-infrared imaging  compared to ultrasound guidance . The number of attempts until 3 consecutive successes was not significantly different comparing the 2 approaches , ultrasound guidance: 3 , P = .63).Forty-one medical students with no experience performing peripheral venous access were enrolled in this study. The rate of successful first attempts did not differ between the 2 groups (70% for near-infrared; 65% for ultrasound guidance; There was no difference in success rate of first-time attempts or acquiring proficiency for the 2 methods. However, duration of the first attempt was significantly shorter with near-infrared imaging than with ultrasound guidance. Near-infrared imaging may require less training than ultrasound guidance. Near-infrared venous imaging may be useful for novices to obtain difficult peripheral venous access in obese patients. The number of obese people is increasing rapidly worldwide. If this trend continues, difficulties obtaining peripheral venous access in clinical practice will also increase. Recently, the usefulness of ultrasound guidance to obtain peripheral venous access has been reported. However, special training is required to master the technique for ultrasound-guided vascular access.,5 Another report states that imaging peripheral blood vessels with near-infrared light facilitates peripheral venous access. This study examined whether ultrasound guidance or near-infrared light is more useful for novice operators to obtain difficult peripheral venous access due to obesity.Peripheral venous catheters are the most commonly used devices for vascular access in routine clinical practice. Obesity is associated with difficult peripheral venous access.The present study was approved by the Faculty of Medicine Research Ethics Committee, Kyorin University  and registered in the University Hospital Medical Information Network Center Clinical Registration System (UMIN000045269). The study was conducted in accordance with Consolidated Standards of Reporting Trials guidelines.The study was designed as a randomized, prospective crossover study. Participants were recruited from among fourth and fifth-year medical students as volunteers. Exclusion criteria included experience of obtaining peripheral venous access in a patient, and refusal to participate. Written informed consent was obtained from all participants. Participant recruitment and data collection were performed from September 2021 to November 2022.Before starting the study, simulation training was conducted. The Intravenous ARM III  simulator was used to train the direct visual and palpation techniques for peripheral venous access for 30 minutes. The peripheral venous catheter was BD Insight 22G, 25 mm . A brief explanation of the principles of near-infrared venous imaging was given, and each participant searched for a vein in his or her own arm using near-infrared vein imaging. The near-infrared visualization system was Vein Viewer Flex .) and in-plane approaches were introduced as ultrasound vascular access techniques.,5,8 A 1-hour practical training session was held using the UGP GEL .–11 This simulator uses a simulated blood vessel 5 mm in diameter and 5 mm deep, embedded in an ultrasound-transparent gel. After simulation training, participants were randomly assigned, using a sealed envelope system, to perform simulated vascular access using near-infrared vein imaging or ultrasound guidance using a “difficult venous access simulator.”Next, the principles of ultrasound guidance were briefly explained, followed by a demonstration of ultrasound imaging of veins in the upper extremities. Ultrasound imaging was performed with a Sonotore Linear . Out-of-plane  Fig. . The newPunctures continued until 3 consecutive successful attempts were made. Even if 3 consecutive successful attempts were not achieved, the trial was terminated after 20 attempts. Three consecutive attempts were hypothesized to represent proficiency with the technique. Success was defined when water in the lumen of the simulated vessel was aspirated from the catheter after placement. Failure was defined as failure to place the catheter into the simulated vessel within 3 minutes, or not to achieve 3 consecutive successes within 20 attempts. The procedure time was defined as the time from the start of puncture to confirmation of water backflow from the simulated vessel. Participants performed the puncture using the assigned method (near-infrared or ultrasound), then performed using the other method (crossover study).The primary outcome measure of the study was the rate of successful first attempts, and the secondary outcome measures included procedure time and the number of 3 consecutive successful attempts. Data were electronically stored in an anonymized manner.U test. Pearson chi-square test was used to compare success rates. The Wilcoxon signed-rank test was used to compare procedure times. Three consecutive successes were analyzed with the generalized estimating equations, using a binomial distribution, and logit for link function. Data was analyzed with EZR statistical software . A P value < .05 was considered statistically significant.Success rates were expressed as percentages (%). Procedure times (seconds) and number of 3 consecutive successes were shown as median . The presence or absence of carryover effects was evaluated with the Mann–Whitney ɑ = 0.05 was estimated to be 30 participants. In this study, 40 medical students were enrolled to account for possible drop-outs or exclusions.At the time the present study began, there were no comparative studies comparing near-infrared vein imaging and ultrasound guidance in adult patients. The clinical difference between the 2 techniques could not be determined. Therefore, assuming a clinically significant difference, the sample size required for 80% power at P = .64). Procedure time for the first attempt was significantly shorter with near-infrared vein imaging compared to ultrasound guidance , ultrasound: 45 , P = .007). The numbers of 3 consecutive successful attempts were not significantly different between the 2 methods , ultrasound guidance: 3 , generalized estimating equations: comparing odds ratios, P = .63).Forty-one medical students participated in the present study. One participant data was excluded due to missing data  was designed to mimic the conditions under which veins are invisible to the naked eye, similar to the situation in some obese patients. The authors believe that near-infrared venous imaging may be useful for securing peripheral venous access in obese patients. Near-infrared venous imaging also has the advantage of requiring less training than ultrasound guidance.–21 Most studies show that the effectiveness of near-infrared venous imaging is limited. Curtis et al compared near-infrared venous imaging and ultrasound guidance in children and found no advantage for either method over conventional device placement. Aulagnier et al studied the usefulness of near-infrared venous imaging in adults and found no benefit. Kumar et al also studied adult patients and showed that near-infrared venous imaging increased only the success rate for the initial attempt.Near-infrared venous imaging was expected to improve the success rate for obtaining peripheral venous access in children. In that study, participants were knowledgeable and experienced in ultrasound guidance and near-infrared vein imaging before the study. Furthermore, participants were assessed for mastery of skills prior to data collection, and if the skill did not reach a predefined “mastery level,” an additional 4 hours of teaching, including simulation training, was added. The study by Yalçinli et al showed that with adequate clinical and simulation training, ultrasound guidance may have a higher success rate than other methods. However, the present study shows that near-infrared venous imaging is more useful than ultrasound guidance for novices. A limitation of the present study is the difference in fidelity between the simulator and a patient. The influence of simulator fidelity requires further study.Recently, Yalçinli et al compared near-infrared venous imaging, ultrasound guidance, and conventional methods in adult patients and found that ultrasound guidance had a higher initial attempt success rate than near-infrared venous imaging or conventional methods.–11 The education is a competency-based modular system designed to allow participants to acquire the basic skills for vascular access, which is constructed in a step-by-step manner. Certain aspects of the effectiveness of this education system have been proven.,11 However, this system targets the acquisition of basic skills and does not guarantee success in more difficult vascular access. It was hypothesized that ultrasound guidance after simulation training using this education system would have a higher success rate and improved skills acquisition compared to near-infrared venous imaging, but the results show that this hypothesis was rejected. The development of skill-acquisition programs for ultrasound-guided peripheral venous cannulation in difficult cases may require advanced skills and the need to set higher goals for skill acquisition.Cannulating veins using ultrasound guidance requires appropriate training and improves with experience. However, no consensus of a clear goal for technical skills acquisition has been established. In the present study, the simulation training given to participating medical students had the same content as preclinical basic training for residents.Ultrasound guidance has a great advantage over near-infrared venous imaging in that it can identify deeper veins. Near-infrared venous imaging has a limitation in its ability to locate deep veins, which cannot be observed over 5 mm deep. For this reason, ultrasound guidance is more clinically useful than near-infrared venous imaging. However, appropriate education is critical for this purpose. Near-infrared venous imaging may be useful as a method that requires less education and a useful way for novices to gain experience. In conclusion, near-infrared venous imaging may be a useful alternative to ultrasound guidance to obtain difficult peripheral venous access in obese patients, especially for novices.Many studies have evaluated the teaching methods used for ultrasound guided venous access, but there is still no method accepted as the optimal approach.The authors thank Ms. Okada  for her assistance.Conceptualization: Shinichiro Sekiguchi, Joho Tokumine.Data curation: Shinichiro Sekiguchi, Joho Tokumine.Formal analysis: Shinichiro Sekiguchi, Kiyoshi Moriyama, Harumasa Nakazawa.Investigation: Shinichiro Sekiguchi, Joho Tokumine.Methodology: Shinichiro Sekiguchi, Kiyoshi Moriyama.Project administration: Kiyoshi Moriyama, Joho Tokumine, Yasuhiko Tomita.Supervision: Tomoko Yorozu.Validation: Tomoko Yorozu.Writing – original draft: Shinichiro Sekiguchi, Kiyoshi Moriyama, Joho Tokumine.Writing – review and editing: Alan Kawarai Lefor, Kiyoshi Moriyama.