Adventure game players had significantly higher mean scores in all four types of aggressive behavior (p < 0.01). Participants who played simulation games had higher mean verbal aggressiveness (p < 0.01). Adolescents who participated in sports games had greater mean levels of anger (p = 0.01) and physical aggression (p = 0.01). Those who played strategy/puzzle games reported significantly higher mean scores of anger (p < 0.01), hostility (p = 0.01), and verbal aggression (p = 0.01). Females were more likely to show higher mean anger (p < 0.01) scores, whereas males were more likely to show higher mean physical aggression scores (p < 0.01). Conclusions: Our results do suggest that playing video games increases adolescent aggressive behaviors, which has been supported by other studies. We recommend educating parents on the pros and cons of playing video games and that parents schedule and limit the time their children spend playing video games.Video gaming is a popular source of entertainment among children and adolescents. Although the Middle East is home to one of the fastest growing communities of video game users, most of the research established on this topic has been carried out through small scale studies. Our aim in this study is to assess the prevalence of video game use and its association with aggressive behaviors among adolescents in Saudi Arabia. This is a cross-sectional study involving boys and girls (aged 15–18 years) in both private and public secondary high schools in Riyadh, Saudi Arabia. Each participant completed a self-administered modified version of the aggression questionnaire, which consisted of 29 items scored on a 5-point Likert scale. This questionnaire assessed aggressive behaviors domains: physical aggression, anger, hostility, and verbal aggression and types of videogames and time of use. A total of 485 students were included in this study. The mean age of participants was 16.5 ± 0.9 years; 48% were boys. Adolescents who participated in action games had higher mean verbal ( Video gaming is a popular source of entertainment among children and adolescents . In the The American Psychological Association (APA) considered violent video games to be a predictive factor for aggressive behavior . There aThe types of video games played in relation to aggressive behavior were examined in the literature with a noticeable interest in violent games impact. Most of the evidence point to a relationship between violent video games and aggression in youth. For example, a meta-analysis of 24 studies with over 17,000 participants, showed that violent video games were associated with aggression . HoweverMost of the research established on video gaming in the Middle East has been carried out through small-scale studies  and didn’t assess the level of aggression or association with different types of video games. Instead, generalized questionnaires were used to assess social health, quality of life, or behavior and attitude ,17,18. TA cross-sectional study was undertaken to identify the prevalence of video game use and its association with aggressive behaviors among adolescents in Riyadh, Saudi Arabia. Boys and girls aged 15–18 in both private and public secondary high schools were invited to participate in the study. A multistage stratified sampling technique was used. The city was stratified into five geographical areas: East, West, North, South, and Central. Each area was stratified into private and public schools, then stratified into middle and high schools, and finally into boys’ and girls’ schools. In the first phase, a cluster of middle and high schools from the public and the private boys’ and girls’ schools were randomly selected. A total of twenty schools were approached, four in each geographical area. However, four school’s principles refused to participate. In the second phase, classes were randomly selected from the schools selected in the first phase, and all students in these classes were delivered an anonymous questionnaire to complete at the schools. It took 15–20 min for the participants to complete the questionnaire. Prior to administering the questionnaire, a standardized training was conducted for test administrators.Each participant self-completed a modified version of the aggression questionnaire, which was originally developed by Buss and Perry 1992) and has been widely utilized and validated to investigate aggressiveness in various populations [92 and haPhysical aggression assesses hurting others physically and consists of nine items (score range from 9 to 45);Anger assesses the affective aspect of aggression and consists of seven items (score range from 7 to 35);Hostility assesses the cognitive aspects of aggression and consists of eight items (score range from 8 to 40);Verbal aggression assesses hurting others verbally and consists of five items (score range from 5 to 25).When answering the survey, were there some unclear or difficult questions for you? and (b) Do you have any comments or additional information to disclose? The questionnaire was translated into Arabic and back-translated for comparison. The instrument was tested on a group of adolescents to ensure an understanding of the questionnaire and clarity of the answer choices. The translated version was amended as a result of this focus group. The overall reliability of the translated instrument was 0.848, which indicates that the instrument yielded consistent results since reliability is accepted (good).Two additional open-ended questions were included to assess if all the items of the instrument were clear to the students. These questions were (a) This pilot cross-sectional study attempted to evaluate the usability and acceptability of the Arabic version of the instrument for a future national surveillance study. It also aims to identify ethical and methodological challenges to measure aggressive behaviors among Saudi adolescents. Since this is a descriptive study, no sample size was calculated. A feasibility sample of 500 adolescents has been selected so that our study will have enough power to be able to detect a prevalence of 50% with a 5% margin of error and 95% confidence level .t-test followed by Bonferroni correction for multiple comparisons (α = 0.02). Cohen’s d was calculated as a measure of the effect size. Correlations between number of video games played and self-reported aggression scores was performed by Pearson’s correlation test. Logistic regression analysis was performed with aggressive behaviors as the dependent variable (1 = Yes and 0 = No).The data were analyzed using SPSS version 23 . Participants were categorized by sociodemographic status, including age, sex, nationality, living arrangement, and caregivers. Scores for different types of aggressive behaviors were calculated by summing scores for corresponding items. Comparisons of scores according to age, sex, nationality, and types of video games used were performed via an independent samples We approached 577 students, of whom 502 completed the survey (87% participation rate). Out of 502 students, 17 were above the age limit, so we excluded them from the study. In the end, we analyzed the data of 485 students. Demographic information and hours spent playing video games per day are shown in p < 0.01) and physical aggression (p < 0.01) scores relative to the scores observed for those who did not play action games and the effect size showed minor difference (Cohen’s d = 0.2). Those who played adventure games showed higher mean scores in all four types of aggressive behavior (p < 0.01) compared to those who did not play adventure games (Cohen’s d = 0.2–0.3). Higher mean verbal aggression (p < 0.01) was found among participants who played simulation games compared to those who did not play simulation games. The observed difference was of medium effect (Cohen’s d = 0.5). Participants playing sports games exhibited higher mean anger (p = 0.01) and physical aggression scores (p = 0.01) (Cohen’s d = 0.2–0.3). Those who played strategy/puzzle games reported higher mean scores of anger (p < 0.01), hostility (p = 0.01), and verbal aggression scores (p = 0.01) compared to those who did not play strategy/puzzle games with a small effect size (Cohen’s d = 0.2–0.3).p < 0.01), while males were more likely to play sports and action games (p < 0.01). Regarding frequency of video game playing, males and Saudi students were more likely to play video games on a daily basis  with medium effect size (Cohen’s d = 0.5) and males were more likely to show higher mean physical aggression scores (p < 0.01) with small effect size (Cohen’s d = 0.3). In terms of nationality, non-Saudi students reported higher mean verbal aggression scores relative to those reported by Saudi students (p < 0.01) and the effect size value showed a minor difference (Cohen’s d = 0.3). Females who played action and adventure games were more likely to show higher mean anger scores (p < 0.01) (Cohen’s d = 0.4–0.6), whereas males who played similar games were more likely to show higher mean physical aggression scores (p < 0.01) (Cohen’s d = 0.3–0.4).A comparison of aggression scores according to demographic characteristics of the participants are also shown in r = 0.11, p < 0.05) was found between total number of games played and anger scores. Furthermore, the results indicate that there was a significant weak correlation in the positive direction  between total number of games played and hostility score, total number of games played and verbal aggression score , total number of games played and physical aggression score  and total number of games played and overall aggression score .A significant weak correlation in the positive direction  . In addiConsidering gender differences, not surprisingly, we found that males play video games about twice as much as females and their aggression scores were significantly higher. This finding was already reported in the literature where young males spend more time and money than girls . AdditioIn Saudi Arabia, little is known regarding the use of video games by expatriate children. They are the sons and daughters of Saudi Arabia’s expatriate professionals, who make up 25% of the country’s current population . InteresThe association between exposure to violent video games and aggression among youth remains debatable . DespiteThis study was limited by the lack of a control group and the lack of correlation with time spent playing. However, this was a preliminary study, and it was the first to be conducted in our region. It was also limiting by not addressing psychiatric illnesses, substance use, and physical illnesses as cofounding factors. Participants recall and observation biases are expected in this study design. The site of the study was limited to a metropolitan capital city; therefore, the results do not represent children across the country of different sociodemographic backgrounds.Our results do suggest that playing video games has the effect of increasing adolescents’ aggressive behaviors, which is a conclusion that has also been supported by other studies.Our recommendations are to educate parents on the pros and cons of playing video games, to raise awareness among adolescents on the negative impact of video games, and to encourage adolescents to play games that develop skills appropriate to their developmental levels and interests. Time spent playing video games should be scheduled and limited.positive effects of playing video games, such as making friends, improving basic visual processes, and problem-solving skills.To conclude, more research needs to be conducted on the effects of playing video games on other significant issues, such as bullying, eating disorders, and cyber harassment. Moreover, other research could be conducted on the


Despite enthusiasm around applications of information and communications technologies (ICTs) to smallholder agriculture in many lower-income countries, there are still many questions on the effectiveness of ICT-based approaches. This study assesses the impacts of video-mediated agricultural extension service provision on farmers’ adoption of improved agricultural technologies and practices in Ethiopia using data from a two-year randomized experiment. Our results show that the video-mediated extension approach significantly increases uptake of recommended technologies and practices by improving extension access and farmer knowledge. Specifically, we find that video-mediated extension reaches a wider audience than the government’s conventional extension approach and leads to higher levels of farmer understanding and uptake of the subject technologies in those locations randomly assigned to the program. While our results also point to greater extension access and greater knowledge among female spouses in locations where both male and female spouses were targeted by the program, we do not find clear evidence that a more inclusive approach translates into higher uptake of the subject technologies. Finally, we find that the video-mediated approach becomes less costly as the scale of operation increases. While eThe video medium offers several advantages over many other ICT-based information dissemination approaches. First, videos can be tailored and customized to address localized information needs and context. Several studies demonstrate the importance of locally relevant information, drawing attention to evidence from studies in the economics on education , entreprOur study explores these issues in the context of smallholder agriculture in lower-income countries with a basic question: does video-mediated agricultural extension lead to increased and sustained uptake of agricultural technologies and practices by smallholder farmers?rhizobium inoculation and legume yields in Ghana but were unable to disentangle the effect of the two interventions.To the best of our knowledge, few studies have sought to measure the effectiveness of videos in promoting agricultural technologies with any degree of rigor or at any sizeable scale  in the treatment woredas (districts).Our results demonstrate that the video-mediated extension approach led to increases in the uptake of key agricultural technologies and practices that were recommended by public extension providers, rural administrators, and researchers. In the first year of the experiment, we find a 6 percentage points overall increase in farmers’ uptake of the recommended technologies, which translates into a 10 percent increase over the mean of the control group. Across technologies, we find that the video-mediated approach resulted in a 13, 20 and 15 percent increase in uptake over control group means for row planting, precise seeding rate, and urea top/side dressing, respectively. These results endure in the second year of the experiment, pointing to farmers’ effective uptake of the technologies beyond a mere trial in one production season. From these effects, we compute the marginal cost-effectiveness of the video-mediated approach under experimental and scale-up (“full saturation”) scenarios. The cost of each additional adoption under the experimental scenario ranges from USD 16 – 30. However, these figures decrease to USD 3 – 6 when we assume that the video-mediated approach is extended to all kebeles randomly assigned to the video-mediated extension approach. While our results also point to greater participation and knowledge gains among  spouses who also participated in the video-mediated extension approach, we do not find clear evidence that targeting both spouses translated into higher technology uptake rates. Lastly, we do not find clear evidence that the increased adoption of the technologies promoted by the Ethiopian public extension system translated into higher yields. These null yield results may be related to issues of measurement error, insufficient adaptation of the technologies to context, or other factors discussed later.Exploring the mechanisms that explain these adoption effects, we find that the video-mediated extension approach led to an increase in extension reach, with a 35 percent increase in farmers’ attendance to extension sessions likely due to increased interest by farmers in the medium. In turn, we find a higher level of knowledge—greater technical understanding of the subject technologies and practices—among farmers in The remainder of this paper is organized as follows. 2kebele is host to an average of three DAs, each with his or her own technical specialization and reporting up to the woreda level.3Ethiopia’s agricultural extension system—one of the largest in Africa in terms of personnel and coverage— has undergone both small experiments and large reforms during the past three decades . A pillaYet, it is often difficult to draw a robust causal link between an extension system’s size and approach and its outcomes on farming practices, such as technology adoption, and productivity growth. Prior studies on Ethiopia suggest a somewhat ambiguous link between the extension system’s size and approach, and farmer outcomes such as technology adoption, productivity growth, and poverty reduction . SpecifiFor instance, despite multiple changes in the extension approaches and methods over the years, the role of DAs has not changed substantially. DAs continue to be involved not only in providing advice and training to farmers, but also in estimating seed and fertilizer requirements, estimating crop production, and other responsibilities less directly associated with extension service provision . BerhaneIn an attempt to improve the extension system’s effectiveness and shift from a “mass campaign” that emphasizes the adoption of physical inputs to a more customized, knowledge-driven service provision system, Digital Green and the Government of Ethiopia piloted a new digitally enabled approach to extension in 2014. The approach builds on a participatory, video-mediated model first developed by Digital Green in India . In its woredas in Ethiopia’s four most agriculturally important regional states.Based on the strengths of the pilot phase results, Digital Green expanded its operations in 2017/18 to 68 Digital Green’s expansion also opens the door to consideration of the gender dimensions of extension and advisory services. The specialization of labor along gender lines in agricultural households is often used to justify targeting the dissemination of certain technologies to men  and others to women . However, there is plenty of evidence to suggest that few technologies and practices can be reduced and assigned as “male” or “female” for a given household. There is also ample evidence suggesting that adoption of many technologies, whether related to agriculture or nutrition, is more an outcome of intra-household decision-making processes e.g., . Such prAt this stage however, the literature on the potential impact of increasing women’s access to extension services remains weak. In a recent paper, In Ethiopia, because women play an important role in agriculture, there is considerable scope to study the interaction between extension agents and women farmers. Women—not just women who head their own households but also women who are part of male-headed households—are potentially central to the adoption of new technologies and practices. For instance, 33.1kebele level; and was implemented during the 2017/18 and 2018/19 meher (rainy) seasons. Clusters were defined at the kebele level since it is the primary level at which agricultural extension is organized in Ethiopia. Within each woreda, kebeles were randomly allocated to one of three groups:(1)A control group (denoted “Control”) in which the government’s conventional extension approach was implemented with its standard targeting of the  household head(2)A treatment group (denoted “Video”) in which Digital Green’s standard video-mediated approach (described above) was targeted to the  household head; and(3)A treatment group (denoted “Video + Spouse”) in which Digital Green’s standard video-mediated approach was targeted at both the  household head and his/her spouse.8To assess the effect of video-mediated extension on our outcomes of interest, we compare how farmers respond to the same information on selected technologies when disseminated through two different approaches: the conventional “chalk-and-talk” extension approachWith this design, we are able to test the impact of the video-mediated approach on our outcomes of interest for any household that participated in the treatment (T1 + T2), and the distinct treatments  separately.kebeles and the conventional extension approach in the control kebeles. The homogeneous content promoted in the treated and control kebeles ensures that we can evaluate the medium used for promotion rather than the content itself. The set of promoted technologies—row planting, precise seeding rates, and urea top/side dressing—for Ethiopia’s three main cereal crops—teff, wheat, and maize have been topics of considerable research in Ethiopia , the bureaus of agriculture in each regional state, and local extension staff at both the 1. Video production: The cornerstone of Digital Green’s approach is the production of video content that is customized to local context, in that it features local farmers. Digital Green works with partners—subject matter specialists from the woreda extension office, DAs from a nearby kebele, and model farmers—to produce short videos on selected technologies.kebeles can tailor the content they deliver to farmers and use lead/model farmers to leverage role model effects, they primarily convey only general messages due to capacity and resource constraints. Customizing content to local conditions and delivering such messages to each farmer group in a consistent and standardized manner is widely recognized as unfeasible for the individual DA specialized on a given topic and following the conventional “chalk-and-talk” approach.2. Video screening. DAs screen the videos to farmers during regular extension sessions organized with kebele development groups. Development groups are semi-formal administrative structures within each kebele that comprises 25–30 farm households and are designed to provide community members with access to extension services and serve as a grassroots forum to discuss local development issues. DAs assigned to a given kebele have access to these development groups as part of their day-to-day work. The screenings are conducted with USB-charged PICO projectors and are structured in a manner designed to facilitate effective learning and discussion. Specifically, DAs screen the videos several times during the meeting, and pause the videos at certain points to answer questions or provide additional details. DAs also augment their facilitation with input from model farmers belonging to the development group(s).kebeles, extension sessions are open to all farmers, organized with development group members, include group discussions, and are conducted several times during the season, each time with new content that is synched with the crop calendar. In both groups, DAs further provide information to farmers through farm visits. Thus, farmers in treatment and control kebeles are exposed to similar messages displayed with similar intensities and similar means, except for the reliance on video screenings during the group sessions in the treatment groups.In both treatment and control Performance monitoring. Digital Green and MoA closely monitor both DA activities and farmer uptake of what they describe as “non-negotiable” elements of the technology package that must be adopted to achieve success. This is managed through Digital Green’s “Connect Online Connect Offline” (COCO) platform, an open-source customer relationship management system in the treatment kebeles. The COCO system provides its users with a back-end data and analytics infrastructure by integrating field-based data collection interfaces designed for low-connectivity environments with databases and dashboards for monitoring program performance. Although the COCO system is not well-aligned with the needs of a program evaluation such as the one described here, it does provide a basic indication of program coverage that can inform more rigorous evaluation activities (kebeles.tivities . DAs actyear 1 survey), following the harvest of all three crops to measure the immediate outcomes of the intervention. A second household survey was conducted in January-March 2019 (hereafter year 2 survey) to measure the persistence of these outcomes and spillover effects to non-treated groups in treated kebeles. These surveys were complemented by (1) qualitative data collection and analysis at multiple points during the study to better understand the mechanisms underlying expected and observed effects, highlighted by key informant interviews, focus group discussions, and in-depth interviews with farmers, DAs, and extension system officials; and (2) a series of surveys on DA characteristics, incentives, activities, and performance.4woredas, kebeles, and households were selected using a four-stage sampling process. We purposefully selected 30 woredas for the study based on three criteria: (i) woredas that were not saturated or fully covered by Digital Green prior to the 2017/18 meher season; (ii) woredas that Digital Green planned to expand into in that same season; and (iii) woredas that would not be fully saturated during the 2017/18 expansion to ensure the presence of within-woreda control kebeles. Woredas with less than nine potential expansion kebeles for the 2017/18 meher season were excluded from the study. Within each woreda, selected kebeles were randomly allocated to one of the three study arms such that each arm contained an equal number of kebeles.Sampled kebele is the lowest administrative unit in Ethiopia, it typically comprises several development groups. Given the limited number of PICO projectors available for video screenings, it was infeasible for DAs to reach all development groups in a kebele with the video-mediated approach. To prevent placement bias in favor of development groups closest to the Farmer Training Center , DAs were instructed to focus their effort on 10 Development Groups spread across the kebele: five randomly selected from among the closest Development Groups (where distance to the FTC was less than the kebele median), and five randomly selected from among Development Groups located further away (where distance to the FTC was greater than the median).Even though the kebele: 2 from the closest treated Development Group, 2 from the furthest Development Group, and 3 from the Development Group situated at the median distance from the FTC. The random selection of households for the survey followed the same procedure in both treatment and control kebeles, thereby ensuring comparability of farmers across groups.11Seven households were then randomly selected from each woredas and 350 kebeles located in the study area, of which 2,422 households in 347 kebeles were interviewed during the first year. In the second year, 2,345 (97 percent) of these households were re-surveyed. For sake of comparability, we focus our analysis on those households who were surveyed in both years , while a negligible number of farmers in the control group reported having participated in the video-mediated approach.13The random assignment of treatment arms generated comparable treatment and control groups at different levels—between  spouses . We furt spouses . We findHousehold data were collected using separate questionnaires for household heads and spouses. The household head questionnaire covered topics including household characteristics, savings and assets, access to services, technology adoption (further defined below), knowledge of agricultural practices, experience with the video-mediated approach, non-farm income, food security, shocks, crop sales, and plot-level information on land use, production, and inputs. The spouse questionnaire contained similar questions on assets, technology adoption, knowledge, and experience with the video-mediated approach.55.1meher season and their continued adoption in the 2018 season. Additionally, we look at the following outcomes to understand the mechanisms driving these outcomes: (i) access to extension services and advice from DAs; and (ii) farmers’ awareness and understanding of the subject technologies. We are further interested in (iii) variations in these outcomes resulting from the distinct gender-targeting strategies used in the two treatment arms. Finally, we investigate (iv) whether enhanced adoption of the promoted technologies translates into yield gains.Our primary outcomes of interest are farmers’ uptake of the subject technologies in the 2017/18 meher 2017/18 has anyone tried [technology x] on your farm?” For the sake of brevity, we report the uptake of these technologies without specific reference to the crop being cultivated, although crop-disaggregated results are provided in the appendices.We measure uptake of the subject technologies based on participants’ responses to questions in the household survey. The question for each crop and technology was structured as follows: “During In x]?” for each of the three focus crops. To measure the intensity of access, we also look at the number of times a DA provided advice for a specific crop.We then measure farmers’ access to extension services and advice from DAs in several straightforward and consistent ways. First, we measure access to extension using farmers’ responses to the question, “Has a DA directly provided you with advice/training on [technology We measure knowledge as the score from a set of questions about the subject technologies that were asked of participants in the household surveys. These questions were drawn directly from the list of “non-negotiable” elements of the subject technologies as set forth by the Ethiopian government’s own technical recommendations, and as incorporated into both the video and the non-video extension materials used by DAs. The knowledge tests were crop-specific, and were made up of 17 questions on teff, 16 on wheat, and 16 on maize. For each respondent, the number of correct responses were totaled and divided by the total number of questions for a given crop yielding a percentage score.14Lastly, we measure yield. We take a cautious approach to measuring yield, recognizing that while this outcome variable is widely used in the literature, it is extremely sensitive to measurement method . As such155.2kebele where the video-mediated extension approach was introduced, regardless of whether the household member(s) actually participated in a video screening. To estimate these ITT effects, we include all sample households—whether or not they were actually “treated” —in our analysis, since extension meetings are open to all development group members. Thus, we are estimating the intervention’s effect on the group for whom it was intended.Our estimation strategy relies on an intent-to-treat (ITT) approach, which captures the effect of being randomly allocated to a kebele. Given the nature of how information is shared between peers within a kebele, we argue that this assumption is overly restrictive. The other reason is operational. From a policy perspective, ITT estimates are often the more relevant estimates because they measure average changes in outcomes across all individuals that are targeted by the intervention. Given that 100 percent compliance with the intervention is nearly impossible in a real-world scenario, ITT estimates are a good proxy for impacts that can be expected beyond the experimental study setting.We restrict our analysis to ITT estimates for two reasons. One is statistical. To estimate the Treatment Effect on the Treated (TOT)—the impact of the intervention on those who were actually “treated”—we would have to assume an absence of spillovers from participants to non-participants within a given kebeleworeda-level stratification of our design through woreda-level fixed effects. Lastly, we account for treatment assignment at the kebele level by clustering standard errors at that level.We estimate ITT effects using the following specification:We also estimate ITT effects for each of the two treatment arms that measure the differential impact of video-mediated extension when it is targeted only to heads of households (“Video”) and when it includes both the heads and spouses in the same household (“Video + Spouse”). This differential effect is estimated as:kebeles, that is, those development groups where at least one farmer participated in the video-mediated extension approach  to first focus their video-mediated extension efforts on 10 development groups from which we later sampled households randomly for our household survey. This design may lead to an over-representation of extension participants in our treatment groups as compared to the control group. Further, if DAs in the control group targeted their effort to particular types of development groups , extension participants may not be fully comparable across samples. While our main strategy relies on the ITT estimations, we also test for the robustness of these results by restricting the sample to those development groups effectively reached by DAs in the treatment approach .66.1Results point to a clear and meaningful effect of the video-mediated extension approach on technology uptake. Specifically, the results show a 6 percentage points increase in uptake in year 1 and a 7 percentage point increase in year 2, which translate into 10 percent and 11 percent increases in the mean uptake rate compared to the control group . As discDisaggregating the results by technology, we find similar patterns. Overall, the video-mediated approach results in a 13 percent, 20 percent and 15 percent increase in uptake over control group means in year 1 for row planting, precise seeding rate, and urea top/side dressing, respectively. Similar results are found in year 2 for the first two technologies, even despite evidence of large increases in uptake in the control group.6.2In unpacking these results, we examine a set of intermediate outcomes to explain the effect of video-mediated extension on farmers’ uptake of the technologies described above.kebeles were 17 percentage points more likely to have had direct contact with a DA in the first year (through extension sessions or field visits) than those in the control group (a 40 percent increase over the control mean). Results hold when combined with the intensive margins (columns 3–4), with close to 40 percent more trainings attended by farmers in the treatment groups. Results hold, albeit with a lower magnitude in year 2. They also hold in both treatment groups, with no statistically significant difference between them, or across crops  motivation to seek out (provide) agricultural extension, we find evidence for both mechanisms in year 1. While the treatment effect on farmers’ attendance in extension sessions persists in year 2, we no longer find evidence of DAs’ increased efforts beyond leading collective extension sessions. Whether this lack of evidence is indicative of a momentary increase in DAs’ motivation in year 1 only, or a reallocation of efforts in year 2 towards other development groups is a key question as it affects the sustainability of impacts over time.kebeles perform better than respondents in control kebeles in year 1 (a 3 percent increase for both household heads and spouses). However, these positive knowledge effects of the video-mediated approach dissipate in year 2. The likely explanation for this—seen in the difference between the control means in years 1 and 2—is that the control group “caught up” with the treatment group. As before, these results hold across both treatment groups for  household heads.Next, we assess whether access to video-mediated extension translated into increased knowledge of the subject technologies , either We also find significant and positive effects on  spouse’s access to extension based on responses to the questionnaire deployed to spouses in year 1, though not in year 2 . These eTaken together, the impact of the gendered treatment arm on extension access and knowledge outcomes for spouses indicate that the video-mediated extension approach resulted in significant gains at early points in the technical change pathway. The question is why higher-level outcomes—increases in uptake—are indistinguishable from the spouse-only treatment. One simple explanation is that decision-making on these crops and technologies is controlled by male household heads. Indeed, the gendered specialization of decision-making on labor and resource allocations within agricultural households is often used to explain why women are not targeted by extension services for certain types of technologies  versus others  see .But this may be more heuristic than empirical: there is ample evidence to suggest that few technologies can be readily reduced and assigned as “male” or “female.” Rather, the evidence strongly points to gender biases in extension targeting e.g.,  coupled 6.3Our results for yields  are sligPotential measurement issues and the subject technologies themselves—many of which have a history of mediocre performance despite being flagships of the government’s efforts to increase yields and improve food security—may jointly contribute to these results. For example, reporting results from a randomized controlled trial of the government’s wheat technology package—comprised of practices similar to those investigated in our study—6.4kebeles, that is, those development groups where at least one farmer participated in the video-mediated extension approach. A description of the sample size, uptake trends, and main results are provided in Finally, we test for the robustness of main results  by restricting the sample to those development groups effectively reached by DAs in the treatment or control 7Because the video-mediated approach is designed to augment the existing extension system, we investigate the cost per additional uptake  resulting from the video-mediated approach. Specifically, we measure marginal cost-effectiveness, which is the cost of an additional adoption that results from adding the video-mediated extension approach to the existing system . Overall, we find that while the cost of an additional adoption of a subject technology under the experimental scenario ranges from USD $16–30, it significantly drops to USD $3–6 in the saturation scenario. Given that so few cost-effectiveness analyses of extension initiatives have been undertaken to complement randomized evaluations such as ours (see We examine two scenarios: (i) the actual cost of Digital Green’s project per adoption attributable to the video-mediated approach , and (ii) the estimated cost of a larger-scale rollout that covers the target 8First, the approach demonstrates its capacity to reach a wider audience than the conventional approach employed by DAs and woreda-level extension staff. More importantly, we found that the video-mediated approach increases extension reach even when we restrict our sample to those development groups where at least one farmer received advice from a DA, indicating that the approach did not lead to a change in the type of development groups that DAs decided to work with, but rather to a change in their reach to farmers within these groups. One plausible explanation for increased extension reach from the qualitative research conducted as part of this study is that video screenings tend to enhance DAs’ capacities to organize farmers at a given location and time, partly due to increased interest by farmers in the medium.Several important findings emerge from our evaluation of the video-mediated extension approach employed by the MoA, Digital Green, and the regional bureaus of agriculture across Ethiopia’s main agricultural regions. Second, the approach leads to higher levels of knowledge about the subject technologies in the first year, with gains observed for both household heads and spouses. This effect on knowledge can be explained by the power of video for delivering technical content in a consistent manner, thereby reducing oversights in conveying information that requires more accuracy than an extension agent may be able to retain/remember and communicate correctly. Moreover, the visual aspect (being able to see how a given technology or practice is implemented first-hand) was indicated by farmers as an important element of the approach in terms of maximizing learning .Third, the video-mediated approach results in increased uptake of the technologies that are central to the extension program of the MoA and regional bureaus, which endure in the second year of the experiment, indicating farmers’ effective adoption of technologies beyond a mere trial in one production season. While increased extension reach and knowledge due to the video-mediated approach are the main mechanisms that explain the sustained technology uptake, the qualitative evidence specifically identifies the local character (farmer) featured in the videos as a key aspect of the approach that encourages farmers to adopt promoted technologies. This is consistent with several theoretical and empirical studies that demonstrate the effects of role models who are similar to individuals across multiple dimensions in facilitating learning that can lead to desirable changes in behavior  increases, given that the video production costs are fixed costs. It is important to emphasize that these figures relate to the cost of increasing adoption beyond the levels obtained by the regular extension system.Because video is an added feature to the regular extension system, we further assess the Overall, this study helps shift focus in national and global discourse on agricultural extension to the power that ICTs can have in augmenting—rather than replacing—extension services and agents through the development and dissemination of targeted/site-specific advisories in a flexible and effective manner. This, in turn, may draw attention to more constructive ways of thinking about lowering costs, improving efficiency, and increasing the impact of existing extension systems. As Ethiopia and other low-income countries explore innovative ways to strengthen their extension and advisory services to farmers, these findings provide evidence on what works—and for whom—in the arena of innovative extension methods and tools.9This study assess whether video-mediated agricultural extension leads to increased and sustained uptake of agricultural technologies and practices by smallholder farmers. We explore this question in the context of a large-scale experimental rollout of a video-mediated extension approach by the Government of Ethiopia and Digital Green over a two-year period (the main production seasons in 2017/18 and 2018/19) in 347 kebeles across the four main regions. Based on a sample of 2345 households, we find that video-mediated extension approach led to increases in the uptake of key agricultural technologies and practices by farmers. Specifically, we find a 6-percentage point overall increase in farmers’ uptake of the recommended technologies in the first year of the experiment, which translates into a 10 percent increase over the mean of the control group. Across technologies, we find that the video-mediated approach resulted in a 13, 20 and 15 percent increase in uptake over control group means for row planting, precise seeding rate, and urea top/side dressing, respectively. These results endure in the second year of the experiment, indicating farmers’ effective adoption of the technologies beyond a mere trial in one production season.We also study whether video-mediated extension targeted at both spouses of a household is more effective than when only targeted at the  household head. While the results point to greater participation and greater agricultural knowledge of spouses who also received the video-mediated extension, we do not find clear evidence that targeting both spouses translated into higher uptake of technologies. Likewise, we do not find clear evidence that the increased adoption of the technologies promoted by the Ethiopian public extension system translated into higher yields. These null yield results may be related to issues of measurement error, insufficient adaptation of the technologies to context, limited investment in complementary inputs or other factors.Looking at the mechanisms that explain the effects of the approach on adoption of technologies, we find that the video-mediated extension approach led to an increase in extension reach, with a 35 percent increase in farmers’ attendance at extension sessions, likely due to increased interest by farmers in the medium. In turn, we find a higher level of knowledge—greater technical understanding of the subject technologies and practices—among farmers in kebeles randomly assigned to the video-mediated extension approach.However, these results come with one caveat: as for any new intervention, we are at this stage unable to assess whether our results are driven by the main features of the Digital Green approach, or by its novelty which may partly drive the observed higher participation of farmers to extension groups, and higher dissemination efforts by DAs. While our study covers two consecutive agricultural seasons, the long-term effect of such interventions remain open to further studies.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


The aim of this animal study was to compare the fluoroscopic image quality (IQ) and radiation dose between a tantalum (Ta)-specific contrast-to-noise ratio-driven exposure control (Ta-CEC) and a detector dose-driven exposure control (DEC) in abdominal angiography.Nine angiography scenarios were created in seven anaesthetised pigs using Ta-based embolisation material during percutaneous liver and kidney intervention. Fluoroscopic images were acquired using three DEC protocols with different dose levels and Ta-CEC protocols with different IQ levels, sampled in small steps. Polymethyl-methacrylate and aluminium plates were used to simulate attenuation of three water equivalent thicknesses (WET). Three blinded readers evaluated the IQ of DEC and dose equivalent Ta images and selected the Ta-IQ equivalent image corresponding to the DEC image.Ka,r) for the Ta-IQ equivalent image 0.73. The average IQ of the dose equivalent Ta images was superior compared to the DEC images (p < 0.001) and also for every WET  and dose level (p ≤ 0.022). The average Ka,r for the Ta-IQ equivalent images was 59 ± 16% (mean ± standard deviation) lower compared to the DEC images (p < 0.001).Interobserver agreement for the IQ assessment was 0.43 for DEC, 0.56 for Ta-CEC and for the assessment of incident air kerma at the interventional reference point (Ka,r. Alternatively, the Ka,r can be significantly reduced by using Ta-CEC instead of DEC, while maintaining equivalent IQ.Compared to DEC, Ta-CEC significantly improved the fluoroscopic depiction of Ta, while maintaining the  Material-specific imaging adds a new dimension to fluoroscopic imaging.Tantalum-specific fluoroscopy offers higher image quality, with the same radiation exposure of conventional imaging.Tantalum-specific fluoroscopy requires lower radiation doses to achieve image quality comparable to conventional imaging.The widely used detector dose-driven exposure control (DEC) in angiography is designed to maintain a constant detector dose, measured by the flat panel detector, in order to produce images of nearly constant noise level , 2. DEC Ka,r) rate [The recently introduced contrast-to-noise ratio (CNR)-driven exposure control (CEC)  aims at reaching a given material-specific CNR in angiography –6. CEC c,r) rate , 3, 7.Phantom experiments indicate a high skin dose reduction potential for materials with a high K-edge, as for example tantalum (Ta) , 3. AlteUp to date, it is unclear to which extent the results from the previously conducted phantom experiments with material-specific exposure control can be transferred into clinical practice , 3. HoweKa,r, and to compare the Ka,r while maintaining the IQ between Ta-specific CEC and DEC in abdominal angiography.The aim of this animal study was both, to compare the fluoroscopic IQ between Ta-specific CEC and conventional DEC, while maintaining the 2 (35−45 mmHg) concentration. The depth of anaesthesia was continuously monitored . Animals received continuous fluid therapy , had a urinary catheter, and were positioned on a warming pad to maintain body temperature. Analgesia was achieved by an initial systemic intravenous dose of 4 mg/kg of carprofen . Lidocaine  was locally infiltrated at the arterial access sites. To obtain series of sharp images without movement of the diaphragm, the animals received an intravenous injection of 0.1 mg/kg of pancuronium  every 1.5 to 2 h during anaesthesia. At the end of the experiment, the pigs were euthanised under deep anaesthesia by intravenous injection of 15–25 mL/animal of T61  until heart arrest was confirmed.The study was conducted in accordance with the European Directive 2010/63/EU and with the German law for animal protection (TierSchG). All experiments were approved by the local animal ethic committee . Seven female domestic pigs weighing 68−88 kg were used. Anaesthesia was induced by intramuscular injection of 10 mg/kg tiletamine/zolazepam  and atropine  followed by intravenous injection of 10 mg/kg of propofol  to enable endotracheal intubation. Animals were maintained under general anaesthesia using an isoflurane precision vaporiser and mechanically ventilated . The breathing rate was set to 12 breaths per minute and a ventilation volume of 8−10 mL/kg per breath was chosen, based on the end-tidal COTM Control Wire, Boston Scientific, Ratingen, Deutschland). Furthermore, a 0.0014” micro guide wire  within a microcatheter  and 5F guide catheter was placed in a liver artery. Overall, nine imaging scenarios were created in the seven animals . In order to simulate iodine injections, an adjacent subsegmental liver and kidney artery occlusion was conducted with Lipiodol  and cyanoacrylate glue  using a 4:1 ratio. A 3F Thru-Lumen embolectomy Fogarty catheter  filled with Iomeprol 300  was placed in the aorta holding a 0.0018” steel guidewire , combined with aluminium plates (30 × 30 × 0.2 cm3) were used to simulate 25 mm of soft and bone equivalent tissue. Two and four doublets were placed below the examination table using a custom-made holder and thus simulated additional 5 cm or 10 cm soft and bone equivalent tissue [In order to simulate different patient absorptions, doublets of polymethyl-methacrylate plates , which is constant for an IQ gradient = 0 and increases strongest towards thinner regions for an IQ gradient = 1.0. In this study an IQ gradient = 0.5 was used, as this provides a nearly constant image noise [Ka,r of fluoroscopic images acquired using CEC with the fluoroscopic images acquired using DEC , incorporating both types of exposure control (CEC and DEC). Fluoroscopic images of each scenario were acquired in one session using three clinically established DEC protocols Table  with thrKa,r measured using the dose-area product meter, which is incorporated into the x-ray source and the collimator assembly [Postprocessing was minimised in order to reduce its possible effects and contained only a quadratic base curve and a gamma correction. All other post processing such as edge enhancement, noise reduction, or temporal averaging was switched off by using the service mode. The images were transferred for further evaluation to the Picture Archiving and Communication System. Images contained all of the image acquisition parameters, the WET of the projection, and the assembly , 12.a,r compared to the DEC acquired fluoroscopic image (DEC-image) was selected. The dose equivalent Ta image was defined as the image with a Ka,r closest to the Ka,r of the DEC image and whose Ka,r was no greater than 5% above the Ka,r of the DEC image. The image dataset containing the LD, ND, or HD DEC image with the respective dose equivalent Ta image were presented on a workstation  to three blinded readers with 5, 8, and 9 years of experience in angiography  fluoroscopic image with an equivalent KKa,r of the Ta-IQ equivalent image was subsequently documented and compared to the Ka,r of the corresponding DEC image . For each image dataset, the radiologist specifically focused on the depiction of the tantalum structures. The age Fig. .VGC) with 95% confidence interval using bootstrapping , taking possible dependencies between ratings into account. An AUCVGC value of 0.5 reflected similar IQ for the two exposure controls, while an AUCVGC > 0.5 indicated superior IQ, and an AUCVGC < 0.5 indicated inferior IQ produced by CEC.Descriptive statistical analyses were calculated  –15. InteKa,r differences between the DEC-image and the dose equivalent Ta image were assessed via paired t test according to Norman [Ka,r values selected by the three readers was first calculated and then compared with the paired t test. Normal distribution of the dose data was confirmed level-wise using the Shapiro-Wilk test. Differences in Ka,r reduction between the different dose levels were assessed with the ANOVA test and post-hoc paired t test with Bonferroni correction. A p value < 0.05 indicated significance.Possible o Norman  who demohttp://www.r-project.org with package “IRR” version 0.84.1) and the sample size estimation with G*Power .The required sample size was conservatively estimated, based on the estimated dose difference of at least 30 ± 20% with an abnormal distribution of the paired acquisitions. This requires at least six scenarios to achieve a power of 0.8 at an α error of 0.05 . The staKa,r . Regarding the radiation dose levels of DEC, the highest average increase in IQ in the dose equivalent Ta images was observed for the HD level (3.1 ± 0.5 versus 4.5 ± 0.6), followed by the ND level (2.8 ± 0.4 versus 4.0 ± 0.7) and LD level (2.5 ± 0.5 versus 3.3 ± 0.5). Considering the change in average IQ dependent on WET, the increase in IQ of the dose equivalent Ta image was similar for the low (2.9 ± 0.5 versus 4.1 ± 0.8) and medium WET (2.9 ± 0.6 versus 4.2 ± 0.8), followed by the highest WET (2.6 ± 0.5 versus 3.6 ± 0.7). The average IQ of the dose equivalent Ta image dependent on WET and DEC dose level was significantly higher as compared to the DEC image ; medium WET (30.9 ± 0.8 cm); and high WET 36.4 ± 1.0 cm). The interobserver agreement for the assessment of the IQ of DEC (0.43) and Ta-CEC (0.56) was fair. Every reader observed a substantial increase in IQ for the dose equivalent Ta image as compared to the DEC image as demonstrated in Fig.  ± 1.0 cmKa,r of the Ta-IQ equivalent images demonstrated a good interobserver agreement (0.73). Overall, the average Ka,r of the Ta-IQ equivalent images was 59 ± 16% (mean ± standard deviation) versus lower (p < 0.001) as compared to the Ka,r of the DEC images. Regarding the radiation dose levels of DEC, the highest average Ka,r reduction of the Ta- IQ equivalent images was documented for the HD level (68 ± 15%), followed by the ND (62 ± 13%) and LD level (47 ± 13%). Considering the dose difference dependent on the WET, comparable Ka,r reductions of the Ta-IQ equivalent image were observed for the low (61 ± 13%) and medium WET (63 ± 15%), while Ka,r reduction for the highest WET (54 ± 7%) was lower. For each WET and DEC dose level, significant averaged Ka,r reductions were noted  lower Ka,r for every WET and DEC dose level. Average Ka,r reductions increased significantly from the LD to the ND level for each WET (p ≤ 0.014) and were comparable for the low and medium WET and lower for the high WET. Between the ND and HD level a significant average Ka,r reduction was only noted for them medium WET (p ≤ 0.007).The assessment of LD level 7 ± 13%. Ka,r. Alternatively, the skin radiation dose can be reduced significantly with Ta-specific CEC maintaining the IQ of Ta. The effective skin dose reduction is beneficial, in particular in long lasting procedures in young patients using tantalum based embolisation material in arteriovenous malformations. In addition, IQ can be adjusted over a much wider range using CEC as compared to DEC, as indicated in Fig. The results of this animal study demonstrate that a tantalum-specific contrast-to-noise ratio-driven exposure control (Ta-specific CEC) significantly improves the depiction of tantalum as compared to conventional DEC in abdominal angiography maintaining a constant Ka,r reductions were noted for the low and medium WET. The increase of the Ka,r reductions with the dose level underlines the importance of material-specific imaging. It also indicates that DEC is not optimised for the imaging of tantalum and can lead to unnecessary high-dose levels.The results confirm the results of the recently conducted phantom studies by Dehairs et al.  and WernOur study augments the results of a clinical study by Vogl et al. on 106 patients receiving transarterial chemoembolisation using ARTIS pheno® , which reported superior IQ in fluoroscopy at a lower radiation dose as compared to the predecessor using DEC, as higher copper filtration was applied . Howevere.g., iodine, iron and bony structures. The reduced visibility of the light materials simulated by the 0.018 in guidewire, the iodine-filled Fogarty balloon, and the Lipiodol/cyanoacrylate-filled vessel in Fig. The skin radiation dose reductions observed in our study can be explained by the different principle of CEC as compared to DEC. DEC aims to achieve a predefined radiation dose at the image receptor, which is achieved by an algorithm that does not take the material properties and acquisition settings into account . CEC, whe.g., for uterine or prostate artery embolisation. The IQ gradient of 0.5 was selected as it provides a similar image noise between the different IQ levels. In clinical routine, a constant IQ with an IQ gradient of 0.0 would be preferred in order to fulfil the “as low as reasonably achievable”, ALARA, principle.The newly introduced parameter “average velocity” in CEC, which limits the pulse width, has an important impact on the possible skin dose savings, as it is directly linked to the x-ray tube capacity, which limits the selection of acquisition settings. For this reason, the slower the object moves, the greater the potential skin dose savings. In this study, we used an average velocity of 15 mm/s, which is used in clinical practice for the depiction of guide wires in abdominal interventions. In regions with very little respiratory motion, such as the pelvis, a lower “average velocity” and thus a lower restriction on maximum pulse widths is possible, which can result in even higher skin dose savings, Ka,r, measured by the DAP ionisation chamber. The advantage of this approach is that Ka,r is provided by International Electrotechnical Commission compliant angiography systems [Ka,r [Several limitations of our study need to be acknowledged. Firstly, only a small subset of Ta-CEC acquisition protocols could be compared to the conventional DEC protocols. As already described, the new parameters “average velocity” and to a smaller extend “spatial frequency”, which limit the focal spot, have a direct impact on the selected x-ray parameters by the CEC and thereby limit the possible radiation dose savings . Therefo systems  and can ms [Ka,r . Thirdlyms [Ka,r –26. FinaKa,r when compared to DEC. Alternatively, the Ka,r can be significantly reduced by using Ta-CEC instead of DEC, if a comparable depiction of tantalum is warranted. Thus, the use of Ta-CEC allowed for a significant improvement in IQ or dose reduction in fluoroscopic imaging of Ta containing embolics, which are regularly used in embolisation procedures in young patients.In conclusion, Ta-CEC significantly improves the fluoroscopic depiction of Ta maintaining a constant incident


When playing handball, the preservation of the subacromial space, which can be quantified by the acromiohumeral distance (AHD), plays a crucial role for shoulder health of handball players. Acute effects of handball-specific loading on the subacromial space with consideration of individual adaptions resulting from long-term handball-specific loading experience have yet to be determined in order to prevent injuries such as e. g. an impingement of the supraspinatus tendon.To (1) assess the acute effects of handball-specific loading on the AHD in healthy experienced handball players (HB) and non-handball experienced athletes (CG) and (2) to assess the AHD behavior in relation to individual intrinsic factors to identify possible risk factors and the effect of handball-specific experience associated adaptations.20 HB  and 20 CG ; 24 ± 5 years.Handball-specific loading protocol.The AHD was measured by ultrasonography at 0° and 60° abduction pre and post intervention. Isometric shoulder strength was measured with hand-held dynamometry. Shoulder range of motion (ROM) was measured with goniometry.p = 0.001, d = 0.69; CG: −1.1 ± 2.0 mm; p = 0.024, d = 0.37) and in the non-dominant shoulder in 0°  and 60° abducted position  in HB only. Handball-specific loading enhanced AHD reduction when elevating the shoulder from 0° to 60° in both groups and arms. Larger shoulder abduction strength affected the maintenance of the AHD positively. HB demonstrated less shoulder strength compared to CG, while ROM did not differ.Handball-specific loading led to significantly reduced AHD in the dominant shoulder in the 60° abducted position in both groups (HB: −1.7 ± 2.0 mm; Handball-specific loading can affect the ability to preserve the subacromial space which might put handball players at risk for shoulder injuries. Poor shoulder strength can aggravate this mechanism. Therefore, implementation of strengthening exercises of the external rotator and abductor muscles in the training schedule may improve shoulder health of handball players. Handball is a physically demanding sport, characterized by a large number of sprints, jumps and throws, and quick changes in direction. While those characteristics contribute to its huge international popularity  the repeApart from many other shoulder structures, pathologies of the rotator cuff and the subacromial bursa are considered to be a principal cause of shoulder pain . These sIt has yet to be determined which factors contribute to maintaining this space and whether handball players can do this better by means of their specific adaptations. It is known that the population of overhead athletes whose shoulders are exposed to specific and chronic overhead loading displays biomechanical and structural adaptive changes such as altered shoulder range of motion (ROM) patterns and altered strength ratios in the dominant shoulder , 18. FurSeveral previous studies have investigated the acute effects of exercise induced fatigue on several parameters related to the shoulder joint of athletes  and espeThe aim of this study was to assess the acute effects of handball-specific loading on the AHD in experienced handball players and in non-handball experienced athletes. Handball-specific loading during gameplay was simulated by means of a standardized protocol of handball-related movements to investigate its effects on the subacromial space. We hypothesized that handball-specific loading will reduce the AHD.As a secondary objective, we examined the AHD behavior in relation to individual intrinsic factors such as shoulder strength and range of motion in order to identify possible intrinsic risk factors which could be addressed by preventive interventions, and which may contribute to the development of suitable and sport-specific prevention programs. We hypothesized that poor shoulder strength and poor range of motion will have a negative effect on the ability to preserve the subacromial space.Third, we investigated the effect of handball-specific experience respectively therewith associated adaptations on the response of the AHD to handball-specific loading by comparing experienced with non-experienced handball players. We hypothesized that handball-specific experience and therewith associated adaptations may affect the response of the AHD to handball-specific loading while we did not expect an effect of sex.n = 20; 10 m and 10 f) were recruited from local handball clubs by contacting the coaches via email while a control group of non-handball experienced athletes , were recruited from sport science students attending handball courses as part of their sport science degree by contacting the handball lecturer of an university. To be included in the study, all participants had to be between 18 and 40 years of age. Participants of the HB group had to have played handball at competition level  with at least two training sessions per week and a minimum of 5 years' experience. Participants of the CG were physically fit sport science students. They had learned and practiced handball specific movements in the handball course for several weeks but had no further previous handball experience other than in the one acquired in the University course. Exclusion criteria were current shoulder pain and shoulder pain during 6 months before the study for which a medical doctor was consulted. Furthermore, people with systemic diseases, previous shoulder surgery as well as diagnosed and documented structural damage or known anatomical alterations of the shoulder joint were excluded from the study.A group of experienced handball players  patient-reported outcome measures were obtained and AHD was measured with ultrasonography before and after a handball-specific loading protocol. (2) anthropometric measures, shoulder muscle strength and range of motion were obtained. All athletes were assessed within the same phase of the competitive season to prevent varying conditions within the course of the season.The sessions took part at the sports facilities of the handball clubs (HB group) and at the University sports facility (CG), respectively. Measurements were performed by the same two trained investigators, of which one is a physiotherapist and one is a sports scientist. The study protocol was approved by the Ethics Committee of the Faculty of Humanities and Social Sciences of the Humboldt-Universität zu Berlin (HU-KSBFEK_2019_0013).Anthropometric measures such as body height, body mass, arm  and forearm  length were determined. The dominant arm was defined as the arm with which the participants reported to preferably throw a ball. To identify shoulder impairments all participants completed the German version of the Kerlan-Jobe orthopedic clinic shoulder and elbow score (KJOC-G), which is a reliable and valid tool that specifically identifies impairments, activity limitations and sports participation restrictions of overhead athletes .Participants underwent clinical examination, including active movements and impingement tests  , by an eThe participants were advised not to intensively exercise 48h before examination. Abduction (ABD), external rotation (ER) and internal rotation (IR) maximum isometric shoulder strength of the dominant and non-dominant shoulder were measured with a microFET2 hand-held dynamometer  as described previously . Hand-he® Absolute Axis 360 Grad-Digital-Goniometer, model 1013990) which is considered as reliable and valid method for shoulder mobility measurements  and external rotation (ER) of the dominant and the non-dominant shoulder joint were measured as described previously  with gonurements . The toturements . Furtherurements , 34.Sonographic measurements were performed before (PRE) and after (POST) execution of the handball-specific training protocol, using the mobile Echo Blaster 128 CEXT  and a 5.0- to 8.0-MHz linear transducer (LV7.5/60/128Z-2). The participants were sitting upright during the measurements. Images were taken for the dominant and the non-dominant shoulder in two standardized positions: (1) 0° shoulder neutral position with the arm positioned aside the body; (2) 60° of active abduction in the coronal plane. The 60° abduction angle was determined with a digital goniometer. A marker tape was placed on an adjacent wall at the level of the participant's finger tips in order to maintain the correct angle of arm abduction during the measurement. The participant's arm was moved back into the neutral position in between measurements to avoid fatigue. Each position was repeated two times for every shoulder, and the mean was calculated.The AHD was measured in the coronal plane by placing the ultrasound transducer on the center of the acromion parallel to the longitudinal axis of the humerus as described previously . The min3, 1 0.996) and inter-rater reliability   .Ultrasound images were excluded from statistical analyses when accurate distance measurements with the software were impossible due to poor image quality or in case the respective landmarks of the image could not be clearly visualized. In total, for all measurements 15 of 320 values could not be established.Literature on sport-specific characteristics of a handball game , 35, 36 p ≤ 0.05 for all statistical procedures.All statistical analyses were performed using IBM SPSS Statistics software for Mac, Version 24.0 . Data normality was assessed by the Shapiro-Wilk test and frequency histograms. The significance level (α) was set at t-tests. Differences between the shoulder sides and between pre and post AHD measurement after handball-specific loading within the groups were analyzed by paired t-tests. Mann-Whitney-U-Test and Wilcoxon signed-rank test, respectively, were used in case of non-normally distributed variables .Group and sex differences in demographic characteristics, ROM, strength and AHD were analyzed by independent A repeated measures ANOVA was used to detect between-group differences and interactions between group (HB and CG) and time (pre and post).s), for non-normally distributed variables were used. Classifications were used as follows: <0.10 = negligible, 0.10–0.39 = weak, 0.40–0.69 = moderate, 0.70–0.89 = strong and >0.90 = very strong correlation  and non-parametric Spearman's rank correlation coefficients .In general, the elevation of the arm from 0° to 60° led to significantly shorter AHD . The AHDA larger reduction of the AHD with arm abduction  correlated moderately and significantly with smaller normalized abduction strength in both arms in both groups . No othep ≤ 0.05) higher in HB  compared to CG .The subjectively perceived local fatigue in the dominant 'and non-dominant arm 'post handball-specific loading was significantly  = 0.09, p = 0.765, partial η2 = 0.00; 60° dominant: F = 1.14, p = 0.292, partial η2 = 0.03; 0° non-dominant: F = 0.69, p = 0.410, partial η2 = 0.02; 60° non-dominant: F = 0.81, p = 0.375, partial η2 = 0.02].No significant interaction was detected between time and group for all positions and sides [0° dominant: FHB and CG did not significantly differ in AHD absolute values  and ROM In terms of strength differences, CG showed significantly higher absolute ER, IR and ABD strength and normalized peak torque values in both shoulder sides and a larger ER/IR ratio in the non-dominant shoulder compared to HB .In terms of the effects of muscle strength on the AHD, the relationship of the ER/IR strength ratio and the AHD at 0° and 60° pre-loading  and the While in HB a larger AHD before loading was associated with a higher ER/IR strength ratio both at 0° and 60° with significant correlations detected for the dominant shoulder, this association was not detected in CG  and corrA larger AHD reduction with loading was associated with larger normalized ER strength in both shoulders (at 60°) in HB only ,B. Post Regarding anthropometric measures, males were displaying a significantly larger body height, mass, BMI, arm and forearm length. Furthermore, they displayed significantly larger KJOC-G scores for the non-dominant arm. Within CG, male athletes were older than female athletes.ROM did not significantly differ between male and female participants. Absolute strength  and normalized peak torque (ABD) were significantly higher in male compared to female participants.Absolute AHD were larger in male participants in both shoulder sides which was significant in all conditions, except for the AHD of the non-dominant shoulder in 0° (pre-measurement) and the AHD of the non-dominant shoulder in 0° and 60° (post-measurement).To uncover how handball-specific loading acutely affects the subacromial space, we measured the AHD before and after a handball-specific loading protocol to provoke muscle fatigue that resembled handball-specific fatigue. At the same time, we wanted to determine the relation of effects with individual athlete characteristics and adaptations.Handball-specific loading can aggravate AHD reduction, while the magnitude depends on sport-specific experience and arm abduction angle. Furthermore, shoulder abduction strength affects the maintenance of the AHD positively. In comparison to controls, experienced handball players showed less shoulder strength. Handball players displayed AHD reductions in both sides after fatigue, while in controls fatigue reduced the AHD in the dominant side only.We hypothesized that handball-specific loading will have negative effects on the AHD in experienced handball players and non-handball experienced athletes. Our hypothesis was confirmed as handball-specific fatigue led to an AHD reduction, especially when the arm was raised. This may constitute a potential injury risk of the structures located inside the subacromial space, e.g., the supraspinatus tendon.Our results are in accordance with Chopp, O'Neill  who inveIn contrast to our results, Maenhout et al.  found anIt maybe questioned to what extent the described AHD reduction of few millimeters from pre- to post-fatigue is clinically important. However, even a small reduction of the AHD may increase the pressure in the subacromial space and thus compromise inlying structures. As Girometti, De Candia  detectedOur hypothesis that poor shoulder strength and poor range of motion will have negative effects on the ability to preserve the subacromial space can only be confirmed with regard to shoulder strength. Shoulder muscle strength affects the maintenance of the AHD. One goal should be appropriate training of the shoulder muscles so that the AHD is maintained as much as possible. It must be taken into account that it is not generally greater muscle strength that has a positive effect, but that the strength ratio between external and internal shoulder rotation is also important.Since larger normalized abduction strength was related to smaller reduction of the AHD with arm abduction, we conclude that abduction strength contributes to the preservation of the AHD during arm lifting in non-fatigued conditions. The protective effect was observed independent of the investigated arm (dominant and non-dominant) and group (experienced and non-experienced), which points toward a general mechanism. Although the AHD is reduced during arm abduction, when the abductor muscles are active , 42, thiIn contrast, the finding that poor abduction strength has a negative effect on maintaining the AHD suggests that it is relevant for athlete health to include abduction strength exercises into handball specific strength and conditioning training in order to prevent subacromial space reducing conditions that can lead to injuries .In addition, the finding that experienced handball players examined in our study showed lower shoulder strength and reported higher fatigue in the dominant arm than the non-handball experienced athletes suggests that additional strength training in handball is indispensable and should be expanded. Upper extremity strength training can be easily and inexpensively implemented in regular handball training  as previous studies have already shown , 45.We hypothesized that handball-specific experience and therewith associated adaptations may affect the response of the AHD to handball-specific loading. Our hypothesis was confirmed since experienced handball players and not-handball experienced athletes showed different effects after handball-specific loading. Although the handball players show handball-specific adaptations, this does not necessarily lead to a better preservation of the AHD and thus no better injury protection.Our results do not confirm protective, impingement-sparing conditions in overhead athletes as detected by Maehnout et al. . HandbalIn experienced handball players the absolute AHD and its reduction after fatigue are related to strength and strength ratios differently than in controls. A larger ER/IR ratio was associated with a larger AHD in handball players in the pre-fatigue state. Larger ER and smaller IR strength abilities appear to be conducive to maintain the AHD. After fatigue, the handball players with greater IR strength showed a smaller AHD in the hanging arm, which corresponds to the previous result. However, the change through fatigue in terms of AHD reduction was greater in those with greater ER strength. This might be due to the larger space for reduction.Nevertheless, these results suggest that greater ER strength has a positive effect on preserving the subacromial space, which is why strengthening the external rotators should be taken into account in the training of handball players.Since this association was not detected in non-handball experienced athletes a disparity in ER/IR strength might affect the AHD only in connection with other sport specific adaptations which have not been identified within this study. This fact illustrates the effect of interpersonal differences related to the investigated groups, which might be caused by handball-specific experience and morphological adaptations.We found larger AHD values in male participants, which has already been documented in previous studies . HoweverSince this study investigated athletes with healthy shoulders only, our assumptions cannot be extended to athletes suffering from shoulder pathologies.ER and IR strength testing was performed in in 90° abduction position of the shoulder, as this is the sport specific position for throwing movements. However, this position may have an effect on force development, so that comparisons with other studies and positions must be made with caution.Although our standardized handball-specific loading protocol resembled the characteristic load of handball players, the intensity of movement executions and movement patterns could differ in real gameplay. Since our loading protocol resulted in individualized fatigue, it is possible that participants within a group experienced different levels of fatigue. Although subjective fatigue was measured using the Borg scale, differences in heart rate or distance covered may have occurred and may have affected the results.Handball-specific fatigue leads to an AHD reduction which is enhanced with shoulder abduction. Furthermore, poor abduction strength affects the preservation of the AHD negatively in both handball experienced and not experienced athletes, which may increase the risk for shoulder injuries. In handball players, greater ER and ABD strength had a positive effect on the maintenance of the AHD. Therefore, strengthening of external rotator and abductor muscles should be an important part in handball training.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the Faculty of Humanities and Social Sciences of the Humboldt-Universität zu Berlin (HU-KSBFEK_2019_0013). The patients/participants provided their written informed consent to participate in this study.CR and KL contributed to conception, design of the study, and performed the statistical analysis. CR conducted the data collection and wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.This study is part of the PhD project of CR, which is partially funded by a PhD scholarship of the FAZIT-Foundation of the Frankfurter Allgemeine Zeitung, Frankfurt am Main, Germany. The article processing charge was funded by the Deutsche Forschungsgemeinschaft  - 491192747 and the Open Access Publication Fund of Humboldt-Universität zu Berlin.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To provide a structured Multidisciplinary team (MDT) checklist to improve the quality of ward rounds in Ward 3, Wishaw General hospital. Ward rounds normally involved patient and electronic documentation review during MDT. Feedback from medical and nursing staff indicated inconsistencies in finding up to date Do not resuscitate cardiopulmonary resuscitation (DNACPR)forms/Treatment escalation plans, treatment forms, care plans, thromboembolism prophylaxis during ward rounds. Discussions about who will update the family, make social work referrals needed clear documentation in order to follow up efficiently post MDT. Food, fluid, and weight charts although done regularly there was no single place to keep them together. These charts to be kept in a separate folder for finding easily during ward rounds. The Royal College of Psychiatrists sets standards that managers and practitioners have agreed standards for ward rounds. Structured ward rounds and check lists have shown to prevent omissions in care and improve patient safety.Discussions with Ward 3 team, nursing colleagues and ward Quality improvement group were held. A Standard MDT Quality improvement Checklist was devised and used as a Pilot in W3, WGH.This was first introduced in August 2021. Plan, do, study, act (PDSA) cycle was carried out.Plan: Trial MDT checklist at Ward 3 ward RoundDo: Use Initially for two Consultant ward roundsStudy: Ask all MDT staff members for feedback on the formAct: Reformat the checklist for the following ward rounds and distribute among all consultants.Repeated Revisions of MDT checklist done after feedback from ward staff and final version devised and results audited in Nov 2021 and Jan 2022.Food, Fluid, and weight charts were put in separate folders.Before MDT Checklist nil up to date MDT checklist information available, 10% individual food and fluid charts and 0% folders.After MDT checklist in November 2021, 73% increase in up-to-date checklist items, 100% increase in finding charts in folders.In January 2022 decrease to 44% of up-to-date MDT checklist items, 100% food and fluid charts in folders.MDT Checklist provided robust structure to our Ward rounds along with the regular electronic record and has been incorporated in our shared drive. The results in January for up-to-date checklist were down because of staff sickness due to new Omicron variant and less people available to keep documentation up-to-date.


Conclusion: We present a standardized, comparable approach of ICG-NIRF visualization in pouch surgery. Our data indicate that the visual interpretation of ICG-NIRF alone may not detect ALs of the pouch in all cases—quantifiable, objective methods of interpretation may be required in the future.Background: An anastomotic leak (AL) after a restorative proctocolectomy and an ileal J-pouch increases morbidity and the risk of pouch failure. Thus, a perfusion assessment during J-pouch formation is crucial. While indocyanine green near-infrared fluorescence (ICG-NIRF) has shown potential to reduce ALs, its suitability in a restorative proctocolectomy remains unclear. We aimed to develop a standardized approach for investigating ICG-NIRF and ALs in pouch surgery. Methods: Patients undergoing a restorative proctocolectomy with an ileal J-pouch for ulcerative colitis at an IBD-referral-center were included in a prospective study in which an AL within 30 postoperative days was the primary outcome. Intraoperatively, standardized perfusion visualization with ICG-NIRF was performed and video recorded for postoperative analysis at three time points. Quantitative clinical and technical variables (secondary outcome) were correlated with the primary outcome by descriptive analysis and logistic regression. A novel definition and grading of AL of the J-pouch was applied. A postoperative pouchoscopy was routinely performed to screen for AL. Results: Intraoperative ICG-NIRF-visualization and its postoperative visual analysis in 25 patients did not indicate an AL. The anastomotic site after pouch formation appeared completely fluorescent with a strong fluorescence signal (category 2) in all cases of ALs (4 of 25). Anastomotic site was not changed. ICG-NIRF visualization was reproducible and standardized. Logistic regression identified a two-stage approach vs. a three-stage approach (Odds ratio (OR) = 20.00, 95% confidence interval [CI] = 1.37–580.18,  Restorative proctocolectomy (RPC) followed by the formation of an ileal pouch reservoir and ileal pouch-anal anastomosis (IPAA) as first described by Parks and Nicholls is the surgical procedure of choice for patients with inflammatory bowel disease (IBD) in cases of medically refractory ulcerative colitis (UC), UC-associated neoplasia, familial adenomatous polyposis (FAP) as well as other conditions including synchronous colorectal cancer ,2,3,4. DIndocyanine green derived near-infrared fluorescence (ICG-NIRF) enables the clinician to visualize bowel perfusion in real-time ,24. The This study aimed to evaluate ICG-NIRF for the intraoperative detection of ischemia-related complications in ileal J-pouch formation and to develop a standardized approach for an ICG-NIRF perfusion assessment to improve data comparability of future trials.This prospective cohort study (NCT04695184) was performed at the Department of General and Visceral Surgery, Charité University Hospital Berlin, Campus Benjamin Franklin, a tertiary colorectal and inflammatory bowel disease (IBD) referral center, from February 2019 to December 2020. The study protocol was approved by the Charité University Hospital Ethics Committee  and conducted in agreement with the Declaration of Helsinki. Data were reported conforming to the STROBE guidelines . Patients undergoing ileal J-pouch formation either in a two- or three-stage approach were eligible for study inclusion. In the two-stage approach, patients underwent a proctocolectomy simultaneously with ileal J-pouch formation and a loop ileostomy. Patients undergoing the three-stage approach received a completion proctectomy with ileal J-pouch formation and a loop ileostomy following a prior subtotal colectomy with an end ileostomy. Inclusion criteria were a diagnosis of medically refractory ulcerative colitis, indeterminate colitis, colorectal cancer, FAP, age ≥ 18 years and an American Society of Anesthesiologists (ASA) physical status ≤ 3, laparoscopic and open surgery. Exclusion criteria were the coexisting malignancy of a different etiology, liver dysfunction (MELD score > 10), hypersensitivity to indocyanine green (ICG) or sodium iodide, iodine allergy, hyperthyroidism, thyroid nodules, a previously poorly tolerated injection of ICG, as well as pregnancy and breastfeeding.Written informed consent for participation and ICG-administration was obtained on the day before surgery. Following the standard procedure of a high-volume tertiary IBD referral center, ileal pouch-anal anastomosis (IPAA) was standardly achieved without a mucosectomy by circular mechanical double-stapling using a 29 mm end-to-end anastomosis (EEA) stapler after fashioning the J-pouch to a length of 14–16 cm by linear single-stapling . In cases where this technique was not possible following good clinical practice due to the risk of malignancy, single-layer hand-sewn anastomosis was performed after the completed mucosectomy.® Fluorescence Imaging Platform  directly after each ICG injection. Intraoperatively, ICG  was dissolved in 5 mL sterile water to yield a 5 mg/mL concentration and administered intravenously as a bolus of 1 mL (5 mg), respectively, at three consecutive time points. Real-time intraoperative perfusion visualization was performed with the Quest Spectrum® system was equipped with the ring light camera for open surgery, which was adjusted manually in position and focused for the optimal visualization of the imaging site and secured in position by an attachment to the stabilizing arm to ensure a fixed distance to the imaging site , to protect the IPAA while allowing 360° visualization by manual air insufflation (At time point 1 (T1), the terminal ileal loop was visualized prior to J-pouch formation. At time point 2 (T2), the J-pouch was visualized immediately after formation by side-to-side stapled anastomosis. At time point 3 (T3), the IPAA was visualized after completion by trans-anal circular stapling. At time points 1 and 2, the Quest Spectruming site a. At timfflation b.At each time point, the time period from ICG injection to the visual detection of a full fluorescent signal was video recorded for postoperative analysis in the fluorescent mode and the overlay mode of fluorescence and color image . Additional clinical and technical data were documented, as well as the timing between the subsequent measurements. It was noted whether the operating surgeon decided to change the area of transection according to the ICG-NIRF signal. Postoperatively, the video recordings of visualization were analyzed to determine the quantitative subjective parameters. The clinical outcome was unknown to the investigator at this point. Fluorescence signal strength was categorized as “0”, i.e., signal not detectable; “1”, i.e., signal detectable; or “2”, i.e., strong signal detectable. It was further categorized as “homogenous”, i.e., uniformly distributed across the bowel included in the imaging site; or “heterogeneous”, i.e., unevenly distributed across the bowel included in the imaging site. Complete fluorescence of the pouch anastomotic site was categorized at time points T2 and T3 as “Yes”, i.e., completely fluorescent; or “No”, i.e., not completely fluorescent. An AL of the pouch was defined as the primary outcome. A change of the anastomotic site was not intended based on NIRF visualization. The secondary outcome consisted of clinical and technical data during and after visualization.Clinical data were collected from all patients on 30-day postoperative morbidity, mortality and length of hospital stay, including ALs of the pouch, pouch necrosis and pouchitis. An endoscopy (pouchoscopy) with a flexible endoscope was performed six to eight weeks after hospital discharge or during the postoperative hospital stay if signs of ALs or pelvic sepsis , fever > 38.5 °C, prolonged postoperative ileus) were detected.To date, there is no standardized definition of an AL of the ileal pouch. Thus, in conformity with previous definitions of an anastomotic leak in colorectal surgery , we specGrade A: Anastomotic leak of the pouch requiring no active therapeutic intervention.Grade B: Anastomotic leak of the pouch requiring active therapeutic intervention, but manageable without a relaparotomy.Grade C: Anastomotic leak of the pouch requiring a relaparotomy. www.r-project.org, the R foundation, Vienna, Austria; accessed on 1 December 2021). A two-sided p value < 0.05 was considered statistically significant. Continuous data are expressed as the means (standard deviation) or medians with interquartile ranges (IQRs). Proportions were compared by Mid-P-chi-square statistics or Monte Carlo (MC) simulated chi-square statistics as appropriate. Continuous variables were compared by Mann–Whitney U-tests. Leakage was further assessed by logistic regression analysis. p values were estimated by likelihood-ratio tests. For continuous predictors, the p values were estimated based on the mean ranks . . 29]. Additionally, detailed clinical and technical parameters at the time points of ICG-NIRF visualization T1–T3 were determined for statistical analysis . The admp = 0.029) was identified as a significant risk factor for ALs  = 20.00, 95% confidence interval [CI] = 1.37–580.18,  for ALs .Univariable logistic regression of technical parameters at the time of ICG-NIRF visualization was performed additionally and showed no statistical difference for the event of an AL of the pouch.As intraoperative ICG-derived near-infrared fluorescence imaging is becoming increasingly popular, publications in this field are accumulating fast. While the potential of the technique has been shown, its validity and reproducibility remain unclear, as there are considerable differences in its individual application and interpretation. Thus, establishing and maintaining a high scientific standard when conducting ICG-NIRF studies is acutely important. In the work presented here, we focused on an accurate and reproducible methodology, aiming for a comparability of data with other and future studies. In particular, our methodology addressed variables for enabling a quantitative comparison of ICG-NIRF visualization data. In the present study, ICG-NIRF was conducted in a standardized and controlled manner, including the distance and timing of visualization. Quantitative subjective criteria of fluorescence were defined and applied in the postoperative blinded analysis. The results demonstrated that ICG-NIRF was reproducible, did not indicate an AL of the pouch within 30 days post-operation and identified a two-step surgical approach as a significant risk factor for AL . Three oIn several recent reviews on fluorescence-guided abdominal surgery, a lack of quantitative, unbiased data in the available literature and the need for further research into the specifics of its application were pointed out ,30,31,32As the comparison of time points T1, T2 and T3 shows, the methodology presented here is quantitative, accurate and reproducible, allowing a comparison of subsequent ICG-NIRF visualizations and takes into account previously unreported variables. It seems probable that the time points T1 (before pouch formation), T2 (after pouch formation) and T3 (after completed IPAA) have different degrees of relevance for assessing postoperative pouch perfusion. T1 was chosen to indicate the baseline perfusion of the ileum segment to be used for ileal pouch formation in order to investigate reproducibility and potentially detect areas of initially impaired perfusion after bowel mobilization and transection. The visualization of the J-pouch at T2 after its formation has a conceivably high validity in assessing postoperative pouch perfusion, although perfusion may additionally be affected after delivery of the pouch down into the pelvis. The visualization at T3 can potentially indicate perfusion across the IPAA, which can be regarded as the Achilles’ heel of the ileoanal pouch. However, at T3, the technical difficulty of standardizing the endoluminal field of view in a dynamic environment may have affected the validity of the visualization. Advances in the form of near-infrared fluorescence endoscopes are needed, as this imaging location and timing is vital for assessing the perfusion of ileoanal and colorectal anastomoses.Despite the standardized quantitative analysis of ICG-NIRF visualization, no significant differences were seen in patients developing an AL of the pouch. The intraoperative fluorescence signal was completely fluorescent at the anastomotic site in all patients with an AL. This was reproduced in the postoperative analysis of the video recordings and demonstrates that the visual interpretation of ICG-NIRF remains subjective irrespective of quantification and standardization. Subjective ICG-NIRF visualization does not seem to be sufficient to completely assess pouch microperfusion to detect an AL. Anastomotic tension could have contributed to the occurrence of an AL; however, tension-free anastomosis was achieved in all patients, excluding this factor as a cause. While numerous studies have adequately described the feasibility of ICG-NIRF for visualizing overall perfusion before or after intestinal anastomosis ,34,35,36In our study, a pouchoscopy was included in the follow-up of each patient, which explains the higher rate of AL detection. Thus, we identified ALs of the pouch in 4 out of 25 (16%) patients. In the literature, the reported rates of ALs of the pouch differ considerably, most often ranging from 6 to 10%. However, complications such as pelvic sepsis range from 7 to 36% and may likely occur due to an AL of the pouch. Additionally, to date there is no standardized definition or grading for an AL of the pouch, which suggests that there are significant differences in its detection. A considerable occurrence of asymptomatic ALs of the pouch masked by the presence of an ileostomy has already been described in the literature ,40. In aFinally, we acknowledge the limitations of the presented study. We conducted a study with a limited number of patients without randomization. Therefore, the impact and reliability of the statistical analysis may be limited. Accrual was mainly limited due to the later availability of a software allowing the video recording of NIRF visualization for a postoperative, strictly accurate assessment and the high degree of standardization and detail during visualization, requiring extensive data sets. However, we aimed to control for an extensive number of variables during ICG-NIRF visualization, therefore reducing potential confounders to a minimum. While the descriptive analysis of patient characteristics and the technical data of ICG-NIRF visualization did not provide significant differences for patients with an AL of the pouch, logistic regression did identify a two-stage approach as a risk factor for ALs, which has been repeatedly reported previously ,5,6. ThiDespite the relatively small sample size and thus possibly a limited external validity, the findings may indicate that a visual interpretation of ICG-NIRF visualization may not be objective or detailed enough to indicate cases of impaired microperfusion leading to an AL. Follow-up studies including objective interpretation methods and an evaluation of different techniques are needed. Additionally, other surgery- and patient-related factors contributing to ALs will continue to be of investigative importance to improve patient outcomes.The findings of this study provide a methodology for standardizing ICG-NIRF perfusion visualization and provide a model for investigating the outcome of ileal pouch surgery. They may further indicate that the visual interpretation of ICG-NIRF alone may not be sufficient to assess the risk of an AL of the J-pouch in RPC intraoperatively. Objective methods of interpretation may be required for valid intraoperative perfusion assessments.