Cumulative Experience Research Articles

Cumulative Surgeon Experience Is Associated with Improved Abdominal Wall Reconstruction Outcomes

Cumulative Surgeon Experience Is Associated with Improved Abdominal Wall Reconstruction Outcomes

A practical guide to botulinum neurotoxin treatment of shoulder spasticity 1: Anatomy, physiology, and goal setting

Botulinum neurotoxin type A (BoNT-A) is a first-line treatment option for post-stroke spasticity, reducing pain and involuntary movements and helping to restore function. BoNT-A is frequently injected into the arm, wrist, hand and/or finger muscles, but less often into the shoulder muscles, despite clinical trials demonstrating improvements in pain and function after shoulder BoNT-A injection. In part 1 of this two-part practical guide, we present an experts' consensus on the use of BoNT-A injections in the multi-pattern treatment of shoulder spasticity to increase awareness of shoulder muscle injection with BoNT-A, alongside the more commonly injected upper limb muscles. Expert consensus was obtained from five European experts with a cumulative experience of more than 100 years of BoNT-A use in post-stroke spasticity. A patient-centered approach was proposed by the expert consensus: to identify which activities are limited by the spastic shoulder and consider treating the muscles that are involved in hindering those activities. Two patterns of shoulder spasticity were identified: for Pattern A (adduction, elevation, flexion and internal rotation of the shoulder), the expert panel recommended injecting the pectoralis major, teres major and subscapularis muscles; in most cases injecting only the pectoralis major and the teres major is sufficient for the first injection cycle; for Pattern B (abduction or adduction, extension and internal rotation of the shoulder), the panel recommended injecting the posterior part of the deltoid, the teres major and the latissimus dorsi in most cases. It is important to consider the local guidelines and product labels, as well as discussions within the multidisciplinary, multiprofessional team when deciding to inject shoulder muscles with BoNT-A. The choice of shoulder muscles for BoNT-A injection can be based on spastic pattern, but ideally should also firstly consider the functional limitation and patient expectations in order to establish better patient-centered treatment goals. These recommendations will be of benefit for clinicians who may not be experienced in evaluating and treating spastic shoulders.

Access to online learning: Machine learning analysis from a social justice perspective

Access to education is the first step to benefiting from it. Although cumulative online learning experience is linked academic learning gains, between-country inequalities mean that large populations are prevented from accumulating such experience. Low-and-middle-income countries are affected by disadvantages in infrastructure such as internet access and uncontextualised learning content, and parents who are less available and less well-resourced than in high-income countries. COVID-19 has exacerbated the global inequalities, with girls affected more than boys in these regions. Therefore, the present research mined online learning data to identify features that are important for access to online learning. Data mining of 54,842,787 initial (random subsample n = 5000) data points from one online learning platform was conducted by partnering theory with data in model development. Following examination of a theory-led machine learning model, a data-led approach was taken to reach a final model. The final model was used to derive Shapley values for feature importance. As expected, country differences, gender, and COVID-19 were important features in access to online learning. The data-led model development resulted in additional insights not examined in the initial, theory-led model: namely, the importance of Math ability, year of birth, session difficulty level, month of birth, and time taken to complete a session.

Development of ETStig, a measure for stigma in essential tremor

IntroductionPeople with essential tremor commonly experience psychological difficulties that are not addressed. The effect of stigma, i.e., negative judgement by others because of a perceived difference in this case shaky movement, is a heretofore unstudied element. This project was undertaken to develop and field test a new measure for stigma associated with essential tremor. MethodsUnder guidance from a patient panel and an expert panel of neurologists and psychologists, the essential tremor stigma construct was delineated, and survey items were written to quantify three dimensions of interest: cumulative experience of stigma; related psychological distress; and resulting behavioral dysfunction. After pilot testing and revision, the essential tremor stigma measure underwent field testing by 198 essential tremor patients at two academic neurology clinics. ResultsThe experience, distress and dysfunction scales were shown to have good internal consistency and test-retest reliability. Retained items demonstrated acceptable correlations and response properties. The validity of the distress scale was supported by concurrence with an existing stigma scale for neurologic disease, while a patient's openness to psychologic referral was predicted by higher scores on the dysfunction scale. ConclusionThis new measure is introduced to study the phenomenon of stigma associated with essential tremor. It may prove useful in assessing potential treatments for the psychological distress and maladaptive behavior that result from this stigma.

Trans-catheter edge-to-edge mitral valve repair in patients with acute decompensated heart failure due to severe mitral regurgitation – a single centre experience

Abstract Introduction Recent series have demonstrated the benefit of trans-catheter edge-to-edge mitral valve repair (TEER) in acutely ill hospitalised patients with severe mitral regurgitation (MR) and intractable heart failure despite intensive intravenous therapy. We describe our cumulative experience with such patients at the Sheba Medical Centre over a 10 year period. Purpose The purpose of this study was to evaluate the safety and efficacy of TEER in hospitalized patients with acute decompensated heart failure and severe MR that was deemed to play a major role in the patients' deterioration. Methods We included 30 hospitalised patients with intractable heart failure and MR ≥3+ (20 males; mean age 74.2±10.6 years; 10 had cardiogenic shock). MR was primary in 4, secondary in 24 and mixed in 2 patients. Acute results were assessed by echocardiography prior to discharge and safety was evaluated clinically, according to the occurrence of procedure-related adverse events. Mortality data were drawn from the national death registry. Results TEER devices were successfully implanted in 28 patients. Early (POD 1) procedure-failure was noted in one patient due to recurrence of flail. There was no peri-procedural mortality. Two patients were hemodynamically unstable during the procedure. One patient had peri-procedural access site bleeding necessitating blood transfusion. Following intervention, 16 patients required ICU care (mean stay 4.8±2.5 days), shock was recorded in 7 patients, 16 required hemodynamic support, and 8 required invasive ventilation. At 30 days 7 patients had died and an additional 4 died 1 to 6 months following intervention. However, mortality in the remaining patients was low with only 3 additional deaths up to 4 years after the procedure (80% of patients alive at 6 months). MR reduction was achieved in 24 patients (to ≤mild in 10 and to moderate in 11). At 12 months follow up MR severity was mild in 3 (37.5%) and moderate in 5 (62.5%) patients. Only 1 patient reported HF rehospitalisation during the year following the procedure. Conclusion TEER for hospitalised patients with severe MR and intractable heart failure is safe, associated with high early mortality, and good long-term outcome for patients alive 6 months after the procedure. More research is needed to better characterise patients likely to benefit from TEER in this clinical scenario. Funding Acknowledgement Type of funding sources: None.

Percutaneous interventions in Fontan circulation

Abstract Background In light of increased survival of patients with Fontan circulation, percutaneous interventions in these patients have become growingly significant in the recent years. Percutaneous treatments in patients with univentricular physiology can optimize the short term hemodynamics in these patients. However, information on long term outcomes is scarce. Purpose To present the cumulative work experience in percutaneous interventions of a tertiary center in the past 12 years in patients that have undergone total cavopulmonary deviation (TCD) and to investigate long term outcomes. Methods In this retrospective study, all patients with TCD that underwent follow-up in our specialized department of congenital heart disease in the past 12 years, were eligible for chart-review. Cardiac catheterization was performed by experienced interventional cardiologists, specialized in structural interventions in congenital heart disease. All catheterizations were performed under general anesthesia and mechanical ventilation. All patients underwent Fontan pressure measurements and cardiac output estimation with Fick method. Results A total of 80 patients, with a mean follow-up time of 24 (±7.1) years, were included in the study. Details on baseline characteristics are depicted in Table 1. Fifty-two (65%) patients underwent percutaneous intervention during follow-up, and 33% (n=17) of these patients required multiple interventions. Angioplasty with stent implantation of the Fontan conduit or the pulmonary arteries was the most common intervention (30 (58%) and 8 (15%) patients, respectively), followed by embolization of collaterals (11 (21%) patients). Patients with right systemic ventricle physiology needed more interventions and had a shorter time-to-first-intervention period. (Figure 1) Pacemaker implantation was required in a total of 15 patients, being significantly more frequent in patients with atriopulmonary connection than in patients with lateral tunnel or extracardiac conduit (11 (36%) vs 4 (11%), p<0.01). Overall long-term outcome (with regards to mortality) was good (4 (0.5%) patients). Patients that required percutaneous structural interventions showed a tendency towards a higher mortality than those not in need of intervention (4 (8%) vs 0 (0%), respectively, p=0.14). Conclusions During long-term follow-up of patients with Fontan circulation, almost two thirds of the patients required percutaneous intervention. Patients with right systemic ventricle physiology were in greater need of intervention. Patients that required intervention had a tendency towards a worse clinical outcome. Funding Acknowledgement Type of funding sources: None.

O029 / #627 DEEP BRAIN STIMULATION FOR PARKINSON: AWAKE VS ASLEEP SURGICAL TECHNIQUE: TRACK 2: DEEP BRAIN STIMULATION FOR MOVEMENT DISORDERS

Electrical stimulation of deep brain nuclei is a well-stablished technique for the treatment of movement disorders, when refractory to medical management. In its early beginnings, functional neurosurgery relied in stereotactic atlases and intraoperative micro-registration in awake patients to achieve correct electrode placement (indirect method). However, the cumulative experience on target description and the evolution of MRI resolution have made it possible to accurately define the target preoperatively (direct method).

ABCL-405 Patient, Caregiver, and Physician Preferences for Treatment of Relapsed or Refractory Diffuse Large B-Cell Lymphoma (R/R DLBCL)

Relapsed or refractory diffuse large B-cell lymphoma (R/R DLBCL) patients ineligible for transplantation face complex treatment decisions. Shared decision making (SDM) can improve patient engagement and satisfaction, despite limited data on patients' treatment preferences and values, particularly for 2nd- and 3rd-lines. To better understand R/R DLBCL treatment decision-making in patients, caregivers, and physicians. We enrolled 30 people; 14 adult patients who are in or have completed 2nd- or 3rd-line treatment in the past 5 years, 8 caregivers, and 8 oncologists. 50% of patients and 87% of caregivers were over 50 years old. 79% of patients and all caregivers were White. We also collected education, insurance, and household income data. We conducted 1-hour interviews to understand patient and caregiver involvement in treatment-related decisions, 2nd- and 3rd-line preferences, treatment satisfaction, and current SDM practices. Transcripts were coded using template analysis from 6 a priori codes. 2 interviewers double-coded 8 interviews and independently coded remaining interviews. Patients said rapid-moving care, shock of diagnosis, or failing treatment impeded individual and caregiver involvement in treatment decision-making, and thus they tended to rely on physician recommendations for treatment. All patients felt they followed a well-established standard of care, adding to low self-efficacy for SDM in 71% of patients and 38% of caregivers. While physicians believe patients should have control over their treatment, they agreed on barriers for involving patients in decision-making (i.e., limited treatment options, established standard of care). Patients found that cumulative treatment experience shaped preferences in 2nd- and 3rd-line treatment; 43% perceived higher autonomy over decision-making and had clearer expectations. 71% of patients said their oncologists shared educational materials around treatment options, but some wanted resources to address ancillary concerns. Patients found caregivers helpful in treatment-related discussions, and physicians encouraged caregiver inclusion in treatment planning. 71% of patients felt satisfied with their experience, but 21% would have liked a more individualized approach. Results suggest while 2nd-and 3rd-line R/R DLBCL treatment options may be limited, patient preferences can be incorporated into treatment planning. Opportunities for improvement include tailored educational materials for caregivers and physician tools to support integration of patients' lived experiences into clinical workflows.

Retrospective Assessment of Human-Chemical Interactions in Health-Disparity Populations: A Process Evaluation of Life History Calendars.

Life-history calendars (LHCs) can produce retrospective data regarding numerous events, exposures, and sequences that have occurred across participants’ lifespans. In this mixed-quantitative-and-qualitative-methods study, processes of LHC administration were evaluated in two populations experiencing health disparities: foreign-born agricultural workers (n = 41) and Indigenous people who used injection drugs (IPWIDS) (n = 40). LHC administrator and participant perspectives were elicited during follow-up survey activities. In both agricultural workers and IPWIDs, over half of participants reported that the LHC made it easier to remember things about the past, and participant age was associated with cumulative experience in different domains of interest. Qualitative findings suggested that data-collector training and the development of concise interview guides are critical for improving LHC data quality. Participants described ethical themes, including utilitarian, cathartic, and reflective aspects, of LHC participation. Future iterations of the LHC may benefit from providing free-form and open-ended spaces for participants to reflect on the LHC activity following LHC administration.

596. MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL AND GASTRO-ESOPHAGEAL JUNCTION TUMORS. A SINGLE CENTER EXPERIENCE

Abstract Esophagectomy carries high rates of post-operative morbidity and mortality. Minimally invasive esophagectomy was introduced more than 20 years ago offering all the advantages of minimally invasive surgery and significantly reducing post-operative pulmonary and cardiac complications associated with open esophagectomy. Clinical and oncological outcomes are vastly improved standardizing this approach as inferior in the hand of experts. Herein, we aim to present our results of minimally invasive esophagectomy for esophageal and gastro-esophageal junction cancer. This is prospective analysis of consecutive patients that underwent 2-stage minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. Operations included hybrid 2-stage esophagectomy (laparoscopic/open thoracotomic or open laparotomy/thoracoscopy) and 2-stage totally minimally invasive esophagectomy (laparoscopic/thoracoscopic). Study included adult patients with no upper age limit (>18 years). All esophagectomies for benign disease, as well as emergency operations were excluded from the study. Primary endpoints were 30- and 90-day mortality rate, anastomotic leak, anastomotic stricture, pulmonary complications, and length of hospital stay. Secondary endpoints were overall survival and progression-free survival rates respectively. During an 8-year-period, n=350 consecutive patients underwent 2-stage minimally invasive esophagectomy for cancer. Our team has a cumulative experience of more than 300 open-esophagectomies. Since September 1st, 2013, hybrid 2-stage esophagectomy program was initiated. On September 1st, 2016, the program offered 2-stage totally minimally invasive esophagectomy in-all comers. Most patients were males. Anastomotic leak complicated 5.1% of the patients; 10% of the patients presented anastomotic stricture post-operatively, while pulmonary and cardiac complications reached up to 25 and 12% respectively. Medial LOS was 8 days. Median follow-up was 60 months. OS survival rate was 53 months and PFS was 48 months. Advances in minimally invasive surgery can benefit all patients with esophageal and gastro-esophageal junction tumors. Hybrid and totally minimally invasive 2-stage esophagectomy are well established approaches, with safe and feasible profile in tertiary cancer centers. They can lead to significantly improved clinical and oncological outcomes comparing to open esophagectomy and its complications burden.

Application of 3 D digital technology in transmission line engineering and waste soil disposal mechanization construction

Under the background of the innovation in the field of construction engineering toward the direction of intelligence and digitalization, the three-dimensional digital design means with the digital information model as the core has gradually become the main content of the industry discussion in the new era. According to the cumulative experience of transmission line construction in recent years in our country, three-dimensional digital technology can simulate and arrange the construction link comprehensively during the construction of the project, and shorten the construction period and reduce the cost. Therefore, on the basis of understanding the current situation of transmission line engineering and the mechanized construction of residual soil disposal, this paper deeply discusses how to apply three-dimensional digital technology in the mechanized construction of transmission line engineering and residual soil disposal according to the research situation of three-dimensional digital technology at home and abroad. The final experimental results show that the 3D digital technology has a good application effect during the project construction, which is helpful to guide the high-quality development of power design industry in the new era.

Application of 3 D digital technology in transmission line engineering and waste soil disposal mechanization construction

Under the background of the innovation in the field of construction engineering toward the direction of intelligence and digitalization, the three-dimensional digital design means with the digital information model as the core has gradually become the main content of the industry discussion in the new era. According to the cumulative experience of transmission line construction in recent years in our country, three-dimensional digital technology can simulate and arrange the construction link comprehensively during the construction of the project, and shorten the construction period and reduce the cost. Therefore, on the basis of understanding the current situation of transmission line engineering and the mechanized construction of residual soil disposal, this paper deeply discusses how to apply three-dimensional digital technology in the mechanized construction of transmission line engineering and residual soil disposal according to the research situation of three-dimensional digital technology at home and abroad. The final experimental results show that the 3D digital technology has a good application effect during the project construction, which is helpful to guide the high-quality development of power design industry in the new era.

Variables affecting pharmacy students' pursuit and attainment of postgraduate residency and fellowship positions

IntroductionPostgraduate pharmacy residency and fellowship positions have remained competitive. We evaluated factors predicting students' pursuit and attainment of postgraduate pharmacy training positions. MethodsA web-based survey was administered to students from a three-year accelerated pharmacy program. The survey asked questions regarding the participants' demographics, cumulative academic pharmacy grade point average (GPA), school leadership positions in organizations or committees, and research activities. Students' resilience was measured by the Academic Pharmacy Resilience Scale questionnaire. Multiple logistic regression was used to determine variables that predicted the pursuit and attainment of residency positions. ResultsThe survey response rate was 46.7%. Students with greater cumulative GPA (odds ratio [OR] 6.3; 95% CI, 2.25–17.68), research experience (OR 3.3; 95% CI, 1.29–8.45), resilience scores (OR 1.07; 95% CI, 1.03–1.12), and leadership in an organization (OR 3.27; 95% CI, 1.46–7.33) or school committee (OR 2.29; 95% CI, 1.04–5.07) were more likely to apply to a residency program. Students with greater cumulative GPA (OR 9.93; 95% CI, 1.33–74.23), self-rated performance score in the residency interview (OR 5.32; 95% CI, 2.47–11.44), and leadership experience on a school committee (OR 15.37; 95% CI, 3.94–59.93) were more likely to match with a residency program. The average scores on interview performance and networking were significantly higher in students who obtained a fellowship position compared to those who did not obtain that. ConclusionsThis study identified several predictors for the pursuit and attainment of residency or fellowship positions, which could inform pharmacy educators, students, and program directors.

Efficacy of a dedicated plastic stent in endoscopic ultrasound-guided hepaticogastrostomy during the learning curve: cumulative multi-center experience

Background and objectives Currently, there are no reports on the learning curve of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) using dedicated plastic stents. Therefore, we evaluated the outcomes of EUS-HGS using dedicated plastic stents at tertiary referral centers during the initial development phase of EUS-HGS. Materials and methods Endoscopic retrograde cholangiopancreatography (ERCP) was strictly prioritized over EUS-HGS. Twenty-three consecutive patients treated using EUS-HGS with a 7-Fr dedicated plastic stent over 4 years beginning in 2018 were analyzed retrospectively. Results The most common primary disease was pancreatic cancer, and the most common reason for difficulty in ERCP was duodenal obstruction, followed by surgically altered anatomy. The overall technical success rate of EUS-HGS was 95.7% (22/23). One failed case was converted to EUS-guided choledochoduodenostomy. The clinical success rate was 90.9% (20/22). Adverse events (AEs) related to the procedure were observed in four (17.4%) patients, including mild biliary peritonitis in three (13.0%) and mild cholangitis in one (4.3%) patient; all patients received conservative therapy. No serious AEs, such as stent migration, bleeding, or gastrointestinal perforation, were observed. Recurrent biliary obstruction (RBO) was observed in eight (34.8%) patients. Of these, HGS stent replacement was performed in four patients, and other treatments were performed in the remaining four patients. Another four (17.4%) patients did not develop RBO but underwent periodic HGS stent replacement. Conclusions EUS-HGS using a dedicated plastic stent was performed safely even in its initial phase of introduction. The approach using this stent can be useful in case of ERCP failure for biliary decompression because of the high feasibility and low risk of serious adverse events.

Defining the learning curve for endotracheal intubation in the emergency department

To determine the minimum number of endotracheal intubation (ETI) attempts necessary for a novice emergency medicine (EM) trainee to become proficient with this procedure. This single-center study retrospectively analyzed data obtained from the institutional airway registry during the period from April 2014 to March 2021. All ETI attempts made by EM trainees starting their residency programs between 2014 and 2018 were evaluated. We used a first attempt success (FAS) rate of 85% as a proxy for ETI proficiency. Generalized linear mixed models were used to evaluate the association between FAS and cumulative ETI experience. The number of ETI attempts required to achieve an FAS rate of ≥ 85% was estimated using the regression coefficients obtained from the model. The study period yielded 2077 ETI cases from a total of 1979 patients. The FAS rate was 78.6% (n = 1632/2077). After adjusting for confounding factors, the cumulative number of ETI cases was associated with increased FAS (adjusted odds ratio, 1.010 per additional ETI case; 95% confidence interval 1.006–1.013; p < 0.001). A minimum of 119 ETI cases were required to establish a ≥ 85% likelihood of FAS. At least 119 ETI cases were required for EM trainees to achieve an FAS rate of ≥ 85% in the emergency department.

33150 Safety of guselkumab in patients with moderate-to-severe psoriasis: Pooled analyses across clinical studies

Introduction: Studies of guselkumab in plaque psoriasis have established a favorable safety profile for the drug. To evaluate the cumulative safety experience in psoriasis, we pooled safety data from phase 2/3 studies of guselkumab (CNTO1959PSO2001, CNTO1959PSO3001/3002, CNTO1959PSO3003, CNTO1959PSO3004, CNTO1959PSO3006, and CNTO1959PSO3009). Methods: Safety data were summarized for the placebo-controlled (wk 0-16 in CNTO1959PSO2001, CNTO1959PSO3001/3002, and CNTO1959PSO3006) and end-of-reporting (wk 0-40 for CNTO1959PSO3006; wk16-44 for CNTO1959PSO3003; wk0-52 for CNTO1959PSO2001 and CNTO1959PSO3004; wk0-56 for CNTO1959PSO3009; and through wk264 for CNTO1959PSO3001/3002) periods. Pooled data were adjusted by exposure per 100 patient-years of follow-up [100PY]). Results: During the placebo-controlled period, 544 patients received placebo (165 PY) and 1220 received guselkumab (378 PY). Adverse event (AE) rates were similar for placebo (341.12/100PY) and guselkumab (345.63/100PY); corresponding serious AE (SAE) rates were 6.66/100PY and 6.34/100PY. Infection rates were 83.61/100PY (placebo) and 95.92/100PY (guselkumab). Serious infections (SIs) occurred at rates of 1.21/100PY and 1.06/100PY in the placebo and guselkumab groups, respectively. The rate was 0.26/100PY for both NMSC and malignancies other than NMSC in the guselkumab group (none in the placebo group). Through the end-of-reporting period (n = 2891 patients; 8662 PY), rates remained low for guselkumab-treated patients: 169.02/100PY (AE), 5.26/100PY (SAE), 65.92/100PY (infections), and 0.88/100PY (SIs). Other AEs of interest rates were 0.43/100PY (malignancies), 0.35/100PY (NMSC), and 0.33/100PY (MACE). In guselkumab-treated patients, there were no reported active tuberculosis or opportunistic infections; no serum sickness-like/anaphylactic reactions related to guselkumab were reported. Conclusions: Pooled analyses confirm the established safety profile of guselkumab for patients treated for up to 5 years.

Reintervention for Achalasia: A Review of the Literature

Achalasia is a complex, debilitating, and incurable disease. Several treatment modalities exist for palliation of symptoms. Up to 25% of patients will require reintervention yet no gold standard treatment for reintervention has emerged. Cumulative experience suggests reoperative Heller esophagomyotomy (HM) is a safe and viable option after previous myotomy or pneumatic dilation. Peroral endoscopic myotomy (POEM) has shown promising results for index treatment and reintervention. Single center studies suggest HM after POEM carries a lower success rate and should be chosen in select situations. Disease progression, sigmoid or megaesophagus favor esophagectomy as a definitive option.

Estimating Early Language Input in Deaf and Hard of Hearing Children With the Language Access Profile Tool.

The purpose of this study was to describe the Language Access Profile Tool (LAPT) and its psychometric properties with the aim of evaluating its suitability as an alternative to the deaf or hard of hearing (DHH) Language Exposure Assessment Tool (D-LEAT) in clinical practice with DHH children age 12 years and younger. We administered both the LAPT and D-LEAT to the caregivers of 105 DHH children 12 years old and younger from across the United States, 40% of whom were interviewed again after a delay of at least 1 month. Each interview resulted in a child-specific estimate of their cumulative experience with language input, expressed as a proportion divided across eight categories. Participants in the sample reported experience with all eight input categories, but four categories were common and four were rare. Estimates for all input categories were consistent at both initial and follow-up interviews. Estimates for each input category were also strongly correlated with the corresponding estimates from the D-LEAT, although correlations for the rare categories should be interpreted cautiously. The LAPT demonstrates sufficient test-retest reliability and convergent validity to be a useful and more user-friendly alternative to the D-LEAT. We provide recommendations for how the LAPT and the D-LEAT can be best used in their current form. https://doi.org/10.23641/asha.20669001.

Numerical rules or political government, that is the (European) question

Numerical rules can be defined as legal rules, the operative part of which is an economic indicator. This peculiar recombination of the technologies of government through law and governance by numbers is the result of the return of the regulatory ideal of neutral government in the 1970s (powered by the amalgamation of ordoliberal and neoliberal ideas into what may be called neo-ordo-liberalism) and the search for solutions to the contradiction at the heart of European integration after 1971: the will to have a common currency without the will and institutional means to ensure its political government. The ground for the emergence of European numerical rules was laid by the establishment of the European Monetary System in the late 1970s, which resulted in the subjection of national monetary policy (and to a lesser extent, national fiscal policy) to relevant economic constraints. European numerical rules were codified and thus juridified in the Maastricht Treaty, concretised in the Stability and Growth Pact, and retooled in the wake of the financial, economic and fiscal crises of the 2010s. Cumulated experience confirms that the elimination of discretion in the process of application of numerical rules is an illusion. In fact, resort to economic indicators to define the operative part of legal rules does not do away with discretion, but merely changes the way in which discretion is exerted. This is so because economic indicators are not sources of objective and impartial economic knowledge, but social constructs, open indeed to be articulated in different forms. The curious case of the structural deficit as defined in the Stability and Growth Pact illustrates the point quite vividly. The need to resort to discretion in the process of application of numerical rules should be explicitly acknowledged instead of denied. Otherwise, the result will be the cloaking of discretionallty, which breeds arbitrariness.

Generation of Digital Brain Phantom for Machine Learning Application of Dopamine Transporter Radionuclide Imaging.

While machine learning (ML) methods may significantly improve image quality for SPECT imaging for the diagnosis and monitoring of Parkinson’s disease (PD), they require a large amount of data for training. It is often difficult to collect a large population of patient data to support the ML research, and the ground truth of lesion is also unknown. This paper leverages a generative adversarial network (GAN) to generate digital brain phantoms for training ML-based PD SPECT algorithms. A total of 594 PET 3D brain models from 155 patients (113 male and 42 female) were reviewed and 1597 2D slices containing the full or a portion of the striatum were selected. Corresponding attenuation maps were also generated based on these images. The data were then used to develop a GAN for generating 2D brain phantoms, where each phantom consisted of a radioactivity image and the corresponding attenuation map. Statistical methods including histogram, Fréchet distance, and structural similarity were used to evaluate the generator based on 10,000 generated phantoms. When the generated phantoms and training dataset were both passed to the discriminator, similar normal distributions were obtained, which indicated the discriminator was unable to distinguish the generated phantoms from the training datasets. The generated digital phantoms can be used for 2D SPECT simulation and serve as the ground truth to develop ML-based reconstruction algorithms. The cumulated experience from this work also laid the foundation for building a 3D GAN for the same application.