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Five years ago, Korevaar and colleagues proposed a framework for designing diagnostic accuracy studies, focusing on the definition of clear study hypotheses. This proposal filled a gap and was well received by the scientific community. In this commentary, I suggest five potential refinements. They aim at increasing the flexibility of the framework while pertaining its logical consistency. The refinements address the following five topics: (1) The relationship between minimal criteria and the choice of the null hypothesis region; (2) The potential to allow compensation between sensitivity and specificity; (3) The possibility to use other pairs than sensitivity and specificity; (4) The potential phrasing as an estimation problem; (5) The advantages of directly moving to a comparative accuracy study.

To control the COVID-19 pandemic, countries around the world have implemented non-pharmaceutical interventions (NPIs), such as school closures or stay-at-home orders. Previous work has estimated the effectiveness of NPIs, yet without examining variation in NPI effectiveness across countries. Based on data from the first epidemic wave of n = 40 countries, we estimate country-specific differences in the effectiveness of NPIs via a semi-mechanistic Bayesian hierarchical model. Our estimates reveal substantial variation between countries, indicating that NPIs have been more effective in some countries (e. g. Switzerland, New Zealand, and Iceland) as compared to others (e. g. Singapore, South Africa, and France). We then explain differences in the effectiveness of NPIs through 12 country characteristics (e. g. population age, urbanization, employment, etc.). A positive association with country-specific effectiveness of NPIs was found for government effectiveness, gross domestic product (GDP) per capita, population ages 65+, and health expenditures. Conversely, a negative association with effectiveness of NPIs was found for the share of informal employment, average household size and population density. Overall, the wealth and demographic structure of a country can explain variation in the effectiveness of NPIs.

In Germany, the use of TAVR increased substantially between 2007 and 2013, whereas the use of surgical aortic-valve replacement decreased modestly. Patients undergoing TAVR were older and at higher operative risk. Mortality decreased over time in both groups. Surgical aortic-valve replacement was a major clinical advance in the 1960s 1 and offered a cure for aortic stenosis, a condition for which no disease-modifying pharmacologic therapy is available. Surgical replacement remained the only treatment option until 2007, when devices for transcatheter aortic-valve replacement (TAVR) were approved. 2 Since then, TAVR has become established not only as an effective therapy for patients for whom surgery is not an option 3 but also as an alternative for high-risk patients. 4 The introduction of TAVR has led to questions about the effect of this relatively new approach on current clinical practice and its effect on surgical . . .

Physical activity trackers are promising for monitoring physical activity in patients after surgery. However, the remobilization of patients following surgery is characterized by low-impact movements. It is often unclear to health care professionals whether a specific physical activity tracker is able to correctly detect steps in this patient population. A protocol is proposed, which allows health care professionals to familiarize themselves with the detection limits of a physical activity tracker. The professional should walk 20 steps under varying conditions mimicking the situation of patients after knee surgery. Conditions vary in step size, walking direction, use of walking aids, and footwear. The protocol was tested in a group of 14 health care professionals. Participants wore four trackers simultaneously, representing different modalities and different locations. For two trackers, the participants could experience a variation in the detection limits across the different conditions. On one hand, the within-participant reproducibility was substantial on average, though the between-participant reproducibility was only fair. On the other hand, experiencing incorrect step counts varied highly across and within participants. In conclusion, the self-familiarization of health care professionals with the detection limits of a physical activity tracker using specific protocols seems to be a feasible approach. Such protocols can provide valuable tools for facilitating the use of physical activity trackers in clinical applications. Additional research may allow for further refinement of the protocol to generate input that is more comparable across participants and closer to the gait of patients.

Background Heterogeneous results are to be expected when multiple raters diagnose whether the dentine of a tooth with erosive tooth wear (ETW) is exposed or not. Identification of notions (fundamental concepts and understanding) about the diagnostic problem shared by groups of raters can be helpful to develop guidelines and to optimize teaching and calibration procedures. We aim to illustrate how clusters of raters with a common notion can be identified and how first insights about the notions can be obtained. Methods This investigation is based on a former study in which 49 tooth surfaces affected by ETW were rated visually by 61 raters (23 scientists, 18 university dentists, 20 dental students) in terms of dentine exposed or not. The true status was determined histologically. Gender, age, professional experience, and specialization of the raters were documented. An algorithm was used to search for clusters of raters with high agreement in their ratings suggesting a common notion. The clusters identified were examined with respect to various aspects. Results Four clusters of raters with high agreement could be found. The ratings of the raters in the cluster with the lowest diagnostic accuracy showed the highest correlation with the degree of tissue loss and the background tooth color, whereas the correlation with tissue loss was least in the cluster with highest diagnostic accuracy. The 15 raters of the latter cluster covered both students and dentists with or without specialization in erosion/cariology and/or long experience. This suggests that similar conceptual understanding of ETW can exist independent of professional experience. Conclusions The described methodology is useful to identify clusters of raters with a common notion about a specific diagnostic problem. The cluster-specific notions can be further examined based on existing study data or by group-based interviews of the raters of a cluster. This methodology allows investigators to learn more about useful or useless cues in diagnostic decision-making. This information can facilitate development or enhancement of guidelines on diagnostic decision-making.

The novel coronavirus (SARS-CoV-2) has rapidly developed into a global epidemic. To control its spread, countries have implemented non-pharmaceutical interventions (NPIs), such as school closures, bans of small gatherings, or even stay-at-home orders. Here we study the effectiveness of seven NPIs in reducing the number of new infections, which was inferred from the reported cases of COVID-19 using a semi-mechanistic Bayesian hierarchical model. Based on data from the first epidemic wave of n = 20 countries (i.e., the United States, Canada, Australia, the EU-15 countries, Norway, and Switzerland), we estimate the relative reduction in the number of new infections attributed to each NPI. Among the NPIs considered, bans of large gatherings were most effective, followed by venue and school closures, whereas stay-at-home orders and work-from-home orders were least effective. With this retrospective cross-country analysis, we provide estimates regarding the effectiveness of different NPIs during the first epidemic wave.

When compared with more traditional instructional methods, Game-based e-learning (GbEl) promises a higher motivation of learners by presenting contents in an interactive, rule-based and competitive way. Most recent systematic reviews and meta-analysis of studies on Game-based learning and GbEl in the medical professions have shown limited effects of these instructional methods. To compare the effectiveness on the learning outcome of a Game-based e-learning (GbEl) instruction with a conventional script-based instruction in the teaching of phase contrast microscopy urinalysis under routine training conditions of undergraduate medical students. A randomized controlled trial was conducted with 145 medical students in their third year of training in the Department of Urology at the University Medical Center Freiburg, Germany. 82 subjects where allocated for training with an educational adventure-game (GbEl group) and 69 subjects for conventional training with a written script-based approach (script group). Learning outcome was measured with a 34 item single choice test. Students' attitudes were collected by a questionnaire regarding fun with the training, motivation to continue the training and self-assessment of acquired knowledge. The students in the GbEl group achieved significantly better results in the cognitive knowledge test than the students in the script group: the mean score was 28.6 for the GbEl group and 26.0 for the script group of a total of 34.0 points with a Cohen's d effect size of 0.71 (ITT analysis). Attitudes towards the recent learning experience were significantly more positive with GbEl. Students reported to have more fun while learning with the game when compared to the script-based approach. Game-based e-learning is more effective than a script-based approach for the training of urinalysis in regard to cognitive learning outcome and has a high positive motivational impact on learning. Game-based e-learning can be used as an effective teaching method for self-instruction.

There is evidence from previous studies that pregnancies and diseases are recorded in the tooth cementum. This study aims to assess the degree of concordance between signals based on irregular incremental lines (ILs) and reported pregnancies. 23 recent and 24 archaeological human teeth with known birth history were included in this investigation. 129 histological sections of tooth roots were assessed for irregularities in appearance and width using a standardized protocol. Similarity of observed irregularities at the section level allowed us to define signals at the tooth level. The sensitivity of signals to detect pregnancies was determined and related to the signal prevalence. Pregnancy signals were frequently visually observed. However, applying a standardized process we could only reach signal sensitivities to identify pregnancies up to 20 percentage points above chance level. Based on a standardized and reproducible method it could be confirmed that some pregnancies leave visible signals in the tooth cementum. The results show the potential of the tooth cementum to support reconstruction of life courses in paleopathology. However, it seems that not all pregnancies affect the cementogenesis in such a way that irregular ILs are identifiable. Further research is needed to better understand which type of pregnancies and other conditions are recorded in the tooth cementum.

An increasing number of International Medical Graduates (IMG), who are defined to be physicians working in a country other than their country of origin and training, immigrate to Western countries. In order to ensure safe and high-quality patient care, they have to take medical and language tests. This systematic review aims to (1) collect all empiric research on intercultural communication of IMGs in medical settings, (2) identify and categorize all text passages mentioning intercultural issues in the included studies, and (3) describe the most commonly reported intercultural areas of communication of IMGs. This review was based on the PRISMA-Guidelines for systematic reviews. We conducted a broad and systematic electronic literature search for empiric research in the following databases: MEDLINE, BIOSIS Citation Index, BIOSIS Previews, KCI-Korean Journal Database and SciELO Citation Index. The search results were synthesized and analyzed with the aid of coding systems. These coding systems were based on textual analysis and derived from the themes and topics of the results and discussion sections from the included studies. A quality assessment was performed, comparing the studies with their corresponding checklist (COREQ or STROBE). Textual results of the studies were extracted and categorized. Among 10,630 search results, 47 studies were identified for analysis. 31 studies were qualitative, 12 quantitative and 4 studies used mixed methods. The quality assessment revealed a low level of quality of the studies in general. The following intercultural problems were identified: IMGs were not familiar with shared decision-making and lower hierarchies in the health care system in general. They had difficulties with patient-centered care, the subtleties of the foreign language and with the organizational structures of the new health care system. In addition, they described the medical education in their home countries as science-oriented, without focusing on psychosocial aspects. There is a need for a better training of IMGs on culture-related and not culture-related topics in the new workplace country. The topics that emerged in this review constitute a basis for developing these courses. Further empiric research is needed to describe the findings of this review more precisely and should be in accordance with the existing reporting guidelines.

Background The clinical course of low back pain (LBP) is highly variable. While some recover quickly, others experience prolonged or fluctuating disability. Understanding this heterogeneity, and the factors that influences it, is important for effective clinical management and for communicating realistic prognosis to patients. The aims of this study were to describe the variation in disability courses among chiropractic patients with LBP and to investigate how selected biopsychosocial characteristics measured at baseline can predict these courses and potentially explain the observed variation. Methods Longitudinal data from 2,777 Danish adults consulting chiropractors for a new episode of LBP were analysed. Disability was measured at baseline, 2, 13, and 52 weeks using the Roland Morris Disability Questionnaire (0–100 scale). Latent Class Analysis was applied to identify disability trajectories. Associations between baseline patient characteristics and trajectory class membership were examined across demographic, psychological and social domains. A post hoc composite index score was developed to summarize the cumulative burden of unfavourable baseline characteristics. Results Nine distinct disability trajectories were identified, ranging from rapid recovery to persistent high disability, and fluctuating patterns. Six classes accounted for approximately 90% of patients, while three smaller classes with more irregular trajectories accounted for 10%. Higher number of MSK pain sites, comorbidities, and higher levels of BMI, depression, anxiety, kinesiophobia, prescription analgesic use, and poorer general health were associated with increased likelihood of belonging to less favourable trajectories. Both individual baseline characteristics and the index score combining these characteristics showed a clear dose–response relationship with disability trajectories. Patients with higher burden were more likely to follow less favourable trajectories. However, substantial variation remained within index groups, indicating that baseline characteristics alone cannot fully predict individual outcomes. Conclusion Among chiropractic patients with LBP, trajectories of disability over one year can vary substantially in pattern. Baseline biopsychosocial characteristics influence trajectories and prognosis in a cumulative, dose-dependent manner. Clinicians should be aware of this variability and tailor communication about expectations accordingly.