Paulsson (United States)

Contemporary general surgery is practiced in environments characterized by high cognitive complexity, time pressure, and uncertainty, where surgeons must make rapid decisions with significant clinical consequences. While technical proficiency remains essential, increasing evidence highlights the central role of cognitive processes, non-technical skills, and system-level factors in shaping surgical performance and patient safety. This study aimed to synthesize current evidence and expert convergence regarding the cognitive and decision-making demands of contemporary general surgery and to organize these demands into a coherent framework relevant to surgical education and clinical practice. A narrative review was conducted integrating foundational and contemporary literature on cognitive psychology, human factors, and surgical safety, supported by a structured Delphi-based framework to consolidate and refine key domains through iterative thematic convergence. Findings identified six core domains: cognitive load and multitasking, fatigue and decision fatigue, cognitive bias and heuristics, non-technical skills, team communication and coordination, and system and environmental stressors. Cognitive load emerged as the central domain, closely interacting with fatigue and bias, while progressive convergence across Delphi rounds supported the robustness of the final framework. Alignment with Bloom’s taxonomy highlighted the educational relevance of these domains. Overall, surgical decision-making is a multidimensional process shaped by individual cognition, team dynamics, and system design, underscoring the need to address cognitive demands alongside technical training to enhance decision quality, surgical performance, and patient safety in contemporary general surgery.

Throughput is a common metric in performance tests, particularly for capacity planning. Traditionally, systems are tested until failure, using the maximum throughput achieved as the primary performance measurement. However, this method does not accurately reflect system capacity, especially when response time is a major factor of user experience. We propose a comprehensive performance testing strategy that explores the full operational envelope of the system. By introducing the concept of maximum recommended throughput, we demonstrate that this new benchmark provides more reliable information for performance testing, benchmarking and capacity planning. In some cases, the concept can be extended to resource utilization. Finally we show that exploring the full operational envelope is also powerful in identifying connection throttles.

Opportunistic osteoporosis screening using deep learning (DL) analysis of low-dose chest CT (LDCT) scans is a potentially promising approach for the early diagnosis of this condition. We explored bone mineral density (BMD) profiles across all adult ages and prevalence of osteoporosis using LDCT with DL in a Korean population. This retrospective study included 1915 participants from two hospitals who underwent LDCT during general health checkups between 2018 and 2021. Trabecular volumetric BMD of L1-2 was automatically calculated using DL and categorized according to the American College of Radiology quantitative computed tomography diagnostic criteria. BMD decreased with age in both men and women. Women had a higher peak BMD in their twenties, but lower BMD than men after 50. Among adults aged 50 and older, the prevalence of osteoporosis and osteopenia was 26.3% and 42.0%, respectively. Osteoporosis prevalence was 18.0% in men and 34.9% in women, increasing with age. Compared to previous data obtained using dual-energy X-ray absorptiometry, the prevalence of osteoporosis, particularly in men, was more than double. The automated opportunistic BMD measurements using LDCT can effectively predict osteoporosis for opportunistic screening and identify high-risk patients. Patients undergoing lung cancer screening may especially profit from this procedure requiring no additional imaging or radiation exposure.

In this perspective, we discuss the promise of virtual reality (VR) as an immersive therapeutic (ITx) delivery device. We review the neurobiology of learning and show that VR broadly engages multiple learning systems in the brain in synchrony thus having the unique potential to increase the effectiveness and speed of therapeutic change. We examine one application of VR in the delivery of chronic pain management therapy. We discuss the strengths and weaknesses of current therapies such as pain education and cognitive behavior therapy and suggest that VR has the potential to deliver self-administered, accessible, low risk, in-home chronic pain therapy. We briefly review effectiveness data from an FDA-authorized 8-week self-administered behavioral skills VR program for chronic low-back pain called RelieVRx®, discussing the strengths and weaknesses of the data. We conclude by predicting that ITxs will continue to develop as our knowledge of their effectiveness in treating chronic pain and other mental and physical health conditions grows.

ClinicalTrials.gov NCT04415177; https://clinicaltrials.gov/ct2/show/NCT04415177. RR2-10.2196/25291.

This study evaluated the implementation outcomes of GenerationPMTO, an evidence-based parenting intervention for child and adolescent behavior problems, in three European countries. The implementation approach was full transfer, in which purveyors train a first generation (G1) of practitioners; adopting sites assume oversight, training, certification, and fidelity assessment for subsequent generations (Forgatch & DeGarmo, 2011; Forgatch & Gewirtz, 2017). Three hundred therapists participated in trainings in GenerationPMTO in Iceland, Denmark, and the Netherlands. Data are from the implementation’s initiation in each country through 2016, resulting in 6 generations in Iceland, 8 in Denmark, and 4 in the Netherlands. Therapist fidelity was measured at certification with an observation-based tool, the Fidelity of Implementation Rating System (Knutson, Forgatch, Rains, & Sigmarsdóttir, 2009). Candidates in all generations achieved fidelity scores at or above the required standard. Certification fidelity scores were evaluated for G1 candidates, who were trained by the purveyor, and subsequent generations trained by the adopting implementation site. In each country, certification fidelity scores declined for G2 candidates compared with G1 and recovered to G1 levels for subsequent generations, partially replicating findings from a previous Norwegian study (Forgatch & DeGarmo, 2011). Recovery to G1 levels of fidelity scores was obtained in Iceland and the Netherlands by G3; in Denmark, the recovery was obtained by G5. The mean percentage of certification in each country was more than 80%; approximately 70% of certified therapists remained active in 2017. Findings support full transfer as an effective implementation approach with long-term sustainability and fidelity.

Clinical studies show an increase risk for cardiovascular disease (CVD) at the site of irradiation years after exposure. Radiotherapy together with other cancer therapies contributes to a growing population of cancer survivors in risk of developing radiotherapy induced vascular disease. However, traditional treatments for CVD such as thrombolytic inhibitors and lipid lowering drugs (statins) seem to have no effect on radiation induced vascular disease in mouse models. We have previously demonstrated a sustained chronic inflammation by NF-kB activation in irradiated human arteries. To further investigate radiation induced vascular disease and potential therapies against innate inflammation, we established a mouse model of local irradiation in an atherosclerotic prone ApoE-/- background. ApoE-/- mice fed chow diet were exposed to a single dose of 0 Gy (sham/controls) or 14 Gy at the upper chest and neck area and harvested 10 weeks later. Plasma, thoracic aorta, aortic arch, heart were retrieved and taken for plasma, blood count, en face, mRNA, immunohistochemistry and immunofluorescence analysis. Irradiated mice presented higher total plasma cholesterol levels than controls. En face analysis of aortic arches showed a decreased percentage of lesion size in irradiated arteries compared to controls. However, an increase of MHC class II (IA-b) staining in irradiated aortic roots suggested an induction of inflammation in the context of radiotherapy. These data were supported by the quantification of monocyte chemotactic protein 1 mRNA expression in the thoracic aorta showing a significant increase in irradiated animals compared to unirradiated (p≤0,001). The current data demonstrated that radiotherapy induces a macrophage-rich and inflamed plaque that may explain the increased risk of developing severe clinical events i.e. myocardial infarction or stroke. Further analyses of this partial irradiation mouse model are on-going to assess the potential therapeutic targets involved in innate immunity and NF-kB activation. Results of currently performed therapeutic experiments will be further presented.

Proprotein convertases (PCSKs) are conserved among species and involved in processing of MMPs and growth factors, but poorly characterised in atherosclerosis. Previously we demonstrated upregulation of PCSK6 in a large cohort of plaques from symptomatic vs. asymptomatic patients. This protease localized to smooth muscle cells (SMCs) and showed a positive correlation to markers of inflammation, extracellular matrix remodeling and cytokines in plaques. Here we aimed at elucidating its role in vascular development and disease. In zebrafish embryos PCSK6 localized to heart and vasculature and its ablation caused defective peripheral vascular patterning with cerebral and myocardial hemorrhage. Increased expression of PCSK6 in vascular pathologies was validated by microarrays from carotid plaques vs. undiseased arteries (n=32 patients, p<0.0001), abdominal (AAA, n=14, p<0.0001) and thoracic aortic aneurysms (TAA, n=244, p=0.012). By immunohistochemistry, PCSK6 localized mainly to SMCs in the fibrous cap and neo-vessels in plaques, AAA and TAA tissues. Investigation of mouse carotid ligation, rat artery balloon injury and human restenosis tissues with pronounced intimal hyperplasia confirmed induction of PCSK6 in proliferating SMCs. By microarrays following progression of rat carotid injury, PCSK6 was downregulated in early phases defined by inflammatory pathways, while upregulated in later phases with SMCs activation and localized in SMCs. Expression of PCSK6 in this model was positively correlated to PDGFB and IGF1 (Spearman r>0.7, p<0.0001). PCSK6 overexpression in SMCs in vitro increased their migration in a wound-healing assay, especially upon PDGFBB stimulation. By eQTL analyses several polymorphisms in the PCSK6 gene were found to influence its expression in plaques and aneurysm tissue. Among these, rs6598465 showed association with maximum progression of arterial intima-media thickness in high-risk coronary artery disease subjects (n=3400, p=0.037). We identified a functional link between elevated expression of PCSK6 and vascular remodeling characterized by SMC activation. The present study establishes PCSK6 as one of the key modulators of pathological processes in relation to plaque vulnerability.

Abstract Up until today operators have been facing a challenge on how to place memory gauges as close to the perforations as possible when collecting data to perform pressure transient analysis. Various methods have been used including hanging the memory gauges in nipple profiles or below a retrievable packer or even setting the memory gauges at the bottom of the well to be retrieved later. Suspending the memory gauges in the well using slick line is another commonly used method in certain areas. Pressure transient analysis (PTA) plays a key role in determining reservoir parameters for both stimulated and non stimulated wells. Some of the results from PTA include permeability, skin factor, flow efficiency, average reservoir pressure, system geometry and reserve estimates. To make the collection of such key data more efficient in both vertical and horizontal wells Saudi Aramco is now using a Retrievable High Expanding Gauge Hanger®, Figure 1, which has been designed incorporating a large by-pass flow area to minimize restriction in the wellbore. With a simple adjustment the hanger can be set in 4½ in., 5 ½ in. or 7 in. tubing or casing. The tool can be run through smaller ID tubing and set in larger ID liners and is designed for the memory gauges to hang below. The tool is run on slick line and set using a non-explosive hydrostatic setting tool. Retrieving the tool is easy utilizing a standard JDC Pulling Tool. High levels of H2S and CO2 in some Saudi Arabian gas wells required the re-useable hanger to be made from an Inconel® material. This paper will compare the different methods used for data collection; discuss the development process of the gauge hanger tool as well as the final design of the hanger and setting tool currently being used. Case histories will also be presented from several prolific Saudi Arabian gas wells.