Message Invalid character found in the request target [/en/princess-of-asturias-awards/laureates/1990-arturo-uslar-pietri/?texto\u003dtrayectoria ]. The valid characters are defined in RFC 7230 and RFC 3986 Description The server cannot or will not process the request due to something that is perceived to be a client error (e.g., malformed request syntax, invalid request message framing, or deceptive request routing). Note The full stack trace of the root cause is available in the server logs. In demanding work situations (e.g., during a surgery), the processing of complex soundscapes varies over time and can be a burden for medical personnel. Here we study, using mobile electroencephalography (EEG), how humans process workplace-related soundscapes while performing a complex audio-visual-motor task (3D Tetris). Specifically, we wanted to know how the attentional focus changes the processing of the soundscape as a whole. Results show the robustness of the N1 and P3 event related potential response during this dynamic task with a complex auditory soundscape. Furthermore, we used temporal response functions to study auditory processing to the whole soundscape. This work is a step toward studying workplace-related sound processing in the operating room using mobile EEG. Volume 3 - 2022 | https://doi.org/10.3389/fnrgo.2022.1062227 Introduction: In demanding work situations (e.g. the processing of complex soundscapes varies over time and can be a burden for medical personnel how humans process workplace-related soundscapes while performing a complex audio-visual-motor task (3D Tetris) we wanted to know how the attentional focus changes the processing of the soundscape as a whole Method: Participants played a game of 3D Tetris in which they had to use both hands to control falling blocks participants listened to a complex soundscape similar to what is found in an operating room (i.e. participants had to react to instructions (e.g. “place the next block in the upper left corner”) and to sounds depending on the experimental condition either to a specific alarm sound originating from a fixed location or to a beep sound that originated from varying locations Attention to the alarm reflected a narrow attentional focus as it was easy to detect and most of the soundscape could be ignored Attention to the beep reflected a wide attentional focus as it required the participants to monitor multiple different sound streams Results and discussion: Results show the robustness of the N1 and P3 event related potential response during this dynamic task with a complex auditory soundscape we used temporal response functions to study auditory processing to the whole soundscape This work is a step toward studying workplace-related sound processing in the operating room using mobile EEG In the former case auditory attention is focused only on task-relevant sounds (e.g. instructions or alarm sounds) and suppresses irrelevant sounds (e.g. the attentional focus is narrowed to the task In the latter case attention switches between multiple sound sources such as task-relevant instructions and task-irrelevant chatting the attentional focus is wide and a large extentd of the soundscape is processed Our goal was to study a narrow compared to a wide focus to better understand auditory attention in a complex and multi-sensory environment with EEG we want to study auditory attention in the operating room and understand when sounds become a burden We decided to develop a complex and dynamic audio-visual-motor task while maintaining experimental control over stimuli EEG responses related to auditory attention can be studied in a complex environment We first operationalized the soundscape of an operating room into five stimulus categories: a continuous background stream, as well as, task relevant and irrelevant sounds, and task relevant and irrelevant speech stimuli (Hasfeldt et al., 2010; Engelmann et al., 2014) The background stream represents sounds originating from running machines Task relevant speech represents exchanges about the surgery Task irrelevant speech represents private conversations alarm sounds and feedback from instruments We then combined our operationalization of the soundscape with a visual-motor task The game requires the use of both hands to navigate blocks participants received instructions within the game For task irrelevant speech a conversation unrelated to the game was presented The task relevant sound changed between two conditions monitor sounds from a surgery machine were presented we manipulated the attentional focus of the participants by changing the task relevant sound while keeping the complexity of the soundscape constant In a narrow attentional focus condition (from here on narrow condition) participants had to attend to an alarm sound (from here on the alarm) This sound originated from a specific location The rest of the soundscape (except the task relevant speech) could be ignored In a wide attentional focus condition (from here on wide condition) we implicitly direct the participants attention toward all sound streams This was approached by instructing participants to attend to a sound that was embedded in any of the five streams as it served the purpose of manipulating participants attention but was generally unrelated to the operating room soundscape we expected a larger N1 for irrelevant sounds (i.e. non-target sounds in both conditions) in the wide condition than in the narrow condition should lead to a stronger processing of the whole soundscape we expected a stronger processing of the irrelevant sounds The P3 is a late positive deflection in response to target sounds (from here on targets). As this response is absent in non-targets, it thereby marks attentional processes (Polich, 2007; Luck, 2014) For our second and third hypotheses we expected a P3 to the target of the respective conditions The alarm was the target in the narrow condition we expected a larger response in this condition compared to the wide condition The beep was the target in the wide condition we expected a larger response in this condition compared to the narrow condition We used TRFs to investigate processing of the soundscape as a whole. TRFs are the result of correlating a continuous EEG signal with a continuous audio signal (Crosse et al., 2016). The correlation (i.e., response) is larger for attended compared to unattended signals (Mirkovic et al., 2015; O'Sullivan et al., 2015) we expected a larger TRF in the wide compared to the narrow condition as the beep should direct attention toward the whole sound environment This study was registered prior to any human observation of the data (https://osf.io/sgvk6). Deviations from our preregistration are described in the Supplementary material. We provided the experiment, as well as the code and data to reproduce the statistical analyses and figures, here: Rosenkranz and Bleichner (2022) Twenty-two participants (age range: 20–30 years; female: 16) were recruited through an online announcement on the University board. We based the sample size on previous studies showing P3 effects in naturalistic settings (e.g., Protzak and Gramann, 2018; Scanlon et al., 2019; Hölle et al., 2021) due to the exploratory approach of this study All participants signed prior to the experiment their informed consent approved by the medical ethics committee of the University of Oldenburg Eligibility criteria included: normal hearing (self- reported) no psychological or neurological conditions and compliance with current COVID-related hygiene regulations (e.g. Two participants were excluded from the final analysis One participant showed high impedance (>100 kΩ) for 10 channels at the end of the experiment and overall poor data quality One participant had a very low hit rate which indicates that this participant did not follow task instructions The final sample consisted of 20 participants (female: 14) Participants performed a complex audio-visual-motor task—an adapted 3D Tetris game. The basis for the game was developed by Kalarus (2021) and we changed it to our needs. Below is a short description of the paradigm. For a detailed description of the game and generation of the auditory stimulus material see Supplementary material Participants had to play a 3D Tetris game while reacting to different sounds and instructions (see Figure 1A) In 3D Tetris one is presented with a three-dimensional space in which differently shaped The falling blocks must be placed in such a way that they form a layer Participants controlled the rotation of the blocks with the left hand and position of the blocks with the right hand The goal was to place blocks to remove as many layers as possible to receive points participants could not loose when the blocks were stacked too high the game restarted at the bottom layer to allow for a continuous game-play (A) Experimental Setup: Participants played 3D Tetris (with their left hand the participant controlled the rotation of a block with their right hand the position of a block) The soundscape was presented via headphones EEG was recorded using a 24-channel mobile EEG setup (B) Soundscape: A continuous background sound was presented throughout the task Discrete stimuli were subsequently presented while the beep was the target in the wide condition The alarm was presented from one direction while the beep was presented from any direction as the other sounds participants should have attend to the task relevant speech which instructed participants to place the next block in one of the four corners of the Tetris layer participants played the game twice (a game lasted approximately 18 min) and received a different instruction for each condition that the soundscape was conceptually the same for both conditions participants were instructed to additionally attend to the alarm participants had to attend to the task relevant speech and the alarm and was presented always from the same direction it was not necessary to attend to the rest of the soundcape to detect it participants were instructed to attend to the beep participants had to attend to the task relevant speech and the beep the whole soundscape had to be monitored to detect it the difference between the two conditions were the instruction on which target should be attended to The target of the narrow and wide condition were the alarm and the beep while misses and not following instructions subtracted points All discrete auditory stimuli were initially presented 48 times in a random order the response to the beep overlapped with the response to the alarm and irrelevant sounds when it was integrated into them we added all overlapping sounds again to derive at 48 non-overlapping sounds that only responses to non-overlapping sounds were used in the ERP-analyses Participants were asked to wash their hair on the day of recording. EEG data was recorded using a wireless 24-channel amplifier (SMARTING, mBrainTrain, Belgrade, Serbia) attached to the back of the EEG cap (EasyCap GmbH, Hersching, Germany) with Ag/AgCl passive electrodes (see Supplementary Figure S3 for the channel layout) and the reference and ground electrode at position Fz and AFz The data was recorded using a sampling rate of 500 Hz and transmitted via Bluetooth from the amplifier to a Bluetooth dongle (BlueSoleil) that was plugged into a computer (Dell Optiplex 5070) The same computer was used for data recording and experiment presentation The EEG was analyzed using EEGLAB (v2021.0, Delorme and Makeig, 2004) in MATLAB R2020b (The MathWorks For each participant and condition, the continuous data was filtered with Hamming windowed FIR filter using the EEGLAB default setetings: (1) high-pass: passband edge = 0.1 Hz5; (2) low-pass: passband edge = 30 Hz.6 These filter settings are recommended for ERP analyses (Luck, 2014), as well as TRF analyses (Crosse et al., 2021) The filtered data was re-sampled to 250 Hz Channels were visually checked for flat lines and bad data quality (e.g. Bad channels were removed from both conditions the data was cleaned from artifacts using infomax independent component analysis (ICA) 2.8 (±1.32) components were rejected previously rejected channels were interpolated using spherical interpolation channels were re-referenced to the linked mastoids (TP9/TP10) a constant delay of 19 milliseconds (ms) between the sound marker and sound presentation was taken into account epochs from −200 to 800 ms with respect to the stimulus onset were generated and a baseline correction from −200 to 0 ms prior to stimulus onset was performed Epochs with a global or local threshold of 3 standard deviations were automatically rejected only hit trials were included in the analysis A hit was defined as any space bar press within 3 seconds after a target The average response was used to find the component peaks of each participant we searched for a negative deflection between 50 and 150 ms following stimulus onset we searched for a positive deflection between 300 and 400 ms following stimulus onset a time-window of ±25 ms and ±50 ms around the N1 and P3 peak was taken the mean amplitude over the individual time-window was calculated a forward model was trained on the epoched EEG data and audio data using the function mTRFtrain Time lags were calculated from −200 to 800 ms and a lambda of 0.1 was used The TRF usually reveals classic ERP peaks known from the auditory processing literature (Crosse et al., 2016, Mirkovic et al., 2019; Jaeger et al., 2020) Based on pilot data from three participants (not included in the final analyses) we expected these peaks at approximately 100 We verified these condition-independent peaks using a permutation- based approach, which was implemented with the Mass Univariate ERP Toolbox (Groppe et al., 2011) and channel was baseline corrected within the function sets2GND using time lags from −100 to 0 ms two-sided t-values were calculated and corrected for multiple comparisons within the function tmaxGND using a time-window from 0 to 450 ms time lag a time-window was identified as significant when t-values exceeded a significant threshold of p < 0.05 Within the significant time-windows, we determined individual TRF peaks. For this, we first calculated the standard deviation over channels to derive the global field power (GFP) of the TRF. The GFP indicates the magnitude of a signal across channels. Thereby, it accounts for individual differences in spatial distribution and avoids channel selection (Murray et al., 2008) The resulting GFP of each condition were averaged maximum GFP value in each significant time-window and for each participant we calculated for each participant the full width at half maximum with respect to the peak to determine individual time-windows we averaged over the individual time-windows of the GFP of each condition This resulted in an average GFP value for each participant Condition differences of the auditory task were analyzed using a linear mixed model (LMM) The analysis was performed in RStudio (version 2021.09.0) using the R package lmer4 (version 1.1-23) For all analyses a categorical fixed factor 'condition' with two categories was used For the ERP analysis, the response amplitude was predicted for each trial. Participant and channel were included as random factors (Volpert-Esmond et al., 2021): For the ERP model of the beep, we encountered singularity issues. The random factor for channel showed a variance of 0 indicating over-specification of this random factor (Volpert-Esmond et al., 2021) We therefore excluded this factor when computing the model for the beep GFP differences were predicted for individual time averaged peaks Participants were included as a random factor: LMMs allow the investigation of the random factors participant and channel. For this, the intraclass correlation coefficient (ICC) was used, which represents the amount of variance in the predicted variable that is explained by the random factors (Lorah, 2018; Volpert-Esmond et al., 2021) Variances for each factor were calculated using an intercept only model for the analysis of ERPs (AMP~ 1 + (1|partcipant) + (1|channel)) and TRFs (GFP ~ 1 + (1|partcipant)) ICCs were calculated by dividing the variance of participant or channel by the total variance Fixed effects were evaluated using Satterthwaite approximations within the R package lmerTest which estimates the degrees of freedom to calculate two-tailed p-values Evidence for an effect were assumed for p-values below 0.05 We also report standard errors (SE) and 95% confidence intervals (CI) We checked task performance on the Tetris task by comparing the number of completed layers We also checked performance on the speech instruction task by comparing the number of instructions that were correctly followed Workload and behavioral scores were compared between conditions by computing LMMs for each score (i.e. workload; completed layers; followed instructions) with condition as a fixed factor and participant as a random factor (Score ~ condition + (1|partcipant)) We further explored reaction time and hit rate in response to the targets the target in the narrow condition was the alarm and in the wide condition the beep For this we used all trial-level responses also those that were not considered in the ERP-analyses Individual reaction times between conditions were compared using a generalized linear mixed model (GLMM) with an inverse Gaussian distribution to account for a positive skew in reaction time data (Reactiontime ~ condition + (condition|participant)) as hits and misses were coded one and zero Differences between conditions was therefore compared using a GLMM with a binomial distribution and logit link function (Hitrate ~ condition + (condition|partcipant)) The statistical significance of differences in reaction times or hit rate between the alarm in the narrow and the beep in the wide condition was evaluated using the Wald Chi-square test (A) Subjective workload scores measured by the NASA-TLX (B) Trial-averaged reaction time and (C) trial-averaged hit rate in response to the targets of the respective condition the alarm and the beep in the narrow and wide condition **p < 0.01 and ***p < 0.001 We investigated ERPs in response to task-relevant and irrelevant sounds The alarm was relevant in the narrow and the beep relevant in the wide condition and expected that targets show larger P3 amplitudes than non-targets The irrelevant sounds were ignored in both conditions Here we investigated the N1 and expected a lower amplitude in the wide compared to the narrow condition Figure 3A shows the grand average ERP (i.e., averaged over participants and selected channel) in response to the alarm in the two conditions. We see a clear N1 peak around 100 ms, a P2 peak around 200 ms, and a P3 that starts around 300 ms. The topographies of the narrow condition shows a typical parietal P3 distribution (Polich, 2007) The mean amplitude of the P3 for the alarm in the narrow condition was 4.2 μV with a significant mean amplitude decrease in the wide condition of −2.3 μV (SE = 0.53; CI = [−3.39 and (C) Irrelevant sounds for each condition and averaged over participants and selected channel The selected channels are marked in white in the topographies The narrow and wide condition are marked with orange and green Color shades indicate the 95% confidence interval The gray area indicates the average time-window and the topographies show the average amplitudes averaged over this time-window that individual time-windows were used for the statistical comparison the fixed effects (thick black lines) and the variability of effect between individuals (i.e. each gray line corresponds to one participant) are displayed ***p < 0.001 Computing the ICC showed that variance between people and channel accounted for 12.2 and 0.1% of the total variance, respectively (see Supplementary Table 2 for the results of the random effect models) Figure 3B shows the grand average ERP in response to the beep The topography also reflects a P3 to the beep in the wide condition The mean amplitude of the P3 for the beep in the narrow condition was −0.609 μV with a significant mean increase in the wide condition of 4.1 μV (SE = 0.92; CI = [2.58 The ICC showed that the variance between people and channel accounted for 6 and 0% of the total variance Figure 3C shows the grand average ERP in response to the irrelevant sounds We see a clear N1 peak around 100 ms and a P2 peak around 200 ms The mean amplitude of the N1 for the irrelevant sound in the narrow condition was −7.81 μV which did not differ from the wide condition (b = −0.28; SE = 0.48; CI = [−1.02 The topography reflects a frontal N1 in both conditions The ICC showed that variance between people and channel accounted for 14.8 and 0.2% of the total variance We found evidence for two of our three hypotheses. The alarm and beep both showed a P3 when they were the target. This shows that participants were able to detect the sounds. The P3 subsides after approximately 1.5 s (see Supplementary Figure S5) The response to the irrelevant sounds did not change In the following we look at the processing of the entire soundscape The individual GFP in the third time-window was on average 5.57 in the narrow condition which significantly increased in the wide condition to 6.43 (b = 0.77; SE = 0.3; CI = [0.15 1.38]; p = 0.0211) We did not find significant differences for the first (b = −0.26; SE = 0.68; CI = [−1.63 1.1]; p = 0.705) and second (b = 0.11; SE = 0.59; CI = [−1.07 1.3]; p = 0.853) time-window (A) The topographies show the significant time-windows averaged over time Orange and green mark the narrow and wide condition Black marks the TRF calculated over both conditions The significant time-windows are marked in gray (B) The GFP of the TRF is shown for each condition Color shades mark the 95% confidence interval an individual time-window within the significant time-window was calculated The gray area marks the average individual time-window (C) Boxplots show the differences of the individual time-window for each significant time-window The ICC of the third time-window showed that variance between people accounted for 73.3% of the total variance indicating a large between-person variance that the high between-person variance of the TRF compared to the ERPs is the result of using averaged compared to trial-level data One participant showed extremely high standard deviations (see Supplement Figure S9) across all channels we excluded this participant and ran the analyses again this did not change the results (First: b = 0.28; SE = 0.43; CI = [−0.58 1.15]; p = 0.5174; Second: b = 0.44; SE = 0.52; CI = [−0.61 1.48]; p = 0.414; Third: b = 0.84; SE = 0.31; CI = [0.22 1.47]; p = 0.014) From Figure 4B and the Supplementary Figure S9, it appears that the time-windows vary largely between participants, especially with regards to the last time-window. Therefore, we re-analyzed the data by averaging over the significant time-windows that are seen in Figure 4A Using the same time-window for each participant we receive the same results (First: b = −0.03; SE = 0.46; CI = [−0.96 0.9]; p = 0.95; Second: b = 0.13; SE = 0.48; CI = [−0.84 1.1]; p = 0.791; Third: b = 0.628; SE = 0.26; CI = [0.106 1.15]; p = 0.026) We investigated auditory attention using a mobile EEG setup while participants completed a complex audio-visual-motor task with a rich soundscape We manipulated auditory attention while keeping the complexity of the soundscape constant this target was a clearly audible alarm originating from one direction which required a narrow attentional focus this target was a beep originating from different directions which required attention to the whole soundscape that the sound that was assumed to be more difficult to detect (i.e. was indeed less often detected than the sound that was assumed to be easy to detect (i.e. This is also reflected in perceived workload which was higher in the wide condition than the narrow condition but in contrast to Tetris and speech instruction performance which was similar across conditions It appears that a trade-off between the Tetris task and the auditory task occurred participants rather concentrated on the Tetris task and speech instructions we found a larger P3 if a sound was a target compared to the same sound if it was not the target the response was larger for the alarm in the narrow compared to wide condition and for the beep in the wide compared to narrow condition We observed the difference around 300 ms after stimulus onset we did not find a clear difference in the N1 to stimuli that were irrelevant in both conditions We also found that the TRF was larger in the last time-window for the wide compared to narrow condition Importantly, the P3b morphology was comparable between conditions (also when looking at the individual participant data in Supplementary Figures S6, S7) despite the fact that the targets differed in their characteristics it always came always from the same direction and was the only sound coming from that direction originated from different directions and was embedded into the other sound streams The behavioral results show that the alarm was easier to detect than the beep The reaction time for the detected sounds was not significantly different This shows that a sound which is hard to detect can elicit a clear attention response if it is considered task-relevant we did not find a difference between conditions in the N1 We expected that attention to the beep (i.e. the wide condition) would draw attention to the whole soundscape and in turn also lead to a stronger processing of the irrelevant sounds This manipulation was apparently not strong enough to produce a difference in the N1 component the clear peak of the alarm and irrelevant sounds might indicate that these sounds showed a different early processing compared to the beep We found reliable TRFs in response to the complex soundscape (including language and non-language stimuli) in this complex task, with three time-windows which significantly differed from zero. These time-windows have repeatedly been reported for speech and music stimuli (e.g., Horton et al., 2013; O'Sullivan et al., 2015; Hausfeld et al., 2018) As we expected that participants attend to the whole sound scape more in the wide compared to narrow condition it is plausible that we observed a difference in the last time-window There are several reasons why the observed difference was small participants did not attend to the whole soundscape much more in the wide than in the narrow condition This would also explain the low hit rate for the beep there was no incentive to ignore the soundscape in the narrow condition which might have increased the response to the soundscape in the narrow condition We conclude that our results are an indication that differences in the processing of the whole soundscape are found in late time-windows We further investigated the random effect structure for a better understanding of the variance that contributed to our models (Lorah, 2018; Volpert-Esmond et al., 2021) the between-person ICC of the response to the alarm was twice as large compared to the beep This indicates that in naturalistic soundscapes reliable sounds (such as the alarm which was presented from the same direction with the same sound intensity) produce a more reliable trial-level response than unreliable sounds (such as the beep which was presented from different directions and with different sound intensities) The low between-channel variance indicates that we used channels that were related to the investigated components (i.e., N1 and P3; Volpert-Esmond et al., 2018) the selected channels had a close proximity For the beep we even had to exclude channel as a factor We designed our study to contain several factors that characterize the working environment in an operating room multiple sound streams from different locations with relevant and irrelevant sounds Our results demonstrate that it is feasible to study auditory attention in such a complex scenario We observed a clear N1 peak for sounds that were acoustically salient and a TRF in response to the whole soundscape our study is a step toward studying auditory responses in the operating room using mobile EEG Studying the relationship between load and auditory processing in the operating room is therefore necessary to understand the effect that sounds have on surgery staff are useful tools to study different aspects of sound perception in complex sound environments To balance between high control over stimuli and the uncontrolled operating room we developed a laboratory experiment with a naturalistic soundscape ERPs are robust to detect attention responses to specific sounds while TRFs can measure responses to an uncontrolled soundscape Our results demonstrate that we can use mobile EEG in a complex acoustic-visual-motor task to study auditory perception and are therefore an important step toward understanding auditory attention in uncontrolled settings The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found below: Zenodo (https://zenodo.org/record/7147701) The studies involving human participants were reviewed and approved by Medizinische Ethikkommission The patients/participants provided their written informed consent to participate in this study and MB contributed with critical revisions All authors approved the final version and agreed to be accountable for this work This work was funded by the Deutsche Forschungsgemeinschaft (DFG German Research Foundation) under the Emmy-Noether program–BL 1591/1-1–Project ID 411333557 and by the Forschungspool Funding of the Oldenburg School of Medicine and Health Science 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 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 The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fnrgo.2022.1062227/full#supplementary-material 1. ^https://github.com/labstreaminglayer/liblsl-Matlab 2. ^https://github.com/labstreaminglayer/App-Input 3. ^https://github.com/labstreaminglayer/App-AudioCapture 4. ^https://github.com/labstreaminglayer/App-LabRecorder 5. ^filter order = 16,500 6. ^filter order = 220 cutoff frequency (−6dB) = 33.75 Hz 7. ^filter order = 1,650 Noise patterns in visceral surgical procedures: analysis of second-by-second dBA data of 599 procedures over the course of one year Pocketable labs for everyone: synchronized multi-sensor data streaming and recording on smartphones with the lab streaming layer Effects of perceptual and working memory load on brain responses to task-irrelevant stimuli: 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Volpert-Esmond Using trial-level data and multilevel modeling to investigate within-task change in event-related potentials Volpert-Esmond Using multilevel models for the analysis of event-related potentials Towards the measurement of event-related EEG activity in real-life working environments Neuroergonomics on the go: an evaluation of the potential of mobile EEG for workplace assessment and design Uslar VN and Bleichner MG (2023) Investigating the attentional focus to workplace-related soundscapes in a complex audio-visual-motor task using EEG Received: 05 October 2022; Accepted: 16 December 2022; Published: 02 February 2023 Copyright © 2023 Rosenkranz, Cetin, Uslar and Bleichner. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) distribution or reproduction in other forums is permitted provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited in accordance with accepted academic practice distribution or reproduction is permitted which does not comply with these terms *Correspondence: Marc Rosenkranz, bWFyYy5yb3NlbmtyYW56QHVuaS1vbGRlbmJ1cmcuZGU= Disclaimer: 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. 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Volume 5 - 2018 | https://doi.org/10.3389/fsurg.2018.00073 and interactive anatomy atlas for surgical anatomical training The aim of this study was to test the usability of the VR anatomy atlas and to measure differences in knowledge acquirement between an immersive content delivery medium and conventional learning (OB) Twenty-eight students of the 11th grade of two german high schools randomly divided into two groups One group used conventional anatomy books and charts whereas the other group used the VR Anatomy Atlas to answer nine anatomy questions duration for answering the individual questions and existence of a medical career wish were evaluated as a function of the learning method The error rate was the same for both schools and between both teaching aids (VR: 34.2%; OB: 34.1%) The answering speed for correctly answered questions in the OB group was approx twice as high as for the VR group (mean value OB: 98 s There was a significant difference between the students of the two schools based on a longer processing time in the OB condition in School B (mean OB in School A: 158 s; OB in School B: 77 s) The subjective survey on the learning methods showed a significantly better satisfaction for VR (p = 0.012) Medical career aspirations have been strengthened with VR while interest of the OB group in such a career tended to decline The immersive anatomy atlas helped to actively and intuitively perform targeted actions that led to correct answers in a shorter amount of time even without prior knowledge of VR and anatomy orientation difficulties and/or the technical effort in the handling of the topographical anatomy atlas seem to lead to a significantly longer response time especially if the students are not specially trained in literature research in books or texts This seems to indicate that the VR environment in the sense of constructivist learning might be a more intuitive and effective way to acquire knowledge than from books The amount of knowledge that can be retrieved depends on the teaching method Learning pyramid based on the learning pyramid published by the NTL Institute for Applied Behavioral Science Against the background of practical actions virtual worlds open up new possibilities to support learning processes more strongly through active interactions such as moving things acting and being able to more strongly involve in the subject matter Through this visual exploration and the virtual touching of objects learning content seems to be conveyed more intensively Based on the constructivist learning theory a higher learning efficiency is conceivable through these mechanisms one motivation of our group to develop the immersive and interactive anatomy atlas (which in the future will be developed into an immersive surgical simulator) was the intention to create a learning tool which raises motivation We developed a prototype of the immersive anatomy atlas where anatomical structures and arrangements of the human body can be explored through an immersive dissection we examined the feasibility and usability of the immersive anatomy atlas in comparison to the open book method (OB) under exam conditions in 11th grade students from two different high schools randomized into two groups (VR vs As a measure for the usability and ease of handling of both learning tools we determined the error rate for 10 questions posed to each student in addition to the duration for answering correctly By wearing a headset with integrated screens for each eye, special lenses and software to bend the image, the all-round view of a virtual reality is simulated. The user is placed in a virtual operating room with realistic lighting and medical equipment. A virtual dummy with precise human anatomy is placed on the operating table, ready to be inspected (Figure 2) Individual organs can be manipulated via bi-manual controllers The virtual hand is closed by pressing the action button on the back of the right controller with the index finger For anatomical structures that are currently held in the hand The left controller can be used to hide nearby anatomical structures Each organ will snap back to its original pose when it is within a translational and rotational threshold of said pose a context menu allows switching the controller-assigned actions A screenshot of our immersive anatomy atlas The grabbing action uses a specially designed collision detection algorithm that only allows grabbing of structures that are reachable from the outside This increases the intuitiveness when interacting with the virtual environment Collision detection is performed on the raw mesh structure instead of being approximated by bounding volumes A video of the version of the anatomy atlas used in this study can be viewed here (Supplementary Video). There is also a video of the latest version, which has some additional features for manipulating the anatomical dummy (https://youtu.be/JY50Wjh-olw) We conducted our study in collaboration with two high schools (“school A” and “school B”) We chose those two schools in order to draw a larger number of participants these two schools follow different teaching approaches which allowed us to consider the effect of an immersive teaching method within different teaching contexts The eleventh-graders of the two high schools are normally introduced to new respective topics by different learning methods students typically receive what is known as “smart” teaching geared toward utilization of digital media Lectures by students are regularly delivered as power-point lectures which are then shared at school via smartphone and projector The communication during the lessons is also carried out via the school's own internet-based communication platform modern “whiteboards” and tablet PCs are permanently used as interactive teaching media in the classroom students are explicitly trained in research in books Visual media are used more cautiously in high school B but experimental investigations and a dialogue-based transfer of knowledge are promoted Medical students show very differing levels of anatomical knowledge whereas the high school students are more comparable since they had no specific knowledge of anatomy we conducted the experiment with high school students to avoid bias due to heterogenous knowledge a sketching task had to be completed (question 10) Translated question catalog and correct answers Before the students were included in the study the parents and participating students were informed in writing a written declaration of consent was obtained for participation in the study The test was carried out by a high school student of the same age. All participating students were randomized into one group using the immersive anatomy atlas (VR group; n = 5) and into another group provided with a topographic anatomy atlas and separate anatomy tables (OB group; n = 5) (22, 30) The average age of the participants was 17 years (range: 16–17) The questions were answered on 2 consecutive days (day 1: VR Group day 2: OB Group) There was no time limitation the analysis of response times and error rates was pointed out The participating test persons were not allowed to discuss the contents of the examination At the beginning of the test, the participants of both groups were given an orientation time of 5 min. Within this time frame, the operating instructions of the immersive anatomy atlas and the familiarization in virtual space as well as the review of conventional teaching aids for orientation in the open book test (Figures 3A,B) were given for each group as a whole The participants in both groups were under constant supervision The questions were put to both groups orally the time required to answer each question was measured and documented by the test manager (A,B) Photos of the conduction of the study at school A In high school B, the same questions were asked in a group of n = 18 students specially trained to understand texts. Students were randomized to each group (OB: n = 10; VR: n = 8). The teaching aids in the “open book” to compensate for a potential methodological advantage in the VR group (31) two questions were added to the questionnaire for subjective appraisal of both teaching methods: Translation of the questions regarding the subjective appraisal of the teaching methods: Assign a school grade for the teaching unit: (German school grade system: 1–6 Has this teaching unit given you the idea of taking up a medical profession (doctor The trial was supervised by scientific staff of the University Clinic for Visceral Surgery at the Pius Hospital Oldenburg The test was carried out according to the specifics described above for high school A The participants were on average 17 years old (range: 16–19 years) VR = 2) from high school B took part in the study An exchange about the content of the questions and the examination situation was impossible both between the pupils and between the schools The error rates and the processing time were analyzed The data was tested for normal distribution using Shapiro-Wilke's test a three-way ANOVA was used to calculate statistical differences The independent variables used were school affiliation (Gymnasium A and B) teaching conditions (VR and OB) and question number (Q1 to Q10) The processing time data was not distributed normally Here a Kruskal-Wallis one-way ANOVA was calculated with the four groups VR in school A The Mann-Whitney U-Test was used to compare the subjective appraisal of the teaching methods All statistical tests were performed with Sigma-Plot 12.0 the graphics were created with Origin 2016 The 28 participants of both high schools were motivated and concentrated All students conducted the test in a very disciplined manner All questions were dealt with and in the case of unclear solutions the answers were commented on by the test persons The experiment showed a content error in question 9 which could not be answered correctly due to a programming error in the immersive anatomy atlas The following calculations therefore refer to n = 9 questions The three-way ANOVA showed no difference in the error rate in relation to the respective high school or the respective learning condition. The average error rate in the VR group was 34.2%, in the OB group 34.1% (p > 0.05). Clear but not significant differences were found between the error rates for the respective questions [F(1.35) = 2,913; p = 0.076; see Figure 4) The VR error rate was at least equal to or better than the error rate of the OB group Error rate in percent depending on the question The average processing time for all correctly processed questions over all participants was 76 s per question (range: 1–410 s; see Figure 5) The average processing time in the VR Group was 50 s per question (range: 1–290 s) The average processing time in the OB group was 98 s (range: 2–410 s) per question the processing time for the OB group is on average twice as high as for the VR group Processing time for correctly answered questions depending on school affiliation and teaching conditions The individual measured values and the average value per group are shown The Kruskal-Wallis One Way ANOVA showed a significant difference between the four groups School A in OB and VR, and School B in OB and VR [H(3) = 44.324; p < 0.001]. The average processing time in the OB group in school A was 158 s (range: 42–410 s) and in the VR group 56 s (range: 5–290; Figure 5) In school B the average processing time in the OB group was 77 s (range: 2–291 s.) and in the VR group 42 s (range: 1–120 s) The group differences between schools and teaching methods are significant except the difference between VR in both schools (Dunn's All Pairwise Multiple Comparison: Q always > 3.1; p always < < 0.05) the pupils in school A seem to benefit more from the immersive learning method The subjective survey on the learning methods showed a significantly better school grade for the VR learning method (Figure 6; Mann-Whitney U-Statistic = 16.0; T = 52; p = 0.012) Evaluation of the teaching unit using the German school grading system (1–6; with 6 as the lowest grade) Every point represents a participant's answer The immersive teaching unit seems to have additionally aroused the desire and interest in the medical field (Figure 7) these results should be interpreted cautiously because of the small number of students answering this question Answers to the question about the desired career Data per group (OB or VR) in percent of students surveyed The present study examines the acceptance and ease of use of a virtual anatomy atlas in a group of young people without specific prior anatomical knowledge in order to avoid bias The fact that the results are not influenced by previous knowledge is shown by the almost equal error rates in VR and OB groups of 34.2 and 34.1% respectively it seems as if most questions were easier to answer in the VR environment since VR showed higher error rates only in two questions A reason for the higher error rate for VR regarding question 1 might be a simple left/right orientation problem whereas higher error rates for question 10 indicate a lower level of detail in VR which will be corrected in future versions one may conclude that the amount of knowledge to be gained is comparable between both conditions our results also seem to reflect the learning environment of the students students of both schools took approximately the same time to complete the tasks the students who were less trained in text comprehension needed significantly longer to find a solution than the more trained group This indicates that the intuitive interaction and the playful approach in the VR condition is more accessible to everyone than the more traditional learning method for which one must acquire at least some knowledge about text interpretation This more traditional method of knowledge acquisition and processing seems more complex and it seems as if it has to be specifically trained our observations during the study support our considerations of a potentially increased intrinsic motivation through playful learning using the VR approach OB and VR students in high school B, who are all very well-trained in text comprehension, show little difference in answering duration. However, the conventional teaching medium is not only rated worse, but beyond that, it reduces interest in the medical field. In comparison, the VR group showed twice as much potential interest in taking up a medical profession. These results are comparable with the findings of Fairén et al. (21) who showed that satisfaction of students' expectations was high in a VR anatomic course our pilot study not only shows higher satisfaction with the VR teaching method it also increased the interest to take up a medical profession the constructivist type of learning enabled by the VR anatomy atlas seems to lead to a faster solution since the participants of the VR group found the right solution in a 50% shorter time It is conceivable that the interactive and thus constructivist learning methodology of the immersive anatomy atlas has made it possible to better understand the information sought through active actions and thus to solve it more quickly Constructivist learning by definition means that through the interaction of cognitive performance and simultaneous physical activity new and unknown topics can be grasped and classified more quickly from our point of view cadaver training is still irreplaceable insofar as it offers haptic feedback that cannot currently be produced with VR simulations VR and AR systems are currently not designed for several simultaneous users an important prerequisite for an educational exchange between pupils or between teacher and pupils integration of haptic feedback as well as possibilities for several users in one OP simulator are current important research topics our study also shows that compared to the open-book method the immersive anatomy atlas can currently already improve the learning effect for anatomical structures with the help of the immersive anatomy atlas it was obviously easier for the participants to actively perform a targeted action according to the question which then quickly led to a correct answer in over 60% of the questions orientation difficulties and/or the manual effort in using the topographical anatomy atlas in general seem to lead to a significantly longer response time As shown by the fact that in the OB condition students from school B trained in text analysis were significantly faster than the untrained students from school A but they still needed twice as long as the VR group from the same school to find the right solution Unclear in our study is the retention rate of the acquired knowledge Further limitations of this study are the use of a non-scientifically validated questionnaire and not using a standardized intelligence test that they are supported by the interactivity in memorizing names of and positional relationships between anatomical structures Further studies with medical students should therefore be developed and carried out together with specialized learning theorists and university didactics to develop informative tasks more geared toward retention and spatial relations between anatomical structures The comparative study of the usability of a VR anatomy atlas in high school students without previous anatomical knowledge shows not only that correct answers might be found 50% faster with the help of the digital medium It also shows a higher acceptance of the learning unit The effect is particularly clear for students learning in a “smart” learning environment Students specially trained in text analysis are comparatively good in using a more traditional way to access knowledge but even they profit significantly from the digital teaching medium Further scientific interdisciplinary studies should follow this pilot study to formulate and validate the basis of a digital-based constructivist learning theory in medical studies FW carried out the measurements at school A VU carried out the measurement at school B together with two colleagues and was mainly responsible for the analyses of the data and the creation of the figures MK developed the anatomy atlas with the help of several University of Bremen students and described the technical aspects of the anatomy atlas in the manuscript We would like to thank the students of the two participating high schools and the two research assistants Sonja Janssen and Heike Nerenz for their help in carrying out the experiments Students at the University of Bremen helped develop the anatomy atlas We also would like to thank Lea Huang for script revision The Supplementary Material for this article can be found online at: https://youtu.be/gGsLkDfxqLc and https://youtu.be/JY50Wjh-olw Heuristics for designing instructional computer games In: Proceedings of the 3rd ACM SIGSMALL Symposium and the First SIGPC Symposium on Small Systems (Palo Alto Toward a theory of intrinsically motivating instruction Google Scholar “Intrinsic motivation and instructional effectiveness in computer-based education” in: Aptitude Google Scholar Spielend Lernen im Flow: Die Motivationale Wirkung von Serious Games im Schulunterricht Heidelberg; Berlin; Germany: Springer-Verlag (2015) Google Scholar 6. 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Lippert H. Medizinstudium: Sind Präparierübungen an der Leiche noch zeitgemäß? Dtsch Arztebl. (2012) 109:A-1758/B-422/C-140. Available online at: https://www.aerzteblatt.de/archiv/128775/Medizinstudium-Sind-Praeparieruebungen-an-der-Leiche-noch-zeitgemaess Cadaver laboratory as a useful tool for resident training PubMed Abstract | Google Scholar Basic laparoscopic skills training using fresh frozen cadaver: a randomized controlled trial Kaluschke M and Zachmann G (2018) Immersive Anatomy Atlas—Empirical Study Investigating the Usability of a Virtual Reality Environment as a Learning Tool for Anatomy Received: 22 October 2018; Accepted: 15 November 2018; Published: 30 November 2018 Copyright © 2018 Weyhe, Uslar, Weyhe, Kaluschke and Zachmann. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) *Correspondence: Dirk Weyhe, ZGlyay53ZXloZUBwaXVzLWhvc3BpdGFsLmRl Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations 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 94% of researchers rate our articles as excellent or goodLearn more about the work of our research integrity team to safeguard the quality of each article we publish Please enable JS and disable any ad blocker Nicaragua asks UN’s highest court to halt German weapons sales to Israel alleging it is breaching obligation to prevent genocide Germany has said Israel’s security is at “the core” of its foreign policy because of the history of the Holocaust, but denied accusations at the UN’s highest court that is aiding genocide in Gaza by arming Israel. Nicaragua has brought a case against Germany at the international court of justice (ICJ) urging judges to order a halt to German weapons sales to Israel, alleging it is in breach of its obligation to prevent genocide and ensure respect of international humanitarian law. On Tuesday, Germany had its chance to respond to the accusations levelled against it after Nicaragua’s legal team opened the case on Monday. Nicaragua told the ICJ that it was “pathetic” for Germany to provide Palestinians with humanitarian aid while supplying the arms that killed them, and that Germany seemed “not to be able to differentiate between self-defence and genocide”. Germany’s representatives insisted that it supplied arms only “on the basis of detailed scrutiny … that far exceeds the requirements of international law” legal adviser for the German foreign ministry told the court: “Our history is the reason why Israel’s security has been at the core of Germany’s foreign policy “Where Germany has provided support to Israel including in a form of export of arms and other military equipment the quality and purposes of these supplies have been grossly distorted by Nicaragua.” She added: “Germany has learned from its past a past that includes the responsibility for one of the most horrific crimes in human history Despite Nicaragua’s criticisms of such an argument emphasised that “Germany continues to provide humanitarian support (in Gaza) every single day” Germany has also made clear that it believes Israel is acting in self-defence in response to the 7 October attacks in which Hamas and other Palestinian militants killed approximately 1,200 people Israel has killed more than 33,000 Palestinians in its retaliatory offensive Nicaragua also wants the ICJ to make Germany resume funding of Unrwa. Germany withdrew support for the UN agency for Palestinian refugees after Israel’s so-far unsubstantiated allegations that 12 staff were involved in the 7 October attacks The ICJ is expected to issue provisional measures on Nicaragua’s case in weeks In January, in response to a case brought against Israel by South Africa, the ICJ issued several interim measures designed to halt any potential acts of genocide. You don't have permission to access the page you requested What is this page?The website you are visiting is protected.For security reasons this page cannot be displayed Germany has defended itself against allegations that it is "facilitating" a genocide in Gaza with its uncritical support for Israel's assault on the Palestinian enclave Speaking in the International Court of Justice (ICJ) on Tuesday the country said its own involvement in the genocide of Jews during the Holocaust justified its support for Israel “Our history is why Israel's security has been at the heart of German foreign policy,” said Tania von Uslar-Gleichen On Monday, Nicaragua presented its case against Germany as part of a two-day hearing, accusing the country of "facilitating the commission of genocide" and demanding the court impose emergency measures to halt German arms exports to Israel and reinstate funding for the UN Palestinian refugee agency, Unrwa In his opening comments to the court, Nicaraguan Ambassador to the Netherlands Carlos Jose Arguello Gomez said that through its continued support of Israel: "Germany is failing to honour its own obligation to prevent genocide or to ensure respect of international humanitarian law." Nicaragua demanded the court issue five provisional measures including that Germany "immediately suspend its aid to Israel including military equipment" and that it "reverse its decision to suspend the funding of Unrwa" The implementation of these measures was "increasingly more urgent and necessary" in light of the rapidly deteriorating humanitarian situation in the Strip Germany on Tuesday said they strongly rejected Nicaragua's accusations "They have no basis in fact or law," said Uslar-Gleichen From the start of the war, Gemany has justified its unwavering support for Israel by invoking the country's right to self defence, with Federal Chancellor Olaf Scholz saying in parliament that "Israel’s security is part of Germany’s raison d’état." Germany is the second largest arms exporter to Israel, approving $354m worth of weapons exports in 2023 a tenfold increase compared to the previous year On Friday, the UN Human Rights Council called for a suspension of arms sales to Israel marking the first time the body has taken a position since war broke out on 7 October Uslar-Gleichen stressed that Germany only supplied weapons "on the basis of careful consideration which far exceeds the requirements of international law" adding that the supply of weapons and other military equipment to Israel was "subject to a continuous assessment of the situation on the ground" “Germany’s action in this conflict is firmly anchored in international law,” she insisted Israeli forces have killed at least 33,360 Palestinians and wounded 75,993 others in Gaza since 7 October the Palestinian health ministry said on Tuesday The majority of those killed are women and children The new death toll comes after 153 people were killed and 6o wounded over the past 24 hours Copyright © 2014 - 2025. Middle East Eye Only England and Wales jurisdiction apply in all legal matters Middle East Eye          ISSN 2634-2456                      Germany has rejected Nicaragua’s accusations that it is enabling a "genocide" by Israel in the Gaza Strip “They have no basis in fact or law,” top German official Tania von Uslar-Gleichen said in The Hague on Tuesday at the International Court of Justice (ICJ) according to the Palestinian authorities in Gaza and international observers Nicaragua wants the court to compel Berlin to cease its military support for Israel during wartime But Uslar-Gleichen said that Nicaragua “rushed to bring this case to court on the basis of the flimsiest of evidence,” stressing that Germany “has left no stone unturned” to address the humanitarian crisis in Gaza as its Foreign Minister Annalena Baerbock traveled many times to the region to discuss aid issues Germany, however, has still not lifted its ban on funding the United Nations Relief and Works Agency for Palestine Refugees (UNRWA) in Gaza, after the agency was accused of aiding Hamas fighters — a claim that was dismissed in March by a top EU humanitarian aid official Janez Lenarčič as unfounded since Israeli officials had not provided any evidence German officials have faced increasing domestic hostility to the continuation of arms sales to Israel. In 2023, Germany approved weapons exports to Israel worth €326.5 million While supporting Israel is seen as a historic duty in Germany due to the Nazi Holocaust the mounting death toll has led some German officials to ask whether that backing is going too far In a separate case brought by South Africa, the ICJ ruled that "at least some of the acts and omissions alleged by South Africa to have been committed by Israel in Gaza appear to be capable of falling within the provisions of the (Genocide) Convention." A Brussels-backed project to develop the lithium reserves needed to power electric vehicles is fueling political instability on the European Union’s doorstep. The bloc designated Kosovo, Colombia, Morocco, Tunisia, Egypt, Bangladesh and India as “safe.” The market volatility caused by Trump’s back and forth on tariffs shows the U.S. “is not in a strong position,” the former EU commissioner tells Le Soir. “The development of nuclear weapons in space is a way for Russia to improve its capabilities,” NATO Secretary-General Mark Rutte tells Welt am Sonntag. Background: We want to investigate if a routine preoperative dietary supplementation of calcium and magnesium prior to thyroidectomy for nodular goiter and graves' disease can influence patients' outcome with regards to hypocalcemia associated symptoms and quality of life in order to reduce the risk of post-thyroidectomy hypocalcemia and to improve patient's quality of life. Discussion: A prophylactic dietary supplementation with calcium and magnesium, which could easily be implemented in the preoperative setting, could potentially help to avoid or reduce hypocalcemia-associated symptoms and improve quality of life. In the event of a positive outcome, this preoperative procedure can be an inexpensive way to prepare patients scheduled for thyroidectomy and can possibly reduce disease-specific costs by reducing the postoperative complication rate. Clinical Trial Registration: DRKS00017195 in the German clinical trials register (Deutsches Register Klinischer Studien, DRKS) on the 22.05.2019. Volume 8 - 2021 | https://doi.org/10.3389/fsurg.2021.758205 Background: We want to investigate if a routine preoperative dietary supplementation of calcium and magnesium prior to thyroidectomy for nodular goiter and graves' disease can influence patients' outcome with regards to hypocalcemia associated symptoms and quality of life in order to reduce the risk of post-thyroidectomy hypocalcemia and to improve patient's quality of life Methods: The study will be conducted as a two-armed randomized controlled trial including patients scheduled for total thyroidectomy Patients assigned to the intervention group will receive calcium carbonate and magnesium oxide starting 2 weeks preoperatively Primary outcome is the postoperative quality of life measured by the ThyPRO-39 and EQ-5D questionnaires Secondary outcome is the assessment of postoperative biochemical (calcium and PTH levels) and clinical hypocalcemia (symptoms as reported by the patient) Discussion: A prophylactic dietary supplementation with calcium and magnesium which could easily be implemented in the preoperative setting could potentially help to avoid or reduce hypocalcemia-associated symptoms and improve quality of life this preoperative procedure can be an inexpensive way to prepare patients scheduled for thyroidectomy and can possibly reduce disease-specific costs by reducing the postoperative complication rate Clinical Trial Registration: DRKS00017195 in the German clinical trials register (Deutsches Register Klinischer Studien Evidence exist that thyroidectomy can cause significant hypomagnesaemia, possibly correlating with the development of hypocalcemia (1, 12–14) postoperative monitoring after thyroidectomy This background provides the motivation for this study which aims to investigate the quality of life and the development of clinical hypocalcemia in relation to preoperative calcium and magnesium administration We want to investigate whether a routine preoperative dietary supplementation of calcium and magnesium influences patients' outcome with regard to hypocalcemia-associated symptoms and quality of life in order to reduce the risk of post-thyroidectomy hypocalcemia and to improve patient's quality of life This could potentially reduce hospital length of stay and medical expenses The primary aim of this study is to investigate the influence of preoperative calcium and magnesium supplementations starting 2 weeks prior to surgery on quality of life measured by the ThyPRO-39 questionnaire over a time interval of 2 weeks prior to 6 weeks post-surgery in a randomized controlled trial The secondary aim is to learn how the aforementioned supplementation may influence the development of clinical and biochemical hypocalcemia the ThyPRO-39 and the EQ-5D-5L questionnaires outcomes should be compared at the time of hospital discharge We propose a prospective randomized controlled intervention study with a postoperative follow-up of 6 weeks (Figure 1; Table 1) and assessments according to SPIRIT statement The monocentric study will be conducted at a DGAV (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie; German Society for General and Visceral Surgery) certified center for thyroid and parathyroid surgery in a German university hospital for visceral surgery The hospital performs more than 350 thyroid surgeries per year • Adult patients (> 18 years) • Diagnosis: symptomatic bilobular nodular goiter or graves' disease • Thyroid cancer treated with total thyroidectomy without lymph node dissection • Thyroid cancer treated with TT and lymph node dissection • Mediastinal goiter with need for sternotomy • Inability to communicate in German • Medication with thiazide diuretics • Previous neck operations or radiation • Inability to follow the supplementation regimen • Necessity of following central or lateral neck dissection due to malignancy • Accidentally removed parathyroid gland or autologous reimplantation of removed parathyroid gland Informed consent will be obtained prior to patient enrolment The consent form will be validated using both the physicians' (DF or and patients may quit the trial at any time without disclosing their motives Disenrollment will not affect subsequent medical care relevant data will be deleted if desired by the patient Patients' names and all other confidential information are patient of medical confidentiality under the German Data Protection Act Any data transmission will be performed using an encrypted format Third parties not involved in the trial will not have access to original documents This study will be carried out in accordance with the Helsinki Declaration in its current version The local university's medical ethical committee has approved the study protocol (No One group (intervention group; IG) will receive calcium carbonate and magnesium oxide nutritional supplementation Ingestion will begin 2 weeks preoperatively The comparison group (control group; CG) will receive no nutritional supplements The chosen supplementation period allows to build-up significantly higher calcium and magnesium levels in IG-patients compared to CG-patients Patients assigned to the IG will receive calcium carbonate 3 × 500 mg/d (Calcium Sandoz® 500 mg Hexal) and magnesium oxide 1 × 375 mg/d (Magnetrans® 375 mg One week after having started supplementation IG-patients will be contacted via phone to evaluate their well-being and ask for any side effects If patients report any intervention-related side effects (e.g. patients may reduce the dose or stop ingestion Those patients will be excluded from the analysis The planned phone call is meant to improve adherence Since the supplementation dosage is within the range of recommended calcium and magnesium uptake no harm from trial participation is expected patients are encouraged to contact the involved physicians at any time Primary outcome will be the postoperative quality of life measured by the ThyPRO-39 questionnaire over time between both groups Secondary outcomes will be the post-operative biochemical levels of calcium and PTH the development of clinical hypocalcemia (symptoms as reported by the patient) during post-operative hospital stay and the ThyPRO-39 and EQ-5D-5L results at hospital discharge After checking the indication for total thyroidectomy and obtaining informed consent, the patients's quality of life will be assessed by the health-related EQ-5D-5L and the disease-specific questionnaire ThyPRO-39 (Figure 1) alkaline phosphatase (AP) will be performed body mass index) and the ultrasound thyroid examination results will be recorded Patients assigned to the intervention group will start supplementation as described above the ThyPRO-39 questionnaire will be filled out again and PTH calcium and magnesium levels will be determined performed under intraoperative neuromonitoring of the recurrent laryngeal nerves the macroscopic view of the parathyroid glands and description of structure and blood flow are required If the lower parathyroid glands are not in loco typico an explicit representation is not necessary In the case of an accidentally removed parathyroid gland or insufficient blood supply cut into small cubes and autologously reimplanted in a muscle pocket of the sternocleidomastoid muscle The affected patient is then excluded from the study Postoperatively, all patients are routinely monitored on the intermediate care unit, especially with regard to potential postoperative hemorrhage. PTH and calcium will be checked on first postoperative day. Depending to the measured PTH level (norm 15–65 pg/ml) calcium with or without Alfacalcidol (Einsalpha®, LEO) will be supplemented, regardless of group affiliation (Table 2) Postoperative procedure dependent on PTH levels on first postoperative day the EQ-5D-5L and ThyPRO-39 will be completed for a third time Patient's discharge is planned on the 2nd or 3rd postoperative day depending on his condition The histological result will be available within 24–48 h postoperatively L-Thyroxin substitution is started at a dosage of 1.5 μg per body weight and is adjusted at the following examination after 6 weeks depending on thyroid parameters Six weeks postoperatively laboratory examinations for TSH AP and ThyPRO-39 questionnaire will be carried out during a clinical visit calcium- and magnesium-substitution is to achieve a serum calcium level in the lower normal range (2.0–2.2 mmol/l) calcium and phosphate values should be determined at 2-weekly intervals and vitamin D dose should be adjusted by 10–20% depending on the calcium level The laboratory exams will be repeated after 6 months to determine a potential persistent hypoparathyroidism We aim for a patient population of 80 male and female adults. This is based on a sample size calculation using data from our own validation study of the ThyPRO-39de (15) For sample size calculation the free software G*Power (Version 3.1.9.4) was used The sample size calculation for the between-factors (i.e. supplementation or not) Repeated Measures Analysis of Variance (RM ANOVA) for the test of the primary outcome was based on the following assumptions: • Power (1-β err prob) = 0.8 • Correlation among repeated measures = 0.4 The effect size was calculated based on a mean of 30 points and a standard deviation of 19.6 for the ThyPRO-39 composite score for the control group [according to (15)] We assumed a mean decrease of about 10 points which reflects a clinically relevant change and no change in standard deviation for the intervention group This yields the aforementioned effect size an overall sample size of 72 patients is needed All patients scheduled for total thyroidectomy at our hospital will be asked to participate in this trial by one of the responsible physicians in case indication for surgery and eligibility criteria are met After explaining the study procedures to eligible patients in an accessible way Since about 100 patients are surgically treated by total thyroidectomy in our hospital per year we expect to enroll 80 patients in about 18–24 months The recruitment period will be extended if the target sample size is not met within this period A block randomization with a block length of 6 will be applied The randomization script is written in Matlab by an uninvolved researcher (VU) Sealed consecutively numbered envelopes will be prepared where each envelope will contain a slip of paper indicating group allocation The allocation sequence will be generated by VU as previously reported All other personnel will be blinded to the exact randomization method used The same uninvolved researcher will also prepare the sealed envelopes The envelopes will be stored in the study office Patients will be enrolled either by DF or NT After patients have provided their written informed consent the next envelope will be opened by the investigator or an assigned study nurse in front of the patient and will thus assign participants to the intervention or control groups as described above The surgeons will know about any patient's study enrollment but will be unaware of patients' group allocation The physicians and study nurses mentioned as authors are responsible for data collection and need to be aware of the treatment arm in order to assess any side effects The physicians and study assistants responsible for data collection will collect all data on paper and in an Excel spreadsheet As all important outcome variables will be collected during hospital stay it is expected that there will be an almost complete follow-up This will be additionally ensured by the study team informing themselves daily about any patient's time of discharge and contacting corresponding patients in time to obtain any missing data In case a patient wants to terminate study participation prior to the final follow-up appointment they will be asked whether their so-far collected data may still be used Data will be collected either on paper (i.e. conversations with the patient) or by obtaining relevant data from the hospitals' patient database (e.g. Paper-based information will be kept in a secure which only authorized study personnel can excess All data will be entered into a pseudonymized excel spreadsheet by only two different individuals (DF and the responsible study nurse) The spreadsheet will be kept on a hospital computer to which only authorized study personnel has access A codebook will be available in the spreadsheet to ensure correct data entry The data will be checked for plausibility and completeness by an independent third person (VU) A list including patients' names and contact information connecting each patient to their pseudonym will be kept in a separate excel spreadsheet which can only be accessed by DF and the responsible study nurse such that it can be destroyed after data curation All documents will be accessible only for study personnel Electronic documents will be password protected A coding list will be created in which patients' names will be entered following their assent to participate This coding list will contain each patient's real name and contact details The aforementioned pseudonymized Excel spreadsheet only contains the corresponding study number so that only the Excel spreadsheet with completely deidentified data is available This password secured Excel spreadsheet will be stored for 10 years in accordance with the recommendations for good clinical and scientific practice and will be available upon request to other researchers Laboratory evaluation will be based on blood samples which are routinely collected during the hospital stay and follow-up appointments all data will be collected in the regular clinical database and extracted using patients' pseudonyms generated for this study EQ-5D-5L- and ThyPRO-39 will be analyzed according to previous recommendations and laboratory findings will be analyzed descriptively separately by intervention and by follow-up time Means or proportions will be reported as appropriate and accompanied by 95% confidence intervals Interferential statistics will be performed using a between-factors repeated-measures ANOVA (i.e. supplementation or not) for the primary outcome QoL over time as measured with the ThyPRO-39 The chi-square test or Fishers exact test will be used for between-group difference calculations regarding the development of postoperative clinical hypocalcemia For comparison of the EQ-5D-5L questionnaire with the ThyPRO-39 at the time of discharge A p-value < 0.05 is used as a measure of statistical significance the respective effect size (?2) will be reported As the pathomechanism of nodular goiter and graves' disease differ a subgroup analysis for these two diseases will be performed and the results of laboratory evaluations will be analyzed descriptively within both groups for both diseases separately reporting means or proportions as appropriate together with the 95% confidence intervals Patients allocated to the intervention group but for whatever reason not undergoing the intervention are excluded from the analysis Missing values will be handled using multiple imputation All data will be made available upon reasonable request from the corresponding author The trial steering committee will be comprised of NT They will conduct all measurements and report to the data monitoring committee DF is responsible for data collection and data entry VU and DW constitute the data monitoring committee VU will be responsible for checking data completeness and plausibility while DW functions as the sponsor for this study The study is initiated by the involved scientists although an amount of 3000$ was provided by Handke Medizintechnik GmbH for additional laboratory examinations in the follow-up period Handke Medizintechnik GmbH is no member of any committee and does not have a say neither with regards to the trial design nor to the reporting of the results Any occurring adverse event will be reported to the medical ethic committee of the Carl von Ossietzky University Oldenburg After the first 5 patients have been enrolled the implementation procedure will be reviewed by the trial steering committee together with the data monitoring committee to ensure that the procedure is appropriate appropriate steps will be taken to assure that the protocol will be followed a monthly auditing will be implemented to keep all personnel up to date The auditing will take place in form of discussions with the entire study team Further meetings will be held if necessary If the audits reveal that changes to the study protocol are mandatory appropriate amendments will be submitted to the responsible ethics committee such changes to the protocol will be reported to the DRKS trial registration system Participants will be informed if necessary Results will be published in a medical journal we decide to determine PTH and calcium level on the first postoperative day and to substitute calcium with or without vitamin D depending on the PTH value supplementation of calcium and vitamin D can be applied to facilitate a safe early discharge leading to cost savings for instance by reducing inpatient treatment time and improved patients' satisfaction and quality of life They stated that calcium supplementation before TT for graves' disease significantly reduces biochemical and symptomatic postoperative hypocalcemia It has to be pointed out that for comparison of different thyroid diseases such as graves' disease subgroup analysis should be performed as the pathophysiology of postoperative hypoparathyroidism depends on the primary diagnosis and on the extent of surgery (i.e. In order to avoid surgery-related hypoparathyroidism due to central or lateral lymph node dissection only TT for benign diseases such as symptomatic nodular goiter or graves' disease is included in our trial Studies on the role of preoperative vitamin D level on early postoperative hypocalcemia reveal contradictory results. On the one hand, low preoperative vitamin D and low postoperative parathyroid hormone levels were seen as predictors for the development of hypocalcemia (22, 23). On the other hand, these biochemical parameters could not be detected as a risk factor in other studies (9, 24, 25) the influence of vitamin D level on postoperative hypocalcemia is also regarded Following the here presented preoperative procedure may be useful to prepare patients scheduled for thyroidectomy and can possibly reduce disease-specific costs and improve patient's quality of life This protocol corresponds to version 3.0 of the study design which has been positively reviewed by the Medical Ethics Committee (No Recruitment started on 19.03.2019 and will probably be completed in late in 2022 Currently 35 of the targeted 80 patients are recruited The trial was registered with the DRKS (Deutsches Register Klinischer Studien; German Clinical Trials Registry) on 22.05.2019 The studies involving human participants were reviewed and approved by Medical Ethics Committee of the Carl von Ossietzky Universty Oldenburg /Ref No NT is the principal investigator and developed the study design and wrote the first draft of the manuscript DF will be mainly responsible for data collection and contributed to the study design VU was responsible for the scientific evaluation of the study design development of the statistic analysis plan and wrote the respective parts of this manuscript DW is sponsor of this study and contributed to the study design and revised the manuscript All authors contributed to the article and approved the submitted version Funding was received in the form of financial support (3,000$) from Handke Medizintechnik GmbH The funder was not involved in the study design the writing of this article or the decision to submit it for publication We thank Handke Medizintechnik GmbH for financial support and the study nurse Verena Weber for her help in acquiring the data Complications and risk factors related to the extent of surgery in thyroidectomy Surgery for benign goiter in Germany: fewer operations An algorithm informed by the parathyroid hormone level reduces hypocalcemic complications of thyroidectomy Postoperative parathyroid hormone testing decreases symptomatic hypocalcemia and associated emergency room visits after total thyroidectomy Quality of life in patients with hypoparathyroidism receiving standard treatment: a systematic review Postoperative day 1 levels of parathyroid as predictor of occurrence and severity of hypocalcaemia after total thyroidectomy American College of Endocrinology Disease state clinical review: postoperative hypoparathyroidism–definitions and management Endocrine Pract Official J Am Coll Endocrinol Am Assoc Clinic Endocrinol American thyroid association statement on postoperative hypoparathyroidism: diagnosis The Optimal Parathyroid Hormone Cut-Off Threshold for Early and Safe Management of Hypocalcemia After Total Thyroidectomy Role of oral calcium supplementation alone or with vitamin D in preventing post-thyroidectomy hypocalcaemia: a meta-analysis Preventing postoperative hypocalcemia in patients with Graves disease: a prospective study Impact of postoperative magnesium levels on early hypocalcemia and permanent hypoparathyroidism after thyroidectomy Excessive decrease in serum magnesium after total thyroidectomy for Graves' disease is related to development of permanent hypocalcemia Hypomagnesemia and hypocalcemia after thyroidectomy: prospective study Validity and reliability of the German version of the shortened thyroid-specific quality of life questionnaire (ThyPRO-39de) Perioperative calcium and vitamin D supplementation in patients undergoing thyroidectomy–literature review 17. Docimo G, Tolone S, Pasquali D, Conzo G, D'Alessandro A, Casalino G, et al. Role of pre and post-operative oral calcium and vitamin D supplements in prevention of hypocalcemia after total thyroidectomy. Il giornale di chirurgia. (2012) 33(11/12):374–8. Available online at: http://eprints.bice.rm.cnr.it/8233/1/article%2893%29.pdf Usefulness of pre-and post-operative calcium and Vitamin D supplementation in prevention of hypocalcemia after total thyroidectomy: A randomized controlled trial Hypocalcaemia after total thyroidectomy for Graves' disease and for benign atoxic multinodular goitre Bone and calcium metabolism in subclinical autoimmune hyperthyroidism and hypothyroidism Postoperative hypocalcemia after thyroidectomy for Graves' disease Systematic review and meta-analysis of predictors of post-thyroidectomy hypocalcaemia Predictive value of age and serum parathormone and vitamin d3 levels for postoperative hypocalcemia after total thyroidectomy for non-toxic multinodular goiter The role of vitamin D in post-thyroidectomy hypocalcemia: still an enigma How useful are perioperative biochemical parameters in predicting the duration of calcium and/or vitamin D supplementation after total thyroidectomy EFSA EFSA Panel on Dietetic Products N Allergies Scientific opinion on dietary reference values for magnesium CrossRef Full Text | Google Scholar Scientific opinion on dietary reference values for calcium CrossRef Full Text | Google Scholar Keywords: preoperative calcium supplementation Uslar V and Weyhe D (2022) The Influence of Prophylactic Calcium and Magnesium Supplementation on Postoperative Quality of Life and Hypocalcemia After Total Thyroidectomy: Study Protocol for a Randomized Controlled Trial Received: 13 August 2021; Accepted: 09 December 2021; Published: 06 January 2022 Copyright © 2022 Tabriz, Fried, Uslar and Weyhe. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) *Correspondence: Verena Uslar, dmVyZW5hLnVzbGFyQHVvbC5kZQ== (KION-TV) -- Monterey Fire Chief Gaudenz Panholzer is set to retire effective December 30 The announcement comes after union leaders with the Monterey Firefighters Association issued a vote of no confidence against its chief 87% of people in the MFFA said a change in leadership is needed Chief Panholzer was hired as Monterey Fire Chief in 2013 after serving in multiple districts San Ramon and Carmel Highlands Fire departments The city said an interim chief is expected to be announced in the coming weeks The Monterey Firefighters Association (MFFA) is responding to "disappointing" comments made by City Manager Hans Uslar after the union issued a vote of no confidence in its fire chief in early November Union leaders said they're "extremely disappointed" and claim Uslar attempted to "deflect attention away from operational issues in the fire department by insinuating that firefighters are disgruntled by contract negotiations." MFFA approved a resolution on a vote of no confidence for Monterey Fire Chief Gaudenz Panholzer saying the chief failed to effectively communicate the needs of the fire department to the city council and its city manager as well as contractual agencies They argue the lack of effective communication resulted in deficiencies at the department including negatively impacted emergency service delivery risked public safety and the health and safety of firefighters KION has yet to hear back from Chief Panholzer regarding these concerns despite multiple attempts at reaching out to the chief for comment since the resolution was made public The union said the no confidence vote will not impact services to the community MFFA indicated an independent arbitrator will help with the process of forming a fair contract (KION-TV)- The Monterey Firefighter Association Local 3707 have declared "no confidence" in Fire Chief Gaudenz Panholzer The Firefighters Union say the “No Confidence” resolution contains a list of safety concerns and other issues that have plagued the Monterey Fire Department under the leadership of Chief Panholzer These issues include insufficient training inadequate vehicle replacement and maintenance The firefighters union said 87% of firefighters believe a change in leadership of the Monterey Fire Department is needed members of Local 3707 approved a resolution that highlights the need for a reform in the department these issues have impacted the fire department for years but recently morale has hit an all time low Ross Pounds who is the President of the Firefighter Union spoke about the recent resolution voted on by the firefighters “One of the first concerns that was a part of the resolution was that we don't feel as if our needs are being communicated to the city manager," Pounds said Monterey City Manager Hans Uslar said that the firefighters have been without a labor contract for 18 months "Everyone else got pay increases," Uslar said This resolution comes after Panholzer was fired by former City Manager Mike McCarthy in November of 2017 and rehired in December that same year Panholzer started his career in 1977 with the Carmel Heights Fire District Pounds also expressed concerns over maintainence over the fire trucks "The state of the rest of the fleet is at a point "We feel like that there's been inadequate communication to properly repair and have those in a state of readiness.” The Monterey Fire Department currently operates six fire stations and has 88 people currently employed Leaders also say recent injuries to firefighters and Chief Panholzer's lack of providing for firefighters’ mental health with incident stress management has left the members of the union with a feeling of abandonment They believe the lack of support has slowed the recovery process of those involved "Employees have counseling services at no cost at their fingertips," Uslar said "If there are critical incidents where people get hurt then there are counselors available who work through that.”  The Monterey Firefighter Association also ensures that this "no confidence" vote won't impact daily service in the community Pounds says they'll address their concerns "constructively and collaboratively" to improve the department "We will still be getting to calls as as fast and as safely as possible and providing the highest level of service that we can to the residents and visitors of the Peninsula," Pounds said Panholzer is the 12th Monterey Fire Chief since 1890 We have reached out to Chief Panholzer and we are waiting to hear back Karl Cooke is a Multimedia Journalist for KION News Channel 46 Chief Photographer for KION News Channel 5/46 and Telemundo 23 KION 46 is committed to providing a forum for civil and constructive conversation Please keep your comments respectful and relevant. You can review our Community Guidelines by clicking here If you would like to share a story idea, please submit it here EEO Report | Terms of Use | Privacy Policy | Community Guidelines | FCC Applications | Do Not Sell My Personal Information He took a right and headed toward the Loews Don CeSar Hotel. He was 66 years old and would be in the water all day if everything worked out. He needed to swim to Clearwater. He had tried to do so and failed each of the previous three years. He reached the Courtney Campbell Causeway, the endpoint of the 24-mile Tampa Bay Marathon Swim. He plowed ahead, the water stinging his face. He was not a quitter. Dr. Euler, a retired German-born physician and a fixture at St. Pete Masters Swimming, died Feb. 25 after suffering a heart attack. He was 79. For more than 20 years, Dr. Euler and his wife, Waltraut, had divided their time between St. Petersburg and Uslar, Germany. He was a swimmer since childhood. The water was an important part of recovery from an illness that had stunted the growth of his left leg, leaving it 5 inches shorter than the right. He walked with a limp and avoided canes, which he believed made him appear handicapped. He dived into North Shore Pool nearly every day he was in town, at the 5:30 a.m. time set by St. Pete Masters and sometimes in the afternoon. Sometimes he veered into other swimmers. "I called him the German bulldog," Masters swimmer Patty Nardozzi said. "He'd put his head down and just go. There was no stopping him." He was the kind of man who could recycle a joke a hundred times and get away with it. An old favorite was about approaching women in his black rubber one-piece by the pool and asking, "Will you zip me up?" "He was always looking for the ladies to zip him up," said Nardozzi, 55. "It was cute." At social events, he wore trademark bow ties and hobnobbed with people decades younger. "He insisted we call him Konrad," said Ron Collins, 52, a St. Pete Masters swimmer who directs the marathon. "He wanted to be one of the guys. Konrad Paul Euler [OIL-ER] was born in Munich, Germany, in 1935. The family moved with the changing assignments of his father, a medical officer for the German army during World War II. At age 3 he scraped his knee. Doctors diagnosed the swelling as bone tuberculosis, a potentially fatal illness. They hospitalized the boy and encased him in a body cast so that he could "rest." He could move only his head. "All I could see was just outside my window, whether it was sunny, rainy, snowing … " Dr. Euler told the Times in 2002. Subscribe to our free DayStarter newsletter You’re all signed up!Want more of our free, weekly newsletters in your inbox? Let’s get started. The diagnosis was wrong, but discovering the error took years. In 1948, doctors diagnosed the illness as Staphylococcus aureus osteomyelitis, a bone infection. His father, Herbert Euler, who had by then become a physician, obtained antibacterial drugs not available during the war and cured his son. "He had been cut off from life as a young kid," said Herbert Euler, 47, Dr. Euler's son. "His brain was like a sponge, looking for input." The track team assigned him to run the looped portions of relay races because "his leg was shorter and he could run curves fast," his son said. Dr. Euler completed his college and medical training at universities in Marburg and Kassel, Germany. In 1964, he married Waltraut Krick, a surgeon. He practiced internal medicine in Uslar, a proudly blue-collar village. "He played cards with (patients) and went hunting with them," his son said. "He knew how to talk to people, and not in an artificial way." Visits to St. Petersburg in the 1970s led to buying a house in the 1980s. Dr. Euler retired along with his wife in 1994 and spent about half of each year in St. Petersburg. He entered the Tampa Bay Marathon Swim in 1999, its first year, but after 6 miles developed severe cramps. In 2000, waves and current from an oncoming storm derailed the trip after 11 miles. Dr. Euler tried again in 2001 but swallowed diesel from a boat and became ill. "Now I was running out of time," he told the Times in 2002. "My wife actually did not like the idea anymore." He steeled himself for one more try. In 2002, buoyed by good weather, Dr. Euler fought through aching muscles, chafing swim trunks and even the abrasion of salt water on his face. "You are just literally ripping your skin out there," Nardozzi said. "There are sharks and sea lice. Your shoulders are hurting and you just have to keep swimming." Dr. Euler bored on, past the high-rises of Sand Key. Thirteen hours, nine minutes after he had started the swim, he climbed out of the water, onto Ben T. Davis Beach on the Courtney Campbell Causeway. At 66, Dr. Euler was the oldest swimmer to complete the marathon. The record stood until last year, when Carl Selles, 67, gained that designation. On Sunday, after the 9:30 to 11 a.m. swim at North Shore Pool, the St. Pete Masters will gather for a while. They will face the water and remember Dr. Euler, who reached the other side. Contact Andrew Meacham at ameacham@tampabay.com or (727) 892-2248. Follow @torch437. Andrew MeachamFormer Times Reporter in the border state of Zulia in western Caracas a landmark article burned the phrase “Sembrar el Petróleo”—to sow the oil—into the Venezuelan national consciousness the country’s leading man of letters in the 20th century the philosophy behind the phrase was simple: Oil wealth was fleeting so reinvesting windfall oil profits in the agricultural sector which had always been the driver of Venezuela’s exports until that point Arguing that the effects of oil profits would prove morally corrosive and fiscally destabilizing and that true wealth could never rely on an accident of geology Uslar Pietri urged Venezuelans to “sow the oil,” a pregnant phrase that has become encrusted in our national psyche right and center would reinterpret his phrase in different ways the emphasis was on health and education spending Then came a mania for steel mills and electric dams the effort to sow the oil was reimagined in socialist guise as a program of broad-based nationalizations of the means of production sembrar el petróleo has proven nothing if not versatile The concern in Caracas now is that Venezuela has squandered the last of the great oil booms in grand style Only two aspects have remained constant since 1936: First every Venezuelan government has taken it as self-evident that oil rents are transitory and devoting those rents to diversify the economic base away from oil is a priority every government has catastrophically failed at it Venezuela still gets some 96 percent of its export earnings from oil—a statistic that since much of the remaining 4 percent is made up of energy-intensive products like petrochemicals and aluminum that are renewed oil exploration has chipped away at the conceptual cornerstone of the oil-sowing dogma: the idea that oil supplies are limited and the oil is bound run out soon Venezuela’s reserves turn out to be absolutely gargantuan the largest on earth—an unfeasible amount of oil much more than we’re ever likely to produce Even if we tripled oil production to 7.2 million barrels a day (which no one thinks is doable) we’d still have enough oil for another 114 years It’s hard to find anyone today believing there will still be demand for such volumes in the year 2130 prices will fall over the coming decades as technological change marginalizes gasoline and diesel as transportation fuels piling up debts run up amid a feverish consumption boom that has left the country facing a calamitous social and economic situation and with a sectoral structure just as heavily tilted to oil as ever What is Venezuela to do in a situation like this The answer is as obvious as it is bitterly ironic: diversify Our only hope is to succeed at something we’ve consistently failed at but eight decades of oil-sowing have created a state system and a political culture uniquely attuned to sabotaging oil-sowing Attempts to diversify have traditionally taken a particular shape: State planners pick out a number of “strategic sectors” for priority investment and direct oil rents to them bureaucrats and politicians know exactly how to read those signals: They go wherever the oil-sowing gravy train goes the strategic sectors are top-heavy with rent-seekers and cronies investing lavishly in the kinds of relationships that will keep oil rents flowing into their businesses their companies and their offshore bank accounts The Venezuelan state has proved uniquely incompetent at disciplining this type of rent-seeking behavior spawning white elephant after white elephant and ploughing untold billions in oil rents into diversification schemes that all too often come to naught but only by doing something so strange and counterintuitive that no Venezuelan politico really dares to propose it in public: nothing Venezuela needs to end the huge economic and political distortions associated with sembrar el petróleo-style strategies The rents from the oil industry are so large in relation to the size of the Venezuelan economy that empowering the state to direct them in this direction or that will always create irresistible temptations for rent-seeking and corruption Venezuela is not institutionally developed enough to resist those temptations and there is precious little sign that it will ever be able to reach the level of institutional maturity needed as long as those outsized petro-rents are at the disposal of its politician is anti-industrial policy: a policy stance that is studiously neutral about the sectoral composition of the economy and devotes itself instead to the provision of public goods that to send a strong signal that the era of the petro-gravy trains is over Only then will capital flow to its most profitable uses some non-oil activities that would be interesting even in the absence of oil rents Call it diversification-via-studied-disinterest-in-diversification it’s the one diversification strategy we’ve yet to try Francisco Toro is editor-in-chief of CaracasChronicles.com He is a Venezuelan journalist and political commentator following the restoration of an old forester’s home outside the town of uslar, germany, baumraum have elevated the ‘treehouse solling’ above a pond to serve as sleeping quarters as well as a vantage point for observing the wooded environment a stair passes through a grove of hemlock spruce accessing a deck situated 4.2 meters above the water surface the two-storey dwelling is supported by 12 inclined steel posts while the bridge is hung from cables tied back to the large trees the rounded volume serves as sleeping quarters and as a vantage point for observing the wooded environmentphoto by markus bollen the property is accessed by a private road running along a small stream to complement the home’s restoration the surrounding landscape was carefully designed to amplify the idyllic setting the treehouse provides a space for framing and appreciating the natural and tranquil setting the interior of the rounded dwelling contains sleeping benches and many windows for viewing the forested context a skylight allows for stargazing at night from the upper level the two-storey dwelling is supported by 12 inclined steel postsphotos by markus bollen an exterior stair accesses the upper levelphoto by markus bollen the lower interior space is wrapped with sleeping benchesphoto by markus bollen many windows allow for observation of the forest settingphoto by markus bollen the exterior is clad in zinc platephoto by markus bollen germanytree type: hemlockinterior area: 11.0 sqmterrace area: 26 sqmphotography: markus bollen AXOR presents three bathroom concepts that are not merely places of function but destinations in themselves — sanctuaries of style Shaped and shorn by the surrounding glittering seas it's a mass of enclosed bays with brilliant and slivers of soft sand backed by dramatic dark red cliffs – the diversity belies the island’s relatively small size there are swoon-worthy options to suit every day and mood From hedonistic hotspots like Las Salinas in the south to the spectacular sunsets viewed from Cala Conta in the west and the family-friendly shallows of Cala Llonga in the east to the untamed we recommend hopping from one beach to the next to get a true sense of what the island has to offer Take time for exploring beyond the most popular beaches too – the further into the wild you venture and that’s when Ibiza reveals the true extent of her gem-like charms Here’s a list of some of the island’s most sensational beaches – dive in and let the Mediterranean weave its magic Whether you're in need of a romantic picnic spot for two or a sandy stretch for all the family these are the best Ibiza beaches to know about: steak and fruity sangria beneath fringed lanterns psychedelic skies form the backdrop for romantic seaside dinners and live music Zen-seekers often quest to this northern slice of sand where crowds gather at sunset every day to soak up the mesmerising atmosphere slipping into a daze as the legendary drumming sessions gather pace before reaching their apex as the sky blushes pink behind the famed “finger of god” rock that juts up from the sea bed this beach is beloved by kids born and bred in the north of Ibiza who giddily swap lessons for swim sessions after school A boho-chic hippie market takes place on Tuesdays Ibiza isn’t known for its road trips but don’t write it off till you’ve hopped on a scooter and cruised its winding coastal roads The serpentine route that leads to Cala Vadella on the west coast is shrouded by pine-clad hills Sparkling glimpses of sea and sky flash in front of your eyes between branches the tranquil bay suddenly comes into view below its silvery sand and glistening cerulean water beckons you closer so there are often kids frolicking in the shallows The larger of two neighbouring coves within walking distance of San Antonio Cala Gracio is best reached on foot by following the seaside promenade that closely hugs the coast A family-friendly beach thanks to its fine golden sand and calm it’s also a great spot for snorkelling while diving in and out between craggy rocks Pop to the old school kiosk Cala Gració for refreshing drinks and snacks and head to the back of the beach for respite from the sun beneath pine trees Translucent water and tiny pebbles in shades of fawn oyster and cinnamon form the foundations of this idyllic inlet on the south-west coast but it’s the unpretentious vibe that keeps locals coming back time and time again Take a page turner and lounge on sunbeds plumped up with mattresses under rakish raffia parasols then sit down to pans of mouthwatering paella and ice-cold rosé for hours at a time and since you’ve stumbled upon one of Ibiza’s undiscovered beach gems you may as well settle in for the serenest of rides Kept relatively hush-hush thanks to its location close to the gated community of Roca Llisa on the east coast Cala Olivera is one of those scarce Ibiza gems – a beach that’s rarely overcrowded To reach it requires a drive down a bumpy camino so a car is essential but once there you’re met by a sticker-sized cove of golden sand ensconced in emerald water and contorted rocks that cry out to be used as a makeshift bed for the day The once rustic chiringuito has had an upgrade in recent years eco beach bar specialising in tapas and a range of vegetarian and vegan dishes This tiny coastal nook is pretty as a picture and home to El Bigotes (+34 650 79 76 33) where well worn rumour has it the King of Spain was once turned away because he hadn't reserved a table Come here on scorching hot days to sun worship before taking a well-earned break to feast on freshly caught grilled fish and bullit de peix Beaches that sing as vociferously at night as they do by day are rare but Sol d’en Serra is an exception – this secluded shingly cove becomes even more enchanting at twilight where time seeps away as you gaze out at the inky-black sea shimmering like a silver-threaded blanket below private dining experiences are available down on the beach where the moon’s rays spotlight gentle waves as they crest on the nearby shore Cala Jondal is adored by the conker-coloured nomads who drift through endless summers sailing around the Med so a large proportion of visitors to this pebbly beach arrive by superyacht before being ferried to shore on designated tenders Days then whizz past in a hedonistic haze of cocktails and sun – at least where a roster of international DJs maintain energy levels peaking all day long Jondal boasts the most coveted address on the beach so much so that the chances of scoring a table are slim at best A sheltered bay in north Ibiza that’s surrounded by rickety paths and pine forest immersing yourself beneath the iridescent topaz water here is bliss Explore the subaquatic world before setting off in search of naturally-occurring mud baths that lie to the right of the main beach take a moment to admire the beautiful terracotta-hued villa overlooking the beach the glamorous backdrop for a Slim Aarons photoshoot when he visited the island in 1978 at least those who dare to wander off the beaten track Burrowed among cliffs in the north of Ibiza Es Portixtol is reached along a sea-facing path chiselled into a cliff edge that snakes through fragrant pine forest The bevy of blues and sea views are breath-taking but nothing beats the big reveal after a 30-minute hike of the dewdrop-shaped bay unfurling below It’s a long walk back up for whoever forgets the crisps This stunning little horseshoe bay is a favourite with locals yet remains an undiscovered secret outside in-the-know insiders Even in high season it emanates a certain stillness while always exuding an erstwhile charm thanks to the typical wooden fishermen's huts and crumbling red cliffs that surround it There’s a tiny chiringuito serving drinks and snacks and a couple of nearby restaurants serving up panfuls of piping hot paella There’s no sand at Punta Galera — translated it means 'flat rocks’ — and no phone signal either which means there’s nowhere better for switching off in the height of the summer heat they glow burnt ochre as day draws to a close providing perfect viewing platforms for gazing at the multicoloured sky so bring a yoga mat for some open-air downward-dogging who’s transformed a cave into his makeshift home sandy bay with crystalline shallows perfect for young kids to splash around in on the surface San Miguel is merely a quiet beach overlooked by large-scale resorts but it’s a flat open space that’s ideal for parents trying to juggle down time with little ones tearing up the sand and a coastal path that curves round the coast to the left of the beach to reach a secret bay A smattering of restaurants serve freshly caught seafood — book ahead for tables with a view Neighbouring bays Cala Conta and Cala Bassa are two of Ibiza's most celebrated beaches and rightly so — the water here is gin-clear with a pale aqua glow channelling more Caribbean than Mediterranean energy it’s easy to catch a boat from San Antonio sailing past little islets dotted along the pretty coastline en route Arrive early to snag the best sand space (it gets extremely busy in peak season) and stay once the crowds have dispersed to soak up another scintillating sunset Es Vedrà is the mystical rock that rises dramatically out of the sea at the island's south-west tip and is supposedly the third most magnetic place on earth though locals will snigger when you regale the fact Cala d'Hort has the best view of this iconic landmark as well as gorgeous golden sand and turquoise waters that always draw a crowd Head to the right of the beach for sensational seafood at Es Boldado (+34 626 49 45 37) And take the steep climb to the nearby watch tower for awe-inspiring sunset views Favoured by the kind of stylish sybarites who wouldn’t set foot on San Antonio’s Sunset Strip Cap des Falcó is the perceptive choice for dusk devotees It’s a vast stretch of white pebbles and boulders bordered on one side by the glass-still salt flats of Ses Salines and on the other by the gently crashing Med It’s also home to Experimental Beach cocktail bar so get tipsy sipping on sundowners then leap off the floating jetty for some salty convalescence This deep-set arc of soft sand is met by safe making it one of the best beaches in Ibiza for families It's surrounded by dense pine forest and brimming with activities to keep young children busy all day long so you can kick back and make the most of the picture-postcard views The arrival of swanky Mondrian and Hyde Ibiza has spearheaded a period of luxe transformation for the area but there are still plenty of low-key surrounding restaurants to rock up to with sandy-toed kids in desperate need of a plate of chips A secret cove hidden at the far end of tourist-friendly Es Figueral Look for a circular gateway in the cliff to the left and clamber through using the rope ladder to reach a peaceful Stripping right off is expected and encouraged a vertical descent down a rockface and a rickety ladder that looks like it's seen better days are all part of this hike - the route to Ses Balandres is a bona fide assault course the explorer within you will relish the challenge and the views once you're down are staggering A sweeping stretch of sand hugged by pale-blue waters and gentle little waves (hence 'aguas blancas) this beach is bathed in golden light at sunrise Head south of the chiringuito to avoid the crowds and don't trip over the naked sunbathers — this is one of Ibiza's few official naturist spots a category embraced wholeheartedly by locals this is one of the only beaches that gets even a hint of proper waves Expect to see optimistic Aussies with surf boards waiting in the shadows in winter The precarious jaunt over slippery rocks to Cala Saladeta is soon forgotten once you lay eyes on the sensational crystalline water that laps the pink-gold sand Claim a spot among the blessedly and predominantly adult crowd Made fresh on the beach by vendors that traipse up and down the sand Parking is difficult and restricted in peak season (the main road to the beach is closed) so catch the bus from San Antonio or take advantage of the park and ride system at the nearby Can Coix sports centre Blessed with a slick of unusual ashen sand — a total outlier in Ibiza this beach is blissfully off the tourist trail but beloved by locals It’s a great option for getting off the beaten track and kicking back to savour the remnants of what feels like a long-gone iteration of Ibiza The beach’s no-fuss chiringuito remains deliciously laid-back despite the thrum of progress elsewhere on the island and serves up a mean chicken and chips that taste especially good on a hangover It’s the kind of low-key spot you hope never changes wide stretch of fine white sand met by brilliant bright azure waters — truly a beach to behold diving facilities and restaurants by the bucketload head to the north of the beach to find a more tranquil spot amid a series of picturesque Some of the most dramatic and dazzling sunsets are visible from here Silhouetted by dunes and with a rugged coastline to match the torsos that adorn it, Es Cavallet is all about pomp, posturing and tan maximisation. Head to the south of the beach to be immersed in a fusion of sexualities, naked bodies and naughty vibes at Chiringay (look for the rainbow-covered day beds). Meanwhile, El Chiringuito Ibiza is a classy cosmopolitan beach club that’s been satisfying Ibiza’s most discerning beachside diners for over a decade Excelling in the most vital categories of food History buffs can combine sunbathing with sightseeing at this beautiful cove that’s home to soft golden sand and a Phoenician settlement dating back to 650BC Head to the World Heritage Site early to beat the heat while gaining good tourist bonus points then hit the beach for swims in the lucid waters and leisurely seafood lunches at the much-loved restaurant of the same name Surrounded by striking terracotta-coloured cliffs that create a sense of real seclusion it should come as no surprise that this is a popular spot among naturists This website is using a security service to protect itself from online attacks The action you just performed triggered the security solution There are several actions that could trigger this block including submitting a certain word or phrase You can email the site owner to let them know you were blocked Please include what you were doing when this page came up and the Cloudflare Ray ID found at the bottom of this page remadeThe 1981 film shocked with its portrayal of child drug addicts in the heart of West Berlin A new remake's director and producer explain why they took it on The new Kinder vom Bahnhof Zoo: Lena Urzendowsky (Stella) Lea Drinda (Babsi) and Bruno Alexander (Michi).dpa/Amazon Prime/Constantin Television/Mike KrausBerlin-It's been 40 years since Uli Edel's iconic film "Wir Kinder vom Bahnhof Zoo" hit West German screens a dramatisation of the non-fiction 1978 book about protagonist Christiane F.'s descent into drug addiction and prostitution at just 13 Now an eight-part remake of the story of Christiane her friends and the shady underworld at Zoologischer Garten station is coming to Amazon Prime on 19 February The new series revisits the notorious locations from the original book and film: the concrete jungle of Christiane's neighbourhood in Gropiusstadt Neukölln; Genthiner Straße's Sound nightclub where David Bowie brought the original film's soundtrack to life; and Kurfürstenstraße where the protagonists enter child prostitution to pay for their next hit Previews have praised the performances of the series' young cast Lead author on the new adaptation was Annette Hess known for her work on the popular shows Weissensee and Ku'damm 56 which is still widely read today and has been taught in schools Producer Sophie von Uslar and director Philipp Kadelbach explain why they agreed to retell it now Berliner Zeitung: "Wir Kinder vom Bahnhof Zoo" influenced a lot of people and shaped them too Sophie von Uslar: I read the book when I was 18 or 19 I made a conscious decision not to watch it at first Just so that I wouldn't have it as a reference point in my head - as the only reference point There was always a point where we would ask ourselves: what was the story that was told then I thought it was important to take a different view of it Philipp Kadelbach: I saw the film as a teenager Back then I was one of these arrogant types that just rejected German films per se So I didn't think it was particularly great Now I see it completely differently - Uli Edel's film is really magnificent But I only came back to it when I was offered this project It's amazing that you dared to take it on - these are iconic film images you're going up against Philipp Kadelbach: At first I said I wouldn't do it There's a whole legion of people who grew up with this film and see it as a monument and can't separate themselves from it And they condemned our series within the first few minutes Philipp Kadelbach: The subject matter is still highly topical But it's one that's still with us today More people are taking drugs than ever before (Jana McKinnon) and Benno (Michelangelo Fortuzzi) prepare heroin in a scene from the new series.Mike Kraus/Constantin Television/Amazon Prime/dpaHow are they Philipp Kadelbach: Many factors play a role in these times when everything is just getting faster and faster and we have to achieve more and more perhaps people take drugs because they're trying to cope and because of this pressure they take drugs I think a lot of young people can't cope without using substances to help themselves but I can do without dressing it up in 70s garb because that creates a distance from the viewer But the drug in your series is still heroin Aren't there other drugs in the foreground today that people take to function It's used more now than it was in the 70s and they told us that it depends on how you take heroin They inject themselves with just enough so they don't go shooting backwards but the main thing is that people feel they don't have any problems anymore when they've taken it And it's better than the alternatives It's in your system within 30 seconds Did you try to find visual images for the highs What about the falling into the bottomless pit Or the scene where Christiane's friend Babsi floats underwater with the DJ she idolises Otherwise there's no visualisation of being high on drugs What we do see are the exaggerations of the dreams the kids have when they haven't taken drugs Sophie von Uslar: And the scene with Babsi has a second layer to it With her it's always about longing for death This floating in the water isn't just about being high but also the moment when she lets herself fall into another element She also encounters her dead father outside of her intoxification - that's us playing with levels of reality when the needle hits the vein and the blood mixes with the cooked up heroin inside the syringe You've blown that up to the full size of the screen in part Philipp Kadelbach: We freed ourselves a bit from Christiane - we're telling the story of the children at Bahnhof Zoo It wasn't about celebrating the heroin experience for us And you don't see any close up injections after episode four The iconic Sound club as portrayed in the remake.Mike Kraus/Constantin Television/Amazon Prime/dpaLet's talk about other visuals: the disco where they all meet Philipp Kadelbach: I've already had to hear people tell me I've betrayed Berlin and all the iconic motifs That is all because we were trying to translate the kids' emotional state into images If we had filmed this club on Genthiner Straße as it was in the 70s with this low-ceilinged basement atmosphere the most modern club in Europe at the time with kids lining up in front of it and being euphoric - it wouldn't have worked In your series we sometimes hear techno in Sound Philipp Kadelbach: Because we wanted this feeling of timelessness - and a connection to today If we had "Free Bird" by Lynyrd Skynyrd playing that would have been a very authentic choice of music for the club at the time but it wouldn't have had the identification potential for a teenager in "our" version of Sound (Jana McKinnon) in Zoo station - reconstructed in Prague.Mike Kraus/Constantin Television/Amazon Prime/dpaBut the Zoo station looks exactly as it did then We reconstructed the interiors in a hall in Prague we filmed at Christiane F.'s original front door in Gropiusstadt Your lead characters often look incredibly cool but at the same time you can't glorify them as drug users Philipp Kadelbach: That's largely because we wanted to represent our characters' inner lives externally and we're walking on a knife edge there But by episode five or six they don't look as good as they do in episode one with their first cigarettes in their hands Sophie von Uslar: We go in relatively innocently and create an emotional closeness to our characters We develop an attitude towards drugs together with them that at some point heroin becomes more important to them than friendship Philipp Kadelbach: We're telling a story over eight hours and people shouldn't just throw in the towel after two hours and say we're aestheticising drugs and glorifying it all Neukölln.Mike Kraus/Constantin Television/Amazon Prime/dpaAt one point Christiane's friend Stella stops prostituting herself They set her up in a fur coat on an office chair on the curb-crawling area at Kurfürstenstraße "I'm a capitalist." Is that a social parody Sophie von Uslar: It's just brutally hard Many years ago I produced "Operation Sugar" a film about forced child prostitution in Germany We did a lot of research and it's simply the case that the few women in this scene are usually victims themselves and know no other world beside one of systematic abuse Often they can only save themselves by becoming perpetrators Have you actually spoken with Christiane Felscherinow [the real life teenager whose story was told in the 1978 book] Sophie von Uslar: We were able to get hold of the original recordings of the conversations the journalists had with her These 50 tapes were the nucleus that we built our interpretation of the events on A lot of it didn't even make it into the book And it was just great to hear Christiane speaking.