Using the multi-detector computed tomography and related three-dimensional imaging technology, we developed a vertebral needle targeting simulation training system named spinal needling intervention practice using ray-summation imaging (SNIPURS). Herein, we assessed the utility of SNIPURS by evaluating changes in the learning curves of SNIPURS trainees.Twenty-one examinees were enrolled: seven experienced operators (expert group), seven trainees with coaching (coaching group), and seven trainees without coaching (non-coaching group). They performed six tests of vertebral needle targeting simulation on the workstation-generated spinal ray-summation images of six patients with vertebral fractures. In each test, they determined the bilateral trans-pedicular puncture points and angles on two thoracic and two lumbar vertebrae on ray-summation imaging . The coaching group received coaching by a trainer after Tests 1 and 4, while the others did not. Scores were given based on the trans-pedicular pathway (1 point) or not (0 point). Eight virtual needles were evaluated in each of Tests 1–6.Among the three groups, the expert group had the highest average scores on Tests 1–4 . The coaching group’s scores caught up with the expert groups’ average scores on Tests 5 and 6, whereas those of the non-coaching group did not . All examinees in the expert and coaching groups achieved a perfect score on the final Test 6, whereas three of the seven non-coaching trainees did not.SNIPURS might be suitable for vertebral needle targeting training. The coaching provided during SNIPURS training helped the trainees to acquire the spinal puncture techniques in PVP. Vertebral needle insertion is an important step in the percutaneous vertebroplasty (PVP) procedure. The common puncture route for PVP procedures is trans-pedicular from the dorsal region with the patient in the prone position . The proVertebral needle insertion is not always easily accomplished, as it is difficult to recognize and puncture the narrow pedicle of the vertebral arch in fluoroscopy –12. RadiRecent developments in multi-detector computed tomography (MDCT) and its associated three-dimensional CT imaging (3D-CT) technology have contributed considerably to interventional radiology –16. The Radiology trainees can undergo simulation training for the vertebral needle targeting on the SNIPURS system, using the workstation-generated spinal ray-summation images. Sufficient preoperative simulation training can improve the trainees’ skills without compromising patients’ safety and reduce the risk to patients undergoing PVP. We conducted the present study to assess the usefullness of the SNIPURS system as a preparatory training for PVP by evaluating changes in trainees’ learning curve.This study was approved by the Ethics Review Committee of our hospital . Written informed consent was obtained from all of the examinees. Specifically, examinees decided to participate in this study on their own will after receiving an explanation of the content of this study and an explanation that they would not suffer unreasonable disadvantages by refusing to participate this study. The need for written informed consent from the patients whose anonymous MDCT data were used for the SNIPURS testing was waived.We first selected the patients whose MDCT data were used for the testing as follows. PVP was performed in 199 consecutive patients including 213 procedures in our hospital during the period from April 2014 to December 2017. Of those patients, we selected the thoraco-lumbar spine CT data of six patients based on the following criteria: (1) The target vertebra for the vertebral needle targeting simulation training test is limited to the 11th thoracic to 3rd lumbar vertebrae, where vertebral fractures were frequently encountered and treated with PVP ; (2) Gen® software, Fujifilm Co., Tokyo, Japan) to generate the spinal ray-summation images.The characteristics of the selected patients and target vertebra were summarized in Table n = 7 each). The members of the expert group were all radiologists, and seven of 14 trainees were medical interns and the others were radiological residents. Table Since we could not find existing studies or tests that are similar to our present investigation, we could not properly estimate the statistical effect size to calculate the minimum sample size of examinees . We thusA single trainer (F.U.) first explained the SNIPURS procedures to the examinee, including the imaging tools to zoom, rotate, and reset the view on the workstation with the computer mouse, using the spinal ray-summation image of Test 1. The examinee was not allowed to try to complete the pretest examination, e.g., to point out the puncture site or obtain the result before starting the test described below.The examinee then started the SNIPURS training as follows: 1) The examinee viewed the spinal ray-summation image from any directions using the mouse on the workstation , or outside the vertebral pedicle , which was evaluated by the trainer. Each examinee completed a total of six tests (Tests 1–6) with the highest possible score of 8 points on each test, and the learning curves for the average score of each of the three examinee groups was obtained.The coaching group received the coaching after Tests 1 and 4 by the trainer using the spinal ray-summation images of Tests 1 and 4. The ideal position of the needle was determined so that the needle could pass through the center of the vertebral arch and the tip of the needle could reach the anterior third of the vertebral body. The coaching is as follows: (1) The trainer put two dot marks in the center of the pedicle arch and in the ideal tip of the puncture needle on the ray-summation image Fig. a. 2) Th Th2b–d).We evaluated if the examinees accomplished the following three qualifying scores: (1) To determine that SNIPURS depended on the operator’s PVP experience and was suitable for vertebral needle targeting training, the expert group would achieve the highest scores among the three groups, which was assessed using the intergroup comparisons. (2) To determine that the coaching was effective, the individual coaching group should get the post-coaching scores better than the pre-coaching scores and should catch up with the expert group for the scores by the final Tests 6, which was evaluated using the intragroup comparisons. In addition, we performed an intergroup comparison between the coaching group and the non-coaching group because it could be predicted that score would increase step by step without any coaching. (3) We required all three groups of examinees to reach a perfect score by Test 6.The intergroup comparisons among the three groups for each test and the intragroup comparisons among the six tests of each group were performed using the Kruskal–Wallis test and Scheffe's post hoc test combined with the Bonferroni correction (nine comparisons). The significance level was set to 0.05. The statistical analyses were properly performed using Excel 2013  with the add-in software Statcel-3 .The expert group had the highest scores among the three groupsp = 0.002), Test 1 vs. Test 4 (p = 0.001), Test 1 vs. Test 5 (p < 0.001), and Test 1 vs. Test 6 (p < 0.001).The expert group had the highest SNIPURS score of the three groups. The intragroup comparisons identified significant differences within the expert group for Test 1 versus (vs.) Test 3 , and their Test 5 scores performed after the second coaching were better than their Test 4 scores and caught up with the expert group’s Test 5 scores. The intragroup comparisons of Test 4 vs. 5 scores within the coaching group did not reveal a significant difference. The intergroup comparisons in Test 2 or Test 5 between the coaching group and the non-coaching group also did not show the significant difference.In the coaching group, the Test 2 scores performed after the first coaching were significantly higher than the Test 1 scores  and Test 1 vs. Test 6 (p = 0.002). The average score of the non-coaching examinees never caught up with those of the expert or coaching groups.All of the examinees in the expert and coaching groups got a perfect score (8 points) on Test 6, whereas only three of the seven trainees in the non-coaching group achieved a perfect score on Test 6. However, significant differences in the non-coaching group were shown by the intragroup comparisons of Tests 1 vs. Test 5  clinicians who are experienced in performing PVP and take the SNIPURS test, (ii) beginners who need to increase their degree of proficiency, and (iii) beginners whose scores on the SNIPURS test could improve with coaching, respectively. Our results will provide important data when SNIPURS is used as an instructional approach for PVP.In the expert group, the significant differences were seen in Tests 1 vs. 3, Tests 1 vs. 4, Tests 1 vs. 5, and Tests 1 vs. 6, suggesting that a significant scoring ability for this simulation test can be obtained after just Tests 1 and 2. Ideally, the PVP experts should have achieved high scores on Tests 1 and 2 as well. Low score on those tests in this study may suggest that preliminary experience was still required to become accustomed to SNIPURS even in the expert group. An additional reason for the experts’ initial low scores could be that SNIPURS used the single-puncture view. The puncture direction is determined using a biplane view in most facilities. SNIPURS with a single-puncture view might be difficult for experts who have usually performed vertebral needle targeting with the isocenter puncture (ISOP) method , catheliThe expert group tended to have higher scores than the coaching and non-coaching groups, especially on Test 1, which suggests that the ability of the coaching and non-coaching groups to grasp SNIPURS the first time tended to be lower than that of the expert group. However, the between-group differences did not reach significance, perhaps because the expert group did not acquire the ideal high scores (from the first Test) as mentioned above.Among the examinees who received coaching, a significant increase in score was observed for Test 2 (after the first coaching). In addition, after the second coaching (post-Test 4), the coaching group's average score on Test 5 caught up with that of the expert group. All of the examinees who received coaching achieved the perfect score of 8 points on Test 6, and thus the learning mission in SNIPURS was completed with two brief coaching sessions.Among the examinees of the non-coaching group, a significant increase in score was observed for both Test 5 and Test 6 compared to the score on Test 1; that is, no significant learning results were obtained from Tests 1 to 4. This result may indicate that the learning curve in the non-coaching group tended to increase slowly. In addition, there were 3 trainees in the non-coaching group who did not reach the perfect 8-point score on Test 6, suggesting that they might need to take further simulation training.Based on the results of this study, we reached the conclusion that SNIPURS with two coaching sessions can be recommended to successfully help trainees effectively acquire a precise perception of spinal puncture techniques in PVP. Losch et al. made a similar proposal: that coaching creates a high degree of satisfaction and is superior in helping participants attain their goals, whereas the absence of coaching and other support from a trainer is not sufficient for high goal attainment .n = 7, each group) and the test samples were insufficient. Our results also do not fully demonstrate that SNIPURS for learning vertebral needle targeting is actually useful for trainees to master needle puncture techniques. Further research is necessary to confirm and advance our present simulation training study.There are some limitations to our investigation. The sample size of examinees (In conclusion, we evaluated the vertebral needle targeting simulation training system SNIPURS for clinicians' preparation to perform the PVP procedure. SNIPURS might be suitable for vertebral needle targeting training. The provision of coaching during SNIPURS trainees helped the trainees acquire the spinal puncture techniques used in PVP.


Following the publication of this article , concernThe In Figs 6A, 6B, and 6C, there appear to be vertical irregularities between the SAC+QUIN (lane 3) and the Sham+SAC (lane 4) results, suggestive of splice lines.The corresponding author stated that the The authors confirm that the blots presented in Fig 6 were prepared using spliced blots. They explain that the Sham+SAC panels were run on separate blots at a later time because there were insufficient lanes to include the control on the same blot, and insufficient antibody to develop multiple separate blots at the same time. The authors submitted the original underlying blots used to present the Fig 6 panels, which are provided in PLOS ONE Editorial Board member, who commented that the Sham+SAC control is an essential control for the Fig 6 experiments, and emphasized that this control needs to be included in the same experiment and on the same blots as the Sham, QUIN, and SAC+QUIN samples to serve as a valid internal control. As reported in the published article, i.e. with the Sham+SAC results run on a separate blot, the results presented in Fig 6 are not adequately supported.Fig 6 and the underlying data provided by the authors were reviewed by a The QUIN-induced early striatal alterations matches with RAGE expression: “In this regard, our group has been previously able to demonstrate both the active role of QUIN in promoting oxidative damage in the CNS [In addition, the board member commented that the reduction of RAGE expression by SAC is not sufficient to support conclusions about the role of oxidative stress in response to QUIN. To support such a statement, it would be important to perform additional assays that demonstrate whether QUIN increased oxidative stress-related parameters. The authors stated that they have previously conducted not only these additional assays, but also experiments using an analogous toxic paradigm demonstrating the antioxidant efficacy of SAC. These results have been published in articles referenced below –85. In l the CNS –83, as w the CNS , 85, thuPLOS ONE Editors issue this Expression of Concern to notify readers of the concerns with Fig 6, and to relay the updated The S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(PPT)Click here for additional data file.S4 File(PPT)Click here for additional data file.S5 File(DOCX)Click here for additional data file.S6 File(DOCX)Click here for additional data file.S7 File(PDF)Click here for additional data file.


The transition of adolescents to adult care is known to be challenging. Studies indicate that patients with a chronic disease and cognitive deficits are at risk of inadequate transition to adult care, which eventually may result in disease deterioration. This study investigated the transition process for patients with neurofibromatosis type 1 (NF1) and discussed whether patients with NF1 and cognitive deficits should receive additional attention in their transitional period.A self-reported online questionnaire assessing disease severity, cognitive deficits, psychiatric diagnoses as well as transition experiences was completed by patients with NF1 aged 15–25-years. Patients were assigned to a national NF1 expert centre covering the western part of Denmark. Furthermore, a retrospective medical chart review was performed, and data were collected to estimate the prevalence of psychiatric diagnoses.The questionnaire was completed by 41/103 (39%), median age 20  years. Medical chart review was performed in 103 patients, median age 20 . Participants reporting the transition as difficult all received special needs education, six reported executive function deficits and three out of seven had a psychiatric diagnosis. Fifteen (37%) questionnaire participants reported a wish for more information about the natural history and the prognosis of NF1. The prevalence of psychiatric diagnoses was 24% in the questionnaire survey and 30% in the medical chart review.This study suggests a need of additional care for patients with NF1 and cognitive deficits including psychiatric disorders during their transition to adult care. In addition, it suggests a need for more information on and education in long-term prospects and mental health issues for patients with NF1. Neurofibromatosis type 1 (NF1) is a rare autosomal dominant disorder with an incidence of one case per 3000 caused by germline pathogenic variants in the NF1 tumour suppressor gene . Severe As children with chronic diseases approach their teenage years, the transition into adult care starts. Generally, the transition in the healthcare system is a well-described and organised process focused on increasingly making the adolescents capable of managing their own disease , 9. The To the best of our knowledge, transition in teenagers and adolescents with NF1 and cognitive deficits has not been studied previously. The aim of this study was to investigate the needs of young adults with NF1 and cognitive deficits. This study was based on data from a self-reported questionnaire and medical chart reviews to describe the diagnostic spectrum of psychiatric diagnoses such as ADHD, ADD and ASD.In Denmark, patients with NF1 are followed in accordance with national clinical guidelines at one of two specialised departments: Centre for Rare Diseases, Aarhus University Hospital (CRD-AUH) or Centre for Rare Diseases, Rigshospitalet, Copenhagen . The cenPatients aged 15–25 years with NF1 were included from the outpatient clinic at CRD-AUH. Patients were eligible for inclusion if they had a diagnosis according to the NIH criteria, met the age criteria and were registered for routine clinical follow up at CRD-AUH . After dPatients were invited by letter to complete an anonymous online questionnaire. One month following the invitation, participants received a reminder of the invitation in order to optimize the participation. The questionnaire was designed so that participants could only proceed to the next question if the current question was answered. This eliminated missing data. The questionnaire was divided into age groups; patients aged 15–17 years completed the questionnaire in the beginning of the transition process and patients aged 18–25 years in their post-transition period. The questionnaire was divided into the following six domains and contained 121 closed or semi-open-ended questions: (1) Background characteristics, (2) Disease severity, (3) Executive functions  and psychiatric diagnoses , (4) Well-being, with focus on sexuality, suicidal ideations, and crime, (5) Expectations or experiences with transition from child to adult in the social service sector and (6) Expectations or experiences with health care transition at CRD-AUH.From the medical chart, we collected data on demographics, NF1 diagnostic criteria, psychiatric diagnoses, and number of follow-up visits including non-appearances. Due to ethical regulations, it was not possible to link individual questionnaire data and medical chart data.Study data were collected from the questionnaire as well as medical charts and managed using the REDCap (Research Electronic Data Capture) electronic data capture tool hosted at Department of Clinical Medicine, Aarhus University. REDCap is a secure, web-based software platform designed to support data capture for research, allowing the researcher to handle data and perform automated data exports . DescripThe study was registered by Central Denmark Region ID-number 1-16-02-188-20. Online questionnaires were completed anonymously. The medical chart review was performed as a quality assurance project within CRD-AUH and in accordance with the Ethics Committee of Denmark, no approval is needed for this type of project.Figure A total of 41 completed the questionnaire; ten participants in the group of 15–17-year-olds  and 31 participants in the group of 18–25-year-olds . Thirty-eight (93%) participants had been followed at CRD-AUH since childhood. Five  reported they were assisted by a parent to answer the questionnaire due to dyslexia.The medical chart review was performed in 103 patients  with a median age of 20 years. Twenty-seven (26%) patients were below the age of 18 years . Most participants in both the questionnaire study (85%) and the medical chart review (93%) attended or had completed primary and lower secondary school, which in Denmark ends at ninth grade, at age 15–16 years. However, 60% and 49%, from the questionnaire and medical chart review group, respectively, were dependent on special needs education e.g., extra lessons or a resource teacher, which is an extra teacher who attends to students with cognitive deficits.Table Table Ten  questionnaire participants reported to be diagnosed with a psychiatric disorder; seven had more than one psychiatric diagnosis. The combined prevalence of ADHD, ADD and autism among questionnaire participants was 7% (3/41). Deficits in executive functions were reported by 33 (80%) of the questionnaire participants. Furthermore, 13  participants had experienced suicidal ideations and five  were diagnosed with depression or anxiety.In the medical chart review, the prevalence of psychiatric diagnoses was 31/103 (30%). Eight patients were registered with more than one psychiatric diagnosis. The combined prevalence of ADHD, ADD and autism among patients from the medical chart review was 21% (22/103). Additionally, 15  had milder symptoms of cognitive deficits such as learning disabilities and attention challenges but no psychiatric diagnosis.Seven  questionnaire participants found the health care transition difficult; three had a psychiatric diagnosis and six reported deficits in executive functions. All seven reported a need for special education.Fifteen  questionnaire participants expressed a wish for more information about the natural history of NF1 and the long-term prospects of the disease. Eight of these received special education, while three had a psychiatric diagnosis. Twelve had deficits in executive functions.Twenty-two participants  reported a wish for more information about NF1 and mental health; four had a psychiatric diagnosis and 13 had a need of special education. Participants reporting the transition as difficult predominately reported a wish for seeing the same doctor for consultations at CRD-AUH.None of the questionnaire participants reported non-appearance at medical follow-up visits, while in the medical chart review, 14 post-transitional adults were registered with at least one non-appearance during their period of transition; six of these patients were also diagnosed with a psychiatric disorder.Six  post-transitional questionnaire participants found the transition in the sector of social services such as meetings with a social worker and educational counsellor difficult. They predominantly reported it was due to no formalised transition and from the day they turned 18, they had to manage social laws and regulations on their own. Four of these six participants had a psychiatric diagnosis.All participants were asked if a consultation with a social health care worker employed at CRD-AUH would have been beneficial for their transition; 16 (39%) responded positively to this.This study is the first in Denmark investigating the needs and experiences in the transition process of patients with NF1. We found that all seven participants 7/41, 17%) who reported the transition to be difficult had cognitive challenges; three had a psychiatric diagnosis, six had executive function deficits and all participants had special educational needs. Our findings support our hypothesis that an additional support during the transition of patients with cognitive deficits would be beneficial. Furthermore, this study is the first in Denmark to describe the prevalence of ADD, ADHD and ASD of 21% (22/103) in adolescents and young adults with NF1. The prevalence of ADHD, ADD and autism in our study was lower than reported in the existing literature, in which a prevalence for ADHD and ADD of up to 60% and of 25–40% for ASD was reported 1, 17% wh.Fifteen 15/41, 37%) participants in the questionnaire survey reported a wish for more information about NF1 and the long-term prognosis. When such a need of patient self-management is not fulfilled, the risk of discontinuity of care is more likely, which eventually increases the risk of not detecting disease progression in time , 18. To 7% particThe questionnaire study also assessed the transition from child to adult in the social service sector context. Transition in the social service sector was difficult due to the abrupt change when patients reached legal age and thus, they have to deal with social laws and regulations on their own. Furthermore, in 39% of the cases, participants were favourably disposed towards a consultation with a social health care worker employed by CRD-AUH. This suggests that a closer corporation between the social system and the health care system would be beneficial, which is in line with a previous study by Reiss et al. . Four ouIn previous studies, mental health is reported to be a major concern for patients with NF1 and their relatives , 5. TwenThe limitations of this study were a low response rate (42%), that more mildly than severely affected patients participated in the questionnaire study and that sixty-three percent of the questionnaire respondents were women, while women constituted 44% of the total cohort. Selection bias should be taken into consideration as patients with psychiatric comorbidity may not be as likely to participate in the questionnaire study. Unfortunately, it was not possible to link the data from questionnaires on patient level to the data from the medical chart review as the questionnaire survey participants were anonymous. Also, selection bias should be considered when generalizing this study, as patients with learning disabilities may be more likely to restrain from answering a questionnaire. Furthermore, patients who went through transition several years ago may experience recall-bias. Our study was not designed with a qualitative methodology. We tried to set up panel discussion with participants in order to discuss the results, which unfortunately was impossible within our time frame, although this would have been relevant. A future study designed as a qualitative interview study including a discussion with the adolescents and young adults with NF1 of this study’s results is now being considered. Also, our study was only performed using retrospective and cross-sectional data, and it was not possible to draw conclusions on the possible outcomes for these patients later in life.Our study is among the first to explore the health-care transition process in patients with NF1 and cognitive deficits. The results suggest that patients with NF1 and cognitive deficits may benefit from closer attention in their transition before, during and after the transition process. We found a lower prevalence of ADHD, ADD and ASD, highlighting a probable low recognition of cognitive morbidities among patients with NF1. Our study also highlights the need for better information to the young patient with NF1 on mental challenges and a better education on NF1 disease prognosis and self-management to minimize the risk of discontinuity of care and eventually deterioration in health status of young adults with NF1. This study should act as a pilot study which highlights the need of investigating this topic more thoroughly. A larger qualitative, nation-wide study including interviews or assisted questionnaires is being considered. Also, additional research on prospective outcomes in transition processes is warranted.


To capture and compare the differences in experiences of public health Specialty Registrars who commenced training prior to the COVID-19 pandemic (pre-pandemic Registrars) and those who commenced training during the pandemic (post-pandemic Registrars).This is a mixed methods study comprising a cross-sectional survey and participatory action research.A questionnaire of 10 open and 5 closed questions exploring participants experience of training during the pandemic was sent to East Midlands Specialty Registrars. Thematic analysis and double coding were undertaken, coded based on pre- or post-pandemic Registrar status. Participatory action research was then undertaken in 2 rounds with 2 groups, based on pre/post-pandemic status to consolidate themes.The survey was completed by 17 Registrars  and 19 Registrars took part in participatory action research. The findings showed pre-pandemic Registrars noted the importance of negative impacts on their mental health whilst post-pandemic Registrars were more positive and felt well supported in their training.There is a stark difference in the impact of the pandemic for Registrars who started training before compared to during the pandemic. The training programme was not resilient to the impact of the pandemic. Robustness could be increased by encouraging early leadership experience and providing wellbeing support, particularly for post pandemic Registrars now and in future. The earConcerns have been raised through a General Medical Council (GMC) report , highlig1.To understand the experiences of public health Registrars based in the East Midlands engaged in the protracted COVID-19 pandemic response; and2.To compare the perceptions and experiences of Registrars who commenced their training before the pandemic (pre-pandemic Registrars) with those who started after the pandemic (post-pandemic Registrars).We seek to address two key aims:At the start of the pandemic, colleagues conducted a modified Delphi group to understand how the start of the pandemic challenged public health training in the East Midlands region of England. This found that Registrars had a firm identity as public health professionals, variable experiences of training, and had to adapt to rapid changes in work-life balances . Our res22.1In December 2021 there were 40 Public Health Registrars enrolled within the East Midlands deanery. Approximately 50% are medically qualified, with the remainder from allied health professions and public health practice.2.2The online survey was distributed to the Registrar cohort in December 2021–January 2022 .This consisted of ten open questions relating to training experiences, followed by a section on demographic variables that was developed from the preceding research . An addiResponses were collected on Microsoft Forms and divided into those provided by pre- and post-pandemic Registrars, allowing for a comparative analysis between these two groups ,6. Perso2.3Two concurrent participatory action research (PAR) groups  were conducted using Microsoft Teams on February 2, 2022. In round 1 of PAR, protothemes were condensed to create a ranked list of up to 10 themes. In round 2, themes were further amalgamated to a shorter list. This process is summarised in Participation in each round was voluntary, with participants providing written and verbal consent. Data was held securely in line with the Data Protection Act .33.1The survey was completed by 19 Registrars. One participant did not consent to their response being used in the study and one did not complete the questionnaire within the deadline. The final survey analysis consisted of 17 responses see , with ei3.2Initial thematic analysis revealed 718 codes for the pre-pandemic group  and 257 for the post-pandemic group  .3.33.3.1Pre-pandemic Registrars identified eight themes . The disNearly two years after the start of the pandemic, difficulties remain in maintaining an effective work-life balance. Some positives were noted however, including examples of observed leadership. Most Registrars also found opportunities to fulfil leadership roles themselves, but whilst some enjoyed this task, others felt unprepared. Indeed, some felt that demonstrating and developing essential leadership skills was harder virtually.There was an overall negative impact on relationships with fellow Registrars. An originally collegiate group had found it difficult to gather, affecting access to peer support. This was compounded by two new cohorts starting training remotely.The final two themes related to recognition, with lack of acknowledgement ranking more highly than feeling appreciated. Generally, Registrars felt that they were underutilised during the pandemic with a smaller section feeling that their identity as public health professionals was reaffirmed.3.3.2Post-pandemic Registrars identified 9 themes . The twoThe theme of missed interactions highlighted that Registrars felt a lack of social interaction within the training programme. Registrars expressed that so far, the pandemic had a limited impact on their training. Most felt well supported and encouraged to be involved in non-COVID-19 response work. Some Registrars described pro-active efforts to limit the impacts of loneliness by scheduling social time virtually and promoting personal wellbeing. Registrars also experienced no significant impact on mental health because of remote working.Registrars described increased health protection related learning opportunities arising from the pandemic; projects that would otherwise not have been available, and general learning about complexity of pandemic response. A theme felt by a minority was cancellation and delay of business as usual (BAU) work.Experiences of leadership were mixed with some Registrars feeling they were able to observe good role models virtually whilst others felt they lacked leadership opportunities. The final theme was of professional identity and showed that Registrar's identities as public health professionals were reaffirmed during the pandemic.3.43.4.1The pre-pandemic Registrar PAR group identified four meta-themes . Cutting3.4.1.1“Everything about training has changed  yet the curriculum or expectations of us as Registrars has not. The land grab on your time is acute, trainers and colleagues do not always allow enough time for you to do all the admin stuff”It was felt that the structural demands of Registrar life (including completing learning milestones), was not prioritised early in the pandemic and that doing so is an ongoing challenge for some. There was variation in the quality of training and educational supervision.3.4.1.2“I have background anxiety that never goes away. I've never experienced this before”There were emotional and psychological impacts experienced by Registrars due to increasing pressures and workload. This led to increased worry, anxiety, and risk of burnout.“Training in a pandemic also isolates you from your peers and support group. I try and stay in touch on WhatsApp and attend training days where possible. Feeling part of a peer group is important for feeling connected and coping with the changes to training in a pandemic”A protective mental health factor was feeling supported by peers and colleagues.3.4.1.3The move to work from home has had a negative impact, both in terms of missing out on meeting new colleagues and seeing people in the office and feeling more isolated at home, and in feeling more isolated from other Registrars and not having that reassurance that I'm not alone in finding certain aspects of training challenging”“Registrars identified the importance of feeling supported by peers and colleagues  and were concerned about the negative impact on the training experience of remote working.3.4.1.4It feels it has moved more to the needs of the placement and that there is an underlying expectation some of your time will go to COVID-19 response regardless of if it is beneficial for your learning or not.”“Registrars described roles predominantly in health protection and rapid changes to roles during the pandemic, leading to variations in learning opportunities. All Registrars had improved health protection proficiencies, potentially at the expense of other skills.“My projects were cancelled with pandemic response work taking over. I feel anxious and fearful of my future on the scheme and job opportunities on CCT'ing”There were concerns about the impact on future progression for some due to lost learning opportunities.3.4.2The post-pandemic Registrars identified four meta-themes .3.4.2.1“working from home has allowed me to slow down my pace of life, have more time for self-care and develop new hobbies. I like the freedom to work uninterrupted and get into the flow. I feel like I am more productive at home.”“Working from home is isolating and you lose the normal social corridor conversations and networking opportunities that you might ordinarily experience under usual circumstances”Registrars experienced a mix of positive and negative impacts arising from remote working during the pandemic. These were distributed amongst the group, with a particular focus of its effects on work-life balance. Views that were expressed included an appreciation of the time gained in lieu of commuting and a feeling of being better able to manage time at home than in an office, counterbalanced by a sense of missing the ability to build relationships with colleagues.3.4.2.2“There is a great public health community and I am glad to have joined the team”Registrars expressed sentiments of finding work in public health to be fulfilling and rewarding. Some felt that they had been able to make meaningful contributions to their public health teams, through either pandemic response or BAU projects.The group felt that the training programme supported them well. It was recognised however, that with a focus during the first year of training on completing the MPH, post-pandemic Registrars had perhaps been less exposed to some of the service-related pressures experienced by the wider public health workforce.3.4.2.3“I have also learnt to value the normal day to day social interactions with work colleagues”Registrars strongly felt they had been well supported during their time on the training programme by more senior public health professionals, and particularly by their Educational Supervisors. They recognised the importance of ensuring good personal wellbeing and felt that they had been able to make adaptations to ways of working to ensure this.Despite implementing initiatives such as virtual catchups, Registrars did still feel like they would benefit from face-to-face social interaction with colleagues.3.4.2.4“I have not at any time been pressured into contributing to large operational pieces of COVID response work, but instead been encouraged to work in other areas that will benefit my signing off of learning outcomes.”Most Registrars noted their work was primarily focussed on areas not directly associated with pandemic response.“I think also working in public health has given me greater understanding and insight of the pandemic situation as it evolves, and if I wasn't in public health perhaps, I might have felt more uncertain and as such anxious”Even when contributing towards work that was considered BAU, Registrars noted impacts arising from the pandemic, such as delays resulting from the de-prioritisation of non-COVID-19 work by organisations. Registrars appreciated having been able to observe and participate towards the wider systems’ response to the pandemic and felt they had not experienced difficulties in achieving required learning outcomes.3.5Some themes showed similarities such as a high ranking of the impact of remote working and reaffirmation of professional identity. Relationships between Registrars remained an important part of training with both groups feeling a lack of peer support. Both groups cited the new learning opportunities offered by the pandemic, with the pre-pandemic group being given opportunities to lead and the post-pandemic group learning about health protection and systems.3.6There are multiple differences between the pre- and post-pandemic training groups, including the differing view of mental health impact, support, and remote working. Pre-pandemic Registrars described the pandemic as a difficult time in their lives, where mental, psychological, and emotional health had declined significantly due to the workload and need to work remotely. In contrast, most post-pandemic Registrars cited that there had been no impact on their mental health and a focus on wellbeing and looking after oneself was more prominent. For the pre-pandemic group, negative impacts of remote working ran throughout all themes. For the post-pandemic group, Registrars reported feeling well supported and held positive views of consultants and their training experience.44.1The findings show a difference in training experiences during the pandemic for those who started training before the pandemic versus those who started training after. Some common threads ran throughout both groups, but it is of note that the general sentiment of the pre-pandemic group was a negative one whilst for post-pandemic it was positive.4.2Views of the pre-pandemic group were captured in a previous publication , themes 4.3This study follows the first original research into the impact of the pandemic on public health speciality Registrars training in England. In contrast to the previous paper, this study uses a novel, comparative methodology ,6 to comPre-pandemic Registrars are concerned about poor achievement of learning outcomes due to continued pressure to work on pandemic response as well as a lack of varied opportunities. This coupled with a lack of appropriate leadership opportunities create the risk that Registrars will not be well prepared for consultant practice ,4,10.Post-pandemic Registrars generally felt well supported with no negative impacts on their mental health. For them, negative experiences of completing their MPH virtually meant a potential lack of knowledge of the foundations of public health. Lack of peer support in the early stages can result in lack of social connectivity as training progresses which could impact future mental health.4.4Participation in the research process was voluntary and therefore the views of all Registrars were not captured. Some Registrars who wished to participate were unable due to work pressures. Those in the post-pandemic group were in their first two years of training, which, given those at the start of training spend less time on service work and may experience less service level impacts, could have confounded the results.Although the results are specific to this cohort of East Midlands Registrars, we anticipate that experiences would be similar for Registrars in other English regions , and potentially the wider public health workforce. Whilst the sample was small, this still accounted for almost half of the Registrars in the East Midlands region and enabled us to gather rich insights, as is the aim of a qualitative approach such as PAR.4.5The findings show the need for focussed support from supervisors and programmes to plan how outstanding learning outcomes will be met amongst those who started training pre-pandemic and feel learning outcomes were impacted. This could be through making targeted opportunities available to fulfil outstanding learning outcomes or extensions to training as appropriate, where COVID-19 has impacted ability to make sufficient progress. This may reduce Registrar anxiety. It is acknowledged this will not require implementation for all pre-pandemic Registrars as experience was varied and this support and planning may already be in place. Supported leadership opportunities should be provided to those who feel leadership was negatively impacted.Much of the negative impact of COVID-19 centred around home working and mental health, due to isolation, reduced opportunity for spontaneous learning, issues with leadership experience and pressure. Implementation of wellbeing strategies (co-produced with Registrars), particularly those involving peer support opportunities would proactively address some of the issues regarding reduced networking for pre-pandemic Registrars and act as a protective factor for post-pandemic Registrars who over time may encounter similar negative impacts.Novel ways to incorporate leadership skills whilst working virtually into the curriculum would be a key area for both groups, as well as finding innovative methods to increase spontaneous learning opportunities whilst working from home, addressing the removal of ‘corridor conversation’ type learning. Early leadership opportunities would increase resilience of training to disruption by acute public health emergencies. A balance of home and in person work should be offered based on the individual's needs.In a post-pandemic world of home working, these findings are highly relevant as whilst the pandemic context may have become less acute, some environmental factors that impacted training still prevail, such as home working. If another pandemic were to occur, the findings here should be noted so that involved Registrars experience the varied learning experiences necessary to meet curriculum requirements as well as peer support opportunities to feel connected. Supervisors should have guidance for Registrars’ roles in acute emergency response and recovery to ensure findings are implemented.Registrars are the future public health leaders and will be at the forefront of future public health emergencies. Their training should be prioritised to ensure a strong public health response in future.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Due to this work being undertaken independently of any particular institution, no formal ethical approval was sought. Participants reported on all consented to participation and inclusion of their data in the study.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Some of the authors also took part in the survey. All authors were part of the East Midlands registrar cohort at the time research was undertaken.


Electrical impedance spectroscopy (EIS) is widely recognized as a powerful tool in biomedical research. For example, it allows detection and monitoring of diseases, measuring of cell density in bioreactors, and characterizing the permeability of tight junctions in barrier-forming tissue models. However, with single-channel measurement systems, only integral information is obtained without spatial resolution. Here we present a low-cost multichannel impedance measurement set-up capable of mapping cell distributions in a fluidic environment by using a microelectrode array (MEA) realized in 4-level printed circuit board (PCB) technology including layers for shielding, interconnections, and microelectrodes. The array of 8 × 8 gold microelectrode pairs was connected to home-built electric circuitry consisting of commercial components such as programmable multiplexers and an analog front-end module which allows the acquisition and processing of electrical impedances. For a proof-of-concept, the MEA was wetted in a 3D printed reservoir into which yeast cells were locally injected. Impedance maps were recorded at 200 kHz which correlate well with the optical images showing the yeast cell distribution in the reservoir. Blurring from parasitic currents slightly disturbing the impedance maps could be eliminated by deconvolution using an experimentally determined point spread function. The MEA of the impedance camera can in future be further miniaturized and integrated into cell cultivation and perfusion systems such as organ on chip devices to augment or even replace light microscopic monitoring of cell monolayer confluence and integrity during the cultivation in incubation chambers. A broad range of bioimaging tools have been developed to provide valuable biological information and improve the reproducibility of cell cultivations ,2,3,4. ILight-addressable potentiometric sensors can sense not only the electrical properties of cells but also the metabolic activity of cells in a spatially resolved manner ,11. WithThe high-frequency electrical properties of particle or cell suspensions depend on their size and volume fraction .For cells in suspension, four frequency regions with different relative permittivity can be distinguished  3]: the: the3]: In this work, simple two-electrode measurement areas, which can be placed spatially densely, were arranged as an 8 × 8 array based on a commercial PCB technology to establish a low-cost impedance camera system. A low-cost impedance readout electronics based on a microcontroller and two multiplexers addressing the electrode array was developed. The MEA with 8 × 8 coplanar electrode pairs was realized based on a commercial low-cost PCB four-layer technology  with layers for shielding, interconnection, and electrodes as illustrated in The measured impedance value of every electrode pair indicates one pixel value in the mapping and the concentration of the cells are scaled as color range from red (high concentration) to blue (low concentration).A 3D printed barrier with a height of 5 mm was adhesively bonded to the PCB to surround the MEA. Into the resulting reservoir, 4.5 mL of the solution was accurately dispensed with a pipette to ensure that the liquid level was reproducible. Commercial dried edible yeast powder  was mixed with sugar  water (3 g/L) to prepare different concentrations of yeast suspensions. While the impedances were measured, the CCD camera directly above the device recorded the spreading of cells optically. A read-out circuitry was built with commercial components as sketched in For the selection of good operational conditions, measurements with a single micro electrode pair were performed. The strength of stimulation signals must be adapted to the composition of the sample. Then, 100 mM, 200 mM, 500 mM, and 2000 mM NaCl solutions were filled into the reservoir. For a good signal–noise ratio, the value of the voltage must be sufficient. However, too high voltage leads to undesirable electrochemical reactions, such as hydrolysis. Cyclic voltammetry measurements of the solutions were performed by applying isosceles triangle wave voltage stimulus and measuring the current response with the described two Au-electrodes system. CV measurements are presented in s), a constant–phase-element (CPE) representing the double layer on the electrodes, a resistor (Rcell) connected in parallel with a capacitor (Ccell), and a small inductive contribution from the measuring electronics (Loffset) which caused the shift in the Nyquist diagram. Rcell‖Ccell represented the contribution of the cells. In a third step, impedance spectra of different yeast concentrations within 1 g/L sugar solution in normal water, 30 g/L, 50 g/L, and 70 g/L were recorded as shown in offset and Rs, are practically insensitive to cell concentration. However, Ccell has a strong and monotone dependence of the cell concentration just like Im[Z] measured at 200 kHz . As can be seen from the fitted parameters in  200 kHz d. The laSince those cells located on top of one pair of electrodes create an image point that is blurred by this PSF, the unprocessed image is a convolution of the real distribution of cells with the PSF see . For debAs a first step, 45 mL of water of 3 g/L sugar solution was added to the reservoir and one Im[Z] imaging was performed to determine the background signals. Then, 20 µL of 70 g/L yeast solution was dispensed into the reservoir at different positions before the Im[Z] imaging was performed 30 s, 2 min 43 s, and 5 min 38 s after dispensing  were taken from The larger the PSNR value, the better the image quality compared to the reference image. Usually, a value higher than 10 dB means that the structural similarity between reference and test images can be recognized by human eyes . As can We have successfully developed a low-cost impedance camera that can map the concentration of yeast suspension cells using an MEA obtained by standard four-layer PCB technology and a home-built read-out circuitry made from commercial components. Conditions for amplitude and frequency of the excitation signals were chosen not to induce electrochemical reactions and to provide high sensitivity to cell concentration and negligible sensitivity to ion concentrations in the media. Next to the hardware, a software was developed to control the hardware and to generate the impedance camera images. A deblurring based on an experimentally obtained PSF proved to sharpen the impedance images. The metric PSNR was used to evaluate the impedance image qualities and to prove the success of the deblurring.Further miniaturization also facilitating portability of the impedance camera technology is possible. Scanning speed can be accelerated but real-time scanning may require more complex electronic systems. Higher resolution can in future be realized with smaller and more electrode pairs, which increases the complexity of the MEA. The camera concept shall in future be integrated into organ-on-chip devices to augment or even replace optical imaging, especially in permeation chips with porous membranes.