BACKGROUND:Nonorganic erectile dysfunction (nonorganic ED) is a common subtype of ED characterized by impaired erectile function in the absence of identifiable organic causes. Although ED is increasingly recognized as a multidimensional condition involving interacting biological, psychological, relational, and sociocultural factors, how these influences are integrated within central neural systems in nonorganic ED remains incompletely understood. Objective neurobiological markers are therefore still lacking. OBJECTIVES:To investigate whether patients with nonorganic ED exhibit abnormalities in local intrinsic brain activity and to examine the association between these alterations and erectile function. MATERIALS AND METHODS:Resting-state functional magnetic resonance imaging data were acquired from 29 patients with nonorganic ED and 29 age-matched healthy controls. Regional homogeneity (ReHo) was used to assess local synchronization of spontaneous neural activity across the whole brain. Between-group differences were evaluated using voxel-wise analysis. Correlation analyses were performed to assess associations between altered ReHo and erectile function as measured by the International Index of Erectile Function (IIEF). RESULTS:Compared with healthy controls, patients with nonorganic ED exhibited significantly decreased ReHo in the right anterior insula (family-wise error corrected). Furthermore, reduced ReHo in this region was significantly associated with greater ED severity. DISCUSSION:These findings indicate that nonorganic ED is associated with disrupted local functional coherence in the anterior insula, a key region involved in integrating interoceptive, emotional, cognitive, and autonomic processes. The observed association with erectile function suggests that impaired integration of these processes may contribute to the central neural mechanisms underlying nonorganic ED. CONCLUSION:Patients with nonorganic ED exhibit reduced local functional coherence in the anterior insula, which is associated with ED severity. These findings provide preliminary evidence linking central neural dysfunction to clinical symptoms and support the further evaluation of resting-state fMRI metrics as candidate neurobiological markers for nonorganic ED.

Phenomenon: Educational activities for students are typically arranged without consideration of their preferences or peak performance hours. Students might prefer to study at different times based on their chronotype, aiming to optimize their performance. While face-to-face activities during the academic schedule do not offer flexibility and cannot reflect students' natural learning rhythm, asynchronous e-learning facilitates studying at one's preferred time. Given their ubiquitous accessibility, students can use e-learning resources according to their individual needs and preferences. E-learning usage data hence serves as a valuable proxy for certain study behaviors, presenting research opportunities to explore students' study patterns. This retrospective study aims to investigate when and for how long undergraduate students used medical e-learning modules. Approach: We performed a cross-sectional analysis of e-learning usage at one medical faculty in the Netherlands. We used data from 562 undergraduate multimedia e-learning modules for pre-clinical students, covering various medical topics over a span of two academic years (2018/19 and 2019/20). We employed educational data mining approaches to process the data and subsequently identified patterns in access times and durations. Findings: We obtained data from 70,805 e-learning sessions with 116,569 module visits and 1,495,342 page views. On average, students used e-learning for 16.8 min daily and stopped using a module after 10.2 min, but access patterns varied widely. E-learning was used seven days a week with an hourly access pattern during business hours on weekdays. Across all other times, there was a smooth increase or decrease in e-learning usage. During the week, more students started e-learning sessions in the morning (34.5% vs. 19.1%) while fewer students started in the afternoon (42.6% vs. 50.8%) and the evening (19.4% vs. 27.0%). We identified 'early bird' and 'night owl' user groups that show distinct study patterns. Insights: This retrospective educational data mining study reveals new insights into the study patterns of a complete student cohort during and outside lecture hours. These findings underline the value of 24/7 accessible study material. In addition, our findings may serve as a guide for researchers and educationalists seeking to develop more individualized educational programs.

The chemical composition of exhaled breath was examined for volatile organic compound (VOC) indicators of sexual arousal in human beings. Participants (12-male, 12-female) were shown a randomized series of three emotion-inducing 10-min film clips interspersed with 3-min neutral film clips. The films caused different arousals: sports film (positive-nonsexual); horror film (negative-nonsexual); and erotic (sexual) that were monitored with physiological measurements including genital response and temperature. Simultaneously the breath was monitored for VOC and CO2. While some breath compounds (methanol and acetone) changed uniformly irrespective of the film order, several compounds did show significant arousal associated changes. For both genders CO2 and isoprene decreased in the sex clip. Some male individuals showed particularly strong increases of indole, phenol and cresol coincident with sexual arousal that decreased rapidly afterwards. These VOCs are degradation products of tyrosine and tryptophan, precursors for dopamine, noradrenalin, and serotonin, and therefore represent potential breath markers of sexual arousal.

Current understanding of human genital-brain interactions relates primarily to neuroendocrine and autonomic control, whereas interactions during sexual stimulation remain largely unexplored. Here we present a systematic approach towards identifying how the human brain encodes sensory genital information. Using a validated affective touch paradigm and functional magnetic resonance imaging, we found that hedonic responses to discriminatory versus affective tactile stimulation were distinctly different for both penile shaft and forearm. This suggests that, as with other body sites, genital skin contains small diameter mechanoreceptive nerve fibres that signal pleasant touch. In the brain, secondary somatosensory cortex (S2) distinguished between affective and discriminative touch for the penile shaft, but not for the forearm. Frenulum stimulation induced the greatest reports of subjective pleasure and led to the greatest deactivation of the default-mode network. This study represents a first pass at investigating, in humans, the relationship between innervation of genital surfaces, hedonic feelings, and brain mechanisms, in a systematic way.

Objectives Penile detumescence is an essential part of erectile physiology. Furthermore, abnormal penile detumescence might play an important role in erectile dysfunction and priapism. Nevertheless, many characteristics of penile detumescence remain to be explored. This pilot study investigates, for the first time to our knowledge, the duration of penile detumescence in the general population. Methods Men were recruited online, through social networks of the authors (convenience sampling). After inclusion, volunteers received online instructions and a survey. Detumescence measurements were self-performed by the volunteers at their convenience. Volunteers were asked to achieve orgasm by self-chosen means, and to start a stopwatch measurement as soon as orgasm had taken place. Then, following the instructions, the volunteer registered two time points expressing their tumescence perception: i) onset of flaccidity; ii) complete flaccidity. In the survey, participants were asked to provide information about other variables such as age, satisfaction, erection hardness score (EHS) and the presence of a partner. Results In the study, 83 volunteers were included (mean age 26.9 +/-8.9 years). The mean duration between orgasm and the onset of flaccidity was 57.9 (35.5) seconds, with a near-normal distribution according to the Kolmogorov-Smirnov test, and the mean duration between orgasm and complete flaccidity was 180.7 (83.5) seconds, normally distributed. Most volunteers achieved orgasm in an unpartnered fashion (83.1%) and had an EHS of 4 (71.1%). Satisfaction levels mainly varied between a little bit (26.5%), moderately (37.3%) and quite a bit (30.1%). Conclusions The results suggest that the duration of penile detumescence can be adequately measured outside of a laboratory setting. Future studies can use this first exploration to investigate the distribution of penile detumescence duration in different populations, as well as the variables that mediate this penile mechanism. This might be of importance in understanding the pathophysiology of erections, which will lead to better interventions and improvement in quality of life. Conflicts of Interest We have no conflict of interest to declare. Penile detumescence is an essential part of erectile physiology. Furthermore, abnormal penile detumescence might play an important role in erectile dysfunction and priapism. Nevertheless, many characteristics of penile detumescence remain to be explored. This pilot study investigates, for the first time to our knowledge, the duration of penile detumescence in the general population. Men were recruited online, through social networks of the authors (convenience sampling). After inclusion, volunteers received online instructions and a survey. Detumescence measurements were self-performed by the volunteers at their convenience. Volunteers were asked to achieve orgasm by self-chosen means, and to start a stopwatch measurement as soon as orgasm had taken place. Then, following the instructions, the volunteer registered two time points expressing their tumescence perception: i) onset of flaccidity; ii) complete flaccidity. In the survey, participants were asked to provide information about other variables such as age, satisfaction, erection hardness score (EHS) and the presence of a partner. In the study, 83 volunteers were included (mean age 26.9 +/-8.9 years). The mean duration between orgasm and the onset of flaccidity was 57.9 (35.5) seconds, with a near-normal distribution according to the Kolmogorov-Smirnov test, and the mean duration between orgasm and complete flaccidity was 180.7 (83.5) seconds, normally distributed. Most volunteers achieved orgasm in an unpartnered fashion (83.1%) and had an EHS of 4 (71.1%). Satisfaction levels mainly varied between a little bit (26.5%), moderately (37.3%) and quite a bit (30.1%). The results suggest that the duration of penile detumescence can be adequately measured outside of a laboratory setting. Future studies can use this first exploration to investigate the distribution of penile detumescence duration in different populations, as well as the variables that mediate this penile mechanism. This might be of importance in understanding the pathophysiology of erections, which will lead to better interventions and improvement in quality of life.

Background Game-based learning appears to be a promising instructional method because of its engaging properties and positive effects on motivation and learning. There are numerous options to design game-based learning; however, there is little data-informed knowledge to guide the choice of the most effective game-based learning design for a given educational context. The effectiveness of game-based learning appears to be dependent on the degree to which players like the game. Hence, individual differences in game preferences should be taken into account when selecting a specific game-based learning design. Objective We aimed to identify patterns in students’ perceptions of play and games—player types and their most important characteristics. Methods We used Q methodology to identify patterns in opinions on game preferences. We recruited undergraduate medical and dental students to participate in our study and asked participants to sort and rank 49 statements on game preferences. These statements were derived from a prior focus group study and literature on game preferences. We used by-person factor analysis and varimax rotation to identify common viewpoints. Both factors and participants’ comments were used to interpret and describe patterns in game preferences. Results From participants’ (n=102) responses, we identified 5 distinct patterns in game preferences: the social achiever, the explorer, the socializer, the competitor, and the troll. These patterns revolved around 2 salient themes: sociability and achievement. The 5 patterns differed regarding cheating, playing alone, story-telling, and the complexity of winning. Conclusions The patterns were clearly interpretable, distinct, and showed that medical and dental students ranged widely in how they perceive play. Such patterns may suggest that it is important to take students’ game preferences into account when designing game-based learning and demonstrate that not every game-based learning-strategy fits all students. To the best of our knowledge, this study is the first to use a scientifically sound approach to identify player types. This can help future researchers and educators select effective game-based learning game elements purposefully and in a student-centered way.

To become sexually aroused and eventually engage in sexual behavior, a sexual incentive must first capture our attention. A mechanism that can enhance the salience of such stimulus is multisensory integration (MSI), where input from different sensory modalities (e.g., visual, auditory, and tactile) that occurs close in time is integrated to form a single multimodal percept. Our main objective was to test whether the salience of sexual images would be enhanced by the simultaneous presentation of (task-irrelevant) sexual audio. Sixty-one heterosexual males took part in a modified attentional blink (AB) paradigm. They were instructed to detect the rotation of two target images (T1 and T2) amongst a rapid series of 17 images, presented for 100 ms each. T1 could show a nude (rated as highly erotic) or a dressed female (rated as neutral), whereas T2 displayed a control image (random animal). T1 and T2 were separated by a single (Lag-2) or seven (Lag-8) filler images. To investigate MSI, we added a task-irrelevant auditory stimulus (1,000 ms) that was always concurrently presented with T1 and either erotic (climatic female voice) or neutral (pseudo-words). Our data show that sexual images induced a larger AB than non-sexual images. However, we found no main effect of audio (sexual vs. non-sexual) on target detection, but a complex interaction between lag, T1 type, and audio type. For Lag-8, the sexual image-sexual audio combination resulted in the lowest target detection. For Lag-2, whenever the image was sexual, there was a substantially larger AB, regardless of the audio. In other words, our results indicate a possible MSI effect for Lag-8 but not for Lag-2. Thus, our study provides the first evidence that MSI modulates the salience of sexual stimuli. Interestingly, sexual MSI seems to require additional processing time or attentional resources before it can have an effect. There are no conflicts of interest.

BACKGROUND:In times where distance learning is becoming the norm, game-based learning (GBL) is increasingly applied to health profession education. Yet, decisions for if, when, how, and for whom GBL should be designed cannot be made on a solid empirical basis. Though the act of play seems to be intertwined with GBL, it is generally ignored in the current scientific literature.OBJECTIVE:The objective of our study was to explore students' perceptions of play in leisure time and of GBL as part of a mechanistic, bottom-up approach towards evidence-informed design and implementation of GBL in health profession education.METHODS:We conducted 6 focus group discussions with medical and dentistry students, which were analyzed using thematic analysis.RESULTS:A total of 58 students participated. We identified 4 major themes based on the students' perception of play in leisure time and on the combination of play and learning. Our results indicate that, while play preferences were highly various in our health profession student cohort, pleasure was the common ground reported for playing. Crucially, play and the serious act of learning seemed paradoxical, indicating that the value and meaning of play are strongly context-dependent for students.CONCLUSIONS:Four key points can be constructed from our study. First, students play for pleasure. Perceptions of pleasure vary considerably among students. Second, students consider play as inefficient. Inefficiency will only be justified when it increases learning. Third, play should be balanced with the serious and only be used for difficult or tedious courses. Fourth, GBL activities should not be made compulsory for students. We provide practical implications and directions for future research.

Abstract Background Microsurgical transplantation of vascularized lymph nodes (VLNT) or lymphatic vessels (VLVT) alongside derivative lymphaticovenous procedures are promising approaches for treatment of lymphedema. However, clinically relevant training models for mastering these techniques are still lacking. Here we describe a new training model in human cadaver and validate its use as training tool for microsurgical lymphatic reconstruction. Methods 10 surgeons with previous exposure to microsurgery were trained in a controlled environment. Lymphatic vessel mapping and dissection in 4 relevant body regions, harvesting of five different VLNTs and one VLVT were performed in 5 fresh-frozen cadavers. The number of lymphatic vessels and lymph nodes for each VLNT were recorded. Finally, the efficacy of this model as training tool was validated using the Dundee Ready Education Environment Measure (DREEM). Results The average cumulative DREEM score over each category was 30,75 (max = 40) while individual scoring for each relevant category revealed highly positive ratings from the perspective of teaching (39,3), training 40,5 (max = 48) and self perception of the training 30,5 (max = 32) from all participants. The groin revealed the highest number of lymphatic vessels (3.2 ± 0.29) as all other regions on the upper extremity, while the gastroepiploic VLNT had the highest number of lymph nodes (4.2 ± 0.37). Conclusions This human cadaver model represents a new, reproducible “all-in-one” tool for effective training in lymphatic microsurgery. Its unique diligence in accurately reproducing human lymphatic anatomy, should make this model worth considering for each microsurgeon willing to approach lymphatic reconstruction.

Anecdotal evidence suggests that sexual attraction is flexible, and that high levels of sexual arousal can promote sexual willingness and approach tendencies toward a priori low attractive mates. This experimental study tested whether heightened sexual arousal can lower the threshold for sexual willingness and automatic approach tendencies toward potential sex partners of low and medium attractiveness. Heterosexual male (n =54) and female (n =61) participants were randomly assigned to a sexual arousal or control condition. Approach tendencies were indexed using a reaction time task. Sexual willingness was indexed using participant ratings of willingness to kiss and to consider having sex with same- and other-sex models of low, medium, and high attractiveness. Overall, participants showed stronger approach to models of high and medium than of low attractiveness. Sexual arousal weakened this differential responding but did not result in a robust increase of approach toward less attractive other-sex or same-sex models. Sexual willingness toward less attractive models was not affected by sexual arousal. Independent of condition, women reported greater sexual willingness toward same-sex models. The current pattern of findings does not support the notion that sexual arousal promotes automatic approach and sexual willingness to a broader array of sex partners.

Gamification refers to using game attributes in a non-gaming context. Health professions educators increasingly turn to gamification to optimize students’ learning outcomes. However, little is known about the concept of gamification and its possible working mechanisms. This review focused on empirical evidence for the effectiveness of gamification approaches and theoretical rationales for applying the chosen game attributes. We systematically searched multiple databases, and included all empirical studies evaluating the use of game attributes in health professions education. Of 5044 articles initially identified, 44 met the inclusion criteria. Negative outcomes for using gamification were not reported. Almost all studies included assessment attributes (n = 40), mostly in combination with conflict/challenge attributes (n = 27). Eight studies revealed that this specific combination had increased the use of the learning material, sometimes leading to improved learning outcomes. A relatively small number of studies was performed to explain mechanisms underlying the use of game attributes (n = 7). Our findings suggest that it is possible to improve learning outcomes in health professions education by using gamification, especially when employing game attributes that improve learning behaviours and attitudes towards learning. However, most studies lacked well-defined control groups and did not apply and/or report theory to understand underlying processes. Future research should clarify mechanisms underlying gamified educational interventions and explore theories that could explain the effects of these interventions on learning outcomes, using well-defined control groups, in a longitudinal way. In doing so, we can build on existing theories and gain a practical and comprehensive understanding of how to select the right game elements for the right educational context and the right type of student.

The female reproductive system includes an active and responsive genital tract that shows involuntary activity triggered by sexual arousal, genital stimulation and/or orgasm. This pelvic and perineal somatic and autonomic reflex muscle activity ("genito-pelvic reflexes") may be an important constituent of the female sexual response. The aim of this study was to review the literature critically on female genito-pelvic reflexes. Only a small number of studies (15) have been published on this issue. More neurophysiological research is needed to search for the implications of these genito-pelvic reflexes for female sexual (dys)function.

Seksualiteit is voor veel, zo niet de meeste mensen een belangrijk thema in hun leven. Seksualiteit kan hen plezier of ellende bezorgen en gaat gepaard met toestemming of afkeuring van henzelf of anderen. Niet alleen voor individuen is seksualiteit belangrijk, ook voor samenlevingen is het een gewichtig thema. Zij voorzien seksualiteit van geboden en verboden en beïnvloeden daarmee in niet geringe mate de regulering van seksualiteit of seksueel gedrag. Maatschappelijke regelsystemen vertonen historische en crossculturele variatie. En ook personen vertonen seksuele verschillen: sommigen hebben relatief veel seks, anderen betrekkelijk weinig; sommige personen vrijen vooral met partners van dezelfde sekse, terwijl de meerderheid van de mensen vooral met partners van de andere sekse vrijt; een deel van de mensen heeft enkel positieve ervaringen met seks, terwijl een ander deel (vrouwen meer dan mannen) slachtoffer is geweest van seksueel geweld. Vele andere voorbeelden van variatie, zoals seksuele veranderingen in de loop van het leven, worden in dit boek besproken. De conclusie is duidelijk: variatie is een belangrijk kenmerk van seksualiteit en dat leidt tot belangrijke vragen als: vanwaar komt die variatie, hoe en door wie wordt ze bepaald, welke effecten heeft ze op mensen?

Needles are commonly used in the clinic for percutaneous procedures. The outcome of such procedures heavily depends on accurate placement of the needle. There are two main challenges to achieve high accuracy: First, aligning the needle with the targeted lesion, and second, compensating for the deflection of the needle in the tissue. In order to address these challenges, scientists have developed several robotic setups for needle steering. However, the subject is still under research and reliable implementations which can be used in clinical practice are not yet available. In this paper, we have taken some steps in order to bring needle steering closer to practice. A new hybrid control algorithm is developed, which enables us to control a flexible needle by combing base-manipulation and beveled-tip steering methods. A pre-operative path planner is developed which considers the clinical requirements. The proposed method is tested in the lung of a fresh-frozen human cadaver. The work-flow of the experiments are similar to the current clinical practice. Three experimental cases are used to evaluate the proposed steering algorithm. Experimental Case I shows that using the proposed steering algorithm controllability of the needle is increased. In Case II and Case III, the needle is steered in a gelatin phantom and a human cadaver, respectively. The targeting accuracy of 1.35±0.49mm in gelatin phantom and 1.97±0.89mm in cadave is achieved. A feasibility study is performed, in which a fine needle aspiration (FNA) needle is steered in the lungs of a human cadaver under computed tomography guidance. The targeting error for the feasibility study is 2.89±0.22mm. The results suggest that such a robotic system can be beneficial for clinical use and the patient receives less x-ray radiation.

Background: Unmyelinated low-threshold mechanoreceptors-the so-called C-tactile (CT) afferents-play a crucial role in the perception and conduction of caressing and pleasant touch sensations and significantly contribute to the concept of erotic touch perception.Aim: To investigate the relations between sexual desire and sexual performance and the perception of touch mediated by CT afferents.Methods: Seventy healthy participants (28 men, 42 women; mean age+/-SD = 24.84+/-4.08 years, range = 18-36 years) underwent standardized and highly controlled stroking stimulation that varied in the amount of CT fiber stimulation by changing stroking velocity (CT optimal = 1, 3 and 10 cm/s; CT suboptimal = 0.1, 0.3, and 30 cm/s). Participants rated the perceived pleasantness, eroticism, and intensity of the applied tactile stimulation on a visual analog scale, completed the Sexual Desire Inventory, and answered questions about sexual performance.Outcomes: Ratings of perceived eroticism of touch were related to self-report levels of sexual desire and sexual performance.Results: Pleasantness and eroticism ratings showed similar dependence on stroking velocity that aligned with the activity of CT afferents. Erotic touch perception was related to sexual desire and sexual performance in a gender-specific way. In women, differences in eroticism ratings between CT optimal and suboptimal velocities correlated positively with desire for sexual interaction. In contrast, in men, this difference correlated to a decreased frequency and longer duration of partnered sexual activities.Clinical Implications: The present results lay the foundation for future research assessing these relations in patients with specific impairments of sexual functioning (eg, hypoactive sexual desire disorder).Strengths and Limitations: The strength of the study is the combination of standardized neurophysiologic methods and behavioral data. A clear limitation of the study design is the exclusion of exact data on the female menstrual cycle and the recruitment of an inhomogeneous sample concerning sexual orientation.Conclusion: The present results provide further evidence that unmyelinated CT afferents play a role in the complex mechanism of erotic touch perception. The ability to differentiate between CT optimal and suboptimal stimuli relates to sexual desire and performance in a gender-specific way. Copyright (C) 2017, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

PURPOSE OF REVIEW:The purpose of this study is to provide a comprehensive summary of the latest developments in the experimental brain study of human sexuality, focusing on brain connectivity during the sexual response.RECENT FINDINGS:Stable patterns of brain activation have been established for different phases of the sexual response, especially with regard to the wanting phase, and changes in these patterns can be linked to sexual response variations, including sexual dysfunctions. From this solid basis, connectivity studies of the human sexual response have begun to add a deeper understanding of the brain network function and structure involved.SUMMARY:The study of "sexual" brain connectivity is still very young. Yet, by approaching the brain as a connected organ, the essence of brain function is captured much more accurately, increasing the likelihood of finding useful biomarkers and targets for intervention in sexual dysfunction.

A specialized class of unmyelinated nerve fibers in human hairy skin – the so-called C-tactile afferents – is known to play an important role in the perception of pleasant sensations in human-to-human caressing touch as well as in the perception of erotic touch. The sense of smell is also important in human intimate relationships with significant contributions to social behavior through mate choice and empathic functioning. In an explorative study, we investigated the relation between individual sensitivity to stimulation of these primary senses and levels of sexual desire and performance in young, healthy individuals. Seventy volunteers (28 male, 42 female; mean age 24.84 ± 4.08 years SD, range from 18 to 36 years) participated in a standardized and controlled tactile experiment that applied stroking stimuli with different velocities (C-tactile stimulation optimal: 1, 3 and 10 cm/s; C-tactile stimulation suboptimal: 0,1, 0,3 and 30 cm/s) and rated the perceived pleasantness, eroticism and intensity of those stimuli on visual analogue scales. Further, odor threshold was assessed using the “Sniffin’ Sticks”. All participants additionally responded to a battery of questions on sexual desire (SDI Sexual Desire Inventory), sexual pleasure (orgasm frequency, perceived pleasantness of sexual activities on a VAS) as well as sexual behaviour (stating the number of sexual partners, frequency of having sex, average duration of sexual intercourse).