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Surgical specialization training has evolved considerably in recent years [21]. Especially during the Covid-19 period, the number of assisted surgeries decreased along with the total number of surgeries performed by residents continuing their training, leading to gaps in resident education [22,23,24]. Recently, surgical training has become more challenging due to the rise in resident numbers and the decline in available educators. For these reasons, the use of surgical videos in training has increased more frequently. Therefore, it is crucial to evaluate these videos, which serve as educational tools, objectively. Additionally, analyzing parameters such as the number of views, likes, and the length of these videos by correlating them with IVORY and LAP-VEGaS scores can provide insights for creating new videos. In our study, we found that the quality of endoscopic type 1 tympanoplasty and myringoplasty surgery videos uploaded to YouTube was generally low in terms of education. Previous studies assessing the quality of surgical videos in otolaryngology often used grading systems that were not specific to the field. These studies typically employed general quality scales like JAMA, DISCERN, or the Global Quality Score (GQS) [25,26,27]. Recently, some studies have evaluated otologic surgical videos using the IVORY grading system for procedures such as DSR, stapedectomy, and parotidectomy [1, 2, 18]. A common finding across these studies is that the videos assessed did not meet the expected educational quality standards. Similarly, in our study, the majority of the evaluated videos were scored as low-quality according to the IVORY scale.

In Mayer et al.‘s study, a correlation was found between the number of views and the total IVORY score videos [18]. However, in Yıldırım and Özdilek’s study, no such correlation was found [2]. In our study, the number of views was not significantly correlated with the IVORY score (p = 0.940), but there was a significant positive correlation between the number of views and the LAP-VEGaS score. (r = 0.299, p < 0.002).

In our analysis, we found that increasing video length had a negative impact on the IVORY score in Section B (technical aspects). This section includes questions that assess the video based on its duration, so longer videos are expected to have lower scores in Section B. Conversely, scores for Section D (surgical procedure) increased significantly with video length, likely because longer videos allowed for more detailed descriptions of the surgical process. However, the total IVORY score was negatively affected by longer video length in the correlation analysis, suggesting that the extended duration of some videos may not have been used effectively. In contrast, video duration was not identified as a significant predictor in the regression model, which may indicate the influence of potential interactions or the effect of other confounding variables.

Videos with a higher number of likes performed better in Sections B and D of the IVORY score, suggesting that providing technical details and thoroughly explaining the surgical procedure may enhance a video’s appeal. Furthermore, a significant positive correlation was observed between the number of likes and LAP-VEGaS scores, indicating that higher-quality videos tend to receive more viewer approval. This relationship was also confirmed in the linear regression model, where the number of likes emerged as a significant positive predictor of LAP-VEGaS scores (B = 0.008, p = 0.002), reinforcing the association between perceived video quality and viewer engagement.

A significant negative correlation was found between dislikes and Section E, indicating that videos lacking critical organ-specific components (such as the demonstration of essential steps in the surgical procedure) were more likely to attract dislikes. The like rate was positively correlated with Section E, meaning that videos with well-executed organ-specific sections were associated with higher like rates and fewer dislikes.

Older videos generally received lower quality scores, and this trend was supported by both correlation and regression analyses. In our study, the video upload date was significantly negatively associated with both IVORY and LAP-VEGaS scores (p < 0.001). Linear regression analyses further confirmed this relationship: video upload time was a significant negative predictor for both LAP-VEGaS (B = − 0.001, p < 0.001) and IVORY (B = − 0.001, p < 0.001) scores. These findings suggest that older videos may have lower technical and pedagogical quality, possibly due to limitations in recording equipment, editing capabilities, and the absence of standardized educational video guidelines at the time they were made. Interestingly, this pattern had not been consistently observed in previous IVORY-based studies, highlighting the potential impact of changing multimedia standards on perceived educational quality [1, 2, 18].

Inter-rater reliability is essential when assessing scoring systems such as IVORY and LAP-VEGaS, especially in studies involving subjective evaluations. In our research, Cohen’s Kappa values showed good agreement for items 6, 7, and 9 of the LAP-VEGaS score, while the other items demonstrated excellent agreement. For the IVORY score, item 6 had good agreement, item 14 showed moderate agreement, and all remaining items showed excellent agreement. The variability observed in Item 14 could result from differences in how raters interpreted and segmented the videos into distinct surgical steps, which may reflect the subjective nature of the scoring criteria. Overall, both scoring systems demonstrated high inter-rater reliability, with intraclass correlation coefficients (ICCs) above 0.75. These results align with previous studies using similar video assessment tools, which have reported acceptable reliability levels when raters are properly trained and scoring criteria are well-defined [24, 28].

A review of the literature on YouTube and otolaryngology reveals that the focus has primarily been on evaluating patient informational videos [29,30,31]. The evaluation of surgical training videos has only recently gained attention [1, 2, 18, 28, 32]. While research on surgical education videos is fairly common in urology and general surgery, there have been fewer studies in otolaryngology.

In our study, the IVORY scoring system was modified to better suit the context of YouTube-based educational videos and the specific features of endoscopic type 1 tympanoplasty and myringoplasty procedures. For example, organ-specific criteria were adjusted to emphasize key video quality elements relevant to these surgical techniques. Similar modifications have been made in previous studies evaluating videos from various surgical fields [1, 2, 18]. Although such adjustments may reduce direct comparability with research using the original IVORY framework, they enhance the relevance and usefulness of the scoring criteria for our particular procedure. This customized approach allowed for a more detailed and context-aware assessment of video quality.

While this study primarily centered on objectively assessing video quality, it is also crucial to consider the broader context of content creation and user behavior on platforms like YouTube. Although content creators do not disclose their specific motivations for uploading surgical videos, it can be assumed that the videos—many of which are excerpts from live surgeries—mainly target an audience of otolaryngology residents and specialist physicians rather than patients seeking general information. These videos may serve various purposes, such as educational uses, showcasing surgical techniques, or generating income or visibility through video content. Regardless of the original intent, such videos can still offer educational value by demonstrating surgical techniques, anatomical landmarks, the use of new surgical instruments, procedural tips, or aspects of training that may have been insufficiently covered during residency. In a survey of 70 surgical residents, medical students, and faculty surgeons, 95% of participants reported regularly watching surgical videos before performing surgeries, with YouTube being the most popular platform. YouTube’s widespread accessibility—available as a mobile app on nearly all smartphones, free of charge, and open to global content upload and viewing—likely explains its popularity among surgeons as an on-demand educational resource [33].

Within the framework of widely accepted educational theories such as Bloom’s taxonomy and Miller’s pyramid of clinical competence, watching high-quality surgical videos can support lower-level cognitive objectives, including knowledge acquisition, comprehension, and recognition of procedural steps. Visually well-designed, structured, and pedagogically aligned videos help develop mental models, especially for learners in the early stages of surgical training [34,35,36]. The LAP-VEGaS and IVORY video assessment systems are valuable tools for evaluating the presentation quality of such materials and generally align with approaches like Mayer’s Cognitive Theory of Multimedia Learning. For instance, items related to the structured presentation of surgical steps and use of visual aids reflect Mayer’s segmenting and signaling principles, which facilitate learner attention and retention. Similarly, videos with minimal extraneous content and clear narration adhere to the coherence principle, reducing cognitive overload. However, these systems seem to fall short in capturing more comprehensive pedagogical dimensions, such as clearly defined learning outcomes, assessment of learners’ cognitive engagement, and measurement of educational effectiveness. Therefore, we believe that to more holistically define and evaluate educational quality, these scoring systems should be more closely integrated with advanced learning theories. Future scoring frameworks may benefit from incorporating validated educational metrics that align with broader instructional design and multimedia learning principles.

In European countries, otolaryngology residency training is based on the core curricula and logbooks outlined by the UEMS ORL Section and Board training requirements [37]. Currently, these programs do not include educational objectives related to using videos as instructional materials, nor do they cover training in video assessment, editing, or production. However, every resident is also a potential peer educator and future trainer. Active participation in the learning process is essential for reaching higher cognitive levels of learning. Activities like producing, editing, and narrating educational videos can foster deeper understanding by encouraging learners to synthesize and organize knowledge while taking on a teaching role. Familiarity with video assessment criteria is also helpful for creating new, high-quality content. Supervised video creation integrated into surgical education curricula may effectively bridge passive observation and active development of clinical skills. We believe future research should examine the role and impact of such video-based instructional strategies within structured training programs.

This study, to the best of our knowledge, is the first to evaluate the quality of endoscopic type 1 tympanoplasty and myringoplasty videos. Previous studies have generally focused on total IVORY scores, with little attention to section-specific analysis. We believe that analyzing videos segment by segment is essential, as viewer behaviors, view rates, likes, dislikes, and comments have been linked to specific parts of the videos. By focusing on these sections, video creators can potentially reach a larger audience and enhance video quality. We also recommend developing and widely adopting a specialized grading system for otolaryngology, instead of relying solely on general video scoring systems.

There are some limitations to our study. One limitation is that videos were selected solely based on their English language and a minimum view count. While these criteria were chosen to ensure accessibility, relevance, and comparability of content, they may have introduced selection bias by excluding potentially high-quality videos in other languages or with limited exposure. Using only English content may especially underrepresent surgical techniques from non-English-speaking countries. Similarly, restricting inclusion to videos with over 1.000 views might exclude recently uploaded or niche instructional videos that have not yet gained widespread visibility. Our research focused only on videos from a single platform (YouTube), and other platforms were not considered. Although YouTube offers broad accessibility and convenience for learners, it also has inherent limitations as an educational platform. Content on YouTube is not peer- reviewed, and the qualifications of content creators are often not disclosed, raising concerns about the accuracy, safety, and educational quality of surgical videos. YouTube’s engagement-based algorithm tends to favor videos with high watch time or user interaction, metrics that do not necessarily reflect educational value. As a result, newly uploaded yet high-quality videos, especially those made by academic institutions or experienced educators, may be overshadowed by more popular but less pedagogically sound content. While all analyzed videos were recorded during surgeries, they are likely to be clicked, liked, and commented on by viewers who are not necessarily healthcare professionals. This cycle, where popularity is driven by engagement rather than instructional merit, may limit learners’ access to the most relevant and well-prepared material. We did not formally assess or verify the credentials of video uploaders. It is plausible that content uploaded by experienced surgeons or academic institutions may differ in quality from that shared by non-experts or laypersons. Additionally, the motivations behind uploading these videos may not always be educational. As Luu et al. noted, the likelihood of uploaders knowing the IVORY and LAP-VEGaS guidelines is quite low [24]. Video uploaders were evaluated based on criteria they probably did not consider when creating their content. Another limitation is the lack of external validation for the modified IVORY scoring system. While modifications were tailored to better reflect the characteristics of endoscopic tympanoplasty and myringoplasty videos on YouTube, the newly added or omitted items have not yet undergone independent validation. Future studies should aim to assess the construct validity, reliability, and applicability of these modifications across different datasets and surgical procedures, while also expanding to multilingual content and exploring other platforms or institutional video libraries to gain a more comprehensive understanding.

It’s been a long-accepted reality that with age comes increased inflammation – so widely accepted it’s been dubbed “inflammaging.” With this increase in age-related chronic inflammation also comes serious health concerns, such as cardiovascular disease and Alzheimer’s. But according to new research, inflammaging isn’t as universal of an experience as previously thought.

Published today in Proceedings of Royal Society B, “Inflammaging is minimal among forager-horticulturalists in the Bolivian Amazon,” the work highlights little inflammaging in one non-industrialized community, and notably found an increase of inflammation with moderate levels of modernization in another.

Led by Jacob Aronoff – a postdoctoral research scholar at Arizona State University’s School of Human Evolution and Social Change, affiliate with the Institute of Human Origins and a member of the Center for Evolution and Medicine – the study looked at two communities in the Bolivian Amazon: the Tsimane and Moseten. 

The Tsimane are a community of more than 17,000 people across 90 villages in the lowlands of the Bolivian Amazon. Living a hunter-farmer lifestyle, their everyday life is very similar to human life prior to the Industrial Revolution. This offers a unique glimpse into the health and aging processes for humans before modern-day influences came into play. Previous research has shown that they have the healthiest hearts and lowest rates of Alzheimer’s and dementia in the world.

Benjamin Trumble, senior author on the article and professor in ASU’s School of Human Evolution and Social Change, serves as the co-director of the Tsimane Health and Life History Project. The group has a longstanding relationship with the Tsimane to collect demographic and biomedical data, as well as helps to provide medical care for the community – a relationship that has been in effect for more than 20 years. 

This latest look into our human past set out to determine if the inflammation we experience in old age is a universal, human experience. 

To see if they develop inflammaging, we measured a collection of cytokines in a sample of older Tsimane adults to see if they increase with age – we found minimal increases with age.”

Jacob Aronoff, postdoctoral research scholar at Arizona State University’s School of Human Evolution and Social Change

To deepen their findings, the researchers also examined the Moseten. Although genetically very similar to the Tsimane, the Moseten underwent significant cultural change beginning 300 years ago when Jesuit missionaries settled among them.

“They’re still the same genetic group, same language group, but the Moseten now have running water, electricity and indoor plumbing,” said Trumble, who is also a research scientist with ASU’s Institute of Human Origins and core faculty of the Center for Evolution and Medicine.

“They’re kind of in an in-between place where they aren’t as industrialized as people living in the U.S., but they aren’t as traditional as a population like the Tsimane that’s still living much more like most of our human ancestors.”

This in-between stage of modernization provides an interesting opportunity of comparison for the researchers.

“We measured them together in the same lab, using the same technology, and we found clearly more pronounced inflammaging in the Moseten, suggesting that inflammaging – to a large extent – is a product of industrialized lifestyles,” Aronoff said.

Inflammation isn’t the guarantee with age as previously thought. While more research is needed, it does appear to largely be impacted by environmental and lifestyle factors, such as diet and exercise. It also shows that even slight modernization has an impact on deviating the human body from its ancestral path. 

“For 99% of human history we were physically active hunter gatherers. Now with sedentary urban city life we are basically operating outside the ‘manufacturer’s recommended warranty’ right now,” Trumble said. 

“By working with populations that are living a more traditional lifestyle, we can get a better idea of what the baseline for human health is.”

Other possibilities could be high parasitic and pathogen exposure, something lacking in industrialized communities, but common for the Tsimane. While more research is needed, the immune system response developed from parasitic exposure may play a role in the Tsimane’s lack of age-related inflammation. 

“We’ve eliminated most of our parasites, and that’s a good thing. We should keep it that way,” said Trumble.

But there may be a way we can harness the potential without the negative impact. 

“One of the things that we could do in the future, potentially, is instead of, say people getting infected with hookworm, we could figure out what are the proteins on the surface of hookworm cells – and what if we could turn that into a drug that people could take and trick our immune system. Our immune system would think we had that problem, and then it would develop differently to fight that off.”

Much like how we utilize vaccinations for viruses like the flu, where a controlled pathogenic exposure boosts an immune system response to fight off a natural exposure, the same may one day be true for our age-related inflammation.

Ultimately, though, there is no “silver bullet,” according to Trumble, as lifestyle and diet are also likely major contributors to inflammaging. 

“We have future studies underway to look at diets, physical activity and infectious exposures that the Tsimane are infected with that can have these anti-inflammatory effects. We’re going to have to do a lot of future studies to figure out what, exactly, are all the factors and how they work together,” explained Aronoff. 

Study area and population

This cross-sectional study, nested within a cohort study, was conducted in May–June 2022 and included 990 participants aged 18 to 88 years living in 21 villages near Sibiti, Republic of Congo. Participants had been previously screened for Loa microfilaremia [20]. For the current study, individuals with blood microfilariae detected in 2021 were matched for sex and age (± 5 years) with two amicrofilaremic individuals from the same village. Detailed description of the study population has been published previously [8, 21].

The sample size for the underlying cohort study (n = 990) was calculated to provide 80% statistical power to detect an increased risk of malaria (1.4-fold) and pneumonia (2.4-fold) among microfilaremic compared to amicrofilaremic individuals, based on the hypothesis that loiasis may impair splenic function and thereby increase susceptibility to infections. However, due to the lack of prior data, the sample size was not calculated to evaluate differences in renal outcomes.

Participation in the study required informed consent from all individuals. The research was approved by the Ethics Committee of the Congolese Foundation for Medical Research (036/CIE/FCRM/2022) and by the National administrative authorities of Congo (376/MSP/CAB/UCPP-21).

Sociodemographic and exposure covariables

Data on age, sex, anthropometric measurements (weight, height, and body mass index—BMI), and tobacco use were collected from each participant. Blood pressure was measured supine after 10 min rest. High blood pressure (HBP) was classified into three stages (see Table 1) and mean arterial pressure (MAP) was defined as (frac{{{text{Systolic BP + 2 }} times {text{Diastolic BP}}}}{{3}}).

Laboratory procedures for parasitic infections

Fifty µl of capillary blood were collected by finger-prick between 10 a.m. and 4 p.m. (to take into account the day and night fluctuation of Loa MFD) to prepare thick blood smears (TBS) which were then Giemsa-stained, and examined at 100 × magnification by experienced technicians to count Loa and Mansonella perstans mf. Each TBS was read twice; the arithmetic mean was recorded. Prior exposure to Onchocerca volvulus was assessed using the antibody detecting Onchocerciasis rapid test targeting Ov16 antigen (Drugs & Diagnostics for Tropical Diseases, San Diego, USA). Two skin snips were taken from seropositive individuals using a 2 mm Holth punch, incubated in saline at room temperature for 24 h and examined microscopically to count the emerged mf. O. volvulus MFD was calculated as the arithmetic mean of the two counts, expressed per snip.

Schistosoma haematobium infection was investigated in participants with haematuria detected by urine dipstick. Positive cases underwent urine filtration, Lugol staining, and microscopic examination for eggs. Soil-transmitted helminths (STH) were identified via microscopic examination of morning stool samples, transported within 6 h and processed immediately or after overnight storage at 6 °C. Stool smears were prepared using the Kato-Katz method and examined at 40 × magnification. For asymptomatic Plasmodium infection, thin blood films from venous blood (heparinized tube) were stained with RAL 555 (RAL Diagnostics, Martillac, France) and examined microscopically. An indirect ELISA was used to quantify the Immunoglobin G (IgG) antibodies levels against P. falciparum antigens [22].

Biological examinations

Creatinine levels were measured for each patient in whole blood with a point-of-care device (iSTAT-1; Abbott Point of Care, Princeton, NJ, USA). For logistic reasons, glycated haemoglobin (Hb1Ac) and fasting serum total cholesterol level, triglycerides, HDL, and LDL were only measured in a random subset of patients, using a point-of-care device (Afinion 2, Abbott Rapid Diagnostics, Bièvres, France). Eosinophilia and lymphocyte counts were conducted using the HemoCue WBC DIFF system (HemoCue AB, Ängelholm, Sweden).

Arterial stiffness assessment

Arterial stiffness was assessed through finger-toe pulse wave velocity (PWV) using the pOpmètre device (Axelife SAS, Paris, France), which records pulse waves via two infrared photodiode sensors at the finger and toe. This method is a validated, non-invasive alternative to carotid-femoral PWV, which requires skilled staff and femoral artery access [23].

Outcome: chronic kidney disease

Ultrasound examination

The US examination of the kidneys was performed by experienced physicians (VD, LR) using a CX-50 device (Philips Medical Systems, Suresnes, France). Measurements included height, width, length. A second reading of the digital images (DICOM files) was performed to confirm and characterize kidney parenchymal or structure abnormalities (pyelocaliceal dilatation, cystic, or other description).

Urine collection and dipstick analysis

Each participant provided a morning midstream urine sample, following instructions from a trained nurse. Urinalysis was performed immediately using dipsticks (Reactif 10SL Urinalysis Strips, 41101-M, Nal von Minden, Moers, Germany) to detect proteinuria and haematuria. A single physician interpreted the results and did a second confirmatory dipstick if the initial result was positive. No discrepancies were observed. Haematuria was assessed as negative, traces, + , +  + , or +  +  + . Positive cases (≥ 1 +) underwent urine filtration and microscopic examination for S. haematobium eggs. Proteinuria was classified as negative, traces (< 0.3 g/l), level–1 (0.3–1 g/l), level–2 (1–3 g/l), or level–3 (> 3 g/l). Albumin-to-creatinine ratio (ACR, mg/mmol) was measured for proteinuria ≥ level–1 using the Afinion 2 device.

Estimated glomerular filtration rate (eGFR) and chronic kidney disease (CKD) classification

Given limited data on creatinine distribution and CKD in our population, we applied two formulas. First, the 2009 CKD-EPI equation without ethnicity factor, as current recommendation [24, 25]. Second, the EKFC equation, a newer formula more robust across all ages [26, 27]. Only one published Q-value (median normal creatininemia) exists for Central Africa [28], based on 494 urban individuals [25]. Therefore, we estimated our own Q-values by calculating median creatinine levels in individuals without HBP or renal abnormalities (proteinuria or haematuria). CKD-EPI and EKFC eGFRs were expressed in ml/min per 1.73 m², and classified per KDIGO (Kidney Disease: Improving Global Outcomes Guidelines) categories [29]. Renal abnormalities (RAb) were defined as ACR > 3 mg/mmol or ≥ 1 + haematuria, excluding ultrasound-confirmed causes (9 cases of pyelocaliceal dilatation suggestive of lithiasis were excluded, as the associated haematuria was most likely of urological rather than nephrological origin and thus not indicative of intrinsic renal disease).

Statistical analysis

Continuous variables with normal distribution were presented as mean ± standard deviation (SD); non-normal variables were reported as median (interquartile range). Explanatory variables included: age (continuous), sex (male/female), tobacco use (yes/no), MAP (continuous), PWV (≥ 12 vs. < 12 m/sec), lymphopenia (< 1200/µl), hypereosinophilia (> 1500/µl), Ascaris lumbricoides and/or Trichuris trichiura (present/absent), Loa MFD (0, 1–7999, 8000–19 999, ≥ 20 000 mf/ml), anti-Plasmodium falciparum IgG (quartiles), and Plasmodium smears (negative/positive). BMI was not included since anthropometric parameters are integrated into eGFR estimations. Lipid profiles and diabetes were not included due to substantial missing data (see Results). The PWV cutoff (12 m/sec) reflects its established association with organ damage [30]. HIV status was unknown, but lymphopenia < 1200/µl was used as a proxy.

In our study, 25% weighed < 50 kg (10% < 45 kg, range: 30–120 kg), 25% had a height < 157 cm (10% < 152 cm, range: 141–190 cm), and 25% had a BMI < 18.9 kg/m² (10% < 17.8, range: 13.2–47.7). Given this heterogeneity, we chose to apply Dubois body surface area (BSA) correction to both CKD-EPI and EKFC equations to better assess associations. eGFR was calculated with CKD-EPI and then de-indexed using individual BSA via the Dubois formula: BSA = 0.007184 × Weight(kg)^0.425 × Height(cm)^0.725, resulting in CKD-Dubois and EKFC-Dubois values (ml/min).

First, a saturated linear regression model on eGFR was performed. Because KDIGO-CKD staging could not be used directly in the regression analysis—due to the necessity of adjusting for BSA and the small number of participants in advanced CKD stages, which limited statistical power—we defined three alternative severity thresholds based on the distribution of eGFR values in our study population to investigate a potential gradient effect of CKD severity. These were the median (Cutoff-1), the 10th percentile (Cutoff-2) – corresponding to the global prevalence of CKD –, and the 2nd percentile (Cutoff-3) –reflecting the prevalence of advanced CKD. Thresholds were calculated separately for each equation. Given that the presence of RAb is an essential component of CKD staging, it was incorporated in the categorization and thus the categories were: “ ≥ Cutoff-1 & no RAb”, “ ≥ Cutoff-1 & RAb”, “Cutoff-1 – Cutoff-2 & no RAb”, “Cutoff-1 – Cutoff-2 & RAb”, “Cutoff-2 – Cutoff-3 & no RAb”, “Cutoff-2 – Cutoff-3 & RAb”, “ < Cutoff-3 & no RAb”, “ < Cutoff-3 & RAb”.

Due to the ordered nature of outcome variables, ordinal logistic models were initially considered. However, they were rejected after a Brant test indicated a proportional odds violation. Instead, multinomial logistic regression was used. A manual stepwise backward selection (P < 0.100) was applied to the saturated model via the likelihood ratio test. To prevent convergence failure, Loa MFD was re-categorized into three groups (0, 1–19 999, ≥ 20 000 mf/ml). Finally, potential interactions between Loa MFD, age, sex, and eosinophilia were assessed using the likelihood ratio test. After finalizing the model, we extracted risk probabilities. We then estimated the population attributable fraction (PAF) from a logistic model including the final significant variables identified (age, sex, and Loa microfilaremia as a binary variable) using the KDIGO CKD classification with the EKFC formula.

All statistical analyses were performed using Stata 18 (StataCorps LP, College Station, Texas, USA).