Adults with attention deficit hyperactivity disorder (ADHD) represent a heterogeneous group with both strengths and difficulties associated with the diagnosis. An online intervention attuned to their needs may improve their everyday functioning. When designing online interventions, it is important to adapt the therapeutic content to the values and needs of the target group.This paper describes and evaluates a participatory process used to produce content for an online intervention for adults with ADHD by producing video vignettes clarifying core training principles grounded in the participants' everyday experiences.We report on the qualitative data from 2 research phases: the design and evaluation of video vignettes for an online intervention. In the first phase, 12 adults with ADHD, 2 clinicians, and 2 research assistants participated in the production of video vignettes for the online intervention. In the second phase, participants (n=109) gave feedback on the videos as part of a clinical trial of the intervention. A subgroup (n=7) was interviewed in-depth regarding their experiences with the videos. The qualitative data were analyzed using thematic analysis.In the first phase, the participants with ADHD contributed with experiences from challenging everyday situations. In the process, we navigated between therapeutic principles and the participants' experiential perspectives to create content relevant and consistent with the target group's values and experiences. In the second phase, we identified 3 themes related to the participants' experiences and interpretation of the video vignettes: (1) recognition of ADHD-related challenges, (2) connection with the characters and the situations, and (3) video protagonists as companions and role models for change.A participatory design process for designing online mental health interventions can be used to probe and balance between the therapeutic principles defined by clinicians and the participants’ experiences with mental health issues in the production of therapeutic content. In our study, the inclusion of video vignettes in an online intervention enabled a contextualized and relevant presentation of everyday experiences and psychosocial factors in the life of an adult with ADHD.ClinicalTrials.gov NCT04511169; https://clinicaltrials.gov/ct2/show/NCT04511169 Interactive technology has the potential to enhance mental health treatments by improving their access, affordability, and effectiveness . When deIn general, online interventions with guidance from a supporter  result in higher engagement and improved treatment outcomes when compared to unguided interventions ,12. ThisAdults with attention deficit hyperactivity disorder (ADHD) are expected to benefit from an unguided online intervention, as it is a low-cost, easily accessible, and flexible alternative. This is related to the disorder’s frequency, with an estimated prevalence of 2%-7% ; heterogQualitative studies of everyday experiences of people with ADHD provide insight into the lived experiences of having ADHD and demonstrate how the term “people with ADHD” refers to a heterogeneous group and that there are several positive traits attributed to the disorder. In a study by Holthe and Langvik , a groupPublic stigma causes additional challenges for people with ADHD -38. StigDisclosures of mental health in social media have challenged public stigma and empowered people with mental health issues -48. VisuThis study goes beyond the focus on the management of core symptoms and considers everyday experiences of adults with ADHD in the design of an online intervention. We explored how a participatory approach can ensure that the participants’ perspectives are included in the design of psychoeducative therapeutic content in mental health interventions. With this aim, we directly included adults with ADHD in the design process to empower their perspective through active participation. In this study, their experiences were ultimately represented as video vignettes in an online intervention, which aimed at communicating the therapeutic principles and coping techniques. A further aim of this study was to explore how participants in an online intervention experienced and made sense of the video vignettes.The qualitative research presented in this paper was conducted in 2 phases: (1) a participatory process for the design of video vignettes as psychoeducative, therapeutic content for an online intervention for adults with ADHD; (2) the collection and analysis of qualitative feedback on the video vignettes during and after a clinical trial of the online intervention.The intervention addressed in this paper, MyADHD, was designed as a modular web-based course. Once a module was opened, the participant could browse freely within all the available modules and revisit content as they saw fit. MyADHD is comprised of 7 modules representing different topics . Each of the first 6 modules included psychoeducative information, skill-building exercises, and coping techniques for everyday challenges for adults with ADHD. Additionally, each module featured 2 video vignettes that explained the use of coping techniques and contextualized their suitability and application.person-based approach  was like seeing myself [emoji: Face with Tears of Joy].”As the videos portrayed relatable characters and situations because of their ADHD symptoms, it is interesting to investigate their level of credibility. In the interview, Charlie explained that seeing the way that the characters handled challenging situations resembled similar experiences they had:You can see the experience from [the videos], and it is not made in such a way that seems fake. You know...you can watch a feature film and you can see that it is fake. This is realistic.The content of the video appeared credible to Charlie, and they went on to explain how seeing the videos made it possible to see their own actions in a new light:[The videos are] done in a way that allows me to see my negative things without it becoming uncomfortable. I do not feel offended.Elliot shared how the situations displayed in the videos reminded them of concrete experiences and similar situations, such as driving off without noticing or remembering the coffee cup on the roof of the car before it is too late. However, regarding the experience with having ADHD, Elliot was not convinced that the videos gave a credible impression of the felt experience. Elliot said that the videos do not capture the turmoil of having a family and explained how ADHD is heritable and, thus, something their children struggle with as well:I think [the videos] fall flat. Because it...it does not say anything about the seriousness, in a way, how fierce those [situations] actually are [...] So, I have been sitting in the mornings [after the family is out for work or school] crying. And it is not something I had been doing much before. And I am not afraid of emotions per se, but I am not used to crying. But I have been left behind with such...deep, deep despair and, uh...crying after being called the most insane things by my teenage daughter and her brother, who is a little younger.The way the participants related to the videos depended on their experiences with similar situations. Elliot criticized the video of Erik's morning routine, based on a personal comparison.The characters in the videos were portrayed by actors that followed an agreed-upon script. As such, the videos communicated a certain understanding of what it means to have ADHD. One participant wrote about the first video with Nora:I do not identify with the character; I get the feeling she was chosen to “look like” she has ADHD. However, some parts of what she said were more relatable.P #15The participant distinguished between what is shown and what is said. The use of quotation marks can be interpreted as an ironic remark, and, therefore, such a depiction  is an inconceivable feat to truly accomplish. Looking like something includes imitating the mannerisms supposedly associated with it.By the third module, the same participant had now changed their mind about whether Nora as a character was relatable:This time, the video with Nora was “spot on.” It is definitely like me.P #15They went on to describe how Nora’s postponing chores was relatable. Here, the participant qualified the character of Nora as realistic because what she does is what the participant does. However, the participant did not revisit the previous theme of “looking like ADHD.” Elliot, who said the videos did not depict their experiences with ADHD accurately, was much more positively inclined to how Erik represents a “person with ADHD”:He is like many, many others with ADHD. He is a dude that lives a family life and tries to handle his shit. He is not a caricature. He is...a normal dude, and that is nice.Overall, the participants did not report a feeling of being misrepresented as a caricature of people with ADHD, except for participant #15 who gave a statement that could be interpreted in that direction.In this theme, we take a closer look at how the participants related socially and emotionally to the characters and their situations.Alex said that the videos showing how to apply the techniques in corresponding situations were motivating:I see that they can cope or make a change. [...] It inspires and motivates me to use the techniques shown in the videos, and the othersthat are not covered in videosFurthermore, Alex said that the videos show how the techniques are meant to be used:Of course, I could have made the connections [between the technique and their intended outcomes] myself, but there is something extra with those videos: You get to seehow it is doneThus, by setting an example of how to use a technique in the videos, the participants further understood the application of the technique in a certain context.The video in which Nora is distracted during housework by a phone call from a friend who needed help purchasing a new dress (see example 2 in the Phase 1 Results section) received varied interpretations by the participants. Dylan speculated that Nora’s decision to go shopping with her friend was an act of procrastination because shopping with a friend is generally a more attractive option than housework:It's a lot more fun to be with your friend, [...] it is really just that simple, that you do what is fun, right? But then things are constantly postponed, and then you come home, like Nora, to a messy apartment.On the contrary, another participant related personally to Nora’s video, having a bad conscience when putting her needs before an important task:[I] see that personality also plays a role here. [To what extent] do you get a bad conscience for your friend if you postpone or drop her [need for help]? I, myself, have had to do a major cleanup in my head over the past year to make more room for myself and my chores. It feels a little selfish and it is hard. But necessary.P. #81Similarly, Dylan explained the turmoil that postponing chores can lead to:And then, for me, for example, that's when the negative self-talk begins: “That is what you should have done.” And then, you start cleaning, and then, it becomes a very big thing, a very negative thing.The participants emphasized different aspects of the videos that made sense in relation to their own experiences in social situations where dilemmas can create feelings of uneasiness. Participant #81 and Dylan agreed that Nora represents how the negative outcomes of the dilemma commonly are turned inwards, either towards the self as feelings of guilt (#81) or as the negative self-talk described by Dylan. The participants showed empathy with the characters and used the situation in the video to contemplate their own experiences with everyday challenges and self-stigma.We now turn to how the videos aroused negative feelings and recollections of past experiences in some of the participants. Alex found similarities between his or her own life and Erik’s morning routine in the videos for Module 2 (Breathe):It is a situation I want to handle better. I should be able to do it, a few minutes for myself without an audio file, where I could breathe and relax the way he did in the video. I have not managed that yet, because I do not remember to do it.Alex saw that Erik handled the situations in a better way because he had internalized techniques for controlled breathing to alleviate stress. Alex, on the other hand, said that they “should be able to do it,” but has not yet been able to implement the technique in everyday life. Alex needed a reminder for the breathing exercise, which seemed to be disappointing in comparison to the character Erik’s apparent mastered application of the technique.In Module 6 (Acceptance), Erik is in a video conference planning a party with his friends. Erik loses focus and, when asked a question, becomes agitated and slams the laptop computer shut. Participant #62 wrote in the evaluation of this module:[It] is useful to have a reminder to be kind to yourself. [I] realize that I still have a way to go when it comes to self-acceptance.However, in the evaluation of the videos, the participant stated that “I thought this video was painful to watch, I cried afterward.” In the posttrial evaluation of the entire intervention program, the participant wrote that “[...] I could not complete the module [on acceptance] after the first video.” The negative experience with the video impeded the completion of the module, although this participant had identified it as useful. Unfortunately, we lack additional information on the participant’s experience of the situation. However, this example of adverse effects shows how videos that depict sensitive issues can be painful for participants that have lived such issues.In this theme, we have seen how the participants reacted to the videos, sometimes by showing empathy with the characters and other times reflecting on their similar challenges.The videos were motivating for the participants when there was a certain agreement between the depiction of ADHD in the video and the participant’s own experiences. In this theme, we explore how some participants related to the protagonists as role models for change.One participant wrote the following as feedback to the videos that were shown in Module 6 (Acceptance):For me, the videos are the best! At the same time, it hurts. But they show an educated, well-versed lady who struggles with the same things as me, and this is motivating.P #50Here, the participant described how they were motivated by the protagonist Nora, despite the videos provoking negative feelings. For participant #50, Nora impressed and motivated them. The protagonist appeared to be a “educated, well-versed lady” at the same time as she struggled with relatable challenges in everyday life.The protagonists in the video served as role models for the motivation of the participants. Participant #81 found it helpful to see that others had similar thoughts and actions and used Nora as starting point for a reflection on their present situation:Nora says that she will be better at using her time more constructively. [And] she will not be impatient if she does not see results right away. It is the same with me. [...] [I] do not have everyday routines yet. [I have a] new job, a new place to live, and I am looking for a romantic partner. So, making routines can be a bit of a challenge now.Even though the participant does not explain how Nora influenced their perspective, their attitude toward their own life is influenced by knowing Nora as a character.Participant #60 further elaborated on Nora being a role model, in the posttrial evaluation of the intervention program:My biggest challenge in everyday life is postponing boring things, and it was precisely the video with Nora where I recognized myself. I set goals in everyday life. Thus, I have pushed myself to do all these routine chores better than before. I tidy up the apartment more often. The dirty dishes do not stay that long; instead, I clean them daily. I do the laundry, hung it up. This has been better almost throughout the training program.It is striking how the participant’s reported improvements on everyday chores mirrored the challenges that Nora faces in the videos. The way that the participants addressed the protagonists shows that the videos contributed a social component to the intervention program.Another social response to watching the videos is reflected in the report of feeling less alone:It is good to watch the videos; it gives a feeling of not being alone when struggling with various things. And it gives me a sense of mastery in knowing I can do a lot of things that others are struggling with.P #19Alex found comfort in the videos:I was looking forward to the movie clips because they felt so familiar. I saw myself, and it was amazing — what can I say? — good to feel that others are like that too.Dylan, who struggled with feelings of low self-esteem and mental turmoil, found comfort in learning that others may feel the same way:It has actually been a huge relief to find out that there are others who have it just like you; you are not as unique as you thought!The experience of feeling less alone when struggling with everyday life was a relief for the participants. They learned about what it was like to have ADHD as an adult through participating in the intervention. For example, Dylan had little knowledge about ADHD, other than receiving the diagnosis and medication from their local psychiatric clinic, before participating. The study and the videos taught Dylan that their struggles with self-esteem and negative self-talk were something that others also experience.Finally, participant #74 wrote in the posttrial evaluation that seeing the characters live ordinary lives was a positive aspect of the intervention program:Seeing other adults with ADHD, who live ordinary lives, in the videos, has been very nice, and [...] the focus on the fact that there is a lot of positive [aspects of] the diagnosis. I live a very good life myselfemoji: HeartIn this study, we addressed the design of therapeutic content, in particular video vignettes, for adults with ADHD founded on the experiences of their peers. It was carried out as a participatory design study, followed by qualitative feedback from participants in a clinical trial of an online intervention.Our findings show that the video vignettes’ depiction of everyday situations resonated with the participants and, as a result, reflected their experiences. The participants recognized the situations and used the characters as role models for change.Personal narratives on social media have become an increasingly important and popular source of information about physical -48 and mThe use of video vignettes was an engaging feature of the MyADHD intervention, and by producing our videos, we could ensure that the content would abide by the therapeutic principles. Video as a design material offers diverse ways to contextualize narratives. For example, the choice of actors, location, set decoration, editing, and general style of the video lay the foundations for the viewer’s experience with the content. However, in our intervention, the protagonist Nora seemed to be “chosen to ‘look like’ she has ADHD,” as reported in theme 1 in the thematic analysis. This remark is timely because ADHD is associated with public stigma, often perpetuated in media reports -34. In tHonary et al  found thBased on our thematic analysis, we found that the participants perceived the protagonists Nora and Erik as characters. The participants related to them as examples of how ADHD symptoms may manifest in everyday life while being aware of the boundaries of the characters and understanding that they do not necessarily generalize the ADHD experience. Looking like someone with ADHD, however, can take many forms since people with ADHD represent a heterogeneous group with diverse characteristics and experiences. For example, the video content designed in this study is limited to a dichotomy between male and female ADHD. However, people’s gender identities are known to be fluid, implying that inclusive intervention content is needed. Future research should explore how we represent the diversity of mental health in online interventions. For example, including people with multiple marginalized identities as reported in former studies  is an eIn designing video vignettes that apply narratives of the everyday lives of people with mental health disorders, designers must be aware of the trade-off between preserving the authenticity and reinforcing stigmatizing characteristics of mental health. Using actors protects the identities of people with mental health problems, while, on the other hand, affects the authenticity and may contribute to stigmatizing caricatures of the experience of mental health.Online clinical health communication has been described as fact-based and prescriptive . In our In online interventions, exercises and coping techniques from CBT, DBT, and other therapies are presented through text, audio, or video; they guide the participant in successfully applying these techniques and self-managing their mental health. However, in the design of unguided online interventions, it is particularly important to consider how the techniques are presented. In this case, the absence of a therapeutic relationship places greater demands on the design of the therapeutic content. Exercises and techniques can be difficult to understand as they are intended. They presuppose the understanding of both the application and the relevance to one’s everyday life. For the intervention to be effective and meaningful, the exercises and coping techniques should be exemplified by everyday relatable situations. By doing so, the techniques can be transferable and implemented into day-to-day challenging situations. Seeing peers cope with challenging situations may enhance one’s sense of self-efficacy ,55.The video vignettes in MyADHD offer contextualization of difficult everyday situations in scenarios recognizable and relatable to adults with ADHD, based on their own experiences. For example, in the first video for Module 2  involved in the design of the video vignettes. This learning was developed within meetings, workshops, and film production sets. For example, clinicians would learn about specific difficult situations for the adults, whereas the participants learned how their experiences fit within a clinical viewpoint and boundaries for the management of ADHD symptoms. The film production team conceptualized these ideas into a video format. The video scripts would then be reworked under the other parties’ perspectives. The presentation of the video vignettes was further enhanced as engaging content by the skillful execution of the film production team. The video vignettes were, in a sense, grounded in the tacit knowledge  of the pThe design process of making video vignettes for the MyADHD was costly and time-intensive: It required resources for a film production team that would realize the vision of the participatory design process. However, we encourage the application of our process in the development of psychological online interventions that aim to create therapeutic content grounded in everyday contexts for their target groups. Similar to how health vloggers produce technically simple productions with consumer products , designers of content for psychological interventions can do the same.We suggest that resonance with the participant’s values and experiences is vital for this kind of content to be perceived as meaningful and further suggest that researchers and designers of online interventions should strive to achieve this in their efforts to produce narrative content that supports therapeutic principles.Person-centered approaches to design have been emphasized as essential to create content that is adapted to the target group’s shared values and experiences ,9. In thRegarding the involvement of people with ADHD in our process, we found, contrary to Yardley et al , that thThis qualitative study has limitations. First, in the clinical trial and the follow-up interviews, women were overrepresented compared to men. Thus, our findings may not be representative of men with ADHD. Second, the ADHD diagnosis was self-reported. Last, this is a qualitative study and thus does not ascertain the videos’ or the intervention’s clinical effects. Further details of the study design and dissemination of the effects and clinical outcomes will be reported in a separate publication.In this paper, we presented our process for designing video vignettes portraying challenging situations of living with ADHD, with the participation of and directed to adults with ADHD in a therapeutic context. Based on our findings, the approach of using an everyday lens and describing ostensibly mundane and everyday contexts in the videos was well-received by the participants in a clinical trial of an unguided online intervention. The videos provided rich and contextualized illustrations of life with ADHD, designed beyond the need for self-management in core symptoms. Applying a participatory approach when designing for online interventions, however, requires a balance between the lived experience as reported by the participants and the therapeutic expertise of the clinicians to be relevant to the target group.


Despite effectiveness in delaying the spread of the pandemic, frequent and extended disruption to children’s livelihoods have fomented new norms in which learning routines encounter immense change. In particular, increased sedentary e-learning engagement with electronic screens and exposure to stressful circumstances are likely to pose adverse risks for children’s vision development.This present study examines the link between near-sighted refractive error, and sedentary exposure to electronic screens, psychosocial stress level, and outdoor activities. A Rapid Survey Methodology (RSM) design was utilized to collect information on subject’s vision condition, sedentary electronic screen use, and level of psychosocial stress, in addition to detailed socio-demographic background characteristics.p-value< 0.050), while every 1 h • W m− 2 sr− 1 of illuminance-weighted electronic screen use per day is associated with 2.285 OR  increased likelihood of near-sighted refractive error. Higher level of psychosocial stress is associated with 2.441 OR  and 2.403 OR  increased likelihood of near-sighted refractive error. Frequency of outdoor activity is not significantly associated with increased likelihood of near-sighted refractive error .This study involves 2234 subjects enrolled in 1st to 6th grade in primary schools. Every 1 diopter hour increase in electronic screen use per day is associated with 1.036 OR (95% CI =1.024–1.047, Findings in this study show that many factors, including grade level and prior vision condition, contribute to increased risks of near-sighted refractive error during the COVID-19 pandemic. More strikingly, pandemic-related behavioral modifications such as lengthy sedentary electronic screen use and elevated levels of psychosocial stress are two critical channels affecting children’s eye health. The rapid rise in share of individuals affected by near-sighted refractive error, or myopia, has unfortunately coincided with the COVID-19 global pandemic declared by the World Health Organization (WHO) on March 11th, 2020. As of Aug 1st, 2021, more than 200 million confirmed cases and close to 4.3 million deaths were recorded in more than 200 countries/territories around the world [Globally, a common mitigation strategy to address widespread school-closure policies has been the adoption of remote e-learning engagements, through the use of electronic and telecommunication devices as means of learning at home . While pTo this end, eye health is important for children’s growth throughout life, and the state of visual acuity at a young age can have significant impact on visual development later in life. Existing studies have suggested that early decline in eye health is associated with elevated risks of developing glaucoma, macular degeneration, and other myopia-related complications that may lead to blindness later in life . In thisTo add, acute reduction of outdoor activity can also influence eye health in critical ways, via channels such as the lack of natural light exposure, decrease in depth of visual field, and more frequent eye strain as result of extended indoor near-work and dim-lighting . MoreoveIn this study, we set out to understand factors associated with risks of developing near-sighted refractive error among young children in China during the COVID-19 pandemic, focusing specifically on their socio-demographic traits and pandemic-led behavioral modifications, including sedentary exposure to electronic screens, psychosocial stress level, and outdoor activities.Teacher Daily. Rapid survey methodology (RSM) is a widely adopted data collection approach in developing countries that aims to maximize sample size within a relatively short and fixed timeframe, to allow for quick and timely monitoring of subject’s health status [Between the months of January and May of 2020, all primary schools were closed in China due to the COVID-19 pandemic, and remote e-learning arrangements were made available to all school-age children. In this context, this study utilizes a rapid survey design to capture the state of children’s vision during the first-wave of the COVID-19 pandemic, which was conducted between May 12th to May 18th, 2020 by a nationally-known education press, h status .The study was approved by the Shaanxi Normal University Institutional Review Board, and abided by ethics code of the World Medical Association Declaration of Helsinki. Informed consent for participation in this study was collected from parents/guardians of subjects electronically before commencement of the survey.Inclusion of subjects in this study were based on the following selection criteria: (1) could fully understand the questionnaire; (2) enrolled in 1st to 6th grade of primary school; (3) fully voluntary participation; (4) recorded only one response under the same IP address. A total of 2234 subjects satisfied the inclusion criteria and are included in the analytic sample.The survey questionnaire requires approximately 10–15 min to complete, and is intended to guide subjects in reporting demographic background, visual acuity, time use, and stress level during the nationwide school-closures. Importantly, subjects were guided to evaluate occurrence of near-sighted refractive error using the Lay Terms Approach, which anchors on a selection of easy-to-understand and age-appropriate vocabulary to young children, such as “blurry,” “foggy,” “squinting,” etc. . The que− 2 sr− 1), leveraging on prior evidence that had evaluated such weighted measures. Specifically, proximity-weighted eye use is computed based on average distance from electronic screens [In this study, we compute proximity-weighted eye use  and illuminance-weighted eye use . In this study, we adopt a two-stage analytic plan, where univariate analyses are conducted in the first stage, and multivariate logistic regression models are employed in the second stage. A Information on sample descriptive statistics, chi-square tests, and paired sample t-test are reported in the first analytic stage in order to evaluate the association between occurrence of near-sighted refractive error (dependent variable) and subjects’ socio-demographic traits. Results from multivariate logistic regression are reported in the second analytic stage as means to assess the risk likelihood of sedentary exposure to electronic screens, psychosocial stress level, and outdoor activities on occurrence of near-sighted refractive error (dependent variable).In Table − 2 sr− 1 per day (SD = 0.45). For assessment of psychosocial stress, 318 subjects (14.2%) reported as being “Apprehensive,” 375 subjects (16.8%) reported as being “Composed,” while 1541 subjects (69.0%) indicated as “Indifferent.” For frequency of outdoor activity, 414 subjects (18.5%) report 7 times per week, 288 subjects (12.9%) report between 4 and 6 times per week, 1123 (50.3%) report between 1 and 3 times per week, while 409 subjects report 0 times per week.Information on sedentary exposure to electronic screens is reported daily and in terms of proximity-weighted diopter hours and illuminance-weighted hours. On average, subjects in the sample indicate using electronic screens 11.04 dh per day (SD = 8.91) and 0.64 h • W m2 = 0.053, p-value> 0.050), grade , residential location , and frequency of outdoor activity . Second, those subjects reporting refractive error condition before start of the COVID-19 pandemic school-closures are more likely to also experience occurrence of near-sighted refractive error during the COVID-19 school closures . Third, subjects reporting occurrence of near-sighted refractive error on average indicate 3.64 dh  and 0.21 h • W m− 2 sr− 1  additional exposure to electronic screens per day than subjects who did not experience near-sighted refractive error. Fourth, subjects who report being under “Stressful” circumstances also indicate occurrence of near-sighted refractive error at higher proportions .In terms of univariate association between subjects’ occurrence of near-sighted refractive error and the above variables, several observations can be made. First, there is no statistically significant relationship between occurrence of near-sighted refractive error and sex  increased likelihood of near-sighted refractive error. On the other hand, every 1 h • W m− 2 sr− 1 of illuminance-weighted electronic screen use per day is associated with 2.285 OR  increased propensity in near-sighted refractive error.Across both Models 1 and 2, results show that e-screen use is positively associated with elevated risks of near-sighted refractive error. On the one hand, each additional diopter hour increase in electronic screen use per day is associated with 1.036 odds ratio (OR)  and Model 2 predicts 2.403 OR . Conversely, “Composed” level of psychosocial stress is associated with decreased risks in occurrence of near-sighted refractive error, with Model 1 predicting 0.671 OR  and Model 2 estimating 0.667 OR .In addition, across both Models 1 and 2, “Apprehensive” level of psychosocial stress is associated with elevated risks in occurrence of near-sighted refractive error, such that Model 1 predicts 2.441 OR , 1.455 OR , and 1.469 OR  respectively. Results are statistically similar in Model 2, such that the odds ratios are 1.428 OR , 1.522 OR , and 1.474 OR , respectively. Additionally, risks of near-sighted refractive error are also categorically higher for subjects reporting refractive error condition before start of the COVID-19 pandemic school-closures, evaluated at 3.853 OR  and 3.827 OR  for Models 1 and 2, respectively.Moreover, in both Models 1 and 2, results suggest that lower grade-levels are shown to exhibit higher risks of developing near-sighted refractive error. For instance, Model 1 estimates that odds ratios of 1st grade, 2nd grade, 3rd grade in relation to 6th grade are 1.335 OR , and so are the relationships for sex  and residential location .Noteworthy, both Models 1 and 2 concurrently predict that frequency of outdoor activity is not significantly associated with occurrence of near-sighted refractive error . According to World Health Organization eye health guidelines, daily use of digital electronic screens of more than 2 h is not recommended for young children [p-value< 0.050). Using multiple logistic regression, point estimates indicate that each additional diopter hour is associated with 1.036 OR  and every 1 h • W m− 2 sr− 1 is associated with 2.285 OR , increased likelihood of near-sighted refractive error. These results translate into sizable eye health risks considering that subjects report 11.04 dh and 0.64 h • W m− 2 sr− 1 per day on average, and highlights close-proximity of e-screen use as a main source of vision risk affecting children’s eye health.Results from the survey reveal that subjects, on average, use electronic screens 11.04 dh per day (SD = 8.91) and 0.64 h • W mchildren . More woNotably, these findings are consistent with emerging evidence that changes in behavior norms during the pandemic have created favorable myopigenic conditions which can have consequential adverse effects on eye health among school-age children , 27. In p-value< 0.050), while frequency of outdoor activity does not seem to correlate with elevated risks of refractive error . On the one hand, these findings are in line with recent investigations in confirming that children’s state of mental health during the pandemic can have influential effects on their physical health [In addition, this study also evaluated the extent to which psychosocial stress level and frequency of outdoor activity is related to occurrence of near-sighted refractive error. Particularly, heightened level of psychosocial stress is positively correlated with increased risk of developing myopic refractive error (l health , while cl health , and illl health , becauseNevertheless, there are a few limitations in this study that needs to be accounted for in future research. First, this study elected an RSM design in consideration of the time-sensitive, logistical, and public health circumstances that are unique to the COVID-19 pandemic. However, studies utilizing RSM are prone to nonrandom sampling bias due to the voluntary nature of study enrollment, which is nevertheless not entirely uncommon in other observational studies. Second, this study prompted subjects to evaluate vision status using the Lay Terms approach, instead of relying on eye specialist examinations. While the Lay Terms approach has been previously shown not to differ systematically from ophthalmologist assessments , future In conclusion, findings in this study show that the scale at which COVID-19 is affecting children’s lives, behaviors, and vision development is unprecedented. While some of these consequences are less noticeable than others, their long-term effects hold important weight in determining the status of children’s health and wellbeing for an entire generation to come, intervening in their vision growth during a critical yet delicate phase. In light of several education systems continuing to rely on remote distance learning modalities in on-going and future waves of the pandemic, findings in this study highlight the urgency of developing appropriate mitigation strategies to address the increasing likelihood of a global myopia crisis.


In this study, we introduce a new wrinkle method for intracorporeal anterior vaginal wall plication during sacrocolpopexy for pelvic organ prolapse (POP) aiming to decrease POP recurrence and postoperative vaginal wall mesh erosion. The wrinkle method was performed using robotic sacrocolpopexy (RSC) on 57 symptomatic POP patients. Sixty-six patients underwent conventional RSC before the development of the wrinkle method. Feasibility and perioperative outcomes were compared. The wrinkle method is not time consuming. The total operative time was shorter in the wrinkle group than in the non-wrinkle group; however, this was attributed to lower adhesiolysis in the wrinkle group. No differences were recorded in the mean estimated blood loss and complication rates between the two groups. In conclusion, although we were unable to confirm that the wrinkle method decreased POP recurrence and vaginal wall mesh erosion after RSC because of the short follow-up period, our preliminary findings are positive in terms of safety. Further long-term well designed randomized controlled trials are required to elucidate the benefits of the wrinkle method. Pelvic organ prolapse (POP) is a common condition in older women, with a prevalence of 41–50% in examination, and a probability of 12.6–20% to undergo surgery for POP before the age of 80 years ,4,5. SacMesh-related morbidity, including vaginal mesh erosion, chronic pain, and reoperation, is a crucial issue. The mesh erosion rate after pelvic reconstructive surgeries has been reported to be much lower in the laparoscopic approach (2–8%) ,13 than Risk factors associated with vaginal mesh erosion can be classified as mesh-related, patient-related, and surgery-related. Monofilament, macroporous, light-weighted, and soft mesh can decrease mesh erosion; however, smoking, the use of steroids, diabetes, premenopause, estrogen replacement therapy during postmenopause, and an advanced stage of POP can increase mesh erosion ,19,20,21The recurrence rate of POP after various types of reconstructive surgeries is reported to be as high as 30% ,29, whicWe propose a new “wrinkle method”, hypothesizing that this technique might decrease both anterior compartment recurrence and vaginal mesh erosion after SC. The wrinkle method consists of creating two or three rows of purse-string sutures with delayed absorbable monofilament suture material on the anterior vaginal wall and anchoring the mesh on the wrinkle .Using this method, we can expect not only a decrease in the anterior vaginal wall width but also a narrowing of the vaginal canal caliber . AnchoriThe aim of this study was to suggest a new “wrinkle method” for intracorporeal anterior vaginal wall plication during RSC and to evaluate its feasibility. We also compared the anterior compartment prolapse recurrence rates and perioperative outcomes in patients who underwent RSC with or without the new wrinkle method.Patients with pelvic organ prolapse quantification (POP-Q) stage III–IV who underwent RSC with or without the new wrinkle method for symptomatic POP between 1 January 2018 and 30 June 2020, with a follow-up (FU) period of at least 3 months were included in this study. The wrinkle method was initially developed in March 2019 by one surgeon (Lee S.R.) and applied to cases operated on between April 2019 and June 2020.We obtained the following data from each patient’s chart review: age, body mass index (BMI), detailed gynecologic, medical, and surgical histories, and POP-Q stage. We also collected the time of suturing for the creation of the wrinkle on the anterior vaginal wall by reviewing recorded surgical videos. Furthermore, we obtained the following surgery-related data: use of the wrinkle method, concomitant surgery, and total OT from skin incision to the completion of the skin closure including all the concomitant operations. Additionally, we collected data on perioperative outcomes, including estimated blood loss (EBL), any intra- or postoperative adverse events, length of hospital stay, postoperative fever within 48 h, and any complications related to the wrinkle method. Postoperative FU data for the recurrence of POP were collected as well. The diagnoses of POP, POP-Q staging, surgery, and postoperative FU were performed by a single urogynecologist (Lee S.R.). All surgical procedures were performed without modification with the same mesh and suture materials. The wrinkle method was applied in some cases but not in others. The physician was blinded to the use of wrinkle method during the postoperative FU examination; the data were collected by another gynecologist (Kim J.H.) and statistical analysis was performed by an independent statistician.® and da Vinci Xi® systems  with central or side docking types were used. In the case of single-incision RSC, single-site RSC (SS-RSC) was performed using the da Vinci Si® or da Vinci Xi® system and single-port RSC (SP-RSC) was performed using the da Vinci SP system with central docking type. A 2.7-cm intraumbilical incision was made.The surgical steps were the same as the ones in our previous report ,39. In t® PA B2 type; Serag-Wiessner KG, Naila, Germany) was used in all cases. Most intra-corporeal procedures were the same in all cases and only differed in terms of whether the wrinkle method was used. Supracervical hysterectomy (SCH) with or without adnexectomy was performed, and the cervical stump was sutured with 1-0 V-Loc (Covidien) sutures using a continuous running suture technique. This step was omitted in the 20 cases of vault prolapse. Dissection of the avascular anterior vesicovaginal plane and posterior rectovaginal plane of approximately 6–7 cm in length was performed, and the mesh was sutured to fix approximately 5–6 cm of the anterior and posterior vaginal wall.All surgeries were performed under general anesthesia, and all patients underwent standard operative care. The surgical materials, including suture materials and mesh, were almost the same in all cases. Non-absorbable suture materials  and absorbable suture material  were used as mesh anchoring sutures. Complete peritoneal closure was performed using absorbable barbed suture materials , 2-0 V-Loc , or 1-0 Quill™ SRS bidirectional barbed suture . A Y-shaped, 2 cm × 18 cm size, partially absorbable macroporous polypropylene light-weight mesh (Seratexn = 57), involving the creation of two or three rows of purse-string sutures with 2-0 PDS on the anterior vaginal wall and anchoring of the mesh on the wrinkle, as illustrated in ® .The wrinkle method was performed in the wrinkle group . All computations were performed with R, a language and environment for statistical computation  [To compare continuous variables in the wrinkle and non-wrinkle groups, we used Student’s Austria) .n = 55; single incision, n = 2) underwent RSC with the wrinkle method (wrinkle group) and 66 patients  underwent RSC without the wrinkle method (non-wrinkle group). The FU period was 24.03 ± 4.26 months ) for the non-wrinkle group and 9.13 ± 4.61 months ) for the wrinkle group. The mean age of patients was significantly higher in the non-wrinkle group . The mean BMI was comparable between the two groups. There were no differences in the proportion of menopausal patients, history of previous pelvic surgery, vault prolapse, or distribution of preoperative POP-Q stages between the two groups  between the two groups. However, the rates of adnexectomy and adhesiolysis were significantly higher in the non-wrinkle group, whereas the rate of posterior colpoperineorrhaphy was significantly higher in the wrinkle group. The mean EBL was comparable and below 75.0 mL in both groups  .In terms of operative adverse events, no patient in either group required transfusion or conversion to laparotomy or to multiport RSC of single-incision RSC. There were no cases of bowel obstruction, deep vein thrombosis, pulmonary embolism, or cardiac, respiratory, renal, or neurological complications. There were four cases of bladder injury (cystotomy) during surgery, two cases in the wrinkle group and two cases in the non-wrinkle group. This complication was resolved using intraoperative primary repair of the cystotomy site, extended urinary drainage with an indwelling urethral Foley catheter for 7 days, and removal of the Foley catheter after confirmation of no extravesical leakage of dye on cystography. There was no difference in the rate of complications between the two groups.2) woman. This patient developed umbilical incisional hernia during the 3-month FU, and POP recurred. Although primary umbilical facial closure and anterior colporrhaphy had been performed concomitantly, 6 months later, symptomatic POP-Q stage II anterior compartment recurrence was noted again; however, the patient did not desire further surgical treatment. There was one other case of POP recurrence in the non-wrinkle group; however, the patient had no symptoms, and therefore no further treatment was administered.At the postoperative 4-week FU, all cases were at POP-Q stage 0–I, except two non-wrinkle group patients  with anterior compartment recurrence that was at POP-Q stage II. There was one case of umbilical incisional hernia in the non-wrinkle group  in an 86-year-old obese  with a retroperitoneal abscess in the wrinkle group preceded by a large hematoma that formed following bleeding during retroperitoneal dissection. The patient complained of postoperative ileus, and fever developed during the 5-day postoperative period. The abscess was drained using a double J catheter and intravenous antibiotics were administered. The mesh was not removed because there was no sign of mesh infection, and the patient recovered well without recurrence of POP. There was one case  of de novo stress urinary incontinence in the non-wrinkle group, which was resolved after anti-incontinence surgery (using TOT) performed 6 months postoperatively. There were two cases  of posterior vaginal wall mesh erosion of approximately 1 cm in size in the non-wrinkle group . The expWe designed this study to investigate the feasibility of the new wrinkle method during RSC and to evaluate the perioperative outcomes. This method may broaden the anterior vaginal wall surface covered by mesh and may also narrow the caliber of the vaginal canal. Furthermore, the wrinkle method may decrease the rate of mesh erosion by thickening the anterior vaginal wall below the mesh. A similar hypothesis was proposed by Noe G.K. et al. They have been performing the laparoscopic anterior and posterior native tissue repair since 2015, and they published an article demonstrating the safety of the new surgical method for the treatment of midline cystocele and rectocele . The autSimilarly, we hypothesized that the wrinkle method would decrease the recurrence of POP and vaginal wall erosion after RSC; however, the short follow-up period of our retrospective study precludes any conclusion about the effect on the risk of vaginal mesh erosion and POP recurrence. Furthermore, in the current study, erosion was only noted in the non-wrinkle group, and the difference was statistically insignificant. Moreover, erosion was noted only in the posterior vaginal wall, not in the anterior vaginal wall where we created the wrinkles. Therefore, we could not conclude on the effect of the wrinkle method in terms of decreasing the rate of the vaginal wall erosion. Long-term FU data and randomized controlled trials with large numbers of patients, calculating the sample size with high power, are required to determine this effect.Concerning objective POP recurrence after SC, van Zanten et al.  publisheAttempts to prevent recurrent POP after SC have been reported. The reduction in recurrent POP of the anterior compartment is challenging because the anterior compartment is most commonly involved after SC ,29,30. Cn = 62) or without PVR (n = 108) at the 16.0- and 12.9-month FUs, respectively. However, there was only a trend toward improved clinical outcomes, which was not statistically significant. Hoke et al. [n = 21) or without PVR (n = 102) at the 3-month FU. However, concomitant PVR performed during RSC also failed to provide significant objective and subjective improvement. The authors stated that this result may be attributed to the fact that patients undergoing RSC with PVR usually had worse baseline prolapse, and a prospective RCT will be needed to conclude on the effect of PVR on the decrease in POP recurrence after RSC.In terms of PVR, it was theorized that a paravaginal defect may cause a lateral cystocele, and, therefore, concomitant PVR during SC was considered to be helpful in anterior POP recurrence. The effect of concomitant PVR to decrease a recurrent cystocele was initially reported in open SC by Shippey et al. in 2010 . The aute et al.  also comIn our study, no case of mesh erosion on the anterior vaginal wall was noted, and all cases  involved the posterior vaginal wall. A thin or injured posterior vaginal wall during electrocauterization for the bleeding on the posterior vaginal wall during rectovaginal wall dissection may have predisposed patients to posterior vaginal erosion. The reason for the lack of cases of mesh erosion in the wrinkle group may be the shorter FU periods in the wrinkle group. After SC, both mesh erosion and POP recurrence rates are known to increase over long-term FUs, and the probability of mesh erosion was reported to reach 10.5%  at the 7-year FU in an RCT for open SC . Unger eThe total OT was significantly shorter in the wrinkle group without differences in EBL or an increase in perioperative complications. We had expected that when reviewing the full surgical videos, we would find that an additional 4–6 min of surgical time would be required for the wrinkle method and ultimately a longer total OT. However, this was not the case, and the reason for the shorter total OT in the wrinkle group may be attributable to improvements in surgical proficiency over the study period. The learning curve for robotic surgery is known to be steeper than that of laparoscopic surgery. In terms of RSC, initial reports have suggested that RSC is associated with longer surgery duration than LSC ,51. HoweAdditionally, the lower rate of concomitant adnexectomy and adhesiolysis and the higher rate of posterior colpoperineorrhaphy in the wrinkle group than in the non-wrinkle group may also result in a shorter total OT. Therefore, a well-designed randomized control study should be conducted to reach further conclusions.This study had several strengths. First, to the best of our knowledge, this is the first study to suggest a new wrinkle method and compare RSC with and without the use of the wrinkle method. Second, the relatively short study period of 30 months meant that surgical procedures were relatively consistent. Third, this is the experience of a single surgeon, and this minimized the influence of variations in surgical experience and proficiency across different surgeons. Fourth, we used a validated POP quantification system both pre-and postoperatively. Fifth, the wrinkle method was not time-consuming, was easy to perform, was applicable to abdominal SC and LSC, and did not require additional training or instruments. Finally, none of the cases required additional skin incision or mini-laparotomy.However, this study has some limitations that should be considered. First, this was a single-center retrospective study and not a multicenter RCT with a large number of patients and calculation of the sample size with high power. Second, both groups comprised a relatively small number of cases, and the relatively short-term FU data precluded us from concluding on the long-term efficacy and safety of the wrinkle method. Third, the wrinkle method was applied to cases operated after April 2019 and the FU period was significantly different between the two groups. This is the main reason we cannot conclude on the effect of wrinkle on recurrence and mesh erosion, both affected by the FU periods. Fourth, we did not evaluate the sexual function of patients and their partners following RSC using a validated questionnaire, which can help reveal the effect of the wrinkle method. Narrowing the vaginal caliber and creating wrinkles may have positive effects on sexual function; however, the thickening of the vaginal wall may negatively affect the patient’s sexual sensation. Finally, as a single surgeon performed the surgery in all cases, we cannot exclude the possibility of selection biases.In conclusion, performing the proposed wrinkle method during RSC is simple and not time-consuming. It may decrease anterior POP and vaginal erosion; however, long-term RCTs are essential to confirm our findings.


Additionally, their contribution to the cardiac action potential (AP) profile is unclear. Immunofluorescence assays showed the expression of the TRPM6 and TRPM7 proteins in isolated pig atrial and ventricular cardiomyocytes, of which the expression was modulated by incubation in extracellular divalent cation-free conditions. In patch clamp studies of cells dialyzed with solutions containing zero intracellular Mg2+ concentration ([Mg2+]i) to activate the Mg2+-sensitive channels, raising extracellular [Mg2+] ([Mg2+]o) from the 0.9-mM baseline to 7.2 mM prolonged the AP duration (APD). In contrast, no such effect was observed in cells dialyzed with physiological [Mg2+]i. Under voltage clamp, in cells dialyzed with zero [Mg2+]i, depolarizing ramps induced an outward-rectifying current, which was suppressed by raising [Mg2+]o and was absent in cells dialyzed with physiological [Mg2+]i. In cells dialyzed with physiological [Mg2+]i, raising [Mg2+]o decreased the L-type Ca2+ current and the total delayed-rectifier current but had no effect on the APD. These results suggest a co-expression of the TRPM6 and TRPM7 proteins in cardiomyocytes, which are therefore the molecular candidates for the native cardiac Mg2+-sensitive channels, and also suggest that the cardiac Mg2+-sensitive current shortens the APD, with potential implications in arrhythmogenesis.The cardiac Mg These cardiomyocyte Mg2+-sensitive channels have been detected in various species, including humans, rats, pigs, guinea pigs, and mice. However, the nature of the proteins underlying the cardiac TRPM6- and TRPM7-like currents and the functional consequences of their cation fluxes have remained unclear.We have previously characterized cardiac Mgchannels ,15 with  cations ,18,19,202+-sensitive channels to be permeable to Ca2+ and Mg2+  ([Mg2+]i = 0.8 mM) or with the Mg2+-free solution ([Mg2+]i ≈ 0 mM). The latter condition is known to cause a progressive activation of Mg2+-sensitive channels with time by removing the inhibition exerted by intracellular Mg2+ [2+] ([Mg2+]o = 0.9 mM) or with high Mg2+ ([Mg2+]o = 7.2 mM). High [Mg2+]o is known to cause a complete suppression of any activated Mg2+-sensitive current [To examine the role of Mglar Mg2+ . The cel current .2+]i .2+]i A,C,E or ]i . The experiments were performed at 36 °C using K+-containing intra- and extracellular solutions. In cells dialyzed with physiological levels of [Mg2+]i  at potentials negative to −75 mV, and the current–voltage relationship was relatively flat at more positive potentials. Raising [Mg2+]o to 7.2 mM did not affect the current–voltage relationship, indicating that the high [Mg2+]o did not affect the IK1 and that no other Mg2+-sensitive current was present  are not expressed in this species [2+]o, the action potentials were generally shorter in cells dialyzed with Mg2+-free internal solution  and the delayed rectifier K+ current (IK). The analysis was done in cells dialyzed with 0.8-mM [Mg2+]i to inhibit the Mg2+-sensitive currents. For the measurements of IK, K+-containing intracellular and extracellular solutions were used, and nifedipine (25 µM) was included in the external solution, whereas, for the measurements of ICa-L, K+ was replaced by Cs+ in the external and pipette solutions, and 10-mM BAPTA was used in the pipette solution instead of EGTA. 2+]o alteration on ICa-L. Where lowering the [Mg2+]o by 10-fold to 0.09 mM reversibly increased the amplitude of ICa-L continuously monitored at 0 mV .2+]o also decreased the magnitude of the total IK  and only mildly shifted the activation curve to the right  effective in producing a partial block of IK without excessively prolonging the APD (not illustrated). 2+]o, the addition of small concentrations of IK inhibitors (100-nM HMR1556 and 500-nM E4031) lengthened the APD, as expected from a decrease of the repolarizing K+ current . Consistent with a decreased relative contribution of IK, raising the [Mg2+]o to 7.2 mM in the presence of the IK blockers decreased the APD , indicating a predominant effect of ICa-L suppression by high [Mg2+]o under these conditions. Qualitatively similar results were obtained in three other cells dialyzed with 0.8-mM [Mg2+]i under the ruptured cell membrane conditions (not illustrated). These results suggest that the lack of effect of raising [Mg2+]o on the APD in cells dialyzed with 0.8-mM [Mg2+]i reflects a balance in the effects of the decreases of both ICa-L and IK on repolarization.Since high [Mg2+]i see C,E, it i2+]i, was absent in cells dialyzed with 0.8-mM [Mg2+]i and was suppressed by high [Mg2+]o. Thus, the results are consistent with our previous proposal that the Mg2+-sensitive channels in the heart are likely due to TRPM6 and/or TRPM7 proteins i conditions, since endogenous polyamines would still continue to provide a sufficient block of the outward IK1 [2+o suppressed the outward current while having no effect on the inward currents. Our results suggest that there is practically no contribution of TRPM6 and TRPM7 currents to the AP when [Mg2+]i is at the physiological levels. This result is consistent with a lack of changed currents through mutant TRPM7 channels expressed in cultured cardiomyocytes on the action potentials measured in such cells i, the Mg2+-sensitive channels are also regulated by factors such as the pH change and membrane phospholipid metabolism o was raised in a stepwise manner, and the cells were stored at room temperature (21–22 °C). Ca2+-tolerant rod-shaped ventricular myocytes with clear striations were selected for the electrophysiological studies.The methods used for the dissociation of pig cells have been described before ,25. In s2+-free Tyrode solution (see the composition below) supplemented with 3-mg/mL 2,3-butanedione monoxime, which was washed out 2 to 3 times before the enzyme application. The cardiac tissue chunks were transferred to a beaker with nominally Ca2+-free Tyrode solution supplemented with 1-mg/mL bovine serum albumin (BSA), 1-mg/mL collagenase , and 0.5-mg/mL protease  and continuously bubbled with 100% O2. After 30 min of shaking in a water bath at 37 °C, the solution with both enzymes was replaced by fresh solution containing only collagenase (1 mg/mL) and shaken until cardiomyocytes appeared in the aliquots obtained from the mixture. When the yield appeared to be optimal, the leftovers of the tissue chunks were resuspended in nominally Ca2+-free Tyrode and gently subjected to trituration by suction with a pipette. The cell suspension was filtered, centrifuged, and washed 2 to 3 times either with normal  or with divalent cation-free Tyrode solution and stored at room temperature.For the immunofluorescence studies, the cardiomyocytes were isolated from a small tissue specimen as previously described . In shor+ and L-type Ca2+ currents. For measuring the L-type Ca2+ currents (ICa-L), 400-ms depolarizations to various potentials were given after a 400-ms pre-step at −40 mV, designed to inactivate the voltage-dependent Na+ current. The total delayed rectifier K+ currents IK were measured using voltage steps from a holding potential of −40 mV to various positive potentials, and the tail currents were then measured upon reverting to −50 mV. The action potentials were measured by stimulating with a 2-ms rectangular pulse at a frequency of 1 Hz. The action potential duration (APD) was measured at 30% (APD30), 50% (APD50), and 90% (APD90) repolarization. The current and voltage protocols were generated and data recorded online using the Axopatch 200B amplifier and pClamp 8.1 software via the Digidata 1322A acquisition system .Whole-cell currents were recorded under a voltage clamp, and the action potentials were recorded under a current clamp at 36 °C within 4 h after cell isolation. The membrane currents of interest were measured using 2-s descending voltage ramps from +80 mV to −120 mV applied every 10 s after a 600-ms pre-step at 0 mV from a holding potential of −80 mV, designed to inactivate the voltage-dependent Na® 488 conjugate; A21206, Invitrogen, Thermo Fisher Scientific, Rockford, IL, USA; dilution 1:200) co-stained (for 20 min) with Phalloidin-Alexa Fluor® 546  and with Hoechst 33342  for labeling of the F-actin cytoskeleton and of the nucleus, respectively. Cardiomyocytes were visualized under a confocal laser scanning microscope  from which images were taken using the same scanning parameters for both the TRPM7 and TRPM6 proteins in all the cardiomyocyte preparations.Enzymatically dissociated cardiomyocytes were allowed to settle on the bottom of 8-chamber slides. The cells were permeabilized and incubated with primary rabbit polyclonal anti-TRPM7  or rabbit polyclonal anti-TRPM6 antibody  diluted (1:200) in PBS containing 3% BSA in blocking buffer overnight at 4 °C. The TRPM6 and TRPM7 antibodies were obtained from the same company in order to minimize the possibility of cross-reactivity during immunolabeling. For the negative controls, incubation with the primary antibody was omitted to check for nonspecific binding of the secondary antibody. The cells were incubated for 1 h with a fluorescently labeled secondary antibody : 155 KCl, 5.5 MgCl2, 5 Na2ATP, 1 EGTA, 0.1 Na2GTP, and 5 HEPES  and was modified by changing the levels of Mg2+, by replacing K+ with Cs+, or by substituting EGTA with BAPTA. The phosphate-buffered saline (PBS) used in immunofluorescence contained (in mM): 155.2 NaCl, 2.71 Na2HPO4·2H2O, and 1.54 KH2PO4 .The standard Tyrode solution used during cell dissociation contained (in mM): 135 NaCl, 5.4 KCl, 0.9 MgClHMR1556 was from Aventis Pharma, Frankfurt Am Main, Germany, and E-4031 was from Tocris, Bristol, UK. All the other drugs or chemicals were from Sigma-Aldrich  or Merck . Nifedipine was prepared as a stock solution in ethanol and was protected from light, whereas HMR1556 was prepared in dimethyl sulfoxide (DMSO). All the other chemicals were dissolved in water.An electrophysiology data analysis was performed using Clampfit 8.2  and Origin 7 .The distribution of the immunofluorescence was analyzed using the Olympus Fluoview FV1000  and ImageJ software. Sixty-times magnifying (60×) of the oil immersion objectives were utilized for all the acquisitions. The images were presented as stacks of 8–10 slices at a fixed intensity. The cardiomyocyte area (pixels) and fluorescence intensity were measured in stacks using Imaris software . The immunodetected TRPM6 and TRPM7 protein levels were calculated by the formula: fluorescence intensity × 1000/cell area. In order to reduce the effect on any statistical confounder, the same parameters for fluorescence intensity detection  were always applied. In addition, the immunofluorescence reading was blinded, as the conditions used to keep the cells were unknown to the person performing the reading.n indicating the number of cells studied under each condition. The means were compared using the two-tailed Student’s t-test, whereas differences among the multiple groups were evaluated using an analysis of variance (ANOVA). p ≤ 0.05 was taken as the threshold for statistical significance.The average data were presented as the mean ± standard error of the mean (S.E.M) or box plots, with


The vital signs—temperature, heart rate, respiratory rate, and blood pressure—are indispensable in clinical decision-making. These metrics are widely used to identify physiologic decline and prompt investigation or intervention. Vital sign monitoring is particularly important in acute care settings, where patients are at higher risk and may require additional vigilance. Conventional contact-based devices, while widespread and generally reliable, can be inconvenient or disruptive to patients, families, and staff. Non-contact, video-based methods present a more flexible and information-dense alternative that may enable creative improvements to patient care. Still, these approaches are susceptible to several sources of bias and require rigorous clinical validation. A recent study by Jorge et al. demonstrates that video-based monitoring can reliably capture heart rate and respiratory rate and overcome many potential sources of bias in post-operative settings. This presents real-world evaluation of a practical, noninvasive, and continuous monitoring technology that had previously only been tested in controlled settings. For patients, probes may irritate the skin, disrupt mobility and sleep, and harbor hospital-borne pathogens. For staff, wires and straps may interfere with patient transport, while inadvertent or purposeful sensor disconnections may require repeated attention, especially for delirious or agitated patients.The modern hospital room is equipped with a battery of automated bedside monitors. The standard set—electrocardiography, impedance pneumography, and pulse oximetry—require probe attachments to multiple sites across the patient’s chest, fingers, or earlobe. While necessary, these sensors are often undesirable2, intraoperative3, and during hemodialysis4, most studies assessed brief, daytime measurements for healthy patients. To contribute evidence in less-controlled settings, Jorge et al.5 present data that video-based systems can deliver accurate, robust, and actionable vital sign estimates in the post-operative intensive care unit (ICU). The studied hardware consists of an optical camera, thermal camera, infrared light source, and privacy blind placed on a mobile trolley behind the foot of the bed. Captured video data were then processed for frame-by-frame changes attributable to cardiac and respiratory patterns2. Using this system, the authors observed 15 patients in the post-operative ICU for an average of 16 h each.One proposed solution is video-based photoplethysmography, which extracts cardiorespiratory signals using light reflected from the skin. While this technology has been evaluated in diverse settings, including outpatient6.The resulting data support several important findings for video-based monitoring. First, the study demonstrated practical availability. After removing privacy periods  and low-quality recording periods (43% for heart rate and 35% for respiratory rate), heart rate and respiratory rate were estimated for 44% and 51% of total recorded time, respectively. Vitals were measured regardless of patient position: lying in bed, sitting in a bedside chair, moving around, on ventilatory support, or receiving routine care. Of note, this study was the first to evaluate video-based monitoring overnight and for extended times (over 12 h) in the adult acute care setting. Second, video-based monitoring demonstrated reliable accuracy. When available, heart rate and respiratory rate were estimated with low mean absolute error (2.5 beats/min and 2.4 breaths/min) and low underestimation bias (−2.0 beats/min and −1.4 breaths/min) relative to reference values from contact-based methods. These metrics are consistent with previous studies on video-based monitoring and compare favorably to those of standard monitoring devices1 or analysis methods 7. Beyond heart rate and respiratory rate, computational methods may also recover and magnify other signals with important health implications, including oxygen saturation, heart rate variability, volume status, distal perfusion, fall risk, activity, sleep, and delirium. The information density of visual inspection in routine clinical evaluation suggests that video-based methods may succeed for some of these applications and perhaps others not listed. For example, Jorge et al. retrospectively analyzed a recorded episode of diaphragmatic rupture with lung collapse and liver herniation, finding that the algorithm’s respiratory mapping aligned closely with known locations of thoracic and abdominal injury. Though further investigation is needed, this preliminary analysis suggests that video-based methods may capture more detailed physiologic information than conventional methods alone.Despite these reassuring results, much work remains for video-based methods to attain their full potential. Technical improvements may involve alternate sensors 8, including patients with darker skin9. As physiologic surveillance technologies continue to improve, it will become increasingly important to address questions of bias, privacy, and possible misuse that inevitably arise with such tools.Future work should investigate the relative frequency of various failure modes , document their most common causes , and demonstrate generalizability across sites and settings. In particular, replication in larger cohorts with improved demographic representation will be critical given potential inaccuracies in certain populations10. Although technical, trust, and implementation challenges remain, we believe these may be overcome for a more robust, cost-effective, and unobtrusive future of medical data collection.The ubiquity of smartphones and webcam devices has dramatically expanded the feasible applications of video data in healthcare. Physiologic values that could previously only be measured using single-output, directly-attached probes in hospital settings may be increasingly derived using multichannel, no-contact monitoring devices serviceable in any environment. Such tools promise to improve care by characterizing longitudinal clinical status, alerting staff to detected emergencies, and capturing data from unwitnessed events for retrospective evaluation. Broader implementation may be fast approaching. During the COVID-19 pandemic, new regulatory guidance and reimbursement coverage has enabled rapid deployment of similar tools for remote patient monitoring


There is a lack of knowledge about malnutrition and risk of malnutrition upon admission and after discharge in older medical patients. This study aimed to describe prevalence, risk factors, and screening tools for malnutrition in older medical patients. In a prospective observational study, malnutrition was evaluated in 128 older medical patients (≥65 years) using the Nutritional Risk Screening 2002 (NRS-2002), the Mini Nutritional Assessment-Short Form (MNA-SF) and the Eating Validation Scheme (EVS). The European Society of Clinical Nutrition (ESPEN) diagnostic criteria from 2015 were applied for diagnosis. Agreement between the screening tools was evaluated by kappa statistics. Risk factors for malnutrition included polypharmacy, dysphagia, depression, low functional capacity, eating-related problems and lowered cognitive function. Malnutrition or risk of malnutrition were prevalent at baseline (59–98%) and follow-up (30–88%). The baseline, follow-up and transitional agreements ranged from slight to moderate. NRS-2002 and MNA-SF yielded the highest agreement  0.18–0.44) to 0.57 (95%CI 0.42–0.72)). Prevalence of risk factors ranged from 17–68%. Applying ESPEN 2015 diagnostic criteria, 15% had malnutrition at baseline and 13% at follow-up. In conclusion, malnutrition, risk of malnutrition and risk factors hereof are prevalent in older medical patients. MNA-SF and NRS-2002 showed the highest agreement at baseline, follow-up, and transitionally. Worldwide, older patients (≥65 years of age) make up 41–46% of acute admissions, and risk of malnutrition based on nutritional screening is frequent, with a reported prevalence of 35–70% ,3,4,5. TAcute hospital admissions offer an opportunity to identify malnutrition that would otherwise not be revealed, as 47% of acutely admitted older Danish patients receive only hospital treatment and no other healthcare services . HoweverTo design interventional studies with a transitional nutritional intervention, we need information on whether malnutrition or the risk of malnutrition that has been identified during hospitalization still prevails after discharge, or whether it has resolved after treatment of the acute disease. A challenge in this regard is the use of different screening tools during hospitalization and in the community after discharge, as well as the lack of tools that are valid in both settings . FurtherAccordingly, the aim of this study was four-fold: (1) to describe the prevalence of malnutrition and risk of malnutrition upon acute admission and four weeks after discharge; (2) to determine the agreement between malnutrition risk screening tools upon acute admission and four weeks after discharge as well as the transitional agreement within and between malnutrition risk screening tools; (3) to determine the prevalence of malnutrition according to ESPENs 2015 diagnostic criteria; and (4) to determine the prevalence of commonly known risk factors for malnutrition.The study is part of FAM-CPH, a prospective observational cohort study registered at Clinical Trails.gov (identifier: NCT03052192) with the purpose of investigating medication, malnutrition, chronic inflammation, and biological aging among acutely admitted older medical patients. The participants in the FAM-CPH study were included in the Emergency Department (ED) of Copenhagen University Hospital, Hvidovre, from November 2016 to August 2017. The ED is a 29-bed ward, which is handling acute medical admissions. Minor injuries or traumas are handled in a separate Emergency Room. Other results of the study regarding medication, inflammation and biological aging have been published elsewhere .On weekdays between 7 and 8 am, a list of all older medical patients admitted to the ED within the last 24 h and not yet discharged was generated in random order by a computer. Patients on the list were consecutively invited to participate if they fulfilled all the inclusion criteria and none of the exclusion criteria. Inclusion criteria were: age ≥65 years and being acutely admitted. Exclusion criteria were: unable to speak and understand Danish, not Caucasian, unable to cooperate cognitively or physically, in isolation room stay, terminally ill or admitted due to suicide attempt. Invited patients, who accepted participation, provided written informed consent.Baseline data were collected by three research assistants  immediately after inclusion. Four weeks after discharge, home visits were performed to collect follow-up data. Whenever possible, the same research assistant performed both baseline and follow-up data collection.2) was calculated based on body weight and self-reported height. Hand grip strength (kg) was measured as described by Bodilsen et al. [Comprehensive baseline characteristics were collected using a structured interview and included information on civil status, level of education, smoking, physical inactivity  and falls within the previous year. Health-related quality of life was measured by the EQ-5D-5L (with permission from EuroQol Research Foundation). EQ-5D-5L consists of 5 questions rating mobility, self-care, usual activities, pain/discomfort and anxiety/depression on a 5 level scale, and a visual analog scale  ,24. The n et al. . C-reactn et al.  was calcn et al. . Malnutrition and risk of malnutrition were evaluated using the Nutritional Risk Screening 2002 (NRS-2002), the Mini Nutritional Assessment-Short Form (MNA-SF) and the Eating Validation Scheme (EVS). The diagnostic criteria for malnutrition proposed by ESPEN (2015)  were appIn Denmark, the most commonly applied screening tool during hospitalization is NRS-2002, which is endorsed by ESPEN . NRS-200ESPEN also endorses the use of MNA-SF for screening in older adults . MNA-SF In Danish primary care, the majority (72%) of municipalities use EVS . EVS was2 or (2) an unintentional weight loss of more than 10% in an undefined timeframe or an unintentional weight loss of more than 5% within the past 3 months in addition to a BMI < 20 kg/m2 if age < 70 years, or a BMI < 22 kg/m2 if age ≥ 70 years or a fat free mass index <15 kg/m2 in men and <17 kg/m2 in women [Retrospectively, we applied diagnostic criteria for malnutrition based on the criteria proposed by ESPEN in 2015 , i.e., bin women . In thisThe following risk factors for malnutrition were assessed: (1) polypharmacy was assessed only at baseline and was evaluated by extracting the prescribed medication from the admission note in the medical record. Polypharmacy was defined as simultaneous use of ≥5 prescribed medications ; (2) dysThe calculated sample size for this sub-study was 98 participants, including an expected dropout of 15% of the participants at the follow-up visit. A two-sided non-inferiority test  was usedt-test or Satterthwaite test or a Wilcoxon signed-rank test when appropriate. Categorical variables are presented by percentage, and differences were tested with the Chi-squared test or Fisher’s exact test when appropriate. Descriptive statistics were used to describe baseline characteristics and risk factors for malnutrition. Continuous variables are presented with a mean and standard deviation (SD) when normally distributed and with median and interquartile range (IQR) when not normally distributed. Differences between continuous variables are tested by p-value < 0.05 was used as a confirmation that the kappa value was statistically different from a kappa value of 0.4, and the 95% confidence interval (CI) was used to indicate if the kappa value was smaller or larger than 0.4. Agreement between malnutrition risk screening tools is described by the positive predictive value , the negative predictive value , sensitivity , specificity  and agreement ). The PPV was further used to describe the development of the risk factors for malnutrition. The development of the malnutrition screening status within each screening tool was further described by the number of participants who were not at risk of malnutrition at baseline or at follow-up; those who were not at risk of malnutrition at baseline, but developed a risk of malnutrition at follow-up (Acquired); those who were at risk of malnutrition both at baseline and at follow-up (Maintained); and those who were at risk of malnutrition at baseline but not at follow-up (Recovered). A non-inferiority test was used to confirm the kappa value. A kappa value of 0 represents no agreement between two screening tools, 0.01–0.20 represents none to slight agreement, 0.21–0.40 represents fair agreement, 0.41–0.60 represents moderate agreement, 0.61–0.80 represents substantial agreement, and 0.81–1.00 represents almost perfect agreement . A p-valData were collected on paper case report forms and double-entered in REDCap . Data analysis was performed with SAS Enterprise Guide version 7.1  and R version 3.6.1 .A total of 128 participants were included in the study, and 93 completed the 4 weeks follow-up visit, see flowchart, p = 0.041), a lower quality of life , a higher CRP , and higher frequency of low muscle strength in the lower extremities , see The baseline characteristics of the participants are shown in Malnutrition and risk of malnutrition were prevalent at baseline according to MNA-SF, NRS-2002 and EVS . At follow-up, malnutrition and risk of malnutrition were still prevalent according to MNA-SF, NRS-2002 and EVS . Prevalence of malnutrition according to the ESPEN 2015 diagnostic criteria was 15% at baseline  and 13% at follow-up . The prevalences of malnutrition or risk of malnutrition at baseline and the development at follow-up for MNA-SF, NRS-2002 and EVS are shown in p = 0.024 for difference from kappa = 0.4), a sensitivity of 79% and specificity of 82%. NRS-2002 and EVS had a classification agreement of 62% (kappa = 0.07 (95%CI: 0.01–0.15), p < 0.001 for difference from kappa = 0.4), a sensitivity of 61% and a specificity of 100%. MNA-SF and EVS had a classification agreement of 70% (kappa = 0.1 (95%CI: −0.01–0.21), p < 0.001 for difference from kappa = 0.4), a sensitivity of 69% and a specificity of 100%. The kappa values between the malnutrition screening results at baseline showed slight to moderate agreement. The best overall agreement was found between NRS-2002 and MNA-SF with a classification agreement of 80% (kappa = 0.57 (95%CI: 0.42–0.72), p = 0.155 for difference from kappa = 0.4), a sensitivity of 42% and a specificity of 100%. NRS-2002 and EVS had a classification agreement of 45% (kappa = 0.14 (95%CI: 0.06–0.22), p < 0.001 for difference from kappa = 0.4), a sensitivity of 35% and a specificity of 100%. MNA-SF and EVS had a classification agreement of 73% (kappa = 0.21 (95%CI: 0.06–0.47), p = 0.200 for difference from kappa = 0.4), a sensitivity of 74% and a specificity of 64%.At follow-up, the kappa values between the malnutrition screening results showed slight to fair agreement between screening tools. The best overall agreement was found between NRS-2002 and MNA-SF, with a classification agreement of 60% (kappa = 0.31 (95%CI: 0.18–0.44) The transitional kappa value, PPV, NPV, sensitivity, specificity and agreement within and between the three screening tools are shown in p-values for the kappa results or the kappa values shown in The transitional kappa values within and between the screening results indicate slight to moderate agreement. Due to the high dropout-rate, a sensitivity analysis with worst-case scenario was performed with regard to the transitional kappa value. We defined the worst-case scenario as a screening result for malnutrition indicating risk of malnutrition at follow-up for all participants who dropped out. This was deemed a plausible scenario as most participants who dropped out reported illness or lack of energy to participate. The sensitivity analysis (data not shown) with worst-case scenario did not change the The prevalence of the risk factors for malnutrition at baseline and follow-up and their development, described by PPVs, are shown in The probability of having a risk factor for malnutrition when at risk of malnutrition or with malnutrition according to MNA-SF, NRS-2002 or EVS, respectively, is shown in Malnutrition and risk of malnutrition are prevalent among acutely ill older medical patients upon admission and four weeks after discharge, when assessed with the screening tools for malnutrition: MNA-SF, NRS-2002 and EVS. The prevalence ranges between 59–98% at baseline and between 29–88% at follow-up. The prevalence of malnutrition is lower when the diagnostic criteria proposed by ESPEN in 2015 is applied with a prevalence of 15% at baseline and 13% at follow-up. The agreement within and between the applied screening tools for malnutrition at baseline and follow-up was slight to moderate, with NRS-2002 and MNA-SF showing the best agreement at both time points. Moreover, the transitional agreement between the applied screening tools was also slight to moderate, again with MNA-SF and NRS-2002 showing the best agreements. Further, all assessed risk factors for malnutrition were prevalent at baseline and prevailed to a moderate degree at follow-up (PPV ranging from 13–70%). Upon admission, the prevalence of malnutrition and risk of malnutrition according to MNA-SF (68%) is comparable to findings from other studies reporting 48–64% of acutely admitted older medical patients to present with malnutrition or risk of malnutrition upon admission to the ED ,4,5. OneDiagnosis of malnutrition according to the ESPEN 2015 criteria was present in 15% of our study participants at baseline. We are not aware of other studies that have used ESPEN 2015 criteria for malnutrition in acutely admitted older medical patients. A prevalence of malnutrition of 33% and 35% was found by Raupp et al.  and VelaDifferent screening tools for malnutrition are used during hospitalization and after discharge in primary care. The transitional agreement of screening tools for risk of malnutrition is important in order to correctly identify patients who would benefit from a transitional nutritional intervention. The best transitional agreement when combining tools was found when using NRS-2002 at baseline and MNA-SF at follow-up, with a kappa of 0.42, a sensitivity of 68% and a specificity of 79%. The agreement of NRS-2002′s results at baseline and follow-up and the agreement of MNA-SF’s results at baseline and follow-up were comparable with this, meaning that these could also be used to identify patients with risk of malnutrition or malnutrition that still prevails after discharge. However, we applied NRS-2002 at follow-up, which is a setting it has not been developed or validated for. Compared to MNA-SF and EVS, the NRS-2002 identifies fewer patients with risk of malnutrition at follow-up as it evaluates disease severity and decreased food intake within the previous week. This and the fact that only 12% of those at risk of malnutrition or with malnutrition according to MNA-SF at baseline had recovered at follow-up (versus 30% when NRS-2002 was applied), implies that MNA-SF used in both settings or the combination of NRS-2002 at baseline and MNA-SF at follow-up are the best tool(s) to evaluate transitional malnutrition or risk of malnutrition. When a person is identified with malnutrition or risk of malnutrition in one setting but not in another setting, misunderstandings and miscommunication may arise. In Danish hospitals, NRS-2002 is the most widely used screening tool for risk of malnutrition, whereas EVS is the most widely used tool in primary care. The transitional agreement between NRS-2002 and EVS is reflected by a kappa value of 0.15, a sensitivity of 59% and a specificity of 69%, which indicates that identification of malnutrition and risk of malnutrition is a challenge in the transitional setting. In this regard, it should be noted that re-screening after discharge with EVS is not standard procedure if the patient is discharged with a nutritional plan. However, as many patients in the ED are discharged quickly, they presumably do not receive a nutritional plan and therefore screening after discharge is relevant. In addition, we applied EVS in the hospital setting, which it has not been developed or validated for. This is reflected in the extremely high prevalence of risk of malnutrition on admission according to EVS, and the low transitional kappa values and low specificity when compared to MNA-SF and NRS-2002. The reason for this classification is the fact that a “yes” to the EVS question concerning acute disease will classify the patient as at risk of malnutrition.The risk factors for malnutrition were prevalent and more than half (66%) of the participants had between three and five risk factors. The risk factors of malnutrition persisted after discharge, with PPVs ranging from 27–84%. These results emphasize the relevance of a multidisciplinary and transitional intervention to prevent or treat malnutrition. Polypharmacy and xerostomia showed the highest prevalences. The high prevalence of polypharmacy is comparable to findings in similar studies reporting prevalences of 64%  and 79% n = 3). We expect that this is explained by selection bias, as those who declined participation presumably needed more help. Low muscle strength in the lower extremities was prevalent in those who could be assessed. A large part of our population was too ill upon admission for assessment of muscle strength in the lower extremities. Furthermore, the high prevalence of low muscle strength in the lower extremities indicates that the participants at risk of malnutrition or with malnutrition need an intervention aiming to increase muscle strength in the lower extremities. Risk of depression was present in one in four participants at risk of malnutrition, this being a relatively low frequency compared to a prevalence of 84% in a comparable study by Pereira el al [Limitations in functional ability regarding cooking and grocery shopping were relevant to one in three participants at risk of malnutrition. This indicates that interventions aiming at improving these specific activities of daily living are relevant in this population. The number of participants who needed help eating was low . This must be taken into account when designing a transitional and multifactorial intervention. A major strength of this study is that it is the first of its kind to look at malnutrition prevalence and risk factors in a transitional setting. It provides new and valuable information that emphasizes the importance of nutritional screening and intervention in the ED and after discharge and provides information relevant for designing future interventional studies. The study also has several limitations. A limitation may be the sample size calculation, which assumed a good agreement between the nutritional screening tools. As the agreement was lower than anticipated, the study may lack power. Further, both the nutritional screening tools applied and the questionnaires used to identify causes of malnutrition rely on patient self-reporting. This poses a challenge, as participants may answer, for example, that they do not have a problem with chewing, when in reality they do and have just adapted their diet to the poor chewing ability. This is a limitation of our study as risk factors in this regard may be underreported. Further, the interpretation of the results from EVS upon admission and NRS-2002 in the community setting, is limited due to the lack of validation of the tools in these settings. Using the MNA-SF as a stand-alone tool and not applying the full-MNA may have resulted in higher prevalences of risk of malnutrition and hereby affecting agreement estimates. Another limitation of the study is that the duration of follow-up is shorter (four weeks) than the timespan referred to in the questions regarding weight loss and dietary intake in the NRS-2002 and the MNA-SF (three months) and thus, the two assessments overlap by up to two months. However, one could argue that a given pre-post difference would encompass a change within the follow-up period.Another aspect that would have strengthened our design is the use of a gold standard for assessing malnutrition. There is no global consensus on how to define a gold standard, but Keller et al.  recommenFurther, the study population might be subjected to selection bias, as most of the patients we excluded could not cooperate cognitively. Thus, our study does not provide information concerning the most vulnerable patients, which might have altered the prevalences of both nutritional status and risk factors. Lastly, we did not collect data on possible interventions towards malnutrition, which might have been provided in the four weeks from discharge to follow-up. Thus, it is unknown if nutritional support could have affected the screening scores and the nutritional status of the patients and hereby the transitional agreement of the nutritional screening tools. However, as transitional nutritional support is not yet part of standard care, we assume that no intervention has been initiated or impacted the scores during the four weeks following discharge. Malnutrition and risk of malnutrition are highly prevalent among acutely ill older medical patients upon acute admission to the ED and four weeks after discharge. The use of MNA-SF and NRS-2002, alone or in combination, poses the best transitional agreement. However, this agreement was only rated fair to moderate. The high prevalence of risk factors for malnutrition highlights the need for multifactorial interventions to overcome malnutrition in acutely admitted older medical patients. This study provides valuable new knowledge on malnutrition in acutely ill older medical patients which can be used when designing future interventional studies aiming to treat and prevent malnutrition.