The advent of deepfakes - the manipulation of audio records, images and videos based on deep learning techniques - has important implications for science and society. Current studies focus primarily on the detection and dangers of deepfakes. In contrast, less attention is paid to the potential of this technology for substantive research - particularly as an approach for controlled experimental manipulations in the social sciences. In this paper, we aim to fill this research gap and argue that deepfakes can be a valuable tool for conducting social science experiments. To demonstrate some of the potentials and pitfalls of deepfakes, we conducted a pilot study on the effects of physical attractiveness on student evaluations of teachers. To this end, we created a deepfake video varying the physical attractiveness of the instructor as compared to the original video and asked students to rate the presentation and instructor. First, our results show that social scientists without special knowledge in computer science can successfully create a credible deepfake within reasonable time. Student ratings of the quality of the two videos were comparable and students did not detect the deepfake. Second, we use deepfakes to examine a substantive research question: whether there are differences in the ratings of a physically more and a physically less attractive instructor. Our suggestive evidence points toward a beauty penalty. Thus, our study supports the idea that deepfakes can be used to introduce systematic variations into experiments while offering a high degree of experimental control. Finally, we discuss the feasibility of deepfakes as an experimental manipulation and the ethical challenges of using deepfakes in experiments. By making the computer code available, other users could produce deepfakes themselves and contribute their results through the platform, leading to their immense popularity  have been altered  media and trust. For example, Vaccari and Chadwick  teaching situation. Thereby, deepfakes can also account for the fact that some researchers assume that the evaluation of static and dynamic faces is based on different evaluation schemes  and subjects (N = 37) which also limits the possibilities to dig deeper into the underlying mechanisms at work.Guided by our theoretical framework, we created a deepfake based on two persons with varying physical attractiveness and conducted a small experiment among student subjects. In the experiment, we focus, on the one hand, on practical and methodological aspects such as the effort needed to manipulate the videos for social scientists without a strong background in computer science, the challenges we encountered when implementing the deepfakes, and the realism of the resulting videos according to participants of the study. On the other hand, we provide suggestive evidence on a substantive research question by exploring whether there are differences in the SET scores of a more and of a less physically attractive instructor. Given that the deepfakes allow us to control all other nuisances, finding such differences would point toward a beauty premium or beauty penalty. However, it is important to note that this is only suggestive evidence due to the small number of videos .deepfacelab for extracting the images from both videos. We then started the training running three weeksIn a next step, we recorded the videos and generated the deepfakes. To facilitate the creation of the deepfake, both videos were shot under the same conditions  and with neutral background. After the recording, we switched to In order to ensure that the person depicted in the deepfake video was indeed physically less attractive than the person in the original video, we also asked 18 external reviewers to rate the physical attractiveness of the hypothetical person shown in the deepfake. This rating matches almost perfectly to the one of the physically less attractive person . With those results, we can ensure that the treatment group evaluates the physically less attractive person (deepfake), while the control group assesses the physically more attractive person . An image of the stimulus material used in the experiment is shown in The experiment was embedded in an online bachelor course at Friedrich-Alexander University Erlangen-Nürnberg with 39 students. All students received the same instruction, explaining that after watching a video of a hypothetical teaching situation, they would have to rate both the presentation and the instructor. By having only one person giving the instruction, interviewer effects were avoidedN = 19, deepfake N = 18) and were not able to switch between groups. The treatment group watched the deepfake video, which contained the physically less attractive instructor, and the control group watched the original video with the physically more attractive instructor. Accordingly, each participant watched either the deepfake video or the original video. The 2-minute video was an introduction to the topic of social inequality based on Solga et al. , our analyses concerning covariate balance suggest that the randomization was successful. Regarding interest in the topic, differences in average ratings are less than half a scale point . Similarly, prior knowledge of the topic differs between the treatment and the control group by only half a scale point . Given those small differences, we checked the robustness of the reported results by controlling for interest, prior knowledge, and the number of correct test answers in a linear regression model. Despite the small number of cases, we follow the request of a reviewer to report results from significance testing, but want to emphasize that due to the low statistical power of our study the results of significance testing should be treated with caution. In particular, conclusions about statistical significance should not be mixed with the strength of substantial relevance of an effect .Second, we evaluated the authenticity following Haut et al. .Finally, we analyzed the perceived t et al. . This qut et al.  in theirTo sum up, we find no indications that the deepfake was detected by the participating students or that the deepfake video was perceived of lower quality than the original video. The deepfake also was not perceived as less authentic, although - as explained in footnote 5 - some concerns remain regarding the exact meaning of this authenticity measure in our study.evaluation of the presentation. Since we used the identical video in both experimental groups except for the persons' face, we expect the presentation ratings to be very similar. Our results largely confirm this expectation. As displayed in structure: t = 0.83; p = 0.41; comprehensible argumentation: t = 0.59; p = 0.56; impact on interest: t = 0.76; p = 0.45). In line with this, the overall ratings of the presentation in grades (from 1.00 = poor to 5.00 = excellent) only slightly differ between the two experimental groups . The only exception concerns student's rating of the speed of the presentation. Surprisingly, students especially expressed that the speed of the original video is too fast compared to the deepfake . Even if this difference is not statistically significant, the difference is remarkably large given that the original and the deepfake video are based on exactly the same source, involving the identical audio record. We interpret this result as a first indication that the beauty premium does not show in our experiment, while there might be a beauty penalty at work.Having ruled out concerns about the potential detection of deepfakes, we can now explore whether differences in the evaluations between treatment and control group using deepfakes exist and whether they point toward a beauty premium or penalty. First, we present the results of students' evaluation of the instructor, where we expect larger SET differences due to the face swap. The results are well in line with this suspicion  and good preparation  are similar in the two groups. All other items differ by almost one scale point or more. The largest differences exist in ratings on general competence  and clear core statements . Likewise, the perception of the rhetorical skills , leadership qualities , open-mindedness  and reliability  are influenced by the appearance of the instructor. Overall, both instructors are perceived to show only average enthusiasm for their subject, although here, again, the degree of enthusiasm of the deepfake instructor is rated 0.93 scale points better . Taken together, we see more positive instructor ratings for the deepfake than for the original video. The analysis of the overall instructor ratings in grades (from 1.00 = poor to 5.00 = excellent) points in the same direction (3.31 vs. 3.52) - even though the overall grade does not differ significantly . Therefore, there is no evidence for the existence of a beauty premium here either, but rather some suggestive evidence for a beauty penalty.Next, we focus on students' cion see . Only thThe nascent technology of deepfakes has important implications for the social sciences, both concerning its substantive research question such as misinformation and media trust and, as we contend, as a potential method for experimental manipulation. Our literature review shows that only a few social science studies address deepfakes while moving beyond the detection and dangers of this technology. In particular, deepfakes so far have been very rarely used as a tool for developing manipulations in experiments. We fill this research gap with our pilot study, and our findings suggest the feasibility of such an approach. Social scientists can successfully create a credible deepfake even without a corresponding education in computer science. Based on different test trials, we acquired appropriate knowledge in a reasonable amount of time that allowed us to create a deepfake using standard software and hardware. Notably, the quality of the deepfake was - in the eyes of the experimental subjects - comparable to our original video. None of the student subjects realized that they are watching a manipulated video.Our study further underlines that deepfakes are suitable for researching social science issues in general and discrimination in particular. Because deepfakes maximize the videos' comparability , differences in ratings can be causally attributed to the varied stimulus. Using the case of physical attractiveness, our study supports the idea that deepfakes can be used to introduce systematic variations into experiments, while offering a high degree of experimental control. As a result, there are only small differences in students' evaluation of the presentation in the two videos, but larger differences in the evaluations of the two instructors. By holding all other factors constant, we can attribute these differences to the appearance of the instructors. However, in contrast to previous studies  for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The Global Leader Initiative on Malnutrition (GLIM) criteria have been recommended for malnutrition diagnosis recently, for which the first step is malnutrition risk screening with any validated tool. This study aims to investigate the incidence of malnutrition risk in gastrointestinal stromal tumor (GIST) inpatients and compare the suitability of Nutritional Risk Screening 2002 (NRS2002) and Malnutrition Universal Screening Tool (MUST) as the first-step screening tool for GLIM criteria.We retrospectively analyzed the clinical data of GIST inpatients in our hospital from January 2015 to December 2019. NRS2002 and MUST were used to screen malnutrition risk at the time of admission. The diagnostic consistency of these two tools with GLIM criteria for malnutrition was analyzed, and the predictive performance of both tools for the length of hospital stay and the occurrence of complications was also evaluated in surgical and non-surgical inpatients.K = 0.75 vs. 0.80), and high nutritional risk classified by NRS2002 and malnutrition identified by GLIM criteria were found to be associated with the length of hospital stay. In surgical inpatients, MUST had better diagnostic consistency with GLIM criteria in sensitivity (86.1 vs. 53.5%) and Kappa value (K = 0.61 vs. 0.30) than NRS2002, but no factors were found associated with the length of postoperative hospital stay or the occurrence of complications.A total of 269 GIST inpatients were included in this study, of which 45.7 and 40.9% were at malnutrition risk determined by NRS2002 and MUST, respectively. In non-surgical inpatients, NRS2002 and MUST had similar diagnostic consistency with GLIM criteria in sensitivity (93.0 vs. 97.7%), specificity (81.1 vs. 81.1%), and Kappa value (The malnutrition risk is common in GIST inpatients. NRS2002 is more suitable than MUST for the first-step risk screening of the GLIM scheme in non-surgical inpatients, considering its better performance in screening malnutrition risk and predicting clinical outcomes. MUST was found to have good diagnostic consistency with GLIM criteria for malnutrition in both non-surgical and surgical GIST inpatients, and further studies need to be conducted to investigate its predictive performance on clinical outcomes. Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm in the digestive tract , which cAlthough the diagnosis of malnutrition is the basis of clinical nutrition intervention, there were no recognized definitions and uniform diagnostic criteria for malnutrition for quite a long time around the world. Recently, the global (nutrition) leaders launched the criteria for the diagnosis of malnutrition, referred to as Global Leader Initiative on Malnutrition (GLIM) criteria. According to GLIM criteria, malnutrition can be diagnosed by conforming to at least one phenotypic criterion  and one etiologic criterion (reduced food intake or assimilation and inflammation or disease burden) .A consensus scheme for malnutrition diagnosis in adults was also proposed by GLIM, of which the first step is malnutrition risk screening with any validated tool, and the second step is assessment for diagnosis and severity grading of malnutrition . Over thAt present, the management of GIST inpatients has been mainly focused on surgery and medication, and the nutritional status of GIST inpatients has been less explored. Therefore, this study aims to investigate the incidence of malnutrition risk by the use of NRS2002 and MUST, as well as to compare the suitability of these two tools as the first-step screening tool for GLIM criteria in GIST inpatients.This study retrospectively analyzed the clinical data of GIST inpatients in our hospital from January 2015 to December 2019. Participants were patients with GIST admitted to the department of gastrointestinal surgery in the First Affiliated Hospital of Chongqing Medical University during that period. This study was performed in accordance with the World Medical Association Declaration of Helsinki and approved by the Medical Ethical Committee of the First Affiliated Hospital of Chongqing Medical University. All the patients included in this study provided informed consent.The inclusion criteria were as follows: (1) pathologically confirmed GIST; (2) aged 18–90 years; (3) hospitalized for more than 24 h; (4) no emergency surgery within 24 h after admission; and (5) willing to accept malnutrition risk screening and assessment. Patients were excluded if it was difficult to obtain their accurate height and weight, perform body composition measurements on them, or they could not complete malnutrition risk screening and assessment.The collected data mainly included the following aspects: patient general information, anthropometric measurement, implementation of malnutrition screening and malnutrition assessment.Patient general information were obtained from medical records, which included age, sex, medical treatment history, laboratory examination and combined symptoms at admission, primary tumor site, tumor risk stratification, length of hospital stay, or complications, during hospitalization.2). Muscle mass was determined by fat free mass (FFM), which was obtained through bioelectrical impedance measured by InBodyS10. Fat free mass index (FFMI) was calculated as FFM divided by the square of height (m2).Anthropometric measurements included body weight, height, body mass index (BMI), and muscle mass, which were carried out by a trained nurse or dietician. The weight and height of the patients were measured by using uniform calibrated instruments on the morning within 24 h after admission. After overnight fasting, emptying of bowels, and urinating in the morning, the patients wearing hospital gowns were weighed before breakfast without shoes. Meanwhile, barefoot heights were measured. BMI was calculated using the standard formula as weight (kg) divided by the square of height (m2), unplanned weight loss in past 3–6 months, and absence or inadequacy of dietary intake for > 5 d due to the presence of acute disease  reduced muscle mass: a low FFMI . Etiological criteria include: (1) < 50% of energy requirements > 1 week, or any reduction for at least 2 weeks, or any chronic gastrointestinal symptoms that lead to inadequate or impaired absorption and assimilation in patients; (2) inflammation associated with acute disease/injury or chronic disease. As GLIM consensus mentioned that most chronic organ diseases, such as cancer, are associated with chronic or recurrent inflammation of a mild to a moderate degree, patients diagnosed with GIST in this study were all thought to meet the etiologic criterion.According to GLIM criteria , malnutrU-test or the chi-square test depending on data characteristics. Multivariable logistic regressions were used to identify the factors associated with the length of hospital stay or the occurrence of complications.Statistical evaluations of the two risk-screening tools  compared with the GLIM criteria for malnutrition diagnosis were performed in both total sample and subgroups (with surgery or not suitable for surgery because of metastatic or advanced GIST). Continuous variables were expressed as mean values ± SD (mean ± SD), while categorical variables were presented as absolute values and percentages. Differences between variables were tested with the use of the Mann–Whitney Cohen's Kappa statistic was calculated to determine the diagnostic consistency between the screening tools  and GLIM criteria for the identification of malnutrition according to some studies , 16, 17.P < 0.05 were considered statistically significant (two-tailed).Statistical analysis was performed by SPSS for Windows , and At the time of data analysis, a total of 301 GIST inpatients from January 2015 to December 2019 were alive, of which 7 inpatients were excluded because of emergency surgery on the day of admission and 25 inpatients were excluded because they refused to accept risk screening and assessment for malnutrition. Finally, 269 inpatients were included. The median age was 57 years (range: 29–90), with a sex ratio of 1.07:1 (51.7% were women). The characteristics of the total, surgical, and non-surgical participants were shown in P < 0.001), a significantly lower level of serum albumin in total and non-surgical GIST inpatients (P < 0.001), and a significantly longer length of hospital stay in non-surgical GIST inpatients (P < 0.001) as compared with well-nourished patients. In addition, GIST patients with targeted therapy had a higher incidence of malnutrition compared to the patients with no targeted therapy . With the number of combined symptoms at admission increasing, the incidence of malnutrition increased significantly .In this study, we found that malnourished patients had a significantly lower BMI in total, non-surgical, and surgical GIST inpatients (K = 0.70 vs. 0.47), and a larger area under the ROC curve (AUC = 0.90 vs. 0.83) compared with NRS2002.K = 0.75 vs. 0.80), and area under the ROC curve (AUC = 0.94 vs. 0.94). In surgical inpatients, MUST had a higher value of sensitivity (86.1 vs. 53.5%), PPV (60.7 vs. 39.5%), NPV (95.3 vs. 88.5%), Kappa (K = 0.61 vs. 0.30), and a larger area under the ROC curve (AUC = 0.86 vs. 0.75) compared with NRS2002. ROC curves were presented in Considering that there might be some heterogeneity between non-surgical and surgical inpatients, we performed subgroup analyses to further evaluate the accuracy of NRS2002 and MUST in light of GLIM criteria for the malnutrition diagnosis . In the P = 0.013), and no statistical difference was found in other factors among surgical or non-surgical inpatients.In the univariate analysis of complications occurrence, gender was the only associated factor in surgical inpatients .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Few studies have described the impact of urinary, bowel and sexual Adverse Health Outcomes (AHOs) on Quality of Life (QoL) in Prostate Cancer Survivors living for more than 5 years after curative radiotherapy (“long-term PCaSs”), and compared the findings with those in men from general population. Here we assess self-reported AHOs in such PCaSs focusing on the association between problem experience and QoL. The findings are compared to corresponding symptoms in age-similar men from the general population without a PCa diagnosis (Norms).Nine years (mean) after curative radiotherapy 1231 PCaSs and 3156 Norms completed the EPIC-26 questionnaire and the EORTC QLQ-C30 instrument. Domain Summary Scores (DSSs) for the urinary, bowel and sexual domains, the percentages of moderate/big dysfunctions and the proportions of overall problems were determined. Inter-cohort differences were interpreted based on cut-off values for published Minimal Clinically Important Differences (MCIDs). Multivariable linear regression models analyzed the associations between QoL and domain-related overall problems.Only the inter-cohort differences regarding bowel and sexual DSSs exceeded the respective MCIDs. Among PCaSs 54% had at least one moderate/big problem (Norms: 30%). In PCaSs and Norms, QoL increased with decreasing urinary and bowel problems, For sexuality this association was weaker in Norms and was almost lacking in PCaSs. Multivariable-adjusted QoL was similar in PCaSs and Norms, with general health being the strongest covariate.During follow-up of long-term PCaSs health professionals should be aware of the survivors’ persisting moderate/big urinary, bowel or sexual problems associated with reduced QoL. In particular , alleviation of urinary and bowel problems can increase the men’s QoL. However, with rising target doses the risk of urinary, bowel and sexual Adverse Health Outcomes (AHOs)  increases, with eventual negative impact on Quality of Life (QoL). New radiotherapy (RT) techniques such as Intensity- modulated radiotherapy (IMRT), Image Guided Radiotherapy, Volumetric Modulated Arc Therapy (VMAT) and new brachytherapy techniques are expected to reduce this risk Typical post-RT AHOs have in PCa survivors (PCaSs) been described in multiple studies 1.To describe the severity of patient-reported typical AHOs after RT combined with ADT as well as the prevalence of rmoderate or big typical dysfunctions and related problems.The two co-primary aims of this nation-wide observational cohort study in long-term PCaSs are therefore.2.To assess the associations between overall urinary, bowel and sexual problems and QoL.andAll findings in PCaSs are compared with corresponding observations in Norms.https://www.helsedirektoratet.no) curative RT for PCa implied a total dose of ≥70 Gy, applied by a 3-or 4- field conformal technique most often combined with 2–3 years of neoadjuvant ADT. Since 2011 IMRT was gradually used by the country’s nine radiotherapy units. MVAT was first introduced in 2017. The most frequent daily dose was 2 Gy. High-dose rate brachytherapy combined with external beam RT (HDR / EBRT) was also used at one hospital For each PCa patient diagnosed in the country the Cancer Registry of Norway (CRN) documents basic diagnosis- and treatment-related data, collects data on total and daily radiation doses and the number of daily fractions. Following the Norwegian guidelines from 2009 and 2015  without a PCa diagnosis but similarly aged as men with PCa. Totally 9509 of these men, aged within the age range of the study’s PCaSs, were invited to complete the same questionnaire as presented to the PCaSs, omitting PCa-related questions.https://medicine.umich.edu/), each DSS reflecting the severity of the domain’s AHOs, ranging from 0 (worst) to 100 (absent). Minimal Clinically Important Differences (MCIDs) assessed differences between DSSs The questionnaire contained the Norwegian versions of EPIC-26 substantial dysfunction” or “substantial problem”.Each domain in EPIC-26 covers aspects of functional impairment (“dysfunctions”). Within the bowel and sexual domain one additional question and question 5 of EPIC-26 assess overall urinary, bowel and sexual problems, ranked as “No problem”, “Very small problems”, “Small problems”, “Moderate problems“ and “Big problems”. Following Downing et al Responses to Item 30 of the EORTC QLQ-C30 reflected QoL. The original scale of item 30 , ranging from 1 to 7, was transformed covering 0 (worst) to 100 ( best) points or was dichotomized: 1–4: (poor QoL) versus 5–7 (satisfactory QoL) Standard descriptive methods were used, presenting means and corresponding standard deviations (SDs) of continuous variables, and absolute and relative frequencies of categorical variables. Due to considerable differences in the age distribution between PCaSs and Norms, descriptive statistics for Norms were age-adjusted, based on three age categories .Following the principles laid out by causal inference theory it can be argued that sexual, bowel and urinary problems affect overall health, social function and other parts of everyday life The Regional Committee for Medical Research Ethics South-East approved this study (no.165867).3With similar response rates in both groups 1,231 relapse-free PCaSs, and 3,156 Norms were finally evaluable . AdjustiIn spite of statistically significant differences between the age-adjusted DSSs (p < 0.01), only the inter-cohort differences of the bowel and the sexual DSSs exceeded the respective MCIDs . CompareForty-six percent of the PCaSs did not record any substantial problem compared to 70 % of the Norms . All pro4In this nation-wide survey, 54 % of long-term PCaSs but only 30 % of Norms reported at least one moderate or big post-RT urinary, bowel or sexual overall problem. An almost linear QoL increase emerged in PCaSs and Norms along with decreasing overall urinary and bowel problems. The corresponding association regarding overall sexual problems was weaker in Norms and was almost lacking in PCaSs. Adjusted QoL was similar in PCaSs and Norms.The DSSs and the means of overall problems in our PCaSs are comparable to published figures from EPIC-based surveys performed in PCa survivors >5 years after RT , and ourLong-lasting hypogonadism rises the risk of physical and mental morbidity More PCaSs than Norms reported substantial overall urinary problems , mostly due to increased micturition frequency and weak stream, neither uncommon in our Norms. Post-RT pelvic and bladder wall fibrosis Our bowel DSS is lower than Bergengren et al’s We could not confirm data on reduced post-RT toxicity using IMRT EPIC-26 is internationally recommended for assessment of post-treatment AHOs in PCaSs In agreement with other studies Our registry-based study has several limitations. Only about one third of the invited men participated in the survey, the low compliance possibly related to the men’s high age, reduced health and lack of Internet competence. Further, the RT techniques used could only be broadly described, disabling to study more detailed correlations between RT and AHOs. Neither do we have any information on therapeutic procedures performed to reduce severe problems in individual PCaSs. As detailed data on comorbidity were lacking , Item 29 of the C30 questionnaire served as a measure of general health, while only Item 30 reflected QoL thus slightly deviating from the recommended operationalization The large sample size of populations-based cohorts and the long observation time of the PCaSs represent the study’s advantages. The real-world design minimizes selection bias which must be considered when PCaSs from trials or single institutions are evaluated As far as we know, this is the first European report which compares post-RT long-term urinary, bowel and sexual AHOs between PCaSs and men from the general population and describes the associations between related problems and QoL.5About 10–15 % of long-term PCaSs suffer from post-RT big or moderate urinary or bowel problems, with sexual problems in 50 % of them. Such problems are two-to threefold increased compared to age-similar men from the general population, and they are inversely associated with the men’s QoL. Improvement of post-RT QoL can be expected by therapeutic tasks which alleviate these problems, in particular within the urinary and bowel domain. Overall, PCa patients can during pre-treatment counseling be informed that their long-term QoL after RT most probably will be similar to that of non-irradiated age-comparable peers. Future studies should address whether modern RT-techniques and today’s reduced ADT duration decrease the prevalence of moderate/big long-term post-RT problems thereby increasing QoL.Fosså SD / Myklebust TAA: Principal co-investigators, manuscript writing, statistical analyses.Johannessen TB / Gjelsvik Y: Data provision, comments to and interpretation of the findings.Dahl AA / Storås AH: Comments to and interpretation of the findings.The Movember Foundation in partnership with the Cancer Registry of Norway, Norwegian Prostate Cancer Association.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Supplementary information) that relates technologies to the key considerations and attributes relevant to DVI practice, for readers to apply to their own context. While this research directly contributes to DVI, it also has applications to other domains in which a physical/digital linkage is required, and particularly within high stress environments with little room for error.Disaster victim identification (DVI) entails a protracted process of evidence collection and data matching to reconcile physical remains with victim identity. Technology is critical to DVI by enabling the linkage of physical evidence to information. However, labelling physical remains and collecting data at the scene are dominated by low-technology paper-based practices. We ask, how can technology help us tag and track the victims of disaster? Our response to this question has two parts. First, we conducted a human–computer interaction led investigation into the systematic factors impacting DVI tagging and tracking processes. Through interviews with Australian DVI practitioners, we explored how technologies to improve linkage might fit with prevailing work practices and preferences; practical and social considerations; and existing systems and processes. We focused on tagging and tracking activities throughout the DVI process. Using insights from these interviews and relevant literature, we identified four critical themes: protocols and training; stress and stressors; the plurality of information capture and management systems; and practicalities and constraints. Second, these findings were iteratively discussed by the authors, who have combined expertise across electronics, data science, cybersecurity, human–computer interaction and forensic pathology. We applied the themes identified in the first part of the investigation to critically review technologies that could support DVI practitioners by enhancing DVI processes that link physical evidence to information. This resulted in an overview of candidate technologies matched with consideration of their key attributes. This study recognises the importance of considering human factors that can affect technology adoption into existing practices. Consequently, we provide a searchable table (as Disaster victim identification (DVI) processes require us to link physical evidence and digital information. While technology could improve this linkage, experience shows that technological “solutions” are not always adopted in practice.Our study of the practices, preferences and contexts of Australian DVI practitioners suggests 10 critical considerations for these technologies.We review and evaluate 44 candidate technologies against these considerations and highlight the role of human factors in adoption. The scale of the incident and the diverse international response created significant challenges in managing human remains and associated information. These challenges included allocating unique identifiers to dead bodies and human remains, tracking the location of physical remains as they progressed through DVI processes, and associating and communicating new information about the remains. This leads to the provocation for this paper: DVI is information intensive, and the digital domain facilitates information work through lossless storage and communication (including copying) as well as manipulation, analysis, search, and retrieval. However, that information is about unique physical entities: human beings, human remains, disaster scenes, and other physical evidence. To take advantage of the digital domain, we need to create reliable links from these unique physical entities to information about them   way. You shouldn’t be doing that.” This faith was based upon a success rate that was “scientifically proven” (P7), however, it could also produce an attachment to procedure that could lead to “checking the fingerprints even though we know they haven’t got hands” (P5).Practices are scaled up from the local to larger DVI operations through ongoing local-level training and adherence to INTERPOL processes. This was apparent when the idea of having one tagging system for the local level and one for the international level was broached:It goes against the process. I can understand the possible need for it, but the protocols would have to be written so everybody understands it. You don’t want people coming in to go, “Oh, you’ve learned this way forever and a day, but now we’re doing this.”—P7Similarly, changes were initiated at the state level before advocating national change:…[the Scene Recovery Booklet] is a Queensland document…we’ve recently modified it…last week, went to the annual Australian conference for everybody to look at…because they want to try and use it everywhere across Australia and New Zealand.—P6Potential changes to protocols were identified during training exercises, as well as regular operations. For example, QPS’s Scene Recovery Booklet was examined in light of its use:…for the last two or three years, we’ve run scene phase training, and from there, the coordinators sit down and actually look at it…And basically every year we review. We’ll sit down and just go, is it working? Is it not working? And we get feedback from the whole squad on that. So they’re the ones that actually go and do it. We’re testing them, but then it’s like, “Oh, what do you think of the book? Is there anything that needs changing?”—P6However, within Australia, there are considerable differences in the way that DVI staffing is arranged across the different states, with subsequent impacts on training. For example, P6 reports:…so Victoria for instance…their antemortem and their recon, is done by the detectives. New South Wales, if you’re a scene-of-crime officer, you’re automatically a DVI officer…Up here [Queensland], we’re totally voluntary. We ran a course this year. I think we’re seeing fifty-five. So we may still have the lowest numbers. But then we’ve got fifty-five people training at every phase, where other states can’t say that. I think WA [Western Australia] went away from that, and they’ve come back to it. So they’re starting to train their staff up. Tasmania, their scene team, and this was two or three years ago when I did a coordinators’ course, their scene team hadn’t been together for five years…And our guys are trained every year in every phase.—P6The implication for DVI work practices is that routine, local operations can exert powerful forces; even though change may be extremely globally beneficial in unusual situations, the benefits to local, routine operations will strongly influence new technology adoption. Importantly, proposed technologies should facilitate existing processes and procedures without significant disruption, and in ways that still allow for human oversight. These could be best introduced and tested during training exercises.Participants reported engaging in repetitive activities that were physically and mentally draining. These could occur across the DVI phases but were particularly noticeable in the postmortem phase. For example, P2 recounts the intensity of the smell within the morgue during a mass disaster, which took time to acclimate to:…if you leave, you’ve got the same experience going back in, the next time. So, the urge not to leave is really, really strong…if you’re working for six or eight hours at a go, you’re full of adrenaline, you’re pumping, you have no sense that anything is a mess…up becomes down, back becomes front, left becomes right, and you don’t notice. And the errors compound the longer you go.Similarly, large-scale disasters present challenges to mortuary staff who must “…spend hours searching for bodies in fridges with racks, and racks, and racks of them” (P1). Also reported by P1, a solution of a whiteboard with a schematic of the freezer unit and magnets that corresponded to remains’ IDs was used to great success, and could be potentially be translated to a more automated system. Beyond tracking human remains, there is also a need to identify what tests have been or need to be carried out—a problem magnified by large-scale operations.This study was unable to gain access to the personnel tasked with data transcription, i.e. digital data entry of paper scene recovery booklets. However, data were reported as being manually transcribed into data matching software (Plass Data):…we’re happy to wear that basically per file: an hour data entry for an AM, an hour data entry for a PM, because the ability to do the advanced searching and the functionality of it to reduce our end paperwork without having to retype in numbers—the benefits outweighed that time.—P4Direct importation of these data was hindered by reliance on paper-based scene data collection (for reasons explored below). Regardless, the mental load of DVI response within a complex and changing environment—or even a simpler one—produces the need for easily understood processes and technologies; as P1 relates: “…in a disaster we keep it simple … we don’t want a system that we’re using for the first time.”Training offers one solution for improved quality assurance by reducing both mental load and reinforcing clear protocols. Further to this, technologies that can reduce repetition, reduce mental load (or at least not add to it), and improve the ability to track or locate remains in mortuaries are likely to be appreciated.Across Australia, DVI involves a range of information systems. In Queensland, for example, data are always entered into the state’s Forensic Register and selectively shared into the National Missing Person and Victim Service (NMPVS). Consequently, there is no guarantee that state-level information will be shared nationally. Since missing persons can be considered “a mass disaster happening over a long period of time” (P2), and since information about missing persons is used in antemortem DVI investigations, ways to facilitate greater information exchange between databases would be valuable. More aligned systems, particularly ones in which data can be immediately entered into a shared system, could also produce greater efficiencies both within and across DVI phases.P5 imagines an idealised system in which:…we could input data from the scene directly into a database that would capture it and provide information through to the next, the other phases, which will inform him of all the circumstances and…opportunities. For example, if we are getting a lot of information or we were at a scene that had a particular type of remains that lends itself to a particular primary identifier, then that’s something we can prepare for both in the PM phase and the antemortem phase.However, identifiers may change or multiply throughout the DVI process. P1, a pathologist, notes that errors at the scene may need to be corrected at the PM phase:Ideally you tag once at the scene and that stays as a tag and that doesn’t change. It has consistency. But there are occasions in which you can have a body bag, and a scene person would’ve put three people in one body bag. So that means that…if you’ve got three knees in there, one knee has to come out or the two knees have to come out, so then we create new case numbers in the mortuary.Multiple databases increased confidence that data were backed up and could be accessed if one system failed. Similarly, individual paper-based data capture (i.e. one scene recovery booklet for each remain) was seen as a safer way to capture information than a system that relied on a single device whose failure could be catastrophic. As P7 relates: “I would much rather have handwritten notes. Then we can scan it…If something were to happen to that device on the way, you’ve lost all your data.” A similar concern was voiced regarding the idea of all the scene information being held on an RFID tag:It’s always got to be linked to some other central computer system for us as well. Can’t be just attached to a body. I always find body tags…go missing. As long as it’s all connected to some sort of central mainframe and central location.—P1The need for data entry and database design that reduces the frictions of data collection and improves information exchange between databases is indicated. However, the application or design of new technologies will also need to be respectful of separate jurisdictions and their need to maintain data security. Finding opportunities to introduce data backup or partitioning of data will also sustain data continuity and confidence in the use of new technologies.DVI procedures at the scene and postmortem phases entail interactions with diverse physical environments and remains. Reasons for avoiding new technologies reflected concerns that they would add to the effort:…we had a 1km hike to the crash site and we went down 900 meters…if I’ve got to lug something with me apart from my equipment to bring the body out, you’re adding that on. Like, I don’t know what you’d need to take, but how do we test that whatever we tagged them with is actually working? Do we need a portable something or other? And then how much does that cost? And then where’ve we got to put it, or where else do we need it?—P6Typically, the only electronic devices used at the scene would be cameras, used by the photographer who “pulls on rubber gloves—but they’re clean. The photographer doesn’t touch the body” (WS). Relatedly, personal protective equipment hampered the use of touch-screens within postmortem data collection, and the presence of bodily fluids hampered all direct data collection, requiring information to be communicated verbally to an assistant to record it (as reported by P2). This was another reason why paper scene recovery booklets were preferred:All that recording on the book, the recording booklet is actually done in the scene on hardcopy papers. We’ve looked at medical Toughbooks, that sort of stuff, and we know that they’re fine for operating theatres. They’re not necessarily good for being dropped on the side of the hill. Ruggedized Toughbooks won’t like being wiped over with bleach and chemicals and everything. You need to get all human remains out of them.—WSIdentification tags had to be robust to liquid, chemical and mechanical degradation, yet able to readily capture and communicate information. At a minimum, they needed to convey the site from which the remains were retrieved, the team conducting the retrieval, and a unique identifier which could be visually read by a human and optionally read by a machine. For this, water-repellent paper tags that could be easily printed were preferred and used, with a bar code and nine digits for identification purposes.While options such as video capture, dictation, and speech-to-text technology were mentioned as possible “hands-free” solutions to data entry, the idea of capturing interpersonal communications, particularly at the scene, evoked mixed reactions:Due to the nature of a lot of conversations that go on, we don’t want to be video recorded… If it was a live, just a direct feed with no recording, we could possibly look at that. —WSSpeech-to-text and other methods (e.g. live streaming with no saved recordings) could be deployed in ways that avoid this concern.DVI may also be competing for resources with other priorities in larger organisations. In the initial disaster response, external pressures  can generate greater resourcing (e.g. staffing), but as the DVI process stretches out and other priorities emerges, the reconciliation phase may be under-resourced. Practitioners may also face dual workloads: “my business as usual work is backlogging while I’m off doing a DVI job” (P4).While some technological solutions may offer potential improvements to efficiency by reducing repetitive data entry, we need to consider how practical concerns of robustness, accessibility and affordability overlap with social concerns , affecting technology use and adoption. Stakeholders also have to be convinced that the benefits of change offset other costs, including the opportunity cost of investing in that technological change rather than another priority.Synthesising the insights gained from the interview and workshop investigation of DVI practices with the combined expertise of the authors, we developed a list of 10 high-level considerations to keep in mind while assessing the potential of technologies for local or global adoption in DVI .These general considerations can be linked to specific technology attributes or features that are meaningful to DVI practice . Table 4What follows captures many of the ideas that arose in the course of our study, but is not an exhaustive list. We hope that the range of candidates we describe, and the way we organise our thinking about them will be a useful basis for DVI practitioners and policy makers to consider the merits of different alternatives.We organise candidate technologies into those that primarily relate to the physical domain, to the digital domain, or whose role is to span both domains .The physical domain refers to the real world in which physical evidence exists.The digital domain is where information is represented digitally.Some technologies straddle these two domains, connecting the physical to the digital, linking or supporting transactions between them.In comparison to Pate’s (2008)  list of Supplementary Information. Some technology-attribute combinations are not especially meaningful: these are left blank. Ticks/crosses indicate where a candidate technology has/lacks a specific attribute. Hollow circles indicate a situation where an attribute may depend on how the technology is implemented, or where further consideration must be given—details of which are given in the searchable Excel spreadsheet.Each candidate technology has, or lacks, certain attributes that are relevant to DVI practice. Supplementary Information be used in conjunction with the following overview.In the following three sections, we pick out some details to give the reader a useful overview of the technologies and their merits. We suggest that In the physical domain, the chain of links between the evidence at the scene begins with a tag which is attached to evidence and which bears a label embodying an identifier uniquely associated with digital information about the remains . LocatinTechnologies in the physical domain of DVI need to be robust enough to handle heat, cold, moisture, solvents, rough handling; intuitive to use correctly under challenging circumstances; and readily accessible to first responders and other practitioners. Cost will be an important issue when many remains need to be tagged, but we can imagine scenarios where more expensive devices could be reused (e.g. audible or visible “beacons” to help retrieve specific remains in a mortuary).We organise physical domain technologies into three groups relating to the tag, the label and methods of locating a labelled tag.Tag technology enables the creation and reuse of physical tags, such as:Flexible tags on various media . These still need to be attached to or somehow kept with remains (e.g. with string or cable ties).Rigid tags, e.g. rigid plastic, as used in ID and credit cards.Adhesive tags can be stuck on evidence bags or other containers.Tags with RFID can be made from flexible, or rigid media; adhesive versions are available.Implantable RFID: small glass or plastic capsules containing a passive RFID device. Commonly used for pet identification.Enclosures: typically small plastic containers, often waterproof. Commonly used in logistics with active RFID.Label technology refers to the ways that a unique digital identifier can be associated with a physical tag. Labels can be directly readable or writable by humans, or may need a machine  to be read or written. Tags generally use more than one kind of label (e.g. human-readable text plus a machine-readable bar code).Human-interpretable labelling can be handwritten or machine-printed directly onto a tag. Information can be encoded in many ways  and consideration should be given as to who will have to interpret it . Thought should also be given as to how easily and accurately this information can be communicated by speech (e.g. over the phone or in a noisy environment) or remembered [membered .Direct part marking (DPM) is a term used to describe information physically encoded into the tag material .Bar codes are visual, machine-readable representations of data. Most familiar are the 1D linear stripes used to identify products in retail using the UPC , and the 2D matrix QR (quick response) code.Passive RFID: small  electronic device, powered by radio-frequency electromagnetic radiation from an RFID reader. Available in many formats, including flexible or encapsulated. Often used in ID cards.Active RFID: similar to passive RFID but powered by internal battery which affords greater range and some data storage, in a larger, more expensive format. Often used in logistics.Locator technology enables labelled tags and associated remains to be spatially located.Automated locator systems: use information gleaned from tags and their interaction with readers to automatically updated database with location information.Global positioning systems (GPS) compare signals from multiple satellites to triangulate position. Lack precision indoors.Indoor positioning systems (IPS) use transmitters mounted indoors to improve tracking precision.Choke point based systems use sensors installed in doorways, cabinets or other choke points to detect the passage or presence of a labelled tag.Human-powered systems manually track and record the location of a labelled tag.Semi-automated systems require humans and machines to read labelled tags, e.g. via handheld scanners.Beacon location systems help retrieve specific labelled tags by allowing users to trigger an audible or visible response from the tag.direct part marking as an example of physical domain technology, we see it can meet some high level considerations by being highly robust ; it is machine readable, and can be read with common equipment, e.g. mobile phone; and can be inexpensive. However, it is also difficult to create by hand; the equipment needed to create them is not widely available; they are only useful for some tag types; access control is not possible; and while humans can read and compare them they are hard to interpret.Taking It takes time and effort to accurately capture and move information about physical evidence into the digital domain: any technologies that save precious time and effort in DVI are appealing. At all phases of DVI, data collection and entry must also comply with international, national and local protocols; technology has the potential to ease the burden of compliance, and streamline workflows within and across DVI phases.data collection from the scene, data entry, and workflow.We have organised technologies that span physical and digital domains into three groups relating to Scene data collection deserves special consideration because, unlike human remains and other pieces of evidence, the scene itself cannot typically be removed or preserved for further analysis. Two technologies stand out as ways to preserve information about the scene and evidence in situ, and these are especially important in preserving information when the scene has to be disrupted in the search for further evidence (e.g. by excavation):Aerial image capture, typically by drones, enables investigators to obtain a plan view of the scene and key locations within it (e.g. the position of remains).3D image capture, enables the physical configuration of the scene to be reconstructed.Data entry refers to the transcription of scene, antemortem, or postmortem data into digital formats that increase data longevity and utility. Technologies include:Automated speech recognition enables live or recorded speech to be transcribed to text and stored, potentially avoiding manual data entry.Smart-phone sensors: modern commodity smart-phones provide an array of sensors and input methods to capture image, video, location, orientation, time, audio and text. Smart-phones can also read and interpret RFID tags, bar codes and QR codes.Machine-readable form elements  enable some automation of optical scanning.Automated forms, such as fillable PDF forms or dedicated applications on smart-phones, tablets or laptops, can reduce typing and repetition by simplifying what the user has to enter or by re-using existing information.Workflow technologies seek to simplify and facilitate the complex, interdependent phases of DVI processes by ensuring information is communicated within and across phases.Matching labels are a simple, practical strategy to ensure information about unique identifiers is reliably propagated through DVI processes. The same identifier is used to label many tags, possibly on different tag media. These labelled tags can be made in advance or on demand.Workflow metadata carries information about the processes that physical evidence has gone through . This could include information about who did what with the evidence, when, where, why and how, so that there is an auditable trail of workflow steps. Workflow metadata is particularly important to indicate related samples (e.g. a tissue sample that has been taken from another set of remains).Automated process logic uses and creates metadata to guide and control DVI process workflows. This logic could be used to determine, allocate and schedule different process tasks based on the state of the physical evidence .automated speech recognition as a technology that spans physical and digital domains, it can be useful when hands are busy  or typing is slow or inconvenient (e.g. when wearing gloves). However, it requires a quiet environment, and is most convenient when microphones are deployed in the work area for true hands-free operation. This suggests it may have greater uses in controlled environments such as morgues, and fewer in the field.Considering The primary motive for getting information into the digital domain is to take advantage of information technology, e.g. to store, communicate, manipulate, integrate, analyse, search, retrieve, manage and make sense of information. Given our focus on linking physical and digital domains we have organised our presentation under the broad headings of information standards, infrastructure and security.Information standards are fundamental to information exchange within and between systems. Worldwide, we rely on a wide range of standards from organisations like the IEEE and ISO. Most critical to linking physical and digital information in DVI are identifier standards which fall into two categories:Open identifier standards, such as the GS1 system, designed to help organisations identify, capture, share and use information [Closed identifier standards, local schemes for creating unique digital identifiers specific to events, jurisdictions or organisations. Australian DVI uses identifier standards specific to different states and organisations.Information infrastructure describes the computing, telecommunication and storage systems that support the usage and transmission of information in DVI.Local applications do not require constant communication, with data stored on the device and communicated later. Remote applications require constant network access, but are easier to build and maintain. Distributed databases can provide robust data storage.Disasters often happen in places or times when communication is limited. Mobile data networks (used by mobile phones) are not available, mobile ad hoc networks (MANETS) or self-managed mobile networks can provide communication to a locally established server. Opportunistic communication, whereby mobile devices automatically forward data via other devices can help get data back to home base.When traditional cloud computing where services are provided from remote data centres to take advantage of economies of scale. However, self-hosting services on computers that can be taken to the field can provide services where internet access does not exist.Much of the modern internet relies on Information security means ensuring that information infrastructure is only used in approved ways. Digital signatures and digital certificates can be used to ensure the origin and authenticity of data relating to remains. Encryption prevents unauthorised parties from reading DVI data. Access control is used to ensure that only authorised parties can read/write data or perform other actions. Audit trails can be used for quality control of DVI processes. Permissioned block chains can be used to reliably share information between jurisdictions without giving control to any one party.Supplementary Materials.We remind the reader that we present a comparative analysis of all candidate technologies in the protocols and training; the impacts of stressand stressors; the plurality of information capture and management systems; and the practicalities and constraints of DVI work each emerged as themes in participant responses and shaped our review of candidate technologies.Our interviews of Australia DVI practitioners have revealed a range of important issues to consider in designing or deploying technology to improve linkage between physical evidence and digital information. The application of direct part marking would likely require a rigid tag medium to support some kind of bar code conforming to an identifier standard that links physical domain labels to an information infrastructure. Similarly, technologies for tagging and tracking have to work as part of larger systems, processes and priorities. Technologies need to be considered, understood and improved in context, i.e. with reference to the broader systems of which they are a part.While our review presents each candidate individually, they are often interdependent and need to be deployed in combination, e.g. Interdependencies make technological change complex, as does the need to consider the impacts of change on multiple stakeholders. We suspect a consequence of this is for people and teams to develop local practices that enhance tagging and tracking within their local work context, while still fitting in with larger systems. Team-focussed work provides incentives to adapt tools to increase effectiveness and cooperation . People Practices and challenges within DVI are also context-specific. For instance, the problem of locating remains within a single freezer unit could be solved by simple beacon location systems. However, if those remains are to be linked to additional data (e.g. antemortem or postmortem) further levels of technological support are required: postmortem tests may require remains to be transported or that there be auditing to show who had accessed the remains and when; what tests had been performed; and where the remains are. In this scenario, information about the remains would need to be read from and written to a database. While automated or semi-automated systems could be developed (e.g. using RFID), this approach might be best suited to a fixed mortuary facility, rather than a temporary mortuary at a disaster scene.There could also come a point when local practices “speciate”, i.e. become so different that they are no longer compatible with practices elsewhere . This presents real challenges when circumstances demand coherent, coordinated and consistent action from many different teams, as is the case in international disasters like the Boxing Day Tsunami or, more frequently, air crash disasters. However, local operations can also provide an environment for experimentation with new technology as well as reinforcement of practice.Training is clearly a critical pathway to technology adoption. Regular training enables DVI practitioners to adapt to sudden, catastrophic events without the additional mental load of learning new ways of doing things. Participants said their training relies upon one set of protocols and technologies to be applied in all situations. Thus any newly introduced technologies or practices should be careful not to negate previous training and be applicable to the wide variety of DVI contexts. Naturally, this constrains which technologies can be adopted.credibility (as in “this process/technology is a credible means to achieve a desired end”) and reliability (as in “this process/technology will perform predictably well”). Ideally, the benefits of change will be so compelling that desire for adoption will spread by word-of-mouth but realistically, training will also be critical.Training also establishes trust in terms of This, in turn, leads to the question: what are the opportunities and avenues for training those who would need to use new technology? We note that large-scale simulation events play an important (though infrequent) part of preparing for major disaster and emergency response. These events demand extensive preparation and are probably not the right place to experiment with novel approaches. Small-scale simulation, perhaps even involving virtual reality, seems a more promising avenue, and may also aid in the maintenance of DVI skills between real-world simulation events and actual disasters.New technologies must work across the physically challenging contexts of actual disasters. As such, designing or choosing technologies to support DVI systems requires an awareness of how these technologies may fail, yet continue to work well enough for the DVI process to be completed. For example, providing labels with identifiers that are both human- and machine-readable and writable allows for the human to take over when the machine is unavailable, and enables the cross-checking of human use when the machine is available. Identifiers exist in a great range of formats and, while care should be taken to not impact human readability, an increased number of identifiers on a single label would ensure its continued usefulness over a greater number of contexts and over time. This approach of ensuring graceful degradation of the transmission of information can be used with a number of DVI technologies.Proposed technologies also have to maintain interoperability with associated systems (e.g. police databases) over time. In scientific research, the guiding principles of Findability, Accessibility, Interoperability, and Reusability (FAIR) have been established with this issue in mind . UpgradiFor this reason we make a strong recommendation for engaging with tried and true technologies and systems already in use in DVI associated domains. We note that the GS1 information standard has had a distinct focus on healthcare since 2005, encompassing products , personnel  and processes (including sample handling in pathology). However, GS1 is yet to be embraced in DVI operations, at least in Australia where police and pathologists use closed identifier standards, local to each jurisdiction. One participant described their concerns about using an open system:…if one of these comes out in transit…someone can QR and scan it and get the information off it…That worries me. We’ve just got a straight bar code that will mean nothing to anyone that finds it.—WSThis caution is understandable, however GS1 supports identifiers that contain a mix of public and private information: a label could reveal only that it relates to a particular entity  while keeping more detailed information “opaque”, i.e. secure and interpretable only by that entity.DVI is a complex process performed in extraordinary circumstances by a diverse range of actors from first responders through to specialists in forensics, pathology and disaster response. By linking physical evidence to digital information, how can technology help us tag and track the victims of disaster? We have explored this motivating question by considering technology in the human system of DVI, mindful that it is not just usefulness and usability, but also the context and social practices around technology that affect its successful adoption.Protocols, and the training processes that embed them, are critical to coordinating the efforts of the many people involved in DVI. Training exercises provide a natural pathway to introduce, test and embed technological change.stress and a range of stressors on practitioners. Efforts to introduce new technology should be sympathetic to human factors by making key tasks easier to execute; reducing mental load and unnecessary repetition; and either avoiding opportunities for human error or flagging instances of human error.DVI involves significant plurality of information capture and management systems which have tended to evolve in parallel, rather than in strong coordination, at local, state, national and international levels. We anticipate that this is also the case for DVI in many other countries. Accepting that wholesale global redesign of these systems is unlikely, technology that improves information exchange would be welcomed, provided it enhances data security, business continuity and respects different jurisdictions.DVI in Australia uses a practicalities and constraints, from the physical challenges of the scene, to the social concerns of trust and teamwork under stress, as well as time and resource pressures. These issues affect technology choices both in terms of the extent to which the technology is practical to a situation and also whether a technological solution is the best investment of limited resources.DVI faces a host of Our interviews with Australian DVI practitioners elicited four main themes that systematically influence practice and shape candidate technology choice:Supplementary Information.We synthesised insights from study participants with our own expertise and research to produce 10 high-level considerations for technology to improve the linkage of physical evidence and digital information in DVI. We then characterised a range of technologies in terms of how their attributes meet these considerations, the details of which are available in searchable form as In abstract terms, this study evaluates different technologies for adoption to help humans (DVI practitioners) link physical evidence with digital information in a particular situation (disaster and emergency). We think that our approach could provide a useful framework for considering candidate technologies in other settings  where a range of actors and systems must cooperate to achieve high-quality outcomes.Starting with a holistic view of existing systems, processes, practices, preferences and social considerations reminds us that technology has to be accepted and adopted before it can yield its potential benefits.


Health-care-associated infective endocarditis (HCA-IE), a disease with a poor prognosis, has become increasingly important. As surgical treatment is frequently required, this review aims to outline surgical perspectives on HCA-IE. We searched PubMed to identify publications from January 1980 to March 2022. Reports were evaluated by the authors against a priori inclusion/exclusion criteria. Studies reporting on surgical treatment of HCA-IE including outcome were selected. Currently, HCA-IE accounts for up to 47% of IE cases. Advanced age, cardiac implants, and comorbidity are important predispositions, and intravascular catheters or frequent vascular access are significant sources of infection. Staphylococci and enterococci are the leading causative microorganisms. Surgery, although frequently indicated, is rejected in 24–69% because of prohibitive risk. In-hospital mortality is significant after surgery (29–50%) but highest in patients rejected for operation (52–83%). Furthermore, the length of hospital stay is prolonged. With aging populations, age-dependent morbidity, increasing use of cardiac implants, and growing healthcare utilization, HCA-IE is anticipated to gain further importance. A better understanding of pathogenesis, clinical profile, and outcomes is paramount. Further research on surgical treatment is needed to provide more comprehensive information for defining the most suitable treatment option, finding the optimal time for surgery, and reducing morbidity and mortality. Infective endocarditis (IE), still a condition with high morbidity and mortality, is a disease that summarizes a broad spectrum of infections of endocardial structures and cardiac implants with multifactorial pathogenesis and therefore requires a collaborative approach for adequate diagnosis and treatment ,2. AlthoA comprehensive database search was performed on PubMed for the period between 1 January 1980 and 31 March 2022, applying the following search terms: [“infective endocarditis” AND ] AND (“cardiac surgery” OR “heart surgery”). Reference lists of other published reviews and relevant reports were cross-checked to identify any additional studies. As depicted in Despite improvements in diagnostic and therapeutic strategies, neither the incidence of IE, ranging between 1.5 and 9.6 cases per 100,000 people, nor its mortality, ranging between 15 and 25%, have decreased ,6,10. ThThe development of IE is multifactorial . BecauseAlthough a variety of microorganisms can cause endocarditis, Staphylococcus aureus, followed by Streptococcus viridans and Enterococcus faecalis, are the most important pathogens being responsible for approximately 80% of IE cases overall ,10. NoneThe diagnosis of IE is based on clinical symptoms, blood cultures, and findings of imaging studies, primarily echocardiography . Regardi18F-FDG PET/CT), magnet resonance imaging (MRI), may provide more reliable results [18F-FDG PET/CT and radiolabeled leucocyte  scintigraphy could be helpful, as normal echocardiography does not rule out CIED related infective endocarditis [Positive blood cultures and echocardiographic findings  remain the cornerstones of diagnosis . In inco results ,10. Alth results ,12. Furt results . The diacarditis . For claFor diagnosis as well as for medical and surgical treatment, guidelines strongly recommend a multi-disciplinary approach (endocarditis team) involving cardiologists, cardiac surgeons, specialists for infectious disease, microbiologists, neurologists, neurosurgeons, and other experts, e.g., in congenital heart disease .As in IE in general, successful treatment of HCA-IE also relies on microbial eradication by antimicrobial drugs, preferring more effective bactericidal over bacteriostatic regimens . TreatmeThe goals of surgical treatment are radical resection of infectious material, prevention of embolism, and restoration of valvular function. In general, surgery is performed in about 50% of all patients with IE, although a theoretical indication is present in 70% ,10. RemaIn HCA-IE, outcomes, foremost survival, are significantly inferior as compared to CA-IE. In-hospital mortality, being 18–68% overall , is highThe study populations of included references are very different, i.e., different countries/continents, different centers, different patient cohorts, different study periods, etc. This heterogeneity among studies is an important limitation as it prevents the pooling of collective key characteristics and outcomes for analysis. In terms of study design, there is no publication comparing the surgical and medical treatment of HCA-IE. Nonetheless, using the semi-systematic approach as transparently described provides a current understanding of this complex area and shines a light on issues that warrant further research. Although the data regarding epidemiological features of HCA-IE refer to well-designed epidemiological studies on a more global level, they are still scarce and have limitations , to which barely cover a period beyond a decade.In summary, HCA-IE, characterized by high complication rates and adverse outcomes, continues to gain importance. Despite effective preventive measures, e.g., antimicrobial prophylaxis in patients at risk, meticulous care of intravascular lines, etc., its incidence is anticipated to rise, basically due to the increasing use of invasive medical procedures in the aging population. Moreover, the high rate of staphylococcal infection rather turns HCA-IE into an acute disease. Diagnosis, risk assessment, and decision making remain challenging. Although the theoretical indications for surgery are clear, their practical application relies largely on the clinical status of the patient, the patient’s comorbidities, and the patient’s operative risk. Considering that no single operative risk score is perfect, preoperative assessment of operative risk is of utmost importance. Given the paucity of published data, further research on surgical treatment of HCA-IE is needed to provide more comprehensive information that can support defining the most suitable treatment option, finding the optimal time for surgery, and reducing morbidity and mortality.


N = 60 participants  watched a relaxation video intervention depicting different natural scenery. We analyzed changes in HR and respiratory sinus arrhythmia (RSA) as a standard HRV measure, both based on 3-min segments from the experimental session, in multiple growth curve models. We found a decrease in HR and increase of RSA during the video intervention. Higher paternal care and lower trait mindfulness observing skills (assessed via questionnaires) were associated with higher RSA values before but not during video exposure. In Study 2, N = 90 participants  were assigned to three video conditions: natural scenery from Study 1, meditation video, or short clip from “The Lord of the Rings.” Again, HR decreased, and RSA increased during video segments, yet without expected group differences across different video types. We found higher parental care and lower parental overprotection to predict higher RSA at different times during the experiment. Interestingly, lower paternal overprotection predicted overall higher RSA. These results suggest a generic relaxation effect of video interventions on autonomic regulation that we discuss in light of different theories mapping restorative effects of natural environments. Further, psychological characteristics like aspects of early life adversity and trait mindfulness could contribute to individual differences in autonomic regulation. This study contributes to a better understanding of autonomic and psychological responses to relaxation videos.Growing evidence suggests that natural environments – whether in outdoor or indoor settings – foster psychological health and physiological relaxation, indicated by increased wellbeing, reduced stress levels, and increased parasympathetic activity. Greater insight into differential psychological aspects modulating psychophysiological responses to nature-based relaxation videos could help understand modes of action and develop personalized relaxation interventions. We investigated heart rate variability (HRV) as an indicator of autonomic regulation, specifically parasympathetic activity, in response to a 10-min video intervention in two consecutive studies as well as heart rate (HR). We hypothesized that a nature-based relaxation video elicits HRV increase and HR decrease, with response magnitude being affected by aspects of early life adversity  and trait mindfulness. In Study 1,  To understand the psychological and physiological effects of relaxation videos, standardized measures to identify the various aspects of reactivity to relaxation are needed  after a cognitive stressor showed significant stronger physiological relaxation than the control group, who viewed a video of an empty classroom, indicated by a reduction in electrodermal activity and an increase in HRV . This liEven though there are studies showing an increase in relaxation in reaction to either a real e.g.,  or virtuIn contrast, trait mindfulness, i.e., the general ability of being aware of one’s present surroundings, emotions and thoughts, is associated with life satisfaction, optimism and mental health  and coulIn two independent experiments, we aimed to investigate autonomic responses to different video contents and their generic ability to induce physiological relaxation in two consecutive studies, while exploring the potential impact of interindividual differences. In Study 1, we investigated whether popular nature-based videos (including audio) showing either a river stream in a forest, rain in the thicket, the crackling of burning wood in a fireplace, or waves crashing on a beach induce a psychophysiological relaxation response. We hypothesized that HR decreases and HRV increases as a result of the (video-based) nature exposure alone in comparison to a questionnaire baseline controlling for sex, age, and depressive symptoms cf. . BuildinN = 60 students  who responded to our advertisements posted on site at the University of Konstanz (flyers and online participant recruitment platform of the University of Konstanz). For inclusion in the study, participants were required to be at least 18 years of age, have sufficient German language skills, and be free of cardiovascular diseases  that could influence HRV measures. Inclusion criteria were part of the advertisements and verified during the laboratory assessment. Data collection for Study 1 took place from April to May 2018. All participants received 10€ or 1 h of course credit as study compensation after debriefing. The study protocol was approved by the Ethics Committee of the University of Konstanz and followed the guidelines outlined in the Declaration of Helsinki. Sample size was determined using the tool G*Power  river stream in the forest and bird sounds , (2) rai2. As it is recommend to calculate HRV in constant time intervals lasting between 1 and 5 min  on a two-electrode chest belt. The HR sensors were connected via Bluetooth with an 11-inch iPad  running the HRV Logger App for iOS  that recnd 5 min , we subsnd 5 min , we compnd 5 min , we applWe retrospectively assessed self-reported early life adversity with the Parental Bonding Instrument PBI, . The PBIWe used the Five Facet Mindfulness questionnaire FFMQ,  to measuUsing the Beck’s Depression Inventory II BDI-II, , we assek = 13 missing items in the PBI, k = 7 missing items in the FFMQ). If a participant omitted more than 20% of the items of a given subscale, this variable was coded as NA and excluded from the respective analysis . If addition of a random effect significantly improved model fit, we assumed that there was a significant amount of variance explained by inter-individual differences, either regarding average outcome values (intercept) or regarding change in outcome values over time (slope). The analysis of Study 1 included four time points: first set of questionnaires (t1), first half of videos (t2), second half of videos (t3), and second set of questionnaires (t4). We first defined the basic model structure regarding fixed and random effects by comparing model fit indices to find the model that best explained the data using LogLikelihood ratio tests. If the addition of the respective step improved the model fit significantly, this change was retained for the next step. We first introduced a fixed intercept, then random intercept on participant level, followed by fixed time effects for linear, quadratic and cubic trends over time , and finally random effects of the best-fitting time trend. To this basic model, we added potential covariates  one at a time to examine their effects on HR or RSA. Finally, we investigated the influence of the secondary predictors, early life adversity and trait mindfulness by adding each of the four PBI subscales  and each of the five FFMQ subscales  individually as interaction with trend of time to the final model. For these secondary predictors, we applied Bonferroni corrections for https://osf.io/wcdku/.Using the R package “performance” , we checN = 60 students in Study 1. We assessed F = 16.14, p < 0.001, marginal R2 = 0.17) to predict HR decrease during the video segments showed the best fit. For HRV, the best model fit was achieved by a random intercept (ICC = 0.74) and random slope for the linear time trend in combination with a fixed quadratic effect of time  = 33.80, p < 0.001, conditional R2 = 0.84, marginal R2 = 0.05) predicting RSA increase during the video segments. Potential covariates  did not change the results nor improve model fit for HR or RSA and were thus not included in the final model  looking at the effect of the nature-based relaxation videos in contrast to the two sets of questionnaires before and after the video. We found a significant decrease of HR and increase of RSA, respectively, while watching the video see . For HR,odel see .t(174) = –2.19, p = 0.030) and paternal care  = 2.25, p = 0.026). Higher maternal care was associated with lower HR before and during the first half of the video (t1 and t2); higher paternal care was associated with lower HR during the first half of the video only (t2). For RSA, only the interaction of quadratic time and paternal care reached significance  = 2.81, p = 0.006) participants with higher paternal care showing higher RSA before and after  but not during the video . However, after Bonferroni correction for four tests (αBonferroni = 0.013), only the interaction effect of paternal care and quadratic time to predict RSA remained significant.Adding PBI subscales as secondary predictors to the mixed model regarding HR, we found a significant interaction for the quadratic time effect with maternal care  = 2.71, p = 0.007). For RSA, we found an interaction between the quadratic time trend and FFMQ-observing  = –2.91, p = 0.004). Both effects of FFMQ-observing skills survived Bonferroni correction for five tests (αBonferroni = 0.01). Higher FFMQ-observing scores were associated with higher HR and lower RSA before (t1) but not during the video segment .Concerning trait mindfulness and HR, we found an interaction between quadratic time and FFMQ-observing  participated in the study. Sample size was determined using the tool G*Power  < 17.5 or > 30, or having clinically relevant depressive symptoms, i.e., a BDI-II score > 18. A total of  G*Power  based on G*Power .The laboratory assessment in Study 2 resembled Study 1 if not described otherwise see . After gIn addition to the nature-based relaxation videos (describe above), two more video conditions were added to the design in Study 2. Participants watched the 10-min videos on a 13-inch MacBook Air  and used circumaural earphones  to maximize video audio and minimize ambient noise.The meditation video used in Study 2 invited participants to practice a beginner’s mindfulness exercise guided by a female voice . MeditatAs a control condition, we presented the third group in Study 2 with a film clip from the movie “The Lord of the Rings: The Fellowship of the Ring” . In addiThe measurements used in Study 2 to assess HRV, early life adversity, trait mindfulness, and depressive symptoms resembled Study 1 except two modifications: First, the physiological baseline implemented in Study 2 before the first set of questionnaires was added as the first time point (t0). To analyze this segment, we extracted one 180-s RR-interval from the middle of the 6-min baseline. Second, we used a BDI-II score > 18 in a pre-screening as an exclusion criterion for the laboratory assessment.k = 4 or k = 5 tests, respectively, thus adjusting the level of significance to αBonferroni = a/k. Again, for every step of model building, resulting model fits were evaluated using the Log-Likelihood Ratio as described above. An R Markdown file with the statistical analyses of Study 1 and study 2 can be found at https://osf.io/wcdku/.We applied the same pre-processing rational to outliers and missing values and the same growth curve analysis procedure as in Study 1. The available HRV time intervals entering into the analysis were: physiological baseline (t0), first set of questionnaires (t1), first half of videos (t2), second half of videos (t3), and second set of questionnaires (t4). After exploring random effects for intercept  and slope (time variable) in addition to a linear, quadratic, and cubic time trend and adding potential covariates  as described for Study 1, we examined the main effects of video condition and the interaction between video condition and the time trends on HR or RSA. Finally, as in Study 1, we investigated the influence of the secondary predictors, early life adversity and trait mindfulness by adding each of the four PBI subscales  and each of the five FFMQ subscales  individually as interaction with trends of time to the final model. For these secondary predictors, we applied Bonferroni corrections for N = 90 people. n = 30 each). Except for mindfulness experience the groups did not differ in any of these characteristics. Furthermore, the movie clip was rated as significantly more familiar, while all three videos were mostly rated as pleasant and relaxing. Regarding nature video content, we found that most participants chose “rain falling in the thicket” (32%); followed by “river stream in the forest” (27%), “fireplace” (22%), and “beach” (20%). Due to the unbalanced distribution of the selected video contents, this factor was not included in the subsequent analysis.In Study 2, we assessed F = 2.53, p = 0.041) and the interaction effect between group and quadratic time  = 7.91, p < 0.001, marginal R2 = 0.03, conditional R2 = 0.93) significantly predicted decrease of HR during the video segment. The interaction effect of group with the quadratic time trend was mainly driven by a stronger decrease of HR during the video segment in the meditation group  = –3.11, p = 0.002). For HRV, the mixed model with random intercept (ICC = 0.76) and fixed slope controlled for age as a covariate  = 15.32, p < 0.001) the cubic effect of time  = 5.92, p < 0.001) showed a main effect of group  = 7.07, p = 0.001, conditional R2 = 0.78, marginal R2 = 0.21) predicting RSA increase during the video segment. Notably, the relaxation video group presented a reduced RSA throughout the experimental session independent of time  = –3.03, p = 0.003). As expected, higher age was associated with lower RSA. Other potential covariates  did not improve model fit neither for HR nor for RSA and were thus not included in the final model . Comparable to Study 1, we found a significant decrease in HR and increase in RSA during the video segment compared to baseline see . For HR,odel see .t(350) = –3.24, p = 0.001) and overprotection  = 2.20, p = 0.028). Higher maternal care and lower maternal overprotection predicted a more pronounced increase of RSA during the video segment (t2). In addition, we found a main effect of paternal overprotection, with higher overprotection predicting lower RSA throughout the experiment  = –2.09, p = 0.040). Only the interaction of maternal care and quadratic time to predict RSA survived Bonferroni correction for four tests (αBonferroni = 0.013). None of the PBI subscales significantly predicted HR. Concerning trait mindfulness, none of the FFMQ subscales revealed significant results when added to the models predicting HR or RSA.When adding PBI subscales as secondary predictors to the mixed models regarding RSA, we found a significant interaction for the quadratic time effect with maternal care  to predict higher HR and lower RSA during the video in Study 1 only. This finding that higher scores of trait mindfulness, especially mindful observing skills, are associated with higher HR and lower RSA seems counterintuitive at first since it suggests less relaxation during the video. We assessed trait mindfulness using the FFMQ, including observing as one subscale, which can be seen as a cognitive function linked to attention. It was found that mindfulness positively influences executive control , self-ren Theory . Accordin Theory . In our The relationship between HRV and mindfulness experience is a complex one. We found that less mindfulness experience is associated with a lower HRV in general but scoring high on trait mindful observing skills leads to reduced HRV during the video. It is important to note that there is a fundamental difference between resting-state HRV and HRV in reaction to a stimulus. Therefore, it is not counterintuitive that mindfulness skills might lead to an increase in baseline HRV but prohibit a strong increase in reaction to a relaxation video.Several limitations should be considered when interpreting these results. First and foremost, we planned Study 1 with more liberal exclusion criteria and included a questionnaire baseline only. Adding a physiological baseline  in StudySecond, as discussed previously, the selected video material might not have been appropriate to investigate differential effects of a nature videos for several reasons: (a) content of the control video, (b) video presentation on laptop screens, and (c) unbalanced nature sceneries in the nature video condition. The control video, as discussed before, might have been too similar to the experimental condition and thus, we failed to investigate group differences even though we attempted to create comparable control intervention with the movie clip. Many studies researching the relaxing effects of a natural environment have used urban environments to search for group differences. This can be seen in real-life experiments, for example, the effect of a walk in a forest compared to a walk through a city . The forThe observation of overall lower RSA during the video condition in Study 2 was unexpected, but as this main effect was independent of the video intervention, it is most likely linked to group differences that exist beyond the experimental manipulation of our study. Though we tried to form comparable groups by quasi-randomly assigning participants to the different conditions, a more comprehensive pre-screening might be necessary in future studies to prevent such an effect. This should be applied especially when psychological characteristics that could constitute group differences are part of the research focus.n = 4 participants older than 30 years. Taking age into account when measuring HRV is especially important since HRV decreases with age in our and other studies, mainly between 20 and 35 years (n = 9) which suggests clinically relevant depressive symptoms  can be found below: The studies involving human participants were reviewed and approved by Ethics Committee of the University of Konstanz. The patients/participants provided their written informed consent to participate in this study.AB carried out the project administration, data curation, and formal analysis, did the conceptualization, performed the methodology, investigated the data, visualized the data, wrote the original draft, and edited the manuscript. RG wrote the original draft, edited the manuscript, carried out the formal analysis, and visualized the data. SS, CJ, and MW performed the methodology, collected the data, wrote, reviewed, and edited the manuscript. MM, UB, BD, and SD wrote, reviewed, and edited the manuscript. EU carried out the formal analysis, wrote, reviewed, and edited the manuscript, and performed the methodology. JP carried out the formal analysis and resources, wrote the original draft, supervised the data, did the conceptualization, and performed the methodology. All authors approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.