Many institutions implemented telehealth initiatives to provide social support for patients during the SARS-CoV-2 (COVID-19) pandemic. Little is known about the impact of these programs on patient support persons and the trainees who facilitated them.To assess perceptions of a resident physician and medical student-driven video visit program.We designed and implemented a trainee-led video visit navigation program across three affiliated urban hospitals to facilitate video visits between patients and their support persons. We used descriptive statistics to understand the patient population served by the program and employed surveys for support persons and trainees to assess attitudes on the program.From April to June 2020, a total of 443 video visits were completed. Surveys were conducted for 101 out of 184 (54.9%) support persons and 39 out of 65 (60.0%) of medical trainees. Surveys demonstrated that video visits helped alleviate the stress and anxiety of support persons having a hospitalized loved one they could not visit. For trainees, facilitating these connections helped mitigate stress and provided a mechanism to contribute to the pandemic response.Telehealth navigation programs provide high levels of connection for patients and their support persons during the COVID-19 pandemic and potentially beyond. Residents and medical students involved in these initiatives mobilized telehealth modalities to improve experiences with care delivery.The online version contains supplementary material available at 10.1186/s12909-022-03172-6. Visitor restrictions designed to limit the spread of SARS-CoV-2 COVID-19) isolated patients from their support persons [9 isolateIn response to visitor restrictions, many hospitals implemented telehealth initiatives designed to facilitate patient connection to outside support persons through video visits –7. HowevAt our academic medical centers, a group of medical students and resident physicians implemented an inpatient telehealth program to connect patients and support persons through video visits. In this study, we report on the characteristics of patients served by the video program intervention, as well as the impact on patients’ support persons and the trainees who implemented the program.The video visit navigation program was designed in March 2020 by a group of resident physicians, medical students, and faculty at affiliated teaching hospitals where medical trainees participate in clinical rotations. The institutions include a tertiary and quaternary referral center, a community safety net hospital, and a federal healthcare facility.Trainees used a rapid quality improvement approach to design the video visit navigation program aimed at facilitating video visits between patients and their support persons , 10. TraWe identified all patients and their support persons who participated in a video visit from April 13, 2020, to May 31, 2020, at all three clinical sites. We collected demographic and clinical data of all patients who participated in video visits via chart review. Patients with missing medical record number data or restricted medical records were excluded from the analysis. COVID-19 positive patients were not represented in the analysis, as hospital administration restrictions at the time of this initiative precluded medical students from engaging in the care of and facilitating video calls for COVID-19 positive patients. Contact information of patient support persons was collected as part of the video visit intervention. Support persons without recorded contact information were excluded from the study. The trainees involved in facilitating video visits were identified through a communication platform used during the navigation program operations.We developed two survey instruments, one for support persons who participated in the visits and one for the trainees who facilitated them. The development of both surveys was informed by focus groups and interviews with physicians and by a systematic review of prior surveys to assess patient and clinician perspectives on telemedicine satisfaction –13. As nThe support person survey assessed the impact of video visits on support persons’ feelings of isolation and stress. Support persons rated their agreement with statements regarding their perspectives on visitor restrictions and the video visit navigation program on a Likert scale from 1 (strongly disagree) to 5 (strongly agree) Appendix ppendix ATrainees also provided their perspectives on visitor restrictions and the impact of the video visit navigation program on connection and emotional distress using a Likert scale from 1 (strongly disagree) to 5 (strongly agree) Appendix . TraineeWe contacted patient support persons, the primary recipient of video visits, by phone a maximum of two times to administer the phone-based survey. Support persons provided verbal informed consent during the survey for this minimal risk study. Trainees who facilitated the video visits were contacted by email with an online survey. A total of two reminder emails were sent to each trainee.Patient demographics were summarized using descriptive statistics. Continuous variables were reported as median and interquartile range. Categorical variables were reported as number and percent of total. Survey questions that were not answered or skipped by respondents were omitted from the analysis. Fisher exact test at a significance level of 0.05 was used to compare categorical variables. Qualitative responses in the trainee survey were analyzed using a rapid qualitative template analysis which included themes from the Theory of Planned behavior . Templates were iteratively revised to incorporate emergent themes . Two revDuring the seven-week period from April 13, 2020, to May 31, 2020, trainees facilitated a total of 443 video visits for 184 unique patients from a range of referring services. The characteristics of the video visit participants are summarized in Table Of the 184 support persons that participated in video visits, 101 (54.9%) completed the survey, 58 individuals could not be contacted or did not answer the phone call, and 25 refused the survey. Of the patient support persons who completed the survey, 88 (87.1%) were immediate family members.n = 80, 82.5%) that the visiting restrictions isolated them from patients in the hospital, but they felt that the video visit helped them connect  and cope with the stress of their loved one being in the hospital . A smaller proportion agreed or strongly agreed that the video visit helped them stay involved in the care of the hospitalized patient . Support persons reported a preference for video visits over using a phone  and endorsed the continuation of video visit when visitor restrictions are lifted . There were no significant differences in the proportion of support persons of patients who received ICU level of care compared to the support persons of patients who did not receive ICU level of care who agreed or strongly agreed with all statements in the survey.Patient support persons agreed or strongly agreed  completed the survey. One trainee who could not be contacted by email and five trainees who submitted surveys with empty responses were not included in the analysis. Survey respondents included 31 (79.5%) medical students and 8 (20.5%) resident physicians.n = 39, 100%) agreed or strongly agreed that the visitor restrictions isolated patients from their support persons, but they felt that video visits helped connect patients to their support persons  and helped support persons stay involved with care of hospitalized patients . Trainees involved in the program reported high levels of emotional distress due to visitor restrictions during the pandemic: 33 (84.6%) trainees agreed or strongly agreed that witnessing the isolation of patients during visitor restrictions was stressful. Trainees felt they were having a positive impact during the pandemic through their involvement in the initiative  and felt that being a part of the program engendered a sense of belonging and community . There were no significant differences in the proportion of medical students compared to residents who agreed or strongly agreed with all statements in the survey.Trainees  that limited their ability to participate in surveys, we chose to investigate the perspectives of the other important people directly involved in the video visits: the patient support persons who were recipients of the video visits and the medical trainees who facilitated the video visits. Both patient support persons and medical trainees had high levels of agreement that the video calls helped provide meaningful connection during visitor restrictions. While the isolation of patients in the context of visitor restrictions was distressing for all, participating in this video visit initiative helped alleviate this stress for both the support persons who connected with their loved ones and the trainees who facilitated this connection.While 89.7% of medical trainees agreed or strongly agreed that the video visits helped loved ones stay involved in the care of hospitalized patients, only 73.5% of loved ones of patient support persons agreed or strongly agreed that the video visit helped them stay involved in the care their loved one received in the hospital. Given that this initiative was designed primarily with the goal of bridging connection between patient and their support persons rather than between support persons and patient care teams, further design considerations could be implemented to enhance and better incorporate the communication of care planning to remote patient support persons.Our program demonstrates the ability of trainees to creatively organize a volunteer workforce and mobilize the support of the community around enhancing patient care. Our entirely volunteer workforce received no compensation, and the operational costs were entirely funded by donations. Our team solicited tablet donations, utilized free video conferencing software, and fundraised around $10,000 to pay for ancillary hardware . In June of 2020, at our main hospital the Telemedicine Resource Center (TRC) assumed responsibility for staffing the video visit service supporting two full-time equivalent clerk positions. The TRC also integrated consult ordering workflows into the electronic medical record, allowing providers to order a video visit within the electronic medical record seven days a week from 8 AM – 8 PM. The success of the program and the responses of our trainees suggest that medical trainees are suited to mobilize resources and advocate for sustainable improvements in gaps of care delivery, which may serve as a powerful antidote for their own anxiety and stress.Limitations of this study include response bias since support persons with strongly negative or positive experiences may have been more likely to engage in the survey. Consults to the video visit service were initiated by providers, which may pose a source of selection bias of the video visit participants. Additionally, survey administrators also led tablet operations, which may introduce acquiescence bias for the support persons who engaged in video visits as well as the trainees who facilitated the program. Lastly, patient experience and satisfaction were not directly assessed in this analysis.This study demonstrates the meaningful benefits a telehealth initiative had on engaging trainees and connecting patients with their outside support systems across diverse practice settings. Engaging trainees directly in times of crisis may foster a sense of meaning, purpose, and community that can lead to sustainable improvements in the healthcare delivery system.Additional file 1.


Active plant-based systems are emerging technologies that aim to improve indoor air quality (IAQ). A person’s olfactory system is able to recognize the perceived odor intensity of various materials relatively well, and in many cases, the nose seems to be a better perceiver of pollutants than some equipment is. The aim of this study was to assess the odor coming out of two different test chambers in the SenseLab, where the participants were asked to evaluate blindly the level of acceptability, intensity, odor recognition, and preference at individual level with their noses. Two chambers were furnished with the same amount of new flooring material, and one of the chambers, Chamber A, also included an active plant-based system. The results showed that in general, the level of odor intensity was lower in Chamber B than in Chamber A, the level of acceptability was lower in Chamber A than in Chamber B, and the participants identified similar sources in both chambers. Finally, the preference was slightly higher for Chamber B over Chamber A. When people do not see the interior details of a room and have to rely on olfactory perception, they prefer a room without plants. The improvement of indoor air quality (IAQ) is a constant and significant concern among researchers. Indoor air pollutants can be emitted by several indoor sources, such as furnishings, building materials, and cleaning products ,2,3,4,5.On the other hand, health and comfort complaints have been associated with poor IAQ due to emissions from building materials and furnishings where people spend most of their time. These complaints can range from annoying smells to symptoms such as dry eyes, irritated skin, and airway problems, to carcinogenic effects ,17. ThesThe aim of the study was to test the effect of an active plant-based system on the perceived air quality of a recently furnished room. For this purpose, two identical test chambers of the SenseLab were furnished with new carpet tiles. In one of the chambers, an active plant based-system was added. The SenseLab is a laboratory for testing and experiencing single and combinations of indoor environmental conditions located at Delft University of Technology .Based on previous studies, first an active plant system was designed and realized. Then, two test chambers of the SenseLab  were furNephrolepis exaltata L. in the medium expanded clay performed the best.From earlier conducted experiments on the depletion of formaldehyde by potted plants , it was Nephrolepis exaltata L.  plants were re-potted on expanded clay. In addition to having the best performance in the depletion of formaldehyde during the laboratory tests, the density of this medium allows the air to go through the substrate easier than it does with other substrates . The structure of the active plant-based system was built with low-emitting materials: aluminum frame together with Plexiglas elements that held the 30 plants.Therefore, for the prototype of the active plant-based system, 30 3/h, 0.16 A/12 V, 1.92 watt, sound level: 0.3 sone/22.4 dB) that forced the air to go through the plant itself and through the growth medium. To keep the plants in the system alive and provide the right amount of light that the plants need to grow, a growing LED (Light-emitting diode) light  was installed in Chamber A. The fans were activated for 12 hours every day during the whole experiment with the help of a plug-in mechanical timer, and the plants received water once per week. Each of the 30 plants was then connected to a fan , was furnished with 9.36 m2 of new carpet tiles. To evaluate the efficacy of the active plant-based system on the perceived air quality, two chambers in the SenseLab were selected to execute the experiment. The two test chambers have the same features and are constructed of low-emitting materials to ensure a good air quality. Each chamber, having a volume of 19.7 m2 levels were monitored during the whole experiment (from 04 April 2019 to 14 May 2019). Three sessions of evaluation with subjects were executed every two weeks. The sessions were executed during the same season around the same time to keep the variables as similar as possible. The changes in temperature and relative humidity inside of the chambers were monitored with two HOBO External data loggers, and the CO2 levels were monitored with HOBO® MX CO2 loggers. A FlowFinder MK2 and ComfortSense Mini (compact anemometer for ventilation and draught measurements) were used to measure the air supply in the chambers and the air velocity in the (sniffing) tube, respectively. Additionally, a VOC-monitoring instrument (Photoionisation Detector (PID) ppbRAE 3000 with 11.7 eV UV lamp) was used to measure the air pollutants coming out of both chambers. It is important to mention that all the instruments used during this study were calibrated and tested prior the experiments to obtain reliable data.The temperature (T), relative humidity (RH), and COTo assess the perceived air quality coming out of the chambers, a questionnaire was developed based on the questionnaire used by Gunnarsen and Fanger, 1992 . For thi3/h to 500 m3/h to reduce the amount of air (~130 m3/h to ~50 m3/h inside of the selected chambers); therefore, the air velocity also changed from 2.3 m/s to 1.5 m/s coming out of each funnel. During the pilot test, the air velocity was found to be too high (2.3 m/s) for properly assessing the perceived air quality. It is important to mention that every funnel had a diameter of 0.11 m, and with 1.5 m/s air velocity, therefore, 12 L/s of air were coming out of the funnel.To evaluate the procedure and the questionnaire, a pilot test composed of three sections—intensity, acceptability and recognition—was executed on 4 April 2019 with 59 participants. Before the participants completed the questionnaire, an explanation was given of the contents and purpose of the experiment and questionnaire. In general, it took the participants approximately 3–5 min to perform the test and complete the questionnaire. After the pilot test, the questionnaire was modified and the section “Preference” was added in the last part of the questionnaire. Additionally, the air supply rate to all the test chambers  was changed from 1000 mAfter the pilot test, the questionnaire was fixed and three sessions of assessments were performed, each with two weeks in between. The recruitment of the participants was on a voluntary basis. When the participants arrived in the SenseLab, they were given a questionnaire with some general information about themselves and with some questions related with the assessment of the odor coming out of every chamber. The participants were assigned randomly where to start the assessment . The participants were asked to give their assessments of the air for each of the chambers by completing the questionnaire. For each question, the participants were allowed to take only one sniff in order to avoid “adaptation” to the smell coming out of the funnel . After tThe participants took 5 min to perform the assessment and complete the questionnaire of both chambers.The Ethics committee of the TU Delft provided approval for the study. Each participant received a voucher after they completed and handed in their completed questionnaire. By handing in the questionnaire, they gave consent for using their assessments.All data from the questionnaires were manually typed in and stored in IBM SPSS Statistics version 25.0 and Microsoft Excel. First, comparisons of mean values were performed with independent t-tests, and standard deviation and standard errors were used to evaluate levels of intensity and acceptability of every chamber. These tests were used to evaluate whether statistically significant differences between different sessions and chambers occurred, in time. In addition, descriptive statistical analyses were executed to evaluate frequencies in odor recognition and preference, and chi-square tests were executed to evaluate the correlation between the starting funnel and the level of preference of the participants.Although the participants pointed out that they perceived an odor , the 11.7 eV PID monitor used to measure the TVOC concentration resulted in 0 ppb for both chambers. This could be due to the measurement range of the VOCs that the instrument can detect, or the detection limit of the instrument .2 concentration inside of the Chambers A and B at each of the session days are presented in 2 levels were on average ~197 ppm higher than in Chamber B during the first session. 2 levels in Chamber B during session 2 and 3 were quite similar, while in Chamber A, those levels presented a slight fluctuation. Finally, the air supply and the air velocity of the chambers were measured before the sessions  and stayed constant throughout the execution of the experiment.The temperature, relative humidity (RH), and COThe participants were asked to take a sniff from one of the two funnels and to answer the following question: “How strong is the odor that you smell? Give your opinion with a cross or a dash on the scale below (intensity)”. p = 0.004). Additionally, a statistically significant difference between Session 1 and Session 2 (p = 0.02), and between Session 1 and Session 3 (p = 0.005), was found for Chamber A, indicating the odor intensity became stronger over time. For Chamber B, a statistically significant difference between Session 1 and Session 3 (p = 0.022) was found, showing that the odor intensity in Session 1 was significantly lower than in Session 3.Several independent-samples t-tests were conducted to evaluate whether differences between the odor intensity assessments of Chambers A and B were present during the sessions, and between the sessions. The analysis resulted in a statistically significant difference in odor intensity between the two chambers for Session 2 ”. For this analysis, the range of the acceptability scale considered is from clearly acceptable = 1 to clearly not acceptable = −1. p = 0.045). In general, the participants evaluated the acceptability level of the air in funnels A and B to be less acceptable for each session (p = 0.005) was found, as well as for Session 1 and Session 3 (p = 0.012). For Chamber B, no statistically significant differences between the sessions were found.Several independent-samples t-tests were conducted to evaluate whether differences between the acceptability assessments of chambers A and B were present during the sessions, and between the sessions. A statistically significant difference between the chambers was found for Session 2 ”. Last but not least, the participants were asked to answer the following question (about preference): “Which funnel do you prefer?” To evaluate the preference of the participants during the sessions, frequency analysis was performed. p = 0.23; Session 2: p = 0.35; Session 3: p = 0.57).To evaluate whether there was a statistically significant relation between the starting funnel of the tests and the level of preference of the participants, chi-square tests were performed. The outcome showed no correlation between the starting funnel and the preference level during the three sessions  ,15 whereFor this study, the concept of active biofiltration was built in one prototype with a fixed air flow rate created for the fans connected to the plants. It is, therefore, recommended that future studies test the effect of different air flow rates to choose the optimal option. Additionally, The aim of the study was to assess the perceived air quality coming out of two different test chambers in the SenseLab: Chamber A, which was furnished with new carpet tiles and an active plant-based system, and Chamber B, which was furnished with the same amount of carpet tiles as in Chamber A, but without the active plant-based system. From the assessments performed in the three sessions, it can be concluded that the level of acceptability in Chamber A was lower than in Chamber B, and the level of intensity was higher in Chamber A than in Chamber B. Moreover, three main odors were identified in both chambers: medicinal, chemical, and earthy. Finally, the participants expressed a slightly higher preference for Chamber B over Chamber A.Although there are many possible factors that might have influenced the assessments, the outcome indicates that when people do not see the interior details of a room and have to rely on olfactory perception, they prefer a room without plants. The results also show that sensory evaluation is a necessary instrument for the assessment of the indoor air quality because chemical and physical measurements and analysis alone cannot be used in the majority of the cases to predict how the pollutants and their emissions will be perceived by occupants.Finally, even though previous laboratory studies have shown the chemical depletion of air pollutants in the close surrounding of vegetation ,11,12,13


Players covered the highest amount of sprinting distance in L5 games compared to all other game formats . In all the game formats, players spent from 3.04 to 5.96 min in 180–200 bpm and 0.03 min to 0.85 min in >200 bpm of the total 15 min. In addition, both genders had more shots in S3 + 1 than M5 ) and L5 ). Team handball matches have high heart rates, total distances covered, and high-intensity running distances for U9 boys and girls irrespective of the game format. Locomotor demands appeared to be even higher when playing on larger pitches, whereas the smaller pitch size and fewer players led to elevated technical involvement.The purpose of this study was to quantify the exercise intensity and technical involvement of U9 boys’ and girls’ team handball during different game formats, and the differences between genders. Locomotor activity , heart rate (HR), and technical involvement  metrics were collected during various 15 min game formats from a total of 57 Danish U9 players (37 boys and 20 girls). Game formats were a small size pitch (20 × 13 m) with 3 vs. 3 players and offensive goalkeepers (S3 + 1) and 4 vs. 4 players (S4), a medium size pitch (25.8 × 20 m) with 4 vs. 4 (M4) and 5 vs. 5 (M5) players, and a large size pitch (40 × 20 m) with 5 vs. 5 (L5) players. Boys and girls covered a higher total distance (TD) of high-speed running (HSR) and sprinting during L5 games compared to all other game formats ( Team handball is an intermittent high-intensity body contact team sport, characterized by sprinting, jumping, throwing, blocking, and pushing . VariousMoreover, the sex-specific timing of maturation ,12 and tBased on previous findings in a study of the game format of U13 handball , we hypoThe purpose of this study was, therefore, to quantify the exercise intensity, the technical involvement, and a gender comparison of U9 boys’ and girls’ team handball during different game formats. The study provides useful knowledge that might change the game format used in tournaments for U9 players for relevant development and health promotion. 2 per player);(S3 + 1): 3 vs. 3 + offensive goalkeepers on a small size pitch size of 20 × 13 m (37 m2 per player);(S4): 4 vs. 4 on a small size (33 m2 per player);(M4): 4 vs. 4 on a medium size pitch size of 25.8 × 20 m (65 m2 per player);(M5): 5 vs. 5 on a medium size (52 m2 per player).(L5): 5 vs. 5 on a large size pitch size of 40 × 20 m  participated in a 1-day tournament. Up to 5 games per player were used. Game formats were classified according to the pitch size and number of players that represent possible official games:In all of the above formats, goalkeepers participated, but they only were tracked in S3 + 1. To remove the effect of exercise volume and fatigue, the game duration was maintained at 15 min, and the games were played in a randomized order on the same day. All games were played on indoor team handball pitches. The sizes of the goals were 1.6 × 2.4 m on the small pitch, 1.78 × 3 m on the medium pitch, and 2 × 3 m on the large pitch. The games were played with all the official rules of the team handball game. The study was carried out according to the Helsinki protocol.n = 37) and four teams of U9 girls (n = 20) participated in the study. All participants were 8–9-year-old recreational handball players.Six teams of U9 boys (Vpeak) attained, and number of sprints (>18 km/h). Exercise intensity was also distributed in the following running zones: standing/walking , jogging (3.00–7.99 km/h), moderate-speed running , high-speed running , and sprinting (>18 km/h), according to previous studies describing the locomotor demands of team sports’ children [The activity patterns were recorded using a wearable device incorporating a 200 Hz accelerometer and gyroscope , which was placed on the lower sternum using an elastic band. The following variables were adopted: total distance (TD) covered, peak speed  engaged by the Danish Handball Federation (DHF). The operational definitions of these variables were the following: goal (an attempt with successful scoring), shot  part of the body, either on or off-target), successful shot , 1 vs. 1 duels  ,20.p ≤ 0.05. Data analysis was performed using the Statistical Package for Social Science statistical software  and an online-available Excel spreadsheet [Differences between game formats and between sexes were analyzed using a linear mixed model with unstructured covariance, considering the fact that participants differed regarding the number of game formats they participated in . The gameadsheet . p < 0.05; ES = 0.9 to 1.9). Moreover, the TD was moderately higher in S3 + 1 compared to M5 . Higher peak speed were reached during L5 compared to S4 and M5     A.p < 0.05; ES = 0.9–2.1). In addition, the TD was moderately higher in M4 compared to M5 . Higher peak speed were reached during L5 compared to S3 + 1 . Girls covered more HSR and sprinting and performed more sprints in L5 compared to S3 + 1, S4, M4, and M5     B.total and Dectotal were lower in L5 compared to S3 + 1, S4, and M4 . In addition, M5 exhibited lower number of Acctotal and Dectotal than S3 + 1 and S4 . The numbers of Acc<1.5 and Acc1.5–2.3 were lower during L5 compared to S3 + 1, S4, and M4 . Conversely, the number of Acc<1.5 was moderately higher in S4 compared to M5 ), and the number of Acc1.5–2.3 was largely higher in S3 + 1 than M5 ). Notably, lower number of decelerations were observed during L5 compared to S3 + 1, S4, and M4 . Furthermore, higher number of Dec1.5–2.3, were observed in S3 + 1 compared to M5 and L5 . Additionally, S4 showed higher number of Dec1.5–2.3 than M5 ). S3 + 1 showed higher number of Dec>2.3 than M5 ).Furthermore, number of Acctotal and Dectotal were lower in L5 compared to S3 + 1, S4, and M4 . In addition, M5 exhibited lower number of Acctotal than S3 + 1, S4, and M4 . M5 had moderately lower number of Dectotal than M4 ). Girls had lower number of Acc<1.5 during L5 compared to S3 + 1, S4, M4, and M5 . Similarly, during L5, girls had lower number of Acc1.5–2.3 than S3 + 1, S4, and M4 . In addition, Acc1.5–2.3 had fewer efforts in M5 than in S3 + 1 and S4 . In Dec1.5–2.3, L5 had lower number of efforts than S3 + 1, S4, and M4 . In addition, Dec1.5-2.3 in S3 + 1 had higher number than M5 . Detailed representations of accelerations and decelerations are reported in For girls, number of Accpeak in S3 + 1 compared to S4 ) ) (p > 0.05). Girls had higher times below 120 bpm during S3 + 1 compared to M4 and L5  ) (p > 0.05) ) . In addi3; 1.3)) . No sign to 1.6) . In addi3; 1.5)) . No sign > 0.05) .p < 0.05; ES = 0.8 to 1.1). In contrast, no differences were observed for goals, successful shots, or duels in all the formats. For girls, the total amount of goals was higher in S3 + 1 than in M4, M5, and L5 , as well as in S4 compared to M5 ). In addition, situation S3 + 1 had more shots than M5 and L5 . Furthermore, girls were less successful with shots in M5 than in S3 + 1 and S4   .p < 0.05; ES = 0.8 to 0.9). Furthermore, the boys reached higher Vpeak during S4 and M5 compared to the girls . Moderate higher sprints were observed in the M4 format for boys compared to girls . Notably, the jog distance was higher for boys during S3 + 1, S4, M4, M5, and L5 compared to girls . In addition, sprinting in M4 and L5 was higher for boys than girls . Moreover, Acctotal and Dectotal were higher in S3 + 1 for boys compared to girls . Acc<1.5 was moderately higher during S4 in boys compared to girls ). Notably, boys had higher numbers of decelerations during L5 compared to girls in Dec>2.3 ). Furthermore, S3 + 1 and S4 formats had more decelerations for boys compared to girls . Conversely, in Dec1.5-2.3, girls had more decelerations in M4 than boys ).The boys covered more TD in S3 + 1, S4, M5, and L5 compared to the girls  ). A detailed representation of the differences in activity profile, heart rate, subjective ratings, and technical involvement is reported in The girls had higher Time to 1.9) . In addiVpeak, sprints, HSR, and sprinting were higher, whereas St/W, JOG, Acctotal, Dectotal, Acc<1.5, Acc1.5–2.3, Acc>1.5, Dec<1.5, Dec1.5–2.3, and Dec>1.5 were lower than other formats and, on many occasions, significantly different. This may be because there is more room for sprinting and high-intensity running on larger pitches, which is supported by the greater distance covered with high-intensity running and higher Vpeak during games on larger pitch sizes (40 × 20 m) compared with small pitches (20 × 13 m) in adult football players [180–200 and Time>200 in S3 + 1 format, young girl and boy team handball players spent more time above 180 bpm, which is not significantly different but working at a high intensity for more time could improve cardiorespiratory fitness positively [1.5–2.3, which had more decelerations in the M4 format. However, for physical loading between sexes, similar HR values were found, with only three comparisons, girls spent more time below 120 bpm in S3 + 1 and S4 compared to boys for Time>200 in S4. Additionally, no significant differences were found for subjective perceptions or the technical analysis. In conclusion, having both genders mixed in the same format and game would possibly be very demanding for girls in terms of activity patterns at this age.This study provides the first detailed analysis of movement patterns and heart rates in U9 team handball for boys and girls, showing that the exercise intensity, heart rates, and technical involvement are high during small, medium, and large-sized games in all investigated formats. When comparing game formats, we observed higher distances covered and more sprints with L5 but a lower number of accelerations and decelerations compared to all the other formats. Notably, heart rates were similar between game formats. Irrespective of game format, boys covered 977–1320 m and girls covered 846–1124 m. For boys and girls, remarkably in the L5 format, TD,  players . Interes players . It is w players ,28, and  players . The mea players . Aerobic players ,32, whic players . Sports  players . For thesitively . No diffsitively  that fousitively . Interessitively , as it hsitively . Only onIt is important to underline some limitations inherent to this study, Firstly, physical and physiological demands were compared across game formats of various pitch sizes and numbers of players, and thus, relative space per player was not constant. Secondly, maximum HR, maximal aerobic speed, and maximal sprinting speed were not assessed. The use of fixed HR and speed zones does not reflect the actual individual capacity, possibly resulting in under- or overestimating the real physical and physiological demands of the game. Although the technical analysis was carried out by experienced handball coaches, this analysis could be somewhat subjective. Thus, our technical analysis should be interpreted with caution. Finally, for logistical reasons, we were unable to describe the physical levels of the players. Future studies are warranted to use individualized HR and speed zones to accurately quantify the physical and physiological demands of youth team handball as well as physical evaluations of the players. In this context, the fitness component of max speed can be adopted in future studies as suggested by .In summary, the HR and high-intensity distances are high in U9 team handball matches irrespective of the game format. The present data provide insight into how different game formats influence the physiological and the physical loading and evidence that various types of match-plays can contribute significantly to the improvement in the musculoskeletal and cardiovascular fitness of U9 boys because of high HRs and high-intensity running distances, along with multiple accelerations and specific actions with considerable impact. In all the game formats, physical loading seems similar but, interestingly, on the large pitch, the physiological load was higher. Playing with fewer players on smaller pitches resulted in minor changes to the physiological loading but elevated the technical involvement of players, which favors the use of smaller formats to emphasize technical demands. Several differences between girls and boys were found in U9 team handball players that should be considered when planning games for boys and girls separately or for mixed-gender games. The various game types could provide valuable information to coaches in the selection of players or training guidance. We would recommend the use of games with fewer players on smaller courts for U9 boys and girls since we believe that technical development is the most important factor at this age.


Background: Alcohol consumption and distress have increased among Canadians since the start of the COVID-19 pandemic.Methods: We examined whether sociodemographic and COVID-19-related worries are associated with various combinations of alcohol consumption and comorbid psychological distress variables among a Canadian sample of adults. Data were derived from a sample of Canadian adults  who participated in an online survey in May 2020. Four multivariate ordinal logistic regression models were used to estimate the odds of binge drinking, increased alcohol consumption during the pandemic, and psychological distress. Predictor variables used in the analyses included self-reported sociodemographic characteristics, financial worries, COVID-19 impact on work, and worrying about getting ill.Results: Women were found to have higher odds of increased drinking and anxiety. Also being divorced, separated, or widowed was associated with higher odds of binge drinking and anxiety, and binge drinking and depression. Furthermore, being 60 or older was associated with lower odds of binge drinking and depression and increased drinking and depression, as well as lower odds of increased drinking and depression and increased drinking and anxiety. High income groups were associated with higher odds of binge drinking, increased drinking, and mental distress. Compared to those less worried, being very worried about finances were associated with higher odds of binge drinking and anxiety, increased drinking and anxiety, and increased drinking and depression. Also, being very worried about getting ill with COVID was associated with higher odds of binge drinking and anxiety and increased drinking and anxiety.Conclusion: Our findings identify several demographic and COVID-related worries for increased odds of alcohol intake and co-morbid psychological distress during the COVID-19 pandemic, including identifying as a woman, high income groups, being divorced, separated or widowed, and experiencing financial worries and COVID illness worries. These characteristics should be considered when developing prevention and treatment programs for adults with problematic alcohol use and comorbid anxiety and depression. At the beginning of Spring 2020, the coronavirus disease 2019 (COVID-19) hit many countries globally, including Canada. This led the federal and provincial authorities to implement stringent measures to limit the virus' spread and flatten the curve. These measures included closures of schools, non-essential businesses, and community centers, resulting in most of the population being confined to their homes. Upon a phased reopening, strict physical distancing measures were implemented, resulting in diminished frequency and quality of social interactions  anxiety, depression, and problematic substance use as the demands of coping with the pandemic may outweigh perceived emotional and financial resources to cope . Indeed,Several studies have examined substance use, such as alcohol consumption, during the COVID-19 pandemic –9. A recIncreases in alcohol consumption and binge drinking, relative to pre-pandemic levels, could be due to many factors including a maladaptive way of coping with stress and anxiety  , 11. AddAlthough, the determinants of anxiety, depression, and problematic substance use are each widely studied, less attention has been paid to the factors associated with experiencing both mental health and substance use problems at the same time, a phenomenon known as concurrency. It can also be called, dual diagnosis, dual disorders, or co-occurring substance use and mental health problems . PreviouThe high prevalence and personal and economic costs of concurrency highlight a crucial need for a better understanding of its determinants, and this is especially important during the pandemic to inform the development of effective treatment and prevention strategies. The relationship between the two concurrent conditions is complex  and factAccordingly, the purpose of this study was to examine the association between socio-demographic, and COVID-19 related worries and combinations of concurrent alcohol use, depression, and anxiety in a sample of Canadian adults during the COVID-19 pandemic.N = 1,005) completed an online survey in the early part of the pandemic from May 8 to 12, 2020, through an automated web-based panel which links organizations to real people to obtain data . Participants were sourced from the AskingCanadians web panel (http://corporate.askingcanadians.com/) of over 1 million Canadians hosted by Delvinia . Respondents were recruited on the basis of loyalty collaborations with retailers, departmental stores, and airlines. The study was approved by the Research Ethics Board at the Centre for Addiction and Mental Health. Also, this study has been reviewed by the Research Ethics Boards of the Children's Hospital of Eastern Ontario (CHEO). Participation was voluntary, and all participants provided their consent electronically. Quota sampling was utilized such that the sample of 1,005 adult respondents reflected the distribution of English-speaking Canadians by gender, age, and geographic region .This study performed a secondary data analysis based on data from a survey conducted by the Centre for Addiction and Mental Health in collaboration with Delvinia, a research technology and market survey company. An English-speaking Canadian adult sample  . The 3-iAnxiety was measured using the Generalized Anxiety Disorder (GAD-7) scale . This isIncreased alcohol consumption was measured using the following item: “In the PAST 7 DAYS, did you drink more ALCOHOL, about the same, or less alcohol overall than you did before the COVID-19 pandemic started?” Response options were coded 1 = “Drink much more alcohol,” 2 = “Drink slightly more alcohol,” 3 = “No change,” 4 = “Drink slightly less alcohol,” 5 = “Drink much less alcohol.” A dichotomous measure was created to reflect increased alcohol consumption  or not. Individuals who did not report consuming alcohol in the past week were coded as no increase in use.Binge drinking was assessed by the item: “how many of the PAST 7 DAYS did you drink [four (if woman) or five (if man) or five (if another gender)] or more drinks on one occasion? A drink means 341 ml or 12 oz. bottle of beer or cider/cooler , a 142 ml or 5 oz. glass of wine , or a straight or mixed drink with 43 ml or 1.5 oz. of liquor .” Response options ranged from 0 to 7 days. In the data analysis, binge drinking was operationally defined as consuming five or more drinks per episode for men and as four or more drinks per episode for women. This was coded dichotomously as binge drinking (1) or not (0). Individuals who did not report consuming alcohol in the past week were coded as not binge drinking.Risk variables were created using the following combinations of both distress and problematic drinking variables: (1) binge drinking and anxiety, (2) binge drinking and depression, (3) increased drinking and anxiety, (4) increased drinking and depression. Risk items were coded from 0 to 2 with 0 = no risk and 2 = 2 risks for each combination of mental distress and alcohol use variables.For COVID-19 illness worries and financial worries, participants were asked the following questions: (1) Whether they are worried that they or someone close to them will get ill from COVID-19? (2) Whether they are worried about the impact of COVID-19 on their personal financial situation? Responses included . COVID-19 illness worries, and financial worries variables were coded from 0 to 3 after reversing the scoring .Sociodemographic measures consisted of the following variables including how they were coded in the analysis:Gender ; age , marital status , education , number of children aged 6–12 years at home, and household income . Ethnicity included , we dichotomized this variable as the following .Analyses were done within SPSS (version 26) and Stata 14.1 . Descriptive analysis was used to describe the sample. Correlations were calculated to assess relations and directionality between independent variables  and primary dependent variables . Multivariate ordinal logistic regression was performed for all candidate predictor variables to examine their associations with co-occurrence of (1) binge drinking and anxiety, (2) binge drinking and depression, (3) increase drinking and anxiety, and (4) increase drinking and depression. Odds ratios (OR) and 95 % confidence intervals (CI) for fully adjusted models are presented.Furthermore, 7.5% of participants had elevated depressive symptoms and 25.5% experienced moderate to severe anxiety. Furthermore, 23.7% reported binge drinking and 25.2% reported an increase in alcohol consumption. Concurrency variables indicated that higher percentages of respondents reported binge drinking and anxiety (9.7%) and increased drinking with anxiety (10%) compared to binge drinking and depression (2.2%) and increased drinking and depression (2.5%).p < 0.01), and binge drinking and depression , as well as increased drinking and anxiety , and increased drinking and depression .Bivariate correlations for all variables of interest are shown in p < 0.01), and increased drinking and depression . Income was positively correlated with increased drinking and anxiety  and increased drinking and depression . Having elementary school age children 6–12 years was positively associated with binge drinking and anxiety  and binge drinking and depression , but not increased drinking and distress. Furthermore, being divorced, separated, or widowed was positively associated with binge drinking and depression . Worrying about getting ill from COVID-19 was positively associated with binge drinking and anxiety , and binge drinking and depression , and increased drinking and anxiety , and depression as well . Moreover, financial worrying was positively associated with binge drinking and anxiety, and depression  and binge drinking and depression , as well as increased drinking and anxiety , and increased drinking and depression r = 0.10, p < 0.05).Being a woman was correlated with increased drinking and anxiety , and increased drinking and depression  compared to low-income groups. In addition to that, experiencing a lot of financial worries was associated with significantly higher odds of binge drinking and anxiety , and binge drinking and depression  as well as increased drinking and anxiety  compared to not being worried. Also, being very worried about getting ill from COVID-19 was associated higher odds of binge drinking and anxiety , and increased drinking and anxiety  compared to not being worried about COVID-19 illness.To our knowledge, this study is the first to examine factors influencing the concurrency of alcohol use and mental health in a Canadian population of adults during the COVID-19 pandemic. Our study identified several sociodemographic, and COVID-19 related worries that were associated with concurrency. Being older in age (60 years and more) was associated with higher odds of binge drinking and distress and increased drinking and distress symptoms. Also, being a woman was associated with higher odds of increased drinking and anxiety. Being divorced, separated, or widowed was also associated with both binge drinking and anxiety and binge drinking and depression. High income was associated with higher odds of binge drinking and anxiety and binge drinking and depression. In addition to that, those who were very worried financially and were very worried about getting COVID-19 illness were more likely to consume alcohol and experience more mental health issues compared to those who worry less, in a dose-response gradient.As the present study contributed to the literature with an aim to examine COVID-19 factors on symptoms of concurrency, drawing on previous literature examining the pandemic's impact on alcohol consumption and mental health issues separately is informative , 44. ForWhile previous studies have focused on either mental health or substance use during the pandemic, our study has more specifically examined risk factors for the concurrency of alcohol use and elevated symptoms of anxiety and depression in adults. We found that those who are very worried about the impact of COVID-19 on their finances were more likely to binge or increase drinking and experience feelings of depression and/or anxiety. This would suggest that financial stress related to possibly losing their job or possibly to reduced work hours may lead to increased alcohol intake and heightened distress, perhaps due to maladaptive coping skills. This study also found that being very worried about getting ill from COVID-19 was also associated with higher odds of binge drinking and anxiety, and increased drinking and anxiety compared to those who were less worried. These findings are in line with previous studies examining stress and drinking showing that elevated stress may be associated with increased alcohol consumption , 46 as aMoreover, individuals with higher income were more likely to consume alcohol and suffer from mental distress. However, our bivariate analysis indicates that higher income is associated with increased drinking but not mental distress. Thus, income may be a predictor of concurrency more because of boredom and access and not as a coping mechanism for anxiety as higher income individuals are less worried financially and their distress levels are lower. This aligns with previous studies which indicated that people with a higher income reported consuming more alcohol during the pandemic than those of the lower income –51. ThisOur study also showed that older adults were at lower odds of increased alcohol consumption and comorbid psychological distress, consistent with recent literature which examined the impact of COVID-19 relevant factors on mental health, and/or substance use separately , 55–57. Our findings showed that identifying as woman was associated with increased odds of increased alcohol and anxiety.This aligns with previous studies which indicated that women were more likely to experience stress, anxiety and depressive symptoms during the pandemic than men , 60, 61.The etiology and treatment of concurrent mental health and alcohol use problems are typically more complex than either alcohol use or mental health disorders alone . EffectiAdditionally, telehealth can be used to provide resources for alcohol counseling and addiction treatment, and to follow up closely with patients and give them 24/7 access to care . But, acThis study has several limitations. First, the study's cross-sectional nature with self-reported responses prohibited the determination of any causal relationship between substance use and emotional distress with COVID-19 risk factors. Second, response bias might have occurred from the self-reported answers. Third, survey questions were only accessible for those who have access to electronic devices and the internet, limiting the generalizability of findings. Also, this secondary data analysis was restricted to the current risk factors and questions on frequency of alcohol intake, therefore, we could not capture additional modifiable risk and protective factors associated with changes in alcohol intake, patterns of use and associated impairment, and mental health. Furthermore, future longitudinal analyses will provide a greater understanding of directionality of the observed associations, along with potentially identifying factors that mediate or moderate these associations.Our results indicate that symptoms of concurrent mental distress and alcohol use are a serious concern during the pandemic, and women and older adults, divorced, separated, or widowed, and individuals with financial worries, COVID-illness worries, and higher income groups appear to be at highest risk. As the pandemic continues to evolve, further research evaluating risk and protective factors and the long-term impact that COVID-19 has on mental health and alcohol intake is warranted to inform treatment and prevention strategies.http://www.delvinia.com/solutions/askingcanadians.Publicly available datasets were analyzed in this study. This data can be found here: The studies involving human participants were reviewed and approved by Research Ethics Board at the Centre for Addiction and Mental Health and Research Ethics Boards of the Children's Hospital of Eastern Ontario (CHEO). The patients/participants provided their written informed consent to participate in this study.FM: conceptualization, methodology, analysis, writing, review, and editing. HS-K: methodology, analysis, and review. BH: methodology and analysis. KC and HH: writing, review, and editing. GG: conceptualization, methodology, writing, review and editing. All authors contributed to the article and approved the submitted 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.


Pandemics and lockdowns may be associated with unpremeditated consequences, such as bodyweight changes, isolation, as well as sedentarity. Reports have been published on malnutrition among patients suffering from COVID-19. This study aimed to highlight the short-term effects of the lockdown on the nutritional health of elderly people living at home and benefiting from home care services, yet without any COVID-19 pathology. In 50 subjects displaying weight, body mass index, and MNA score stability two months earlier, we observed significant alterations in these parameters following the lockdown. Thus, malnutrition rose from 28–34% to 58%. Furthermore, trigger factors for malnutrition changed, with social isolation accounting for 64% of the confinement’s deleterious effects among the elderly. In conclusion, despite the elderly being not directly affected by SARS-CoV2, the nutritional status of elderly subjects living at home with no or only mild autonomy loss was greatly and rapidly affected by the lockdown. Moreover, the main trigger factors for malnutrition were essentially related to social isolation and depressive syndromes. Knowing the impact of confinement on the elderly’s health, these results may help further modulate ongoing public health interventions in case of future lockdowns.  Though the pandemic linked to the SARS-CoV2 coronavirus has spread around the world, scientific research is still heavily mobilized to enhance the production of knowledge on the virus to optimize treatment and prevention of this disease. Clearly, although without suffering directly from SARS-CoV2, many people are affected by serious deleterious effects in relation with the pandemic. Above all, malnutrition among the elderly is a vicious cycle that alters the person’s state of health, associating weight loss and fragility. This, in turn, translates into increasingly long and common pathological episodes ,2. The risk of malnutrition is multifactorial in nature, including psychosocial aspects, autonomy loss, decompensation of chronic pathologies, dementia syndromes, oral disorders, poly-medications, and other medical conditions. There are multiple consequences, including increased mortality and morbidity, as well as autonomy loss and deteriorated quality of life. In addition, malnutrition is associated with its own morbidity and mortality in the elderly, which is independent of the underlying disease, and exerts a negative impact on their quality of life. It is, therefore, essential to prevent malnutrition or, in a worst-case scenario, to manage this condition as soon as diagnosed.Although COVID-19 is expected to increase malnutrition, as well as stunting, and micronutrient deficiencies , only reThis study, therefore, thought first to assess the impact of COVID-19-induced lockdown on the nutritional status of elderly subjects living at home, with none or only mild loss of autonomy. The study’s second objective was to examine the origins of such impairment.https://www.apamad.fr/e-nutriv-detecter-risques-de-denutritions-personnes-agees/ accessed on 19 August 2021), supported by the APA  network, recruited a cohort of 300 people, who were living in France and receiving help at home, involving monthly monitoring of weight and MNA® scoring. The criteria of inclusion were an age of at least 65 years, living autonomously (without the help of the family) at home, as well as benefiting from home care services with the APA network. Due to the pandemic, a complete stop (for the entire 300 subjects) of the one-month follow-up was implemented due to the lockdown (March 2020). For fifty subjects, follow-up was resumed one month later (April 2020), and this sub-cohort served as the basis for our analysis. This sample of fifty persons has remained stable in regards to the two measurements performed before the March 2020 lockdown in France. These fifty subjects  signed a written informed consent jointly with their families. This consent form was approved by the Ethical Committee of the Strasbourg University .In order to detect and prevent undernutrition in the elderly living at home, the service e-Nutriv (available online: Haute Autorité de Santé (HAS) in 2007 [® score  [As proposed by the  in 2007  and the  in 2007 , the subtrition) . Indeed,https://www.r-project.org/, accessed date 19 August 2021). The paired binomial test and symmetry tests were performed for malnutrition alert analysis. A paired t-test was applied to assess malnutrition indicator variations. A Spearman’s test was carried out to assess the potential relationships between weight and MNA® Score. Statistical significance was set at 0.05.The e-Nutriv project deploys connected objects, such as connected tablets or weighing pads, which allowed for notifying alerts to medical, family, and professional circles, in addition to monitoring their situation. All the data collected were anonymized and analyzed using the statistical software R , most home care services were suspended, and malnutrition suddenly rose to 58%.p = 0.03 and p = 0.02 for February 2020 and April 2020, respectively. Paired binomial testing for alert tests and symmetry tests of alert tables revealed a significant switch from normal nutrition to a malnourished status, with values of ® scores had been stable before the lockdown, whereas they significantly decreased during the lockdown  for MNA® scores)  .To better understand our subjects’ characterization, we considered a weight loss of ≥5% to be of concern, which concerned 11 persons versus 39 (22%) .® score, and mobility.Nevertheless, no significant difference was observed between these two groups in terms of gender, age, MNAp = 0.000), whereas the MNA® score was positively, yet not strongly, correlated with weight . However, BMI was strongly and positively correlated with weight (r = 0.0003, Our second aim was to investigate the mechanisms potentially involved. To this end, we analyzed known risk factors leading to malnutrition changes, before and after the lockdown. The percentage of the malnutrition’s trigger factors among our population was added to the table established by the HAS in 2007 . We haveInterestingly, before the confinement, the malnutrition triggers were mainly dementia and dependency, each of them contributing to 30% of the total malnutrition causes. This was followed by psycho-socio-environmental factors, involving mainly social isolation, as well as acute disorders such as infectious disease, with 17 and 13% contributions, respectively .After the confinement, about 64% of the malnutrition cases appeared to be related to psycho-socio-environmental factors, the second cause being psychiatric troubles, resulting in a 13% contribution. For the third place, the factors contributing to malnutrition were mobility dependence and acute infections, with a 7% contribution for each .These results clearly demonstrated that, despite acute infections being markedly reduced on account of the confinement, social and psychological factors were clearly enhanced among the studied population.This is particularly significant. Indeed, when analyzing social connections with variables that predict a person’s chances of survival or death, social relationships, including family, friends, and neighbors, were shown to increase our chance of survival by 50% . Thus, “In brief, we summarize the prevention of malnutrition by four specific terms, involving promotion, enhancement, information, and training. Of course, it is absolutely essential to promote and enhance prevention measures, usually by means of communication with regard to the means available, achievement and pursuit of specific objectives, and contribution of each item to risk protection.In contrast, the treatment of malnutrition often involves more individualized approaches. The standard treatment of undernutrition aims to achieve an optimal protein and energy supply according to the patient’s specific needs, so as to reduce the effects of catabolism, and minimize the loss of the body’s protein mass.Even if not struck directly by SARS-CoV2, the nutritional status of elderly subjects living at home with no or only mild autonomy loss has been greatly and rapidly affected by the lockdown established in France and almost all countries around the world. Importantly, the main trigger factors for malnutrition in the elderly were thereby altered, with social isolation accounting for 64% of the confinement’s deleterious effects.We are aware that the study’s population size was too small for good-quality statistics, given that out of the 300 people initially recruited into the cohort, only 50 completed the study with good quality data. From a quantitative analysis, the study has thus been condensed to a qualitative analysis on account of these circumstances.These original data should be taken into serious consideration before any political decision is made concerning a new future confinement—moreover, actions should already be planned and implemented to further reduce social isolation of the elderly that are in enough good health to be able to stay at home.® scoring, would be instrumental in early detecting and diminishing malnutrition among elderly people living at home.Further perspectives could involve determining whether such e-Nutriv follow-up, which considers weight, BMI, and MNA


This insightful paper by Wherton et al  suggestsThe finding relating to the “focus on region-by-region” quality improvement approach noted can be explained by how the National Health Service is set up across Scotland, with 14 different health boards . AlthougMy urban general practice embraced the opportunity to perform video consultations. We implemented these by deciding to “convert” telephone consultations to video consultations, when clinically appropriate. This occurred if the patient agreed and had the appropriate technology. We welcomed the improvement allowing the Near Me video service to send direct links to the virtual waiting room.However, despite this improvement, when discussing video consultations with colleagues, we perceived that many patients then faced technical and accessibility issues. Patients frequently could not enter the virtual waiting room due to low levels of digital literacy.A recent internal practice audit performed in August 2021 showed that only around half of the patients opted for a video consultation  if offered instead of a telephone consultation. Furthermore, of those who requested a video consultation, a large proportion was unsuccessful .If a patient was unable to connect to the video consultation, they would not have the opportunity to complete the patient satisfaction survey, which is given out after the video consultation. Therefore, the patient survey, which reported that the majority of video consultations had no technical problems , is potentially an underestimate as it does not include some consultations in which patients were unable to access the service at all.I am pleased to report that the Near Me video service has just been upgraded to include a Consult Now feature. This enables a one-time-only link to be sent, bringing the patient directly to the video call, without having to enter their details and access the virtual waiting room.In an attempt to offer patients choice, I believe patients should be offered a video consultation instead of a telephone consultation, if they prefer. A video consultation may not objectively aid the consultation; however, it can assist with the clinical relationship.To do this while addressing digital inclusion, including digital access support is fundamental. We must be mindful to continue to strive to reduce health inequalities and address the “digital inverse care law.” I am personally very supportive of Scotland’s digital health and care strategy, which aims to achieve world-leading levels of digital inclusion .


In this paper, a joint early stopping criterion based on cross entropy (CE), named joint CE criterion, is presented for double-protograph low-density parity-check (DP-LDPC) codes-based joint source-channel coding (JSCC) systems in images transmission to reduce the decoding complexity and decrease the decoding delay. The proposed early stopping criterion adopts the CE from the output likelihood ratios (LLRs) of the joint decoder. Moreover, a special phenomenon named asymmetry oscillation-like convergence (AOLC) in the changing process of CE is uncovered in the source decoder and channel decoder of this system meanwhile, and the proposed joint CE criterion can reduce the impact from the AOLC phenomenon. Comparing to the counterparts, the results show that the joint CE criterion can perform well in the decoding complexity and decoding latency in the low–moderate signal-to-noise ratio (SNR) region and achieve performance improvement in the high SNR region with appropriate parameters, which also demonstrates that this system with joint CE is a low-latency and low-power system. As the most challenging application scenario of the fifth-generation wireless communication, the ultra-reliable low-latency communications (URLLC) need to meet the latency requirement of 1 ms or less  have beeThere have been many works focusing on the transmitting terminal of the DP-LDPC JSCC system, such as the coding design and its optimized methods. In the aspects of coding design, they are mainly from the perspectives of the source codes, channel codes, and connection edges, separately ,4,5 or jN represents the number of the edges in LDPC codes, which is determined by coding design, and I represents the iteration number. To reduce the decoding complexity for the low-power applications, reducing the iteration number is a highly effective method, which is closely related to the decoding algorithms. The decoding algorithm mainly consists of the scheduling method and stopping criterion in the decoding process. Different from the purpose of scheduling methods to decrease the iteration numbers efficiently [The decoding complexity of LDPC codes can be approximately represented by ON*I . Here, Niciently ,21,22, eiciently ,24,25.Stopping criterions determine whether the iterative process needs to continue. When the performance of the decoding process reaches a certain degree or the channel environment is bad, the further iteration process has little impact on the performance. Instead, unnecessary iterations will lead to higher decoding complexity and bigger delay, which are very harmful to the performance of DP-LDPC JSCC system. In order to tackle this problem, efficient early stopping criterions for DP-LDPC JSCC systems need to be discussed. There are different early stopping criterions in the tandem coding system that source coding and channel coding are separate. According to whether the a posteriori log-likelihood ratios (LLRs) of VNs are judged or not, they can be mainly classified into two kinds: soft decision-based (SDB) criterions ,24,25 anIn this paper, we design a joint CE stopping criterion for DP-LDPC JSCC system in image transmission, which considers the matching relationship between the source decoder and channel decoder. To be specific, we find the changing process of cross entropy (CE) in the JSCC system is different from that of the SSCC system. In summary, the main contributions of this paper are as follows.(1) Early stopping criterion based on cross entropy is first introduced for the DP-LDPC JSCC system to avoid unnecessary iterations and the specific properties of the joint decoder are well considered. It can efficiently reduce the decoding complexity and lower decoding latency in low-moderate SNR region and achieve better performance in the high SNR region with appropriate parameters, compared to its counterparts.(2) To overcome the impact from the oscillation-like phenomenon in the changing process of the CE in source decoder and channel decoder, which is unique in DP-LDPC JSCC system, unequal threshold factors are considered and the depth factor is adopted in the joint CE stopping criterion.(3) It is found that the DP-LDPC JSCC system with joint CE stopping criterion can realize the trade-off between latency and performance, which is suitable for low-latency and low-power scenarios with appropriate parameters.The reminder of this paper is organized as follows. s is compressed by an unpunctured P-LDPC code at first, and then the sequence of compressed bits b is protected by another punctured P-LDPC code. Afterwards, the sequence of encoded bits c is transmitted in AWGN channel by BPSK modulation as the sequence of x. At the receiver, the JSCD is used to recover the sequence of the corrupted information bits y by joint BP decoding algorithm. The information bits s are generated by a binary independent and identically distributed (i.i.d.) Bernoulli source with entropyThe model of the DP-LDPC JSCC system is shown in The joint-BP decoding algorithm is described shortly as follows. For the sake of simplicity, there are six types of LLRs are shown in ocess in . After tStep 1: LLRs updating.Channel decoder:For For Source decoder:For For Step 2: Hard decision.Calculate Step 3: Stopping Criterion.If Step 4: Output i-th iteration is considered in the joint decoder. We first extend the HDA stopping criterion to the DP-LDPC JSCC system directly and then the proposed joint CE, which combines the properties of this system is detailed in the following.Based on the works in ,24,25, tThe HDA criterion can be applied to the DP-LDPC JSCC system directly:(1) Compute the hard decision of the source decoder and channel decoder, (2) If The cross entropy is defined as the difference of the output LLRs between the current iteration and last iteration in the source decoder and channel decoder; the cross entropy of both decoders are represented by i-th iteration (denoted by C.(1) Set the threshold factor i-th ((2) At the end of the (3) If (4) If In this section, the simulation results consist of three parts: performance analysis of the joint CE algorithm, performance between joint CE and other stopping criterions, and image transmission performance comparison. In all the simulations, the frame length is set as 3200 bits and the maximum iteration number is set as 50. The simulations are assumed under an AWGN channel and all encoded bits are modulated by BPSK. The rate-1/2 The label Original represents the traditional method to stop the iteration in joint BP algorithm, that is, the parity-check constraints of the both decoders are satisfied or the iteration number reaches (1)The higher threshold factors, the faster convergence, worse FER performance, and little influence on BER performance with safe property in low–moderate SNR region.(2)The depth factor can obviously improve the FER performance, improve BER performance slightly, and lower the converged speed when this factor increases.From p = 0.04. We can easily find that the proposed stopping criterions, including the joint CE and joint HDA algorithm, can efficiently reduce the AINs in low–moderate SNR region. For example, the AINs of joint CE, with From (1) In the low–moderate SNR region, this system with joint CE can realize low latency with a little performance loss and the AINs are lower than 25 , which can satisfy the requirement of the voice transmission at the BER level of (2) In the high SNR region (larger than (3) The DP-LDPC system with joint CE is a low-latency and low-power transmission system.D is 255, which is the peak value of signals for gray images.To verify the applicability and feasibility of the proposed joint early stopping in specific application, we consider the application of our proposed technique to image transmission that uses an equal error protection technique . To evalIn this paper, we proposed early stopping criterions based on LLRs values, including joint HDA and joint CE algorithms to reduce the unnecessary iteration numbers for the DP-LDPC JSCC system to decrease delay in low-moderate SNR region and achieve the performance improvement in the high region for the image transmission. By introducing the unequal thresholds factors and the depth factor, the joint CE can efficiently utilize the asymmetry oscillation-like convergence (AOLC) phenomenon, which does not appear in tandem coding system. Through these works, it is known that this system with joint CE can realize the trade-off between latency and performance, which can be applied to different application scenarios, and it is found that this system with the joint CE is a low-latency and low-power system. In the future, we will adopt the unequal error protection method to further improving better images transmission performances.


The normalized lean volume was significantly larger in the high activity group compared to all the other groups . Employing a hierarchical linear regression analysis, we found that hip pain, low physical activity, female gender and high BMI were statistically significant predictors of increased GMAX fat infiltration.We aimed to determine if gluteus maximus (GMAX) fat infiltration is associated with different levels of physical activity. Identifying and quantifying differences in the intramuscular fat content of GMAX in subjects with different levels of physical activity can provide a new tool to evaluate hip muscles health. This was a cross-sectional study involving seventy subjects that underwent Dixon MRI of the pelvis. The individuals were divided into four groups by levels of physical activity, from low to high: inactive patients due to hip pain; and low, medium and high physical activity groups of healthy subjects (HS) based on hours of exercise per week. We estimated the GMAX intramuscular fat content for each subject using automated measurements of fat fraction (FF) from Dixon images. The GMAX volume and lean volume were also measured and normalized by lean body mass. The effects of body mass index (BMI) and age were included in the statistical analysis. The patient group had a significantly higher FF than the three groups of HS (median values of 26.2%, 17.8%, 16.7% and 13.7% respectively,  A high content of IMF has been linked mainly to aging/sarcopenia8, but also to muscular10 and physiological pathologies15 and low levels of physical activity16.An increase of intramuscular fat (IMF) in the muscles is associated with loss of strength and mobility, making it an important marker for muscle health21 and calf muscles22, while the hip muscles have been overlooked despite their fundamental role in running, walking, standing and other human daily activities24. In the small number of studies looking at this muscle group, fatty infiltration in the glutei was found in patients with diseased hips26 and was also correlated with accidental falls in elderly people27. Of the gluteal muscles, gluteus maximus (GMAX) is particularly involved in physically demanding activities, such as in running, climbing or lifting29. However, to the best of our knowledge, GMAX fat content has not been studied for different levels of activity, including demanding physical tasks such as endurance running.IMF accumulation has been mainly evaluated in the thigh8, muscle composition changes, in particular an increase of IMF and intermuscular fat (IMAT), proved to be a better predictor for the loss of mobility and muscle strength observed with aging22. In addition, fat infiltration in the thigh and calves has been correlated with a reduction of physical activity in healthy young adults and obese adults16 with diabetes30. Identifying and quantifying differences in the IMF content of gluteus maximus (GMAX) in subjects with different levels of physical activity can provide a new tool to evaluate hip muscles health.When compared to the reduction of muscle volumeIn this study, we aimed to better understand fat infiltration of GMAX. Our primary objective was to determine the association between IMF of GMAX and level of physical activity using a group of patients with hip pain, and three groups of healthy subjects with low, medium and high levels of physical activity. Our secondary objective was to determine the effect of female gender, older age, high BMI and hip pain/symptoms on the relationship between physical activity and fat infiltration of GMAX.This was a cross-sectional study involving 70 subjects who underwent Dixon MRI of the pelvis. The study participants were recruited for a study looking at the effects of marathon running in the hip and were divided into three groups of healthy subjects (HS) and a group of patients. The inclusion criteria for the HS was absence of hip injury or hip surgery, and no contraindication to MRI. In the HS (n = 51), eight were no runners , 27 were in the first weeks of a training programme for their first marathon  and 16 were experienced runners that have run at least three marathons or ultra-marathons in the past.The HS filled out a structured questionnaire regarding their training, where the number of hours per week of running and of other physical activities per week  were registered. Using these data, the healthy subjects were regrouped into three groups: a) low activity: subjects doing less than 4 h per week of physical activity (Low); b) medium activity: subjects doing between 4 and 8 h per week (Mid); and c) high activity: subjects doing more than 8 h per week (High).31 and their hip dysfunction was graded as Severe (scores 0–19), Moderate (20–29), Mild (30–39) and Satisfactory (40–48) as recommended in the OHS system. We used these grades as a measure of the degree of hip pain. This group represented the subjects with lowest physical activity in our study. A detailed description of the patients group can be found in the Supplementary Table The patients’ group (n = 19) consisted of subjects with very low levels of physical activity due to hip pain. All of them had an MRI investigation requested after being assessed for hip pain by an orthopaedic surgeon. The MRI reports indicated a variety of injuries and hip conditions, being gluteus medius or hamstring tendinopathy (n = 7) and arthritis (n = 5) the most frequent findings. In only one case, fatty atrophy of the gluteal muscles was reported. All the patients completed the Oxford Hip Score (OHS) questionnaire32).In terms of sample size, we aimed for approximately 16 subjects per group that is the sample size needed for a statistical power of 0.8 and an effect size of 3% in fat fraction (FF) between groups. To estimate this, we assumed that the standard deviation for each group was 4%  using a body coil. The scanning protocol consisted of standard clinical sequences for the hips and axial Dixon  4570 ms, echo time (TE) 45 ms, number of excitations 1, number of echoes 14, flip angle 120°) of the pelvis. The field of view (FOV) of the Dixon sequence covered axially from 1 cm below the lesser trochanter to the top of the iliac crest. The voxel size was 0.47 × 0.47 × 1.95 mm3. We used Dixon MRI because it provides a FF signal, obtained from fat and water images, which can be used to measure quantitatively IMF36. The tool is an in-house plugin for Simpleware ScanIP  based on a multi-atlas segmentation method that employs a library with 15 manually segmented Dixon scans. Different to most of the studies looking at fat-content, where cross-sectional areas (CSA)39 of the muscles were used, our tool obtains the mean FF of the full 3D muscle volume. The method automatically generates 3D labels for left and right GMAX in the in-phase Dixon image, being a label the sets of voxels that represent each muscle in the image. Next, the mean GMAX FF value is computed by averaging the label voxel values of the FF image, being the latter the ratio image between the fat image and the sum of the water and fat images. In average, 1.2 × 106 voxels were averaged per GMAX label. In32, we showed that the FF error for the comparison of two small groups of subjects was lower than 0.6%. The resulting mean FF value of each label quantifies GMAX IMF. The latter, which is the adipose tissue depot between and among skeletal muscle fibres in the skeletal muscle bed40, needs to be distinguished from IMAT, which is fat underneath the deep fascia and between adjacent muscle groups.We estimated the GMAX IMF content using an automated tool that computes the FF of GMAX from Dixon images36. In addition, we measured GMAX volume and lean volume for the muscle bulk regions. The lean volume was defined as the volume multiplied by (1-FF). Both volume measurements were normalized by the lean body mass (LBM) of each subject using the Boer formula41.In order to standardize the measurement and to avoid regions with tendinous tissue, we computed the FF in the muscle bulk, which we defined as the region of the gluteus maximus that goes from the axial slice where the tip of the lesser trochanter (LT) is found to the slice at the level of the anterior superior iliac spine (ASIS). This muscle bulk definition was previously proposed inFigure The FF values of GMAX were tested for normality within each group using a Shapiro–Wilk test. For some of the groups, the null hypothesis that the group’s samples followed a normal distribution was rejected. For this reason, we reported parametric [mean ± standard deviation (SD)] and non-parametric [median and interquartile range (IQR)] descriptive statistics for the FF values in each group, with and without considering gender.The FF, volume and lean volume population distributions were first compared for the four groups with different levels of activity  using a Kruskal–Wallis test for not normally distributed samples. The mean value of left and right GMAX for each variable was used for this analysis. A multiple comparison test was executed using Tukey’s Honestly Significant Difference procedure to obtain more information of the Kruskal–Wallis test.We also compared left and right GMAX FF for each activity group using a Wilcoxon signed-rank test. For the patient group, we additionally used Wilcoxon signed-rank test to compare the symptomatic to the pain free side.2 of the linear regression.We performed a hierarchical linear regression analysis to study which variables explained a significant amount of the GMAX FF variance. In this analysis, we built a set of linear regression models adding sequentially gender, BMI, age, level of physical activity, the OHS grading, muscle side and pain side as predictor variables, while the FF was the dependent variable. The left and right FF values were considered separately. We used a categorical variable for the level of physical activity and a numerical for the OHS grading (1 to 4). For the pain side variable, we used a categorical variable (on/off) indicating if there was pain on a given side. The models were estimated using MATLAB  and each variable was included sequentially in each new model in the same order as they were described previously (i.e. the first model would only include gender as predictor variable). A variable was considered a FF predictor if it was statistically significant and its inclusion increased the R42. In this analysis, the power of the four physical activity categories was estimated taking into account the seven predictor variables .A post hoc power analysis was computed for the hierarchical linear regression using the G*Power softwareFinally, we compared FF and volume metrics as predictors of physical activity using a multivariate logistic regression analysis. For this test, we grouped the study subjects into Not Active  and Active . Gender, BMI and age were also included as independent variables. We computed the odds ratios (OR) with their 95% confidence intervals (CI) for each variable. A similar analysis was performed to compare if FF and volume variables were predictors of hip pain. In this case, we compared the patients group against all the healthy subjects.We used a level of statistical significance (α) of 0.05 for all the tests.The patient group had a significantly higher GMAX FF than the three groups of healthy subjects and the high activity group had lower GMAX FF than the low activity. In the hierarchical linear regression analysis, female gender, high BMI and low level of physical activity were all predictors of higher FF values, and therefore of GMAX IMF content; but the degree of hip pain was not. The normalized volume of GMAX was larger for the high activity group than for the patient and low activity groups, but no differences were found between the patients and the low and medium levels of activity groups. GMAX IMF was a predictor of physical activity, while GMAX volume was not.p < 0.001). The post-hoc Tukey’s Honestly Significant Difference analysis indicated that the patient group was different to the three other groups , while there was a significant difference only between the low and high activity groups (p = 0.03) for the healthy subjects when gender, BMI and age were not considered.The mean ± SD and median (IQR) FF values of GMAX are presented in Table For the HS, two outliers with a GMAX FF higher than 26.1%  were found, while 10 of the 19 subjects in the patients group exceed that level of FF. In Fig. p < 0.001). When looking at the groups separately, left FF was significantly higher in the low (p = 0.006) and mid (p = 0.01) activity groups, but not for the high activity (p = 0.09). Figure p = 0.90).In the healthy subjects group, the GMAX FF was 3.3% higher in the left than in the right  and low activity groups (p = 0.004), but not for the mid group (p = 0.06). The normalized lean volume was larger in the high activity group compared to all the other groups . There was not any statically significant differences between the patient, low and medium activity groups.In order to complete the analysis, we have also included results for volume. In Fig. p = 0.03) and GMAX FF . This means that the odds of being physically inactive are 1.22 times higher among subjects with higher GMAX intramuscular fat. GMAX volume was not associated with the probability of being physically inactive.We tested GMAX FF and volume, together with the other covariates, as predictors of physical activity using a hierarchical logistic regression Table . The varp = 0.02) and age  were associated with hip pain, while GMAX FF was only borderline associated with it .Finally, we also tested GMAX FF and volume as predictors of hip pain. In this case, BMI , potentially reducing the mean FF for this group as female gender was a predictor of higher FF. Another potential limitation is that the hours of physical activity were obtained by a self-reported questionnaire. Despite these limitations, the differences between the levels of physical activity were statistically significant when taking into account all the covariates and the tests performed had good statistical power.There was a marked difference in GMAX FF values between patients with hip pain and healthy subjects, but we also found significant differences for different level of physical activity. The low activity group consisted of young and slim subjects with a low mean BMI of 22 kg/m44; while loss of muscle strength, muscle atrophy and a sedentary lifestyle is associated with increased extramyocellular lipids (EMCL)46. The Dixon FF signal has contributions from both IMCL and EMCL48, therefore a potential lower content of EMCL in the high activity group, with several multiple marathon runners in it, could be harder to distinguish due to increased IMCL deposits.Another factor to take into consideration is that endurance athletes have a higher content of intramyocellular lipids (IMCL) than other athletes and sedentary individuals as this is an adaptation in response to endurance training49. On contrary, we did not see any difference between sides on the patients group, probably due to the effect of the hip pain being dominant over footedness. When comparing the pain side with the asymptomatic side, the FF differences were not significant. However, only eleven out of 19 had unilateral hip pain, making this comparison statistically challenging.The GMAX FF was higher in the left side than in the right for the healthy subjects, very likely due to leg dominance. We did not record footedness in our study, but the vast majority of the population is right-footed50 and Dixon MRI of the thigh51. Age was not a strong predictor of IMF content of GMAX in our study sample, where all the subjects were younger than 63 years and the mean age was 50 and 33 years for the patient and HS groups respectively. This agrees with other studies were an increase of IMF with age was mainly observed in individuals aged 70 years or more52. On the other hand, BMI was a moderate predictor for GMAX IMF and this has been also previously observed in the thigh muscles51.Female gender was a predictor of higher GMAX IMF. These gender differences have also been observed in studies using needle-biopsies of quadriceps femoris52, but not for GMAX. Mean FF values of 8–9% were found for these two muscles, and no significant differences were found between genders52. On the other hand, we obtained a mean FF value of 14.8% for male and 20.4% for female healthy subjects. This would indicate that FF values are higher for GMAX than for the other gluteal muscles. These differences, which are usually noticeable by visual inspection of MR images, can be related to the different function and fibre composition of the gluteal muscles. Differences in IMF content within a muscle group have also been detected in other studies30.The reported FF values for healthy subjects can be used as baseline values for GMAX IMF content. Normative FF values have been previously reported for gluteus medius and minimusThe GMAX FF was significantly higher in the patients than in the healthy subjects, which can be attributed to a very low physical activity due to hip pain. Only one of the 19 patients’ scans were reported with fatty atrophy, however a considerable high GMAX IMF content (defined as a FF higher than the outlier level of the HS) was measured in 9 patients. This would indicate that GMAX FF from MRI can detect and quantify fat infiltration in early stages of hip disease or injury.25. In addition, GMAX fat infiltration was linked to falls in the elderly using computed tomography (CT)27 and Goutallier’s staging19 to quantify IMF. Our results and these other applications show that automated assessment of GMAX IMF can be a clinically relevant marker.GMAX FF can be potentially used to study and assess quantitatively the progress of mobility and muscle health in patients with certain pathologies such as osteoarthritis (OA) as well as the effects of rehabilitation practice. In this regard, a more pronounced fatty infiltration in the gluteal muscles was related to the severity of OA, when fatty infiltration was limited to a qualitative assessmentIn this work, we focus on IMF, but we have also included results for volume, as this is another marker of interest when assessing muscle health. The normalized volume of GMAX was statistically significantly larger for the high activity group than for the patient and low activity groups. However, the differences were much smaller than for FF as it can be seen in Figs. In this work, we used an automated tool to compute FF in GMAX muscle as a measure of GMAX IMF content in four groups of subjects with different levels of physical activity. We report novel quantitative data of GMAX IMF content for these groups that ranged from patients with reduced physical activity due to hip pain to highly active subjects reporting more than 8 h of physical activity per week, included experienced marathon runners. The group of patients with hip pain had a significantly higher IMF content than the three groups of HS and the group of high levels of activity had a significantly lower IMF content than the low activity group. We found that hip pain, low physical activity, female gender, BMI and left side are predictors of GMAX fat infiltration, even within healthy subjects. These results show that automated measurements of GMAX FF could be used to quantitatively assess muscle health, mobility and sarcopenia in clinical trials and clinical practice.Supplementary Information.