Methods for No-Reference Video Quality Assessment (NR-VQA) of consumer-produced video content are largely investigated due to the spread of databases containing videos affected by natural distortions. In this work, we design an effective and efficient method for NR-VQA. The proposed method exploits a novel sampling module capable of selecting a predetermined number of frames from the whole video sequence on which to base the quality assessment. It encodes both the quality attributes and semantic content of video frames using two lightweight Convolutional Neural Networks (CNNs). Then, it estimates the quality score of the entire video using a Support Vector Regressor (SVR). We compare the proposed method against several relevant state-of-the-art methods using four benchmark databases containing user generated videos . The results show that the proposed method at a substantially lower computational cost predicts subjective video quality in line with the state of the art methods on individual databases and generalizes better than existing methods in cross-database setup. User-Generated Content (UGC) produced with smartphones or tablets is very prone to natural capture artifacts, such as out of focus, object motion camera shakiness, under/overexposure, sensor noise, adverse weather, and so on. The automatic estimation of the quality of a UGC as perceived by human observers is fundamental for a wide range of applications. For example, to discriminate professional and amateur video content on user-generated video distribution platforms , to chooBlind/No-Reference Video Quality Assessment (NR-VQA) aims toward the development of methods that estimate a quality prediction in close agreement with human judgment in the absence of the pristine video. NR-VQA in the wild is a challenging task not only for the reason that the pristine videos are not available, but also due to the fact that video content is unknown and affected by mixed real-world distortions, especially some of which are temporally heterogeneous . For this reason, methods designed on synthetically distorted video datasets do not scale on natural distortions and more effort needs to be made to develop datasets and methods suitable for NR-VQA in the wild. Recently, some quality databases with UGC videos affected by natural distortions have been published ,7,8 and In this paper, we mainly focus on the problem of efficiently assessing the quality of in-the-wild videos. The proposed method relies on the insight of our previous article that the combination of quality features with semantic features produces video quality scores in close agreement with human judgment . In thisThe main contributions of this work are the following.A lightweight and efficient video quality assessment method for in-the-wild videos using two CNNs thoroughly trained for encoding video frames in terms of both semantics and quality attributes and a Support Vector Regressor (SVR) machine.A frame sampling algorithm capable of selecting a predetermined number of frames that exhibit a wide variation in terms of content and/or imaging conditions.An evaluation of the proposed method and a comparison with previous VQA methods on four benchmark databases containing UGC videos also in cross-database setup.An ablation study that estimates how performance varies as the number of sampled frames changes and that measures the benefits of using our sampling method instead of other strategies.This paper extends our previous work  in threeThe rest of the paper is organized as follows. Many frame-based NR-VQA methods are based on image quality assessment methods that involve the analysis of Natural Scene Statistics (NSS). Among such methods there are the Naturalness Image Quality Evaluator (NIQE) , the BliGiven the growing interest in the quality assessment of in-the-wild videos, four relevant datasets have been collected and annotated: CVD2014 , KoNViD-In , the natSACONVA  exploitsThe proposed method for No-Reference Video Quality Assessment (NR-VQA) follows the insights of our previous QSA-VQM , but impOne of the bottlenecks in video quality assessment is the encoding of all video frames, especially if they are many and have a high resolution. Moreover, we know that temporal redundancy is present in video signals when there is a significant similarity between successive video frames. For both reasons, we propose a sampling algorithm able to maintain video frames that present variations in content and especially in terms of imaging conditions. The HSV color space, which contains the three components hue, saturation, and value, provides an intuitive color representation and is more suitable than the RGB color space to capture features correlated well with human perception . It was n frames is sampled from the entire video. Video frames are first rescaled using bilinear interpolation to a resolution with the smaller edge equal to s and the other edge adapted to preserve the frame aspect ratio. They are then converted from the RGB to the HSV color space. For each video frame, the Mean Absolute Error (MAE) is calculated with all subsequent frames. Algorithm 2 is applied for selecting the indices of frames having an error higher than a threshold. In order to obtain the required number of frames, n, the threshold is optimized using a naive algorithm. The initial r. The first condition allows selecting frames with a high difference in terms of content and imaging variations, while the second condition prevents the selection of frames that are too close to the detriment of those that are far away. This condition can occur, for example, in case of camera shake.Algorithm 1sampleFramesAlgorithm 2selectIndicesIn Algorithm 1, a subset of Given that human judgments of visual video quality are strongly influenced by the different sensitivity to low-level visual features ,32 and tIn To train the Extractor-Q, we combine two databases for image quality assessment: the CID2013 database  and the The semantic features for each frame are simply obtained using the Extractor-S which consists in a MobileNet-v2 pretrained on ImageNet for image categorization.K video frames from both CNNs is obtained by truncating the networks to the last convolutional block, which generates an activation volume of As graphically described in ng (SSP)  is appliWe exploit a Temporal Statistics Pooling to aggregate spatial features obtained from the Multi-level feature extraction into a spatiotemporal feature vector of length equal to 7680. In practice, we found that the use of mean and standard deviation of the features obtained for the various frames of the video does not sacrifice much the performance. The use of a parameterless layer makes our Video quality estimation module very efficient and lightweight. The video level spatiotemporal features are mapped into video quality scores using a Support Vector Regressor (SVR) machine. Specifically, we exploit a SVR with a Radial Basis Function (RBF) kernel as it has shown better performance than simple linear regression and SVR with other kernels.s to 16, the value for r is equal to half the frame rate value, the number of frames to sample n is 15, For frame sampling, we set the frame target size The training of our NR-VQA method takes place in two stages. In the first stage, the two CNNs of the Multi-level feature extraction block are used to encode the frames are trained. These two training processes are conducted using the PyTorch framework . In the C trading off complexity and data misfit. We select these hyperparameters by running a Bayesian optimization framework [C and The SVR with RBF kernel has two hyperparameters that need to be tuned: the kernel parameter ramework . The latC and The training set data are split into 80% train and 20% validation. The SVR is trained with a pair of hyperparameters—In this section, we first describe the databases considered for the experiments, we then present the experimental setup and the evaluation criteria.There are four publicly available databases for video quality assessment in-the-wild: Camera Video Database (CVD2014) , KonstanCVD2014  is a colThe KoNViD-1k database  contains dataset . The resThe LIVE-Qualcomm database  consistsFinally, the LIVE Video Quality Challenge (LIVE-VQC) database  containsAn overview of database properties is provided in The evaluation metrics for NR-VQA methods are Pearson’s Linear Correlation Coefficient (PLCC), Spearman’s Rank-order Correlation Coefficient (SROCC), and Root Mean Square Error (RMSE).N is the number of samples, i, and finally The PLCC measures the linear correlation between the actual and the predicted scores, and it is defined asN is the number of samples, and N is again the number of samples, while i.Finally, the RMSE measures score accuracy and it is defined asFor the experiments, the same experimental protocol used in ,8 was foIn this section, we compare the performance achieved by our method with those obtained by the previous NR-VQA methods for each of the considered databases. Furthermore, we conduct a performance evaluation of the generalization ability of the proposed method in cross-database scenarios, which are more challenging due to different types of contents and degradation characteristics. Finally, we report an ablation study in which the different choices that have been investigated during the design of the proposed method are compared.https://rb.gy/tyhlk1; accessed on 13 March 2021). The experimental results are reported in terms of average PLCC, SROCC, and RMSE across the 100 iterations of train–test random splits for all the considered databases . We compare the proposed method with several benchmark methods, namely, NIQE , BRISQUEIn After demonstrating the effectiveness on different databases, in this section we focus on cross-database experiments to verify the robustness and generalization capacity of the proposed method. To this end, for each training database we took the 100 trained models and used them to estimate the quality scores of all the videos from the other databases. Finally, we reported the average and the standard deviation on the 100 iterations for each test database. We compare the performance of the proposed method with state-of-the-art methods which achieved similar performance on the different databases, namely, TLVQM, VSFA, and QSA-VQM. For NR-VQA methods, efficiency is also crucial. In this section, we complement the part of performance estimation with that of computational efficiency. We measure the computational efficiency of several methods on the same desktop computer with an Intel Core i7-7700 CPU@3.60GHz, 16 GB DDR4 RAM 2400 MHz, and NVIDIA Titan X Pascal with 3840 CUDA cores. The operating system is Ubuntu 16.04. We compare computation time of our method with the one of BRISQUE, NIQE, TLVQM, V-CORNIA, V-BLIINDS, VSFA, and QSA-VQM. Most of the methods are implemented in MATLAB, TLVQM has the feature extraction part in MATLAB and the regression part in Python 3.6. VSFA, QSA-VQM, and our method are implemented in Python 3.6 and exploit the PyTorch 1.5.1 framework. For estimating the computation time of all methods, we run the original codes using default settings without any modification in CPU. As in , we seleTo complement the previous analysis we also estimate the number of floating point operation (FLOPs) for previous methods and we compare them with the one of our method. In this section, we present the alternative design choices that have been investigated to lead us to the definition of the final model. In particular, we compare several design choices adopted for the frame sampling module and the multi-level feature extraction module, respectively.Frame sampling. We assess the performance by varying the number of sampled frames, the size of the minimum step (r) to sample the frames, and the size of the minimum edge to which to resize the frames (s). We also compare the proposed sampling algorithm with other solutions. We perform experiments on all databases with a number of sampled frames ranging from 5 to 30 with a step of 5. In r) to sample frames in the proposed algorithm. We choose five different values for r: framerate/4, framerate/3, framerate/2, framerate, and framerate×2. s equal to framerate/2, while the performance worsens for higher steps. This behavior occurs for all databases except for CVD2014. We also measure the impact of the frame size on the sampling algorithm. Specifically we choose five different sizes to re-scale the short edge of the frames: 16, 32, 64, 128, and 256. These values have been chosen in order to reduce the computation time taking into account the possible masking effect of the artifacts within frames. s) in the frame sampling module. We point out that the performance is not significantly different as the size of the frame increases. This means that even if the size of the frames is very small, it does not impact the choices that our algorithm makes. As there is not a big difference in terms of correlation, we choose We evaluate how the performance varies when modifying the minimum step (K frames with the highest MAE with respect to the previous. To better understand the actual benefit provided by the proposed frame sampling algorithm, we compare its performance with those obtained by considering all video frames, by linearly sampling frames from the whole video, or by selecting the frames with the highest MAE. The latter is implemented by simply taking the first Multi-level feature extraction. We evaluate the performance of the proposed NR-VQA method considering the logits, rather than the features, as outputs of Extractor-Q and Extractor-S, respectively. To this end, we follow the same procedure described in K frames is finally represented by a feature vector of We introduced an effective and efficient NR-VQA method for in-the-wild videos. It consists of a sampling algorithm that removes temporal redundancy by selecting a set of representative frames. These frames are passed to two lightweight CNNs that encode both the quality attributes and the semantic content for each frame. Frame-level features are then aggregated into video-level features and finally mapped to a quality score using a SVR. Experiments on four recent large-scale UGC video databases show the accuracy of the proposed method. Cross-database experiments also showed that the proposed method is more robust and generalizes better than the algorithms in the literature. Finally, an analysis of the computational efficiency of methods highlights that the proposed method is several orders of magnitude less expensive than methods achieving very similar accuracy. It runs at a speed up to 185 FPS on one NVIDIA X Pascal GPU and 12 FPS on one Intel i7-770 CPU for 1080p videos. At the same resolution, TLVQM and QSA-VQM, when achieving the same accuracy, are approximately  CPU see .The sampling algorithm proposed in this article could bring benefits to state-of-the-art NR-VQA methods. In the future, we intend to conduct a comprehensive analysis to assess what are the pros and cons of its adoption.


We found that total drinking frequency, liquor drinking frequency, rice wine drinking frequency, and alcohol consumption were significantly associated with an increased risk of hypertension. Compared with the non-drinking group, a heavy drinking pattern was positively correlated with hypertension. Drinking can increase the risk of hypertension, especially heavy drinking patterns, with a high frequency of alcohol intake and high alcohol consumption. From the analysis results of the longitudinal data, drinking alcohol is still an important risk factor for hypertension among Chinese subjects, especially for men, the rural population, the employed, the Han nationality, smokers, and certain exercise populations.Based on a prospective cohort study of adults from southwest China with heterogeneity in their demographical characteristics and lifestyles, we aimed to explore the association between drinking patterns and incident hypertension under the interaction of these confounding factors. The Cox proportional hazard model was used to estimate the hazard ratios (HR) and 95% confidence intervals (95% CI). Subgroup analysis was performed according to sex, ethnicity, area, occupation, smoking, and exercise to compare the differences in the association between drinking patterns and the incidence of hypertension. Blood pressure was higher in participants with a high drinking frequency than those with a low drinking frequency ( Hypertension seriously affects human health and quality of life, threatening the health of 1.13 billion people around the world . AlcoholSeveral studies have shown a positive association between alcohol consumption and the risk of hypertension ,5,6. A mTherefore, based on a cohort study of adults from southwest China with heterogeneity in their demographical characteristics and lifestyles, using the Cox proportional hazards regression model and performing detailed subgroup analysis, we aimed to assess the effects of different baseline drinking indicators on the risk of hypertension, and ultimately provide a theoretical basis for the etiology of the disease.The Guizhou Population Health Cohort Study (GPHCS) was a prospective cohort study based on a community in Guizhou province, China. Using the method of multi-stage proportional stratified cluster sampling, 9280 adult residents were recruited from 48 townships of 12 districts in Guizhou province from 2010 to 2012. The inclusion criteria were: (1) over 18 years of age; (2) living in the study region and having no plan to move out; (3) willingness to fill out questionnaires and undergo blood sampling; and (4) signing of written informed consent. This study was approved by the Institutional Review Board of Guizhou Province Centre for Disease Control and Prevention (No. S2017-02). All subjects provided a written informed consent form at the time of registration.During 2016–2020, 9280 participants were followed for major chronic diseases and vital status by repeated surveys, and 1117 (12.04%) were lost to follow-up. All deaths were confirmed through the Death Registration Information System and Basic Public Health Service System. We obtained the outcome of hypertension through questionnaire follow-up and physical examination, and we excluded participants if they were lost to follow-up. We further excluded 2132 individuals with a history of hypertension at baseline and 12 individuals without blood pressure information at follow-up. Finally, the remaining 5625 subjects were eligible for the analysis.V is the amount of alcohol consumed in milliliters, x is degree of alcohol, and m is the intake of pure alcohol (g). We can calculate the mass percentage of ethanol by combining the density of pure alcohol (789 kg/m3) and the density of water (1000 kg/m3) when the degree of alcohol and drinking quality are known, and then the intake of pure alcohol is derived from:Six drinking indicators were included in this study: total drinking frequency, liquor (≥42%) drinking frequency, liquor (<42%) drinking frequency, beer drinking frequency, rice wine drinking frequency, and alcohol consumption. Here, liquor (42%) refers to the degree of alcohol, which is 42 L of ethanol per 100 L of liquor. We classified the participants into four groups according to baseline drinking frequency as follows: rarely or never drink, low-frequency drinking (monthly: <1 or 1–3 days per month), moderate-frequency drinking (weekly: 1–2 or 3–4 or 5–6 days per week) and high-frequency drinking (daily). We calculated the average of pure alcohol in g/d using the usual daily amount and frequency of alcohol consumption reported in the questionnaire in the past 12 months. The statistical form of alcohol consumption was divided into two types: volume and mass, and the frequency of alcohol consumption was divided into three forms: days per week, days per month, and days per year. The subjects selected one form to fill in according to their own specific circumstances. The degree of alcohol indicates the volume percentage of ethanol, while the intake of pure alcohol is expressed by mass. With knowledge of the degree of alcohol and drinking volume, the intake of pure alcohol can be directly derived from:m′ is the average pure alcohol intake over the past 12 months; 1n, 2n, 3n are drinking frequencies, indicating days per week, days per month, and days per year, respectively; and m is the intake of pure alcohol (g). The participants were categorized into four groups according to baseline alcohol consumption: non-drinking (0 g/d), light drinking (0–12 g/d), moderate drinking (12–24 g/d), and heavy drinking (>24 g/d) [The average intake of pure alcohol in grams per day (g/d) was finally obtained by combining the frequency of alcohol consumption over the past 12 months:>24 g/d) . AlcoholHypertension was considered present if participants met either of the following criteria: (1) self-reported doctor diagnosis of hypertension or use of anti-hypertensive medications; or (2) systolic blood pressure (SBP) of ≥140 mmHg and/or diastolic blood pressure (DBP) of ≥90 mmHg . Blood p2). Venous blood samples were collected after overnight fasting for at least 8 h, and total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL), and low-density lipoprotein cholesterol (LDL) were measured.Participant demographical characteristics , lifestyle (smoking status and exercise), and history of diabetes were collected by trained investigators through face-to-face interviews using structured questionnaires. Current smoking was defined as: (1) smoking every day presently; or (2) smoking now but not every day. Participants were defined as non-current smokers as long as they did not smoke now. Participants were defined as exercise populations if they met any of the following: (1) high intensity activity with activity lasting longer than 10 min in work, farm work, and housework activities; (2) moderate intensity activity with activity lasting longer than 1 min in work, farm work, and housework activities; (3) walking or cycling for at least 10 min while outside; (4) high intensity activities that lasted at least 10 min and caused significant increases in respiration and heartbeat, such as long-distance running, swimming, or playing soccer; (5) moderate intensity exercise and leisure activities that lasted at least 10 min and caused a mild increase in breathing and heartbeat, such as brisk walking or Tai Chi. If none of the above five criteria were met, the participants were defined as no exercise. Type 2 diabetes mellitus (T2DM) was defined if participants met any of the following criteria: (1) self-reported doctor diagnosis of diabetes or use of anti-diabetic medications; (2) fasting plasma glucose (FPG) of ≥7.0 mmol/L; (3) oral glucose tolerance test (OGTT) result of ≥11.1 mmol/L; or (4) hemoglobin A1c (HbA1c) of ≥6.5% . AnthropThe continuous variables were described by the mean and standard deviation, and the categorical variables were described by frequency and percentage of participants. The number of person-years (PYs) of follow-up was calculated from the date of enrolling the cohort to the date of diagnosis of hypertension, death, or follow-up, whichever came first. The multivariate Cox proportional hazards regression model was used to analyze the hazard ratio (HR) and its 95% confidence interval (95% CI) between drinking indicators and the incidence of hypertension. We developed three separate models for the association between each drinking indicator and the risk of hypertension: (1) Model 1: adjusted for age (as continuous) and sex; (2) Model 2: Model 1 plus area , ethnicity , marital status , occupation , smoking status , exercise , and history of diabetes ; and (3) Model 3: Model 2 plus SBP, total cholesterol, triglycerides, HDL-C value, LDL-C value, and baseline BMI value. For variables that failed the PH test, we established time-related covariates. We divided the period and guaranteed that the PH assumption of the variable held at the two time periods. Subgroup analyses were performed by variables associated with drinking indicators, with stratification factors including sex , area , occupation , exercise , smoking , and ethnicity .To assess the robustness of the results, we estimated the association between alcohol indicators and the risk of hypertension after excluding new cases of hypertension within one year of follow-up. Then, we explored the potential for unmeasured confounding between drinking indicators and the risk of hypertension by calculating E-values ,16. The p < 0.05 was considered statistically significant. All analyses were performed in R software (version 4.1.0).All statistical tests were two-sided and p < 0.001). See At baseline, the age of subjects was 42.03 ± 14.17 years old. The number of women was 3062 (54.4%), and the number of Han was 3236 (57.5%). Most of the subjects were married, employed as farmers, and lived in rural areas. A small proportion had a history of diabetes and were current smokers. The group of subjects who consumed alcohol more frequently (weekly or daily) included a significantly higher proportion of current smokers. The SBP, triglycerides, total cholesterol, and HDL cholesterol all significantly correlated with the frequency of alcohol consumption in the participants , area , occupation , exercise , smoking , and ethnicity . Differences in the association between drinking and the incidence of hypertension were compared. Subgroup analysis was performed for certain variables, adjusting for other confounders.Different degrees of covariate adjustment were performed in the Cox proportional hazards regression models, in which Model 1 only adjusted for sex and age, Model 2 added area, ethnicity, marriage, occupation, smoking status, exercise, and history of diabetes, and Model 3 added SBP, total cholesterol, triglycerides, HDL-C value, LDL-C value, and baseline BMI value. In addition, some lines in the results were removed because the sample size was too small or there were no cases. Only the figures of Model 3 under the classification are presented below; the figures of Model 1 and Model 2 under the classification are provided in the As shown in As shown in The hazard ratio and 95% confidence interval in ethnic minorities are shown on the left panel in We found that drinking alcohol daily, drinking liquor (≥42%) daily, and amount of alcohol consumed increased the risk of hypertension in the employed, whereas these correlations were not statistically significant in the unemployed and retired. In the employed, drinking liquor (<42%) daily had a statistically increased risk of hypertension, with a fully adjusted HR of 1.84 (95% CI: 1.31–2.60). When 6.6 years was used as the boundary to divide the time axis, drinking rice wine monthly in the late-stage increased the risk of hypertension in the employed. Additionally, we found that among the employed, alcohol consumption was associated with an increased risk of hypertension , and compared with non-drinkers, those engaged in heavy drinking had a statistically increased risk of hypertension among the employed, with a fully adjusted HR of 1.43 (95% CI: 1.13–1.81). However, statistical significance was not found for unemployed and retired people. See As shown in The hazard ratio and 95% confidence interval in the smokers are shown in the left panel in In the sensitivity analysis conducted to assess the robustness of our results, the effect estimates of drinking on hypertension did not change substantially after excluding new cases of hypertension within one year of follow-up. See We calculated E-values to assess the sensitivity to unmeasured confounding factors . E-valueIn this study, we analyzed the association between drinking patterns and the risk of hypertension based on a prospective cohort study in southwest China. We found that drinking was associated with the risk of hypertension in adults, especially heavy drinking patterns. Considering the frequency and amount of alcohol consumed, this study provided evidence that heavy drinking patterns increase the risk of developing hypertension. Furthermore, we found that subjects living in rural areas, those who were employed, exercise populations, smokers, and Han Chinese had a higher risk of hypertension. The observed associations were stronger in men than in women.The association between drinking behavior and hypertension has been demonstrated by numerous studies ,21,22,23Several studies have provided evidence that the association between drinking and the risk of developing hypertension differs among men and women; their results were not consistent ,20,24,25The present study found that there was a positive association between alcohol consumption and an increased risk of hypertension among urban and rural residents, which was consistent with previous findings . We alsoWe also found that there was a positive association between alcohol consumption and an increased risk of hypertension among the Han and minority ethnic groups. This study provided evidence that, among Chinese Han people, a high drinking frequency is associated with an increased risk of hypertension only for liquor regardless of degree ≥ 42% or <42%, whereas these correlations were not statistically significant in the ethnic minorities. The finding that the associations between heavy drinking and the risk of hypertension was stronger in the Han nationality than in ethnic minorities was consistent with several previous reports ,32,33. TWe found an association between heavy drinking and an increase in hypertension risk for those living an unhealthy lifestyle with high stress, which was consistent with several previous studies ,35,36. FSmoking and drinking behaviors often occur concurrently ,42. EpidIn this study, we used a well-characterized population-based cohort with long-term follow-up in southwest China. The relatively low loss to follow-up of this cohort limited the potential bias for risk estimates. The kinds of alcoholic beverages were relatively abundant in this study, and the association results of drinking patterns and incident hypertension stratified by sex, ethnicity, area, occupation, smoking, and no exercise were studied in detail. Finally, this study was based on a cohort study of adults in southwest China, which is a region with heterogeneity in ethnicities and lifestyles. However, this study also had notable limitations. Firstly, only baseline information of most covariates was used in all analyses, which might lead to residual confounding if those covariates are time-varying. Secondly, although the current analysis adequately adjusted for major potential confounding factors, we may have ignored other risk factors affecting the incidence of hypertension, leading to the possibility of inconsistent findings. Thirdly, because there was only one follow-up, the timing of the onset of hypertension in this cohort could be inaccurate. Fourthly, our analysis should also consider the timing of exposure to further assess the effect of the cumulative exposure dose on the risk of hypertension. When the PH hypothesis did not hold, most of our results showed that the relationship between drinking and hypertension was not significant over a short period of time, but was significant over a long period of time, and the cumulative effect needs further study. Finally, whether there are differences in alcohol consumption thresholds between different categories, such as men and women , remainsDrinking can increase the risk of hypertension, especially heavy drinking patterns, with a high frequency of alcohol intake and high alcohol consumption. From the analysis results of longitudinal data, drinking alcohol is still an important risk factor for hypertension among Chinese subjects, especially for men, the rural population, the employed, the Han nationality, smokers, and certain exercise populations.


The current study examined if control beliefs predict prescription drug misuse (PDM) 10-years later and how problem drinking status moderates this relationship. PDM refers to taking medications without a prescription or in a manner not intended by the prescriber. Older adults are especially vulnerable to PDM due to drug sensitivity, comorbid health conditions, and high rates of polypharmacy. Participants were adults  who completed Waves 2 and 3 of the Midlife Development in the United States (MIDUS) study. At Wave 2, participants reported on two subscales of perceived control  and past 12-month problem drinking behaviors. At Wave 3, participants reported past 12-month PDM of five substances . Results indicated that at Wave 3, 10% of the sample reported misusing at least one prescription drug in the past year. Logistic Regression analysis revealed that problem drinking was associated with higher odds of PDM (p<0.001), and perceived control was associated with lower odds of PDM (p<0.05) after controlling for previous PDM and sociodemographic, health behavior, and health status covariates. However, there was an interaction effect such that perceived control was not protective for those individuals who engaged in problem drinking at Wave 2 (p<0.05). Future analyses will explore the meaning of this interaction. Identifying psychosocial protective factors, such as perceived control, predicting PDM will be critical for designing interventions that prevent the adverse consequences of PDM among this population.


Tlr13 is upregulated in the muscles of mice with CKD, but the relevance is unknown.Insulin resistance in chronic kidney disease (CKD) stimulates muscle wasting, but the molecular processes behind the resistance are undetermined. However, inflammation in skeletal muscle is implicated in the pathogenesis of insulin resistance and cachexia. Toll‐like receptors (TLRs) are known to regulate local innate immune responses, and microarray data have shown that We performed in vitro experiments in C2C12 myotubes and constructed a CKD murine model using subtotal nephrectomy to conduct experiments in vivo.Tlr13 expression was stimulated in C2C12 myotubes treated with uremic serum. The expression of Tlr13 was also upregulated in the tibialis anterior muscles of mice with CKD. Tlr13 knockdown with siRNAs in skeletal muscle cells decreased insulin resistance despite the inclusion of uremic serum. This led to increased levels of p‐AKT and suppression of protein degradation. Using immunofluorescence staining and coimmunoprecipitation assay, we found that TLR13 recruits IRF3, which activates Irf3 expression, resulting in decreased AKT activity. Moreover, insulin resistance and proteolysis are re‐induced by Irf3 overexpression under Tlr13 deletion.Our results indicate that TLR13 is involved in CKD‐mediated insulin resistance in muscle. In catabolic conditions where insulin signaling is impaired, targeting TLR13 may improve insulin sensitivity and prevent muscle atrophy. Increased levels of TLR13 promote skeletal muscle atrophy and that TLR13 interacts with IRF3, thereby impairing intracellular insulin signaling. The interaction between TLR13 and IRF3 expression resulted in decreased AKT activity, whereas IRF3 knockdown prevented TLR13‐induced insulin resistance and increased p‐AKT. TLR13 is part of a novel mechanism of CKD‐mediated insulin resistance in muscle. In addition, we propose that the ETS2 protein may activate the TLR13 promoter and promote the expression of TLR13 at the transcriptional level. ETS2 is thought to interact with TLR13, and its overexpression leads to a higher expression of TLR13, whereas the activation of TLR2 and TLR3 inhibits TLR13 expression.Toll‐like receptors are believed to control the interferon regulatory factor (IRF) family of transcription factors.AKT  signaling plays a central role in insulin resistance and skeletal muscle atrophy.Through STRING predictive analysis, we found that TLR13 can interact with IRF3. Our results suggest that TLR13 recruits and phosphorylates IRF3 to inhibit AKT activity and impaired insulin signaling, thereby mediating the occurrence of CKD skeletal muscle atrophy.22.1A mouse skeletal muscle cell line C2C12 was propagated as described previously.Irf3 were purchased from GE Dharmacon and transfected into cells using Lipofectamine 2000. The sequences of the siTLR13 were: siTLR13: 5′‐UACAAUUGUUCAUCUUUGCUA‐3′ and siETS2: 5′‐UCCAAAGUCAUUCAUCGCG‐3′.TLR13 (NM_205820.1) siRNA (siTLR13), ETS2 siRNA (siETS2), and recombinant adenovirus expressing IRF3 was constructed by cloning Irf3 cDNA into a pAdTrack‐CMV plasmid using the AdEasy System (Clontech Laboratories). The transfected cells were differentiated into myotubes and placed in serum‐free medium before being treated for 24 h with 15% uremic serum from subtotal nephrectomy mice or normal serum from sham mice.Adenovirus expressing 2.2Blood was drawn at euthanasia via retro‐orbital puncture. BUN and creatinine were assayed in CKD mice. Blood was collected in Vacutainer tubes, and serum was obtained by centrifuging clotted blood at 1100 g for 10 min at room temperature. To minimize minor differences between CKD mice, all serum samples were pooled for the experiments. Serum samples were frozen at −20°C until analysis.2.33 cells/well) were seeded in 96‐well plates and differentiated into myotubes. Normal or uremic serum was added, and cells were incubated for 24, 48, and 72 h. Cell viability was measured using a cell counting kit‐8 (Beyotime) following the manufacturer’s instructions.For investigating the effect of uremic serum on cell viability, C2C12 cells , and cDNAs were synthesized using a cDNA Synthesis Kit (Sigma‐Aldrich). Real‐time PCR was performed with SYBR Premix Taq II (Takara) and a CFX96 Real‐Time PCR Detection System with the following primers: TLR13, forward: TGTCTGCTCTGGTGGACTTG, reverse: GAGGAGTGAAGGCGTCTTTG; atrogin‐1, forward: GAGGCAGATTCGCAAGCGTTTGAT, reverse: TCCAGGAGAGAATGTGGCAGTGTT; MuRF‐1, forward: AGTGTCCATGTCTGGAGGTCGTTT, reverse: ACTGGAGCACTCCTGCTTGTAGAT.2‐ΔΔCT method.The relative expression of target genes was normalized to that of the housekeeping β‐actin gene using the 2.5Proteins were extracted from tibialis anterior (TA) muscles or cultured C2C12 myotubes using RIPA buffer (Thermo Fisher Scientific). Protein concentrations were measured by using a Bradford Protein Assay Kit (Bio‐Rad). About 30 mg proteins were separated by SDS‐PAGE and transferred to nitrocellulose membranes. Membranes were incubated with primary antibodies overnight at 4°C following the manufacturer’s recommendations. The following primary antibodies were used for western blot analyses: TLR13 , Ets2 , phospho‐IRF‐3 (Ser386) , IRF3 , AKT , phospho‐AKT (Ser473) , atrogin‐1 , and MuRF‐1 . Primary antibodies were counter‐probed with secondary horseradish peroxidase antibodies (Sigma‐Aldrich) for 1 h at room temperature. Immunoreactive bands were visualized using enhanced chemiluminescence, and images were captured and analyzed using Image Lab software (Bio‐Rad).g for 5 min at room temperature and then analyzed by western blotting.To perform immunoprecipitation (IP), 4 μg anti‐TLR13 or anti‐IRF3 antibodies were added to the C2C12 lysates and incubated overnight at 4°C with phosphatase and protease inhibitors. Protein A/G Plus Beads (Thermo Fisher Scientific) were added, and the sample was incubated for a further 2 h with agitation. Proteins were collected by centrifugation at 1000 2.6The myotube area was analyzed using a live imaging light microscope at ×10 or ×20 magnification (AF600 Modular System). The myotube number, diameter, and area were assessed in each experimental condition at each time point in six images per well, and data were analyzed using ImageJ software .2.7Protein synthesis and degradation in C2C12 myotubes were measured by adding isotopes to media as described previously.2.8To determine glucose consumption and uptake in cells, a previously published protocol was followed.2.9To determine whether ETS2 interacted with TLR13, a Dual‐Luciferase Reporter Assay System (Promega Corporation) was used as described previously.2.10Male C57BL/6 mice (8 weeks old) underwent subtotal nephrectomy to induce CKD by a method described previously.2.11To assess differences in cross‐sectional areas of myofibers, frozen TA muscle sections (5 μm) fixed with 4% formaldehyde were blocked for 20 min. The sections were then incubated with anti‐dystrophin antibody  at 4°C overnight. After washing with PBS, the samples were incubated with a secondary antibody  for 30 min at room temperature in the dark. At least 1000 myofibers in each section were examined using NIS‐Elements software (Nikon).2.12To measure glucose tolerance, mice were fasted for 16 h, and then blood was obtained from the tail vein to measure glucose levels using a Truetrack Glucometer (Nipro Diagnostics). Mice were then injected intraperitoneally with 1.5 mg glucose, and blood glucose was measured again at 30‐min intervals for 2 h. To measure insulin intolerance, blood glucose was first measured in mice that were fasted for 4 h. Subsequently, the mice were injected intraperitoneally with insulin (0.375 mU/g body weight) and blood glucose was measured again 30 and 60 min later.2.13Sections of TA muscle tissue and C2C12 myotubes were stained using the following antibodies: TLR13 , phospho‐AKT (Ser473) , and phospho‐IRF‐3 (Ser386) .2.14t‐test or one‐way ANOVA were used for statistical analysis using Prism 6 (GraphPad Software). p < 0.05 was considered statistically significant.Data are shown as the mean ± standard error of the mean (SEM). Each experiment was repeated at least three times. Student’s 33.1Tlr13 mRNA were higher in the TA muscles of the CKD mouse model than in the sham control  in C2C12 myotubes with TLR13 expressed or knocked down. When C2C12 myotubes were challenged with uremic serum, both atrogin‐1 and MuRF‐1 were expressed at significantly lower levels when TLR13 was knocked down Figure . As anti3.4AKT regulates insulin resistance. Therefore, we examined the levels of phosphorylated AKT in C2C12 myotubes with and without the expression of TLR13. Western blotting analysis indicated that levels of p‐AKT at Ser‐473 were decreased under uremic serum compared with normal serum Figure . In immu3.5Tlr13 was expressed or when Irf3 was overexpressed. As expected, levels of muscle atrophic factors (atrogin‐1 and MuRF‐1) were significantly higher when Tlr13 was expressed or Irf3 was overexpressed  was higher when TLR13 was expressed or IRF3 was overexpressed than when TLR13 was inhibited Figure . Correspd Figure . To confd Figure  and sugg3.6Tlr13 expression.After establishing that IRF3 may be physically associated with TLR13, we next determined whether TLR13 may be regulated by the transcription factor ETS2. The relative mRNA expression and protein levels of TLR13 were reduced when ETS2 was silenced Figure . Corresp3.7Tlr13 silenced  TLR13 levels are increased by the activation of ETS2; (3) TLR13 recruits IRF3 to increase its serine phosphorylation, thereby impairing intracellular AKT signaling; and (4) increased levels of TLR13 promote skeletal muscle atrophy.The development of atrophy in skeletal muscle is associated with a reduction in insulin‐stimulated glucose uptake and protein degradation.The relationship between CKD and insulin resistance has been well documented.Toll‐like receptors have been found to play an essential role in CKD‐induced skeletal muscle atrophy and insulin resistance.Ets2 is not directly associated with muscle atrophy but is known to be an oncogene that drives various cancers through the aberrant activation of RAS/MAPK signaling, and it is known to interact with TLR13 and other TLRs.Ets2 was upregulated in CKD and is associated with increased levels of TLR13. Moreover, levels of TLR13 mRNA and muscle atrophic factors were reduced when ETS2 was silenced. Therefore, we propose that the ETS2 protein may promote the expression of TLR13. Further studies are needed to identify the exact pathways involved.The relationship between IRF3 and TLRs has been well documented with several studies reporting an interaction between TLR4/TRIF/IRF3 signaling.AKT pathways have been associated with CKD‐induced skeletal muscle atrophy and insulin resistance.There are limitations to this study. We cannot exclude other factors that interact with TLR13 and contribute to CKD‐induced skeletal muscle atrophy. Further research will be needed to determine other genes and pathways that are influenced by the upregulation of TLR13 in CKD.In conclusion, we have found that increased levels of TLR13 promote skeletal muscle atrophy and that TLR13 recruits IRF3, thereby impairing intracellular insulin signaling. The recruitment of IRF3 with TLR13 resulted in decreased AKT activity, whereas IRF3 knockdown prevented TLR13‐induced insulin resistance and increased p‐AKT. TLR13 is part of a novel mechanism of CKD‐mediated insulin resistance in muscle. Targeting the human equivalent to TLR13 or genes that suppress it may be a therapeutic modality in improving insulin signaling and preventing the profound catabolic consequences of insulin resistance in CKD.The authors declared no conflict of interest in this manuscript.SR and LJG participate in the processes of the conception and design of the study. LJG, ZFW, YYZ, NZ, JYL, and MY participate in the processes of experiment execution, data collection. ZFW, NZ, JYL, and LW participate in the processes of data analysis and interpretation of data. LJG, ZFW, YYZ, NZ, MY, and LW participate in the processes of manuscript preparation and the final manuscript improvement. All authors read and approved the final manuscript.This study was approved by the Institutional Review Board of Shanghai General Hospital, Shanghai Jiao Tong University. All animal experiments were conducted in agreement with the Guide for the Care and Use of Laboratory Animals and were approved by the Committee of Shanghai General Hospital, Shanghai Jiao Tong University.


Appropriate soft tissue tension in total knee replacement (TKR) is an important factor for a successful outcome. The purpose of our study was to assess both the reproducibility of a modern intraoperative pressure sensor (IOP) and if a surgeon could unconsciously influence measurement. A consecutive series of 80 TKRs were assessed with an IOP between January 2018 and December 2020. In the first scenario, two blinded sequential measurements in 48 patients were taken; in a second scenario, an initial blinded measurement and a subsequent unblinded measurement in 32 patients were taken while looking at the sensor monitor screen. Reproducibility was assessed by intraclass correlation coefficients (ICCs). In the first scenario, the ICC ranged from 0.83 to 0.90, and in the second scenario it ranged from 0.80 to 0.90. All ICCs were 0.80 or higher, indicating reproducibility using a IOP and that a surgeon may not unconsciously influence the measurement. The use of a modern IOP to measure soft tissue tension in TKRs is a reproducible technique. A surgeon observing the measurements while performing IOP may not significantly influence the result. An IOP gives additional information that the surgeon can use to optimize outcomes in TKR. For many years, intraoperative pressure (IOP) sensors have been incorporated in total knee replacement (TKR) surgery to measure compartmental tissue tension . The firA modern IOP enables precise quantitative assessment of soft-tissue balance rather than manual (surgeon-defined) assessment ,6. SurgeIntraoperatively an IOP informs the surgeon whether soft-tissue corrections, prosthesis manipulation  and/or bone recuts are required to optimize TKR function. These corrections once the trial prosthesis is inserted can be complex and/or challenging, adding to operating time. This could cause the surgeon to unconsciously influence the IOP measurement during dynamic visual feedback while manipulating the trial TKR to decrease operative time. We have examined this by analyzing the correlation between an initial blinded and subsequent unblinded assessment where the surgeon is dynamically visualizing the IOP measurements in real time. Previously published papers using an IOP in the Literature ,10,11 arConventional assessment of soft tissue balance in TKR is traditionally conducted by the surgeon intraoperatively by applying manual tensioning of ligaments throughout a range of motion with the trial implants inserted. This relies on subjective evaluation of tissue tension and is dependent on multiple factors: the magnitude and direction of forces applied, tactile or visual appreciation of laxities, and the ability to control femoral stability/hold the thigh while flexing the knee and holding the tibia and applying a varus or valgus force at the same time. This subjective evaluation is most simple at 10 degrees medial and most challenging at 90 degrees lateral . Another important consideration of manual techniques is that the compartmental tissue tension is significantly altered as the extensor mechanism is not closed or approximated. Surgeons routinely do not close the extensor retinaculum as visual assessment of the trial would not be possible and the tactile assessment becomes more challenging . The useStudies of modern IOPs to improve outcomes in TKR have shown promising early results. Chow et al. compared sensor-assisted TKR balancing to manual balancing and reported significantly greater improvements in patient-reported outcome scores in the sensor-assisted group . Gustke With the increased awareness of the importance of soft-tissue balancing in TKR outcomes, several techniques have evolved and been well documented to manage balance prior to the development of a modern IOP. The gap balancing technique allows for the adjustment of the implant position by force distraction of the collateral ligaments but is not a quantitative evaluation of compartmental pressure . MeasureThe aims of this study were to assess the intraclass coefficients (ICCs) and reproducibility using an intraoperative pressure sensor in TKR and whether a surgeon could unconsciously influence the measurement. To date there has been no evidence of the reproducibility of the use of a modern IOP in a clinical setting and whether the surgeon could unconsciously influence measurement.A consecutive series of patients undergoing primary unilateral TKA at three hospitals were included in this study. An intraoperative load sensor  was used in all cases. Exclusion criteria were a tibial plate size 2 or less as the IOP smallest size was 3 (three patients) or if a constrained implant was preoperatively planned. Approval to conduct this study was sought from our local ethics committee.A total of 76 patients undergoing 80 TKA procedures were assessed. All data was recorded prospectively at the time of surgery. Surgery was performed by fellowship-trained knee arthroplasty surgeons who had been in specialist practice for over 12 years.Surgeons used their preferred prosthesis and the same technique throughout the study. The aim was to restore a neutral mechanical axis of the lower limb. Once the trial polyethylene spacer was inserted into the trial femoral and tibial components, the surgeons assessed soft tissue balance with their normal technique. The polyethylene spacer would be changed to the thickness that the surgeon defined as a balanced TKR. Then, an IOP insert of the same thickness and shape of the polyethylene was exchanged. Medial retinacular closure was simulated using two clips at the superior and inferior patellar edges to prevent the medial parapatellar arthrotomy from altering intercompartmental loads . Data weDuring surgery, data were recorded from the IOP monitor. This involved the intra-articular medial and lateral tissue tensions at 10°, 45°, and 90° flexion as described in Gordon et al. . The datSimple comparison of 95% confidence intervals (CIs) for each ICC can be misleading , as confThe technique is based upon the bootstrap resampling technique of Efron and Tibshirani , and ourBland–Altman plots, associated summary statistics, ICCs, and comparisons between them were obtained using inbuilt, and in the case of comparison between ICCs, custom written  routineideal mean of the differences (represented by the blue line) between blinded 1 and blinded 2 would be zero, i.e., the two sets of scores would be identical. The actual mean of the differences between blinded 1 and blinded 2 is represented by the purple line, and in this case was 0.40, with a standard deviation of 4.20.In the Bland–Altman plot , for 10 The mean of the differences between blinded 1 and blinded 2 was positive, indicating that the reported pressures tended to be higher for blinded 1 than for blinded 2.The 95% limits of agreement, based upon the mean and standard deviation of the differences, were −7.84 to 8.63. Three cases had differences between blinded 1 and blinded 2 that were higher than the upper 95% limit of agreement.The actual mean of the differences between blinded 1 and blinded 2 is represented by the purple line in The mean of the differences between blinded 1 and blinded 2 was negative, indicating that the reported pressures tended to be lower for blinded 1 than for blinded 2.The 95% limits of agreement were −10.06 to 5.97. One case had a difference between blinded 1 and blinded 2 that was higher than the upper 95% limit of agreement.See The Bland–Altman differences  between All ICCs  were 0.8ideal mean of the differences (represented by the blue line) between blinded and unblinded would be zero, i.e., the two sets of scores would be identical. The actual mean of the differences between blinded and unblinded is represented by the purple line, and in this case was −1.44 with a standard deviation of 6.46.In the Bland–Altman plot for 10 degree lateral , blindedThe mean of the differences between blinded and unblinded was negative, indicating that the pressures tended to be higher for unblinded than for blinded.Similar in principle to “process control charts” used in quality control and improvement , BlandOne case had a difference between blinded 1 and blinded 2 that was lower and one case that was higher than the upper 95% limit of agreement.In the Bland–Altman plot for 10 degree lateral , blindedThe 95% limits of agreement were −12.19 to 9.44.One case had a difference between blinded 1 and blinded 2 that was lower than the lower 95% limit of agreement and one case that was higher than the upper 95% limit of agreement.See All the Bland–Altman means of differences  were negThe largest mean difference between blinded and unblinded was for 90 degrees lateral at −2.19 with a standard deviation of 5.86.The largest standard deviation (high variation) was for 90 degrees medial, although it had a low mean of 0.34, with a standard deviation of 6.99.All ICCs  were 0.8In both scenarios, the bootstrap 95% confidence interval of the difference between the two ICCs at 10 degrees medial versus 90 degrees lateral contained a value of zero (no difference) and so the difference between the two ICCs was not statistically significant at the 0.05 level.We have reported for the first time in the literature that the use of a modern IOP  is a reproducible intraoperative technique to quantify the soft tissue tension of a total knee replacement.An ICC of 0.8 or greater is the minimum for human reproducibility and an ICC of 0.90 or greater is the minimum for mechanical reproducibility. In both our scenarios, the range of ICCs fell within 0.80 to 0.90, the expected range for human reproducibility. However, the ICCs when two blinded measurements were taken were greater (0.83 to 0.90) than in Scenario 2 (0.80 to 0.90) when the blinded and unblinded measurement were compared. This suggests that IOP reproducibility is improved when measurements are blind.It is important to know that the use of an IOP is reproducible, particularly as, when an IOP was used in over 300 consecutive cases, there was not a significant learning improvement of manual surgeon-defined knee balance . This coSurgeon-defined manual evaluation of soft tissue pressure is most simple at 10 degrees medial with direct vision of the medial trial TKR and most challenging at 90 degrees lateral with a standard medial parapatellar approach where the lateral trial TKR is not visible. As expected, we found that in both scenarios, when the two ICCs of these measurements were compared, that there was no statistically significant difference for an IOP when the extensor retinaculum was closed.An IOP is appropriate in research to quantify balance with new TKR designs or surgical techniques such as medial pivot TKR, kinematic alignment, or robotic-assisted TKR. By combining IOP and robotic-assisted TKR, the surgeon is able to quantify soft tissue balance, alignment, and range of motion of the trial prosthesis intraoperatively. This gives rise to the concept of using multiple technologies for optimal “functional alignment” rather than commitment to a particular concept such as mechanical or kinematic alignment or gap balancing. Gordon et al. reported that robotic-assisted TKR using a gap balancing technique for the initial trial was only balanced in 65% of cases. With subsequent soft tissue corrections and bone recuts, this changed to 87% of cases becoming balanced through the range of motion. However, this resulted in a wide range of coronal alignment which ranged from 6° valgus to 9° varus and the concept of “functional alignment”. Bardou-Jacquet et al. similarly found that, by combining these two technologies in a series of 29 patients, 27 (93%) showed a well-balanced knee in extension at the end of the procedure and 23 (79%) showed a well-balanced knee in terms of flexion and extension with correcting bone cuts alone without soft tissue release.The aim of the study was to assess the reproducibility of an IOP in two different scenarios. This also allowed us to compare the ICC at 10 degrees medial to 90 degrees lateral, which, respectively, are the most simple and challenging measurements in manual surgeon-defined soft tissue assessment. In both scenarios there was no significant difference, which was expected as the IOP techniques are reproducible.A limitation of this study was to not have both surgeons independently measuring the IOP of the same patient intraoperatively. Due to the logistics of having two surgeons present for the IOP measurement only and in the interests of decreasing the known risks of serious complications , this was not done. The authors believe that, with regards to an operating theatre, there is only one surgeon performing the case and therefore we believed it was important to study what that individual surgeon did rather than compare surgeon to surgeon. It is not possible to examine interrater agreement between the two different scenarios as there was no overlap between the two groups, other than the ICC being slightly greater for Scenario 1, but within human reproducibility for both. The potential for a greater comparison between these two groups is limited as Scenario A compares blinded to blinded measurements and Scenario B compares blinded to unblinded.This study has demonstrated that a modern IOP to quantify soft tissue tension in TKR is a reproducible technique. A surgeon recording and observing the measurements in real time while using an IOP may not significantly influence the result. An IOP gives additional information that the surgeon can use to optimize outcomes in TKR.


To explore the relationships between participant characteristics, perceptions of a short educational video about osteoarthritis and its management, and immediate changes in behavioural determinants for effective self-management behaviours.Seventy-eight participants with knee OA  watched the 9-min video that included evidence-based content and was designed to foster empowerment to self-manage effectively. Data were collected by online questionnaire at baseline and immediately after watching the video. Associations were tested between baseline health and information processing characteristics , perceptions of the video  and pre-post changes in behavioural determinants .ρ = 0.26–0.47). Greater perceived relevance was associated with increased self-rated importance of being physically active (ρ = 0.43). There were small positive associations between health literacy domains related to health information and positive viewer perceptions of the video. People with higher need for cognition may achieve greater improvement in confidence to be physically active (ρ = 0.27).All behavioural determinants improved immediately after watching the video. Positive perceptions were associated with greater improvements in self-efficacy for arthritis (Spearman’s rho, The educational video may help achieve outcomes important for increasing self-management behaviours in people with knee osteoarthritis. Positive perceptions appear to be important in achieving these improvements. People with lower health literacy and lower need for cognition may respond less well to this information about knee osteoarthritis delivered in this way.The online version contains supplementary material available at 10.1186/s12891-021-04751-2. Patient education is the most commonly used intervention for chronic disease management . EducatiThe potential benefits of education interventions for knee OA include improvements in psychosocial outcomes –4, pain This quantitative study aimed to further explore responses to this educational video. The video utilises presentation features and content that moves away from the more common biomedically based-education and pathoanatomical approaches to explaining and managing the disease. It avoids pictures of structural damage and does not describe severity in terms of imaging results. It was designed to communicate positive expectations about the effects of self-management behaviours with optimism for one’s future prognosis . Our ratThe study had three objectives. Firstly, to investigate whether the behavioural determinants targeted by the intervention  changed immediately after watching the video . The second objective was to describe viewer perceptions of the video  , and then explore whether viewer perceptions were associated with changes in behavioural determinants . The third objective was to identify participant characteristics  that were associated with viewer perceptions  and/or changes in behavioural determinants .Successful adult patient education is a planned intervention, grounded in adult learning theory, with multiple components that need careful consideration . ExploriThis exploratory study utilised data collected as part of an evaluation of a novel patient education video . The stuThe 9-min knee OA info video “Knee Pain: What can I do?”  was creaOne hundred Australian participants were recruited via social media, community advertisement and word of mouth during June–November 2019. Participants were eligible if they had knee OA based on self-reported physician diagnosis or clinical diagnostic criteria . ExclusiParticipants completed a baseline questionnaire including demographic details (age), health factors , and information usage attributes . The questionnaire also included behavioural determinants that were hypothesised to be important mechanisms for the intervention to be effective in facilitating better self-management  , 34–37. Having sufficient information to manage my health’, ‘Appraisal of health information’, ‘Ability to find good health information’ and ‘Understand health information well enough to know what to do’. ‘Need for Cognition’, a personality trait relating to how people tend to process information, was measured using three items with 11-point NRS [Pain (average over past week and worst pain during activity) was self-reported using an 11-point numerical rating scales (NRS) . Health oint NRS . People oint NRS . They ofoint NRS . Along woint NRS . To be eThe survey included questions on perceived enjoyment, helpfulness, believability (degree to which the information was believed to be true), novelty (amount of new information), and relevance of the information (average of three items); all rated on 0–6 Likert scales . Scores Activation (or attitude towards self-management) was measured with the 13-item Patient Activation Measure (PAM) , 42. Seln = 78 is 0.10 [Baseline data are described using mean  and range. Pre-post changes in self-efficacy for managing OA, activation, and importance and confidence for physical activity were analysed using paired t-tests . Viewer perceptions of the video  are described using mean (SD), range and the proportion of participants with negative perceptions. To identify the perceptions of the video that were associated with changes in behavioural determinants , Spearman’s rho correlation coefficient with 95% confidence intervals (CI)  were use is 0.10 –47, ther2. The sample included a wide range of knee OA presentations in terms of pain severity and duration. Average health literacy was high (Table Seventy-eight (78%) participants completed the study Fig. . Non-comgh Table , and as Results for the pre-post (within-group) comparison showed statistically significantly improved ratings for all outcomes including arthritis self-efficacy, activation and ratings for importance/confidence with physical activity Table .Table 2RViewer perceptions of the video are detailed in Table ρ = 0.41, 95%CI 0.20 to 0.59) such that the greater the perceived relevance, the greater the increase in ratings of importance of physical activity after viewing the video. Novelty (i.e. information in the video was perceived as being new) was positively associated with both change in self-efficacy for managing pain  and change in self-efficacy for managing other symptoms . The more new information the participant perceived, the greater the increase in self-efficacy. Perceived helpfulness was also associated with increases in pain self-efficacy , and other symptoms self-efficacy . Enjoyment was associated with change in ASES other symptoms , but the association between enjoyment and change in ASES pain was smaller and therefore considered questionable . Viewer perceptions of believability did not seem to be associated with any changes to determinants. In addition, none of the perceptions measured in this study were associated with changes to activation or confidence to be physically active.Some viewer perceptions were associated with changes in the behavioural determinants Table . Relevanρ = 0.36, 95%CI 0.14 to 0.54). These associations indicate better health literacy in relation to health information may lead to more positive perceptions of the video. Or conversely, that people with lower health literacy were more likely to react negatively. There was a questionable negative association between pain severity and believability . If true, that would mean, the more severe the pain, the less believable the information in the video.There were several questionable positive associations between domains of health literacy and the viewer perceptions of helpfulness and believability Table , but theρ = 0.27, 95%CI 0.05 to 0.47) (Table There was a questionable positive association between need for cognition and change in confidence to be sufficiently active (7) Table . No otheThis study showed that people report improvements in self-efficacy for managing their OA, activation, physical activity importance, and physical activity confidence immediately after watching a short educational video that delivers information about knee OA using a biopsychosocial explanation for the pain and a focus on empowerment for self-management. The perceptions of the video ranged amongst the participants with some rating the video negatively for enjoyment, helpfulness, believability, novelty and/or relevance. Positive responses to the video information were associated with greater improvements with self-efficacy for managing OA pain and other symptoms. Perceived greater relevance was associated with greater increase in rating of importance to be physically activity. Taken together the data supports a positive relationship between health literacy related to health information and how the video was received. There may be a negative association between pain severity and belief that the information was true and correct. Finally, there may be an association between greater need for cognition and reporting greater improvements in confidence to be physically activity immediately after watching the video.Interpreting the clinical meaning of the changes in behavioural determinants is difficult as measurement error and minimal clinically important changes have not been determined for these measures. Comparing effect sizes (change score divided by baseline SD ) with coThe measures of importance/confidence to be physically active are measures of cognition rather than action but both are critical to motivation and thus to successful behavior change . If a goRatings of perceptions of the video were predominantly positive, however not everyone (10–23%) found the video enjoyable, helpful, felt there was new information, or perceived it to be relevant to them. It remains unclear whether any of the participant characteristics can predict more positive or negative perceptions, as most associations were of questionable strength. It is pleasing from the perspective of general applicability and acceptability of the video that strong associations were not apparent, however, there was a tendency for health literacy domains to be positively associated with perceptions, in particular helpfulness and believability. Most notably, self-reported ability to understand health information was associated with finding the video believable. Although most of these correlations were categorised as questionable based on our criteria, it does raise some concern that the video may be less useful for people who are potentially most vulnerable in terms of health literacy. Other studies have found that interventions benefitting people with higher health literacy also benefit those with lower  and thisIn line with our logic model, positive viewer perceptions were related to greater improvements in the behavioural determinants. Interestingly though, not all perceptions were correlated with changes in all determinants targeted. Relevance for example, was correlated only with change in rating of importance of being physically active. Whereas, novelty, helpfulness and finding the video enjoyable were associated with changes in arthritis self-efficacy. Based on extant frameworks and theorisations –54, it wIn terms of a direct relationship between participant characteristics and change in behavioural determinants, there was a small and questionable association between higher need for cognition and greater increase in confidence to be physically active after watching the video. Given that confidence to be physically active may be fostered more effectively by this video in those with higher need for cognition, it seems that the video may have catered more in this respect to those people. People with a higher need for cognition tend to enjoy cognitive tasks and process information more elaborately. These people should respond well to a video that presents strong arguments and is factual in terms of intentions and patient activation. People with a lower need for cognition, who rely more on heuristics, emotions and other peripheral cues to process information, were expected to also respond well, given there is sufficient positivity and other peripheral cues to draw from  , 54. SysIt is important to highlight that not all educational interventions produced for people with knee OA can be expected to result in similar findings. Effective patient education has been conceptualised as both an ‘art’ and a ‘science’ . Both coThe lack of a comparator group means we cannot know whether the changes in outcome measures can be attributed to the intervention. The responses were measured immediately after watching the video, so sustainability of the changes is also unknown. The improvements in behavioural determinants must therefore be considered with caution. A further limitation is the risk of Type 1 error due to multiple analyses. Generalisability is limited as we inadvertently did not sufficiently capture the views of people with low health literacy. In addition, the sample was limited to people who were exposed to the Australian health services and Australian societal beliefs and attitudes about health and healthcare, and therefore the results may not be the same for people living in different locations/cultures.This study adds further support that positively framed video information about knee OA with an emphasis on empowerment for self-managing with physical activity and exercise may be beneficial. Findings are suggestive, though not conclusive, that short term benefits may include improvements in self-efficacy, activation, and motivation/confidence to be physically active. The video investigated in this study appears to be slightly better received by people with higher health literacy and higher need for cognition, as these characteristics were associated with more positive perceptions of the video and greater increase in confidence for physical activity respectively. Further research is needed to confirm these findings, but it is recommended that designers of empowerment education for people with knee OA strive to engage those with lower health literacy and lower need for cognition. Our findings also suggest that education interventions that are enjoyable and perceived to be helpful, and relevant to the individual may have greater effect. Thus, efforts by health professionals to help people with knee OA to perceive the information is being relevant to them personally may optimise the potential for the video to increase motivation and confidence to be physically active.Additional file 1.


The availability of intraoperative multimedia recording is increasing. Considering the growing call for physicians’ accountability, it is inevitable that multimedia will play an important role in aiding quality control by improving the adequacy of operative reporting. However, the perspectives of medical professionals on this matter are poorly known. In this cross-disciplinary survey, we aimed to investigate the current viewpoints concerning the use of multimedia recording in the operating room. We conducted an electronic survey among all affiliated members of the Association of Surgeons of the Netherlands, the Dutch Urological Association and the Dutch Society of Obstetrics and Gynecology containing questions regarding current use of intraoperative recording and the level of likelihood or objection for certain scenarios. The response rate was 27.8%. The survey encompasses 370 (54.5%) surgeons, 71 (10.5%) urologists, 80 (11.8%) gynecologists, and 158 (23.3%) residents in training. 52.4% of respondents feel that the currently used operative report is insufficient for future quality requirements. 58.5% think it is unlikely they would behave differently during surgery when intra-operative video recording is applied. 82.8% think it is unlikely that their surgical methods would be altered. 63.8% of respondents preferred only video registration when intraoperative recording is implemented. The majority of respondents agree that the current method of operative reporting is insufficient for future quality requirements. There is support for intraoperative video recording, however, legal transparency is needed before either intraoperative video or audio recording could be implemented to protect not only the patients, but also the healthcare providers.The online version of this article (10.1007/s13304-020-00902-7) contains supplementary material, which is available to authorized users. During the last decade, the use of multimedia in the context of the operating room has increased rapidly. Capturing video, still images or sound have become an essential part of daily practice in many surgical disciplines, with the potential to benefit either individual patient care or treatment as a whole. Alongside photo-documentation of laparoscopic female sterilization, probably the best-known example of multimedia documentation is that of the critical view of safety (CVS) on photo or video in laparoscopic cholecystectomy as an auxiliary to the narrative operative report . This apIn addition to a boost in reporting quality, use of multimedia documentation could also be invaluable for other purposes, for instance, in the case of surgical quality control and quality assurance. In a study by the Michigan Bariatric Surgery Collaborative, peer-rating of procedural videos of laparoscopic gastric bypass surgery was performed to assess participating bariatric surgeons’ technical skills . The autConsidering the growing call for physicians’ accountability, it is inevitable that multimedia will play an important role in the foreseeable future and that it will indeed contribute to quality of care. Nonetheless, the views of key players are of great importance in this evolution, and the perspectives of medical professionals in the current surgical climate are poorly known. Therefore, in this cross-disciplinary survey, we aimed to investigate the current viewpoints of surgical specialists and residents in training concerning the use of multimedia recording in the operating room. Inquiries were made regarding their current practice in documenting surgical procedures, their views in regard to the added value and the exact composition of multimedia recordings, and their perspective on possible privacy and legislative issues in this context.On 20 December 2018, members affiliated to the Association of Surgeons of the Netherlands, the Dutch Urological Association and the Dutch Society of Obstetrics and Gynecology were approached by e-mail to engage in a web-based survey . Respondents not wanting to participate in the survey were provided with an opt-out option. Three reminders were sent to non-responders after initial invitation, with an interval of 4 weeks. Retired surgeons, urologists or gynecologists, approached persons with other functions than surgeon, urologist, gynecologist or resident of one of the corresponding disciplines, and partial responses were excluded from analysis.This questionnaire consists of 16 questions. Questions 1 through 4 covered respondents’ demographics. Questions 5 through 9 were multiple choice questions regarding the current use of operative reporting and its serviceability in the future, when developments in technology and an increased call for accountability will likely add to the requirements in medical reporting . QuestioP value of less than 0.05 was considered statistically significant. Groups were compared using Chi-square test or Fisher’s exact test. When responses of two categories were compared within the same group, McNemar’s test was used.Data were analyzed with IBM SPSS Statistics for Windows, version 25.0  and Microsoft Excel . Data are presented as numbers and percentages. A Invitations to a total number of 3151 e-mail addresses were sent, of which 3056 were successfully delivered. The overall response rate was 876 (27.8%). Replies of 197 respondents were excluded from this survey . After exclusion, a total number of 679 complete questionnaires were analyzed.Among the respondents, 370 (54.5%) were surgeons, 71 (10.5%) were urologists, 80 (11.8%) were gynecologists, and 158 (23.3) were residents in training of the corresponding disciplines.Of the respondents, 147 (21.6%) currently practice their trade in university hospitals, whereas 428 (63.0%) and 82 (12.1%) work in general teaching and general non-teaching hospitals, respectively. Respondents’ demographics can be found in Table P = 0.267 and 0.850, respectively), nor between differences in practicing years among specialists  or different years of training among residents .Overall, 356 (52.4%) respondents feel that the currently used narrative operative report—without video and/or sound—is insufficient for future quality requirements . There was no significant difference in responses among specialists and between specialists and residents . Data of all separate specialties is delineated in Table Overall, 621 (91.5%) of respondents stated that routine video recording of conventional procedures was not common practice in their department. For endoscopic procedures, this number was 186 (27.4%). There was no significant difference within departments (P =  < 0.001). There was no significant difference among specialists (surgeons 217 (58.6) vs. gynecologists 44 (55.0%) vs. urologists 42 (59.2%); P = 0.821). Of the respondents who do know the retention period in their institution, 20 (2.9%) reported a retention period of less than 30 days, 109 (16.1%) between 30 and 90 days, 40 (5.9%) 90 days and up to a year and lastly 87 (12.8%) reported a period of more than a year.423 (62.3%) respondents did not know the retention period their institution upholds for video recordings of surgical procedures. Residents know the retention period significantly less often than specialists (120 (75.9%) vs. 303 (58.2%); P = 0.710 and P = 0.605 for endoscopic and conventional procedures, respectively). Surgeons significantly more often utilize video recording in open procedures than gynecologists and urologists (P = 0.002). There was no significant difference among specialists in regard of work experience; P = 0.710 and P = 0.605 for endoscopic and conventional, respectively) as well as among residents in terms of year of training .Overall, the number of respondents answering ‘never’ or ‘almost never’ regarding intraoperative video recording was 130 (19.1%) for endoscopic procedures and 483 (71.1%) for conventional procedures. For specialists only, these numbers were 104 (20.1%) for endoscopic procedures and 421 (81.3%) for conventional procedures. When comparing specialists in terms of experience level, there was no significant difference (P = 0.018). There was no significant difference within departments concerning the recording of video files for quality control purposes, educational purposes, or in the context of proctoring . Respondents from the surgical department record video to provide information for patients and their family or for colleagues significantly less often than those from gynecology or urology . All purposes for intraoperative video recording reported by respondents are delineated in Table Respondents from the surgical department include video in the patient file significantly less often than those from gynecology or urology  P < 0.001 and 512 (75.4%) P < 0.001, respectively). Responses by residents indicated that they would behave differently in the operating room significantly more likely when intraoperative video recording is applied in comparison to responses by specialists . When inquired about the effect of video and audio recording, this significant difference increases to 71.0% vs. 56.5% (P = 0.003), respectively. No significant difference among specialists with different experience levels was found regarding the effect on their behavior in the operating room or their surgical methods for both the context of video  and video with audio (P = 0.734 and P = 0.329). Cronbach’s alpha of internal consistency for five-point Likert type scale questions in this section was 0.871.Among all respondents, 397 (58.5%) responded that it would be “unlikely” or “very unlikely” that they would behave differently during surgery when intra-operative video recording is applied. 562 (82.8%) responded that it would be “unlikely” or “very unlikely” that their surgical methods would be altered by the presence of intra-operative video recording. When intra-operative video P = 0.589 and P = 0.071). In the context of quality of surgical care, there was a significant difference between the different levels of experience (P < 0.001), with those who are less experienced (5 years or less) more likely to object compared to those with the most experience  vs 21 (32.3%), respectively). Cronbach’s alpha of internal consistency for these questions was 0.726.In the context of the recognizability of the respondent in the situation of intraoperative video recording, 252 (37.1%) of respondents find this either “objectionable” or “very objectionable”. 358 (52.7%) find it either “objectionable” or “very objectionable” to be recorded on intra-operative video in regards of medical liability. Finally, 241 (35.5%) find it either “objectionable” or “very objectionable” to be recorded on intra-operative video in the context of quality of surgical care. Among specialists, there was no significant difference concerning the years of practice in the context of recognizability or medical liability (with sound as either “likely” or “very likely”. 602 (88.7%) and 419 (61.7%) deemed this for educational purposes. 302 (44.5) and 148 (21.8%), respectively, found intraoperative video and intraoperative video with sound useful in providing information for patients, family and/or colleagues. 411 (60.5%) and 269 (39.6%) saw potential in the use of these respective modalities for quality control purposes. 453 (66.7%) and 312 (45.9%) deemed it likely that intraoperative video and intraoperative video with sound respectively would be an addition in the context of proctoring. Finally, 378 (55.7%) and 282 (41.5%) of respondents found it likely that intraoperative video and intraoperative video with sound could play a supportive role in medicolegal proceedings.409 (60.2%) and 222 (32.7%) respondents recognized the added value of intraoperative video and intraoperative video Cronbach’s alpha of internal consistency for these questions was 0.84.and audio recording. 84 (12.4%) would rather not have any recording at all. 18 (2.7) did not submit any preference.Table An increasing number of studies are exploring the values of multimedia recording in the surgical setting today. Some are exploring its role in surgical quality analysis and control , 16, 18.About half of the respondents agree with the statement that the currently used narrative operative report, without the addition of intraoperative video and/or sound, is lacking for future quality requirements. Today, the majority of institutions use either dictation devices, typed reports or modified pre-written concept reports. This method of reporting, however, is subjective by nature and often lacks essential information , 14.As expected, endoscopic procedures are far more often recorded by respondents compared to conventional (“open”) procedures. This is mostly due to the fact that the endoscope’s camera function is essential to conduct minimally invasive surgery. Video recording could then be implemented at the press of a button. Therefore, far less use a different, dedicated modality to record surgical procedures on video, such as a camera mounted to the surgical lamp (26.4%) or a fixed camera in the operating room (12.5%). Often, the quality is lacking, or the operator’s head and body are in its line of sight. Furthermore, for dynamic procedures, such as in orthopedic surgery or vascular surgery, it is virtually impossible to capture the essential moments through this method. Noteworthy is the use of mobile phones to record certain aspects of the surgery; about half of respondents have stated to use their mobile phone. This is probably due to the ease of use and the possibility to use the phone’s video call function to consult colleagues or other specialists.More than half of respondents did not know the duration of the retention period for intraoperative video recordings in their institution. Most that did know, reported a retention period between 30 and 90 days. Rules regarding the production and handling of medical documentation have been laid down in the Health Insurance Portability and Accountability Act (HIPAA) for the United States and the European General Data Protection Regulation for the European Union , 23. HowThe results of this survey suggest that surgeons are less likely than urologists and gynecologists to include video in the patient file or to record video to provide information for patients and family. A possible explanation is the fact that both of the latter specialties perform endoscopic procedures such as hysteroscopy and cystoscopy, during which it is customary to include photography or video with the report.The majority (58.5%) would think it is unlikely they would behave differently during surgery when intra-operative video recording is applied. Even more (82.8%) think it is unlikely that their surgical methods would be altered. An important finding is the fact that residents among respondents find it significantly less unlikely that their behavior or surgical method would be altered . Being in specialist training, it is important for residents to feel at ease and to be able to perform their surgery with as less additional pressure as possible. However, as our previous study has demonstrated, the role of intraoperative video recording in behavioral modification, also known as the “Hawthorne effect”, is negligible .A major concern related to the recording of intraoperative video (and audio) is the risks regarding the privacy of the patient and the operating room personnel alike. This is illustrated by the fact that over a third of respondents find it objectionable to be recognized on intraoperative video recording. Regarding possible medico-legal liability, over half of respondents find it objectionable.At this moment it is unclear when and for what purposes and by whom these recordings could be accessed. International legal texts mainly focus on the individual’s privacy, and are yet to incorporate specific situations for the surgical setting –24.Overall, the majority of respondents consider the added value of intraoperative video recording for multiple uses. This is less for intraoperative audio recording. The main sentiment in this regard is about significant loss of privacy. For instance, many respondents commented that in the operating room it is of great importance to be able to talk about non-work-related issues for an adequate balance between focus and being at ease. Sometimes, these topics can be of intimate nature. Without the proper delineation of who is able to access such audio recordings, most fear for their privacy and current job satisfaction.55.7% and 41.5% of respondents recognized the benefit of intraoperative video recording and combined video- and audio recording, respectively, in regard to its supportive role in medicolegal proceedings. In contrary of what is often feared, intraoperative recording could aid in medicolegal proceedings, instead of merely posing risk for medical negligence . The impThis survey yielded a response rate of 27.8%, a rate similar to other surveys having approached a comparable number of possible respondents . Also, dAs the results of this study suggest, the surgical landscape is still divided in terms of intraoperative multimedia recording. Whilst the majority of respondents feel the current method of surgical reporting is insufficient and a large portion are open to the idea of documenting the operative phase on video or audio, there are still certain issues to be sorted out before implementation could be considered. First of all, a significant portion of respondents expressed their concern in regard to potential privacy infringement. Currently no specific law is in effect to shield healthcare providers for their exposure when being recorded during practice. Furthermore, the issue in terms of ownership has not been resolved yet. Up to now, all documentation in healthcare, albeit written, photographed or recorded, are incorporated in the patient file, rendering it patient property by law. In this case, no protection for the healthcare provider is specifically implemented. It is, therefore, imperative that specific legislation will be developed for these methods of intraoperative documentation to adequately protect all subjects in the recordings as well as securing ease of use and harnessing its potential in quality and safety procurement.In conclusion, the majority of respondents find the current method of operative recording insufficient for future quality requirements. There is support for intraoperative video recording, however, most respondents fear privacy infringement. These concerns are greater for audio recording compared to video recording only. Legislation is necessary before either intraoperative video or audio recording could be implemented to protect not only the patients, but also the healthcare providers.Supplementary file1 (DOCX 21 kb)Below is the link to the electronic supplementary material.