Today, international mental health care increasingly focuses on creating recovery-oriented systems of support. This study aims to unravel the daily practice of an inpatient psychiatric ward that engages with persons with complex mental health needs.17 in-depth interviews were conducted with patients and staff of the ward. Data was analyzed by means of thematic analysis.asylum, a safe environment where patients can ‘simply be’. Second, the ward is experienced as a particularizing space, as support is organized in an individualized way and patients are encouraged to reconnect with their own identity. Third, the ward functions as a transitional space towards a valuable community life, in which finding adequate housing is of central importance.Three important functions of the ward were identified in the participants’ experiences. First, it functions as an The results show that inpatient forms of support tally with personal and social dimensions of recovery and fulfill important roles in recovery-oriented systems of support. Under impetus of the deinstitutionalization wave from the 1960s onwards, international mental health care has been undergoing a reform in an effort to offer more adequate and holistic support to persons with mental health needs . In thatWhilst residential treatment in psychiatric hospitals still makes up a large part of today’s mental health care, the implementation and operationalization of the recovery concept has primarily and most explicitly taken place in outpatient and community settings . Many gohow these inpatient spaces play a role in their recovery journeys. Considering the idiosyncrasy of recovery processes and the versatility of such settings, several authors have recommended the use of qualitative research approaches that are context-close, focus on micro-level recovery dynamics and are grounded in the lived experiences and perspectives of the persons who are directly involved in the practice under study , a bit between Tom and Leanne.” The patient population at the ward is characterized by a large diversity in terms of mental health problems, biography and the shape their recovery process takes. Consequently, all patients have different motives for spending time at the ward, as one psychiatric nurse describes:“Here, everything is very open. A lot more like, yeah… You (the patient) tell us what to do. And that’s what we work with. We are not going to tell you here how you should do it, but you have to do it for yourself.” “Having a low threshold. Not setting too many conditions for someone to come to the ward. (…) Actually, you put forward that the aim is to travel a road that is very individual. (…)What does one expect of one’s future? How does one picture that? What does one need? And we try to anticipate that. (…) But we try to do it in a very individual way, because it should always fit like a key in a lock.” Given the great heterogeneity in the motives and support needs of the patients, it would be inadequate to provide a one-size-fits-all therapeutic group program. Instead, the ward aims to give shape to an approach that is tailored to the recovery process of each patient. Rather than starting from a predefined therapeutic program that comes with a set of expectations (‘what do we want from the patient?’), patients are encouraged to formulate what they expect from their admission and how it can support their recovery process. In doing so, they are actively invited to give meaning to their stay on the ward themselves, thus take (back) agency over their lives:“If someone says ‘I want to use cocaine weekly for the rest of my life, but I can do it in a limited way and I can do it once a week on Saturday night at a friend’s house’, then we won’t… As long as his cocaine use doesn’t stand in the way of his trajectory towards outside… If he has enough money to rent a house or something else, then we won’t make a problem of it. (…) But imagine that the same man says ‘I want to live in sheltered housing, anything else isn’t possible for me’, then we will make a problem of it, because no sheltered housing unit will allow [people who are not abstinent].” This particularizing approach is also reflected in the ward’s policy regarding substance use. Although using alcohol or drugs on the ward is not allowed, there is also no zero-tolerance policy. Instead, an individual approach is outlined for each patient, that corresponds to that patient’s personal needs and wishes. In other words, in the ward’s vision on recovery, abstinence is not put forward as a fundamental precondition. One of the psychologists explains how such an individual approach can possibly take shape:“They approach everybody individually here. And I think that they know of some people that they drink something every now and then, or smoke a joint, and that they turn a blind eye. Well, that’s what I think. And they can’t do that for me, because it is not allowed. If they know that I drink, they are legally obliged to pass it on.” In other words, the ward’s substance use policy is attuned to the recovery process of each patient, as it is the result of a negotiation between staff and the patient. Consequently, patients gain a sense of ownership over these rules. For example, one patient talks about the nuances in the reactions of the staff regarding the use of drugs depending on the patient involved:“Definitely when you’re homeless, you don’t have many friends or acquaintances, you don’t own things. And then you’re put into a system where the only thing that is left of your identity is that you are a patient. And that can… work in a paralyzing way, depressing way, make you apathetic if you stay in it. So it is an art to listen… like what do you identify yourself with that might be snowed under by your patient identity?” In their daily lives, patients are often confronted with stigmatizing experiences in which their identity is narrowed down to their psychiatric label or their status as a homeless person. Facilitated by the individualized approach of the ward, however, patients are not reduced to their psychiatric diagnosis but are rather seen as individuals with unique aspirations and vulnerabilities. One of the psychologists explains how the staff on the ward actively tries to oppose a narrow interpretation of the patients’ identities:“There (at another ward) I had the impression that they had a prejudice or an image that something was wrong with me, that I had symptoms, those moments of illness or when it became acute… Something that had something to do with my mental problems. And that it is disabling. And here, indeed, it is more… I grow conscious of the fact that it is just… That it is about functioning… How can I function outside the admission?” By actively engaging in dialogue with patients about their personal interests and social roles, a new dynamic is created in which they are challenged to (re)connect with and show these aspects of their identity, thus shifting their ‘illness identity’ to the sideline. Consequently, patients are not approached as passive recipients of a certain treatment but rather as active agents of their own  recovery process. In this respect, one of the patients points out how this activating approach caused a shift in his mindset regarding his own recovery process:“First I need to find some day activities. Maybe a volunteering job, then that would also be fine. But I am going to work so that I can find my own apartment, my own job. I just want to get away, I want to get back into the system, work every day so I have money in my pocket. So that people look at me respectfully because I work.” This shows how, through widening the lens on their identity, patients are no longer seen (and see themselves) as fundamentally different, i.e. as mentally ill persons who need to recover clinically. Rather, they are approached as individuals who try to give meaning to their lives in fundamentally similar  ways to most people. This is reflected, for example, in the experiences of one of the patients who stresses the importance of being able to fulfill valuable social roles in the community:“Often it is about really practical things, such as… letting patients decide about certain things. It is about food, about TV, about… (…) You can’t let family stay over, because of the fact they’re all hospital beds. People who have a pet, who need to find shelter for it because it is a hospital. But also really small stuff… Having a piano on the ward, because of fire safety. Such things. Having your own key to your room. I could spend a whole day listing these things.” In its daily practice, the ward strives to support patients in establishing a personal and social identity. As this support is powered by the patient’s own interests and aspirations, it can take on many forms, such as searching for meaningful activities in the community, restoring contact with family, finding a place to live, helping applying for volunteering/paid work, developing an interest or skill, and so on. Paradoxically, helping patients (re)connect with their personal identity is at times hindered by factors that are characteristic of the culture of the psychiatric hospital itself. For example, the psychiatric hospital has to comply with legislation in which a set of rules and regulations regarding the hygienic and safety standards of the provided care is specified. However, one of the psychologists gives a list of illustrations of how these imposed rules can stand in the way of a more tailor-made and identity-focused approach to support:Also at the level of the ward itself, different factors  can at times make the atmosphere on the ward hectic, even chaotic, leading to more superficial and fragmented conversations between staff and patients and leaving less room for quality interactions such as one-to-one trips outside the hospital.“I have worked at a ward with more rules, and that is very comfortable but also quite blunting, because you… You are just a representative of rules that you can hide behind. And here, that is way less the case. It is a tiring reflex to continuously find the particular… In consultation with the patient or with each other, to get to a logical plan of action. It is more intensive, but I believe in it. (…) At the same time I hope it is that vision, that you can’t simply summarize people or practices into something that is easy to capture. It is all very difficult to capture and that takes time and communication and re-inventing.” An important implication of offering an individualized approach to support on the ward is that patients do not follow a pre-structured, one-size-fits-all therapeutic group program. As patients are encouraged to take agency over their own recovery process, support takes the shape of a continuous (re)negotiation, both between the staff and each patient and between the staff members themselves. Consequently, the therapeutic trajectories that patients travel during their stay often take a less straightforward, less predictable course. One of the psychiatric nurses explains how this requires a particular attitude from the staff, that is different from other more traditional inpatient settings:“That’s recovery. That you never say to someone… In the beginning, this is not going to work. But that you stumble over the same things together and that you keep standing beside that person and that you try something different, something that person can identify him/herself with.” In such a process of negotiation, staff members take the position of travel companion rather than guide in the recovery journey of the patients, as one caregiver explains:“But what I personally find difficult sometimes, is when you have the feeling that what someone wants is very unrealistic. (…) But that is also part of the job of course. (…) From that perspective I can frame it and I know it is linked to recovery, with ups and downs, and that people have to learn to discover things for themselves. Or rather, that we need to let them discover.” In doing so, patients are given as much ownership as possible over their own trajectory, but this can also bring new difficulties. One staff member explains how she finds it difficult to take the position of travel companion when the direction the patient chooses is, in her opinion, not realistic:“When you are alone here, you are like a walking key who just keeps things going a bit. Then you can’t really speak of rehabilitation. (…) The only people who are here then, are the ones who are bored, who don’t have much outside, who aren’t always feeling very well. Then I rarely go home happy.” In other words, offering particularizing support is time-intensive and requires space for trying different things, starting over and thinking outside the box of traditional options. However, in the daily practice of the ward, precisely this improvisational space is continuously under pressure from macro-level  policy decisions regarding personnel and finances. For example, to meet the patients’ individual needs, the ward offers a wide range of support modalities , which is a very challenging task compared to the financial resources of the ward. Also, during weekends the ward is only staffed by one or two people. One of the psychiatric nurses expresses how he finds it frustrating to work at weekends, when the ward can only fulfill its asylum function because of staff shortage:This example illustrates how the economic logic of the hospital  can sometimes be in conflict with the particularizing vision of the ward.The third function of the ward that can be distinguished in the experiences of the participants is that of a place of transition towards a meaningful community life. When discussing this function, two themes come to the fore: minimizing disruptions between life inside and outside the ward and finding adequate housing.“Here, we really need to work hard towards outside. (…) Because actually you still need to create the outside. You still have to register them on a waiting list for sheltered living or the social housing company. And sometimes the work will never be finished, because they will never make it outside. Or working outside means installing the idea of outside, that there is something else besides the ward.” Many patients on the ward have experienced previous admissions as major disruptions to their everyday life. The ward aims to avoid such disruptions, by striving for a seamless continuity between life ‘inside’ (i.e. spending time on the ward) and ‘outside’ , both by bringing in the outside world  and by actively supporting patients in finding a meaningful place in the community . Considering the heterogeneity of the patient population, the psychiatrist describes how challenging it can be to work towards a life outside with/for the patients on their ward:“It always surprises me when people are told “you’re safe here, outside it is dangerous”. (…) To say it in psychoanalytic terms, you’re working in a very dual way, I find. (…)So it comes down to saying “you are here and I am here and outside we might find some people who could be interesting and reliable, I don’t know”. (…) It is by talking about the other that you install a third point.” One of the psychologists points out how the psychiatric institution in itself has an alienating effect on the patients’ everyday lives. More precisely, he warns for the risk of installing a false dichotomy of the ward as a safe shell versus the outside world as threatening. From that perspective, he argues that a continuous focus on the outside world in the ward’s daily practice offers a vital complement to the asylum function of the ward:“We work with long trajectories. To continuously try again. For example, someone who’s having a hard time on the ward, to give him a break, such as asking for a time-out, but to then… always give him or her the chance to return if that person wants that. At the moment, I don’t think that is the case on other wards. (…) And I notice that people find it easier to return to us too. That it is an interruption, but not a stepping out of the trajectory.” Another essential facilitator of this continuity between life inside and outside the ward is to install a non-controlling climate, in which patients are not punished for their setbacks or mistakes but remain welcome on the ward and are encouraged time and time again to pick up the thread of their lives. Talking about this, one of the caregivers stresses the importance of applying a long-term vision to the recovery trajectories of the patients they work with, to prevent bridges being burnt:“I like it here, that the activities are not mandatory. If they would be mandatory, yeah, then I’d… I’d take part in them, but there wouldn’t be much benefit for me. (…) Actually, now I mainly need to do things outside the clinic, like cleaning up my apartment and stuff. Yeah, and if I can do sports here, or reading together or… Then that is nice, but I mean, in the first place I need to do some things outside if I want to feel better.” This climate also becomes visible in the fact that patients are given as much freedom as possible by not obliging them to take part in the available therapeutic activities . As a result, they are more inclined to engage in meaningful activities outside the ward. For example, one of the patients explains how the fact that no obligated therapeutic program is imposed on him motivates him to work on his living conditions outside the ward:“There is some sport, and music therapy and stuff, but most of the therapists are already looking towards the outside, or even the other way around. They are sitting outside and looking in and asking people ‘do you wanna come? There is an event in the library, we are helping with that, do you want to help too?’ That vibe. Yeah, that’s something I believe in strongly.” The above experiences clearly show how the ward’s mission to provide continuity between being admitted and living in the community also entails a shift in the job description of the staff working on the ward, from a traditional institutional approach towards a more community-oriented way of working. This shift is formalized in the job description of certain staff members. For example, three staff members practice the function of ‘road builders’ (‘spoorleggers’) and actively search and create spaces  in the community that welcome people with mental health problems. In doing so, they actively pave the way (hence the name ‘road builders’) for the patients on the ward. In that sense, their primary function is that of ‘quarter making’ (‘kwartiermaken’), i.e. actively creating hospitable niches in society for people with mental health problems, who are often confronted with exclusion and stigma . Another(interviewer) “When will you be ready to leave the ward, do you think?” (patient) “That is related to finding alternative ways of living that for me… So somehow I expect a search to find another place I believe in. (…) If I get discharged whilst I don’t believe there is a connection, I will go back into crisis. Period. This is no emotional blackmailing, that’s just how it goes. Then I go into destruction.” Housing came to the fore as a prominent theme in all interviews. Since the majority of the patients on the ward are or become homeless during their admission, finding adequate housing forms an essential part of the patient’s transition process towards a meaningful community life. For example, one patient expressed how, for him, finding a place to live in which he can feel safe and at ease is a primary need:“I think we do miss opportunities sometimes, but… I can also see why. Jimmy (one of the patients) is my referee. I find it difficult to keep it going with him. Sometimes we go look at a house, and then he makes a bit of a strange impression. Maybe this will stick to the estate agent, and then we are back at… I would like to spend an entire day convincing landlords that actually, Jimmy is the perfect tenant. (…) He’s on benefits, that is pretty stable, I mean, that will keep going… And he is clean, he is very predictable. He is supported by us in case something goes wrong. So actually he is a catch, but I’d like to see that happen.” Although searching for adequate housing is a key function of the ward, the rhythm of this search is largely determined by external organizations and factors. For example, social housing companies, organizations for sheltered living and psychiatric nursing homes often have long waiting lists. Also, in some cases, it is not the patient but a judicial actor who decides if and when one is capable of living independently. Another factor that often impedes the search for appropriate housing, especially on the regular housing market, is the stigma that many patients have to face on a daily basis. One of the psychiatric nurses gives a striking example of the impact of this stigma on a patient’s search for an apartment:“Deciding whether someone is ready, is something we actually never do. It depends on what is available at that moment. (…) Often, when a [housing] situation presents itself and the patient agrees, then we try to look which supportive framework we need to install, so that it might succeed. Does that mean that people are ready or not? Actually that is a question we never ask ourselves.” As a result of these external factors, patients and staff do not have control over the search for adequate housing, which has implications for the daily practice of the ward. According to one of the psychologists, the rhythm of the  housing market is predominant in such a way that it makes it impossible to see the ward as a space where patients ‘are being prepared’ for a more independent life in the community. Instead, both staff and patients need to respond ad hoc to housing opportunities when they present themselves: “Our problems are solved, so actually we could go, but yeah… We can’t go because we don’t have that one thing.” (interviewer) Because you don’t have a roof over your head? (patient) “Yeah.”As a consequence of the fickle rhythm of the housing market, patients are more often discharged from the ward based on the availability of a housing spot than based on their ‘readiness’ to go. Although the staff always attempts to build a supportive network to make the move to the new living situation as smooth as possible, it does not always end successfully. Some patients need to return to the ward several times and make repeated attempts at living independently before finally succeeding in finding a stable place in the community. For other patients, the ward has become more of a ‘waiting room’, as it can take a long time until a housing spot is available:asylum (i.e. a safe haven where patients are given time and space to ‘simply be’), the ward as a particularizing space (i.e. a place to reconnect with one’s identity and aspirations), and the ward as a transitional space (i.e. a place to work towards a meaningful community life).This study aimed to gain insight into the different functions that inpatient psychiatric settings have in the recovery processes of persons with complex mental health needs. We investigated this by unraveling the daily practice of one ward that actively engages with this population. The results showed how the ward’s daily practice takes shape in the continuous dialectic between the inside and the outside world, in the tension between different  dynamics, and in the—at times dissonant—harmonies between the rhythms of different actors involved . Within this entanglement, three functions of the ward could be distinguished: the ward as an quarter making (translated from the Dutch ‘kwartiermaken’), their work does not take place within the ward, but explicitly aims to open up welcoming spaces in society in which patients can participate and belong as inclusive citizens [permeability to describe the extent to which psychiatric (inpatient) settings are interacting with the outside world [Several aspects of these functions tally well with the personal, social and relational ways in which recovery is conceptualized in the literature , 9. Firscitizens . In othecitizens . Relatedde world . The finAsylums and the subsequent deinstitutionalization wave, the image of psychiatry as totalitarian and hermetically sealed institutions was gradually rejected and replaced by a focus on community-oriented support [“the provision of safety and security for individual patients needing refuge” ([feeling safe) and time (cf. the ward as a pit stop), where they find rest and feel contained. However, in today’s recovery-oriented and community-based mental health care policy, in which the focus lies on supporting people with mental health problems to live independently in the community, the provision of this asylum function risks being overlooked or even ignored [Whilst the daily practice of the ward shows a lot of common ground with the recovery framework, it also remains interwoven with the more traditional institutional culture of the hospital in which it is located. In that respect, two critical side notes need to be made. First, under impulse of Goffman’s  support , 32. Howrefuge”  ignored .“hospitalization syndrome”, i.e. the inability to imagine a life outside the hospital walls. Alternatively, however, this (apparent) lack of imagination could also be explained as a side-effect of the ward’s former institutional vision that some patients should be given life-long protection from a threatening outside world. Today, the ward has shifted to a recovery-oriented vision in which patients are seen as active agents of their lives and are encouraged to (re)connect with social roles and aspirations outside the hospital. A potential danger of this activating and individualized approach is that difficulties in orienting patients towards a valuable community life are translated as a matter of reluctance or inability on the patients’ side, e.g. by saying that they suffer from a “hospitalization syndrome”, rather than considered the shared responsibility of different parties . In other words, when the psychiatric institute represses its own historical evolution, it risks slipping into a neoliberal mindset in which patients are exclusively seen as individuals, self-managing and self-responsible for the success or failure of their therapeutic trajectory [Second, although the ward aims to help patients gain perspective on a meaningful life in the community, the results also showed that it can be particularly challenging to do so with patients who have lived at the ward for many years, as they experience the hospital as their home. One participant attributes this difficulty to the fact that these patients suffer from the ajectory , 36.The above-described findings of this study do not only provide us with insight into the roles of inpatient settings in mental health recovery, but also point to important insights regarding the support and treatment provision for persons with complex mental health needs. First of all, the results resonate well with existing evidence that support should be organized from a person-centered and holistic perspective (cf. ‘a tailor-made approach’), in which persons with complex mental health needs themselves hold the compass that directs their support trajectories , 38. Thia place to be, or even as the place to be, as visitors experience the place as their ‘second home’. These characteristics tally well with the asylum function of the ward in the current study, in which aspects such as feeling safe and feeling ‘at home’ also stand out. Besides a safe haven, the meeting place also functions a lively hub in which all kinds of  activities are organized, all rooted in the personal interests of the visitors. Through these activities, visitors are encouraged to find a medium to engage in dialogue with others and to establish a personal sense of identity  that moves away from other stigmatizing identities. Because these activities often take place in the community , they help visitors become ‘visible’ citizens in society. In that sense, the meeting place functions as a place to be me. In this function, several commonalities can be found with the ward as a particularizing and transitional space, such as the function of ‘quarter making’ (cf. supra), the focus on inclusive citizenship and the importance of creating space for patients to (re)connect with their identity (e.g. by not having an obligatory set of activities).Up until today, research into recovery-oriented practice has largely focused on outpatient and community-based initiatives . AlthougDespite their diverse contexts, the similarities between these studies show how recovery-oriented support is not the exclusive terrain of community-oriented initiatives. Moreover, the daily practice of the ward also shows that a recovery-oriented approach is not irreconcilable with an institutional approach to support. It is precisely in the entanglement of different approaches and in the complementarity and diversity of different support settings that persons with complex mental health needs find the resources for their recovery. Therefore, we propose to think about recovery-oriented systems of support in terms of differentiated landscapes in which persons with mental health needs can circulate between different enabling places, tailored to the ebb and flow of their recovery process –43. As t


As multimedia traffic has been increasing and is expected to grow more sharply, various technologies using caches have been attracting lots of attention. As one breakthrough technology to deal with the explosively growing traffic, exclusive OR (XOR)-based index coding has been widely investigated because it can greatly enhance the efficiency of network resource by reducing the number of transmissions. In this paper, we investigate how to apply XOR-based index coding to large-scaled practical streaming systems for video traffic that accounts for more than 70% of total Internet traffic. Contrary to most previous studies that have focused on theoretical analysis of optimal performance or development of optimal index coding schemes, our study proposes a new XOR coding-based video streaming (XC). We also propose a new grouping algorithm for creating XC groups while guaranteeing the complete backward compatibility of XC with existing streaming schemes such as unicast (UC), multicast (MC), and broadcast (BC). The performance of the proposed scheme is analyzed in two steps. First, the behavior of video contents in caches at clients is modeled as a Markov chain, and the steady-state probabilities and caching probabilities for each piece of video content are derived. Based on the probabilities, the performance of the proposed system is then analyzed in terms of the average number of connections that each client requires in order to receive one video content. Our numerical results show that the proposed video streaming scheme using XC can reduce the average number of transmissions by up to 18%, compared to the conventional scheme. A recent study showed that the total amount of Internet traffic will increase three-fold over five years from 2017 to 2022, and video traffic would be growing more sharply than other types of traffic . An alteContrary to previous studies that considered transmitters with cache and studied how to use the transmitters’ cache efficiently, some studies focused on clients with cache ,17,18,19Moreover, more advanced transmission schemes that use the contents stored in clients’ cache more efficiently were proposed to improve the efficiency of limited network resource ,17,18,19In this paper, we thus propose a new video streaming system that supports XC. We also propose a new grouping algorithm for creating XC groups while guaranteeing the complete backward compatibility of XC with existing streaming schemes such as UC, MC, and BC. The performance of the proposed system is analyzed and compared with that of a conventional streaming system to verify its gain. We first model the behavior of contents in caches at clients as a Markov chain and derive the steady-state probabilities and caching probabilities for each video to mathematically analyze the statistical characteristics of caches at clients in video streaming systems. Based on the statistical characteristics of caches, the performance of the proposed system is analyzed in terms of the average number of connections that each client requires in order to receive one video content. The proposed scheme can be widely applied for various types of networks including mobile networks and sensor networks with video streaming.The rest of this paper is organized as follows. In N clients, which is illustrated in V and C videos n and n for a simplicity of the notation, now and hereafter. s-th memory of a cache We investigate a video streaming system with a single streaming server and v-th can be predicted by Zipf distribution ∪[(i∉C1)∩i and j, A. Then, the average total probability that the number of required connections is 2 can be calculated asi and j. In this case, clients are supported by UC through two independent connections, respectively.Finally, for given In this subsection, we propose a transmission algorithm by extending the transmission for two clients described in the previous subsection in order to support XC for n in S, the client n can join the existing XC group S only if the following conditions are satisfied:In the second phase, the clients who are not included in either n fails to join any existing XC group, the client n attempts to create a new XC group with another client m who is included in If there is no existing XC group or the client This process is repeated for all clients in n succeeds to join the existing XC group or to create the new XC group, the client n becomes an element of For the case that the client Algorithm 1 Proposed Video Streaming:Phase 1. LC and MCInitialization:1: 2:   3:   Obtain a set of candidate clients for LC:4: 5:   fordo6: ifthen7:     8:       end if9:     end for10. Obtain a set of candidate clients for MC:11: 12:   whiledo13: 14:     15:     fordo16:     ifthen17:       18:         end if19:       end for20:     ifthen21:     22:       23:       24:       end if25:     end while26: Algorithm 2 Proposed Video Streaming:Phase 2. XC and UCInitialization:27: 28:   29:   Obtain a set of candidate clients for XC:30: 31:   32: whiledo33: 34:     35:     ifthen          ▹ XOR group already exists.36:     fordo        ▹S is a set.37:       38:         fordo39:         40:           j *= end for41:         ifthen42：        u is added into S.43：           44：           45：           break46：          end if47：        end for48：      end if49：    if (then50:     fordo51:       ifthen52:         53:           54:           55:           break56:           end if57:         end for58:       end if59:     end while60: 61: In this section, the performance of video streaming scheme using XC is analyzed in terms of average connections required to serve each client’s video play, and compared with that of a conventional scheme without XC. Let For the conventional scheme without XC, we need to allocate a dedicated connection to every client in Please note that All numerical results were obtained through mathematical analysis given in C, increases, the probabilities that contents are cached increase regardless of popularity. Thus, for given C also reduces the average normalized load. To be more specific, when C increases from 1 to 5, the average normalized load decreases from 0.7 to 0.3 for both proposed and conventional schemes. In this figure, although the proposed scheme using XC outperforms the conventional scheme without XC, the gap of the performance is marginal, because when the number of clients is small N. N from 2 to 10 when N increases, the frequency of using MC for the conventional scheme and the frequency of using MC or XC for the proposed scheme both increase. Thus, the average normalized load decreases with an increasing N for both the proposed and conventional schemes, as predicted in C because the frequency of using LC for the conventional scheme and the frequency of using LC or XC for the proposed scheme both increase as C increases. N and C values, the proposed scheme outperforms the conventional scheme due to the gain obtained from XC, and thus N or C increases and thus, N or C. As a specific example with In N, we plot the average normalized load in N or C. By comparing C and N as well as C is relatively large, e.g., N values. For example, when C, N, and N, V, and C to simplify computer simulations, the proposed scheme can be applied to real large-scaled video stream systems.In A streaming server can process requests from multiple clients simultaneously by coding the bit streams requested from the multiple clients with XOR operation and multicasting the coded bit stream to the multiple clients. Each client can recover its content from the coded bit stream with XOR operation using contents stored in its cache, which is based on zero-identity and self-inverse properties of XOR and can reduce the number of transmissions by dealing with the requests simultaneously. Existing studies on the data transmission using XOR-based coding mainly focused on theoretical analysis or optimal coding in limited environments, and most of them were thus less feasible. In this paper, we investigated how the data transmission using XOR-based coding could be applied to video streaming systems without interfering existing video streaming methods such as UC, MC, and BC. We first modeled the behavior of video contents in clients’ caches as a Markov chain, and derived the caching probability that a video content has been already cached in the client’s cache when a client wants to play the content at an arbitrary moment. We also proposed a new video streaming scheme for supporting XC while guaranteeing a backward compatibility with the conventional video streaming methods. With a simplified case of two clients, the basic concept of the proposed scheme was described, and the performance of the proposed scheme mathematically analyzed in terms of average normalized load. All analytical results were verified by computer simulations. Then, the proposed scheme was extended to a complete algorithm that can support multiple clients more than two. Our numerical results showed that the proposed scheme using XC outperforms the conventional scheme without XC in all situations and the performance enhancement of the proposed scheme becomes more noticeable as the number of clients or the length of cache increase. For a specific situation with


Whereas excessive alcohol consumption increases liver disease incidence and mortality, evidence on the risk associated with specific drinking patterns is emerging. We assessed the impact of binge drinking on mortality and liver disease in the Swiss HIV Cohort Study. All participants with follow-up between 2013 and 2020 were categorized into one of four drinking pattern groups: “abstinence”, “non-hazardous drinking”, “hazardous but not binge drinking” (Alcohol Use Disorder Identification Test Consumption [AUDIT-C] score ≥ 3 in women and ≥4 in men), and “binge drinking” (≥6 drinks/occasion more than monthly). We estimated adjusted incidence rate ratios (aIRR) for all-cause mortality, liver-related mortality and liver-related events using multivariable quasi-Poisson regression. Among 11,849 individuals (median follow-up 6.8 years), 470 died , 37 experienced a liver-related death , and 239 liver-related events occurred . Compared to individuals with non-hazardous drinking, those reporting binge drinking were more likely to die  and to experience a liver-related event . We observed no difference in outcomes between participants reporting non-hazardous and hazardous without binge drinking. These findings highlight the importance of assessing drinking patterns in clinical routine. The harmful use of alcohol has been identified as one of the leading threats for global health. The World Health Organization (WHO) estimated that in 2016, 5% of all deaths were due to the harmful use of alcohol globally, and up to one in ten deaths were attributable to the consumption of alcohol in Switzerland . Among pMany studies have shown the association between heavy alcohol consumption and liver-related events and mortality ,10,11. HWe took advantage of the systematic assessment of alcohol consumption patterns in a nationwide prospective cohort of PLWH to assess the impact of drinking patterns on all-cause and liver-related mortality, as well as on the occurrence of liver-related events.www.shcs.ch) is an ongoing nationally representative cohort study which includes close to 80% of all PLWH receiving ART in Switzerland  38 to 53), 9097 (76.8%) were Caucasian, and 5425 (45.8%) were men who have sex with men (MSM). Individuals provided a median of 12 AUDIT-C assessments (IQR 7 to 13). Non-hazardous drinking was the most frequent alcohol consumption pattern in 6861 individuals (57.9%), followed by abstinence in 2718 individuals (22.9%), hazardous but no binge drinking in 1814 individuals (15.3%), and binge drinking in 456 individuals (3.8%). Patient characteristics stratified by the most frequent drinking pattern reported during follow-up are shown in Overall, 54.6% of the follow-up time was spent in the non-hazardous drinking category, followed by 24.2% in the abstinence category, 16.8% in the hazardous drinking category, and 4.4% in the binge-drinking category. The proportion of individuals who reported hazardous and binge drinking remained stable over time . The indn = 105, 22.3%), cardiovascular , HIV-related , accident , and other infections . Liver-related deaths occurred in 37 individuals . Detailed causes of liver-related deaths, stratified by drinking pattern, are shown in During 66,153 person-years (PY) of follow-up, 470 individuals died ; the most common causes of death were non-AIDS cancer , with a diagnosis of cirrhosis based on a confirmed APRI score above 2 in 140 individuals . Incidenn = 1347), all-cause mortality was higher in individuals reporting abstinence  and binge drinking  compared to those reporting non-hazardous drinking. Repeating the analyses with each individual’s most frequently reported alcohol drinking pattern over the follow-up period as time-fixed exposure, binge drinking remained strongly associated with all-cause mortality  and with the development of a liver-related event  when compared to non-hazardous drinking  and in Switzerland (35.6%) . In our Individuals who reported abstinence from alcohol consumption had a higher risk of all-cause and liver-related mortality than those with non-hazardous drinking. Such a “J-shaped” association has been described previously among the general population and in PLWH ,11,23. CThe stringent ascertainment of causes of death and the detailed availability of information about risk behavior (such as smoking) and education level (a determinant of socioeconomic status) allowed us to study the long-term impact of alcohol drinking patterns on mortality, and to adjust these analyses for important confounders. Due to the systematic and complete longitudinal assessment of alcohol drinking patterns using AUDIT-C, we were able to establish a clear relationship between binge drinking and mortality as well as the occurrence of liver-related events among PLWH. These results were robust across a range of sensitivity analyses, and after taking viral hepatitis and mode of HIV transmission into account. Some limitations, inherent to routine data collection in cohort studies, may have influenced our results: although the occurrence of predefined liver-related events is routinely reported in the SHCS, no systematic assessment of liver fibrosis/cirrhosis has been performed among individuals without viral hepatitis. Our use of APRI, a non-invasive marker for liver fibrosis, as a diagnostic marker of liver cirrhosis, may have led to the under-estimation of the rate of this outcome due to its low sensitivity . ConversIn conclusion, our study suggests higher mortality rates and an increased risk of liver-related events associated with binge drinking among PLWH, a population with a high prevalence of alcohol use disorder and pre-existing liver disease. Our findings confirm the results of studies in the general population and warrant the inclusion of detailed alcohol pattern assessments into clinical routine to identify individuals at highest risk for complications. Our results could help tailor risk reduction counseling based on alcohol drinking patterns to the specific needs of PLWH. Studies with longitudinal assessment of liver fibrosis among PLWH are needed to fully grasp the impact of alcohol drinking patterns on the development of liver cirrhosis in this population.


N = 198) completed a need for cognition scale and then watched a video containing either several bespoke card tricks that had been specially devised to help tell the story of the Apollo Moon landings (Magic Video), or an almost identical video that did not contain any magic tricks (Control Video). All participants rated their levels of engagement, absorption and recall. Compared to the Control Video, the Magic Video was rated as significantly more interesting, informative and absorbing. There was no difference between the groups for recall. There was a positive correlation between participants’ need for cognition scores, and the degree to which they found the Magic Video interesting, and were willing to share it with others. The theoretical, methodological and practical implications of these results are discussed, along with recommendations for future work.Previous research suggests that magic tricks can be employed within an educational context to enhance attention, engagement, critical thinking and recall. This study builds on this work by examining the impact of incorporating magic tricks into an online educational video. Adult participants ( Many educational practitioners have described using magic tricks to help promote attention, engagement, curiosity and critical thinking . WisemanAs well as having practical implications, the work may help to inform two quite different theoretical perspectives.First, a large amount of work into key epistemic emotions, such as surprise and curiosity, has consistently shown that such emotions are positively associated with increased levels of knowledge engagement in both adults  and infaSecond, other research has examined the effect of ‘seductive details’  on learning , whilst in the other the cards were simply dealt from the deck (Control Video). Following the methodological guidelines recommended by It was predicted that participants would find the Magic Video more engaging, absorbing and memorable than the Control Video. In addition, it was predicted that participants’ need for cognition scores would positively correlate with engagement, absorption and recall in both conditions, and that these correlations would be significantly higher among those who had watched the Magic Video compared to those who had watched the Control Video.N = 202, mean age = 30.45, range 18–65 years) were recruited from the crowdsourcing platform Prolific Academic. The use of these types of platforms for psychological research has been validated in several studies .Participants  that consisted of a soundtrack containing key facts about the Moon landings and several magic tricks performed with a playing cards containing relevant images. For instance, at the start of the video the narrator explained that the race to the Moon began in 1957, when the Soviets launched the world’s first satellite, Sputnik. At this point, the date “1957” suddenly appeared on a previously blank playing card, and moments later another card with an image of the Sputnik satellite magically emerged from the middle of the deck. The video lasted 1 min 50 s, and involved a static shot of a performer’s hands manipulating the cards above a black tablecloth. A version of the video was posted online prior to the experiment as part of the Moon landings 50th anniversary celebrations.The magic tricks used to illustrate the story were chosen to use easily recognisable objects (playing cards and a coin) and to feature a series of fourteen impossible moments over the course of the video. The illusions were chosen to feature a variety of effects  that were developed by combining and adapting existing magic techniques to suit the required moments in the narrative .A second video (Control Video) contained the same audio narration as the Magic Video but did not contain any magic tricks. Instead, the cards were simply dealt from the pack and placed onto the table. The video was closely matched to the Magic Video, in that it contained the same playing cards, displayed each for the same amount of time, had the same duration, and also involved a static shot of playing cards being manipulated on a black tablecloth. The videos are available in The NCS-6 is a reliable and valid short measure of need for cognition . It invoParticipants were asked to rate on a 5-point Likert scale (i) how interesting they found the video , (ii) the degree to which the video had made them interested in the Apollo Moon landings , (iii) how entertaining they found the video , (iv) how informative they found the video , (v) how likely they were be to share the video with others , and (vi) the degree to which the video made them feel as if anything were possible . Participants’ scores on each item were treated as separate variables.This measure was devised and used by Participants were presented with six questions about key factual information presented in the videos  along with five possible responses for each question . The correct answer was assigned 1 point, and participants’ scores were averaged across the six items.No other measures were administered or data collected.The study received ethics approval (number 10-1920/1) from the University of Edinburgh PPLS Research Ethics Committee. Participants were recruited on the Prolific Academic crowdsourcing platform, and the study was presented via Qualtrics. After giving written informed consent, participants were asked to enter their age and complete the NCS-6. They were then randomly assigned to watch either the Magic Video or the Control Video. After watching the appropriate video, participants were asked to indicate whether they had seen the video before . Participants then completed the Engagement Items, the Absorption Questionnaire and the Recall Questionnaire. The time taken for each participant to complete the survey was recorded (in seconds), and they received $2.00 for taking part.N = 198, mean age = 30.60, range 18–65 years). There were 99 participants in the Magic Video condition, and 98 in the Control Video condition. The two groups did not differ in mean age , mean NCS-6 scores , or mean time taken to complete the study .Four participants indicated that they may have seen the Magic Video before, and so were excluded from the analyses , or a very similar video that did not contain any tricks (Control Video). Participants then completed measures of engagement, absorption and recall. Compared to the Control Video, the Magic Video was rated as significantly more entertaining, informative and interesting. The Magic Video was associated with significantly higher levels of absorption, and there was no difference between the two videos for recall. There was a positive correlation between participants’ need for cognition and the degree to which they found the Magic Video interesting and were willing to share it with others. Finally, there was a positive correlation between participants’ need for cognition and recall for the Control Video. These findings will be discussed in turn.First, the finding that the Magic Video was rated as more entertaining, informative, interesting and absorbing, supports previous work suggesting that magic tricks can play a positive and practical role in education . However, if the effect is genuine, the lack of a significant correlation for the Magic Video may be due to a form of “attention residue” (Finally, for the Magic Video participants’ need for cognition was positively correlated with their interest in the video and willingness to share it with others. This is in line with previous work showing that need for cognition is associated with greater engagement with educational material , and sugresidue” , whereinOn a methodological level, the study was designed to adhere to many of the recommendations made by Overall, this work extends the findings from other studies examining the positive impact of magic tricks . Within 10.7717/peerj.9610/supp-1Supplemental Information 1Click here for additional data file.10.7717/peerj.9610/supp-2Supplemental Information 2Click here for additional data file.10.7717/peerj.9610/supp-3Supplemental Information 3Click here for additional data file.


In recent years, researchers have recognized the need to examine the relative effectiveness of different simulation approaches and the experiences of physicians operating within such environments. The current study experimentally examined the reflective judgments, cognitive processing, and clinical reasoning performance of physicians across live and video simulation environments.Thirty-eight physicians were randomly assigned to a live scenario or video case condition. Both conditions encompassed two components: (a) patient encounter and (b) video reflection activity. Following the condition-specific patient encounter , the participants completed a Post Encounter Form (PEF), microanalytic questions, and a mental effort question. Participants were then instructed to re-watch the video  or a video recording of their live patient encounter  while thinking aloud about how they came to the diagnosis and management plan.Although significant differences did not emerge across all measures, physicians in the live scenario condition exhibited superior performance in clinical reasoning  and a distinct profile of reflective judgments and cognitive processing. Generally, the live condition participants focused more attention on aspects of the clinical reasoning process and demonstrated higher level cognitive processing than the video group.The current study sheds light on the differential effects of live scenario and video simulation approaches. Physicians who engaged in live scenario simulations outperformed and showed a distinct pattern of cognitive reactions and judgments compared to physicians who practiced their clinical reasoning via video simulation. Additionally, the current study points to the potential advantages of video self-reflection following live scenarios while also shedding some light on the debate regarding whether video-guided reflection, specifically, is advantageous. The utility of context-specific, micro-level assessments that incorporate multiple methods as physicians complete different parts of clinical tasks is also discussed. Clinical reasoning—the gathering and integration of clinical information combined with medical knowledge to generate a diagnosis and treatment plan—is a complex and challenging endeavor requiring extensive practice to reach proficiency , 2. EvenGiven the need to enhance clinical reasoning proficiency, there has been increased attention on learning methods to optimize these abilities. Common approaches include lectures, case-based learning, clinical case discussions, workplace learning, and simulation-based learning . Simulatrelative effectiveness of such approaches for enhancing clinical reasoning abilities  of the transcripts). A binary variable was used to indicate the absence or presence of each linguistic marker.To assess adaptive inferences, we used two tools from the functional linguistic study of appraisals :  should) , 55. Indronments , 56, 57,We used the automated software, LIWC, to record the number of individual markers of cognitive processing including insight, cause, discrepancy, tentativeness, certainty, and differentiation in each participant’s transcript. To account for varying lengths of think-aloud transcripts, LIWC automatically reports each variable as a rate of instances per 100 words. Thus, a cognitive processing score of 6.5 indicates that the individual provided 6.5 words reflecting cognitive processing for every 100 words spoken.t tests and chi-square) were used to address all research questions. Independent t tests were used to assess group differences in clinical reasoning performance (PEF), linguistic markers of cognitive processing, and perceived mental effort. Chi-square analyses examined group differences in perceived challenges and adaptive inferences . Regarding chi-square tests, given the modest sample size used in this study, the likelihood ratio chi-square was used for the chi-square analysis [p value of .05 was used for all inferential analyses, unless otherwise noted.Descriptive and inferential statistics , family medicine [13.2%), and surgery [18.4%)) with varying levels of expertise . The majority of the participants were male (65.8%), with an average age of approximately 36 years.t test revealed statistically significant group differences in PEF performance (t (36) = 7.22, p < .05, Cohen’s d = 2.32). Thus, individuals from the live scenario condition  outperformed those from the video condition . The effect size for the performance measure is considered very large [An independent ry large .To examine group differences in physicians’ perceived challenges, adaptive inferences, and cognitive processing during the encounter, we used data from SRL microanalytic questions, think-aloud transcripts, and a self-report measure.analysis of data and lack of case information. The total frequency counts across groups for the knowledge/skills  and no challenge  categories were negligible  = 7.16, p < .025, ϕ = 0.43) and lack of case information (χ2 (1) = 5.15, p < .025, ϕ = 0.36). Thus, statistically significantly more physicians in the live condition  than video  focused on the integration and synthesis of data as their primary challenge to accurately diagnose the case. Conversely, a statistically significant greater number of physicians in the video condition  relative to the live group  focused their attention on a perceived lack of case information.Descriptive analysis revealed two categories with sufficient cell sizes to run inferential statistics: ills n = ; 2.6% anclinical tasks and none were the only two response categories with sufficient cell sizes to run inferential statistics  of the physicians did not believe they would do anything differently to improve their performance. Given the unexpectedly high number of “no change needed” responses, we conducted additional exploratory, post hoc analysis. Specifically, we used expert consensus for performance-based scores from three components of the PEF  to identify physicians who performed at an acceptable or subpar level. Acceptable was defined as a score of at least 50% across the three components, while a subpar designation involved a score of less than 50% on any of these components. Approximately, 42% (n = 8) of the physicians who provided a “no change needed” response exhibited subpar performance; that is, many physicians reported that they did not need to change or improve anything about their clinical reasoning task performance even though they underperformed.An interesting pattern emerged, however, as part of a follow-up descriptive analysis of aggregated group data for the microanalytic adaptive inference data. Fifty percent (χ2 (1) = 3.81, p = .05, ϕ= 0.31). Thus, a greater number of physicians in the live scenario condition  relative to the video condition  made statements that reflected appraisals of their initial approaches to the case. Examples of these types of adaptive inference markers from the live scenario condition include  “But I never asked him specifically if he’s ever had a history of a heart attack” (negation) and “I think I should have asked him if he was on a statin” .In terms of linguistic analyses of adaptive inference indicators from the think aloud, chi-square analysis revealed a statistically significant group difference  = 1.97, p < .05, d = .70), with an effect size approaching large. Individuals from the live scenario condition  displayed a greater number of words reflective of higher levels of cognitive processing than those from the video condition . For instance, a live scenario participant stated  “At this point I am trying to tease out whether or not this is something that is specifically related to exercise, if starting and stopping starts and stops the pain, or if it is something that happens to occur at the same time. But all of his answers pushed it towards very much linked to the exercise.” In contrast, this video participant used fewer of these causal and differentiating words: “He’s saying it’s burning. It could be heartburn. Seems like he has a history of heartburn. The pain is similar to that, but different. Doesn’t seem to be in any distress. It woke him up this morning.”The LIWC analysis was conducted to examine differences in the cognitive processing of physicians during the reflection activity. Given that the Levene’s test for equality of variances was statistically significant , we used Welch’s The primary objective of this study was to examine differences in the reflective experiences and clinical reasoning performance of physicians participating in different types of simulation formats. This study is important because it adds to the paucity of studies examining simulation effectiveness and offers a nuanced analysis of the underlying reflective and cognitive processes of physicians during clinical activities. This study also has important implications for learning and practice, specifically the need for educators and trainers to be cognizant of the types of thoughts and reactions medical professionals exhibit when immersed in different learning experiences.d = 2.32), this result diverges from prior research showing equivocal results across different learning formats .These discrepant findings could be partially explained by methodological differences in the studies . In prior research, authors often used medical student populations whereas in the current study, we included experienced physicians. Perhaps, more experienced physicians benefit from simulated experiences that afford opportunities for greater autonomy and authentic patient interactions. These environments may allow experienced practitioners to draw upon their extensive knowledge base and engage in deeper forms of case conceptualization and analysis—a premise supported by our other findings regarding reflective judgments and cognitive processing (see next section).Another important methodological difference involves the level of granularity and task-specificity of the dependent measures. We used a task-specific measure of clinical reasoning performance  rather than more broad outcomes, such as the OSCE or essay exam. The PEF was directly linked to the assigned case and patient encounter, whereas other studies focused on outcome measures necessitating the transfer or generalization of skills from the learning situation. Thus, although we clearly cannot use our data to make broad generalizations regarding the effects on simulation on clinical performance, it is does suggest that future research should consider the nature and granularity of the performance measures to assess simulation effects.data analysis skills  as their primary challenge when completing the PEF, while the video participants seemed mostly concerned about the adequacy of the case scenario; that is, 42% of the video physicians believed that the case lacked the necessary information, even though the experts who created the video purposefully included all of the relevant information to identify the correct diagnosis. One implication of this finding is that when experienced physicians watch videos of a doctor-patient encounter they may not be aware of or notice key pieces of information related to the situation or potential diagnoses. This observation is supported by research showing that physicians often miss key information when viewing videos of patient encounters with contextual factors [Consistent with expectations, we found that the live scenario participants exhibited a more adaptive pattern of judgments and cognitive processes following task performance than video case participants. This pattern was observed across the initial completion of the PEF as well as during the video reflection activity that followed. For example, the majority of physicians from the live scenario condition focused on  factors , 60.not needed. These results align with previous research showing that medical students do not consistently focus on such processes at the outset of a patient encounter and often abandon process-oriented ways of thinking when challenges arise [The results pertaining to adaptive inferences  were also important. In general, group differences emerged when using linguistic analysis of video think-aloud as part of the reflection activity but not when examining microanalytic data following the initial patient encounter. In terms of microanalysis, the physicians from both groups were asked about what they needed to do to improve or sustain high quality clinical skills immediately after completing the PEF. Although no group differences were observed, remarkably, descriptive analysis showed that 50% of the physicians (regardless of group) reported that changes or modifications were es arise , 46.plus video self-analysis using a structured think aloud protocol differs from the more typical simulation practice emphasizing instructor-led reflections through a post-simulation debriefing. The apparent advantage of video self-reflection following live scenarios also sheds some light on the debate as to whether video-guided reflection, specifically, is advantageous. Two recent systematic reviews suggest that video-assisted debriefing may promote improvements in learning outcomes, performance, and attitudes, whereas this study places an emphasis on participants’ cognitive processes and metacognitive process [Conversely, linguistic analysis of think-aloud data revealed important differences in physician reflective judgments and cognitive processes. The live scenario group used more language representing reflection and adaptive-oriented thinking. One implication of this finding is that watching a video of one’s own behavior and performance may lead to greater self-awareness that prompts greater analysis of effective and ineffective actions. Further, it is relevant to note that engaging in live simulations  process , 62.component analysis of clinical tasks; medical students varied in the accuracy of their evaluative judgments at different points during a clinical encounter  [Another important implication of this study involves the importance of using multi-method assessment approaches when targeting complex cognitive or regulatory processes during clinical activities. In our study, we utilized both SRL microanalysis and a think-aloud protocol to examine physician reflective judgments at different aspects of the simulation experience . The use of multiple measures enabled us to provide a more comprehensive and nuanced account of physician experiences during simulated clinical reasoning. Similarly, we believe that researchers should consider different aspects of clinical activities when conducting these types of process-oriented assessments , 63. Becal exam) .Finally, our results have implications for medical educators, specifically the choices they make regarding the use of simulation or more traditional learning modalities. While video cases can help medical students practice and refine clinical skills in an efficient manner, they may not prompt individuals to focus their attention on refinement and self-reflection regarding the quality of their diagnostic reasoning process. Much more research is needed before definitive implications can be made, but it does appear that if medical educators or supervisors want their students to focus more deeply on how they approach a given case, the use of live scenarios and including both a PEF and a video reflection can help to optimize this objective.Although these results are informative, there are a few limitations that warrant attention. First, the modest sample size prevented us from including moderator variables in the analyses . Also, the external validity of this study is limited as it only focused on one diagnosis (stable angina), and we exclusively focused on a task-specific measure of clinical reasoning performance . To more definitively conclude whether simulation experiences lead to different performance outcomes, future studies need to include a broader array of performance measures.Another important limitation is that we did not use SRL microanalysis and think alouds across each component of the simulated experience . Thus, it was not possible in this study to identify whether the differences observed in adaptive inference were a function of the type of assessment tool  or the component of the target activity . Finally, because the length of the patient encounter video varied across conditions , it is possible that some of the observed group differences were a function of the live participants having more time interacting with the patient.The current study adds to the literature examining the differential effects of live scenario and video simulation approaches and demonstrated the utility of using micro-level, context-specific assessment tools during clinical tasks. Based on our study sample, we found that physicians who engaged in live scenario simulations outperformed and showed a distinct pattern of cognitive reactions and judgments compared to physicians who engaged in video simulations. Our study also underscores the use of multi-method assessment approaches when targeting regulatory and cognitive processes, approaches that consider physical performance, and thinking during different aspects of a clinical encounter.Additional file 1. Think aloud protocol warm up.Additional file 2. Coding scheme.


Cynodon dactylon L.), St. Augustinegrass  Kuntze), saltwater couch (Sporobolus virginicus), seashore paspalum , and kikuyu grass (Pennisetum clandestinum) compared with the known positive control, koronivia grass (Brachiaria humidicola). The microbial communities were analysed by sequencing 16S rRNA genes. St. Augustinegrass and bermudagrass showed high BNI activity, about 80 to 90% of koronivia grass. All the three grasses with stronger BNI capacities suppressed the populations of Nitrospira in the rhizosphere, a bacteria genus with a nitrite-oxidizing function, but not all of the potential ammonia-oxidizing archaea. The rhizosphere of saltwater couch and seashore paspalum exerted a weak recruitment effect on the soil microbiome. Our results demonstrate that BNI activity of perennial grasses played a vital role in modulating nitrification-associated microbial populations.Soil nitrification  can lead to nitrogen leaching and environmental pollution. A number of plant species are able to suppress soil nitrifiers by exuding inhibitors from roots, a process called biological nitrification inhibition (BNI). However, the BNI activity of perennial grasses in the nutrient-poor soils of Australia and the effects of BNI activity on nitrifying microbes in the rhizosphere microbiome have not been well studied. Here we evaluated the BNI capacity of bermudagrass ( Unfortuitrate NO− via NH4Brachiaria humidicola) [Brachiaria decumbens [Hyparrhenia diplandra [Sorghum bicolor) [Oryza sativa) [Lolium rigidum, Bromus driandrus, Raphinus raphinastrum, and Avena fatua [B. humidicola populations [Some plants are able to suppress soil nitrifiers by exuding secondary metabolites from roots, a process called biological nitrification inhibition (BNI) . After tidicola) , BNI actecumbens  and Hypaiplandra ), major bicolor)  and rice sativa) ), and agna fatua . In addina fatua , and B. ulations .Hibiscus splendens and Solanum echinatum showed a BNI capacity as strong as sorghum [Plants with BNI functions originate from and/or are adapted to N-limited ecosystems—e.g., the BNI of koronivia grass was observed in Colombian low-N soil  and nati sorghum . Austral sorghum . NaturalPlant root exudation plays a key role in shaping the microbial community of the rhizosphere (the region closely surrounding plant roots in soil). Root exudates include diverse plant metabolites, and account for 10 to 50% of carbon fixed by photosynthesis . Large-sCynodon dactylon L.), St. Augustinegrass  Kuntze), saltwater couch (Sporobolus virginicus), seashore paspalum , and kikuyu grass (Pennisetum clandestinum). All these grasses grow in harsh Australian environments—e.g., desert or coastal sites with low soil organic matter and nutrient status. Koronivia grass (B. humidicola) with strong BNI capacity was used as the positive control. The objectives of this study were to (1) screen the BNI capacity of Australian native or naturalised perennial grasses, (2) evaluate the interspecific variation of rhizosphere microbiota between studied perennial grasses, and (3) investigate the effect of BNI activities on the nitrifying microbes in the rhizosphere.Here, we used C4 perennial grass species native or naturalised in Australia, including bermudagrass .The perennial grasses used included the bermudagrass cultivar “Wintergreen”; St. Augustinegrass cultivar “Sir Walter”; native saltwater couch collected from South Australia ; native seashore paspalum collected from South Australia ; kikuyu grass cultivar “Whittet”; koronivia grass cultivar “Tully” sourced from the Australian Pastures Genebank . Autoclaved nutrient solution was applied, when required, with the baseline concentration as 22.2 mM CH4N2O (urea), 1.75 mM CaCl2, 0.16 mM MgSO4, 0.4 mM KH2PO4, 0.8 mM KC1, 125 µM H3BO3, 50 µM Fe-EDTA, 35 µM MnSO4, 3.0 µM ZnSO4, 1.25 µM CuSO4 and 0.75 µM H2MoO4 [The experiment was conducted in a growth chamber with a controlled environment  filled with sterilised sand and 50 mL of 1:10 diluted baseline nutrient solution was added every 3 days.2O): 6.97; EC: 0.093 dS·m−1; organic C: 1.45%; ammonium-N: 3.07 mg kg−1; nitrate-N: 14.0 mg·kg−1; Colwell P: 62.7 mg·kg−1; Colwell K: 653 mg·kg−1; clay: 25.5% and sand: 69.9%. Non-planted pots were used as controls for sampling bulk soil.After 4 weeks, newly grown nodes were cut off and transplanted to pots  filled with field soil collected from a wheat field at Roseworthy campus, The University of Adelaide . The soil is classified as a Calcisol, and the results of physicochemical analyses were pH . The method was modified from . In brie4)2SO4, 1.5 mL KH2PO4, 3.5 mL K2HPO4, and H2O to 1 L, and pH 7.2 was adjusted using dilute H2SO4 or NaOH. Tubes were shaken at 26 ℃ and 100 rpm. The slurry was sampled at 2, 4, 12, 24 and 48 h. NO3− concentration was analysed using a Segmented Flow Analyzer . The linear regression between measured NO3− and the incubation time was analysed, and the slope was defined as the PNR. BNI capacity of each grass species was calculated as:rh and PNRbs are the PNR values of the rhizosphere soil of the tested grass, and the bulk soil in the same block, respectively.The combined solution was made by adding 15 mL  based on the manufacturer’s instructions. Afterwards, the V3-V4 region of 16S rRNA genes with the forward primer 341F (CCTAYGGGRBGCASCAG) and reverse primer 806R (GGACTACNNGGGTATCTAAT) was amplified by PCR and sequenced on an Illumina MiSeq platform with 300 bp paired-end reads based on the manufacturer’s instructions.q2-demux plugin was conducted on the sequences, which were then trimmed and quality controlled using DADA2 [q2-dada2 plugin). The ASV was annotated against the SILVA reference database (vs. 132) [q2-feature-classifier plugin. All of the sequence data generated in the present study have been uploaded to National Center for Biotechnology Information with the project ID: PRJNA666294 and accessions ID: SAMN16287644.The platform Quantitative Insights Into Microbial Ecology 2 (QIIME2) was used for bioinformatic analysis of the sequences . De-multng DADA2  to genervs. 132)  using thThe organellar ASVs (annotated as chloroplast or mitochondria) and less ubiquitous ASVs (present in <5% of samples) were removed from the ASV table. Variation of sequencing depth among samples was normalised using the Trimmed Mean of M values (TMM) method in the edgeR package in R . Bray–Cuadonis function in the vegan package). The Statistical Analysis of Metagenomic Profiles (STAMP) [p-value was adjusted using the Benjamini–Hochberg FDR method in STAMP. ANOVA was applied to test the effect of grass species on BNI capacity and Shannon index by Minitab .The effects of grass species on ASV composition were examined by performing the permutational multivariate analyses of variance (PERMANOVA) based on Bray–Curtis distance and 999 permutations ( (STAMP)  package p < 0.01 in the ANOVA test) and large , indicating a high similarity between microbial communities in the rhizosphere and bulk soil, but was longer for bermudagrass—almost twice as large as for saltwater couch and seashore paspalum.In addition, the Bray–Curtis distance for microbial ASVs’ composition was estimated between bulk soil and the rhizosphere . The disRubrobacter at the genus level  than the others. Interestingly, Erwinia was the dominant genus in bermudagrass rhizobiome, accounting for 15.1% of the community, but was quite minor in the other grass species, at only 0.45% on average  accounted for 0.4–2.2% of the total microbial community in soils (Nitrospira (the genus including comammox bacteria and other nitrite-oxidizing bacteria (NOB), 0.58 vs. 1.93%) and decreased abundance of every identified key ASVs in family Nitrospiraceae in the rhizosphere, compared with bulk soil and rhizospheres of the other non-BNI grasses.ASV annotated to the family Nitrospiraceae  genus, Candidatus Nitrososphaera accounted for about 99.8% of the total archaea community in rhizospheres and bulk soil and had a higher relative abundance than the genus Nitrospira with nitrite-oxidizing function and potentially comammox bacteria, in the total microbial community (6.22 vs. 1.32% on average). For the grasses with strong BNI capacity, the relative abundance of ASV_18 assigned as Candidatus Nitrososphaera SCA1145 was significantly lower in the rhizosphere of high-BNI grasses  and kikuyu grass than saltwater couch and seashore paspalum (1.02 vs. 4.10%), while ASV_14 (Candidatus Nitrososphaera sp.) was reduced in koronivia grass and St. Augustine grass. In addition, ASV_58 annotated as Candidatus Nitrososphaera gargensis was also less abundant in the rhizosphere microbiome of koronivia grass and St. Augustine grass.In contrast to the bacterial community, only four ASVs made up 85% of the archaeal community b. All ofNitrosomonas and Nitrosospira .The nitrifying genera ira AOB, , belongiNitrobacter , but was lowest in bermudagrass at only 4.7  being tested. The results from the two methods were correlated [The BNI capacity measured in the present study was based on a soil assay that focused on the changes in nitrification potential and indicated the potential BNI capacity. Another method based on incubating bacteria in pure culture with root exudates has also been used to measure the actual BNI capacity. Both methods have shortcomings: our soil assay cannot directly measure the effect of root exudates in suppressing nitrifying microbes, and the incubation method involved collection of root exudates from hydroponic conditions and simplifying the complex soil microbiome, with only 1–2 nitrifying bacterial strains  was quite minor  genus. Unlike the response of Nitrospira to BNI activity, the reduction in different AOA populations was not fully induced by BNI activity. For example, a decrease in ASV_18 (Candidatus Nitrososphaera SCA1145) and ASV_58 (Candidatus Nitrososphaera gargensis) was induced not only by the high-BNI grasses but also the low-BNI kikuyu grass. A previous study on sorghum lines with diverse BNI capacity and under different N fertiliser regimes also showed that Nitrososphareaceae dominated the rhizosphere archaeal community, but their relative abundance was not associated with BNI activity [amoA gene copy numbers (genes controlling ammonia oxidisation) showed that the abundance of AOA was over 3000-fold more than AOB in soils from northern to southern Europe [Almost all the archaea in the bulk soil and rhizosphere were classified as activity . Analysin Europe . HoweverNitrosomonas and Nitrosospira (oxidizing ammonia to NH2OH), were not detected in the soil used in the present study (either bulk soil or rhizosphere soil). Previously, an assay for the suppression of Nitrosomonas europaea and Nitrosospira multiformis bacterial cultures by collected root exudates was developed to screen for BNI capacity of different plant species [Nitrosomonas- and Nitrosospira-based BNI assay might not reflect the BNI capacity of plants, considering the complexity of the indigenous soil microbiome. Similar concern was also expressed by Coskun et al. [Nitrosomonas and Nitrosospira were barely detectable populations in the plant-soil microbiome of BNI species. Previous studies found that Nitrosospira was highly abundant in the soil microbiome [Nitrosospira [AOB,  species ,14,21,22n et al. , while hcrobiome ,47,48, posospira . The soiThe rhizosphere microbiome assemblages were determined by the different genera of grasses.Avena barbata) have demonstrated that the metabolite composition of the exudates was associated with the structure of the rhizosphere microbiome [Two halophyte grass species, saltwater couch and seashore paspalums, were characterised by a weak selective power for rhizosphere bacteria from the bulk soil, indicated by the high similarity in bacterial composition and diversity between their rhizospheres and bulk soil . In extrcrobiome ,55.Brachiaria humidicola “Tully”. BNI activity in perennial grasses suppressed the populations of Nitrospira, a genus with the nitrite-oxidizing activity including potential comammox bacteria, but not all of the potential ammonia-oxidizing archaea. The rhizospheres of two grass species, saltwater couch and seashore paspalum, exerted only a weak recruitment effect on the soil microbiome. Our results indicate directions for future research—e.g., evaluating genotypic variation in BNI capacity within the same perennial grass species collected from diverse Australian environments, identifying the active compounds released from the roots of the studied BNI grasses, and understanding the function and diversity of rhizosphere-nitrifying microbes that are sensitive to BNI activity.The present study demonstrated that Australian naturalised cultivars of St. Augustinegrass and bermudagrass were able to perform strong BNI, comparable with the BNI activity of the known BNI cultivar,