Telephone consultation and triage services are increasingly being used to deliver health advice. Availability of high speed internet services in remote areas allows healthcare providers to move from telephone to video telehealth services. Current approaches for assessing video services have limitations. This study aimed to identify the challenges for service providers associated with transitioning from audio to video technology.Using a mixed-method, qualitative approach, we observed training of service providers who were required to switch from telephone to video, and conducted pre- and post-training interviews with 15 service providers and their trainers on the challenges associated with transitioning to video. Two full days of simulation training were observed. Data were transcribed and analysed using an inductive approach; a modified constant comparative method was employed to identify common themes.We found three broad categories of issues likely to affect implementation of the video service: social, professional, and technical. Within these categories, eight sub-themes were identified; they were: enhanced delivery of the health service, improved health advice for people living in remote areas, safety concerns, professional risks, poor uptake of video service, system design issues, use of simulation for system testing, and use of simulation for system training.This study identified a number of unexpected potential barriers to successful transition from telephone to the video system. Most prominent were technical and training issues, and personal safety concerns about transitioning from telephone to video media. Addressing identified issues prior to implementation of a new video telehealth system is likely to improve effectiveness and uptake.The online version of this article (doi:10.1186/s12913-017-2514-7) contains supplementary material, which is available to authorized users. Emerging evidence demonstrates the contribution of telehealth to improved health outcomes and quality of life . MultiplCurrent approaches for evaluating video services have shortcomings,  particulIn view of these limitations, we undertook a formative evaluation of a telehealth service, comprising a combination of interviews with providers and observations of how the telehealth is delivered in a workplace setting with a simulated patient (actor). Assessing telehealth services as integrated systems, and involving typical users and real world situations as part of the evaluation, is one way to enable problems to be identified and then addressed . SeekingOur study aimed to identify staff perceptions of the potential barriers, benefits, and safety issues associated with transitioning from a telephone helpline to an audio-visual telehealth service. This study was part of a larger project, evaluating implementation of the new service, that included analysis of routinely collected service data.www.pregnancybirthbaby.org.au), two levels of direct client support are provided by the PBB service: (1) Customer Support Officers (CSOs) provide standardised advice on specific topics, including planning for pregnancy, foods to avoid when pregnant, and breastfeeding. This advice is pre-packaged into factsheets on each topic. When delivering advice over the telephone, the CSO reviews the applicable factsheet via a computer terminal and verbally delivers the content over the phone. (2) Professionally qualified and registered Counsellors provide psychological support and counselling. Advice is tailored to the needs of the individual client, but may include sensitive topics such as the decision to terminate a pregnancy.The Pregnancy, Birth and Baby (PBB) helpline, a national phone and online service established in 2010, provides information, advice and counselling about pregnancy, childbirth and parenting in a child’s first year. It is a non-commercial, government funded health information service, operated by Healthdirect Australia. In addition to an online website . The video service was viewed as potentially offering advantages over the telephone service, such as access to callers’ non-verbal cues and visual information, supporting the establishment of greater rapport and trust with service users –14. The The VCC uses open source WebRTC standards for real time video, audio and data communication. In preparation for this new service, a number of simulation sessions were held to train service providers, and to evaluate the final system design.We adopted a mixed method, qualitative approach. This involved 1) observation of the training of telephone service staff members who were required to make the switch from audio-only to video, and 2) pre- and post-training interviews with staff members and their trainers on the challenges associated with transitioning to the new medium. Combining observations and interviews in this way, to obtain an understanding of how technology is implemented and used in practice, is a common and accepted method in the field of human factors and ergonomics , 17.The study population consisted of counsellors and CSOs, who had completed classroom training and were due to participate in simulations over the study period, along with the system trainers. Training consisted of one day in the classroom, followed by one day of simulation, where providers used the actual VCC system to process calls from simulated patients (actors). Recruitment was undertaken using a mixture of purposive homogenous (system trainers) and convenience (CSOs and counsellors) sampling strategies. Fifteen staff members were invited via email to participate in interviews and all agreed. A selection of CSO and counsellor interviewees was assigned to the pre- or post-training groups based on their availability on the nominated interview days. Participants did not meet the researchers prior to commencement of the study, and were not informed of researcher personal motivations associated with the research.A scenario-focused training and evaluation process  was usedSimulations were set up to enable random calls to be made from the patient actor to the provider over a one day period. Providers answered video calls on demand, as part of their normal working day. All calls were initially answered by a CSO, then passed across to a counsellor if required by the situation.Two full days of simulation training were observed by human factors trained researchers : one day was observed from the patient actor viewpoint (two observers) and one day from the service provider viewpoint (one observer). Human factors is “the scientific discipline concerned with the understanding of interactions among humans and other elements of a system” . The resData collection during observations and interviews focused upon five domains: technical professional issues, organisational factors, system and work process effectiveness, and safety and quality. The nature of observation notes and interview questions associated with each domain are provided in Tables Interviews were audio recorded and transcribed verbatim. Inductive thematic analysis of transcribed interviews and observation notes was undertaken to identify key themes across the broad domain areas relating to implementation of the video service. A modified constant comparative method  was usedPre-simulation, four customer support officers (CSOs) and five counsellors participated in a semi-structured interview over the telephone. Following simulation, six post-simulation interviews were conducted with participants, three over the telephone and three face-to-face . Demographic information about the participants, who were all female, is shown in Table Interviews were conducted by three female PhD qualified professional research academics , with experience in qualitative research methods. Average pre-simulation interview length was 26.2 min, and 22 min post-simulation. Three broad categories emerged from an initial analysis of the interview data: social, professional, and technical issues. Within these three categories, eight sub-themes were identified; they were: enhanced delivery of the health service, improved health advice for people living in remote areas, safety concerns, professional risks, poor uptake of video service, system design issues, use of simulation for system testing, and use of simulation for system training.I think for the medical lines , I think it’s really appropriate. I think it’s a brilliant idea … but I don’t think it’s actually appropriate for our line . It’s stressing a lot of the staff. There are several staff who are probably going to leave. There are staff who are going to, if they’re forced to do it, will probably leave. There are staff who are trying desperately to avoid it.” (CSO 3)“Views of the video consultation service were consistent among participants, and data saturation was reached. Overall, providers were quick to identify potential problems with video implementation, and some participants struggled to identify any benefits of using the new service. This was particularly the case for CSOs:Any kind of visual aspect can potentially enhance the connection with the caller, rapport with the caller in the initial stages of a call.” (Counsellor 5)“Some providers also felt that the video view would provide them with useful information about the caller and their situation, which might help them make better decisions about what information to provide:I guess, being able to see a person might give you, you know, that greater kind of ability to being able to read their body language, and you know, seeing where they’re at, all those things that you’re kind of missing when you’re on the phone.” (Counsellor 4)“Most participants felt the service would be of benefit to counsellors who provide medical advice to callers, but of less value to the CSOs who provide standardised advice. Some providers felt that being face-to-face with a caller would increase engagement with callers:I think it’s giving access to people who then can access medical services through rural or regional or even people who have disabilities or who are elderly, house bound, whatever, they don’t have to go their GP or go and see a nurse. They can call a service and still been seen. So I think that’s quite a positive thing for the future.” (Counsellor 2)“A frequently cited benefit of the video service was that it would allow clients in remote and rural areas to have access to face-to-face advice. This was viewed as better than telephone advice, but not as effective as seeing someone in person:once you see something it’s very hard to un-see.” (CSO 2)Providers were apprehensive about being recorded during video consultations and recordings being posted on websites, and felt that this was likely to influence their decision about the type of health advice they provided. Providers felt exposed, and were uneasy about the prospect of callers using the video service inappropriately. They explained that, with the current telephone service, they occasionally received crank calls and expected that these would also be a problem on the video line. The difference was that “brand new skill set” (CSO 2).Participants raised several concerns about the impact of the introduction of video on their professional roles. Participants believed that remaining professional both during and after a distressing call would be more difficult using the video service than the telephone service, because their emotions would be more visible on video. Providers recognised that video counselling required them to attain a “I think a lot of people would feel like they can’t really ask for help all that much, particularly if someone is quite distressed, you don’t want to leave them.” (CSO1)“Participants worried that callers might lose confidence in their ability to give advice if they were seen reading from factsheets, and that this might affect their decision making around the way in which factsheets are accessed and used. Similarly, several providers were apprehensive about their appearance leading callers to think that they were inexperienced:If someone sees the counsellor at the other end they might think things like you look young, are you really experienced enough to kind of help me” (Counsellor 5).“Providers believed that callers using the video service would expect visual demonstrations of practices or techniques. They recognised that one of the benefits of video is being able to show people how to do something, rather than just explain how to do it, but providers were quite anxious about this, because they were not trained to provide demonstrations:With a video thing the first thing they’re going to say is, ‘Show me.’ There is no point in going through the hoops a caller has to go through in order to call in with a video unless they’re going to ask the question, ‘Show me.’ And the reality is I don’t have the training.” (CSO3)“Providers also believed that it would be more difficult to seek advice from a colleague during a video call, particularly if this involved leaving their desk. They explained that this might affect their decision to seek advice from colleagues:I think that some people, we get a lot of calls particularly by people who are wanting to remain anonymous, so I think that in those instances it would be difficult for a person like that to use a video service because obviously that’s disclosing a lot more than a phone conversation does.” (Counsellor 5)“Some providers felt that potential clients may struggle with the new technology. Others highlighted the inability of people to multi-task while on a video call in comparison with the telephone, and also the extra time needed to connect to the video service:I guess most of them – they’re just wanting to pick up a phone, they’re wanting answers pretty quickly whereas I think trying to connect online and go through a video calling and if there’s problems it’s just going to take, I guess, longer than what they’re expecting.” (CSO 2)“All participants believed that uptake of the video service for the PBB line would be poor. This was mainly because they thought callers would prefer to remain anonymous. Many providers explained that the issues discussed with counsellors were often of a private or embarrassing nature. Obtaining advice while not being seen or identified was viewed to be one of the main reasons people used the telephone service.“… there seemed to be a lot going on, where it wasn’t working very well … I didn’t feel very good about it at all … it also gets really quite frustrating …” (CSO 3)System design issues were also identified, including camera positioning problems, difficulty with the logon protocols, technical issues associated with transferring calls from one provider to another, difficulty with quickly locating decision support tools while on a call, and the absence of effective aural alerts to incoming calls.Many technical problems were encountered during the simulations, including sound and video quality issues, and the inability to transfer calls from CSOs to counsellors. Technical problems affected how the CSOs and counsellors perceived the system:[because of the poor sound quality] I couldn’t really understand [what the client was saying] … I knew it was a transfer [from CSO to counselor] … that was me … absolutely winging it” (CSO 4)“The training was generally considered beneficial, however some negative effects were observed as a result of training on an immature system, and interruptions to repair technical faults were frequent. These disruptions were perceived by participants to have impacted the effectiveness of training, with the requirement to improvise to work around technical issues negating the benefit of training for some participants:“ …the things that were a little bit difficult … was knowing exactly where to look [in terms of the camera] … I’m not sure if it was perceived as looking at [the client] or away.” (Counsellor 5)The need for additional training was identified in pre-session system set-up and testing, particularly microphone and speaker testing, and screen customisation. Most of the participants felt that the training was adequate, but expressed the preference for more practice in realistic environments before going live.Both the researchers and participants felt that additional practice ‘being on video’ would be beneficial, including training on how to position the video camera, and how to achieve ‘video presence’ including the importance of non-verbal communication and ‘where to look’:The issues identified are likely to affect successful implementation of the video service, and make it difficult for providers to transition from telephone to video. While technical issues identified in the study can be addressed with design changes or additional training, the social and professional issues identified in this study are previously unreported, and require detailed consideration both in the training and establishment of these types of services. While much has been written about the safety of patients in regard to video telehealth, –23 thereOur study results were fed back to the service provider organisation, and many changes were made to address the issues identified. These changes included that, when CSOs made initial contact with the patient, the video link was not immediately activated. In this way, CSOs could safely screen potential clients via audio, and decide whether to pursue the call, before transferring them to the counsellors who were on video. Another modification was the inclusion of black screens behind service providers, rather than a view of the provider’s workspace, to minimize extraneous information presented to clients.In addition to identifying issues with transitioning to the new system, our study highlighted the importance of training providers in how to communicate in a video-based system. While simulation is an accepted method for training in healthcare, including training in non-technical skills such as communication between clinicians and patients,  trainingWhen training providers in video-based communication, ‘video presence’ should be one of the skills to consider. Training in ‘video presence’ might involve discussing the importance of non-verbal communication (perhaps led by the counsellors) followed by instruction on camera set-up and ‘where to look’. Experts recommend that speech be slowed and body language, such as hand gestures, be augmented for effective video counselling  . These dWhile some technical problems can be addressed in a straightforward manner via a combination of system redesign and training, this is not always the case. International experience with provision of video telehealth services has identified technological problem-solving as a major concern and a possible limitation on future practice , 22. By It is critical for effective provision of care that technology is simplified so that the right information is presented to the provider at the right time . DecisioThe CSOs and counsellors who participated in the simulation and associated interviews were not the same CSOs and counsellors who were interviewed pre-simulation. Therefore, we were not able to assess the degree to which simulation training changed perspectives of individuals. All participants were female, however there we no male CSOs or counsellors on staff at the time of the study. While we had a small number of participants, we did reach data saturation in the later interviews. In addition, the test of the system and the training provided were part of the same exercise. This made it difficult to extricate the true effects of the training, as trainees dealt with technical problems as they practised using the system. Organisations might consider separating system testing from provider training, as training with a system that is not the final design or not working correctly is likely to have a negative effect on competency and foster distrust of the equipment.In exploring service provider experience of planning for the transition from audio to video capability in a telehealth system, we identified a number of unexpected potential barriers to successful transition to the video system. In particular, technical and training issues, and personal safety concerns about transitioning from telephone to video media, are likely to hamper implementation of the new system, and adversely affect effectiveness of the service. Addressing these issues is likely to improve effectiveness and uptake.


Determination of the blood oxyhemoglobin saturation in the retinal vessels of the eye can be achieved through spectrophotometric retinal oximetry which provides access to the state of oxyhemoglobin saturation in the central nervous system circulation. The purpose of this study was to test the capability of the Oxymap T1 oximeter to detect systemic hypoxemia and the effect of supplemental oxygen on retinal vessel oxyhemoglobin saturation.Oxygen saturation of hemoglobin in retinal arterioles and venules was measured in 11 subjects with severe chronic obstructive pulmonary disease (COPD) on long term oxygen therapy. Measurements were made with and without their daily supplemental oxygen. Eleven healthy age and gender matched subjects were measured during ambient air breathing for comparison of oxyhemoglobin saturation in retinal arterioles and venules. Retinal arteriolar oxyhemoglobin saturation in COPD subjects inspiring ambient air was compared with finger pulse oximetry and blood samples from radial artery.COPD subjects had significantly lower oxyhemoglobin saturation during ambient air breathing than healthy controls in both retinal arterioles  and venules . Administration of their prescribed supplemental oxygen increased oxyhemoglobin saturation in retinal arterioles  but not in venules . Retinal oximetry values were slightly lower than radial artery blood values  and finger pulse oximetry values .The noninvasive Oxymap T1 retinal oximetry detects hypoxemia in central nervous system vessels in patients with severe COPD compared with healthy controls. The instrument is sensitive to changes in oxygen breathing but displays slightly lower measures than finger pulse oximetry or radial artery measures. With further technological improvement, retinal oximetry may offer noninvasive “on-line” measurement of oxygen levels in central circulation in general anesthesia and critically ill patients. The eye is a window to systemic and central nervous system circulation. Its transparent anatomical structure provides a unique opportunity for direct noninvasive observation of arterial blood oxyhemoglobin saturation of retinal vessels; part of the central nervous system circulation. The retina has two separate vascular systems which differ anatomically and physiologically: the retinal circulation which supplies the inner retina and the choroidal circulation which supplies the avascular outer layers of retina. Both these circulations derive from the ophthalmic artery which is the first branch of the internal carotid artery on its wIn a variety of clinical settings including the operating room, intensive care unit, emergency department, motor vehicle accidents or combat injury, patients may suffer cardiovascular or other forms of shock. Measurement of oxyhemoglobin saturation by retinal oximetry may be a more reliable and relevant method to determine vital organ oxygenation and guide resuscitation in these shock patients than are measurements of oxyhemoglobin saturation in the peripheral circulation.Dual wavelength spectrophotometric noninvasive retinal oximetry allows direct measurement of inner retinal vessel oxyhemoglobin saturation. It has shown good repeatability and sensitivity ,12 and bMoreover, retinal oximetry has shown sensitivity to changes in oxyhemoglobin saturation in patients with systemic hypoxemia. Traustason et al. measured hypoxia in retinal arterioles and venules in people with chronic systemic hypoxemia secondary to Eisenmenger syndrome . The retThe goal of the current study was to determine the value of retinal oximetry for detecting central and systemic hypoxemia. We compare retinal vessel oxyhemoglobin saturation in patients with severe COPD with healthy subjects. In addition, we evaluated the ability of the retinal oximetry device to measure changes in retinal vessel oxyhemoglobin saturation during variable oxygen breathing. Finally we compare retinal oximetry to radial artery blood sample and finger pulse oximetry values in the COPD group. This is the first report comparing retinal oximetry with direct arterial blood gas analysis in hypoxic COPD patients.2), end-tidal carbon dioxide (EtCO2) and retinal oximetry images were obtained. Radial arterial blood samples for blood gas analysis were drawn during the ambient air breathing period only  and the Icelandic Data Protection Authority (2012010136AT/-) and adhered to the tenets of the Declaration of Helsinki. Oxyhemoglobin saturation in retinal arterioles and venules in subjects with severe COPD were compared to healthy controls while breathing ambient air. In addition, the COPD subjects were exposed to 3 successive inspired gas conditions: 1) prescribed supplemental oxygen; 2) ambient air and; 3) prescribed supplemental oxygen again. Under each condition, blood pressure, finger pulse oximetry, heart rate, respiratory rate, fraction of inspired oxygen (FiOiod only .1 < 50%) were enrolled in the study after signing a written informed consent. All COPD subjects were on long term oxygen therapy and had portable concentrator devices that supplied their prescribed oxygen supplementation . Patients are prescribed long term oxygen therapy based on meeting the international criteria for experiencing sustained hypoxia;[Patients with severe COPD [GOLD  stage 3 or 4] as classified by a forced expiratory volume of less than 50% of predicted in one second  and end-tidal carbon dioxide (EtCO2). Finger pulse oximetry, heart rate, respiratory rate, FiO2 and EtCO2 were continuously measured throughout the study. A non-invasive blood pressure cuff was applied over the brachial artery and blood pressure measurements were obtained at three different study time points . Systolic and diastolic blood pressure values were used to calculate mean arterial pressure (MAP) using the formula: (1/3 systolic blood pressure) + (2/3 diastolic blood pressure). After obtaining the first set of vital signs, and the initial finger pulse oximetry, FiO2 and EtCO2 . The patient’s portable oxygen concentrator device and nasal cannula were then replaced with a dual nasal cannula system  connected to an oxygen cylinder with the flow meter set at the subjects prescribed flow rate. The cannula was also connected to a respiratory gas analyzer  with the ability to continuously monitor the subjects respiratory rate and measure the fraction of inspired oxygen . The supplemental oxygen was then discontinued and the subject inspired ambient air at (close to) sea level for 10 minutes (ambient air period) followed by acquisition of the second set of retinal oximetry images. The prescribed supplemental oxygen was then re-instituted for a period of 20 minutes (second baseline period) and the final set of retinal oximetry images were obtained .Determination of blood oxyhemoglobin saturation in retinal vessels is based on the fundamental principle that oxyhemoglobin and deoxyhemoglobin have different light absorption spectra. In the retinal oximetry application of this principle, an image of the fundus is obtained with the Oxymap T1 oximeter  which has been described in detail elsewhere. ,12 It isA modified Allen´s test was perft-tests and repeated measures one–way ANOVA were used for comparison of means. Dunnett's and Tukey´s multiple comparison post tests were carried out to compare pairs of group means. A p value of < 0.05 was considered to be significant. The data are presented as mean ± SD ). Bland-Altman plots were used to determine the levels of agreement between the different measurement modalities, i.e. retinal oximetry, arterial blood samples and pulse oximetry. The degree of error, defined as the difference between the measurement values, was assessed in terms of bias and variability, where bias was calculated as the average difference between the measurements and variability was calculated as the mean bias ± 1.96 standard deviations.Data analysis was performed using the Prism version 5 . A power analysis indicated that 7 subjects were required to detect a difference of 3 percentage points (%) in oxyhemoglobin saturation between retinal oximetry measurements of subjects inspiring ambient air versus supplemental oxygen with a power of 90%. Two-tailed paired 2 and EtCO2 data from the dual nasal cannula at any of the three study periods. All 11 COPD subjects were included in the ambient air breathing comparisons with the healthy controls.Eleven (11) Caucasian subjects  with severe COPD were enrolled in the study. The mean age was 70.4 ± 5.4 years and the range was 66 to 82 years. The control group data consisted of 11 age and gender matched healthy subjects  selected from a group of 120 patients who had undergone retinal vessel imaging and oxyhemoglobin saturation determination while breathing ambient air prior to the current investigation. Of the 11 COPD subjects, one was not breathing the prescribed supplemental oxygen on arrival and therefore there was no first baseline measurement for this subject and we were unable to obtain an arterial blood gas sample from another. Therefore, data from 10 subjects was included in the statistical analysis at each study time period for comparison of mean and standard deviation within the COPD group. In addition, one COPD subject was a mouth breather and therefore we were unable to acquire sufficient FiOCOPD subjects breathing ambient air (n = 11) had significantly lower mean oxyhemoglobin saturation compared to healthy controls  in both Administration of prescribed supplemental oxygen significantly increased the oxyhemoglobin saturation in retinal arterioles  but not in venules . There were no differences between COPD and healthy subjects in diameter of arterioles  or venules  respectively.Data from 10 COPD subjects after 10 minutes of ambient air breathing  revealed2) and carbon dioxide (PaCO2) of 61.3±10.5mm Hg and 42.2%±5.9 mm Hg respectively, a mean bicarbonate of 26.4 ±3.4 mEq/L, and a mean pH of 7.4±0.0.Bland Altman plots were constructed to compare retinal arteriolar oximetric oxyhemoglobin saturation values with finger pulse oximetry and radial artery blood. Retinal arteriole oxyhemoglobin saturation during ambient air breathing revealed a bias and limit of agreement of -3.1±5.5; 95% CI: -14.05 to 7.84 as compared with finger pulse oximeter measurements and -5.0±5.4; 95% CI: -15.68 to 5.67 as compared with the radial artery blood sample valus . During 2 amplifies the oxygen flux from choriocapillaries, not only to the outer retina but to the inner retina as well [Noninvasive spectrophotometric retinal oximetry was able to detect reduced oxyhemoglobin saturation in patients with severe COPD breathing ambient air compared to healthy subjects. The oximeter also captured an increase in retinal arteriole oxyhemoglobin saturation when the COPD subjects inspired supplemental oxygen. Our findings of increased oxyhemoglobin saturation in retinal arterioles and unchanged AV-difference during supplemental oxygen breathing are in agreement with the study of Palkovits and associates on patie as well  which maOur results demonstrate that while there are some intra-individual differences, in general retinal arteriole oxyhemoglobin saturation values were lower than those measured with finger oximetry and from radial artery blood samples across the three study conditions. The Bland Altman plots demonstrated this tendency of retinal oximetry to produce lower oxyhemoglobin saturation but manifested a fair agreement with the other two modalities. The difference could simply be due to calibration. If the difference is real, however, one possible explanation for lower retinal arterial saturation is that the relatively small retinal arterioles that are measured, simply lose more oxygen through their walls by diffusion than arteries measured in the finger or arm  in healthy subjects has shown to increase the oxyhemoglobin saturation in retinal arterioles to 94.5%±3.8 and 76.2%±8.0% in venules[in vivo. This barrier is also responsible for the lack of a definitive threshold for retinal vessel hypoxemia. Nevertheless, retinal oximeter measurements can provide valuable information with respect to relative and trend oxyhemoglobin saturation values in retinal arterioles and venules.Retinal oximetry has previously been tested over a wide range of oxyhemoglobin saturation levels,24 and vn venules Despite The reason for the differences in oxyhemoglobin saturation of retinal arterioles and peripheral vascular beds need to be elucidated. Reevaluation of the instrument calibration and further studies on larger numbers of healthy subjects and patients suffering from systemic hypoxic condition are needed to address the issues of absolute arterial oxyhemoglobin saturation and retinal arteriolar relative values.Retinal oximetry quantifies oxygen delivery,16 and oNoninvasive retinal oximetry detects lower oxyhemoglobin saturation in central nervous system vessels in patients with severe COPD compared with healthy controls. It is sensitive to changes in concentration of inspired oxygen but measured values are slightly below both arterial blood and finger pulse oximetry values. With further technological improvements and development of a hand held device, retinal oximetry may eventually offer noninvasive “real-time” measurement of oxyhemoglobin saturation levels in the central circulation in the anesthesia and critical care settings.S1 Fig(TIF)Click here for additional data file.


We examined whether problem-based learning tutorials using patient-simulated videosshowing daily life are more practical for clinical learning, compared with traditionalpaper-based problem-based learning, for the consideration rate of psychosocial issuesand the recall rate for experienced learning. Twenty-two groups with 120 fifth-year students were each assigned paper-basedproblem-based learning and video-based problem-based learning using patient-simulatedvideos. We compared target achievement rates in questionnaires using the Wilcoxonsigned-rank test and discussion contents diversity using the Mann-Whitney U test. Afollow-up survey used a chi-square test to measure students’ recall of cases inthree categories: video, paper, and non-experienced. 2=24.319, p<0.001) and paper . Although the video rate tended to be higher than the paper rate, nosignificant difference was found between the two. Video-based problem-based learning displayed significantly higher achievement rates forimagining authentic patients (p=0.001), incorporating a comprehensive approach includingpsychosocial aspects (p<0.001), and satisfaction with sessions (p=0.001). Nosignificant differences existed in the discussion contents diversity regarding theInternational Classification of Primary Care Second Edition codes and chapter types orin the rate of psychological codes. In a follow-up survey comparing video and papergroups to non-experienced groups, the rates were higher for video(χPatient-simulated videos showing daily life facilitate imagining true patients andsupport a comprehensive approach that fosters better memory. The clinicalpatient-simulated video method is more practical and clinical problem-based tutorialscan be implemented if we create patient-simulated videos for each symptom as teachingmaterials.  However,authentic cases are desirable for improving educational effects,,In a past report comparing video- and paper-based PBL, video-based PBL tutorials werepreferred by students and tutors and were regarded as offering better learning effects8-10and memory retention8). The usefulness of videos is controversial; some reports indicatethat more students prefer paper-based PBL tutorialsThe aim of this study is to examine whether the PBL tutorial using patient-simulated videosshowing daily lives offers more practical clinical learning, compared with traditionalpaper-based PBL, about the consideration rate for psychosocial issues and the retention ratefor experienced learning.A cross-sectional survey was conducted at the Chiba University Hospital’sDepartment of General Medicine (hereafter referred to as “our department”)in Japan.The PBL tutorials were conducted from February 2014 to January 2015 as part of clinicalclerkship at our department. The participants were all 120 fifth-year students in ChibaUniversity, School of Medicine in 2014. They were randomly divided into 22 groups of fiveto six students each for clinical clerkship rotations. During the two-week learning periodin our department, 22 groups received PBL tutorials of two cases, one video and onepaper.The 120 students were then gathered in a lecture room at the University in July 2015 fora follow-up survey. There were some differences in the time periods between the PBLtutorials and follow-up survey, but the survey was given to all students at the same timeso that a high responses rate was received at a uniform place and time.The tutors were all seven teachers affiliated with our department, and one tutor wasassigned to each group. Before the PBL tutorials, the teachers were received lecture andgiven materials about the PBL tutorials and the role of the tutors. A tutor meeting washeld after the completion of all PBL tutorials in February 2015.This research was conducted with the consent of the participating students and tutorsafter we received permission from Chiba University, Graduate School of Medicine EthicalReview Committee.In the PBL tutorials, we examined the target achievement rates and the discussioncontents diversity. During the two-week learning period in our department, theparticipating students received two PBL tutorials, one each week. The 22 groups wererandomly divided in two. The first group was given a PBL tutorial using a simulatedvideo (video-based PBL) in the first week followed by a traditional PBL tutorial in thesecond week that used a paper-based scenario assignment (paper-based PBL). The secondgroup was given a paper-based PBL in the first week and a video-based PBL in the secondweek see . In eachFor both PBL, each case was divided in two sessions, for a total of four times, witheach session lasting two hours. In the first session, medical history and physicalfindings were presented, and laboratory findings, imaging findings, and treatment planswere presented in the second session. Digital voice recorder recorded all tutorialsessions.We randomly chose a combination of two cases from a total of five by using the envelopemethod. Five cases were implemented: Fitz-Hugh-Curtis syndrome, panic disorder, subacutecombined degeneration of spinal cord, primary amyloidosis, and sleep apnea syndrome. Apatient-simulated video and paper-based scenario assignment were prepared for each case.These cases were experienced in our department. The patient-simulated videos wereproduced for a television program on the theme of case investigations and were used forthis research with the permission of the production company. The patient-simulatedvideos included medical history information. In addition to medical interview scenes inexamining rooms, they also showed the symptoms displayed in the patient’s home orplace of work, in the patient’s daily life, and so on. These videos weresimulated by professional actors under medical supervision. The patient-simulated videowas shown on a screen, projected from a computer so that the students could view them indetail. The paper-based scenarios were derived from the patient-simulated videos, whichwere produced by the teachers serving as tutors. These scenarios were distributed to thestudents. The patient-simulated videos and paper-based scenarios had different medicalhistory information; physical findings, laboratory findings, imaging findings, andtreatment plans were distributed as paper materials for both.After the completion of the second PBL tutorial session of each week, the questionnaireswere given to each participating students. The students were given identification numbersfor anonymity and to correspond the two results, video and paper.Data was collected using a self-administered five-point Likert scale questionnaire. Thequestionnaire contents were eight items, included achievement rate evaluations for thefive targets of the university’s PBL tutorials see , No.1-5.A comparative survey was also given to the students on completion of the two weeks of PBLtutorials to see whether they preferred video- or paper-based PBL. The scale forpreference was ratings based on strongly prefer video, prefer video, neutral, preferpaper, strongly prefer paper; the participants were also asked to write the reasons fortheir preference freely.The agreement was received from all 120 participating students. A total of 108 (90.0%)were the participants in the questionnaire analysis; this figure excludes 12 who wereabsent from one or more PBL tutorials.Data was collected extracting the differential disease names mentioned in the discussionsof each PBL tutorials. One researcher extracted the disease names from audio recordingsmade with a digital voice recorder and coded them using the disease code (component 7) inthe International Classification of Primary Care Second Edition (ICPC-2).13,14 After this,the number of codes, the number of chapter types and the rate of psychology codes wereevaluated. The ICPC-2 contains 17 chapters. Chapters are based on body systems withadditional chapters for psychological problems and social problems: for example, B isblood and P is psychological. The rate of psychology codes was calculated from the numberof psychology codes / the number of all codes × 100(%). The difference between thevideo- and paper-based PBL was the medical history information presented in the firstsession; for this reason, only the first sessions for each PBL tutorial were used astargets of the analysis. Two PBL tutorials in which there were recording deficiencies (onevideo-based PBL and one paper-based PBL) were excluded from the evaluation of thediscussion contents; as a result of this, 42 of the 44 PBL tutorials were analyzed(95.5%).At the tutor meeting, a focus group discussion was held with all tutors of thedifferences between video- and paper-based PBL.In the follow-up survey, we examined the memory retention rates of PBL tutorial cases.Data was collected using a self-administered survey form presenting the diseases from thefive cases discussed above for each participating students. A time limit of five minuteswas established, and the students wrote the symptoms they recalled, without a limit on thenumber. The survey forms and identification numbers of PBL tutorials were collated. Thecases experienced in the video-based and paper-based PBL were identified as either“video” or “paper” cases, and cases that were not experiencedin either type of PBL were identified as “non-experienced” cases. The fiveresponses from each student were sorted into three groups, with one question for video,one question for paper, and three questions for non-experienced see . If the The data were analyzed on SPSS, version 22.0. The questionnaire of target achievementrates and evaluations of discussion contents diversity were compared for video-based andpaper-based PBL see . A WilcoIn the follow-up survey, we used a chi-square test and a Bonferroni correction method formultiple comparisons to evaluate the recall rate of three groups: video, paper, andnon-experienced. It is possible that the period from the conclusion of the PBL tutorialsuntil the follow-up survey could influence recall; thus, we used a Mann-Whitney U test forthe video and paper groups regarding the relationship between the presence and absence ofrecall and the period before the follow-up survey.The Cronbach’s alpha of the questionnaire was 0.861. Video-based PBL had asignificantly higher achievement rate for “The development of an effective clinicalreasoning process,” one of the five target items for the university’s PBLtutorials (p=0.042). No significant differences were found between the two groups for theother four items see . Video-bIn the comparative survey on which the students preferred video- or paper-based PBL, fouranswered that they strongly preferred video (3.7%); 46 answered that they preferred video(42.6%); three answered that they strongly preferred paper (2.8%); 21 answered that theypreferred paper (19.4%); and 34 answered that there was no difference between the two(31.5%). Many students answered that they preferred video . The mostfrequently mentioned reason for preferring video-based PBL was “Ease of imagining theauthentic patient.”No significant difference was found between video-based and paper-based PBL for thenumber of ICPC-2 codes, the number of ICPC-2 chapter types, and the rate of P codes see.In the tutor meeting, the opinion was shared that “There were many groups thatspent time confirming the video content because it was necessary to extract informationfrom the video in video-based PBL.” Furthermore, the opinion was expressed that“In paper-based PBL the same information is put into words, so no time is requiredto confirm the contents like in video-based PBL, and the students were able to startdiscussing the cases immediately.2=24.721, p<0.001) betweenthe three groups: video, paper, and non-experienced. In multiple comparisons using theBonferroni correction method, video and paper were significantly higher for recall ratebetween video and non-experienced , and betweenpaper and non-experienced . Although the rate forvideo tended to be higher than the rate for paper, no significant difference was foundbetween video and paper (see Significant differences were confirmed (χaper see . For botaper see .The Cronbach’s alpha of the questionnaire exceeded 0.8: internal consistency wasconsidered high. This research used simulated videos showing not only medical examinationsin examining rooms, but also scenes of the patients' symptoms actually appearing andpatients’ daily lives. This should have made imagining the patient easier. As aresult, one can guess that it should be possible to take the patient’s psychosocialaspects into consideration, leading to high achievement rates for “imagining theauthentic patient” and “incorporating a comprehensive approach.”Video-based PBL had a higher achievement rate for “the development of an effectiveclinical reasoning process,” as well as higher “satisfaction with thesession.” Additionally, in comparisons of the modality of the case, more studentspreferred video-based PBL. The reason given, echoing research by de Leng B et alHowever, no significant difference was found between video-based and paper-based PBL forthe discussion contents diversity, as evaluated by the number of ICPC-2 codes, the number ofICPC-2 chapter types, and the rate of P codes. One possible reason is that students feltthat video-based PBL made it easy to imagine the patient, and also that they were able toincorporate a comprehensive approach including psychosocial aspects. However, the number ofdifferential diseases was not larger because this image conversely constrained students.One more factor for no difference in the discussion contents diversity is thought to be thedifferent case recognition processes for the video- and paper-based PBL. That is,video-based PBL required more time for video analysis and problem extraction.clinical reasoning. In this research as well, the view was raised that time was required inthe video-based PBL for group members to discuss the video contents and its analyses.Paper-based PBL provided the same information put into words, so this time was notnecessary.However, the focus group discussion clarified that a great deal of information could beobtained from video-based PBL, resulting in the presence of recall.In the evaluation of discussion contents, only differential disease names were extractedfrom the PBL tutorial audio recordings. For instance, “depression” wascounted, but “psychogenetic” was not counted, so even when clinicalconditions were discussed, they were not counted if no specific diseases were named. Forboth groups, there was a low rate of psychogenic diseases among the differential diseases.We thought that the students were less well versed in psychogenic diseases than inbiological diseases, which might indicate that psychogenic discussion is undervalued.When using patient-simulated videos that included patients’ daily lives, the rate ofpsychosocial issues during the discussion was not higher, due to factors such as the impactsof being constrained by the video images. However, video made imagining the authenticpatient easier and also made it easier to realize a comprehensive approach includingpsychosocial aspects, which is required for actual clinical practice. In the follow-upsurvey, there was a tendency for patient-simulated videos to inspire better recall thanpaper mediums.Patient-simulated video with patients’ daily life facilitates consideration thatincludes psychosocial aspects and is a more practical clinical method in PBL. In the future,we would like to create patient-simulated videos for each symptom and to undertakelarge-scale surveys of the outcome assessments of students and changes in the burdens on thetutors.This study was supported by JSPS Grant-in-Aid for Challenging Exploratory Research GrantNumber 25670242, and Initiative for Realizing Diversity in the Research Environment.The authors declare that they have no conflict of interest.


Mitral regurgitation (MR) is the second most common form of valvular disease requiring surgery. Correct identification of surgical candidates and optimising the timing of surgery are key in management. For primary MR, this relies upon a balance between the peri-operative risks and rates of successful repair in patients undergoing early surgery when asymptomatic with the potential risk of irreversible left ventricular dysfunction if intervention is performed too late. For secondary MR, recognition that this is a highly dynamic condition where MR severity may change is key, although data on outcomes in determining whether concomitant valve intervention is performed with revascularisation has raised questions regarding timing of surgery. There has been substantial interest in the use of stress echocardiography to risk stratify patients in mitral regurgitation. This article reviews the role of stress echocardiography in both primary and secondary mitral regurgitation and discusses how this can help clinicians tackle the challenges of this prevalent condition. Mitral regurgitation (MR) is the second most common type of valve disease requiring surgery in Europe . DespiteVideo 1http://movie-usa.glencoesoftware.com/video/10.1530/ERP-16-0019/video-1.Primary mitral regurgitation with flail A2 scallop of the anterior mitral valve leaflet. View Video 1 at Download Video 1Video 2http://movie-usa.glencoesoftware.com/video/10.1530/ERP-16-0019/video-2.Secondary ischaemic mitral regurgitation (asymmetric). View Video 2 at Download Video 2Class 1 indications for surgery in primary MR have been unchanged for many years . In receP = 0.033) and cardiac event rates   . The mul= 0.002) .Given the consistency of these data, why do current guidelines  not emphMoreover, referral for early surgery may often not be a straightforward decision – even with quantitative echocardiography, grading severe MR is subject to significant variation between operators . When seIn addition to markers of adverse outcome that include the onset of atrial fibrillation , pulmona2 during exercise have a lower symptom-free survival compared with those with no change. Secondly, patients with moderate-to-severe MR who develop pulmonary hypertension above 60 mmHg on exercise are at greater risk of symptoms and adverse outcomes  and and2 duroutcomes . Improveoutcomes . Similaroutcomes  and 5 apoutcomes .Figure Video 3http://movie-usa.glencoesoftware.com/video/10.1530/ERP-16-0019/video-3.Example of latent contractile dysfunction with normal LVEF but systolic tissue velocity below 10.5 cm/s at rest . View ViDownload Video 3Video 4http://movie-usa.glencoesoftware.com/video/10.1530/ERP-16-0019/video-4.Example of reduction in GLS from rest in a patient with mitral regurgitation and LVEF >60%. View Video 4 at Download Video 4Video 5http://movie-usa.glencoesoftware.com/video/10.1530/ERP-16-0019/video-5.Example of reduction in GLS to exercise in a patient with mitral regurgitation and LVEF >60%. View Video 5 at Download Video 5It has been suggested that exercise promotes an increase in systolic blood pressure, but pressure increase alone should not have a major impact on regurgitation without increase in regurgitant orifice as well as flow varies only with the square root of the pressure change between the LV and atrium . It is mCurrent US guidelines support the use of exercise testing in the assessment of patients with asymptomatic severe valvular heart disease to help identify those with latent symptoms and to clarify prognosis . Europea2 when measured by effective regurgitant orifice area (EROA) in 38 (54%) and increased more than this in the remaining 19 patients , increased by less than 13 mmpatients . The pripatients . These apatients , 44, 45.ac death . These aSecondary (ischaemic) MR is usually defined as the presence of MR either at rest or on exertion present more than 2 weeks after myocardial infarction. Although the frequency with which MR is detected may vary according to the method of imaging and the time at which this is carried out after MI, the presence of secondary MR confers a graded inverse relationship with risk of cardiovascular deaths . Even those with mild ischaemic MR have a significantly worse survival . Althoug2). In those in whom there is discussion as to whether percutaneous or surgical revascularisation should occur, demonstration of a significant exercise-related change in severity of MR or pulmonary hypertension would perhaps support surgery in those with symptoms .


It is difficult to detect visual function deficits in patients at risk for glaucoma (glaucoma suspects) and at early disease stages with conventional ophthalmic tests such as perimetry. To this end, we introduce a novel quadrant field measure of the melanopsin retinal ganglion cell mediated pupil light response corresponding with typical glaucomatous arcuate visual field defects. The melanopsin-mediated post-illumination pupil response (PIPR) was measured in 46 patients with different stages of glaucoma including glaucoma suspects and compared to a healthy group of 21 participants with no disease. We demonstrate that the superonasal quadrant PIPR differentiated glaucoma suspects and early glaucoma patients from controls with fair (AUC = 0.74) and excellent (AUC = 0.94) diagnostic accuracy, respectively. The superonasal PIPR provides a linear functional correlate of structural retinal nerve fibre thinning in glaucoma suspects and early glaucoma patients. This first report that quadrant PIPR stimulation detects melanopsin dysfunction in patients with early glaucoma and at pre-perimetric stages may have future implications in treatment decisions of glaucoma suspects. Primary open-angle glaucoma (POAG) is a leading cause of irreversible blindness3436781081112131415161718The discovery of melanopsin2021232425262728293031323334353221282128394142OPN4) variants modulate the pupil response and sleep behaviour555657OPN4 variants could affect the PIPR or sleep, independent of the different stages of glaucoma.Melanopsin function in glaucoma has been assessed by measuring the PLR during light stimulation2735232425263623283544464748494423242526365187953Patients were recruited from the private practice of one glaucoma specialist who determined the stage of glaucoma . The diagnosis of glaucoma suspect and glaucoma followed the American Academy of Ophthalmology Preferred Practice Pattern Guidelines2We recruited 67 participants in the study: 34 patients with early (n = 22), moderate (n = 6), and advanced (n = 6) POAG (age range = 50–90 years), 12 glaucoma suspects (age range = 50–77 years), and 21 healthy controls (age range = 42–74 years) (see ‘Results’ for participant characteristics). As moderate and advanced glaucoma patients are known to have a reduced PIPRAll glaucoma suspects and patients underwent a complete eye examination including visual acuity, intraocular pressure , colour vision (Ishihara), slit lamp biomicroscopy, ophthalmoscopy, visual field , and optical coherence tomography (OCT) nerve fibre layer and disc map . All glaucoma suspects and patients were using IOP lowering topical medications; there is a known miotic effect from brimonidine62636468707173The healthy controls were recruited from a university cohort and age-matched with the glaucoma suspects because the primary aim of the study was to detect early melanopsin dysfunction in suspects. They had no ocular or systemic pathology, no corneal opacity, lenticular opacification < grade 2 (LOCS III), and no history of uveitis. Because the PIPR is robust to healthy ageing74OPN4 gene single nucleotide polymorphisms (SNPs) P10L and I394T; genotyping followed established procedures and as previously performed in our studies79Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI)All experimental protocols were approved by the Queensland University of Technology (QUT) Human Research Ethics Committee  and conducted in accordance with their guidelines. The research followed the tenets of the Declaration of Helsinki and informed consent was obtained from all participants.et al.et al.max = 464 nm, 20 nm band-width at half maximum, corneal irradiance: 15.5 log quanta.cm−2 s−1, luminance: 2.9 log cd.m−2) with high melanopsin excitation  with low melanopsin excitation (0.5 α-opic lux); the presentation order was alternated to account for the effect of a suggested melanopsin bistability3234We designed two new pupillometric stimulus paradigms based on the location of Retinal Nerve Fibre Layer (RNFL) defects in glaucoma8115181In all participants, the left pupil was dilated  to maintain a constant retinal irradiance and was stimulated to measure the consensual PLR of the right eye. All measurements were preceded by 10 minutes dark adaptation (<1 lux) to eliminate the effect of prior light exposure on the pupil light response46et al.The PLR during light stimulation was quantified using the transient PLR, peak pupil constriction amplitude, time to peak constriction, and phase amplitude percentage (PAP) metrics defined in GraphPad Prism  was used for statistical analysis. Comparisons of the PLR and PIPR metrics were performed between the four groups: Healthy controls, glaucoma suspects, early glaucoma, and late glaucoma. The data frequency distributions were evaluated with the D’Agostino and Pearson omnibus normality test. Normal data were analysed with one-way ANOVA (Tukey’s multiple comparisons) and non-normal data were analysed with the Kruskal-Wallis test (Dunn’s multiple comparisons) to compare the PLR and PIPR between the four  study groups . The pupil metrics are presented in Box-and-Whisker plots showing the median, 25% and 75% quartiles, and range of the data. The relationship between the PIPR amplitude and mean RNFL thickness or visual field MD was evaluated with linear or non-linear regression, respectively and the statistical significance of linear regression was determined on the basis of whether or not the slope of the best-fitting regression line was significantly different from zero using F-test . Receiver operating characteristic (ROC) analysis was performed to determine the diagnostic accuracy of the PIPR to differentiate glaucoma suspects and established glaucoma patients from healthy control participants.3,57 = 3.48, p = 0.02; SNF: F3,60 = 4.02, p = 0.01; INF: F3,58 = 5.77, p = 0.002) when compared to healthy controls, and with the SNF sinusoidal stimulus, but not for the blue stimulus. The peak pupil constriction amplitude  stimuli for all stimulus fields. With the blue quadrant stimuli, the peak constriction was also significantly reduced in early glaucoma compared to controls. The time to peak pupil constriction  and full field stimulation  (The melanopsin-controlled PIPR was significantly reduced in early and late glaucoma patients compared to controls with the quadrant (SNF: F 0.0001) . Importa 0.0001) . The sup 0.0001) . Notably 0.0001) 88. ThereThe ROC analysis demonstrated that the superonasal PIPR has a fair diagnostic accuracy89OPN4 SNP P10L that has been associated with sleep disturbances was present in only one participant (an early glaucoma patient). The peak pupil constriction amplitude and the PIPR amplitude did not vary significantly within the OPN4 SNP I394T alleles that have been previously linked with lower PIPR amplitudes  dysfunction in glaucoma suspects in the absence of perimetric deficits . Importa23Our finding of reduced PIPR amplitudes with selective superonasal field stimulation in glaucoma suspects and early glaucoma is consistent with rodent models of ipRGC abnormalities in the early stages of experimental glaucoma9192939495810827Advanced glaucoma patients with deficits in the central 7° on microperimetry that are not evident on Standard Automated Perimetry (SAP), have greater PIPR deficits compared to early glaucoma patientsThe reduced transient PLR to red stimuli in late glaucoma  indicate10028The peak pupil constriction amplitude  was redu274410249OPN4 SNP P10L TT genotype has been demonstrated to be associated with poorer sleep quality, there was only one patient with the TT risk allele in our cohort. We therefore infer that our results of normal sleep behaviour in glaucoma patients may in some part reflect the low frequency of the risk allele in our participants and the smaller sample of late glaucoma patients. Notably, the I394T genotype did not affect any of the pupil metrics .


Like many gambling games, the exceedingly popular and lucrative smartphone game “Candy Crush” features near-miss outcomes. In slot machines, a near-miss involves getting two of the needed three high-paying symbols on the pay-line . In Candy Crush, the game signals when you just miss getting to the next level by one or two moves. Because near-misses in gambling games have consistently been shown to invigorate play despite being frustrating outcomes, the goal of the present study was to examine whether such near-misses trigger increases in player arousal, frustration and urge to continue play in Candy Crush. Sixty avid Candy Crush players were recruited to play the game for 30 min while having their Heart Rate, Skin Conductance Level, subjective arousal, frustration and urge to play recorded for three types of outcomes: wins (where they level up), losses (where they don’t come close to levelling up), and near-misses (where they just miss levelling up). Near-misses were more arousing than losses as indexed by increased heart rate and greater subjective arousal. Near-misses were also subjectively rated as the most frustrating of all outcomes. Most importantly, of any type of outcome, near-misses triggered the most substantial urge to continue play. These findings suggest that near-misses in Candy Crush play a role in player commitment to the game, and may contribute to players playing longer than intended. Since the emergence of multimedia cellular phones in the mid-1990s, mobile phone gaming has claimed some degree of presence in our continuous, ‘on-the-go’ lifestyle. From the initial craze surrounding the game “Snake” on early Nokia devices, our mobile gaming habits have been transformed by the ever-expanding quality, sophistication and overall usage of smartphone technology. Of particular interest is the surging popularity of Candy Crush Saga—a free-to-play, candy themed puzzle game that has captivated at least 93 million daily active users in 2014, and generated $2.2 billion in profits (mostly from in-app purchases) in that same year King Ltd .To play Candy Crush, players are allotted a fixed number of moves in which they can swap symbol positions with the goal of horizontally or vertically aligning three (or more) matching symbols. When matched symbols are aligned, points are awarded and the ‘captured’ matching symbols are removed from the game matrix (and replaced by other symbols). A single match constitutes one move. In each level of the game, the player must achieve a specific objective within a limited number of moves before the player can unlock the next level. The objectives can include bringing a certain number of ‘ingredient’ symbols to the bottom of the game matrix , or ‘freeing’ candy symbols encased in ‘gelatine’ or ‘jelly’ tiles . If the player meets the objective within the allotted number of moves they win, and move on to play the next level . If they fail to meet the objective in the allotted number of moves they lose, and remain at the current level, which they must repeat if they wish to move on in the game.Since games like Candy Crush are typically played on smartphones, they encompass a unique set of traits that distinguish them from console-type video games but intriguingly, bring them closer to the conceptual realm of slot machines. For example, like slot machines, smartphone games are easy to learn, and players are frequently reinforced as each successful move is accompanied by eye-catching animations of points being accrued as the aligned symbols are captured. Perhaps most importantly, play is continuous- there is always a next level to play , but also frustrating events. Near-misses are outcomes that come close to, but fall just short of a win Reid . In tradAlthough no studies have investigated the ramifications of Candy Crush near-misses, one can make reasonable inferences based on near-misses in other scenarios. In slot machine games, near-miss outcomes encourage the urge to continue play despite the absence of reward  investigated near-misses in scratch card play. Players uncovered a series of symbols hoping to find three matching symbols within a 3 × 2 symbol matrix. They compared losing outcomes (no matching symbols), winning outcomes  and near-miss outcomes (where only two of three “jackpot” symbols were uncovered and players “just missed” winning a large prize). In such a game, the outcomes are only known once the last symbol in a matrix is revealed. Stange et al. (in press) showed that during near-misses (compared to regular losses), as players successively revealed a first, then a second jackpot symbol their skin conductance levels (SCLs) increased presumably due to increases in arousal in anticipation of the big win. Elevations in Heart Rate (HR) also took place during near-misses as the first and second symbol were uncovered. They also found that subjective frustration ensued when players uncovered the last symbol and their hopes were dashed. We surmise that this anticipatory build up as players get closer and closer to their goal and the frustration encountered when they “just miss” achieving their goal may occur not only during scratch card play but also during Candy Crush gameplay. As players make more and more moves, they accrue points and get closer and closer to levelling up. When they run out of moves it is reasonable to assume that frustration will ensue.To summarize, most current research on near-misses pertains to studies of gambling, limiting their application to the smartphone gaming context. Here we will examine how winning (levelling up), losing, and just failing to win (a near-miss) in Candy Crush affects players’ levels of physiological arousal (as indexed by HR and SCL), emotional reactions (as indexed by subjective ratings) and reward responses (indexed by PRPs). We hypothesize that near-miss outcomes will produce greater physiological arousal (higher HR and SCL) than full loss outcomes during the game. Here, following Stange et al. (in press), we will measure SCL changes that occur during the game as players get closer and closer to levelling up. We expect near-misses to trigger similar SCL changes to actual wins since the anticipatory build up period prior to winning or proximally winning should be comparable. Based on previous findings by Dixon et al. , we hypoA total of 60 Candy Crush Saga players were recruited to participate from two pools of students at the University of Waterloo. The first pool consisted of students participating in studies advertised for extra credit in a psychology course of their choosing. Students in this pool were recruited through the University of Waterloo’s SONA system—a website that manages student participation in Psychology studies. Out of the 323 students from this pool who were eligible to participate, 39 participated. The second pool consisted of students who voluntarily enrolled in a pool to participate in experiments for financial remuneration. These students submitted their contact information to the department of Psychology to be included in a database accessed only by authorized researchers. A total of 141 students from this pool were contacted. Out of this number, 22 participants responded, and 21 participated. Students recruited from this pool were compensated $10 for their time.Students from both pools were first asked to complete a pre-screen survey to ensure: (1) students reached at least level 70 in the Candy Crush Saga, and (2) students had played the Candy Crush Saga within the last 12 months. Assigning a cut off level of 70 in the Candy Crush Saga ensured that players were adequately experienced players.The final results of the study are based on 57 students  between the ages of 18-24 . Participants were excluded if they did not meet the aforementioned criteria or if there were issues in data collection . Participants on average had achieved level 287 (ranging from 70 to 930). In terms of playing frequency, 23.8 % of players reported playing Candy Crush on a daily basis, 65.7 % reported that they played the game at least twice a week, and 10.5 % reporting that they rarely play.The current study’s protocol was reviewed and approved by the University of Waterloo Research Ethics Committee. All participants were provided sufficient information about the study prior to participating, and were advised that they could withdraw at any point in the study without penalty.Participants played a real, complete version of Candy Crush on an Android tablet device. A built-in video camera on a MacBook Pro laptop was used to capture the tablet screen as participants played the game. The tablet rested on a tilted platform aligned to the computer’s camera. The video was used to record the outcomes  was recorded using two small metallic plates (ADinstruments MLT116F electrodes) attached to the participant’s index and middle finger see Fig. . The elePost-reinforcement pauses (PRPs) were defined as the delay between an outcome delivery in one game and the initiation of the next game, measured in seconds. In Candy Crush, a message at the end of each game appears. The messages associated with the three different outcomes are shown in Fig. Prior to commencing the study, participants were asked to complete a brief questionnaire  composed of demographic information , as well as their experience with the smartphone game .The Self-Assessment Manikin , and averaged .Two items derived from The Gambling Urge Scale (GUS) measured urge to continue playing the game following each outcome experienced. These two items included “All I want to do is keep playing” and “I want to play so badly that I can almost feel it”, and were reworded to exclude gambling terminology. Participants were asked to rate their desire to continue playing using a 7-point Likert scale, with 1 indicating ‘The present study consisted of gameplay epochs and baseline epochs. During gameplay epochs each participant would play up to eight games of Candy Crush. During the eight games, players were expected to encounter all three possible outcome types, . Players were instructed to play a ninth game if they did not experience all three outcome types within the initial eight games. Each outcome was demarcated by a specific message at a game’s end: a ‘sugar crush’ demarcated a win, an ‘out of moves’ message demarcated a regular loss, and a message unambiguously specifying how close the player was to a win (e.g. “You only needed two more jellies!”) demarcated a near-miss . This allowed the participant to adjust to playing the game with the electrodes attached to their left hand. Next was the first baseline task where participants completed a digitized rotary pursuit task on the tablet. They simply traced their finger over a dot moving in a circle. Following the baseline task, participants then played four games on the tablet device. To maximize the probability that participants would experience wins, losses and near-misses during gameplay, the researcher preselected game levels set at 15 levels below his or her personal best. Each of the four games took approximately 5 min to complete. Before initiating the gameplay epoch, participants were shown a button box placed beside the tablet . To circumvent the fact that games could be of different temporal lengths we analyzed BPM and SCLs only for the last 30 s of each game  = 18.75, p < .001, η2 = .25. Fisher’s LSD post hoc tests showed that baseline heart rate was slower than any of the game play outcomes . Near-misses triggered significantly higher heart rates than regular losses (p = .05) but the average HR for wins did not statistically differ from near-misses (p = .30). Wins had higher heart rates than regular losses (p = .03).As shown in Fig. F = 3.11, p = .04, η2 = .06. Fischer’s LSD post hoc comparisons showed significantly larger slope increases for wins compared to near-misses (p = .02), but not losses (p = .13). Losses and near-misses were not statistically different (p = .83). The baseline epoch had significantly lower slopes than wins (p = .01) but not near-misses (p = .34) or losses (p = .21).The changes in skin conductance levels (SCLs) over the final 30 s leading up to a win, loss or near-miss (or the last 30 s of the baseline period) are also shown in Fig. M = 1.85, SD = .89), and losses  had short PRPs compared to wins . Repeated measures analyses with a Greenhouse Geisser correction indicated that there was a significant main effect of outcome type, F = 71.29, p < .001, η2 = .58. Post-hoc comparisons indicated that PRP lengths for near-misses did not statistically differ from PRPs for losses (p = .60). However, PRPs for wins were statistically longer than PRPs for losses (p < .001) and near-misses (p < .001).Near-misses (t(56) = 2.16, SE = .077, p = .03. By contrast, the planned comparison of arousal ratings between wins and losses was not significant, t(56) = −1.37, SE = .124, p = .17, nor was the planned comparison between arousal ratings for wins and near-misses, t(56) = .05, SE = .05, p = .95.Average arousal ratings are shown in Fig. t(56) = 2.01, SE = .12, p = .04. Expectedly, frustration following wins was statistically lower than losses, t(56) = 10.50, SE = .19, p < .001, and statistically lower than near-misses, t(56) = −10.41, SE = .21, p < .001.For frustration  = 1.95, SE = .19, p = .05. The planned comparison between urge ratings for wins and losses was not statistically significant, t(56) = −.52, SE = .24, p = .60. Additionally, the planned comparison between urge ratings for wins and near-misses was also not statistically significant, t(56) = −1.11, SE = .22, p = .27.Average urge ratings are shown in Fig. In the present study, participants experienced three types of outcomes in Candy Crush during 30 min of playing a real version of the game: Wins (when they levelled up), full losses (when they failed to level up) and near-misses (when they came close to levelling up). Based on previous research, we expected wins to be highly arousing, highly rewarding, and highly motivating.At the most general level, our heart rate findings show that compared to the baseline epoch, playing Candy Crush is an exciting, arousing experience. Heart rate for game play was elevated compared to baseline heart rate. Importantly, such increases in arousal were likely due to game excitement as opposed to differences in the movements required in the game compared to the baseline condition. As a baseline, we specifically chose a non-exciting (rotor pursuit) task which nonetheless required finger movements comparable to those required in the game. This greater HR reactivity during gameplay has been consistently observed in previous research even when (as in this study) researchers controlled for metabolic demands due to movement —significantly more frustrated than for regular losses. Such frustration is nonetheless highly motivating, as players report greater urge to play following near-misses than following regular losses. Although near-misses are objectively equivalent to regular losses in that neither outcome results in goal attainment, gambling research suggests that near-misses trigger the urge to continue play and can lead to excessive play , it was expected that wins would be a powerful reinforcement of behaviour in this context  the order in which outcomes occurred. Additionally, the fact that we had participants play levels slightly below their skill level and on a tablet rather than on a participants preferred device, may have disrupted the naturalism of game play. Thus, future research could consider having players play games directly from their device at their current level of success to maximize the potential of affective responses to outcome events. Moreover, since the effect of Candy Crush near-misses on urge has been observed, future research can investigate the behavioural consequence of such urge in terms of persistence in play.Another limitation of this study concerns the post-reinforcement pause lengths following winning outcomes. In Candy Crush, following a winning outcome the players experience a series of eye-catching animations and exciting sounds. Unlike in slots games where players can, with the press of a button, immediately advance to the next game, Candy Crush players must wait until the cessation of these animations before playing a new game in naturalistic play. Thus, had we used the temporal duration between the outcome being revealed and the actual initiation of the next game as a measure of PRPs, these PRPs would be artificially inflated following wins by the presence of the uninterruptable animations. To circumvent this problem, we had players press an external button when they were ready to answer the subjective questions pertaining to that button. Thus, theoretically they could press button this at any time following outcome delivery . Although a substantial portion of our sample initiated a button press during the playing of the animations, some players waited until the end of the animations. Thus it is difficult to get a precise estimate of the length of the true post-reinforcement pause for all participants. To get such a precise estimate, one would have to remove the animations that are played following wins—an empirical move that would dramatically reduce ecological validity.In our version of Candy Crush, we did not subject players to “lock out” periods. In normal game play, players are only given a few chances to level up before being “locked-out” of the game for a set period of time . Yet, to circumvent this waiting period, players are given the opportunity to make a purchase (termed micro-transaction) to resume play immediately. Although we did not use “lock out” periods our findings nonetheless may have implications toward this micro-purchasing behaviour. Specifically, as players get “locked out” following a certain number of failures, the combination of frustration and urge to continue play following a near-miss may lead players to actually pay to continue their play. Recent research has suggested that micro-transactions made in casual games, especially in those that feature gambling relevant themes, are a risk factor to migration to online gambling—even in players who have not engaged in the activity before (Kim et al. In conclusion, the present study demonstrated that Candy Crush near-misses appear to have similar psychological and physiological impacts on Candy Crush players as slot-machine near-misses have on gamblers. Specifically, Candy Crush near-misses, just like their gambling-game counterparts, are physiologically arousing, and frustrating, yet motivate the urge to play.