During the COVID-19 pandemic, parents of infants born very preterm or at risk were exceptionally worried about being infected. The only means of protection during the onset of the pandemic was social distancing. Video consultations for neurodevelopmental follow-up care were offered as an alternative way to stay in contact with patients and their families, to provide expert support, and to monitor and assess children’s development.To assess the feasibility of and family satisfaction with video consultations, interviews were conducted after video and in-person consultations.An interview with 28 questions was created to evaluate parental satisfaction with the consultations . A total of 93 interviews with parents were conducted between March 2020 and February 2021 and compared (58 after video consultations and 35 after in-person consultations). The interviews were conducted at the end of the consultations by a trained professional. The video consultations were conducted using a certified platform created by Zava Sprechstunde Online, maintaining data protection with end-to-end encryption. Follow-up consultations (video or in-person) were performed at corrected ages of 3, 6, and 12 months as well as 2, 3, 4, and 5 years. The rate of total follow-up appointments attended during the survey period was evaluated and compared with the previous year.P=.045; Shapiro-Wilk W=1094.5, Cohen d=–0.1782146) than the in-person consultation group. Parents in the video-consultation group stated that performing a guided examination on their child was comfortable and helped them understand their child’s development. In fact, they agreed to take advantage of future video consultations. The rate of total follow-up appointments increased compared to the previous year. Between March 2019 and February 2020, 782 of 984 (79.5%) children born at Essen University Hospital attended a follow-up appointment. During the survey period, between March 2020 and February 2021, a total of 788 of 1086 children (73%) attended a follow-up appointment, of which 117 (14.9%) were video consultations.There were no significant differences between the video and in-person consultation groups in satisfaction, attitudes on the confidentiality of the consultation, or discussion of private and sensitive information. Following video consultations, parents were significantly more likely to report that they were avoiding contact with medical professionals during the pandemic (The feasibility of attending video consultations for follow-up care of very preterm or at-risk infants and parental satisfaction with these consultations were as high as for in-person consultations. Parents rated video consultations as being as confidential as in-person appointments. Telemedicine can be offered as an equivalent alternative to in-person consultations and is particularly useful under certain circumstances, such as for very sick children who require assistive devices or respiratory support and oxygen or for those living a long distance away. Approximately 15 million newborns are born preterm worldwide each year, which is more than 1 in 10, and this rate is increasing in almost every country. Substantial progress in perinatal care has significantly increased survival rates over the past 3 decades. However, long-term morbidity remains a concern . ApproxiWhereas follow-up care in very preterm children can detect severe motor and cognitive impairment for up to 2 years, long-term follow-up care, until school age, is recommended to detect more subtle development disorders . RegularAt the onset of the COVID-19 pandemic, neither vaccination nor adequate therapies were available, and the only means of protection was social distancing. To reach out to patients and their families who would not or could not attend regular follow-up appointments, video consultations were offered. This method provided several opportunities: it allowed health care providers to stay in contact with patients and their families, provide expert support and information, and keep track of the children’s development. However, there were potential challenges, such as a lack of confidentiality, the discussion of private and sensitive information, technical issues, accessibility, and acceptance of this new digital tool. To assess the feasibility of this method and family satisfaction, we conducted interviews after video and in-person consultations. The rate of total follow-up appointments attended during the period of the survey, which took place during the COVID-19 pandemic, was evaluated and compared with the previous year.A total of 93 interviews were conducted with parents (58 after a video consultation and 35 after an in-person outpatient appointment) between March 2020 and February 2021. On average, parents of the participants were aged 33.45 (SD 5.11) years in the video-consultation group and 31.40 (SD 5.86) years in the in-person group. Inclusion criteria for participation in the video-consultation group were sufficient language skills in German, English, or Turkish and the possession of the minimum required technical equipment, such as a mobile phone. Interviews were conducted at the end of the in-person or digital appointment by a professionally trained neurodevelopmental psychologist. The video consultations were conducted on a certified platform developed by Zava Sprechstunde Online that maintained data protection with end-to-end encryption.The investigation was approved by the ethics committee of the Medical Faculty of the University Hospital Essen (20-9319-BO) and adhered to the Declaration of Helsinki.Starting on March 13, 2020, the German federal states ordered the closure of schools and kindergartens, postponed semester breaks, and banned visits to nursing homes to protect the elderly . Two dayFollow-up care, both via video consultation and in person, was performed by authors BMH, BA, and SG , LJC (a psychologist) AKD  and UT (a physiotherapist). During the in-person visits, a detailed medical history was taken with the parents, and the child was then examined by the various professionals. During video consultations, a detailed medical history was also taken, but the camera was pointed at the child so that he or she could be observed in his or her home environment. After the medical history was taken, parents were subsequently instructed to position the child and the camera. The parents were guided with a mannequin through different positions of the infant, such as a traction attempt, held seat and held stand, the axillary hanging position, the floating stomach position, and the passive rotation and stomach position. The spontaneous movements of the infant in these different positions were observed. Preschool-age children were instructed to perform fine and visual motor tasks, including copying forms; using scissors to cut along a line; and grasping, transferring, and releasing paper clips into a match box, to test precise finger coordination. Gross motor functions were tested using regular neurological examinations, such as the finger-nose test, walking in tandem, and the stance and gait test.While guiding parents, the examiner explained all observed items and findings. In addition, questions regarding the examination, as well as everyday life issues, were answered, including questions related to weight gain, feeding, developmental steps, and self-regulation. Physicians were able to assess fine and gross motor skills, as well as cognitive function, in the children through visual observation, for example, by observing how a toddler explored and handled items.To determine the parents’ perspectives on video and in-person consultations at the follow-up outpatient clinic for preterm and high-risk infants during the COVID-19 pandemic, an interview with 26 questions was created based on a questionnaire by Rutherford et al  Multime. QuestioTo evaluate the total attendance rates for follow-up appointments (for both in-person appointments and video consultations) for the children, the total number of consultations was compared with the number of scheduled appointments for preterm infants born at University Hospital Essen and also compared with the previous year.U test. In cases with significant differences, the effect size was calculated with the Cohen d.Statistical analyses were conducted using the R environment for statistical computing and graphics with the RStudio integrated development environment. All data were tested for normal distribution using the Shapiro-Wilk test. The distribution was not normal, so all comparisons between groups  were calculated using the Mann-Whitney W=1094.5; P=.045; d=–0.1782146). Furthermore, parents in the video-consultation group agreed that they would take advantage of future video consultations . Parents reported being empowered by the self-examination of their child (mean score 6.53. SD 1.39) and learning more about their neurodevelopment. All children were calm and cooperative  in their home setting with only familiar people.Between March 2020 and February 2021, 93 interviews were conducted and analyzed. There were no significant differences between the video and in-person consultation groups in satisfaction or attitudes toward confidentiality and discussion of private and sensitive information. Parents in the video-consultation group were significantly more likely to agree  that they were avoiding contact with medical professionals during the pandemic than the in-person consultation group . The video-consultation group made estimates of the potential waiting time at the clinic that were significantly longer  than estimates of the potential waiting time at the clinic made by the in-person group . Parents reported feeling safer from pathogens at home  after a video consultation than after an in-person appointment .Parents who attended a video consultation were significantly older on average  than parents who attended an in-person appointment ; they considered examining their children themselves under supervision was on average beneficial  and allowed them to better understand their development ; they considered that the video consultations were implemented similarly to in-person appointments ; and they accepted video consultations as an alternative in the future and wished to use them again .Between March 2019 and February 2020, 782 of 984 (79.5%) children born at Essen University Hospital attended a follow-up appointment. During the survey period between March 2020 and February 2021, a total of 788 of 1086 children (73%) attended a follow-up appointment, of which 117 (14.9%) were video consultations.The subjective satisfaction of families attending video consultations for follow-up care for their very preterm or at-risk infants was as high as in-person consultations. Parents found the video consultations to be as confidential as in-person appointments. In addition, parents felt comfortable and self-confident performing the guided examinations of their children by themselves during video consultations. Parents indicated that performing the examinations of their children gave them a better understanding of their development. During video consultations, the parents rated the children as being as calm and cooperative as at in-person appointments. Parents rated the feasibility of the video consultations as very high and similar to in-person appointments. Acceptance of the video consultations was considered high, as the parents agreed to choose video consultations again.During the COVID-19 pandemic, cancellation of in-person appointments due to symptoms of infection with SARS-CoV-2, other viral infections, or quarantine of family members was frequent. However, missed appointments often could not be made up in a timely manner. Dayal et al  comparedParents strongly considered video consultation as an equal alternative for keeping scheduled follow-up appointments. The acceptance of the video consultations by parents and their positive evaluations of the confidentiality of the conversations suggests the possibility of using this modality beyond the pandemic.Offering video consultations from the beginning of the COVID-19 pandemic was a rapid, adaptive response to meet the needs of the patient population. According to Chew et al  the succIt is much more difficult for highly complex patients, such as those receiving home oxygen therapy or those who live far away from the hospital, to attend in-person appointments. However, keeping track of patients with ongoing medical and therapeutic requirements reduces the rate of hospitalization. This also holds true for neonatal patients. Robinson et al  showed tNeurodevelopmental follow-up in preterm infants aims to identify children at risk early, in order to initiate intervention to best promote development. De Kleine et al  investigDuring the first 3 infectious peaks of the COVID-19 pandemic in Germany (March 2020-January 2021), there were several weeks when planned in-person appointments for medical causes that were not urgent were prohibited by social distancing rules. This study showed that parents who preferred follow-up care via video consultation were significantly more afraid of an infection and were significantly more likely to avoid contact with medical professionals. Parents of very preterm children have been exceptionally worried about being infected due to the fact that preterm children suffer from respiratory infections more often and have an increased risk of rehospitalization, especially during the first 2 years of life .In the outpatient clinic, 3 follow-up visits are scheduled in the first year of life and annually until school age (6 years in Germany). The video consultations for follow-up care in this study included patient-reported medical history and a guided examination of the patients by the parents. Observing children in their home environment following parental instructions provided an opportunity to gain insight into the family environment. Standardization was a challenge, and only individual items could be measured. Muscle tone and muscle strength were difficult to examine via video consultation. Nevertheless, observation of the infant’s spontaneous motor skills is one of the most important examinations and is easy to perform via video consultation in most cases. In toddlers and children, an overview of developmental domains in fine and gross motor skills, language and speech, cognition, performance and reasoning, sensory skills, and social-emotional behavior was obtained . The subThis study used a nonrandomized cohort design as the onset of the pandemic required rapid adaptation for developmental neurological follow-up care due to contact restrictions. Due to the completely anonymous collection of the data, no conclusions can be drawn about the families retrospectively. Nevertheless, additional variables would have been of interest from the current perspective, such as the age of the children or the frequency of participation in video consultations. Furthermore, the interviews were conducted after the appointments or consultations and were thus not anonymously registered.Parents in the in-person appointment group estimated the potential waiting time as being shorter than parents in the video-consultation group. However, technical problems  also often led to waiting times before video consultations. The actual waiting time was not recorded in either group. Similarly, parents who were offered video consultations but did not accept the offer were not included or evaluated in this study.The examiners’ perspectives were not elicited but might have revealed valuable new approaches for further research. There appears to be a lack of evidence from research in digital health, which in turn hinders implementation, and vice versa. Future randomized controlled studies are needed for the evaluation of digital tools in medical services offered to chronically ill children . Future In developing countries with low incomes and high rural populations, telemedicine could offer, on one hand, opportunities to bring a higher level of health service to patients in isolated regions ,15, but Independent of the pandemic, video consultation has been developed as a low-threshold service to bring medical care closer to the patient. It serves patients very well who live far away from specialists or who have greater logistical challenges, such as children on ventilators . TelemedThe feasibility of video consultations for follow-up care of very preterm or at-risk infants and parental satisfaction with the consultations was as high as for in-person consultations. Parents rated video consultations as being as confidential as in-person appointments. Telemedicine can be offered as an equivalent alternative to an in-person consultation and is particularly useful under certain circumstances, such as care for very sick children who require assistive devices, such as respiratory support and oxygen, or for children living a long distance away.


Certain diseases and malnutrition are known to co-occur in residents of long-term care facilities (LTCF). We assessed which diseases and health-related problems are associated with malnutrition at admission or with incident malnutrition during stays and how different definitions of malnutrition affect these associations. Data of Dutch LTCF residents were obtained from the InterRAI-LTCF instrument (2005–2020). We analyzed the association of diseases  and health-related problems  with malnutrition (recent weight loss (WL), low age-specific BMI (BMI), and ESPEN 2015 definition (ESPEN)) at admission (n = 3713), as well as with incident malnutrition during stay . Malnutrition prevalence at admission ranged from 8.8% (WL) to 27.4% (BMI); incident malnutrition during stay ranged from 8.9% (ESPEN) to 13.8% (WL). At admission, most diseases (except cardiometabolic diseases) and health-related problems were associated with higher prevalence of malnutrition based on either criterion, but strongest with WL. This was also seen in the prospective analysis, but relationships were less strong compared to the cross-sectional analysis. A considerable number of diseases and health-related problems are associated with an increased prevalence of malnutrition at admission and incident malnutrition during stays in LTCFs. At admission, low BMI is a good indicator of malnutrition; during stays, we advise use of WL. With the ageing population in Europe, the share of people aged >65 years will increase to 30% by 2055 . This prThe high disease burden of residents in LTCFs increases their risk of becoming malnourished. In older adults, malnutrition mainly refers to protein–energy malnutrition, which leads to loss of weight and eventually to a low BMI . Even whAs admission to a LTCF marks the latest phase in life, residential care should focus on function preservation and optimizing quality of life. A good nutritional status can contribute to this, as malnutrition is associated with function loss and impaired quality of life ,16,17. TIn addition, previous studies used different criteria to assess malnutrition . These data have been previously described by our group . InterRAI LTCF is an instrument for healthcare providers to systematically obtain information of about health conditions of LTCF residents. InterRAI LTCF is a so-called minimum dataset (MDS), first implemented in the Netherlands in 2005, covering up to ~50 facilities in 2020. Trained nurses use a standardized assessment form to assess residents’ health status. The assessment form also contains questions regarding nutritional status (weight loss and BMI) and presence of diseases. Each new resident is screened within a month after admission on average (admission assessment). Thereafter, follow-up assessments (same assessment form) are performed every 3–6 months. When a new LTCF first starts to use InterRAI, all existing residents are screened, despite not being recently admitted. This measurement can be seen as a “delayed first assessment” in InterRAI. Dutch InterRAI subjects (aged ≥ 65 years) living in LTCFs between 2005 and 2020 were included in this study. Two groups were formed: the “newly admitted” (those with an admission assessment) and the “existing” residents (those with a “delayed first assessment”). So, the difference between these two groups is the time elapsed between their admission and first assessment, which was shorter in the “newly admitted” group and longer in the “existing” residents group. In total, 4190 residents with an admission assessment were available; median time to first assessment was 16 days [IQR: 7–30] after admission. In total, 5592 residents with a delayed first assessment were available, and this assessment took place with a median time of 345 [IQR: 117–914] days in male and 546 [IQR: 165–1363] days in female residents after their initial admission. Data of admission assessments (“newly admitted” residents) were used to provide an overview of characteristics of the residents at admission and to perform cross-sectional analyses. Inclusion criteria were: age ≥ 65 years and available data on BMI and weight loss. Exclusion criterion was: presence of end-stage disease, i.e., terminally ill residents with a life expectancy < 6 months as indicated by the treating physician, to exclude residents with incurable malnutrition. The total number of included residents for cross-sectional analysis was 3713.2 for residents < 70 years, or <22 kg/m2 for residents ≥ 70 years, or having recent weight loss (5% body mass in the last 30 days or 10% in the last 180 days)), or having end-stage disease at first or/and last available measurement. Total number of included residents for prospective analysis was 3836. Numbers and reasons for exclusion are shown in Prospective analyses were performed for residents (both “newly admitted” and “existing”) with more than one measurement available. In addition to the inclusion criteria described above, participants were excluded when they were malnourished at first available measurement : balance problems , psychiatric problems , GI tract problems , sleep problems , dental problems , aphasia, pain, locomotion , eating help (independent (set-up help only)/supervised), aspiration, fever, peripheral edema. 2 was used for residents younger than 70 years and <22 kg/m2 was used for residents 70 years or older ), pressure ulcers (OR:1.81 [95%CI: 1.30–2.53]) and supervised eating (OR: 1.63 [95%CI: 1.28–2.07]). For all associations, comparable results were seen for low BMI and ESPEN, but odds ratios were smaller for low BMI.Post-hoc analysis showed that an increased number of diseases/health-related problems was associated a with higher prevalence of malnutrition based on WL (OR: 1.21 [95%CI: 1.15–1.27]). This was also seen for ESPEN, although to a lesser extent (1.06 [95%CI: 1.01–1.16]), but not for low BMI. 2, SD:3.9), as residents with a low age-specific BMI were excluded in these analyses. Most frequently described diseases/health-related problems were balance problems (66.7%) and neurological diseases (63.1%). On average, prevalence of diseases was comparable to the cross-sectional cohort. In total, 3836 unique residents had one or more follow-up measurements . Total rIncidence proportions of becoming malnourished during LTCF stay was 13.8% for WL, 11.3% for low BMI, and 8.9% for the ESPEN criteria. The effect sizes of the associations between diseases and/health-related problems and three criteria for malnutrition were relatively comparable . NeuroloPost-hoc analysis showed that incidence of malnutrition increased with a higher number of diseases (HRs ranging from 1.07–1.13).Residents of long-term care facilities are known to suffer from multiple diseases and health-related problems. In addition, malnutrition is a frequently reported phenomenon. This manuscript indicates that a considerable number of diseases and health-related problems are associated with an increased prevalence, as well as incidence of malnutrition in LTCFs. Herewith, this manuscript is one of the first to describe the associations between diseases and incident malnutrition within LTCFs. 2), but the number of diseases was higher in our population (4.5 vs 3.0), which is probably explained by the fact that we also included health-related problems. In general, our population seems to reflect the average population in Dutch LTCFs.The characteristics of our study population are relative comparable to other population-representative Dutch cohorts. On average, in the Netherlands, 70% of residents in LTCFs are female, which is equal to the percentage of females in our sample. Residents in our sample were relatively younger (83.1 years) compared to the average Dutch resident in 2019 (85.0 years) . CompareAt admission, 850 residents (22.9%) had a low age-specific BMI without recent weight loss . This inWe showed that the prevalence and (to a lesser extent) incidence of malnutrition are influenced by the used definition; at admission, low age-specific BMI (27.4%) was almost three times higher as weight loss (8.8%). During stay, weight loss (13.8%) was seen more often compared with low age-specific BMI (11.3%) and malnutrition according to ESPEN (8.9%). Associations between diseases/health-related problems and malnutrition also differed between used criteria; WL was more strongly related to diseases than low BMI/ESPEN (except diabetes and cardiac diseases at admission). The use of BMI for diagnosing malnutrition is often debated because of the generally high BMI in Western societies . Our res2 and an average length (1.70 m) should lose ~14.5 kg bodyweight before dropping below the cut-off point of 22 kg/m2, which is unlikely to happen, keeping in mind the relatively short stays in LTCFs. Therefore, involuntary WL should always be a trigger to start malnutrition interventions in LTCF residents. Based on the effect sizes of the associations, relatively small differences were seen between the use of BMI alone and the ESPEN criteria for malnutrition. As also shown in previous research , diabeteAs expected, one of the strongest predictors for developing malnutrition was the need of supervised/assisted eating. Dependency on staff or informal caregivers places residents at risk for a low intake. Assisting residents with eating their meals is time-consuming , and shoPressure ulcers, infectious diseases and pain were associated with WL at admission, but to a lesser extent during stay. Treatment of these problems could have decreased the risk of further nutritional decline during stay. In general, the prospective analysis may also have underestimated the malnutrition risk because of misclassification; we only used baseline disease status to study associations with malnutrition, and ignored new diseases that may have occurred during admission. We expect that residents who developed new diseases or health-related problems during their stays were at increased risk of becoming malnourished as well. In our analyses, we separately looked at disease groups and at health-related problems. In general, health-related problems  were more strongly associated with all three criteria for malnutrition than diseases. We assume that not all diseases were accompanied by acute health problems, especially if residents already suffered from them for dozens of years, Therefore, screening for health-related problems seems to have additional value, next to (long-)diagnosed diseases, when studying the association with malnutrition. 2 and/or recent weight loss (>10% within 6 months)). In this study, comparable effect sizes were seen for immobility (bedbound OR: 1.28 [99.5%CI: 1.00–1.68]) and musculoskeletal diseases (OR: 1.09 [99.5%CI: 0.91–1.31]), but smaller for neurological diseases (OR: 1.10 [99.5%CI: 0.87–1.38]). The difference in effect size for neurological diseases could be explained by the difference in follow-up time (6 months vs. ~1 year in our study), as most neurological diseases have a progressive development [Our study is one of the first prospective studies that is performed in the LTCF setting. We are aware of a previous study by Torbahn et al. , which welopment . Both ouelopment  study, uThe minimum dataset contains relatively few parameters of malnutrition, as data regarding meal intake, muscle mass, and infection levels are missing. Despite this limitation, routinely collected data (as in InterRAI) can be used to trigger protocols for future assessments. At this moment, the protocol in InterRAI for assessment of malnutrition is only triggered when BMI is below 19. Our data imply that this cut-off point should be raised to 22 and that also those with recent weight loss should be examined for malnutrition by a dietitian. A previous report of our group showed that nearly all residents who displayed recent weight loss or a low BMI also suffered from poor food intake . So, futHealth-related problems and diseases were analyzed in categories, as larger numbers were needed to investigate single diseases. However, it is not expected that effect sizes will differ strongly between separate diseases in one category, as they are likely to share the same underlying mechanism for their relationship with malnutrition. As an outcome of our analysis, we used the ESPEN definition for malnutrition. Recently, the GLIM criteria for malnutrition were launched , and it Strong points of our study are the large sample size and prospective design with long follow-up time. In addition, only physician-documented diagnoses are used in InterRAI, making our data more reliable compared to self-reported health status. By reporting associations for both weight loss, low BMI and the ESPEN 2015 criteria, we provide a valuable insight into how diseases affected different criteria for malnutrition and how different criteria for malnutrition affect prevalence rates. Finally, we identified risk factors for developing malnutrition that were not previously described. Our results can contribute to refining malnutrition screening tools, as most risk factors we described are not incorporated in screening tools currently. Most diseases (cardiometabolic diseases excluded) and health-related problems were associated with being malnourished at admission, but also with incidence rates during stay in LTCFs. Moreover, the strength of the associations between diseases or health-related problems and malnutrition are dependent on the set of criteria to define malnutrition. At admission, the use of low age-specific BMI to assess malnutrition status is recommended, as this reflects nutritional status over a longer period. During a LTCF stay, the use of recent weight loss is advised, as this better reflects acute nutritional problems.


Handball is a high-intensity game, during which players run, change directions with or without the ball, interact with the opponent and make different decisions in both offensive and defensive actions. Players‘ performance may depend on a number of factors, including explosive force, power, speed and agility. Players‘ results may be significantly influenced by their, psychomotor abilities. This article presents an analysis of selected psychomotor abilities of female handball players at different level of competition.Test2Drive computer tests were used. The following four tests were used to measure psychomotor abilities: the Simple Reaction Time Test (SIRT), the Choice Reaction Time Test (CHORT), the Hand-Eye Coordination Test and the Spatial Anticipation Test (SPANT). The study covered a group of 118 female handball players (average age 19.6 ± 3.16), playing in the PGNiG Polish Women’s Superliga, the Polish 1st Handball League and 2nd the Polish 2nd Handball League, in the playing positions: goalkeepers, centre players, pivot players and wing players. The study also included analyses of the players‘ body composition and aerobic capacity through the use of the multistage 20-m shuttle run test. In addition, the players‘ psychomotor abilities were analysed depending on the level of competition and playing position.The analysis of the reaction time and movement time showed statistically significant differences between the results obtained by the female handball players on different levels of competition. Moreover the female players from the Polish Women’s Superliga exhibited the fastest reaction times according to the SIRT, the CHORT and the SPANT. Additionally, on the basis of the linear Pearson correlation coefficient, a statistically significant relationship was determined between the players‘ psychomotor abilities  and elements of their body composition or aerobic capacity.The analysis showed that the higher the level of competition (leagues), the shorter the female handball players‘ reaction times. The study also revealed that the players‘ body mass index and percentage of fat content reassociated with movement times, while their aerobic capacity (measured in the multistage 20-m shuttle run test) had a significant influence on their reaction times. This study shows that reaction time it’s one of ability which should be consider to develop in training of female handball players. Handball is one of the most popular Olympic team games in the world. It is currently played by more than 19 million people and since 1972 has been an Olympic sport for men —and tactThe results achieved in today’s handball may depend on a number of factors . PreviouThe specificity of each player‘s playing position can also be crucial to sporting achievement , 21. FemPrevious studies have indicated that players‘ psychomotor abilities may also be crucial to the effectiveness of the game. Psychomotor abilities are key in open sports and can determine success or failure of the individual athlete or a team. The cognitive training consists of a variety of brain exercises designed to improve performance of psychomotor skills e.g. decision making, anticipation, fast response time . AnalysiA player‘s reaction time has also been related to their playing position , 31, senFor this reason, research in to players‘ psychomotor abilities, the factors that determine their level and the impact of these abilities on sports results is justified and essential. In this context, in order to increase knowledge about the importance and role of psychomotor abilities in female handball, the authors assessed selected psychomotor abilities of professional female handball players from Poland, taking into account their competition class (league), playing position, body composition, BMI and aerobic capacity. In addition, authors investigated which of the above factors affects the average level of the considered abilities and which of them significantly differentiates the results obtained in computer psychomotor tests.The study covered a group of 118 professional female handball players from different levels of competition . On the players are associated with the Polish Handball Federation and participate at various levels of women‘s hanball in Poland: the PGNiG Polish Women’s Superliga, the Polish 1st Handball League and the Polish 2st Handball League. The players are on leading teams and were given permission to participate in the research by the Polish Handball Federation. The study was performed with 17 female players from the Polish Women’s Superliga, 63 from the Polish 1st Handball League and 38 from the Polish 2nd Handball League. The all playing positions were taken into account: goalkeeper (GK) (20 players), centre player (CP) (52 players), pivot player (PP) (14 players) and wing player (WP) (32 players). Each player‘s height and mass and body composition  were measured. In addition, their aerobic capacity was measured with the use of the multistage 20-m shuttle run test (20mSRT) , 42. TheAs the study method, Test2Drive  psychometric computer tests were used Fig. . The varSIRT: used to evaluate reaction speed and its stability. The stimuli-signalling field changed colour in the right moment of research time. Responding to the stimuli involved moving one‘s finger from the START field to the reaction time field marked in blue.CHORT: used to evaluate the speed and adequacy of a reaction in a complex situation. Horizontal (stimuli) benchmarks and vertical stimuli which required a reaction and a slant benchmark  that did not require a reaction, were displayed in the top signalling row. Responding to the stimuli involved moving one’s finger from the START field to one of the two reaction fields . During the neutral stimuli, the participant was asked to keep her finger on the START field.HECOR: used to evaluate hand-eye coordination. The test required careful observation of the board and providing a quick reaction to the red signalling field displayed. The test participant was asked to move her finger from the START field to the blue reaction field and then return her finger to the START field.SPANT: used to evaluate hand-eye coordination via complex spatial information. At the top, and on the left and right sides of the test board were signalling fields, two of which (on in a row and one in a column) turned red simultaneously. In response to the stimulus, the test participant was asked to indicate with her finger the field on the crossing of the lit row and column and then return her finger to the START field.In all the tests the stimuli exposure time lasted 3 s, while the stimulation intervals lasted either 1 s, 1.5 s or 2 s. Each test lasted 3 min. RT and MT were measured for each test, while in the CHORT and the SPANT, the percentage of correct responses was also determined. In the SIRT, the HECOR and the SPANT, 20 stimuli were used, while in the CHORT, 24 cases were used.Information on the four tests is summarised below:for Kruskal–Wallis – for U Mann–Whitney test – for chi-squared test – where H—the Kruskal–Wallis H-test statistic, N—the total number of observations, Z—standardized value for the U-value, r—correlation coefficient where r assumes the value ranging from − 1.00 to 1.00. The analysis was performed with the GNU R software [Basic statistical measures  were used in the study. For the dependent variables analysed, the normality of the distribution was examined (the Shapiro–Wilk test). Given that some of the variables lacked a normal distribution, non-parametric tests were used in further analyses. In order to identify the significance of the differences between the groups, the Kruskal–Wallis and U Mann–Whitney tests were used. The effect size was calculated using the following formulas :for Krussoftware .Table In the next step, the correlations among the various variables , body mass (kg), BMI, FAT%, FFM (kg), TBW (kg), 20mSRT) and psychomotor test results were analysed according to the players‘ fitness levels Table . No releTable This study aimed to assess selected psychomotor abilities  depending on female handball players‘ league, playing position and selected body composition parameters. The research has clearly shown that players in the PGNiG Polish Women’s Superliga have the greatest psychomotor abilities, with the exception of hand-eye coordination. This conclusion is congruent with another study regarding a group of male professional handball players . The resIn addition to the level of competition, the playing position of the player is an important factor influencing the reaction time. Przednowek et al.  have obsThis study also sought to identify the relationship between female handball players‘ psychomotor abilities and body composition. A positive correlation was found between the players‘ BMI and psychomotor test results. For instance, it was observed those players with either a higher body mass, BMI or FAT, FFM and TBW content manifested higher simple and choice reaction time values. Most research in this field has been carried out on groups of non-athletic people –54. StudThe present study has also shown that there is a significant correlation between aerobic capacity and certain psychomotor abilities. In each of the cases analysed, a negative relationship was recorded. It was observed that with increased distance travelled during the 20mSRT, lower response time values were recorded. This phenomenon was seen for the CHORT (Superliga), the SPANT  and the HECOR (1st League). Such findings are congruent with those of Maghsoudipour et al.  regardinThe limitations of the study were related to the research group. Only the data of female handball players without the control group was analyzed in the study. A control group of non-athletes helped to describe in detail the influence of handball training on the development of psychomotor abilities. In the future the studies can be extended to the examine the relationship between psychomotor abilities and effectiveness of playing during the match of female handball.The results of the study revealed a relationship between the BMI of female handball players and the percentage of body fat on the one hand, and their movement time as measured by SIRT, CHORT and SPANT on the other. At the same time, it was found that the aerobic fitness of women in handball is related to CHORT and SPANT. In addition, the results showed that the players’ psychomotor skills were dependent on their handball competitive class. The best reaction times were recorded by players from the Superliga , while the shortest movement times were achieved by players with the lowest level of competition (II league). This supports the conclusion that reaction time it’s one of ability which should be consider to develop in training of female handball players. The conducted research has shown that it is necessary to further monitor handball players’ reaction time, which will allow for detailed training related to working on a faster reaction in defense as well as in position and quick attack in handball.


Uncertainties are omnipresent in health care, but little is known about general practitioners’ (GPs) professional uncertainties concerning digital consultations. This is problematic, as many countries have undergone an extensive digital transformation.The aim of this study was to explore the professional uncertainties that emerged among Danish GPs with the introduction of video consultations.We conducted qualitative interviews with 15 Danish GPs during the beginning of the COVID-19 pandemic in 2020. The interviews were analyzed using an abductive approach.integrity, setting, and interaction. Respectively, these 3 categories of uncertainty refer to (1) uncertainties related to how technology may impede the provision of health care; (2) uncertainties related to the potentials of video technology; and (3) uncertainties related to how the video consultation technology affects interactions with patients.We identified 3 categories of uncertainty: The uncertainties experienced by Danish GPs appear to be a typical reaction to the introduction of new technology. Embedding video consultation technology into GPs’ working routines will take time, and GPs do not necessarily feel intuitively capable of transferring their abilities, such as being good and socially present for video-mediated consultations. The heterogeneity of professional uncertainties experienced among the GPs suggests that they are the product of individual GP-technology relationships—not of the technology in itself. Consequently, we cannot expect that uncertainties can be remedied by changing or precluding new technology. Although video consultations are not “straightforward replacements” of physical consultations , they arMin Læge (“My Doctor” in Danish) as an alternative to face-to-face consultations. Moreover, Danish health authorities encouraged patients to use video consultations to decrease the transmission of COVID-19 ceCOVID-19 -16. In rCOVID-19 . FurtherCOVID-19 .To date, few studies have been conducted on GPs’ perceived uncertainties related to video consultations, which were rapidly implemented due to the COVID-19 pandemic , ‘Could you film all of you?’ Or…But it’s also a little boundary-crossing, you know?” (GP #2).Similarly, another GP questioned whether patients perceived it as intimidating to get undressed in front of a video camera. The GP described their considerations as follows:It might be that it is easier for them to show—how do you put it?—eczema on their breast, and that it’s me who finds it more intimidating that they have to sit in their [own] bathroom and lift up their breast, you know?...They [might] think it’s nicer there, than sitting in some man’s office taking off their bra.GP #9Third, uncertainties related to integrity also included whether GPs can legally stand by the assessments they make over video. Not many GPs explicitly expressed these uncertainties, but one GP stated the following:You’re behind on points. If something goes wrong...then, naturally, there’s a big difference in whether you have seen the patient or not seen the patient from a medico-legal point of view.GP #1The GP further expressed legal uncertainties about whether seeing a patient through video could be acknowledged as “a proper basis for diagnosing and starting treatments” (GP #1). Consequently, this GP expressed uncertainties about whether the use of video consultations could create legal issues, potentially challenging or risking their professionalism.Above, we described the 3 subcategories of uncertainties related to integrity. We identified integrity uncertainties among most of the GPs we interviewed. Some, however, expressed that they were not affected by uncertainties related to integrity, as can be seen in the following answer to the question on whether the GP felt professionally safe when diagnosing a patient through a screen: “Yes, I felt comfortable with that” (GP #9). Similarly, another GP answered an interview question on whether they felt sufficiently professional when seeing a patient over video by saying “Yes, I haven’t really had any concerns about that” (GP #7).Some GPs were thus comfortable with making decisions about patients’ health after having seen them through a video consultation. Although recognizing that some aspects of patients’ health issues might be missed in a video consultation , it was highlighted that “[GPs] could get better at making decisions without [the last 5%]” (GP #12). Thus, the GP suggested that it could be possible to make decisions about a patient’s health even if GPs are missing the small percentage of information that the video consultation does not transfer regarding the patient.setting comprises the uncertainties that the GPs experienced in relation to the video technology’s potentials. This category relates to the execution of video consultations and includes the following subcategories: (1) off-screen setting and (2) on-screen setting.The category First, uncertainties related to off-screen setting emerged because, for many GPs, the video consultation had not become a routine consultation form. Rather, most of the GPs were thrown into the use of video consultations because of the pandemic. Consequently, routines and habits related to video consultations did not exist for patients, GPs, or other health professionals in the GP clinic. One GP questioned how to build a video consultation culture among patients and explained how the patient “also has to sit down, also has to sit in a room without interferences. They can’t be on their way to the bakery, they can’t be driving their car or...” (GP #5). The GP added that “my own culture around having a video consultation is not very developed” (GP #5).Another GP explained how hybrid practices  were not part of everyday life in the clinic and at times created awkward situations:...it’s a bit awkward when I’m sitting and looking in [to the computer], and then a resident comes knocking on my door and “knock knock knock” and “Could you help me with a blood sample?”GP #9Thus, the GPs were uncertain about how to deal with the off-screen aspects of video consultations.setting also included on-screen setting uncertainties. Some GPs experienced difficulties with using the computer software when consulting. For example, they considered the new procedure for booking video consultations difficult and found it tricky to look at files on the computer while also having the image of the patient on the screen. Furthermore, some GPs feared that they would unintentionally share their screen: “I might accidentally share some things that I shouldn’t share with them [during the video consultation]” (GP #5).Uncertainties related to the category Related to the execution of the consultation, we also identified uncertainties among the interviewed GPs regarding how to adjust their consultation practice to the video medium. One GP talked about their uncertainties regarding how to look at a patient’s journal on the computer that was also being used for the video consultation.And the patients, for instance, can’t see that as of right now I’m looking in their journal. They can’t follow in the same way as if they are sitting here [at the GP’s office], then they can see that right now I’m looking at blood samples from the last time [they visited]. If they’re sitting at home, they can only see my head and I have to say out loud: “You know what, just a moment. I’ll go look,” and then you have to remove the image and such.GP #9In sum, the lack of established culture and practices around video consultations created uncertainties about how to create the best setting for a video consultation.interaction comprises the uncertainties that emerged in the GPs’ interactions with patients in video consultations. Examples of these uncertainties are presented in the following 3 subcategories: (1) challenges with focusing and concentrating, (2) challenges with staying present with the patient in the web-based environment, and (3) challenges with showing emotions in the mediated environment without being able to physically touch each other.The category First, challenges with being able to focus and concentrate, especially during longer consultations , were mentioned by several GPs. They stated that they experienced uncertainties related to staying focused and the risk of turning to other tasks during video consultations, such as reading emails. One GP explained the following:And then I also just think it’s difficult to concentrate. Basically, you can do all sorts of things at the same time, read emails and reply to things.GP #2Moreover, the ability to focus and concentrate was experienced as challenging because computers are used for other tasks, such as communication on social media and messages of various kinds . For example, notifications from other programs that popped up behind the video consultation were perceived as distracting, or as one GP explained: “When you’re sitting with your main communication organ in front of you in which all your Facebook thingies appear, then that is constantly disrupting in the background” (GP #4).Second, regarding the uncertainties connected to the inability to stay present with a patient in the web-based environment, the above-cited GP emphasized that they felt they were not fully present in the video consultation, stating simply, “I’m not as present, I mean” (GP #2).Furthermore, some, though not all, GPs experienced difficulties with making eye contact with their patients, to which relational importance was accorded. One GP said the following:But I think it’s hard for me to have eye contact with the patient. I have to have eye contact with the camera, but I can’t see if they...I mean, I have to choose: should they see my eyes, or should I see theirs, you know?GP #4Using video consultations may cause GPs to feel as if they must choose between looking at their patient and allowing the patient to feel as if they are making eye contact with their GP. However, when asking the GPs whether they experienced the ability to establish and maintain eye contact throughout a video consultation, some GPs answered affirmatively: “Yes, I actually do” (GP #8).Third, especially when it came to consultations dealing with emotional issues, several GPs experienced uncertainties due to the perceived challenge of showing emotion when being unable to be near or physically touch the patient. For example, one GP stated that “It’s difficult to have someone crying or in shock on the screen. I think the physical—there’s a kind of contact [in that situation] that on screen becomes sort of cold and cynical” (GP #15).Several GPs mentioned that they perceived a lack of potential for action to compensate for the fact that they could not touch the patient. Moreover, one GP also mentioned uncertainties regarding ascertaining a patient’s emotional state during a video consultation, questioning whether a patient was about to start crying or just staying silent for a short while. However, the same GP summarized that they found that they had managed this part of video consultations well, mentioning that perhaps this was due to the relational continuity that they were holding with the patient.Through our analysis, we have contributed new insights on uncertainties in health care by exploring technologically mediated uncertainties as perceived by GPs in Denmark in the period right after the rapid implementation of video consultations in general practice ,23. Littintegrity, setting, and interaction. These categories are closely connected to and mutually shape one another.We have identified 3 categories through which we can understand how video consultations create professional uncertainties among some Danish GPs: integrity show that the GPs were concerned about whether the video consultation technology would impede the provision of care and, consequently, whether the technology could challenge the GPs’ ability to provide quality in health care and thus be the GPs they wanted to be. However, uncertainties are omnipresent in health care, and, as mentioned in the introduction, the implementation of new media is characterized by uncertainty [In our analysis, the video consultation technology came to play a substantial role in shaping the GPs’ experience of their professional uncertainties as having been compromised. The uncertainties related to ertainty . Historiertainty ,28. Furtertainty ,29. Conssetting. GPs were found to have uncertainties relating to both off-screen and on-screen settings, and the analysis suggests that the practice of video consultation was not yet routinely embedded in general practice [Technologies are not automatically accepted; they must go through a process until they become normalized, pointing further to the uncertainties related to practice —the use practice , and whepractice —it is tointeraction. These uncertainties show that some GPs experienced challenges with focusing and concentrating, staying present, and showing emotions. This can be related to the ongoing scholarly discussion about uncertainties that emerge in the digital sphere in general and concerns about the implementation of new technology  in particular. Uncertainty in the digital sphere has been studied for almost 5 decades, focusing on the question of how one perceives other people during a computer-mediated interaction, also termed “social presence” [For video consultation technology to become routinely embedded in general practice, in addition to not feeling that the technology impedes the provision of health care, GPs must also feel that the interaction through the medium is satisfactory. This points to the uncertainties related to resence” ,33 and “resence” ,35 and rresence” ,37. The Our analysis also shows that the perceptions and experiences of uncertainties vary, suggesting that uncertainties are not entirely a product of the technology but rather of the GP-technology relationship—a point emphasized at large in science and technology studies . ConsequLooking at the above identified GP uncertainties as relationally grounded, the implementation of video consultation in general practice must be acknowledged as “not exclusively a technological issue, but part of a complex organizational change” , involviThis study was conducted during an early stage of the introduction of video consultations in general practice; therefore, it cannot state anything about its adaptation over time. Furthermore, as this is a qualitative study, we are unable to make claims about the general frequency of the uncertainties of GPs in Denmark. However, we have no reason to believe that the sample of GPs in this study is not transferrable to other GPs in Denmark.


Bacillus subtilis CH3-5 isolated from cheonggukjang secretes a 28 kDa protease with a strong fibrinolytic activity. Its gene, aprE3-5, was cloned and expressed in a heterologous host . In this study, the promoter of aprE3-5 was replaced with other stronger promoters  of Bacillus spp. using PCR. The constructed chimeric genes were cloned into pHY300PLK vector, and then introduced into B. subtilis WB600. The P10 promoter conferred the highest fibrinolytic activity, i.e., 1.7-fold higher than that conferred by the original promoter. Overproduction of the 28 kDa protease was confirmed using SDS-PAGE and fibrin zymography. RT-qPCR analysis showed that aprE3-5 expression was 2.0-fold higher with the P10 promoter than with the original promoter. Change of the initiation codon from GTG to ATG further increased the fibrinolytic activity. The highest aprE3-5 expression was observed when two copies of the P10 promoter were placed in tandem upstream of the ATG initiation codon. The construct with P10 promoter and ATG and the construct with two copies of P10 promoter in tandem and ATG exhibited 117% and 148% higher fibrinolytic activity, respectively, than that exhibited by the construct containing P10 promoter and GTG. These results confirmed that significant overproduction of a fibrinolytic enzyme can be achieved by suitable promoter modification, and this approach may have applications in the industrial production of AprE3-5 and related fibrinolytic enzymes. Bacillus spp. have been the subject of many researches owing to their application as potential anti-thrombotic agents [Fibrinolytic enzymes secreted by some c agents , 2. Nattc agents -5, optimc agents , 7, consc agents , 9, and c agents , 11. Onec agents .aprE3-5) encoding the major fibrinolytic enzyme of B. subtilis CH3-5, which was isolated from cheonggukjang, Korean fermented soybean food. aprE3-5 encodes a preproenzyme that yields a mature 28 kDa enzyme. aprE3-5 was expressed in a heterologous host, B. subtilis WB600 [aprE3-5 genes, wherein the original promoter was replaced with one of the four known strong Bacillus spp. promoters. Furthermore, we constructed aprE genes wherein the initiation codon was changed from GTG to ATG and two copies of the most efficient promoter, i.e., P10, were placed in tandem upstream of the ATG initiation codon. We found that promoter replacement along with other modifications were effective in achieving the overproduction of AprE3-5 and in increasing the fibrinolytic activity of the host cell.Previously, we cloned a gene (is WB600 . In thisaprE3-5 with its -35 and -10 promoter sequences were replaced with those from other Bacillus promoters (aprE3-5) was used as the template DNA [ExTaq DNA polymerase . Amplification conditions were as follows: 94°C for 5 min, 30 cycles of 94°C for 30 s, 64°C for 30 s, 72°C for 40 s, and a final extension at 72°C for 5 min.Primers were designed to amplify romoters . PCR realate DNA . The reaR, TcR), an E. coli-Bacillus shuttle vector. The ligation mixture was used to transform B. subtilis WB600 competent cells [B. subtilis WB600 competent cells and electroporation  were done as reported previously [Amplified DNA was digested with BamHI and EcoRI, and ligated with pHY300PLK  at 37°C with shaking. Aliquots were taken at 12 h intervals, and the OD600 values were measured. Culture was centrifuged at 4,000 ×g for 10 min at 4°C and the supernatant was used as a crude sample for fibrinolytic activity measurement. Fibrinolytic activity was measured by the fibrin plate method as described previously [eviously .Supernatants obtained as above were analyzed by SDS-PAGE and fibrin zymography. For SDS-PAGE, proteins (10 µg) in the supernatant was concentrated by TCA precipitation, and loaded onto a 10% acrylamide gel after boiled for 10 min in 4 X SDS sample buffer. For fibrin zymography, supernatant (1 µg) was loaded without TCA concentration. Fibrin gel preparation and fibrin zymography were done as described previously . The DokB. subtilis WB600 TF by using Trizol/bead method [aprE3-5 was amplified by using primer pair in RNA was prepared from 48 h culture of d method , and tre−ΔΔCT method [Quantitative real-time PCR was done using the reverse transcription PCR products as the templates. qPCR reactions were performed by using primer pairs in T method . The 16SaprE3-5 containing 2 copies of P10 promoter in tandem. An aprE3-5 without its promoter was amplified from plasmid pHY3-5 by PCR using aprE3-5-np-F and aprE3-5-R primers, and the start codon was replaced from 'GTG' to 'ATG'. The reaction mixture (50 μl) consisted of 1 μl of template DNA, 1 μl of each primer (10 μM), 5 μl of dNTPs (0.25 mM), and 0.5 μl of ExTaq DNA polymerase . Amplification conditions were as follows: 94°C for 5 min, 30 cycles of 94°C for 30 s, 64°C for 30 s, 72°C for 40 s, and a final extension at 72°C for 5 min. The purified DNA and pHY300PLK were digested with BamHI and EcoRI and ligated by T4 DNA ligase. The ligation mixture was used to transform E. coli DH5α competent cells, and the recombinant plasmid, pHYnpE2, without a promoter was obtained.The primer pairs in aprE3-5 in pHYnpE2 using MegaP10-F and MegaP10-R primers. The PCR product was digested with DpnI, and the resulting plasmid was introduced into E. coli DH5α to obtain the plasmid pHYP10E2. Then, another P10 promoter was cloned into the pHYP10E2 using Mega2P10-F and Mega2P10-R primers. The PCR product was digested with DpnI, and the resulting plasmid was introduced into E. coli DH5α to obtain the plasmid pHY2P10E2. pHYP10E2 and pHY2P10E2 were introduced into B. subtilis WB600 competent cells, respectively. The fibrinolytic activity assay, SDS-PAGE, and fibrin zymography were done to check the effect of tandem P10 promoters on the expression of aprE3-5.Following the Megawhop protocol , the P10aprE3-5 in a heterologous Bacillus host, the -35 and -10 promoter sequences of aprE3-5 (PaprE3-5) were replaced with other strong Bacillus promoters without changes in the intervening sequences  [cry promoter were replaced with the consensus sequences of σA- dependent promoter of B. subtilis, generating Pcry3Aa [10 promoter was derived from quorum sensing related promoter PsrfA where the -35 sequence (GTGATA) was changed into the conserved sequence (TTGACA) [SG1 (same with PSG-TTGACA in the ref. 16) was derived from PSG35.1 where the -35 sequence (TACTAA) was replaced with the consensus sequence (TTGACA) [srfA, has the same -35 (GTGATA) and -10 sequences (TAAACT) of promoter of srfA [To increase the expression level of equences . Pcry3Aans (Cry) . The ori Pcry3Aa . P10 pro(TTGACA) . PSG1 (s of srfA . These paprE3-5 genes with the replaced -35 and -10 sequences were amplified by PCR (data not shown), and ligated with pHY300PLK. B. subtilis WB600 TFs harboring recombinant plasmids were obtained. DNA sequencing confirmed that the replaced -35 and -10 promoter sequences were connected to the 1,146 bp aprE3-5 structural gene as expected (data not shown).Chimeric B. subtilis WB600 TFs harboring different plasmid constructs  were inoculated into LB broth and cultured with shaking at 37°C for 96 h. All strains grew well and OD600 values reached 1.5-1.7 after 24 h incubation, and the growth curve of each strain was similar (aprE3-5 showed fibrinolytic activity (FA) of 369.96 U/ml at 96 h of incubation whereas those of culture carrying Pcry3A, PsrfA, P10, or PSG1 were 376.22, 460.85, 628.15, or 490.23 U/ml, respectively , and the activity was 1.7 fold higher than that of the original strain (369.96 U/ml) at 96 h time point. The strain carrying PSG1 showed 1.3 fold higher activity. All strains showed similar pattern in fibrinolytic activity changes during the 96 h of incubation. The activities increased rapidly during the first 36 h, and then increased gradually. The highest activities observed between 48 and 60 h. However, the activity increased continuously until 96 h in the strain carrying pHYP10 (pHY300PLK with P10 promoter). similar . Cultureectively . Except 10 promoter showed the strongest band intensity for 28 kDa protein  was significantly higher than that from the original strain (lane 1). The 16S rRNA gene concentrations were the same. The results showed qualitatively that the P10 promoter increased the frequency of transcription of aprE3-5.RT-PCR was performed with RNA samples to confirm the ng sizes . The cDN10 promoter. Using 16S rRNA gene as a control, the relative expression level of aprE3-5 was calculated using the 2−ΔΔCT method. The expression level of original strain was set to 1. The expression of aprE3-5 gene by P10 promoter was significantly increased. At 48 h of incubation, the expression level was 2.01-fold higher than that by the original promoter  at 96 h , were obtained , and cul at 96 h . Cells cB. subtilis host. More directly, the band intensity of the 28 kDa protein was the strongest in lane 6, 96 h sample from B. subtilis carrying pHY2P10E2. The results were consistent with the fibrinolytic activity measurements of the cultures (SDS-PAGE and fibrin zymography were done for culture supernatants obtained at 12 h and 96 h. Four bands of 24, 28, 38, and 60 kDa were observed on the gel stained with coomassie brilliant blue . The 28 cultures .We successfully showed that the tandem P10 promoter increased the production of AprE3-5. In order to increase the production of AprE3-5 even further, it is necessary to conduct more researches on other elements which also might be important for overproduction of AprE3-5. These include the optimization of Shine-Dalgarno sequence, adjustments of the length of intervening sequence between -35 and -10 promoter sequences, and the use of transcription terminator . Further


This study aims to quantitatively assess the quality of English YouTube video content as an information source of testicular torsion.Testicular torsion is an acute scrotal disease requiring urgent management, and the COVID-19 pandemic has been demonstrated to lead to poor outcomes for this disease. Presently, many people tend to seek health information In this cross-sectional study, a search was performed with the search term “testicular torsion” on YouTube, and the first 100 videos listed by relevance were selected for our analysis. Duplicate, non-English, videos without audio and surgical videos were excluded. Video features , source of the video, and author's country were collected. Each video included in the study was assessed using DISCERN and Journal of the American Medical Association (JAMA) Benchmark Criteria. A correlation analysis was performed considering video features, video source, DISCERN scores and JAMA scores.P < 0.001), and the quality of video uploaded by independent users was relatively low (P < 0.001). The JAMA score had no relevance to the video source (P = 0.813). The correlation between the video features, DISCERN and JAMA scores was controversial by different assessment methods.A total of 66 videos were included and analyzed. The most common video content was general information, including etiology, symptoms, and treatment. The majority of videos were from education and training websites (30%), physicians (23%), and independent users (21%). The mean DISCERN and JAMA scores were 36.56 and 2.68, respectively. According to DISCERN, the quality of video uploaded by physicians was relatively high (Despite most of the videos on YouTube being uploaded by medical or education-related authors, the overall quality was poor. The misleading, inaccurate and incomplete information may pose a health risk to the viewers, especially during the COVID-19 pandemic. Much effort needs to be undertaken to improve the quality of health-related videos regarding testicular torsion. Testicular torsion involves twisting the spermatic cord and its contents along with the longitudinal access with resultant ischemia . It accoDue to the urgency and harmful outcomes, testicular torsion is challenging for patients or guardians to access early and proper treatment. Testicular atrophy or orchiectomy caused by testicular torsion is not unusual and may affect testicular function and fertility , 8. SomeSince the COVID-19 infection outbreak and global spread, social distancing and reduced travel have been strictly advised to control the spreading of the disease . Usage oThe internet has developed rapidly and become an essential approach for obtaining and disseminating health information , 17. YouThis study aims to quantitatively assess the quality of English YouTube video content as an information source of testicular torsion online.In this cross-sectional study, a search was performed on YouTube on March 15th, 2022, with the search term “testicular torsion.” The search history was deleted before searching to reduce any impact on the search results and outcomes. The first 100 results listed by relevance were selected (default YouTube search setting). Duplicate videos, non-English, videos without audio and surgical videos were excluded.Video features assessed include total video duration, number of days online, number of views, number of views/day, number of “likes,” number of likes/day, number of comments, number of comments/day, video content type, and author's country. According to the authors, video sources were defined as physicians, patients, education and training websites, news media, medical institutes, and independent users. Video content was classified as general information , scrotal ultrasound training, differential diagnosis compared with other scrotal diseases, case discussion, and surgical teaching.DISCERN and JAMA Benchmark Criteria were used for quality analyses of the videos . SpecialDISCERN consisted of 16 questions in total, with each question scored from 1 to 5 points. Questions were divided into three parts: reliability (questions 1–8), quality information about treatment options (questions 9–15), and overall score (question 16). The total DISCERN score was calculated by summing up scores over questions 1–15. All videos were divided into five categories based on their total DISCERN score: very poor (<27), poor (27–38), fair (39–50), good (51–62), and excellent (63–75) , 25. JAMTwo independent urologists (GB and XP) evaluated all videos. Any discrepancies between reviewers were resolved by discussion with a third author for consensus (GL).This study focused on the quality assessment of YouTube videos contributed and viewed by the public, so ethics committee approval was not required.P < 0.05 was considered statistically significant.Statistical analyses were conducted using SPSS software version 26.0 . Categorical variables were presented as frequency and ratios (%), and continuous variables were presented by mean ± standard deviation (SD) and median (min–max). The Kruskal-Wallis test determined statistically significant differences between more than two groups of any independent variable. Spearman's correlation coefficient was used to evaluate the correlations among variables. A Among the 100 videos in the initial search were one duplicate video, 7 non-English videos, 12 surgical videos, and 7 videos without audio, resulting in 66 included and analyzed for this study . The 66 The mean DISCERN total score was 29.60 ± 9.77 (range 1–4), and the mean DISCERN total score was 36.56 ± 13.75 (range 16–66). P = 0.006, 0.004 and 0.001, respectively), but no relevance to number of views. Also, reliability scores, treatment scores, quality scores, and total DISCERN scores had a significant association with the source of videos . According to the Bonferroni adjustment, number of views/day, likes, and likes/day were significantly more in videos uploaded by education and training websites than by independent users , and DISCERN reliability scores were significantly higher in videos uploaded by physicians than by patients and independent users . Additionally, DISCERN total scores were significantly lower in videos uploaded by independent users than by physicians and education and training websites . The JAMA scores had no relevance to the video source (P = 0.813) (see The data in 813) see .According to DISCERN classifications, 30.3% were “very poor,” 30.3% were poor, 18.2% were “fair,” 18.2% were “good” and 3.0% were “excellent.” There was no statistically significant correlation between DISCERN classification and duration, number of views, likes, comments, views/day, likes/day, comments/day, JAMA scores see .P = 0.006), number of views/day , likes , likes/day  and JAMA score . The JAMA scores were positively correlated with duration, number of views, views/day, likes and likes/day, but there were no statistically significant correlations , cannot be included and analyzed in this study. Finally, assessment instruments for video quality are various and constantly updated –36, and YouTube is a popular and indispensable way for the public to learn about testicular torsion. This study is the first report to assess the quality of videos related to testicular torsion on YouTube. The data revealed that despite most of the videos on YouTube being uploaded by medical or education-related authors, the overall quality was poor. The risks of misleading, inaccurate and incomplete information cannot be ignored, especially in the era of the COVID-19 pandemic. Standards for uploading health information videos need to be established to improve the video quality. Video platforms should improve the filtering algorithms to prioritize high-quality videos when searching. Overwhelmingly, specialists and academic institutions should provide more high-quality, reliable videos which follow clinical practice guidelines. Moreover, self-education of the public promoted by high-quality information are also important.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.GB and XP designed the study, carried out data analysis, and drafted the manuscript. TZ and XC participated in data analysis, collected all relevant data, and assisted in study conception and design. GL and WF conceived the study, participated in its design and coordination, and helped draft the manuscript. All authors read and approved the final manuscript.This research was supported by the Research Foundation of Guangzhou Women and Children's Medical Center for Clinical Doctor and the Guangdong Basic and Applied Basic Research Foundation (No. 2020A1515110796).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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During the ICU stay , the members of the VCG made a median of 3 (IQR 1‒10.75) video calls. No difference between the groups was found for conventional telephone calls during the same period . The aFS-ICU 24R scores were high for both groups: 38 (IQR 37‒40) in the VCG and 40 (IQR 37‒40: p = 0.24) in the SCG. Video calls appeared largely ineffective in reducing PTSD symptoms or improving satisfaction among relatives affected by banning/restriction of ICU visits during the COVID-19 pandemic. Further investigations are needed to acquire more data on the factors involved in PTSD symptoms experienced by relatives of ICU patients during the COVID-19 pandemic.To help reduce the spread of the SARS-CoV-2 virus during the COVID-19 pandemic, ICU visits were banned or restricted. Therefore, family-centered care as usually practiced was not feasible Video calls were recommended to meet relatives’ needs. The aim of this study was to investigate the effect of video calls on symptoms of post-traumatic stress disorder (PTSD) in relatives of ICU patients. This single-center study was performed during the first wave  and the second wave (01.10.20‒08.02.21: visits restricted) of the COVID-19 pandemic. The Impact of Event Scale-Revised (IES-R) was used to assess PTSD symptoms and an adapted version of the Family Satisfaction in the Intensive Care Unit 24-Item-Revised questionnaire (aFS-ICU 24R) to assess family satisfaction 3 months after ICU stay. The primary outcome was the difference in IES-R score at 3 months between the video call group (VCG) and the standard care group . In addition, inductive content analysis of relatives’ comments regarding their satisfaction with decision-making and ICU care was performed. Fifty-two relatives  were included in this study. No significant difference in IES-R scores was observed between the VCG and the SCG (49.52 ± 13.41 vs. 47.46 ± 10.43,  ICU visits were either restricted or banned altogether to reduce the spread of the SARS-CoV-2 virus. The normal integration of relatives, family conferences for shared decision-making, direct caregiving, and frequent face-to-face communication were no longer feasible6. This resulted in an extraordinary burden on relatives of patients in the ICU4. The prevalence of post-traumatic stress disorder (PTSD) symptoms has been found to range up to 69%7 and appears higher than before the pandemic (33‒56%)11. Prior to the pandemic, only a small number of interventions were effective in reducing anxiety, depression, or PTSD in relatives12. New approaches have been proposed to meet the needs of patients’ relatives during restricted ICU visiting in the pandemic12. For instance, video calls have been recommended for maintaining communication between relatives and ICU staff16. However, data on the effect of video calls on PTSD symptoms and family satisfaction are sparse.In 2020 the onset of the COVID-19 pandemic disrupted the long-established practice of family-centered care in intensive care units (ICU)Therefore, we conducted a prospective mixed-method study to investigate the effect of video calls versus standard care on the occurrence of PTSD symptoms in relatives of ICU patients.This prospective single-center mixed-method study was performed in a multidisciplinary department of intensive care medicine at a tertiary academic medical center  between March 2020 and February 2021.Relatives were interviewed by telephone, using the Impact of Event Scale-Revised (IES-R) to assess PTSD symptoms 3 months after ICU stay. Furthermore, we performed inductive content analysis on additional comments made by family members regarding their satisfaction with decision making and ICU care in general.To help prevent the spread of the SARS-CoV-2 virus, ICU visits were suspended (except for end-of-life visits) during the first wave of the pandemic (15.03.20‒30.04.20) and restricted (to one relative per day for 1 h) during the second wave (01.10.20‒08.02.21). Most of the video calls were made during the first wave of the COVID-19 pandemic, when only end-of-life visits to the ICU were permitted.All relatives of patients hospitalized in the ICU during the observation period were potentially eligible for the study. The exclusion criteria were insufficient knowledge of German, French, or Italian, unwillingness to participate in the study, and age < 18 years.17 to ensure that all relatives who were interested in the video call service were able to use it  according to published recommendations. Relatives without the technical equipment for video calls  were assigned to the standard care group (SCG). Only one relative per patient participated in the study. Critical care nurses identified relatives potentially eligible for video calls during telephone calls. Specially assigned nurses conducted the video calls with the relatives by appointment. The frequency of the video calls was agreed individually with each relative.We adopted a convenience sampling strategyKantonale Ethikkommission) waived the requirement for ethics approval and the need to obtain consent for the collection, analysis, and publication of the recorded data (KEK Req-2020-00404). The study adhered to the tenets of the Declaration of Helsinki.The Ethics Committee on Human Research of the canton of Bern , with ratings on a five-point Likert scale from 0  to 4 (“extremely”). A score from 0 (best) to 88 (worst) could be achieved. An IES-R score of 33 was used as cut-off for severe PTSD symptoms, as in previously published studies22.The IES-R was used to assess PTSD symptoms in the participating relatives23. The questionnaire was adapted and validated to allow for the special conditions of the suspended/restricted ICU visiting policy (aFS-ICU 24R)7. In brief, questions assuming physical presence in the ICU were excluded. Eight of nine items were rated on a five-point Likert scale from 1 (“very dissatisfied”) to 5 (“completely satisfied”) and one from 1 (“I felt very excluded”) to 5 (”I felt very included”), yielding a total score between 9 (worst) and 45 (best). Three months after each patient’s discharge from or death in the ICU, the relatives were interviewed by telephone using the IES-R and the aFS-ICU 24R. Furthermore, the relatives’ comments and experiences were recorded for qualitative inductive content analysis.The Family Satisfaction in the Intensive Care unit 24-Item-Revised (FS-ICU 24R) was used to assess family satisfaction during the ICU stayThe data recorded on the relatives included demographics . Furthermore, family-centered care items such as keeping of an ICU diary (yes/no), care team involved (yes/no), number of telephone calls , and number of video calls with the participating relative were recorded.The data recorded on the patients included demographics , emergency admission (yes/no), COVID-19 positivity (yes/no), mechanical ventilation (yes/no), duration of mechanical ventilation (hours), length of stay in ICU (days), Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Simplified Acute Physiology Score II (SAPS II), and death in the ICU (yes/no).24.The primary outcome of this study was the difference in IES-R score at 3 months between the VCG and the SCG. Secondary outcomes were the differences in the relatives’ and patients’ indices regarding IES-R < 33 (absence of severe PTSD- related symptoms) vs. IES-R ≥ 33 (presence of severe PTSD-related symptoms) after 3 months and comparisons between the first and second waves of the pandemic25. The family comments were recorded by hand during the telephone survey (by MMJ and KE). These data were used for hypothesis generation regarding potential factors contributing to PTSD symptoms. The analysis was conducted by two experienced researchers  until agreement was reached on relevant categories.Based on the open questions in the aFS-ICU 24R, relatives’ comments on their satisfaction with decision making and with care in general were included in inductive contentContinuous indices were computed as mean and standard deviation (SD) or median and interquartile range (IQR), categorical indices as proportions. The Shapiro‒Wilk test was used to check normal distribution. Comparisons of continuous indices between groups  were compared using the Mann‒Whitney U-test or the t-test, as appropriate. Categorical indices were compared using the chi-square test or Fisher’s exact test, as appropriate. Statistical analysis was performed using MedCalc® Statistical Software version 19.6 .A power analysis was performed for sample size estimation. We assumed a mean IES-R score of 50 in the SCG and hypothesized a 10-point reduction in IES-R score for the VCG. We calculated that a total of 52 relatives would be needed to have 80% power to detect this difference with a two-sided alpha level of 0.05.A total of 52 relatives, each with one family member in the ICU, were included in the study . Their demographic data are given in Table Detailed data are given in Table No significant differences in relatives’ and patients’ characteristics were observed between the IES-R subgroups (< 33 versus ≥ 33), except for the IES-R score itself Table .Table 2CDuring the first wave , 16 patients/relatives were included in this study. In the second wave  36 patients/relatives were included. No patient’s ICU stay covered both waves of the pandemic. Detailed data are given in Table A total of 91 comments on experiences of the participated relatives were divided into three categories: information/communication, emotional support, and technical and emotional aspects of video calls.Forty-six comments fell into the category information/communication. The relatives experienced good provision of information from the medical staff about the patients’ condition: “I always got information when calling;” “I could always call for information.” However, there were also reports of missing or late information about relevant events: “There was no warning before the intubation.” Only a few comments about shared decision making were recorded: “My father was transferred too early;” “I was glad that my wife was not transferred to another hospital/ICU.” Moreover, the relatives would have preferred having only one contact person for all concerns: “Too many different contacts, for long-term patients one single trusted person would be good.”Twenty-seven of the 91 comments were assigned to the category emotional support, which included positive memories of emotional support from medical staff, such as listening to the relatives’ worries, responding to their needs, or just being kind. However, it also included burdensome experiences, such as the visiting restrictions; “Quarantine is very difficult”; or less supportive contacts with the medical staff.In the third category (18 comments), technical and emotional aspects of the video calls, technical difficulties such as poor audio quality were noted: “Very satisfied despite technical problems. Speakers could not be activated but we found a solution together.”As emotional aspects of the video calls, relatives noted reduced feelings of helplessness and the feeling of greater closeness to the patient after/during the video call: “Seeing the patient creates closeness, it makes things easier.” However, some relatives stated that they were saddened or distressed at the sight of their loved ones in the ICU: “The contact, on the other hand, was also shocking, as the image could be very burdening.” Two relatives noted the need for more flexibility of call options . One relative suggested preparing relatives in advance of the video call for the sight of their critically ill family member .10. During the COVID-19 pandemic, family-centered care has been challenged by measures taken to help prevent the spread of the SARS-CoV-2 virus, such as restricted ICU visiting and social distancing6. New approaches have been proposed to meet the needs of patients’ relatives during restriction of ICU visits13. Video calls have been recommended to maintain communication between relatives and ICU staff27.Before the COVID-19 pandemic, integration of family members in terms of shared decision making and direct caregiving, e.g., frequent communication and open visiting, helped to improve family-centered care and assisted relatives in coping with post-intensive care syndrome-family (PICS-F)In a prospective single-center mixed-method study, we investigated the effect of video calls versus standard care on PTSD symptoms in the relatives of ICU patients during ICU visiting restrictions in the course of the COVID-19 pandemic. We found that video calls as an element of family-centered care had no significant effect on PTSD symptoms in these relatives.26. However, compared to the standard care without video calls, shared decision making remains difficult. Unfortunately, the impact of a compromised decision making process during suspension or restriction of ICU visits remains unclear in this study. Further studies are needed.There are several possible reasons why the IES-R scores remained high in the video call group of relatives. First, shared decision making appears to be more difficult in video calls than in face-to-face communication3. Moreover, a no-visiting policy appears to impose an exceptional load on relatives and may cause feelings of “stolen moments”3 and “lost contact with loved ones”7. This may not be prevented by video calls. Therefore, restricted ICU visiting, together with a general burden during the COVID-19 pandemic28 may explain why the IES-R scores remain higher than before the pandemic8, with a large proportion of relatives experiencing severe PTSD symptoms7.Second, direct caregiving to the family member is not possible during restricted ICU visiting, and relatives may be burdened by strong feelings of powerlessness29.We observed no significant differences in family satisfaction with care between the VCG and the SCG. The scores were high for both groups, which may appear to imply that, despite restriction or suspension of ICU visiting, family satisfaction with support, communication, information, and the decision-making process remains satisfactory. In addition, conventional telephone calls may be sufficient to meet these types of needs for family members. Even though family satisfaction with care was high, PTSD symptoms were high for both the VCG and the SCG relativesThe PTSD symptoms remained high in relatives during the second wave, when visiting was less restricted. It could be that open visitation polices do not have a direct impact have on relatives’ PTSD symptoms. However, it is difficult to compare 1 h a day of visitation to completely open visitation, so more research is needed on this.30, although the impact on PTSD symptoms remains unclear32. Although on the one hand some families shared that they had a reduced feeling of helplessness and a feeling of closeness to the patient during the video calls, on the other hand some reported feelings of sadness and distress caused by seeing their loved ones in the ICU during the video calls. This potential negative effect of video calls should be borne in mind when considering their introduction. The use of checklists for video calls may help ICU staff to prepare relatives for the sight of the patient . However, clinical data on the effect of checklists are sparse, so more research is needed on their effectiveness in this situation16. Other research has suggested that imposition of ICU visiting restrictions during the COVID-19 pandemic may have led to an extraordinary burden on relatives3. With this in mind, together with the fact that several important elements of family-centered care are not feasible during restricted ICU visits, it is worth considering revision of the ICU visiting policy. Indeed, resumption and extension of ICU visits may be required to meet the needs of patients’ relatives during the ongoing COVID-19 pandemic2. Furthermore, the poor evidence that single interventions such as video calls reduce PTSD symptoms in relatives underlines the need for a multifaceted approach in the sense of family-centered care32.Most of the video calls were made during the first wave of the COVID-19 pandemic, when only end-of-life visits to the ICU were permitted. All members of the SCG participated during the second wave, when visiting was allowed but restricted (to one relative per day for 1 h). Interestingly, PTSD symptoms or family satisfaction may not be changed by suspension or restriction of visits in combination with conventional telephone calls and video calls. It is tempting to speculate that video and conventional telephone calls are a suitable substitute for ICU visits. However, open visiting policies may affect family satisfaction positively8. In the pandemic, as earlier, female gender and ARDS in patients with COVID-19 are associated with increased PTSD symptoms on the part of relatives33. However, in the COVID-19 pandemic it seems that general disease severity and length of stay have no impact on severe PTSD symptoms in relatives7. Potential effects on relatives’ quarantine or isolation could theoretically influence the occurrence or severity of PTSD symptoms. However, the data on this issue remain controversial35. Furthermore, data on social support additional to the care-team support provided were missing, and this factor could also affect PTSD symptoms38.Gender, COVID positivity, disease severity, and length of stay may impact on family satisfaction. Notably, the adapted version of the FS-ICU 24R used in our study focuses on information provision, emotional support, communication, and the shared decision-making process, which are likely to be independent from these data. In contrast, there is some evidence that female gender is related to PTSD symptoms in relativesThis study features several important limitations. First, the single-center design reduces the generalizability of the findings. The strengths of the study, on the other hand, are the mixed-method approach, the prospective design, and the power calculation for sample size to estimate differences in PTSD symptoms.With regard to the specific sample size calculation only for the effect of video calls to PTSD symptoms, other findings should be interpreted with caution. The use of a convenience sample strategy should be considered in the interpretation of the data. To comply with family-centered care in the COVID-19 pandemic, we refrained from using a randomized controlled design so that no relatives would be denied video calls. However, randomized controlled trials are needed to generate more evidence. Finally, no information was available on pre-existing PTSD or psychological disorders in the participating relatives.The use of video calls appears to have little effect on reducing PTSD symptoms in patients’ relatives at times of suspension or restriction of visits to the ICU, as in the COVID-19 pandemic. Family satisfaction may be better when visiting is restricted than when it is banned entirely. Further research is required to gain more knowledge about the factors involved in the development of PTSD symptoms in relatives of ICU patients during suspension or restriction of ICU visits. In the future, multifaceted strategies should be developed to support relatives of ICU patients in such situations.