Despite the increasing availability of telemedicine video visits during the COVID-19 pandemic, older adults have greater challenges in getting care through telemedicine.We aim to better understand the barriers to telemedicine in community-dwelling older adults to improve the access to and experience of virtual visits.We conducted a mixed methods needs assessment of older adults at two independent living facilities (sites A and B) in Northern California between September 2020 and March 2021. Voluntary surveys were distributed. Semistructured interviews were then conducted with participants who provided contact information. Surveys ascertained participants’ preferred devices as well as comfort level, support, and top barriers regarding telephonic and video visits. Qualitative analysis of transcribed interviews identified key themes.Survey respondents’ (N=249) average age was 84.6 (SD 6.6) years, and 76.7% (n=191) of the participants were female. At site A, 88.9% (111/125) had a bachelor’s degree or beyond, and 99.2% (124/125) listed English as their preferred language. At site B, 42.9% (51/119) had a bachelor’s degree or beyond, and 13.4% (16/119) preferred English, while 73.1% (87/119) preferred Mandarin. Regarding video visits, 36.5% (91/249) of all participants felt comfortable connecting with their health care team through video visits. Regarding top barriers, participants at site A reported not knowing how to connect to the platform , not being familiar with the technology , and having difficulty hearing , whereas for site B, the top barriers were not being able to speak English well , lack of familiarity with technology and the internet , and lack of interest in seeing providers outside of the clinic . Three key themes emerged from the follow-up interviews (n=15): (1) the perceived limitations of video visits, (2) the overwhelming process of learning the technology for telemedicine, and (3) the desire for in-person or on-demand help with telemedicine.Substantial barriers exist for older adults in connecting with their health care team through telemedicine, particularly through video visits. The largest barriers include difficulty with technology or using the video visit platform, hearing difficulty, language barriers, and lack of desire to see providers virtually. Efforts to improve telemedicine access for older adults should take into account patient perspectives. Telemedicine, the practice of medicine using technology to deliver care at a distance, is an innovation with increasing uptake across the United States ,2. DurinDespite the increasing availability of telemedicine and its many advantages, older adults experience high barriers to access compared to younger adults ,10. A PeWhile much has been published on the feasibility of telemedicine in older adults domestically and abroad -18, therWe conducted a mixed methods needs assessment of two independent living facilities in Northern California as part of a quality improvement project to increase telemedicine access. Voluntary surveys  in EngliSurveys queried demographic information including gender, education level, preferred language, and residents’ previous experiences and preferences with technology or devices. While five-point Likert scales assessed comfort level, support, desire for, and barriers regarding telephone and video visits , responsFollow-up semistructured phone interviews were conducted with surveyed participants who provided their contact information and were willing to speak to investigators to elaborate on perceived barriers . The questions asked during these interviews are reproduced in Given that this is a quality improvement project and not human participant research, this study received institutional review board (IRB) exemption from the Stanford University (IRB Protocol 58211).Of the 700 surveys distributed, 249 surveys were completed . There were 125 participants from site A, 69.3% (n=87) of whom were female. Site B had 119 participants, with 84.9% (101/119) being female participants. There were 5 participants that did not designate a site on their survey and were excluded from site-specific analyses. At site A, the average age of participants was 85.5 (SD 6.6) years, while at site B, the average age was 83 (SD 6.6) years. When combined, the average age of all participants was 84.3 (SD 6.7) years. At site A, 88.9% (111/125) of participants had a bachelor’s degree or beyond, and 99.2% (124/125) listed English as their preferred language. At Site B, 42.9% (51/119) had a bachelor’s degree or beyond, and 13.4% (16/119) preferred English, while 73.1% (87/119) preferred Mandarin. Demographic information of survey participants is recapitulated in R2=0.96), it appears that increased age was not associated with decreased interest in telemedicine video visits  of all participants were interested in connecting with their health care team through video visits, and 65.5% (n=163) preferred connecting through telephone. Regarding telemedicine comfort, 69.9% (174/249) of participants knew how to connect with their health care team through telephone. However, only 36.5% (n=91) knew how to connect with their health care team through video visits. Of those 91 participants, 68% (n=61) were from site A. For the 91 participants that were comfortable using video platforms, computers were the most preferred device , followed by smartphones  and iPads/tablets . We found that, while comfort with video visits decreased with increasing age , not being familiar with how to use technology or the internet , not knowing how to get connected to the telemedicine platform , and language barriers  on how to connect. I feel like I am not smart enough to persist through the whole [set of instructions]Others corroborated that they are reluctant to do video visits because “I just don’t enjoy setting it up.” They noted the process is cumbersome, and they need to experiment and get outside help before knowing how to navigate the platforms. Even for those who have successfully set up video visits in the past, the challenges of remembering how to log back on and remembering one’s password make the process difficult. One participant explained:I can’t tell you how many times I’ve had to change my password...If my fingers hit the wrong button [the platform] notifies me the password is not working…We’ve had to reset the password 2-3 times and it took at least 2-3 hours to get a new password.Some noted that they are familiar with platforms they already use such as Zoom or WeChat and would prefer if their care providers switched to simpler platforms for telemedicine video visits:[The telemedicine platform is] very complicated -- much more so than Zoom. I have very poor vision and I’m old and it’s no good for me... I think just having help at the time I have to get on is the best or you should switch to a simpler system.Furthermore, for the participants who did not speak English as their primary language, setting up telemedicine visits involved an added layer of difficulty as most of the instructions are in English. One participant elaborated:If I use English, it will be very hard. I am comfortable with computers, and am willing to give it a try...I hope there is someone who speaks Chinese to help with technology.Some participants reported relying on a spouse, an adult child caregiver, or a social worker to aid with these language barriers.Given the complexity of the setup process and the different telemedicine platforms used by different health care providers, participants noted the importance of having in-person help to establish video visits. For example:I need a person to sit down with me next to my computer to help me set up my account: here’s the icon you click on, the name of your account, where you keep your password, how you enter and use it...I need personal help.Many recognized that in-person assistance was not always feasible or safe during times of quarantine during the COVID-19 pandemic and hoped for easier access to on-demand assistance with troubleshooting. One participant recalled a story in which she followed all the instructions for downloading the video visit platform and did not understand the step about clearing cookies on her computer and went online to find the information technology desk number for help. She relayed:until you give thorough instructions, it’s not going to work. A lot of people give up. A live body [to help] would be the best thing.Another participant emphasized the specialized help needed for older adults:[My healthcare system] is investing a lot in telemedicine. It would be good to have a team of helpers who could help a patient, mostly older people, and get in touch in advance to help them set up appointments.Others voiced frustrations with being placed on hold for a long time when trying to call their clinic for assistance.Of the 249 older adults who completed our survey, most  were interested in using telemedicine to connect with care providers through video visits. While older age was associated with decreasing familiarity with technology, it did not diminish interest in telemedicine. Participants identified several barriers regarding telemedicine use, especially in conducting video visits. The top barriers included not knowing how to connect to the platform (including language barriers that make instructions difficult to understand), not being familiar with the technology, difficulty hearing, and lack of interest in seeing providers outside of the clinic.The digital divide for older adults, who experience challenges with using telemedicine, is well documented -12,14,15We found that older adults are more familiar with telephone than online video platforms, though the majority of participants were interested in learning to use both as a means of connecting with their providers. Similar to a study on older adults’ experiences with technology for socialization , we founOur participants also highlighted the challenges of navigating telemedicine platforms when English is not their first language. Socioeconomic disparities in digital access are well documented , and it We found that in addition to technology barriers, there are nuanced reasons for reluctance in older adults to conduct video visits. Reluctance to adopt telemedicine may stem from the perception that video visits are inferior to in-person care due to the lack of human touch possible through the physical exam. This is congruent with a national survey of older adults whose chief concern about telemedicine focused on limitations in physical exam and worries about decreased quality of care and connection to providers . HoweverThis is a community-based study and has some limitations. Sites A and B are not representative of all older adult residents; we chose these sites to better understand the barriers regarding telemedicine access within our community independent living facilities, as there was a wide range of ages, socioeconomic backgrounds, and primary languages spoken. Furthermore, there may be selection bias given the voluntary nature of the surveys completed; data represent only those who were willing and available to participate.The COVID-19 pandemic necessitated the rapid scale-up of both provider use and patient adoption of telemedicine. There was little time available to elicit patient perspectives in the process of designing technological platforms for care delivery. Older adults make up many patients in our health care system, though their perspectives are rarely formally elicited. Decreased use of telemedicine exposes this already vulnerable population to further health care inequities. In our study, we surveyed the perspectives of older adults to ascertain their perceived barriers to telemedicine access and highlight themes that further our understanding of the challenges that lead to decreased access to care. Due to site-specific differences in reported telemedicine barriers, any intervention to improve access should be tailored to the specific needs of that site. Our study will not only inform our own quality improvement initiatives in our community but also, we hope, open the door to larger scale studies in understanding the patient experience as telemedicine becomes a larger cornerstone of care delivery.


Intracranial hemorrhage is the most common presentation of posterior fossa arteriovenous malformations (AVMs) and may have serious consequences. The authors present a case of a 7-year-old girl with headache, vomiting, dysmetria, and ataxia due to a ruptured cerebellar grade III AVM. After two sessions of embolization, the patient underwent total microsurgical resection through a suboccipital craniotomy. There were no additional postoperative deficits, and the patient improved progressively during 6 months of rehabilitation. These challenging lesions should be removed after rupture, especially in children with long-term cumulative risk of rebleeding. Multimodal treatment reduces the perioperative bleeding, allowing better outcomes for pediatric AVM.https://youtu.be/HQWnjD8ENZQThe video can be found here:  This video demonstrates the multimodal treatment of a pediatric posterior fossa arteriovenous malformation employing both endovascular and microsurgical techniques.0:30 Case Presentation and Exams. The patient was a 7-year-old female presenting with a history of sudden onset of headache, nausea, and vomiting, associated with dysmetria and gait ataxia. The patient underwent a CT scan that demonstrates two sites of acute bleeding, one inside the upper part of the fourth ventricle and the other at the left petrosal surface of cerebellum.0:58 We can better see the sites of bleeding in these coronal and sagittal cuts. The patient developed an obstructive hydrocephalus and an EVD  was placed. Investigation of the underlying cause of acute bleeding has proceeded with MRI. In these FLAIR images, we can observe many flow voids in the left cerebellar hemisphere. Here, we see the sequence of 3D-TOF (time of flight) that depicts better the course of vessels in the posterior fossa.1:29 Now we can observe the site of bleeding at the petrosal surface of cerebellum, close to the cerebellopontine angle. Magnetic resonance angiography (MRA) depicts a lesion highly suggestive of an arteriovenous malformation (AVM) in the left cerebellar hemisphere, presenting arterial supply suggestive coming from SCA (superior cerebellar artery), AICA (anterior inferior cerebellar artery), and PICA (posterior inferior cerebellar artery), as well demonstrates big arterialized venous channels arising from the nidus of the AVM, and we can better see these features in these coronal cuts.1:55 Here we see a 3D reconstruction of the AVM and the arteries from the brain, illustrating its positioning. Now, we can observe the axial cuts from the MRV (magnetic resonance venography), demonstrating engorgement of the left sigmoid sinus and internal jugular vein, and now we have the 3D reconstruction of venous structures demonstrating the dominance of the left side related to the AVM. Here, we see the angiograms performed. A lesion highly suggestive of an AVM was identified, presenting feeders coming from a dilated SCA, as well with filling from AICA and PICA. The nidus measured around 4 cm in diameter. The drainage was both superficial and deep to the transverse and sigmoid sinuses, as well to the basal vein of Rosenthal.2:35 We just saw the left vertebral artery injections, and now we can see the ones from the right side. Here, we can observe other images demonstrating these AVM. Considering the size of the nidus and deep venous drainage, the lesion was classified as grade III of Spetzler-Martin and B of Spetzler-Ponce grading systems.3:08 Anatomy. Here, we can review the anatomy related to this case. We can observe the vertebral arteries joining to form the basilar artery and see the SCA, AICA, and PICA, and we see a better relationship with the cranial nerves from a posterior perspective. We see the SCA, AICA, and PICA. Here, we have a lateral view demonstrating the left cerebellar arteries arising from the basilar and going around brainstem to reach the cerebellum and feed the AVM.In this 3D model, we can better observe the configuration of the AVM, presenting feeders coming from all the left cerebellar arteries , but mainly from a dilated SCA. We observe the nidus and see the dilated veins. Here, we can see the veins draining to the transverse and sigmoid sinuses, as well to the basal vein of Rosenthal that drains into the vein of Galen and then into the straight sinus. We can observe the location of the AVM in the left cerebellar hemisphere, and the anomalous blood vessels circumferentially around the nidus. It is noticed that the left sigmoid sinus and internal jugular vein are significantly dilated compared to the contralateral side and also to the size of internal carotid arteries.4:20 Preoperative Embolization. Considering the complex posterior fossa AVM and that a pediatric patient harbors a lower blood volume, it was chosen to perform preoperative embolization to minimize bleeding during microsurgical resection. Now, we observe the angiograms of the first embolization, employing Onyx. Here, we see a lateral view before embolization, and now observe the first region filled with Onyx, and here the following angiograms. Now, other regions embolized are demonstrated, including apparently some venous channels, suggesting the presence of important AV fistulas.Here, just a better view, depicting the location of the embolized segments regarding the AVM. Now, we see the angiograms of the second embolization, initially the images prior to Onyx injection, depicting the embolized regions from the previous procedure. Now, we observe the new sites embolized, suggestive of reaching the surface, and here the angiograms performed following it, and we can observe that extensive parts of the AVM are successfully embolized. Here, we can observe the CT scan following the embolization; now we have a 3D reconstruction depicting the Onyx inside the AVM and also a 3D model of the Onyx itself filling the vessels.5:48 Microsurgery Planning. In this case, a suboccipital approach will be employed, exposing at midline but more to the left side. After dural opening, we see the cisterna magna and now observe the cerebellar surface. Then, a partial left cerebellar hemispherectomy will be performed, and here we can observe the approximate location of the AVM regarding this anatomical demonstration. Here, we can observe the removal of left cerebellar hemisphere in this demonstration, and we can observe the lower cranial nerves running toward the jugular foramen.6:20 Positioning and Demonstration of Initial Incision. The patient was placed in a Concorde position and an L-shaped (“hockey-stick”) incision was performed. A midline suboccipital craniotomy extending more to the left side was employed, and the microsurgical resection was performed with the aid of neurophysiological monitoring.6:34 Microsurgical Resection. Following dural opening, CSF  from the cisterna magna is released to achieve brain relaxation. Here, we can observe the lower portion of medulla oblongata, the spinal accessory nerve, and see the PICA with Onyx inside from the preoperative embolization. As this is a big and complex AVM, with huge venous channels inside the cerebellar hemisphere arising from the nidus, in order to decrease the chance of bleeding, it was chosen to not get inside and around the AVM itself and instead to perform an en bloc resection in a partial left cerebellar hemispherectomy, removing the adjacent nonfunctioning gliotic cerebellar tissue.7:11 Here, we see the inferior lateral edge of resection, exposing the lower cranial nerves. The dissection continues now medially and deep, in order to reach the region anterior to the nidus to attack the arterial blood supply. The dissection progress deeply, and many vessels are found filled with Onyx. After successful coagulation of arterial blood supply, the removal progress coagulating the venous sites of outflow from the AVM to complete the en bloc resection. Now, we inspect the lower cranial nerves entering jugular foramen, and also see the empty cavity with the tentorium pulsating. Here, we observe the spinal root of the accessory nerve, and also see some rootlets of hypoglossal nerve. Also, the initially identified embolized PICA is exposed. Here, it is dissected between the cerebellar hemispheres to expose the floor of the fourth ventricle.8:01 Closure of Incision and Postoperative Imaging. Here, we have a 3D bone reconstruction of the immediate postoperative CT scan, demonstrating the EVD and the suction drain. EVD was placed considering the potential risk of postoperative hydrocephalus. Now, we can observe the axial cuts of the postoperative CT scan, and now the 3D reconstruction.8:24 Follow-Up. The patient presented improvement of headaches, nausea, and vomiting, with no new neurological deficits. She was discharged on postoperative day 7 and underwent rehabilitation for 6 months, presenting gradual improvement of the dysmetria and gait ataxia, identified in the preoperative period, and now we can observe normal gait and no dysmetria following 6 months of rehab.Primary surgeon: Borba. Assistant surgeon: Demartini, Ceccato. Editing and drafting the video and abstract: all authors. Critically revising the work: all authors. Reviewed submitted version of the work: all authors. Approved the final version of the work on behalf of all authors: Demartini. Supervision: Borba.


Inflammatory bowel disease (IBD) patients with an ileo-anal pouch anastomosis (IPAA) bear an increased risk of pouch neoplasia, with prior colorectal neoplasia as the strongest predictor. It is unknown if pouch neoplasia develops independently or is derived from prior colorectal neoplasia.We aimed to assess potential clonality between prior colorectal neoplasia and pouch neoplasia in IPAA patients with IBD.In this explorative study we used the Dutch Nationwide Pathology Databank to identify IBD patients with both pouch neoplasia and colorectal neoplasia prior to colectomy. Clonality was assessed on colonic tissue of the lesion with shallow whole genome sequencing based copy number aberration (CNA) analysis and validated with immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH).We included 13 patients who fulfilled the inclusion criteria. Three patients showed matching clonality CNA profiles between prior colorectal neoplasia and pouch neoplasia, validated with matching IHC and FISH for p19 and HER2. Patients with matching clonal samples also showed on retrospective review concordant histology of the neoplastic lesion pre- and post IPAA, positive resection margins, metastasized disease or a short interval (<2 years) between colorectal and pouch neoplasia diagnoses.Three patients showed matching clonality patterns of neoplastic lesions, confirmed by clinical and histological data. Most pouch neoplasia in our cohort were molecularly different from their prior colorectal neoplasia. CNA provides a feasible method for clonality assessment in patients with colorectal neoplasia and subsequent pouch neoplasia.None Declared


To assess whether this effect generalizes to misophonic triggers, we developed a Sound-Swapped Video (SSV) database for use in misophonia research. In Study 1, we created a set of 39 video clips depicting common trigger sounds  and a corresponding set of 39 PAVS temporally synchronized with the OVS videos. In Study 2, participants (N = 34) rated the 39 PAVS videos for their audiovisual match and pleasantness. We selected the 20 PAVS videos with best match scores for use in Study 3. In Study 3, a new group of participants (n = 102) observed the 20 selected PAVS and 20 corresponding OVS and judged the pleasantness or unpleasantness of each sound in the two contexts accompanying each video. Afterward, participants completed the Misophonia Questionnaire (MQ). The results of Study 3 show a robust attenuating effect of PAVS videos on the reported unpleasantness of trigger sounds: trigger sounds were rated as significantly less unpleasant when paired with PAVS with than OVS. Moreover, this attenuating effect was present in nearly every participant (99 out of 102) regardless of their score on the MQ. In fact, we found a moderate positive correlation between the PAVS-OVS difference and misophonia severity scores. Overall our results provide validation that the SSV database is a useful stimulus database to study how misophonic responses can be modulated by visual contexts. Here, we release the SSV database with the best 18 PAVS and 18 OVS videos used in Study 3 along with aggregate ratings of audio-video match and pleasantness (https://osf.io/3ysfh/). We also provide detailed instructions on how to produce these videos, with the hope that this database grows and improves through collaborations with the community of misophonia researchers.Misophonia has been characterized as intense negative reactions to specific trigger sounds . However, recent research suggests high-level, contextual, and multisensory factors are also involved. We recently demonstrated that neurotypicals’ negative reactions to aversive sounds  are attenuated when the sounds are synced with  Everyday sounds, such as chewing, breathing, drinking, nasal sounds, or finger tapping, can act as triggers to people with misophonia  or a Positive Alternative Video Source . Participants provided ratings of discomfort (how comfortable or uncomfortable the sound made them feel), unpleasantness (how pleasant or unpleasant the sound was), and bodily sensations . Across all three measures, we found that the cross-sensory temporal syncing of aversive sounds to positive alternative video sources (PAVS) attenuated the negative responses compared to the presentation of sounds with the original video source (OVS).Recently, We hypothesize that the findings of Sound-Swapped Video (SSV) database for misophonia, which we release for use in research. The database includes 20 pairs of PAVS and OVS videos along with the original trigger sound audio files, and aggregate ratings of each of the stimuli. In Study 1, we present the process we developed to generate and evaluate these audio-visual stimuli.Here we present our 3-part methodology for the development and evaluation of a In Study 1, we conducted an idea-generation study to identify examples of alternative videos to create. In Study 2, we present the validation of 39 PAVS stimuli to identify a subset of stimuli that are perceived as relatively pleasant and have adequate audio-video match. In Study 3, we presented individuals with the 20 best PAVS and their associated OVS, to identify whether trigger sounds paired with PAVS are perceived as more pleasant than the same sounds paired with OVS. Although we recruited a general population for these studies, we collected responses on Misophonia Questionnaire MQ;  allowing1 for use and collaboration by misophonia researchers.The validated Sound-Swapped Video (SSV) database for misophonia is available on OSFHere we present the methodologies for Study 1 , Study 2 , and Study 3 .Based on an analysis of the 80 interviews, we generated a list of commonly reported trigger sounds and grouped them into the following ten categories: crunchy chewing, wet chewing, slurping, swishing, sniffling, gulping, drumming, scraping, clicking, and squeaking.We identified each individual’s top three triggers from a set of semi-structured interviews with 80 participants with misophonia. These interviews were part of a longer-term project to explore how different high-level contexts such as one’s social environment and social interactions, attention, visual cues, or experience of agency and control may be related to participants’ misophonic responses. As such, these interviews were designed to be idiographic  and undeParticipants were recruited from the greater Bay Area, California and Santa Cruz, California through the psychology department’s undergraduate participant pool, by word of mouth, and through the use of recruitment flyers on social media. Prior to the core interview, participants completed a pre-screen phone call with one of the researchers to confirm their experiences with trigger sounds were consistent with existing descriptions of misophonic trigger reactions.Misophonia Symptom Scale (where participants were asked to rate how sensitive they are to a category of sound compared to other people), the Misophonia Emotions and Behaviors Scale (where participants rate their reactions associated with misophonia symptoms), and the Misophonia Severity Scale. The first section, the Misophonia Symptom Scale, consists of 7 items, where participants can indicate specific sound sensitivities. Participants respond to items like “Nasal sounds” or “People eating” between 0  to 4 (Always True). The second section, the Misophonia Emotions and Behaviors Scale, assesses emotional and behavioral responses to trigger sounds, and consists of 10 items  with the same response scale as section one. These first two sections are summed into a total MQ Sensitivity Score, which ranges from 0 to 68 points.Before participating in the interview, participants completed a consent form and the Misophonia Questionnaire MQ; . The MQ SD: 10.5) and the mean Severity Score (maximum 15) was 5.5 (SD: 2.2). This is consistent with existing research where SD: 7.64), and SD: 10.73). In the current study, the internal consistency  was 0.715 for the Misophonia Symptom Scale, 0.838 for the Misophonia Emotions and Behaviors Scale, and 0.843 for the Total score (the combination of these two parts).The final section, the Misophonia Severity Scale, consists of a single question where participants rate the severity of their sensitivity from 0  to 15 (very severe). A score above 7 on this scale indicates clinically significant misophonic reactions. For participants in this interview about their misophonic experiences, the mean Misophonia Sensitivity Score  was 36.1 .5.Dynamic factors associated with trigger reactions, e.g., “Do you notice any difference in how you react to trigger sounds when you haven’t slept enough?”6.Multisensory experiences similar to trigger reactions, e.g., “Have you ever SEEN anything that makes you feel the same as when you hear a trigger sound?”We categorized the top 3 trigger sounds into high level categories, and used these categories as seed ideas for our stimuli.Video generation process: For each trigger category, we constructed a number of audiovisual stimuli including OVS of the triggers  and PAVS of the triggers . This was done in 4 stages, which we describe below. A more detailed manual with step-by-step instructions is available here: (see text footnote 2).To generate ideas for what alternative sources might map well with each trigger sound, we used a combination of two approaches: (1) brainstorming sessions among the researchers and (2) collecting behavioral responses from naïve participants to the sounds. In the brainstorming sessions, researchers listened to or talked about the categories of trigger sounds determined from participants’ interviews, such as slurping or crunchy chewing, and imagined alternative sources that might create a similar sound. For example, for the sound of someone slurping, alternative sources included shuffling a deck of cards, flipping through pages of a book, and raising blinds.incorrect guesses as potential candidates for alternative sources as they were reasonably mistaken for the source sound. For example, the sound of finger drumming was once misidentified as “a rubber ball rapidly bouncing on the floor” and as “a plastic bottle rolling on a desk.”One limitation to the brainstorming session was the possibility of functional fixation  on the pThe idea generation stage led to a collection of about 3–5 ideas of alternative sources for each of the ten trigger sound categories. Two research assistants then began the process of constructing each pair of PAVS and OVS stimuli.2, where sound designers will watch footage from a TV show or movie and produce sound effects post-production in sync with what is occurring visually. In this case, it is the reverse—we produce videos that match up with an existing sound.The first step was to record a roughly 15-second audio-video clip of the Positive Attributable Video Source (PAVS). The reason that the PAVS was recorded first is that since most triggers are human-made orofacial sounds, it is relatively easy to generate those sounds to match the rhythm of a pre-existing PAVS. In contrast, we found it was more difficult to generate a PAVS to match the rhythm of a pre-existing OVS. For instance, it was easier to produce chewing sounds in the rhythm of a person walking on snow, compared to trying to walk in the rhythm of a person chewing. Our process is similar to Foley Sound DesignPAVS were self-recorded by research assistants with the use of a tripod and a smartphone with an auxiliary shotgun microphone that directly targets the sound of the action and reduces unwanted low gain background noise. Smartphones with similar video capabilities and resolution were used to capture the action of both the PAVS and the OVS stimuli. Most PAVS stimuli involved an agent , while some PAVS stimuli involved agent-less environmental sources, such as water running down a creek.The next step was to record the OVS stimulus, which always involved a human actor/agent. OVS videos were also self-recorded by research assistants with the use of a tripod and a smartphone with an auxiliary shotgun microphone. The goal of the OVS recording was to create something roughly synchronized to the already recorded PAVS and capture the trigger sound clearly. Therefore the OVS recording process involved the actor attempting to synchronize the trigger action  while carefully watching and listening to the previously recorded PAVS . To aid in this synchronization, the PAVS audio was played through headphones while the video was displayed in Adobe Premiere, allowing the actor to use both visual and auditory cues to determine the rhythm of the to-be-produced OVS. Special consideration was given to recording the audio to match the cadence and dynamics to the video component of the PAVS. The camera was often focused on the orofacial action, which featured the lower half or full face of the human agent. After a successful attempt at creating an OVS, both videos were evaluated to check for the viability of the temporal match. If the video pair was reasonably well synchronized, the raw audio and video were cataloged for further editing. Otherwise, the OVS recording process continued until a good match was achieved.Before the audio was edited, the OVS and PAVS videos were roughly matched on a timeline in Adobe Premiere. A 12-second clip was then selected representing the best matched section that excludes loud noises associated with the beginning and ending of the original recordings. The audio components of the OVS and PAVS were then exported to Audition where the clips were normalized to −3 db. This step raised the volume of quiet parts and lowered the volume of louder parts of the audio waveforms. In some circumstances, additional distracting noises were removed from the waveform with dynamics processing to lower amplitudes of specific frequencies, for instance, a low frequency air conditioning noise that added white noise to the video. This tool was used sparingly as it could end up removing frequencies that are essential to the sound of the OVS.With the audio now normalized, the corresponding video tracks were edited in Adobe Premiere. Due to the prior audio editing and video recording process, the audio waveforms should already be aligned and similar in amplitude, frequency, and height. The two normalized audio and video pairs were then placed on the timeline to find the best fit. The PAVS video was then overdubbed with the OVS sound. However, after an initial playback, additional unwanted sounds may need to be edited out from the audio that affect the believability of the audio-video match. The sounds that were generally removed were not representative of the OVS triggers themselves. For instance, distracting breathing sounds may be spliced out of a chewing sound since they might affect how plausible the match will turn out with PAVS. Additionally, some sections of the OVS audio may be slowed down (up to 85%) or sped up (up to 120%) to create a better match with the PAVS video.Once these 5 stages were complete, we ended up with two audiovisual stimuli corresponding to a particular trigger sound: the OVS with the original triggering audio and video, and the PAVS with a positive attributable video source dubbed with the triggering OVS sound. In addition, we also cataloged the original sound files as well as the PAVS with its original (non-trigger) sound for potential use in future work.The stimuli for Study 2 were the 39 PAVS stimuli constructed as described above. The stimuli contained non-trigger video sources  paired with trigger sounds . The 39 trigger sounds included several examples of the ten categories described earlier.via Qualtrics where they watched each of the 39 12-second PAVS stimuli in a random order.We recruited 34 naïve participants  from the University of California Santa Cruz participant pool who received course credit for their participation. Participants completed a questionnaire After watching each video, participants provided ratings of how pleasant or unpleasant the video clip was, and how well the sound and video matched. The pleasantness scale used the following response scale: 1 (Very unpleasant), 2 (Somewhat unpleasant), 3 (Neither pleasant nor unpleasant), 4 (Somewhat pleasant), or 5 (Very pleasant). The sound-video match question used the following response scale: 1 (Not a good match), 2 (Slightly good match), 3 (Moderately good match), 4 (Very good match), or 5 (Extremely good match).Based on the results of Study 2, we selected the best 20 PAVS stimuli based on the reported quality of the sound-video match, along with the corresponding 20 OVS stimuli. The resulting 40 stimuli were presented to a new group of observers in two possible pseudo-random orders. In both presentation orders, half of the trigger sounds appeared once in the first half and once in the second half, paired with either a PAVS or an OVS video source. The counterbalancing allowed us to collect ratings for each PAVS-OVS pair in two different orders across participants. For half of the participants, “odd” PAVS videos and “even” OVS videos were played first, and “even” PAVS videos and “odd” OVS videos were played second. For the other half of the participants, it was the other way around. Having these two presentation orders allowed us to analyze responses by order .via Qualtrics where they watched and rated the 20 PAVS and 20 OVS stimuli.We recruited 102 naïve participants  from the University of California, Santa Cruz Psychology participant pool who received course credit for their participation. Participants completed a questionnaire After watching each video, participants provided two ratings as in Study 2, indicating how pleasant or unpleasant the sound was, and how well the sound and video matched, using the same 5-point scales as in Study 2. The primary difference here is that in Study 3 we asked about the pleasantness or unpleasantness of the sound itself, whereas in Study 2, we asked about the pleasantness or unpleasantness of the PAVS video clip as a whole. After viewing and rating all 40 stimuli, participants then completed the Misophonia Questionnaire (MQ) and answered several demographic questions.via OSF (see text footnote 2).We produced 39 pairs of PAVS/OVS stimuli, resulting in 78 audio-video files in total. Based on the results of Studies 2 and 3, we release a subset of the best 18 PAVS and the corresponding 18 OVS  as open-source downloads SD: 0.96) on the 5-point sound-video match scale, and 2.67 (SD: 0.60) on the pleasantness scale, although there were large differences across the videos Each of the PAVS video’s mean ratings for sound-video match and pleasantness across 34 observers are shown in Overall, the 39 PAVS videos received mean ratings of 2.36  and the material from the visual source . For Study 2, we selected the best 20 PAVS videos based on the sound-video match rating, with a cutoff value of 2.15 in the 5-point sound-video match scale.SD: 0.91). As expected, match ratings for PAVS videos were consistently lower than those for corresponding OVS videos . Nevertheless a majority (15 of 20) of the PAVS stimuli obtained match ratings of slightly good or above. We first examined ratings of the audio-visual match of the 20 PAVS and 20 OVS stimuli. Match ratings for the PAVS videos closely mirrored the results from Study 2 restricted to the best 20 stimuli. The mean rating of sound-video match across the 20 PAVS stimuli was 2.66  confirmed this was statistically significant. The difference scores (mean PAVS rating minus mean OVS rating) for the 20 sounds are shown in CI: ; Cohen’s d = 0.845] which represents a large effect, where the maximum difference possible in the 5-point scale was 4. An observer-based analysis confirmed that this effect was nearly universal across our 102 participants. t-test  confirmed this effect was significant. The mean difference score across observers was 0.52 , representing a very large effect size.The remaining analyses focus on pleasantness ratings. To better visualize the relationship between pleasantness of PAVS and OVS videos, the average pleasantness ratings for the 20 PAVS and 20 corresponding OVS stimuli are shown in t101 = 5.15, p < 0.0001). This presentation order effect was not observed for OVS-paired sounds, which were rated similarly whether they were presented in the OVS context first (mean = 2.37) or in the OVS context second .Finally, we examined whether pleasantness ratings varied as a function of individuals’ score on the MQ (SD: 11.0) and the mean score for the third section was 4.0 (SD: 2.6). In this study, the internal consistency  was 0.792 for the Misophonia Symptom Scale, 0.834 for the Misophonia Emotions and Behaviors Scale, and 0.863 for the Total score (the combination of these two parts). CI: ] have significantly larger difference scores compared to those with low severity scores . As can be seen in these figures, pleasantness difference scores were positive across most individuals regardless of the sensitivity or severity of their MQ scores. Correlation analyses revealed no relationship between MQ sensitivity and mean difference score , and a moderate positive relationship between MQ severity and mean difference score . Here, participants with higher MQ severity scores showed a significantly larger difference in pleasantness ratings of PAVS-paired vs. OVS-paired sounds compared to other participants. Separate analyses of PAVS and OVS ratings revealed that this relationship was driven by individuals with higher severity scores rating OVS as more unpleasant than individuals with lower severity scores; there was no difference between how these groups rated the PAVS-paired sounds. However, we found that the correlation is driven by four participants with very high scores . When we remove the 4 participants with high severity scores, the correlation drops .Based on the two orders of stimulus presentations across observers that we described earlier, we were able to measure whether the order of presentation (PAVS-first or OVS-first) made a difference in the mean pleasantness ratings of the corresponding sounds. The set of mean pleasantness ratings for PAVS and OVS videos based on whether they were shown first or second are shown in n the MQ . For parWe established a procedure for developing a Sound-Swapped Video Database for the study of misophonia. The validated SSV database, which includes a refined set of 18 misophonic trigger sounds mapped to their original OVS and alternative PAVS sources, is publicly available (see text footnote 2). We have excluded from the database the two video pairs that had low audio-visual match scores for their PAVS, which indicated that they are not believable sources for the trigger sound. We have also made public the aggregate responses of the sound-video match and pleasantness of the stimuli, as well as detailed instructions for future researchers to develop their own stimuli as needed. It is our hope that as a community of researchers and practitioners, the co-development of these stimuli can encourage more multimodal perspectives in understanding misophonia.Our studies validated that our SSV database is constructed of videos with a moderate synchronized match between trigger sounds and video sources, and that sounds presented in the PAVS context are perceived as significantly more pleasant than the same sounds presented in the OVS context. We also found that the modulating effect of PAVS is substantial and works across participants regardless of their reported misophonia severity scores. In fact, individuals who reported higher severity scores on the MQ rated the OVS-paired sounds as less pleasant than those with lower severity scores, making the attenuation effect stronger for these individuals. This suggests that future studies could evaluate if the comparison between PAVS and OVS stimuli may have a therapeutic effect for misophonia sufferers if an extension of our previous work  were to Further, we found an order effect that suggests there is learning involved in the perception of misophonic trigger sounds, where the pleasantness ratings for PAVS-paired sounds were lower if the corresponding OVS videos were presented first. This indicates it may be harder to associate a trigger sound with a PAVS once the exact sound has already been heard in the original OVS context. This result is in line with Another line of work aims to understand intersections between misophonia and other psychiatric disorders or syndromes. Clinical researchers have found that those with misophonia report comorbidities with other psychiatric disorders such as obsessive-compulsive personality disorder, mood disorders, ADHD, and autism spectrum disorder , post-trEven with these comorbidities, it is unlikely misophonia can be fully explained by an underlying psychological disorder . HoweverExisting research has already begun exploring how stimuli manipulation can be used in cognitive behavioral therapy (CBT) to alleviate misophonic trigger reactions. post hoc whether participants knew or suspected that they had listened to the same sounds twice. As such, we were unable to confirm whether the order effect we identified was driven by this conscious knowledge or association. Additionally, the study was conducted remotely and we did not include any tasks to standardize the volume of different sounds across participants. Thus we do not know how soft or loud participants set their volume to, whether they changed the volume over the course of the study, or whether they were listening with headphones or on a device’s speaker. As such, future remote studies should consider using a volume check task or request for participants to report their device setup to account for potential variability in sound delivery. Replicating these experiments in the lab under controlled auditory presentation conditions would be important for future research. Finally, by asking participants to attend to the goodness of the match between the sound and video of each clip, we may have caused an ironic effect where mismatches between the audio and video were made more salient, potentially reducing benefits of PAVS.Our findings should be considered in light of some limitations in our studies. First, we did not confirm We also presented participants with decontextualized examples of trigger stimuli: 12 s videos with an unknown actor. Our 12-second clips were produced to be long enough to provide stimuli for researchers conducting psychological or neuroimaging research  on misophonia, but may not be long enough to elicit strong trigger responses. Future stimuli development may also consider developing longer videos, including ones in more naturalistic contexts.Existing research suggests that misophonic trigger responses are susceptible to contextual factors, such as the meaning tied to the sound, social control, or social relationships . Our stiThe evaluation of our stimuli in Studies 1 and 2 was based on a neurotypical population, and we did not screen for participants with misophonia. Even though we observed a range of misophonia sensitivity and severity scores using the Misophonia Questionnaire  within oWe hope that by releasing our initial set of OVS and PAVS stimuli, along with aggregate ratings and video production methodology, a collaborative effort across multiple research groups can contribute to and refine the database. It is our hope that our work can inspire and encourage broader brainstorming on plausible alternative sources of trigger sounds. Experienced sound and video editors should be able to produce even better matched videos and produce more examples of each trigger sound and PAVS source. Our SSV stimuli and development guide represent a first step in creating a publically available database of audiovisual stimuli for use in Misophonia research.https://osf.io/3ysfh/, further inquiries can be directed to the corresponding author/s.The original contributions presented in this study are included in the article/supplementary material and can be found at The studies involving human participants were reviewed and approved by University of California, Santa Cruz—Office of Research Compliance Administration (IRB). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.PS and ND were co-PIs on the project and developed the concept for the manuscript, supervised the experiments and data analysis, and co-wrote the manuscript. AA, HT, and SS conducted the interviews with 80 individuals with misophonia to identify common trigger categories, with GM, VR, and VH conducting quantitative and qualitative analyses on these interviews to verify the triggers for stimuli development. MY, AK, and CK developed and refined the video construction method, and produced all of the stimuli. MY authored the detailed instruction manual for constructing these stimuli. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The research shows that the structure and equation of state of MgCO3-C2/m are in good agreement with the experimental results, and the phase transition pressure of Mg2CO4 from pnma to P21/c structure is 44.66 GPa. By comparing the elastic properties, seismic properties and anisotropy of MgCO3-C2/m and Mg2CO4-P21/c, it is found that the elastic modulus and sound velocity of Mg2CO4-P21/c are smaller than those of MgCO3-C2/m, while the anisotropy is larger than that of MgCO3-C2/m. These results indicate that Mg2CO4-P21/c exists in the deep mantle and may be the main reason why carbonate cannot be detected. The minimum thermal conductivity of MgCO3-C2/m and Mg2CO4-P21/c is the largest in the [010] direction and the smallest in the [001] direction. The thermodynamic properties of MgCO3-C2/m and Mg2CO4-P21/c are predicted using the quasi-harmonic approximation (QHA) method.The physical properties of Mg-carbonate at high temperature and pressure are crucial for understanding the deep carbon cycle. Here, we use first-principles calculations to study the physical properties of MgCO Previous studies have mainly focused on the structural phase transition of MgCO3-3 (space group C2/m) at around 80 GPa. Oganov et al. used the USPEX method to predict for the first time that MgCO3-C2/m is most stable in the lower mantle greater than 82.4 GPa3. MgCO3-C2/m has 30 atoms, in which adjacent oxygen atoms form tetrahedra around carbon atoms, and Mg atoms are in octet and tenfold coordination. Subsequently, the structure of MgCO3-C2/m was verified experimentally6 and theoretically13. Recently, Gavryushkin et al. used USPEX and AIRSS methods to find that MgCO3 reacts with MgO to form Mg2CO4, which has two structures, orthorhombic (space group Pnma) and monoclinic (space group P21/c), and its structure is P21/c when the pressure is higher than 50 GPa14. Their experiments later confirmed the existence of Mg2CO4-P21/c at the temperature and pressure of the Earth's lower mantle15. Mg2CO4-P21/c has 28 atoms, it is isostructural to β-Ca2SiO416, and the atoms at the two positions Mg(1) and Mg(2) are six-coordinated, with octahedral coordination polyhedra. Earlier reports20, although the structure of Mg2CO4 was not determined, believed that it is stable at high pressure.Magnesite 25 as implemented in VASP27. The electronic configurations: 2p63s2 for Mg, 2s22p2 for C and 2s22p4 for O are considered for the valence electrons. The Perdew–Burke–Ernzerhof modified solid (PBEsol) in the generalized gradient approximation (GGA)28 describes the exchange and correlation potentials. The generation of k-point mesh and the calculation of elastic properties utilize the vaspkit program29. The cutoff energy for the plane wave is set to 900 eV. The k-points mesh of MgCO3-C2/m and Mg2CO4-P21/c are set to 4 × 5 × 5 and 13 × 9 × 7 using the Monkhorst–Pack scheme30, respectively. The thermodynamic properties are calculated by the QHA method31.First-principles calculations are used to investigate the high-pressure physical properties of MgCO3-C2/m and Mg2CO4-P21/c in the unit cell are shown in Fig. 3-C2/m are consistent with the experimental results5. The results for Mg2CO4-P21/c at 100 GPa agree well with the previous calculations14.The crystal structures of MgCO2CO4-Pnma to Mg2CO4-P21/c is 44.66 GPa, while Gavryushkin et al. calculated 52 GPa14. This error may be caused by the use of different exchange correction functions, PBEsol is used in the present work, while PBE was used by Gavryushkin et al.14. The accuracy of using PBEsol to calculate the properties of Mg-carbonate has been examined in the previous studies13. In the previous study, MgCO3-C2/m was stable in the lower mantle above 80 GPa33. Therefore, in order to facilitate comparison, the high-pressure properties of MgCO3-C2/m and Mg2CO4-P21/c in the pressure range of 50–140 GPa are investigated in this work.As shown in Fig. 3-C2/m and Mg2CO4-P21/c at 50 to 140 GPa are shown in Fig. 3-C2/m is in good agreement with available experimental data6. The equation of state of Mg2CO4-P21/c is smaller than that of MgCO3-C2/m, and is almost parallel. The formula unit volume of MgCO3-C2/m is smaller than that of Mg2CO4-P21/c, which is in line with their molecular formula composition relationship.The equations of state for MgCO3-C2/m and Mg2CO4-P21/c, there are 13 independent elastic constants  and shear (VS) velocities of MgCO3-C2/m and Mg2CO4-P21/c are given by the following expressions38:Based on the calculated bulk and shear moduli and density, the compression  and the thermal expansion coefficient (3-C2/m and Mg2CO4-P21/c at various pressures are depicted in Figs. CV and 3-C2/m are larger than those of Mg2CO4-P21/c under the same pressure.Thermodynamic parameters are the preconditions for deriving the thermal state of the Earth's interior. Therefore, the thermodynamic properties of MgCO3-C2/m, the phase transition pressure of Mg2CO4-P21/c is determined. The high-pressure physical properties of MgCO3-C2/m and Mg2CO4-P21/c at 50–140 GPa are investigated by first-principles calculations. By comparison, it is found that the elastic modulus and wave velocity of Mg2CO4-P21/c are smaller than those of MgCO3-C2/m, and the density and seismic anisotropy are larger than those of MgCO3-C2/m. The low wave velocity of Mg2CO4-P21/c may be more suitable to explain the existence of the low-velocity zone near the subducting slab. Therefore, it is believed that Mg2CO4-P21/c may exist in the deep mantle, providing strong evidence for carbon storage in carbonates and the reason why it cannot be detected in the lower mantle. The minimum thermal conductivity of MgCO3-C2/m is greater than that of Mg2CO4-P21/c, and their minimum thermal conductivity is the largest in the [010] direction and the smallest in the [001] direction. The constant volume heat capacity CV and thermal expansion coefficient 3-C2/m are larger than those of Mg2CO4-P21/c. Unfortunately, there are no experimental data on the elastic constants, thermodynamic parameters, and minimum thermal conductivity of MgCO3-C2/m and Mg2CO4-P21/c, so further verification is required.On the basis of verifying the structure and equation of state of MgCO


Video-reflexive ethnography (VRE) has been used to record aspects of patient care which are then shared with staff to drive self-identified improvements. Interpersonal interactions between patients and hospital staff are key to high-quality, patient-centred care and mostly occur randomly throughout a patient’s hospital stay. One of the most common types of hospital admission is for women giving birth.To assess the feasibility of adapting the VRE methodology to capture naturally occurring interactions between patients and health staff over an extended period during hospital admission, and to assess whether the approach would yield useful interaction data.Twelve women, who had a planned caesarean section at 37+ weeks, were considered low risk  and were admitted to a postnatal unit after giving birth, and the staff who attended them.This study took place in a large hospital in Sydney, Australia, where approximately 2200 women give birth each year. Continuous unattended video recordings were made during each woman’s hospital stay to capture interactions with hospital staff. The recordings were reviewed to determine what kinds of interaction data could be obtained.In order to recruit 12 eligible women, we needed to invite 45 to participate. The estimated recruitment period of 3–4 months had to be extended to 8 months. A fixed video camera was successfully installed in the hospital room of each woman and a remote control provided. A total of 246.5 h of video recordings was obtained, of which 38 h (15.5%) involved interpersonal interactions with staff. Two women reported negative responses from staff about being video recorded. Both quantitative and qualitative data could be obtained from the recordings.Video recordings of interpersonal interactions between patients and staff in an in patient hospital care setting can be obtained and can provide unique insights into the complexity of healthcare delivery. However, significant contextual barriers can exist to engaging staff in quality improvement initiatives that are not part of their usual healthcare activities. Video-reflexive ethnography (VRE) is usually used to record specific aspects of patient care; however, interpersonal interactions between patients and healthcare staff during a hospital stay can occur at random times and require innovative study methods.Continuous video recordings can capture patient-staff interactions as they naturally occur and provide rich information about the quality of care.Multiple strategies are needed to support the engagement of busy healthcare staff in health services research.Good interpersonal communication is essential to the development of effective relationships between clinicians and patients and is associated with high-quality care, positive patient experiences and improved health outcomes –3. In heHealth services research investigates how social factors, financing systems, organisational structures and processes, health technologies and personal behaviours affect healthcare quality and delivery including equity of access, cost and impacts on health and well-being . A key oOur feasibility study explored whether we could adapt the VRE methodology to capture, in a more holistic, authentic way, interpersonal interactions that occur between patients and staff over an extended period during a hospital admission . We alsoWill women and staff agree to extended periods of video recording?Can the VRE methodology be incorporated into an inpatient maternity care setting?Can the unattended video recordings provide useful information about interpersonal interactions between women and staff in a postnatal unit?In this study, we addressed the following questions:The feasibility study results would help determine whether the modified VRE methodology could be used in a larger future study to review interpersonal interactions between patients and hospital staff. We considered feasibility would be supported if we could demonstrate that (i) patients and hospital staff were willing to be video recorded, (ii) an unattended video camera could be safely and easily installed into the hospital setting and (iii) useful data could be collected about naturally occurring interpersonal interactions between patients and hospital staff.This study was a small cross-sectional observational study.The hospital in this study is a large public teaching hospital in Sydney, Australia, with approximately 80,000 patient admissions annually including 2200 women who give birth.Early efforts were made to engage with senior staff to plan the project, recognising potential sensitivities around the use of video to record patient-staff interactions. Initial meetings were held with the Directors of Maternity Care  and the managers of the Antenatal Clinic, Birth Unit and Postnatal Unit. While the focus of the study was on interactions during postnatal care, many staff work across all three units. The Directors supported the project as a quality improvement initiative that aimed to explore the interpersonal care experiences of women following birth.The participants in the study were women meeting the eligibility criteria (described below) who consented to have a video camera in their hospital room, and all medical, midwifery, administrative and catering staff attending the Postnatal Unit during the study period.Pregnant women aged between 18 and 45 years who were booked to have a planned caesarean section at 37+ weeks and were considered low risk  were eligible to participate. Women were invited to participate at the hospital’s Antenatal Clinic by a research midwife , usually around 35–36 weeks’ gestation. The planned nature of the birth allowed the research midwives to recruit women in advance, confirm their willingness to participate at the time of the birth admission and install the video camera on their arrival in the Postnatal Unit (after giving birth). Women who consented to participate but who subsequently developed a complication (i.e. necessitating early/emergency delivery) or who had spontaneous labour before the date of the planned caesarean section were withdrawn from the study. Women themselves could withdraw from the study at any time and/or request deletion of video data. We aimed to recruit 12 women for this feasibility study, deemed an adequate number for pilot and early studies when no prior information is available for estimating sample size . In consAll staff who worked in the hospital’s Antenatal Clinic, Birthing Unit or Postnatal Unit were considered participants in the study since a high proportion of staff work in more than one location, either on rotation or when needed. Staff were invited to attend one of several information sessions about the study, held at different times of day over a period of 6 weeks prior to study commencement. Information was also circulated by lead clinical staff to their teams by email, and hard copy information sheets were circulated in the Antenatal Clinic, Birthing Unit and Postnatal Unit. Meetings were held with catering staff supervisors and written information provided. Staff were advised that the aim of the project was to help provide high-quality care by exploring interpersonal interactions with patients. It was understood that some staff might feel uncomfortable or nervous about being video recorded, and staff were assured that any video data involving them would only be shown to other staff with their permission. The local Human Research and Ethics Committee which approved this study accepted the use of implied consent from staff for video recording unless they opted out in writing (HREC/16/HAWKE/128). Video footage of staff who opted out but who were inadvertently filmed would be deleted. Any staff member who was video recorded could also subsequently request deletion of video data pertaining to them.The Postnatal Unit in this study endeavours to provide single-occupancy rooms for women who have had a caesarean section. A research midwife monitored the time of birth for each participating woman and, shortly before transfer from Operating Theatre to the Postnatal Unit, a lightweight video camera was mounted on the wall behind the bed in her room. This location was chosen in consultation with the unit manager and was visible to anyone entering the room. A clock above the door in each room was captured in the filming frame, allowing identification of time of day and length of time recorded. A notice was also placed on the outside of the door of the room advising that video recording was underway.After the woman arrived in her room, a research midwife explained the recording procedure, the operation of the video remote control and the process of daily collection and replacement of the video data card. Each woman had the option of stopping and re-starting the video camera herself to allow for times of privacy. A researcher was not present during the filming process. Women were assured that any filming of family or friends would be ignored since the focus of the study was interactions with hospital staff. Women were encouraged to record on camera any comments about their interactions with staff.Feedback was obtained from the research midwives about the processes of recruiting women to the study (and reasons for declining), and video recording in the Postnatal Unit including logistics and any issues raised by women or staff. The medical educator/facilitator who led all information sessions at the commencement of the project and feedback sessions with staff to discuss selected video snippets (KF) also kept field notes.The video recordings were viewed independently by at least two members of the research team to identify sections that captured interactions between the women and staff. These sections were then assessed to determine the nature of the recorded interactions and were coded thematically. We noted the length of the interaction time (minutes/seconds) and which types of staff were involved ). The video analysis took place within an interpretivist paradigm exploring the nature of interactions from a sociocultural perspective . Short vTo achieve our recruitment target of 12 participants, we invited 45 pregnant women to participate over 8 months (April–December 2017). Eighteen women consented; however, the risk status of 4 changed after giving consent (from low to higher risk due to emerging complications) and 2 withdrew, leaving 12 (27%) women who progressed to video recording  and some were suspicious that the recordings would be used by senior management to monitor clinical practices. Staff were assured that senior management had no access to the recordings except for selected snippets which focused on interpersonal interactions, and which would be approved for sharing by the staff involved.Over the 8-month recruiting and recording period, different junior doctors and midwifery and nursing students rotated through the Postnatal Unit, and a range of casual and agency staff were employed, often on short-term contracts, requiring multiple information sessions. Internal communication with staff about the project was inconsistent over time. As a result, some staff felt unaware or inadequately informed about the project. This included staff who only worked night shifts, even though we scheduled some information sessions to complement the start or end times for these shifts. Further, while some doctors attended the initial information sessions, they did not otherwise engage with the study despite multiple invitations and explicit support for the project by senior medical staff.The location of the video camera on the wall behind the woman’s bed in the Postnatal Unit gave a clear view of people entering the room and the area around the woman’s bed but not the woman’s face (unless she left the bed). Alternate positions for the camera were considered to record facial expressions during interpersonal interactions, for example, by fixing the camera to other standard equipment in the room or on a tripod, but these options breached health and safety regulations. The length of recording time also required access to a fixed power supply, which influenced the location of the camera. Night-time filming appeared ‘ghost-like’ on video, reducing the quality of visual information but audio information was clear.While each woman was given a remote control and the option of switching the camera on/off, 9 of the 12 women chose continuous recording. Recorded time ranged from 2 h 39 min to 38 h 42 min per woman (mean 20 h 33 min). The camera stopped when the video card was full, or a research midwife came for the daily check and video card replacement. Each video card stored about 12–14 h of recordings. Efforts to capture weekend stays in hospital proved unsuccessful; in the busyness of the unit’s usual activities and with more limited staffing, the task of changing the video card was forgotten.We had invited the participating women to record on camera any reflections they might have about their interactions with staff in the Postnatal Unit. Three women reported being very happy with the care they received and thanked the staff on camera shortly before leaving hospital. Two women reported to a research midwife that they had had a negative encounter with a midwife who had told them they were opposed to being video recorded and/or had no knowledge about the study. These staff insisted that the camera be switched off. One of the women reported on camera that she felt very distressed by the encounter and the midwife did not attend her room again.Viewing and coding the video recordings were highly labour-intensive. The total recorded time for the 12 women was 246 h 34 min. Only 38 h (15.5%) of the recorded time involved interpersonal interactions between the women and staff; for the remaining time, the women were alone or with family and friends. Attempts to fast-forward through footage that seemed uneventful (e.g. while the woman was sleeping or had visitors) were not effective, as it was easy to miss brief visits from staff. The recorded interactions did not require transcribing, as the VRE method uses video segments to demonstrate behaviour in context as the teaching and reflection tool. The most frequent staff interactions were with midwives , with total recorded times ranging from 55 min to 5 h 7 min.  Video recordings of interactions with doctors were mostly brief and infrequent . Obstetricians and anaesthetists conducted post-operative checks, or sometimes a paediatrician attended to check the baby. Catering staff attended the women several times each day to bring food for breakfast, lunch and dinner as well as morning and afternoon tea. While these visits were regular, they were fleeting. Ad hoc visits from other staff were also recorded, such as physiotherapists, clerical staff, lactation consultants and a chaplain .The video recordings demonstrated the diverse and individual circumstances and needs of the 12 participating women. For example, Woman #1 and her partner were South American, and English was not their first language. Family members and friends visited the woman during her hospital stay and were seen on video to assist her in many ways . This was the woman’s third child and she appeared relaxed and confident in managing her baby especially with her family around her but was experiencing considerable discomfort following the caesarean section. In contrast, Woman #3 had little family support (most of the extended family lived in the UK) and was quite anxious about her recovery and breastfeeding her baby. Woman #8 appeared self-assured, confident and keen to manage herself and her baby as much as possible. Because of the differences in individual women’s needs and contexts, the interactions with maternity staff were never the same.While recognising the diversity between patients, we were able to identify five common types of interactions: conversations, collaborations, staff noticing care needs and nurturing, staff informing and instructing patients and non-verbal communication Table . We alsoTen face-to-face feedback sessions were conducted, attended by 69 staff, to share and discuss video snippets of interactions between women and staff. The sessions were limited to 30 min, scheduled at the unit’s regular professional development times, to facilitate staff attendance. The snippets engaged staff and elicited discussion about the interactions. Several staff remarked that they rarely had the chance to observe how colleagues interacted with women and how this contrasted with their own behaviour.A feasibility study is designed to focus on process and answer the question “Can it work?” . In thisWe identified three criteria that would lend support to the use of this modified VRE methodology in a larger study. The first was the willingness of patients and hospital staff to participate and be video recorded. Our results suggested enthusiasm among some women and staff, but also disinterest and even opposition among others. Many women who were invited to participate in this study declined, often because they were either not interested in the study or for privacy and modesty reasons. In contrast, the women who did consent appeared comfortable about being recorded and perhaps more self-confident and self-assured. Although we recognise that our participants may not be representative of all women giving birth or all women having caesareans, we would suggest that the interactions between the women and staff appeared typical for this population. It was the nature of these interactions which was the focus of this study. Various staff expressed early concerns about being filmed, raising issues of feeling self-conscious or being monitored by managers. It also became apparent that many staff did not appreciate the potential value of the study to facilitate improvement in the quality of care. Patients can feel quite vulnerable when in hospital, and staff can feel threatened or suspicious about being filmed , 25. SucThe clinical environment in which this project was embedded is a 35-bed postnatal unit in a large urban teaching hospital providing care to over 2200 birthing women, and approximately 80,000 patient admissions each year. While the project team worked with the manager of the unit, the project appeared to be viewed by staff as separate from and outside of their work rather than integral to it. Although we sought to engage all senior managers, we had only partial success. Additional champions and peer leaders might have helped achieve greater buy-in from staff, particularly the medical staff who proved difficult to engage. The focus of the project on interpersonal interactions with patients also did not seem to appeal to medical staff as we had anticipated, and perhaps even threatened some. We sought to inform as many staff as possible about the project prior to commencement, but some remained suspicious of being filmed, perhaps pointing to wider issues between staff and managers. We also acknowledge that the negative reactions from a small number of staff during filming may have been due, at least in part, to not being well-informed about the study, possibly due to the extended recruitment period, because they had joined the unit after the initial study briefings, or were casual agency staff or night staff. Although we were aware of only two staff objecting to being filmed, we had not foreseen that they might verbally ‘attack’ or upset women.The second feasibility criterion we considered focused on the practicalities of embedding an unattended video-camera over an extended period in a hospital setting. To a large extent, this was successfully achieved. Most other VRE studies have typically focused on discrete behaviours and exchanges where timing is more predictable, and a person  operates the video recorder and moves around. The presence of such a person can impact the observed behaviour  and can The third criterion we examined for feasibility with the modified VRE methodology was whether it would yield useful data about interpersonal interactions between patients and hospital staff. A significant benefit of VRE is that it allows us to view complex clinical situations in context and identify potential opportunities for improved care practices , 11. IntVRE has previously been used in a range of clinical settings, including maternity care. Stevens and colleagues  used VREVRE has been used successfully in a range of clinical settings to drive improvements in healthcare delivery. This feasibility study found that it was possible to adapt VRE to record ‘real-world’ interpersonal interactions over an extended period between women who had recently had a caesarean section and hospital staff in a postnatal unit. Further, this approach generated a significant amount of video data that would likely be useful for further analysis. We identified five common types of interactions that could inform future research in other inpatient settings about the provision of healthcare. However, we identified several ‘human’ challenges during this feasibility study that bear consideration. Some patients and staff are uncomfortable about being video recorded. This needs to be acknowledged and managed as part of participant recruitment planning in any future research using VRE. Perhaps more fundamentally, effectively engaging busy health staff in a research project can pose difficulties. In this study, some senior managers provided high level support, and one unit manager was actively engaged, but otherwise for most staff the project seemed of peripheral interest, or if they were interested, their clinical work demands limited their ability to be involved. We believe these practical issues are not unique to maternity units or Australian hospitals or the use of VRE, and significantly curtail truly collaborative health services research and its translation. Research needs to be embedded as an essential element in safe, high-quality healthcare and to be part of the role of health professionals.


Malnutrition is an important public health issue and the main cause of child morbidity and mortality, especially in developing countries. The present study aimed to model trend changes in percentage of the malnourished children under 5 among 39 Asian countries during 1987 to 2016.P < 0.10 in likelihood ratio test (LRT) was considered as statistically significant.Information about percentage of the malnourished under 5 years children based on under-weight (weight for age) malnutrition for 39 Asian countries were extracted from Gapminder web site during 1987 to 2016. To cluster Asian countries based on trend changes, Growth Mixture Model (GMM) was implemented. All the statistical analyses were performed in Mplus 7.4 software and P-value of LRT, the model with 3 clusters was selected. Although, cluster 3 with 9 countries had higher intercept in 1987 and the worst situation in malnutrition, they gained a sharp decrease (− 0.93) in percentage of malnourished children under five annually. The slope of − 0.64 for cluster 1 countries indicate a moderate decrease annually in percent of children with malnutrition. The other 20 countries with slope of − 0.29 in their linear trend belonged to cluster 2 which shows slow decrease in the percentage of children with malnutrition.Based on The investments in public health and education programs, as well as political commitment and government proper response in line with needs and demands are crucial to promote food security, nourishing diets and improving child nutrition. Certainly, most of them are still a long way from eradicating malnutrition. Malnutrition is a critical public health challenge and the leading cause of child morbidity and mortality, especially in developing countries , 2. ArouRegardless of where a child comes from, malnutrition is determined by different factors based on comprehensive strategies , 2, 7, 8The data on the percentage of malnourished children under five based on weight for age for 39 Asian countries were extracted from the Gapminder website from 1987 through 2016. Prevalence of underweight children is the percentage of children under five whose weight for age is more than two standard deviations below the median for the international reference population aged 0–59 months. The data comes from the WHO’s new child growth standards released in 2006.To cluster Asian countries based on trend changes in the percentage of children under five with malnutrition, the Growth Mixture Model (GMM) was implemented. This model estimates the number of unobserved longitudinal patterns (clusters) as a latent variable considering both the inter-individual and intra-individual variations over time. The GMM models estimate the response variable  in each cluster using the intercept and the slope of a linear trajectory .In a GMM with k latent patterns, the following equations estimate intercept and slope in each pattern:Where α_00^k is the overall mean for the weight-for-age malnutrition in the kth pattern and α_10^k corresponds to the annual mean rate of changes in the weight for age malnutrition for the kth pattern.P < 0.10 in the likelihood ratio test (LRT) was considered statistically significant.Recently, GMM has been used to investigate different patterns of breast cancer incidence in Africa , to obtaP-value of LRT, the model with 3 clusters was selected  the current status of these countries is better than the countries in cluster 3 and 1.Investigating underweight malnutrition among children under 5 years old in 39 Asian countries showed an overall decrease from 1987 to 2016. However, Asian countries had different reduction patterns due to experiencing some challenges, such as the economic crisis, which has aggravated malnutrition in 1997 and 2007, especially for clusters 1 and 3 [Cluster 1 included Bhutan, Indonesia, Malaysia, Maldives, Myanmar, North Korea, Philippines, Sri Lanka, Tajikistan, and Vietnam, with a moderate decrease in the percent of underweight children.Sri Lanka is a South Asian low-middle-income country with a high literacy rate . Among cTo end short-term hunger, increase school retention, and improve the food security and nutrition of school-age children, the strategic plan of Sri Lanka ensured receiving school meals for school-age children in high food insecurity and malnutrition areas all year round , 21. DesLike many other Asian countries, the Philippines suffers from micronutrient malnutrition. Implementing homestead food production (HFP) programs from 2003 to 2007 significantly decreased anemia prevalence among children (from 42.9 to 16.6%). HFP products also improved young children’s food security, nutrition status, and household income, significantly reducing the prevalence of anemia among children in the Philippines . MoreoveThe Philippines expanded governance through “Peace and Development Teams” (PDT) in 2002. The program progressively reduced child malnutrition by about 10% after the first year and 30% after 3 years, and its effects persist. PDT proxies for a general expansion of social services, security improvements, access to markets, or existing government services must be the causal mechanisms responsible for the malnutrition reduction .The Philippines and Vietnam are en route to safe water and sanitation, elements recommended by the SUN movement; however, a country such as Indonesia has experienced slow progress in both domains, Myanmar has also acted slowly in providing safe water .North Korea suffered from severe famine and food shortage during the 1990s, two leading causes being the yearly natural disasters, such as flood or drought, and the fall of the Soviet economic system. This shortage affected many areas, including child growth and mortality . As chilDespite the sustained economic growth and progress in reducing poverty, child nutrition in Indonesia was in horrid conditions, with chronic malnutrition rates, which remain high. The recent 2013 Basic Health Survey (Riskesdas) in Indonesia found the prevalence of underweight among children under five to be 19.6%. The experience of Indonesia shows that economic growth alone is not enough to improve the nutritional status of children . The masTwenty countries, including Armenia, Azerbaijan, Bahrain, China, Iran, Iraq, Jordan, Kazakhstan, Kuwait, Kyrgyz Republic, Lebanon, Mongolia, Oman, Palestine, Saudi Arabia, South Korea, Syria, Thailand, Turkmenistan, and Uzbekistan, were categorized in cluster two. Despite the slightest decrease, the current status of these countries is better than in other Asian countries.Childhood malnutrition, including anemia and underweight, depicts a decreasing trend in China. Between 1990 and 2013, the rate of underweight children under five decreased from 13. 7 to 1.37% . Such reMoreover, the supplementation programs reduce significant micronutrient deficiencies in a short period, which localized approaches to maintain their gains. In addition, the advertising law in April 2015 was revised for infant formula, beverage, and other food, which claim its function as a replacement of breastfeeding . Since 2The government of Kuwait also had its programs. It established a comprehensive social welfare program, including free housing and medical services for citizens, financial support of vulnerable groups, guaranteed employment, and free education until 15. Due to such programs and the discovery of oil resources, the country achieved socio-economic development, which considerably changed the food patterns and lifestyles of the people in Kuwait , 33. As In Iran, all types of malnutrition, including underweight, have improved among children under five due to the Iranian food and nutrition security system. Nationwide reports showed that the prevalence of child malnutrition had significantly reduced. The prevalence of underweight decreased from 13.8% in 1995 to 4.6% in 2004 . SimilarMoreover, improved growth monitoring and fostering rural cooperatives were considered . StudiesAlthough this category includes countries such as Syria and Iraq, they have struggled with the economic and political crisis due to war and conflicts that have affected health indicators. They could somewhat tackle malnutrition by supporting international organizations like UNICEF. In 1990, following the Gulf war and throughout the sanctions of the 1990s, UNICEF focused on rehabilitating social services, providing life-saving therapeutic feeding to malnourished and the most vulnerable children. In 1997, this organization again attempted to improve a child’s care via the “Oil for Food” program. As Syria’s conflict brought 250,000 refugees to Kurdistan, UNICEF established water and sanitation, education, health, and child protection services in 2012–2013. Since 2014, when internal conflict uprooted millions of Iraqis, UNICEF has implemented other programs to support children and families . HoweverCluster 3 includes Afghanistan, Bangladesh, Cambodia, India, Lao, Nepal, Pakistan, Timor-Leste, and Yemen, with the highest percent of malnutrition in 1987, which gained a steep decrease. Although these countries did very well in reducing undernourishment, malnutrition is still higher there than elsewhere. Therefore, they should perpetuate their effort and nutrition interventions.The experience of the community-based program linked to nutrition in some of the Asian countries such as Bangladesh, India, and Thailand decreased malnutrition and increased children’s health and nutrition . The homThe Government of Bangladesh (GoB) has considered a National Food Policy since 2006 to enhance food availability, access, and utilization. In addition, Bangladesh joined the SUN movement in 2013 . The expPolitical or government commitment was one of the critical elements to reduce malnutrition. According to Hunger and Nutrition Commitment Index (HANCI) most countries in this cluster, such as Pakistan, Yemen, and Afghanistan, had “low” to “very low” levels of political commitment .As a middle-income country, India reported higher government commitment; however, this was not enough, and essential nutrition interventions did not cover half of the group for whom they were intended. Therefore, more committed action is required in India, focusing on malnourished children , 44. OveThe nutritional status of children in Nepal has also substantially improved over the past 15 years. Child underweight rates have decreased to about 29% of all children aged 6–59 months . SuccessThe efforts of Yemen on hunger and nutrition were also deteriorating . This coCambodia implemented a nutrition-sensitive agriculture project and nutrition education program conducted by the government, health volunteers, and local NGOs, targeting caregivers with a child between 5 and 18 months of age, with excellent potential to improve infant and young child feeding (IYCF) practices. Nutrition education intervention, especially maternal education, was also embedded in a food security project and was positively correlated with the child’s dietary diversity . CambodiData was extracted from Gapminder website, as a rich and reliable data to identify systematic misconceptions about important global trends and proportions. The aggregation of the prevalence data is based on UNICEF, WHO, and the World Bank harmonized dataset  and methodology. However, data is not updated in some countries.In conclusion, although economic growth is an underlying factor in tackling child malnutrition, it is not the only determinant, and other socio-cultural and political factors also play a part. The investments in public health and education programs, political commitment, and proper government response in line with needs and demands are crucial in promoting food security, nourishing diets, and improving child nutrition. To reduce under-nutrition commitment from governments, this should be the priority of political strategies, and health should be considered an inevitable element of each policy. Moreover, NGOs, industry, and society should take the challenges alongside other national and international organizations. The successful experiences and expanding community-based approaches in all Asian countries should not be neglected. In this way, rural areas should receive more attention than before due to the higher prevalence of malnutrition in such areas.Overall, all Asian countries have attempted to reduce child malnutrition, mainly relying on global organizations’ policies. Indeed, most of them are still a long way from eradicating malnutrition. All the countries should emphasize the high micronutrient deficiencies to reduce them further.


Older Veterans at high-risk for institutionalization often require home- and community-based services (HCBS). Yet, current HCBS delivery often fails to meet the needs of high-risk Veterans due to decreased veteran engagement in outpatient programs and limited HCBS capacity. A promising approach to address these gaps is the use of Veteran-Peers to make home-visits. Peer-2-PACT is a peer-led needs-assessment intervention for high-risk older veterans. Two trained peers conducted a checklist-guided virtual and/or in-person home-assessment to identify unmet needs and home-safety concerns. Veterans with access, acceptance and ability for video-capable technology were offered video-visits. We report on the feasibility of video home-visits in this high-risk group, and the experience of the video-visits using the visit-data and interviews with peers.Eight of 27 Peer-2-PACT Veterans successfully completed initial video-visit to home. The video-visit participants (n=8) were age 74±9; Non-Hispanic Black (50%); males (100%), compared to initial in-person home-visit participants (n=19), age 75.3±10.8; Non-Hispanic Black (47%); males (89%). The commonest needs identified during video-home-visits were home-safety devices 5(62.5%), housing assistance 4(50%), and medication refills 2(25%). Peers report that identifying veterans suitable for video-visits was challenging. During video-visits, depth-perception by peers is limited and sometimes needed in-person follow-up. Main advantages of video-visits was ability to identify unmet needs, engage veterans, provide care during COVID, and tele-present to remote clinicians. Preliminary data suggest that peer-conducted video home-visits is a feasible way to identify unmet needs in some high-risk older adults. This is particularly important improve care of Veterans who live at a distance from the facility.