Studying clinician-patient communication can be challenging, particularly when research seeks to explore cause-and-effect relationships. Video vignettes – hypothetical yet realistic scenarios – offer advantages to traditional observational approaches by enabling standardisation and manipulation of a clinician-patient encounter for assessment by participants. While published guidelines outline stages to create valid video vignette studies, constructing high quality vignettes which are accessible to a wide range of participants and feasible to produce within time and budget restraints remains challenging. Here, we outline our methods in creating valid video vignettes to study the communication of diagnostic uncertainty. We aim to provide practically useful recommendations for future researchers, and to prompt further reflection on accessibility issues in video vignette methodology.We produced four video vignettes for use in an online study examining the communication of diagnostic uncertainty. We followed established guidelines for vignette production, with specific consideration of how these might be applied pragmatically to save time and resources. Scripts were pilot-tested with 15 laypeople, and videos with 14 laypeople; pilot-testing involved both quantitative and qualitative analysis.We demonstrate the usefulness of existing guidelines, while also determining that vignette production need not necessarily be expensive or time-consuming to be valid. Our vignettes were filmed using an iPhone camera, and featured a physician rather than a professional actor; nonetheless, pilot-testing found them to be internally and externally valid for experimental use. We thus propose that if care is taken in initial script development and if pragmatic choices are made regarding filming techniques and pilot-testing, researchers can produce valid vignettes within reasonable time and budget restraints. We also suggest that existing research fails to critically examine the potential benefits and harms of online video vignette methodology, and propose that further research should consider how it can be adapted to be inclusive of those from underserved backgrounds.Researchers creating video vignette studies can adapt the video vignette development process to suit time and budget constraints, and to make best use of available technology. Online methods may be harnessed to increase participant accessibility, but future research should explore more inclusive vignette design.The online version contains supplementary material available at 10.1186/s12874-023-02072-7. Various approaches exist for the study of doctor-patient communication , 2. Obseshort, carefully constructed description of a person, object, or situation, representing a systematic combination of characteristics” ) involved two stages: 1) initial study involving doctors using written vignettes (CODUS 1), and 2) video vignette study involving patients (CODUS 2). Figure The methods and results of CODUS 1 are detailed elsewhere . In thisIn light of these results, a second study CODUS 2) aimed to examine the effects on patients of communicating diagnostic uncertainty in two varying clinical scenarios . As such, for our research questions, vignette methodology offers an advantage over observational studies of real consultations.2The use of APs avoids ethical issues which might be associated with using real patients . There iVignette methodology has some limitations. Vignettes may never be identical to real consultations: although APs can effectively put themselves in the position of the patient in the vignettes , 36, thiConsidering these strengths and limitations, we concluded that vignettes would be the optimal methodology for addressing our research questions.We developed four scripts: high and low communicated diagnostic uncertainty for both the ‘change in bowel habit’ vignette V1A and V1B), and for the ‘headache’ vignette (V2A and V2B) .We developed a standard script for each scenario, using common elements from CODUS 1 transcripts to enhance ecological validity. Most responses followed a similar structure: initial introduction and reassessment of the clinical situation, explanation of the investigation results, discussion about the likely diagnosis with a suggested plan, and safety-netting. Two researchers – CC  and TH (an anthropologist) read though the transcripts and noted common phrases, such as “The standard scripts were then manipulated to create high vs low communicated uncertainty conditions.Drawing directly from CODUS 1 transcripts, we created a table with quotations demonstrating high vs low communicated diagnostic uncertainty. Again, by using examples of what doctors had actually said, we aimed to make the scripts as ecologically valid as possible. As the communication of diagnostic uncertainty is not a simple construct, we chose to vary multiple verbal segments. Our ‘high uncertainty’ scripts accumulated verbal segments from multiple doctors. We discussed and iterated these scripts, aiming to balance realism with manipulation success: we aimed to make manipulations which were distinguishable, without descending into caricature , 42.The resulting high communicated uncertainty scripts were longer because of increased discussion. Length discrepancies have been noted in other vignette studies , 19. FolTo isolate the impact of delivering information content about diagnostic uncertainty to patients, we only manipulated verbal elements; non-verbal communication  were kept as similar as possible between the videos. We note that it is impossible to entirely separate non-verbal and verbal communication – for example, the tone in which information is imparted and the speaker’s body language will naturally be somewhat influenced by the information itself . Therefo3Consulting relevant experts can help to establish realism at the script development phase . We sharVideo vignette studies frequently use pilot-testing but vary in the extensiveness of the process , 44. Of We undertook pilot-testing with a convenience sample of 15 participants who met the inclusion/exclusion criteria for the main study . They were laypeople without medical expertise, and were given all the scripts to read in a randomised order. Script-pilot testing focused on testing internal validity: were the manipulations sufficiently distinct in their communication of diagnostic uncertainty?p < 0.001)  Table .Table 2Additionally, we garnered general feedback on the scripts, including comments on realism and understandability. Small changes were made in response, for example to reduce jargon.Filming video vignettes can be prohibitively expensive and time-consuming, particularly if using professional film crews or consulting script advisors. Moreover, these costs can rapidly increase if pilot-testing of videos produces unsatisfactory results, necessitating amendments and re-shooting. Our decisions regarding filming and pilot-testing the videos were shaped by these realities.Various camera angles have been used in existing video vignettes studies, for example showing only what the patient sees (facing the doctor), or alternating between the patient and the doctor . Some stSince the COVID-19 pandemic, there has been a significant increase in telemedicine, including the use of video consultations . We chosWe filmed the vignettes using an iPhone, a tripod and a teleprompter application. Multiple takes of each vignette version were filmed. We chose not to pilot-test different takes due to time constraints – we instead selected the best take for each vignette condition and used these in pilot-testing (see below). These were chosen based on global assessments by the author team, taking into account the overall quality, naturalism of the delivery and consistency of affect and tone across the different vignette conditions.Each vignette was filmed as one continuous take to avoid any transitions between clips which may have been distracting. This approach was more appropriate within our resource constraints as we did not contract a professional recording/editing team.Some existing video vignette studies have used actors, while others have used real clinicians. As Hillen et al. discuss, there are potential advantages and disadvantaged to both: real clinicians may be more naturalistic and adept with medical terminology, while actors may be more comfortable in front of camera and better able to deliver consistency in style .Based upon a previous vignette study in which pilot participants found an actor more realistic , we initUnfortunately, early informal pilot-testing with a convenience sample of 10 laypeople suggested that the realism of the videos produced from this first day of filming was inadequate. These pilot-testers were shown the vignettes and asked for general feedback on their realism: they reported the actor to be unnatural in their tone and non-verbal communication. We subsequently reshot the vignettes using a medical doctor. We showed videos to the same sample of pilot-testers , and again asked them for general feedback on realism. We particularly asked them to compare the re-shot vignettes with the original versions. They universally preferred the videos with the doctor, describing them as more realistic. Subsequently we proceeded with these in the formal pilot-testing phase (see below).As in our experience, amending scripts and reshooting videos in response to feedback can be essential to vignette validity. We urge researchers to account for possible reshooting costs when planning studies to avoid having to decide between compromised validity and excessive costs.or V2A and V2B. Each pilot tester thus watched 2 videos, randomised to watch the A or B video first.We pilot-tested videos with a convenience sample of 14 laypeople who met the proposed inclusion/exclusion criteria for the main study . To replicate the conditions of the main study, each participant was shown the introductory text, before watching either videos V1A and V1B p < 0.05) : Participants rated on a 11-point scale how explicitly the doctor discussed any uncertainty surrounding the diagnosis, from 0 “not at all” to 10 “very explicitly”. For both sets of videos, the high uncertainty communication scripts were perceived as displaying significantly greater explicit communication of diagnostic uncertainty (5) Table .External validity testing : Participants rated on a 11-point scale how believable the doctor was, and how believable the content was, from “not at all” to “very”. They also rated on a 11-point scale to what extent they were able to imagine themselves in the position of the patients, ranging from “not at all” to “very strongly”. Participants rated the realism and their ability to imagine themselves as the patient highly Table . QualitaWe used simple numerical scales to assess both internal and external validity, which have been used in pilot-testing in previous healthcare communication video vignette studies .InternalAs pilot-testing results were positive, no further changes were made to the videos. Additional file Previous vignette studies examining health communication have used healthy volunteers as analogue patients , 50–54, Accordingly, we chose to recruit ‘healthy’ volunteers  as APs. Moreover, recruiting sufficient participants to ensure that the study was adequately powered was important, and we felt this more achievable with healthy volunteers. We aimed to recruit a diverse sample of participants regarding age, gender and ethnicity: anyone aged 18 or over, currently living in the UK was eligible. Participants were not compensated for their participation. We excluded medical doctors/students because we felt their medical knowledge and experience might influence results and produce conclusions less generalisable to the wider population.We administered the videos using Thiscovery, an online platform developed by The Healthcare Improvement Studies (THIS) institute. Participants watched the videos and completed questionnaires on their own electronic devices, without researcher supervision. To mitigate against external distractions and influences, we instructed participants to watch the videos on their own, at a time unlikely to be disturbed. Although participants could access the study on mobile phone devices, we advised them to use a larger screen if possible  to make the experience more immersive.Previous studies have varied in the number of vignettes watched per participant: from one , 56, 57,Our study was a randomised crossover trial, in which participants sequentially watched either V1A and V1B, or V2A and V2B  . DespiteTo avoid providing participants with cues which might change how they respond, participants were blinded to the study hypotheses. In the participant information sheet the aims of the study were described as examining the effects that different types of doctor communication might have on patients. We did not mention the concept of ‘diagnostic uncertainty’ prior to participation. After watching both videos and completing the questionnaires, we provided participants with a debriefing statement explaining the study aims and hypotheses.We have outlined our application of published guidelines to produce four video vignettes used to study the communication of diagnostic uncertainty. We wish to emphasise two aspects of our methodology: firstly, the creation of high-quality vignettes in a cost-effective manner and, secondly, the use of an online platform. We argue that these points are particularly important in making video vignette methodology more accessible – both to researchers, and to diverse patient populations. Below, we draw from our experience to make recommendations for researchers designing video vignette studies.The creation of video vignettes can be time-consuming and costly, particularly if filming involves professional actors and/or film crews. These costs can quickly multiply if reshooting is required following pilot testing. Thus, although video vignettes are a useful tool in studying healthcare communication, they may appear inaccessible to researchers with limited resources.This paper demonstrates that producing and using video vignettes need not necessarily be expensive and time-consuming. We filmed our videos with readily available and user-friendly technology, and we pursued a ‘video consultation’ style; this eliminated the need for extensive technical knowledge or equipment. We also carefully developed scripts and took a pragmatic approach to pilot-testing, saving both pilot testers’ and researchers’ time.Existing vignette studies have taken a variety of approaches to pilot-testing: some have only pilot-tested scripts, others have tested scripts and videos, and some have not reported any formal pilot-testing . There iRecruitment can be challenging in health communication research, and pilot-testing with large numbers may not be feasible. Furthermore, pilot-testing with more participants than is necessary raises ethical issues – we should avoid using participants’ time unless their involvement will positively impact the study.We achieved good results with relatively small pilot numbers: 15 script pilot-testers and 14 video pilot-testers. The final videos were internally valid (the manipulations in uncertainty communication were perceived by participants as intended by the research team), and externally valid .These positive pilot-testing results may reflect the fact that we took steps at an early stage in the design process to ensure validity. Other studies have taken various approaches to initial script development: some have based them upon real consultations  camera angle videos may be more realistic.Although it may have been more naturalistic for the doctor to have memorised the text (as opposed to reading from the teleprompter), we had limited time and we wanted to ensure that there was no deviation from the scripts we had already pilot-tested. We were unable to find any published data comparing the realism of memorisation vs reading from a teleprompter, but this is something future researchers could consider if time permits reliable memorisation of the scripts.Despite suggestions that an actor might be more realistic, we found otherwise. Costs may be saved by using volunteers  in place of professional actors. Alternatively, researchers who decide to use an actor might find it beneficial to perform a screen test with preliminary pilot-testing initially, before employing them for the entire series, to save unnecessary costs.Online vignette studies may increase accessibility for participants, but current research largely overlooks accessibility considerations. With increasing use of online methods , it is uBelow we evaluate the little existing research on accessibility and online methods, and urge researchers to consider how they might account for the needs of underrepresented groups  in vignette studies. For instance, working with stakeholder groups to co-design different conditions related to accessibility, and utilising online platforms to recruit greater sample sizes, may increase inclusivity . Although online technologies can widen participation in research, they can also create barriers to participation by favouring those with good digital literacy and access , 68, 69.When creating our videos we consulted the literature on accessibility. Our choices reflect attempts to balance varying participant needs with logistical constraints the need to ensure validity in results.For video vignette studies, alternative forms of consuming video content – such as subtitles or closed captions, or providing a written alternative which can be read in Braille or screen-readers – could make the research more inclusive . One stuSuch concerns are not, however, evidence-based. A recent study investigating the impact of vignette modality  showed no effect on engagement, recall, trust, satisfaction and anxiety ; this suOverall, there is limited conclusive guidance on how to reduce barriers to participation in vignette studies for those from underserved groups – those from minority backgrounds or who have disabilities like dyslexia, visual/hearing impairment and learning disabilities . FurtherFour video vignettes manipulating the communication of diagnostic uncertainty were created and validated for experimental use. Our reflections provide practically useful recommendations of how to make video vignettes more accessible both to researchers and to participants from a range of backgrounds.We propose that it is possible to produce high quality vignettes without an overly complex or expensive development procedure, potentially increasing accessibility for researchers with budget/time constraints. We highlight the potential benefits of online methods in improving accessibility for participants but suggest a need to acknowledge and explore how to reduce the barriers to participation in online vignette studies for those from underserved groups.Additional file 1: Appendix 1. Vignette scripts and introductory text.


As a calcium (Ca2+) antagonist, it is imperative for numerous neuromuscular activities. The imbalance of body Mg2+  concentration leads to clinical manifestations ranging from asymptomatic to severe life-threatening complications. Therefore, the contribution of Mg2+ measurement regarding various laboratory and clinical aspects cannot be ignored. Mg2+ is often described as the forgotten analyte. However, its close relationship with body potassium (K+), Ca2+, and phosphate homeostasis proves that Mg2+ imbalance could co-exist as the root cause or the consequence of other electrolyte disorders. Meanwhile, several preanalytical, analytical, and postanalytical aspects could influence Mg2+ measurement. This review highlights Mg2+ measurement's laboratory and clinical issues and some analyte disturbances associated with its imbalance. Understanding this basis could aid clinicians and laboratory professionals in Mg2+ result interpretation and patient management. Magnesium (Mg Magnesium physiology2+ is the second most ample intracellular cation in the human being after K+. It is the fourth most abundant cation in the human body after sodium (Na+), K+, and Ca2+  / 0.7 X PMg X UCr] X 100%. U refers to urine, and P refers to plasma or serum Mg2+ (Mg) and creatinine concentration. PMg is multiplied by 0.7, considering approximately 70% of extracellular Mg2+ is free and freely filtered by the glomerulus [Distinguishing between renal and extrarenal causes of hypomagnesemia can also be made using 24-hour urinary Mg+ losses . Alternallection ,10. Genel origin . The forHypermagnesemia2+ level of more than 1.1 mmol/L, with symptoms manifesting at different levels of severity  to rule out renal impairment and any associated electrolyte disturbances, such as K+, Ca2+, and phosphate. If Familial Hypocalciuric Hypercalcemia (FHH) is suspected, a 24-hour urinary Ca2+ test can be conducted. Blood gases, plasma glucose, and ketones should be measured in cases of suspected diabetic ketoacidosis. Other tests may include serum creatine kinase level for rhabdomyolysis, an endocrine workup for conditions like hyperparathyroidism and adrenal insufficiency, and lithium therapeutic drug monitoring (TDM) in cases of suspected lithium overdose [When suspecting hypermagnesemia in a patient, the laboratory approach includes measuring the serum Mgoverdose ,27.Clinical aspects of magnesium measurementAn Often-Overlooked Clinical Importance of Magnesium2+ supplementation has proven safe and convenient in disease and health [2+ levels associated with aging are linked to the rapid generation of oxygen-derived free radicals, the reactive oxygen species (ROS), contributing to DNA damage, lipid peroxidation, and insulin resistance [2+ imbalance in managing electrolyte disturbances should not be overlooked. Dietary Mgd health ,28. Hypod health . Even insistance ,30. Studsistance . The asssistance ,23. BecaAssociation of Magnesium and Potassium+ and Mg2+ is interrelated. Central disturbance in Mg2+ balance, predominantly Mg2+ depletion, will produce a secondary K+ depletion. Mg2+ is necessary to activate the sodium-potassium pump (Na+-K+-ATPase). The low intracellular Mg2+ level inhibits this pump. Hence, it depletes intracellular K+ [2+ provides an inhibitory effect on the renal outer medullary K+ (ROMK) channel [+ reabsorption and, hence, renal K+ wasting. This results in concurrent hypomagnesemia and hypokalemia, which poses a high risk for developing torsade de pointes and other cardiac arrhythmias. In cases of ongoing gastrointestinal loss, alcoholism, or diuretic therapy, the hypokalemia worsens, and the patients could be refractory to K+ replacement therapy. Therefore, simultaneous hypomagnesemia should be suspected [The metabolism of Klular K+ ,23. Mean channel . In hypouspected .Magnesium and Calcium Homeostasis: Parathyroid Hormone (PTH) and Magnesium2+ stimulates PTH secretion, while a sharp increase suppresses PTH release. This relationship is complex and partly because both Ca2+ and Mg2+ compete for transport in the thick ascending limb of the loop of Henle and bind to the human Ca2+-sensing receptor (CaSR) at the renal tubule and parathyroid gland level [An acute decrease in Mgnd level .Magnesium and Calcium Homeostasis: Magnesium and Vitamin D Activity2+ as the cofactor (Figure 2+-dependent vitamin D-resistant rickets. This is because Mg2+ plays a vital role in vitamin D activation. Therefore, lack of Mg2+ prevents vitamin D activation, hence hypocalcemia [Vitamin D metabolism relies on Mgr Figure . Some pacalcemia , 29.Magnesium and Calcium Homeostasis: Magnesium, Calcium, Tubular Transport, and the CaSR2+ binding to the CaSR causes prostaglandin and cytochrome p450 generations that inhibit ROMK. This prevents K+ secretion into the tubular lumen through ROMK, reducing K+ concentration. When both urinary K+ and Mg2+ levels are low, this supports the diagnosis of refractory hypokalemia secondary to hypomagnesemia [+-K+-2Cl--co-transporter [2+ binding also decreases the permeability of the paracellular Ca2+ and Mg2+ pathway. The result is excessive Mg2+ excretion. Therefore, hypercalcemia causes hypomagnesemia, but paradoxically, hypomagnesemia will also result in hypocalcemia because of parathyroid gland-CaSR-mediated PTH inhibition [Cagnesemia . This cansporter ,32. In ahibition . This inAssociation of Magnesium and Phosphate2+ are crucial for the ATP function [2+ wasting [2+ and Ca2+ reabsorption but reduces phosphate reabsorption at the proximal convoluted tubule [Phosphate and Mgfunction . In the  wasting . Neverthd tubule .Limitations of this studyThis study provides a broad overview of magnesium imbalance, which the authors believe could aid in the clinical interpretation and treatment of patients with magnesium-related electrolyte disturbances. The main limitation is that PubMed was the only search engine used, and the related articles selected did not undergo detailed inclusion and exclusion criteria. Future studies could focus more on specific laboratory or clinical aspects to better suggest approaches for raising awareness of magnesium's clinical importance.2+ is essential in the human body. Although it is often a "forgotten" analyte, its imbalance usually accompanies the imbalance of other electrolytes in a sick patient. Its narrow reference range reflects its minimal circulation concentration and high intracellular concentration. However, minute disturbance in its cellular homeostasis can result in a disturbed balance that will affect many Mg2+-dependent physiological activities that disrupt body functions. The laboratory should optimize preanalytical, analytical, and postanalytical processes of Mg2+ measurement. Clinically, Mg2+ imbalance should not be missed when abnormal K+, Ca2+, and phosphate levels are observed. Mg


This video lecture is appropriate for emergency medical providers who are not comfortable with initial assessment of poisoned patients. Ideal learners include medical students and residents.Poisoning is the leading cause of injury-related mortality in the United States, with more than 40,000 deaths annually.By the end of the lecture, learners should be able to: 1) initiate the evaluation of a poisoned patient, 2) identify key interventions to support airway, breathing, and circulation, 3) identify the three components of risk assessment in the poisoned patient, 4) list the four options for gastric decontamination, and 5) select standard diagnostic labs and tests commonly used in evaluating poisoned patients.This is an enhanced live action greenscreen recording with video animation.This video has been made available for a variety of learners on social medial (Facebook and YouTube) and written feedback has been collected on YouTube.The video has been seen over three thousand times and has received positive comments on social media . Comments include “dropping some tox knowledge bombs, proving yet again that #ToxRocks,” and “This is an excellent talk, thank you very much, but I think it would be worth mentioning antidotes.”The goal is to expose learners to basic concepts in approaching poisoned patients and focusses on cognitive knowledge and diagnostic frameworks. The learner may watch the on-demand video as part of a flipped classroom experience with clinical cases, or as a just-in-time resource before seeing a patient who has been poisoned.Poisoning, resuscitation, risk assessment, gastric decontamination, occult ingestion, supportive care. Learner Audience:Medical students, Interns, Junior ResidentsTime Required for Implementation: 18 minutesTopics:Poisoning, resuscitation, risk assessment, gastric decontamination, occult ingestion, supportive care.Objectives:By the end of the lecture, learners should be able to:Initiate the evaluation of a poisoned patient.Identify key interventions to support airway, breathing, and circulation.Identify the three components of risk assessment in the poisoned patient.List the four options for gastric decontamination.Select standard diagnostic labs and tests commonly used in evaluating poisoned patients.The goal is to expose learners to basic concepts in approaching poisoned patients and focusses on cognitive knowledge and diagnostic frameworks. The learner may watch the on-demand video as part of a flipped classroom experience with clinical cases, or as a just-in-time resource before seeing a patient who has been poisoned. Alternative formats such as live lecture or high-fidelity simulation would not provide asynchronous education. In this format, the lecturer first outlines an overview to evaluation of the poisoned patient (objective 1). He then begins to discuss the key interventions for resuscitation at approximately 1 minute (objective 2). This includes airway interventions as well as approach to dysrhythmias. He discusses the three components of risk assessment at approximately 7.5 minutes (objective 3). Specifically this includes considering the drug, the dose, and the patient. He moves on to discuss risk mitigation, initially explaining gastric decontamination at approximately 11 minutes (objective 4). He outlines an approach to testing for occult ingestion at approximately 13.5 minutes (objective 5). Finally, he discusses disposition and observation duration at approximately 15 minutes. He reviews all of his recommendations in closing at approximately 17 minutes.https://youtu.be/JSx86YCGFgUThis can be used as a tool for flipped classroom learning or in a clinical setting just-in-time resource before seeing a poisoned patient. The video has been seen over three-thousand times and has received positive comments on social media . Comments include “dropping some tox knowledge bombs, proving yet again that #ToxRocks,” and “This is an excellent talk, thank you very much, but I think it would be worth mentioning antidotes.” We have added mention of antidotes as well as discussion of naloxone for opioid toxicity as a result of feedback. While we have not received formal feedback from on-site learners, the video has been liked/retweeted/shared over 50 times. YouTube audience retention metrics suggest that average view duration was over 6 minutes, and relative audience retention was above average compared to YouTube videos of similar lengths.The video can be streamed on any electronic screen with access to the internet and is appropriate for computer or mobile phone screens. Approximately 61% and 33% of YouTube viewers watched on computer and mobile devices, respectively.


Episodic growth due to microvascular proliferations (MVP) has been reported in congenital arteriovenous malformations (AVM), which are normally quiescent lesions composed of mature malformed vessels. Since AVM also may worsen under conditions of hormonal dysregulation, we hypothesized that hormonal influences may stimulate this process of vasoproliferative growth through potential interactions with hormone receptors (HR).13 Cases of AVM tissue with histologically documented vasoproliferative growth were analyzed quantitatively for the presence and tissue localization of estrogen receptor (ER), progesterone receptor (PGR), growth hormone receptor (GHR) and follicle-stimulating hormone receptor (FSHR) in relation to resident cells of interest , smooth muscle cells (SMC) and mast cells (MC)) by applying multiplex immunohistochemistry (IHC) staining. Expression patterns in lesions with MVP and mature vessels were quantified and compared. Available fresh frozen tissues of 3 AVM samples were used to confirm the presence of HR using Reverse-Transcriptase quantitative Polymerase Chain Reaction (RT-qPCR).All four HR studied were expressed in all cases within EC and SMC in areas of MVP and mature vessels, but not in normal skin tissue. ER, GHR, and FSHR showed more expression in EC of MVP and in SMC of mature vessels. RT-qPCR confirmed presence of all 4 HR in both areas.Expression of ER, PGR, GHR, and FSHR in vasoproliferative areas of congenital AVM could explain onset of sudden symptomatic growth, as has observed in a subpopulation of patients. These findings may have implications for eventual anti-hormonal targeted therapy in the lesions involved.The online version contains supplementary material available at 10.1186/s40001-023-01436-5. Arteriovenous malformations (AVM) of skin and soft tissues are rare congenital vascular lesions, arising from dysmorphogenesis during embryogenesis. They usually have a slowly progressive growth commensurate with the growth of the patient, and do not regress overtime –3. CompaEpisodic growth of AVM has also been attributed to occurrence of areas of microvascular proliferations (MVP) –6. MeijeSeveral studies have demonstrated that specific hormone receptors (HR) such as progesterone receptor (PGR), growth hormone receptor (GHR), and follicle-stimulating hormone receptor (FSHR) were present in vascular tumors and vascular malformations , 7, 14. Hormones such as estrogen and follicle-stimulating hormone (FSH) have been described to be involved in angiogenesis. Several studies have reported a positive correlation between ER expression, angiogenic activity, and an invasive growth pattern of breast tumors –18. ThesExpression of several HR on the vascular walls of several types of vascular malformations including AVM has been described only in mature vessels of vascular malformations, but was not investigated specifically in areas of MVP , 22. HypTherefore, the present study was designed to immunohistochemically investigate the expression of several types of HR in which a vasoproliferative response had occurred. Archived paraffin blocks of large AVM resection specimens were selected which contained histologically proven vasoproliferative areas amidst the vessels of the pre-existent arteries and veins of the malformation. Immunostaining of ER, PGR, GHR and FSHR was applied, followed by comparing the relative expression of the respective HR in both areas of interest (MVP versus pre-existent mature vessel areas). Since several cell types can be involved in angiogenesis, particularly EC, SMC, and mast cells (MC), we also investigated the co-localization of HR expression in these cell types. Potentially this could improve our knowledge on angiogenic growth in AVM lesion, in addition to the previously known insight of angiogenic factors released by mast cells –25.n = 9) were females , location AMC, a referral center for management of vascular malformations. The study materials were selected from a file of anonymized 37 AVM cases with histologically proven present proliferative areas amidst the conglomerates of mature vessels. Proliferative areas where defined as solid areas of densely packed capillary vessels lined with plump endothelium. Proliferative activity was confirmed by increased Ki67 labelling index of the microvessels , 26. On es Table . AdditioSerially cut sections (4 µm) were stained with Hematoxylin & Eosin (H&E) and Elastic van Gieson (EvG) stains, respectively, to confirm the diagnosis of AVM and presence of representative areas of MVP. Adjacent sections were mounted for IHC staining.The following antibodies were used: monoclonal rabbit anti-Ki67 , mouse anti-estrogen receptor , monoclonal mouse anti-progesterone receptor (DAKO), polyclonal rabbit anti-growth hormone receptor  and monoclonal mouse anti-follicle stimulating hormone receptor , mouse monoclonal anti-CD31 , mouse monoclonal anti-smooth muscle actin/SMA-1  and mouse monoclonal anti-Tryptase .2O2 (30% diluted in methanol to a 0.3% solution). Incubation with primary antibody (Ki67), followed by horseradish peroxidase (HRP) anti-rabbit polymer secondary antibody . HRP enzyme activity was detected in brown using DAB plus , and counterstained with Hematoxylin.Ki67 was applied using single IHC staining to detect vasoproliferative areas. In short, sections were dewaxed in xylene and rehydrated in graded-alcohols prior to antigen retrieval with heat-induced epitope retrieval (HIER) in a PT Module  using Tris–EDTA buffer (ThermoFisher Scientific). Endogenous HRP was blocked in methanol + HIHC quadruple multiplex staining was performed to investigate the distribution of the HR  by resident cells . Essentially, the staining was performed as described above in single IHC staining, with the only difference that the Vector Novared  was used as a chromogen. Sections were counterstained with Hematoxylin, dried on a hotplate, coverslip sealed with Glycerol/Gelatine  and digitized using a Philips IntelliSite ultra-fast Scanner . After scanning, a second staining round was performed by removing the coverslip in hot water and subjecting the sections to a stripping buffer (Tris-SDS + beta mecapthoenatol) in which the colours and immune complexes were eluted from the sections. After washing, the sections were stained with a different antibody and digitized again as described above . The pro2. Colocalization of the HR antibody with resident cell specific antibodies  was quantified by calculating the Manders Overlap Coefficient (MOC), a quantitative co-localization analysis method [In each quadruple multiplex immunostained section containing immunostained EC, SMC, MC and one of the respective HR, regions of interest (ROI) consisting of MVP areas and of mature vessels were selected measuring ± 1.56 mms method , 11. In s method . DigitalTo compare HR expression in different tissue areas of the malformations and its colocalization in specific cell types, a normality test was performed with Shapiro–Wilk test, and a non-parametric Mann–Whitney test were used. Statistical analysis was performed with SPSS 26.00 .RNA isolation was applied on each available frozen AVM samples and control tissues. 30 sections of 20 μm were cut, and RNA was isolated using RNABee  and the RNeasy Mini kit  according to manufacturer’s instructions. Then, RNA concentration was determined at 260/280 nm using a Nanodrop spectrophotometer (Thermo Fisher Scientific) to create cDNA .™ SYBR® No-ROX Kit  was used in a 10 μl reaction. A non-quantitative RT-PCR for HR was applied on breast cancer, kidney, and testis tissue, which were all positive, while a sample of normal skin tissue was negative.Single-stranded cDNA was synthesized from 500 ng total RNA at a temperature of 40 ℃ for one hour using random hexamer primers  and M-MLV Reverse Transcriptase . Finally, four pairs primers Table  were dev2) amidst the mature vessels of the malformations [Histopathology using HE and Elastic van Gieson stains showed in all 13 cases the presence of both mature, but sometimes malformed arteries with a tortuous course  in combination with conglomerates of malformed veins. Presence of intimal thickening and dilatation of veins was also observed regularly suggestive for aberrant (high) flow characteristics of the lesions. These findings were consistent with the diagnosis AVM. In addition, all 13 samples showed areas of closely packed capillary vessels with plump endothelium and MVP and high labeling index of Ki67  were found to be expressed in MVP areas of all 13 cases, albeit in variable amounts. Specifically, PGR and GHR showed a nuclear type of positive immunostaining, while ER and FSHR showed a nuclear and in addition cytoplasmic pattern of immunostaining in all lesions. In normal skin tissue, no expression with any of the HR was observed . All 4 types of HR were expressed on EC and SMC, and none on MC. Overall, most abundant expression was observed in SMC  . The preHR expression has been reported previously in tissue specimens of vascular malformations, especially in AVM , 14, 32.Estrogens are considered to be the most-involved hormones in puberty of both male and female . KulungoGH also tends to have a role during puberty, when levels of GH increase rapidly . IncreasHormonal influence through progesterone in AVM lesions was supported by Duyka et al. who found that 83% of AVM samples in their study group showed diffusely positive PGR expression in EC and SMC compared to controls . HoweverMaclellan et al. have reported the expression of FSHR in a diverse series of vascular anomalies, which included different types of vascular malformations including AVM, and also benign vascular tumors, whereas vascular control tissues were negative. Among these, the highest levels of expression were found in the proliferative stages of IH, which is characterized by abundant microvascular proliferations . The autTaken together, previous publications and this study have provided sample evidence for expression of hormone receptors by vascular wall cells of AVM lesions. At the same time, vascular malformations are likely to grow under hormonal influences as has been noticed clinically during adolescence and pregnancy . MoreoveIt is assumed that the vasoproliferative response represents a reactive phenomenon, which can be induced by external factors such as inflammation, trauma, and especially circumstances of tissue hypoxia as has been published previously –48. The The number of samples included in this study is limited since the study required a highly specific case population. AVM are rare congenital vascular malformations, which require surgical resection only in case of serious symptoms. Moreover, the occurrence of histologically proven MVP occurs only in a subpopulation of the cases, which resulted in a total of only 13 cases.The present study advanced our knowledge on angiogenesis and hormonal involvement in the progression of AVM, since ER, PGR, GHR, and FSHR were expressed not only in the mature malformed vessels of AVM but also in the vasoproliferative areas of these lesions. Based on these findings, we propose that the growth of vascular malformations in situations of hormonal dysbalance could be explained by the expression of hormone receptors on vessels of the malformations, in which MVP components may participate. These MVP areas, characterized by high vascular densities, may serve as a target area for episodic rapid growth under such hormonal dysbalanced situations. Unfortunately, due to the anonymized status, no information was available on the hormonal status of the patients involved in this study, but these findings could be useful for ongoing research on a molecular level to determine the definitive association between hormones and angiogenesis in AVM, and development of targeted therapies for recurrence AVM by reducing the use of hormonal therapy and preventing the use of hormonal drugs or contraception.Additional file 1: Table S1. M1 Score for 4 HR in EC between MVP and mature vessels area. Table S2. M1 Score for 4 HR in SMC between MVP and mature vessels area. Table S3. M2 Score for 4 HR in EC between MVP and mature vessels area. Table S4. M2 Score for 4 HR in SMC between MVP and mature vessels area.


Lockdowns have been used to prevent the spread of transmissible illnesses such as influenza, norovirus, and COVID-19 in care homes. However, lockdowns deny care home residents supplemental care and the socioemotional enrichment that comes from seeing family members. Video calling has the potential to enable ongoing contact between residents and family members during lockdowns. However, video calls can be considered by some as a poor substitute for in-person visits. It is important to understand family members’ experiences with video calling during lockdowns to ensure the effective use of this technology in the future.This study aimed to understand how family members use video calls to communicate with relatives living in aged care during lockdowns. We focused on experiences during the COVID-19 pandemic, which involved extensive lockdowns in aged care homes.We conducted semistructured interviews with 18 adults who had been using video calls with relatives living in aged care during pandemic lockdowns. The interviews focused on how participants had been using video calls, what benefits they gained from video-based interactions, and what challenges they encountered when using the technology. We analyzed the data using the 6-phase reflexive approach to thematic analysis by Braun and Clarke.We developed 4 themes through our analysis. Theme 1 interprets video calling as a medium for the continuation of care during lockdowns. Using video calls, family members were able to provide social enrichment for residents and engaged in health monitoring to uphold residents’ welfare. Theme 2 highlights how video calling extended care by supporting frequent contact, transmitting nonverbal cues that were essential for communication, and negating the need for face masks. Theme 3 interprets organizational issues such as the lack of technology and staff time as impediments to the continuation of familial care through video. Finally, theme 4 highlights the need for 2-way communication, interpreting residents’ unfamiliarity with video calling and their health conditions as further barriers to the continuation of care.This study suggests that, during restrictions arising from the COVID-19 pandemic, video calls became a medium for enabling family members to continue participating in the care of their relatives. The use of video calls to continue care illustrates their value for families during times of mandatory lockdown and supports the use of video to complement face-to-face visits at other times. However, better support is needed for video calling in aged care homes. This study also revealed a need for video calling systems that are designed for the aged care context. Lockdowns are a common measure for preventing the spread of viral diseases in aged care homes ,2. In reAlthough lockdowns can be an effective way to prevent disease transmission, prolonged periods of isolation are highly detrimental to the cognitive and emotional well-being of care home residents . LonelinAfter the onset of the pandemic, many aged care homes adopted video calling systems as a replacement for face-to-face visits ,24. ThesThe need to understand the utility of video calling as a replacement for face-to-face visits, especially during lockdowns, is important for multiple reasons. First, the pandemic was perhaps the first time that video calling was deployed en masse in care homes. There have been studies illustrating the benefits of video calls for aged care residents, including positive impacts on social connection , emotionSecond, studies conducted before and during the pandemic have identified that video calling is affected by challenges in long-term care. A study conducted in Canada by Chu et al  found thThis study aimed to understand how family members used video calls to communicate with relatives living in aged care homes during COVID-19 lockdowns. We focused on experiences of video calling in Australia, where there were extensive and protracted lockdowns that prevented families from visiting relatives during the first 2 years of the pandemic.This study explored the following questions:How did family members use video calling with relatives in aged care during lockdowns?In what ways was video calling beneficial for family members?What challenges or barriers need to be overcome to support high-quality video calling experiences during lockdowns in aged care?This study was approved by the University of Melbourne Human Research Ethics Committee (ID 1851239.5).This study used semistructured interviews to investigate family members’ experiences with video calling. We used a semistructured approach to guide each interview using a broad set of questions while enabling participants to bring their own topics and experiences into the conversations .The reflexive thematic analysis (RTA) approach by Braun and Clarke ,41 was uConsistent with the assumptions of RTA, we adopted a constructionist and experiential orientation for our data collection and analysis. This means that we prioritized participants’ own accounts of their experiences while using our interpretations to interrogate the meaning within those experiences . We adopWe collected data for this study from July 2021 to October 2021 in the state of Victoria, Australia. Victoria was the site of several major COVID-19 outbreaks in 2020 and 2021. The state government imposed a total of 6 lockdowns that lasted a cumulative 8 months . These lWe recruited participants through the University of Melbourne internal staff mailing list and web-based noticeboards, advertisements on Twitter and LinkedIn, and word of mouth. Participants enrolled in the study by contacting the first author via email. There were no preexisting relationships before study commencement.Our sample size was evaluated throughout the research process , and we Interviews were one-to-one and were conducted by the first author. Before study commencement, we emailed participants a Plain Language Statement containing information about the study’s aims and procedures. Participants also signed a consent form, which they returned to the first author via email.The researcher met with participants individually using Zoom videoconferencing software. We used Zoom to comply with social distancing requirements, which were in place when our data were collected. We used a semistructured interview guide, with an initial set of open-ended questions that enabled participants to share their personal experiences . RMK highlighted passages that were relevant to the research questions and used the comment functionality to capture potential codes and thoughts about the data . In phass of RTA , we mades of RTA .In phase 3, RMK assembled the codes into initial candidate themes by manually grouping codes using NVivo and sketching thematic maps using pencil and paper. RMK discussed the evolving analysis with author YX, who also read through the coded data, sense-checked interpretations, and reviewed the candidate themes.In phase 4, RMK refined the themes and discussed them with author JW. The authors felt that an initial “benefits and challenges” framing could be helpful to capture the essence of participants’ experiences. This discussion resulted in 6 initial subthemes related to benefits and 5 subthemes related to challenges. In phase 5, RMK defined and named each theme, selecting participant quotes and data extracts to illustrate key ideas. Phase 6 involved writing an initial draft of the report, which involved further theme refinement .After receiving feedback and peer reviewers’ comments on the report, RMK went back through phases 3 to 6 and revised the themes to develop primary interpretations and address the research questions. We also changed our framing to focus on the continuation of care, removing the initial ideas regarding benefits and challenges. Returning to earlier phases in this way is consistent with the tenets of RTA, which champions iteration and argues that analysis “becomes increasingly recursive”  as the iResults section details these themes after presenting demographic data on the participants.From this iterative process, our analysis converged on the central interpretation of video calling as enabling the continuation of care during lockdowns. That is, video calls were not simply a medium for social connection but were being used to continue care practices that would ordinarily take place during face-to-face visits. We created one theme to capture uses that spoke to continuation of care and a second theme to highlight how video calling extended care. We developed 2 further themes: one that interprets organizational issues as impediments to continuing care through video calling and another that highlights the need for 2-way communication for continuation of care. The Data extractRMK: How do you think going on the video calls helps with that?Gloria: I don’t really know that it does help him, but it certainly helps me because I’m reassured seeing that he’s all right or not too bad. And I have noticed particularly, if I don’t see him, if the video call doesn’t come about, then I go in [to see him] and I go, “Oh, he’s gone downhill.” So, it’s more noticeable that way. It’s very, very lonely for him being in there, he’s really not communicating with other residents because of the PSP. So, he’s just either stuck in his room or sitting, looking out of the window in the lounge areas.CodesFeeling reassured by video callsImportance of visual information and seeing the residentConcern about resident declineResident lonelinessCommunication impairmentFamily members are concerned for residents’ emotional well-beingWe recruited a total of 18 participants  between the ages of 20 and 76  years. Of the 18 participants, 17 (94%) participants lived in Australia, in the state of Victoria, and 1 (6%) participant  were living in Australia, and 5 (23%) were living in care homes abroad . The relatives’ ages ranged from 69 to 98  years. Of the 22 relatives, 18 (82%) were described as having at least one health condition or impairment that affected their use of video calls . All theAll participants had been using video calling with their relatives living in aged care during the pandemic. However, video calling was a new activity for 44% (8/18) of the participants. These individuals had previously visited their relatives in person but turned to video calls during the lockdowns. The remaining 56% (10/18) of the participants had some previous experience using video calling with their relatives in care before the emergence of COVID-19 but became solely reliant on the technology during lockdown periods.This theme responds to our initial question of how video calling was used by family members. The central idea developed through our analysis was that video calling enabled family members to continue participating in the care of their relatives during lockdowns. In other words, video calls provided a way to maintain some of the activities that typically occur during a face-to-face visit. Specifically, participants discussed using video calls for social enrichment and for monitoring residents’ health—both of which would ordinarily take place in person. These uses can be interpreted as relevant to the provision of care—one is about providing social and emotional care, whereas the other is about monitoring physical and mental well-being. Both are about ensuring that the resident is being “cared for” in an appropriate way.The first aspect of continuing care was demonstrated through participants’ descriptions of providing social enrichment when physical visits were not possible. These accounts were often couched in the need to prevent “decline.” Gloria, for example, discussed the welfare of her husband, who had moved into care because of progressive supranuclear palsy. She said that her husband had become “very lonely” during the lockdowns. Therefore, video calling was her husband’s primary source of social enrichment, and Gloria felt that there was a clear and noticeable impact on his well-being if video calls did not occur. Upon visiting him in person between lockdowns, she observed the following:I have noticed particularly, if I don’t see him, if the video call doesn’t come about, then I go in [to see him] and I go, “Oh, he’s gone downhill.” So, it’s more noticeable that way. It’s very, very lonely for him being in there, he’s really not communicating with other residents because of the PSP. So, he’s just either stuck in his room or sitting, looking out of the window in the lounge areas.Participants described diverse uses of video calls for the continuation of social enrichment. In some cases, video calls were used for short “catch ups” and “chit-chat,” which provided opportunities to share updates about happenings outside the care home, keeping the resident involved in family life. Other cases involved the use of video calls for in-depth relationship maintenance. Quinn described how Skype calls with her grandparents would typically last over an hour and would involve different activities:I always use my laptop when we Skype and I share my screen when I want to show them something. It’s always good to show them photos of everything while we are Skyping so that we can talk about them together. And we also watch videos together sometimes.Quinn’s quote shows how video calls were used to mediate intergenerational activities that constitute an enriching social life and that would otherwise be impossible during lockdowns without using technology. Video calls were also used to continue with other events and social situations. Katherine described how, when it was her mother’s birthday, she was able to visit the facility between lockdowns and use a video call to host a celebration with extended family members:When it was her 98th birthday in June (2021), I took my laptop in...Then my brother and I had the laptop and we Zoomed my other brother. We had him sort of in the background, chatting away while we had a birthday cake and some of the staff came in with more cake.Although these findings reinforce the notion that video calls can support social connections between family members and care home residents ,31,59-61I have a four-year-old son, so I try to get him to say hello too, which always puts a smile on dad’s face...then if I’m at home with my son, I can put him on and my husband and we can all say hello.Charmaine[Dad] would be happy and smile and be positive about having received our calls. It’s good for him to see us and remember us, and to see my mother and talk to my mother and me and my brother.LucaThe second aspect of continuing care involved family members using video to monitor the health of their relatives. Outside of a lockdown, such monitoring might naturally occur as part of a physical visit. The fact that this took place through video calls further evidences their use for continuation of care.For participants such as Jackie, monitoring her mother’s health was a key motivator for adopting video calls during lockdown. She felt that information from care staff was useful but not entirely sufficient, and she expressed a need to do “checking up” on her mother:When we went into lockdown, we couldn’t see how she was. She can’t talk to us. Even though the nursing staff will give us some information, you still want a little bit of checking up, if you know what I mean? So we started to have Zoom meetings with her.Participants described making inferences about their relatives’ health during video calls based on visual appearance and the tidiness of their living environment. These actions can be understood as constitutive of care given that they represent attempts to determine whether something is wrong and, hence, whether intervention is required. Olive described how she used video calls to check for what she called “signs of deterioration”:I’m attuned to looking for particular things. Have they done their hair? Have they done their nails? What’s their environment like? Are they taking care of themselves? Are their clothes clean? Those kinds of things are very important to me. That’s part of me knowing that they’re in good health, because that’s how they normally present themselves.A participant, Ben, provided a compelling example in which he used a video call to infer that his father had contracted COVID-19. His father had previously tested negative for the disease following an outbreak within his facility, but interactions during a video call convinced Ben that further action was required. The following extract reveals how Ben’s intervention led to his father receiving treatment and emphasizes the role of the video call in making his assessment:I noticed things were off in his voice. And I just kept asking him, “Are you okay?” And it finally led to me saying [to the staff], “I think you need to test him again.” I just got the sense that he wasn’t well. Based on how he looked, how he was physically presenting on the video, as well as how he sounded. And don’t take the audio too far on that one, because I think a lot of it came from his visual appearance. He just doesn’t look well. They wound up finally having a closer look and he was eventually taken to the hospital and treatedfor COVID-19In addition to monitoring health and well-being, Ben’s quote alludes to the role of video in enabling participants to advocate for care to be provided. In this case, Ben contacted the staff via telephone and requested additional care. Another participant, Fiona, described how video calls enabled discussions with other family members when monitoring the health of her mother, who was living with dementia:Having the video is good, especially for her sake. I can see her health and how she’s behaving. Because my brother will say, “Her memory’s not good. She’s kind of spacey,” and it’s one thing to say it, but then for me to actually see her and how she behaves, it’s a lot easier.Here, Fiona used video to verify information obtained from other people—in this case, her brother—when maintaining an understanding of her mother’s health. Video calls also provided the opportunity to speak with nursing staff at the care homes. Gloria described how she would often be able to speak to staff during the video calls. This helped relieve anxiety about her husband’s well-being:I can ask them questions about how he’s been, “Is he depressed today? Because he has been quite depressed.” And they can reassure me or say, “Look, talk to him for a few minutes.”Using video calls in this manner helped participants alleviate feelings of anxiety and provided “peace of mind.” For example, Olive told us that using video enabled her to feel reassured about her aunt’s welfare when she could not visit:I was able to physically see in the room, and I was able to make sure that she had the things that she needed. Now, she was fine, but the peace of mind it gave me that the room was clean, that her personal effects weren’t being interfered with, that she had the basics...Those sorts of things are really important to me.These examples illustrate how video calls provided opportunities to continue care practices that would ordinarily be conducted face to face and that might have been difficult or impossible when in-person visits were restricted.This theme responds to our initial question of how video calling was beneficial to family members, that is, how specific qualities associated with using video calls contributed to the continuation of care. This means emphasizing the value that video calls add to care—not just how video calls contributed to the continuation of care but how they enhanced care as well.The availability of video calling enabled some participants to contact their relatives more frequently after the pandemic began. Several participants  lived far from their relatives’ care homes and, hence, incurred substantial costs when visiting. These participants described visiting once per week or several times per month before the lockdowns. The transition to video calling allowed these participants to “visit” more frequently than before. Olive, for example, commented on how the frequency of contact with her great-aunts had increased after the lockdowns and how it involved extended family members:In terms of frequency, I would visit once a month on a Sunday [before the pandemic]. During COVID we would FaceTime once a week...That was done as a family, as well. We would have two- or three-way conference calls.Although face-to-face visits were still preferred, the ability to be in more frequent contact was important to those who were concerned about their relative’s health. Ben, for example, valued the ability to pay more attention to his father when there was an outbreak of COVID-19 at his facility. However, some participants  mentioned that facilities had discontinued support for video calling when the lockdowns were lifted as they viewed it as nonessential. These individuals wished that video calling had continued so that they could maintain the increased frequency of contact. Gloria, for example, commented on the inconsistent availability of video calling at her husband’s facility:Once lockdown is over, that’s the end of the video calls and it would be so much better if they could keep it going. And then, I could just touch base with him every day to see how he’s going and he knows that I’m there and caring for him.This extract speaks to frequent contact as a means for families to convey the sense that the resident is being cared for. Although increasing the frequency of contact does not guarantee higher-quality interactions , our parMany participants’ experiences stressed the importance of the visual layer associated with a video call. Being able to see the resident is a key differentiator between video and other communication technologies such as the telephone.We interpreted participants’ experiences as signaling the importance of nonverbal cues for the continuation of care. Such cues include gestures and body movements, facial cues such as lip and eye movements, and the tone of voice. Previous work has argued that nonverbal cues contribute to the “richness” of video calls and enhance feelings of social presence ,57,63, wsee their relatives when communicating with them, which made video calling more helpful than modalities such as the telephone. As an example, Charmaine discussed how nonverbal cues were crucial for interacting with her father, who had become largely mute because of progressive supranuclear palsy. She said the following:Our analysis of participants’ experiences suggested that transmitting nonverbal cues played other roles in providing care. First, nonverbal cues were crucial for participants whose relatives had severe communication impairments. These people emphasized that it was essential to ...he will mouth words, but he doesn’t generally speak out loud and he has trouble finding his words. So we’ve really found that video conferencing works best so you can get the non-verbal cues.When asked to elaborate on what kinds of cues are important and how they help, Charmaine said that nonverbal cues were useful for the following:...being able to see that he’s thinking, because you can see where he’s looking often...And I guess we’re getting better at reading his body language too. He tends to nod, or shake his head, or mouth the words “no” or “yes,” or he’ll just shrug. We also prompt him to speak out loud which used to work more effectively than it does now. But sometimes he can come up with a sentence, and I’ll put my hand up. So I’ll use nonverbal cues as well, like putting my hand up [to show] that I can’t hear.Charmaine’s quote points to the role of eye gaze direction, speed of response, and body language when conversing with her father. It also reveals that the utility of nonverbal cues is bidirectional, with Charmaine using her own gestures to convey information back to her father. These interactions illustrate the complexities of communicating with people living in aged care and highlight the additional value that video-mediated exchanges brought during the lockdowns.A second role of nonverbal cues was to support the conveyance of warmth and affection during emotive communication. Deborah recalled the importance of gestures when interacting with her mother, who has dementia:Gesture communication is very important, especially being Italian. When on the video call, we send kisses to each other, not only at the end, but during the communication itself. I always try to smile to her, she recognizes it. Sometimes I sing songs to her. So it’s not only verbal communication but many other things. I showed her a soft toy and she started laughing. It was funny, she reminded me of a little girl smiling to a doll. It works, somehow, I feel that she is there. She is in a connection with me, a member of the family again.The importance of nonverbal cues also came to the fore when discussing the widespread use of face masks during the pandemic. Several participants  were able to visit their relatives in between periods of lockdown, when bans on visitors were lifted temporarily. These visits required the use of face masks to comply with government regulations. Participants reported that masks made conversations difficult as they occlude facial cues that can underpin nonverbal communication. Masks also made it difficult for residents to understand what was being said, especially among those who were hard of hearing. The fact that video calls did not require masks was said to make conversations “closer to normal.” For example, Elaine told us the following:One difference between face to face and video is that we are not wearing our masks on video calls. When we go there we have to wear a mask in person. So we have these face shields, and that means it is more natural on video calls. It doesn’t seem like there is so much of a barrier, even though we’re not physically there, it just feels like a barrier, a perceived barrier, when we are wearing masks.Taken together, the availability of nonverbal cues can be seen as making a video call feel more like a physical visit compared with wearing a mask or using a modality such as the telephone.This theme brings together organizational issues that negatively affected participants’ use of video calling. Our interpretation is that these issues were problematic as they hampered participants’ ability to enact continuation of care.Consistent with prior work ,34, the Some weeks, we’ll have a beautiful conversation and it doesn’t drop out at all. Then, more often, we’ll have parts of the conversation where we freeze or they freeze. Sometimes they drop-off completely.These connectivity problems led to anxiety and stress for residents and sometimes caused them to think that they had “broken” the technology. Participants described having to spend time reassuring relatives in this situation and had to fix technical problems over the telephone. This was not always easy without the ability to visit in person.In addition to the lack of stable connections, it became apparent that many homes had a limited pool of technologies available to support video calls. Katherine, for example, said that her mother’s aged care home had “only one iPad for 63 families.” This meant that video calls were sometimes cut short as the device was needed for other residents. In some cases, staff members tried to overcome this problem by loaning their personal devices to residents. However, it seemed that the loaning of devices further increased the likelihood of calls being cut short. Robin, who had been using video to see her grandmother, felt that this made some video calls “rushed and inauthentic.” She said the following:...the worst part is when they cut you off...if they use their personal phones, it’s like, “Oh, sorry, I have to take this, there’s something urgent I need the phone for.”We interpret these experiences as limiting participants’ ability to carry out actions relevant to continuing care. That is, poor connections and rushed calls impeded the ability to continue care by providing insufficient information about the residents’ well-being.A putative benefit of video calling is that family members can potentially make and receive calls at any time and at their own convenience. However, the interviews revealed that this benefit was not realized for all participants. Instead, the lack of technology in some homes meant that video calls had to be scheduled in advance. This was done using booking systems created from an assemblage of web-based calendars, email, and telephone. There were also cases where video calls were available only during restricted “visitation hours”—such as at fixed times in the morning, afternoon, and evening. This meant that participants had to schedule their days around these windows, and if they could not be available at the specific time, they were not able to see their relatives.The need to schedule calls was a repeated source of frustration and became a barrier to continuing care. Nicole, for example, described it as “a pain” and wished video calls could be used similarly to telephone calls as “they [the home] allow you to ring anytime.” The restrictions around call times, together with the lockdown conditions in care homes, were described as creating a “prison-like setup.” Irene said that the following occurred during one of the lockdowns:You could not ring anybody in the facility, nor the front desk. It was like a prison, they had one number you could ring and then you could organize something and so you would send an email and say, “Can I have the appointment to Zoom at this time?” And if that one worked, then we could say, “Same time tomorrow, please.” And they’d pencil it in.Despite participants’ attempts to work around the schedules imposed by the care homes, there were cases in which prearranged calls were late or failed to materialize, causing frustration. Gloria told us the following:[the home] might set up a time, but they’re never on time. So, you have to be available for, let’s say, a frame of two hours. I keep telling myself, just be patient.Finally, there was considerable variation in the duration and frequency of calls. Gloria stated that one lockdown involved “two calls a week set up by the staff, but five-minute duration,” whereas Alison said that calls lasted “half hour or a 15-minute session.” These calls were the only source of outside social contact for the residents. Although these short calls may be better than no contact at all, they should raise questions about the adequacy of solutions provided during the pandemic and how these might be improved in the future.Consistent with prior work ,37, partThe need for staff involvement was especially challenging during the COVID-19 lockdowns because of staff shortages and outbreaks within the aged care sector . Some paLike most aged care facilities, they’re at their capacity to provide health assistance. And so it took a while to identify a couple of the nursing staff who both are willing and can find the time to actually help him do calls. And so far, the only ones we’ve been able to do is when I’m calling him and they answer for him.This final theme highlights 2 issues that further impeded continuation of care but that focus on the need for the people in aged care to be able to use and respond to video calls.Some participants  stated that their relatives in care were unfamiliar with video calls and had received no training on how to use them. This was a challenge as their relatives did not know how to operate the software and hardware independently, meaning that calls failed to happen or went unanswered.Participants also mentioned that their relatives did not always understand the concept of positioning oneself in the camera feed. This led to situations in which the participants saw their relatives from awkward angles or without their faces in the frame. Gloria said that her husband did not understand how to manipulate the iPad provided to him at the care home. She recounted the following:[He] just never had anything to do with computers or really technology at all. He didn’t get the concept that you can see yourself on the screen if you’ve got it aimed correctly. That made it rather difficult.To overcome this problem, Gloria and other participants noted that staff involvement was needed. However, as noted previously, this was not always possible. She said the following:[The staff often] go away and leave him, and I would end up looking at the ceiling because the iPad would fall over or something like that, and all I could see was the ceiling.This challenge can be interpreted as further affecting participants’ ability to continue care, especially in monitoring health. This is because the underlying concern relates to acquiring visual cues; when the camera is not angled correctly, it becomes impossible to make inferences about the residents’ welfare.Many people in aged care are living with profound health challenges, some of which precipitate their move into care ,67. Part. To overcome this issue, Paul and his family purchased a large-screen smartphone and “jacked up the size of the keyboard” to make the device more usable for her.For example, Paul discussed how his grandmother had arthritis in her hands, making it difficult for her to use computers for video callsMore challenging cases were reported by participants whose relatives had moderate or advanced dementia. Some  stated that, although video calls were valuable for checking on their relative’s well-being, the conversation was limited as the relative did not fully understand the nature of video calling technology. Our first participant, Alison, had been using video calls to see her mother but decided to abandon them as her mother could no longer comprehend what was happening. She said the following:Sadly, because my mum had dementia, she couldn’t actually use the technology. It didn’t work for her, so we essentially got cut off from her for 18 months. In that way, they made it an option, but it wasn’t an option for someone with [advanced] dementia.When asked to elaborate on why the technology “didn’t work,” Alison discussed how her mother became confused when seeing an image of herself on screen, which is a common feature of video calling applications such as Skype and Zoom. Alison said the following:My mother couldn’t understand what was going on. She wouldn’t interact with it. She wouldn’t look at the screen. If she saw herself on it, she’d just be staring and trying to figure out who that person was. She was better at engaging in person.This example highlights that, although family members may still obtain some benefits from seeing relatives through a video feed, different approaches may be required to enable families to continue seeing residents who have advanced care needs during times of social distancing.This study aimed to understand family members’ uses of video calling during lockdown restrictions in aged care. The main finding of our analysis was that video calling became a medium for family members to enact the continuation of care during lockdown restrictions. Although participants’ experiences of video calling were complex and multifaceted, there was an underlying goal of using the technology to continue care and ensure that care was provided. However, the use of video calls was affected by organizational constraints and the need for 2-way communication with relatives, which was often difficult. These findings contribute to an improved understanding of why video calls were valued during the pandemic lockdowns and extend the knowledge of the challenges that families encountered .Previous research on the use of video calls in aged care has focused primarily on the potential to support social interaction and the technological barriers that can affect their use. Our study is the first to suggest that video calling systems are used for the continuation of care when families cannot visit the facility. This interpretation moves beyond existing characterizations of video as a tool for social connectedness  to one iThis study also suggests that video calling supports family members’ own peace of mind. The COVID-19 pandemic was an extremely stressful time for families, and it has been suggested that the inability to visit during lockdowns produced feelings of helplessness and anxiety , leadingIn addition to continuing care, our analysis indicates that video calling can enhance family members’ caring practices when forced to see their relatives from a distance. When video calling worked well, participants were able to have more frequent contact than before and were able to access nonverbal cues that were essential for communicating with residents who had impairments. This finding is important as, in some countries, care homes are mandated to provide telephone communication with relatives , but vidFinally, our analysis identified that the continuation of care through video calling was impeded by multiple challenges. One problem relates to the constraints of the aged care context, where homes are often underresourced and understaffed . This waThe notion of video calling as a medium for the continuation of care aligns with ideas from early studies that used videophones, which were a primitive form of video calling technology. Demiris et al  suggesteThe challenges identified in this study align with findings of previous trials of video calling in aged care. Examples include limited technology literacy among some residents, low device accessibility, poor Wi-Fi, the lack of devices in care homes, and the need for staff to help with video calls ,34,35. IA novel finding of this study was that resource constraints required care homes and families to coordinate call times using booking systems, which may have also helped ensure fair and equitable access to limited devices. However, this coordination was effortful for family members and led to unsatisfying interactions when calls were late or missed. It is likely that this issue was not documented in previous studies as they did not examine the use of video calling during periods of lockdown. This addition to the literature is important as it reveals a negative experience for families and residents that should be avoided during future lockdowns in care homes.This study highlights that ongoing support for video calling in aged care is essential. We argue that video calling should, therefore, be elevated to the status of critical infrastructure given its potential to enable the continuation of care and mitigate the negative consequences of enforced isolation.However, video calling needs more infrastructural support in care homes. It must be recognized that social connection is an essential human right and must be supported as a basic activity. Policy makers should recognize that staff may need additional time to assist with video calling. Better resourcing is needed for technologies that can be shared among residents at times when face-to-face visits are not possible, and aged care workers should not have to use their own devices to support the social well-being of residents.The problem of coordinating video calls between families and residents should also receive attention in terms of improving residents’ freedom to make and receive calls during lockdown. If video calls are used at times when in-person visits are prohibited, there is a need for care providers to consider ways of ensuring that calls can happen on a regular basis and to support interactions that go beyond mere glimpses of the resident. Although short video calls may be better than no contact at all, they are unlikely to constitute sufficient social contact and can create anxiety among families. This can also be seen as an equity issue in that being able to see a loved one should be a right, not a privilege.Improving the design of video calling systems for aged care can also help lower the burden placed on staff when it comes to administering and running video calls. Our findings reiterate that commercial video calling systems can be hard to use for care home residents ,59. To pThis study has 2 main strengths. First, our analysis is grounded in real-world experiences of video calling deployment during lockdowns. This is different from most previous studies, which typically involved participants who were given a technology to trial by a research team ,31,32,66The second strength of this study lies in our focus on close family members, many of whom played an important role in caring for their relatives. Previous studies have often been designed to test the feasibility of using video calls to initiate connections with family members who do not typically visit the home . Our woThe main limitations of this study are 2-fold. First, the focus on family members does mean that we excluded the views of aged care residents and staff on video calling during periods of lockdown. We were not able to interview these groups as care facilities were inaccessible during data collection. Future research should address this gap. Second, this study focused solely on the experiences of people living in Australia and New Zealand. Aged care systems in other countries may have procedures in place to better support video calling during lockdowns, although as we have noted, a Canadian study highlighted similar concerns . Future Finally, trustworthiness is an important consideration when evaluating the credibility of qualitative research , but theThis study investigated how family members used video calls with older adults in residential aged care during lockdowns arising from the COVID-19 pandemic. Overall, our findings suggest that video calls were used by family members to continue care practices at times when face-to-face visits were not possible. Families were able to provide social enrichment and monitor the residents’ health and well-being, which they could then use to ensure continuity of care. Video calls extended care by enabling frequent contact and were crucial for those who were reliant on nonverbal cues for communication, sometimes making them preferable to physical visits in which masks were required.However, this study shows that family members’ ability to engage in the continuation of care was hampered by organizational issues, particularly the lack of digital technology in aged care. Although this can be partly attributed to the speed at which care homes needed to adapt and to the loss of staff during the pandemic, the situation revealed the paucity of support for video calling in many care homes. If video calls are to be used to mitigate social isolation arising from infection control measures, there is an urgent need for better provision of technology and improvement of infrastructure to enable calling. There may also be a need to allow for staff to support video calling, especially for residents who cannot operate the technology independently.To conclude, our findings emphasize that governments and aged care providers should fully support the implementation of video calls between residents and their family members during times when social distancing is required. This study also reiterates the need for video calling solutions that are better suited to aged care such that families can remain connected with residents even when they are forced to be physically apart.