The block walk method (BWM) is one of the more common approaches for assessing physical activity (PA) performed on sidewalks/streets; however, it is non-technical, labor-intensive, and lacks validation. This study aimed to validate the BWM and examine the potential for using a wearable video device (WVD) to assess PA occurring on sidewalks/streets. Trained observers (one wearing and one not wearing the WVD) walked together and performed the BWM according to a previously developed protocol along routes in low, medium, and high walkable areas. Two experts then reviewed the videos. A total of 1150  and 1087 (video review) individuals were observed during 900 min of observation. When larger numbers of individuals were observed, the traditional method overestimated the overall number of people as well as those walking and sitting/standing, while underestimating the number of runners. Valid estimates of PA occurring on sidewalks/streets can be obtained by the traditional BWM in low and medium walkability areas and/or with non-common activities (cycling); however, its validity is questionable when sidewalks/streets use volume is high. The use of WVDs in PA assessment has the potential to establish new levels of accuracy, reduce resource requirements, and open up the possibility for retrospective analysis. Physical inactivity facilitates the development of chronic diseases including obesity, cardiovascular disease, type 2 diabetes, and some cancers, and independently contributes substantially to the total amount spent on annual US healthcare ,2,3,4. AIn the past 15 years, there has been an exponential rise in studies looking at social determinants of health, especially those in the neighborhood and built environments that could affect PA ,10. NeigStudies and evaluations of physical activities performed on sidewalks/streets, whether to detect changes in usage or determine how associated environmental conditions impact their usage, necessitate a reliable, accurate, and easily administered approach for assessing PA. Self-report questionnaires are hampered by recall bias, plus they have not been adequately validated for geo-locating physical activities ,22,23. TIn contrast, the observation method is a reliable approach to counting the number of individuals engaged in various physical activities in different environmental settings including parks as well as sidewalks/streets ,28. It iToday’s video technology affords unprecedented opportunities to obtain high-resolution, georeferenced imagery. Wearable video devices (WVD) could feasibly be used to assess sidewalk/street users in real-time, thus providing a means to validate the BWM and eventually augment it with video technologies. Although video capture has not been used to study human physical activity in unconstrained conditions , it has been utilized to assess human movement in controlled settings  and examine animal behaviors in the wild , glacial change, and traffic patterns ,36,37,38Overview: This cross-sectional study was conducted in Newark, DE from June to August when temperatures ranged from 63 to 84 °F. The BWM was completed six times along three observation routes representing low, medium, and high walkability. Walking side-by-side, two observers performed the BWM simultaneously with one observer following the traditional BWM procedures and the other recording video using the WVD. Two investigators independently reviewed the videos and reached consensus on the number of individuals being physically active along the observation routes. Comparative analyses were conducted to determine the equivalence of the two approaches. The study was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the Ethics Committee of University of Delaware (Project identification code 1134582-2).Walkability: The WalkScore® search engine was used to measure the walkability of the observation routes where the BWM was conducted [onducted . This pr® is significantly associated with minutes/week of transport and leisure walking independent of socio-demographic and health variables [We used the WalkScore because it is a valid measure for estimating walkability ,41. It iariables . WalkScoariables . The resariables .Observation Schedule: Each observation route was observed on three randomly selected days of the week during three observation periods per day. Each observation period lasted 50 min and occurred during each of the following time periods: 08:00–09:00, 12:00–13:00, and 17:00–18:00 . Observations were not performed on days having an event that would affect counts  or during times when it was raining or snowing.BWM Procedures: During an observation period, two trained observers (one wearing a WVD and the other not wearing a WVD) traversed an observation route at a pace of 100 ft/min (50 steps/min (largo); stride width 2 ft; pace set by a cell phone metronome). The dual observer format was used because the BWM requires an observer to look away from the observation field while entering data on the BWM instrument, and this has been found to be a source of error especially with larger groups [r groups ,31,32. OThe observer without the WVD recorded the number of individuals engaging in the targeted activities within an observation field. The observation field was defined as a line extending to the left and right of the observer’s shoulders, linear and perpendicular to the observer’s plane of motion. The observation fields ranged in width from 30–70 ft. and included both sidewalks (if present) and the streets associated with the observation routes. Individuals were counted only if they crossed a parallel plane of motion with the observer. For example, individuals walking down the sidewalk towards the observer (from ahead or from behind the observer) were counted if they continued to walk past the observer. The observer made every attempt to count an individual only once during an observation period. When an observer encountered a street intersecting the observation route being observed, they ceased observing, crossed the street, and then resumed observations. An observation recording instrument was previously developed specifically for the procedure [Expert Video Review of Videos: A two-step process was used to manually analyze the WVD videos obtained during the BWM. First, the reviewers conducted independent evaluations of the videos using the BWM criteria to count individuals walking, cycling, running, and sitting/standing along the observation routes. Next, they convened to review their findings and reach a consensus.Observer Training: A total of four field observers participated in two training sessions prior to beginning data collection. During the first training session, they were given detailed instructions on the BWM and procedures to be used. The second training session involved mock field observations.Meteorological Conditions: Data on meteorological conditions  for the exact time of day observations were conducted were obtained from an automated weather sensor system (AWSS) located at the local airport.Wearable Video Device—Pivothead Smart : The Pivothead Smart is one of the most technologically advanced WVDs  and total observed was examined using Pearson product moment correlation. Bland–Altman plots and intraclass correlation coefficients (ICCs) were used to assess the agreement between the traditional BWM and expert reviews of BWM video regarding the counts of people walking, running, cycling, and sitting/standing within an observation period. Inter-rater reliabilities, considering the degree of correlation and agreement between measurements, were assessed using ICCs estimated from multiple rater, consistency, 2-way fixed-effects models . Statistđ) ± 1.96 × standard deviation), were also added to the Bland–Altman plots [For the Bland–Altman analysis, pairwise comparisons were made between the traditional BWM and expert reviews of BWM videos for people walking, running, cycling, and sitting/standing . Means aan plots . Linear p < 0.005), number walking , and the number sitting/standing , but not the numbers running  or cycling . Nearly identical outcomes were found when traditional counts were correlated with walkability (results not shown).The BWM was conducted for a total of 900 min . Expert reviews of the BWM videos indicated that 0 walkers were counted during one observation period, 0 runners were counted during seven observation periods, 0 cyclists were counted during three observation periods, and 0 sitters/standers were counted during 10 observation periods. For all 18 observation periods, individuals were observed and counted . Walkability (1 low–3 high) was highly correlated with video review measures of the total observed . Observations for walking (p = 0.04). The plot for running is displayed in p < 0.001). p = 0.72). The last plot for sitting/standing is shown in p = 0.53) and the biases become large when eight or more individuals were counted as either sitting/standing relative to when fewer than four individuals were counted and the biases reflect both over and underestimation by the traditional BWM. walking  are simi walking  in that This study employed WVD technology to examine the validity of the traditional BWM for assessing the number of people engaging in different types of PA and sedentary behaviors on sidewalks/streets. By obtaining videos at the same time traditional BWMs were performed, the recorded images provided an objective record that ultimately served as the criterion measure to which BWM counts were compared. Overall, the traditional BWM provided accurate counts of walking, running, cycling, sitting/standing, and total number of people. However, Bland–Altman analysis revealed that the traditional BWM provided less accurate counts as the number of individuals observed increased.A sparse amount of evidence exists pertaining to the validity of the observation method for assessing PA and the evidence that is available attests to the validity of observation for determining physical activity intensity  ,49. To tThe recommendation for total counts of individuals extends to the specific types of physical activities captured during the BWM. This is especially true for walking and to a lesser extent sitting/standing, which, combined, accounted for ~90% of the total observed. In terms of walking, the traditional BWM provided highly reliable counts when the number counted was low. When the number of walkers seen increased above 50 walkers, significant overestimation by the BWM was found. This could have implications, especially when evaluating community-level PA interventions given that walking is the most common form of PA and most walking occurs on sidewalks/streets ,50. SittThere are two possible reasons for the increased inaccuracy of the traditional BWM with larger numbers of people. First, there is the difficulty encountered by a field observer when tasked with counting large numbers of people who cross the line of observation (meet criteria for being counted) at roughly the same time. In the high walkability areas, the average number of individuals counted during a 50 min observation period was 168 . Video analysis revealed that the field observers simply missed counting people  during high user volume periods. Second, the field observer must make in-the-moment decisions about counting criteria and, if a large group of people is involved, accuracy can be considerably compromised if they make the wrong decision. This happened in the current study when the field observer did not count a relatively large group of sitters/standers (~22 people) they thought were patrons standing in the outdoor area of a restaurant . During the review of the video, it was clear that this group was not on the restaurant property, but rather gathered on the sidewalk, necessitating they be counted.Very few individuals were observed running or cycling, which is consistent with previous studies on the BWM ,31. CounState-of-the-art video technology  affords several advantages for studies using direct observation to assess PA within specific settings . The WVDs are discrete and provide both video and audio data along with date, time, and geo-coordinate information. In addition, videos can be saved indefinitely for subsequent retrospective analysis and they can be examined to detect environmental aspects that may have influenced human utilization of the area observed. Thus, a more robust picture of physical activity can be constructed. Despite these benefits, there are caveats to using video recording behaviors in the field. Reviewing videos is time consuming, but the possibility exists to automate the process using computer vision algorithms, virtually eliminating human involvement in the video review process . AnotherIn conclusion, the traditional BWM provides valid counts of individuals walking, cycling, running, and sitting/standing on sidewalks/streets in low to high walkability areas. However, when large numbers of individuals are encountered, which is typically the case along high walkability routes, the traditional BWM should not be relied upon to provide accurate data. Video capture and analysis  holds promise for improving the assessment of sidewalk/street use for PA. It has the potential to establish new levels of accuracy, create scalable algorithms that could be used to assess PA in other settings, reduce time/resource requirements , which could ultimately lower costs, and open up the possibility for retrospective analysis. Future research on developing innovative protocols involving video capture and analysis for assessing PA in outdoor spaces, as well as environmental context, are highly warranted.


Video activity recognition, although being an emerging task, has been the subject of important research efforts due to the importance of its everyday applications. Surveillance by video cameras could benefit greatly by advances in this field. In the area of robotics, the tasks of autonomous navigation or social interaction could also take advantage of the knowledge extracted from live video recording. The aim of this paper is to survey the state-of-the-art techniques for video activity recognition while at the same time mentioning other techniques used for the same task that the research community has known for several years. For each of the analyzed methods, its contribution over previous works and the proposed approach performance are discussed. Activity recognition consists of identifying some actions from a series of observations. This field has caught the interest of many researchers since the 1980s due to the number of applications for which it is useful, such as medicine , human–cThe task of tracking and understanding what is happening in a video can be very challenging. Many attempts have been made lately using different techniques ,13,14 suHowever, despite remarkable progress, the advances achieved so far do not meet high accuracy standards and the correct realization of this task in some areas, such as video surveillance, is still an open research issue.In the analysis of a video content, many different functionalities can be implemented. One of the simplest ways to detect motion regarding a fixed background is Video Motion Detection ,27,28. VApart from spatial information, temporal context across frames is also required.Huge computational cost.Datasets are more limited, due to the difficulty to collect, annotate and store videos.Hence, action recognition involves the classification of different actions from videos, a sequence of frames, taking into account as well the fact that the action could not be performed during the entire video. Although it seems an extension of image classification tasks, as it has been mentioned before, the progress for video classification has been slower due to various reasons:Throughout this paper, several techniques applied for video activity recognition are mentioned, as well as the latest contributions made in the field. In addition, as a final note, some of the databases used for this topic are presented along with the results of the latest contributions using them. In This review focuses on a specific area of Human Action Recognition, to keep the discussion simple. Only action recognition from a whole video recorded from a fixed position is considered in this paper, as we think this problem setup is the entrance gate to the analysis of other more complex situations, as those presented in the bottom part of The survey is centered in action recognition methods for videos that are recorded in third person and the whole action occurs inside the video. Although different information can be extracted from the videos and there are articles mentioned that also use extra information such as depth sensors’ information, all the presented methods have these two characteristics in common. The methods that are explained use databases with the characteristics of the ones presented in As activity recognition has been an active research area lately, there have been many different approaches to deal with this problem. Throughout the survey, some of these are introduced, starting with simpler approaches and finishing with the newest contributions to the field. The proposed methods that try to solve this problem that are referred to in this paper could be separated into three main groups: methods using hand-crafted motion features, depth information based methods and deep learning based methods. Strictly speaking, these three areas are somehow interrelated and depth sensors features could lie under the hand-crafted or deep learning categorization. For a long time, computer vision has focused on data recorded from RGB (visible light) cameras, especially in the case of videos. Depth sensors have started to be used in the field of video analysis in more recent times and this is the reason why we feel it deserves a separate section.First, hand-crafted motion features methods are explained. In these methods, some interesting features are obtained from the raw pixels of the video frames and then these features are used to perform the recognition. Second, depth information based methods are analyzed, which use depth maps as extra information. Third, deep learning methods are presented, which, unlike hand-crafted methods, achieve the features for the recognition automatically. Throughout the document, several methods that combine some of these three modalities are also presented.Key-frame based approaches, as the name indicates, consist of detecting the key-frames of the video which would be used for classification; BoW based approaches represent the frames of the video segments over a vocabulary of visual features; interest points based approaches focus on simply selecting a specific set of points or pixels for the classification and, to finish, motion based approaches focus on the movement along the video. Throughout this section, only motion based approaches are analyzed.This document focuses on video-based activity recognition, in which the representation of visual and temporal information becomes important. There are several ways to extract visual features, both static image features and temporal visual features, and then use them to perform the recognition. Temporal visual features are a combination of static image features and time information, so, through these features, temporal video information is achieved. Key-frame ,38, bag-r the value that defines the temporal extent of a movement, the binary image is defined this way:The first value indicates the presence of motion and where it occurs by a binary motion-energy image (MEI). Being The second value is a scalar-valued image where intensity is a function of recency of motion of the sequence, represented by a motion-history image (MHI) which indicates how the image is moving. In , the autThen, a recognition method is developed, which matches these temporal templates against stored instances of known actions. They also present a recognition method to automatically perform temporal segmentation being invariant to linear changes in speed.The authors of  demonstrIn , the autLaptev et al.  contribut and Visual features such as edges, corners, interest points, etc. can be used to form a more complicated feature called optical flow. The optical flow methods try to calculate the motion between two image frames which are taken at times xpansion  and furtThe solution, the optical flow, is the value of The authors of  present In , inspireThe authors of  introducDue to the demonstration of dense trajectories being efficient video representations, in , their pIn , the autThe authors of  propose In , human aIn The interest of applying depth data captured from depth cameras for the action recognition problem has grown due to the advances of imaging technology in capturing depth information in real time, such as Microsoft Kinect  and InteIn , the autA new descriptor for activity recognition from videos obtained with a depth sensor is presented in , called In , the autSatyamurthi et al.  propose In After being a breakthrough in image classification, it was a matter of time to start using deep learning for video-based activity recognition. Although great advances have been made and state-of-the-art results have been achieved, the level of image classification has not been reached yet.Convolutional Neural Networks   for imags (CNNs) ,114,115.s (CNNs)  is used.In the same year as the previous paper, another work was published  that hasAfter these two publications, and taking them as a starting point, deep learning has continued to be used for activity recognition, mainly with Convolutional Neural Networks (CNN) and Long Short-Term Memory (LSTM) .In , the autWang et al. in their work  presentemth layer normalized feature map, pth point position of video coordinates of mth layer map size ratio, In , trajectAlthough having some similarities with previous works ,117, in In the work by Feichtenhofer et al. , the autWang et al. also improved the two streams architecture in their work , presentBilen et al.  presenteIn 2017, Carreira et al.  presenteLater in 2018,  improvedUllah et al.  proposedWang et al.  proposedThe authors of  presenteIn Finally, in order to compare the presented techniques briefly, some advantages and disadvantages are presented in Although there is not a standard benchmark in activity recognition, there are some datasets that are being considered as reference ones . As it hUCF101 ,149 is aThe videos have been collected from YouTube, making the dataset realistic, and it provides a great variety of videos with different objects, camera motion, background, lighting, viewpoint, etc. Based on those features, videos are gathered into 25 groups (4–7 videos per action in each group) with videos sharing some of the features, as background, for example.Human–Object Interaction: twenty categories.Body-Motion Only: sixteen categories.Human–Human Interaction: five categories.Playing Musical Instruments: ten categories.Sports: fifty categories.The 101 categories can be divided in five main groups:HMDB51 ,151 is aGeneral facial actions: smile, laugh, chew, talk.Facial actions with object manipulation: smoke, eat, drink.General body movements: cartwheel, clap hands, climb, climb stairs, dive, fall on the floor, backhand flip, handstand, jump, pull up, push up, run, sit down, sit up, somersault, stand up, turn, walk, wave.Body movements with object interaction: brush hair, catch, draw sword, dribble, golf, hit something, kick ball, pick, pour, push something, ride bike, ride horse, shoot ball, shoot bow, shoot gun, swing baseball bat, sword exercise, throw.Body movements for human interaction: fencing, hug, kick someone, kiss, punch, shake hands, sword fight.It consists of 6849 videos with 51 action categories and a minimum of 101 clips belong to each category. The action categories can be divided as well in five main groups:good, medium, bad), and they are rated depending on whether body parts vanish while action is executed or not.Apart from the action label, other meta-labels are indicated in each clip. These labels provide information about some features describing properties of the clip, such as camera motion, lighting conditions, or background. As videos are taken from movies or YouTube, the variation of features is high and that extra information can be useful. In addition, the quality of the videos has been measured , jump-forward-on-two-kegs (jump), jump-in-place-on-two-legs (pjump), side-gallop (side), wave-two-hands (wave2), wave-one-hand (wave1) and bend. Background and the viewpoint are statics.Before the two previous databases were created, many methods used the Weizmann  databasehigh arm wave, horizontal arm wave, hammer, hand catch, forward punch, high throw, draw x, draw tick, draw circle, hand clap, two hand wave, side-boxing, bend, forward kick, side kick, jogging, tennis swing, tennis serve, golf swing, pick up and throw. Seven different individuals performed each action three times, facing the camera during the performance. The depth maps have a size of 640 × 480 and they were captured at about 15 frames per second (fps) by a depth camera with infra-red light structure.In 2010, as there was no public benchmark database, the authors in  publisheThe authors of  presenteThe aim of this database is to collect activities of humans daily life and it has a hierarchical structure, organizing the activities according to social interactions and where they take place.something next to something” where something refers to an object name. This database is already split into train, validation and test, containing 86,017, 11,522 and 10,960 videos, respectively.Later, in 2017, the authors of  introducHowever, there has been a second release of the dataset and now it contains 220,847 videos, 168,913 for the training set, 24,777 for the validation set and 27,157 for the test set. The number of labels remains the same, but there are additional object annotations now. Moreover, the pixel resolution has increased from 100 px to 240 px.In , KarpathNowadays, the YouTube-8M  dataset The authors of  presenteEvery person of the scene is localized by a bounding box and labels are assigned according to the action performed by the actor. Each scene can have more than a label, one of them corresponds to the actor’s pose and additional labels which correspond to person–object or person–person interactions can be assigned. A frame containing more than one actor is labelled separately for each person of the scene.To finish, in To better analyze the explained methods and the contributions of each one of them, the results obtained for mentioned datasets are compared. For each method, the achieved accuracy values for different datasets are shown, together with the reference to the original article where they have been proposed.On the one hand, in On the other hand, most of the hand-crafted feature methods use the Weizmann dataset as a benchmark. However, some of the presented models work with both UCF101 and HMDB51 datasets, which are used as benchmarks in deep learning methods. Thus, in As it can be seen in After reading the previous sections, the researchers could ask themselves which are the most promising lines of research in the field of action recognition in videos, or where it is more likely to get a higher return for the invested effort.For people just interested in applying an existing method to their data, or in minimal modifications or customizations, some authors of the presented methods have made their code available that can be used. These implementations are indicated in For researchers interested in developing new methods or in deep modifications of current ones, deep learning looks like the way to go, although the computations costs could be forbidding.Some researchers could have the resources to generate new datasets similar to those presented in this paper. They need to have in mind several decisions: will the videos have the same resolution and/or length and will they be recorded with the same background? We advocate for datasets covering different kinds of videos, with that information present in the metadata and with enough samples of each type. Anyway, if the researcher resources are somewhat limited, which is usually the case, it is advisable to focus on just one type of video. All the technical information about the sensor might appear in the metadata, as well as lighting conditions or any information of interest. If depth sensors are used, high and low resolution of the depth data could be provided. Processing of depth data can be computationally expensive, and other researchers using that dataset could benefit from access to a standard low resolution version of that data.The task of labeling the database samples can be eased with the help of some tools. While just providing a global label for a video does not require a great deal of effort, the video database curators could choose to gather information about individual frames in the videos. There are several tools that could be useful in this task, like Sloth , LabelMeIt is difficult to predict the future development of this area, but, at least in the short term, the overall tendency in machine learning is going towards massive data, computationally expensive algorithms and dedicated hardware. It is expected that the price of depth sensors will keep a descending curve, as well as the cost of hardware in general. The main challenges are expected to be twofold: for the researchers developing new methods, those related to the storage and processing of massive databases, and for developers integrating the methods into software solutions, those related to a fast classification time.In this paper, different methods for video activity recognition have been presented. Several models have been explained showing the development of recent years. Likewise, several databases used to evaluate the performance of the models have been introduced. The results have been shown together in a table in order to compare the methods presented correctly.Due to the extent width of the subject, there are many more models that have not been mentioned in this document. Even so, an attempt has been made to show a current state-of-the-art by presenting different techniques to deal with the problem. To sum up, through this document, we have tried to show the relevance and current situation of video-based activity recognition.Video-based activity recognition, as it has been mentioned before, is more complicated than static image classification and this is also reflected in the results obtained so far. However, since deep learning is still being exploited, in the near future, this task may become easier to perform and current results may be improved using some deep learning techniques.


Self-reported confidence around hand expressing in pregnancy also improved from an average ranking of not confident  to confident . Almost all women (98%) reported that they would recommend the video to a friend or family member if antenatal colostrum expression was suggested by their healthcare provider. Findings suggest that the use of an online expert video is an acceptable and effective way to educate pregnant women in antenatal colostrum expression.The use of antenatal colostrum expression in the weeks prior to birth may help improve long-term breastfeeding, but few large-scale studies exist. Typically, antenatal colostrum expression instruction relies on face-to-face education, making large interventions costly. We aimed to determine whether an expert online instructional video can improve knowledge and confidence around antenatal colostrum expressing. Pregnant women were asked to complete a questionnaire pre- and post-watching the instructional video online. Ninety five pregnant women completed both pre- and post-questionnaires. Total antenatal colostrum expression knowledge scores improved after watching the video, from a mean of 3.05 ± 1.70 correct out of a maximum of 7, to 6.32 ± 0.76 ( During pregnancy, breasts begin to produce the first milk, colostrum. Historically, antenatal colostrum expression (ACE) was performed as a means of preparing the breasts for breastfeeding after birth. More recently, ACE is performed to collect a supply of colostrum. Colostrum can be collected using a syringe, and safely stored in a freezer. The colostrum can then be defrosted and given to the baby. The stored colostrum can be used to treat hypoglycaemia in the infant after birth, or if breastfeeding issues occur. The collection and storage of colostrum can ensure that an infant receives its own mother’s milk as the first feed after birth, instead of reliance on formula during this time. In women intending to exclusively breastfeed, formula supplementation while in hospital has been associated with a two- to three-fold risk of early breastfeeding cessation . Some haIn addition, there has been some concern that antenatal nipple stimulation while teaching hand expression will act as a precursor for the release of oxytocin, and may induce premature labour . In a CoThe question remains as to the effectiveness of ACE in promoting positive breastfeeding outcomes, and the safety of its practice as part of regular antenatal education at 37 weeks gestation in healthy, low-risk pregnant women. In our own medical record audit of a secondary, general hospital in Greater Perth, Western Australia, we compared the inclusion of ACE in antenatal education in relation to birthing outcomes in a hospital which had previously not included ACE in this education, using a retrospective control group. Results showed that inclusion of ACE in antenatal care was not associated with an increased risk of premature birth or admission to special care nursery .Very few randomised controlled trials have been published in the area of ACE, with none in healthy women, and most using a small sample size (<100). Due to a lack of research investigating the safety and efficacy of antenatal colostrum expression in the general population, ACE is therefore not uniformly encouraged across Australian maternity health services. One major barrier to large scale trials in Australia is the cost of high-quality ACE instruction. A one-on-one session with a midwife (or lactation consultant) provides optimal ACE instruction, however it is not routinely taught as part of antenatal education. In our experience, detailed instruction and assistance with hand expressing is most often provided postnatally, commonly when women are experiencing breastfeeding difficulties , are sleep deprived, and are potentially anxious about their ability to feed their babies.Online videos can be an effective and cheap tool for instruction, in areas where the internet is easily accessible. The expert expressing instructional videos that are currently available demonstrate breastmilk expressing in women who have already given birth. Given that expressing in postnatal women is conceptually different, this type of video is not well suited to an antenatal setting. Colostrum has a different look and consistency to mature milk, and the presence of the baby often stimulates milk “let down”. Feedback from West Australian midwives and lactation consultants, along with our local consumer reference group, indicated that a video of a lactation consultant-led demonstration of ACE using pregnant women would be very valuable. We have therefore developed an online instructional video on ACE specifically for pregnant women. To our knowledge, no such expert-informed video exists nationally or internationally that provides specific enough detail to suit requirements for use in a large-scale trial or in our health setting. The 20 min video featured a real-life situation, with two pregnant women in a session with a lactation consultant. The lactation consultant explained how to use ACE and how to collect and store the colostrum, and guided both women through the process in a practical demonstration . The womThe aim of this study was to investigate whether the instruction on antenatal expression of colostrum via this instructional online video is an effective way to increase knowledge around ACE and confidence in using it, in pregnant women. If so, the use of an instructional video for ACE will provide an economical and feasible education option for future research.This was a pre- and post-test study, using online questionnaires and video. Data collection for the study was completed online between August 2017 and April 2018.Pregnant women were recruited through social media via local university and research institutions, and infant and mother organizations, along with personal contacts. The only inclusion criteria were being currently pregnant (any stage) and having access to the internet. Potential participants were provided with an online information letter and were requested to provide online consent prior to the start of the questionnaires. Ethics approval was granted from the Edith Cowan University Human Research Ethics Committee (17501).Two linked online questionnaires were developed using Qualtrics survey software . The first was a pre-video questionnaire which contained the ACE video at the end, followed by a second questionnaire which participants completed after viewing the video (post-video questionnaire). The pre-video questionnaire asked about age, gestation of current pregnancy, previous children and previous breastfeeding experience. The post-video questionnaire asked for feedback on the video, including aspects that were liked and disliked (free text response), the length of the video , use of real pregnant women in the video (free text), and satisfaction on the depth of information covered, clarity of voices, image quality and overall satisfaction  from very unsatisfied to very satisfied. Respondents were also asked whether they would recommend the video to pregnant family and friends if ACE was suggested by their healthcare provider, and whether they had any suggestions for improvement of the video. Knowledge and confidence were assessed in both the pre- and post-questionnaires. Knowledge was assessed over seven areas and also as a total knowledge score (one point for each correct answer). To assess confidence about hand expressing in pregnancy, respondents were asked to move a sliding scale which ranged from 1–5, representing very unconfident to very confident.t-test was used to compare total knowledge scores and confidence around using ACE. Significance was set at p < 0.05.Descriptive statistics were used to report on subject characteristics, with means and standard deviations used for normally distributed results, and medians and interquartile ranges used to report results that were not normally distributed. The related samples McNemar statistical test was used to compare the number of correct answers in knowledge questions in the pre-video and post-video questionnaires, and the paired samples For free text responses, information was grouped into themes and quotes that were identified as appropriate.A total of 171 pregnant women completed at least one aspect of the survey. Of these, 112 completed the full pre-questionnaire, with 95 going on to also complete the post-questionnaire after watching the video. Subject characteristics for the women who completed both questionnaires are shown in p < 0.001, n = 93, p < 0.001)  . IOR: InWhen asked what they liked most about the video, 90 out of 95 respondents chose to write a full text response, which was subsequently grouped into one of five categories. The most common response was that the video was informative/interesting/detailed (32.6%). The inclusion of a practical demonstration (22.1%) in a real situation, and the use of real pregnant women (20.0%) were the next most frequently cited responses. Respondents also commented that the video was easy to understand and used clear explanations (15.8%). Others liked the video being “unrushed”, “comfortable” or “relaxed” (3.2%). One respondent answered that they liked “everything” (1.1%). Specific quotes relating to the responses are shown in When asked what they didn’t like about the video, the most common response was that it was too long (8.4%). This was followed by requests for more information (7.4%), including requests for information on why colostrum would be used, a visual example of when colostrum is not able to be collected using breast massage, when to stop collecting, and a reference diagram. Two women opposed the term “girls” used as a colloquial term in the video by the lactation consultant. Other comments included that it was hard to read the accompanying text and watch at the same time, that there was a need for more eye contact, and that it was hard to hear in places .When specifically asked about the length of the video, 78.9% of women found it appropriate, while 17.9% found it too long and 1.1% found it too short. A total of 92 out of 95 women responded to the free text answer question about how they felt about the use of real women in the video, and all responded positively. Comments reflected women feeling more comforted about the process, even for those who had breastfed before, and finding a realistic approach helpful from a learning perspective see .A total of 93 out of 95 women responded to questions on video satisfaction which were determined on a continuous sliding scale of 1 (very unsatisfied), to 5 (very satisfied). All three aspects and overall satisfaction scored a median of 5.00, with a small interquartile range (IQR): depth of information covered , clarity of voices , quality of images , overall satisfaction . Free text comments in this section indicated some minor dissatisfaction with the volume of voices, being told breastfeeding is best, a preference for non-scrolling text, a request for more information around how to administer the collected colostrum to a baby, the video being too long and a request for more specific information on hand placement.When asked for additional suggestions for improvement of the video, three responses were received. These were the inclusion of a diagram of exactly where to place the hands with distance from the nipple and direction of pressure improvement, better music, and more focus on the syringe during the demonstration.“Do all hospitals recommend doing this?”“Can I start at 36 weeks?”“Is it recommended for all uncomplicated pregnancies?”“Have any studies been done on women who have previously experienced low supply to see if antenatal hand expressing helps?”“Will this bring on early labour?”“Will it help with establishing a good milk supply?”After viewing the video, approximately a fifth of women still had questions about ACE. Most questions related to safety, current health service recommendations for ACE and evidence around using ACE:This issue of safety and evidence can be better clarified as more research is done in the area.“Should I give my baby the expressed colostrum even if he is feeding well?”“How long can you store it frozen?”“How do you defrost it?”Other questions focused on the use of stored colostrum, and have since been addressed in a revised version of the video:“What is the best time of day to express if you have gestational diabetes—does it matter if it’s done before or after a meal?”“What are the benefits for GDM?”There were also questions specifically regarding expressing with gestational diabetes mellitus (GDM):In addition, one mother asked what to do if ACE was hurting, and another asked what to do if they try ACE and do not produce any colostrum.After viewing the video, women were also asked whether they would be likely to recommend the video to pregnant family or friends, if hand expression of colostrum was suggested by their healthcare provider. Responses were gauged using a five-point Likert scale ranging from “definitely yes” to “definitely not”. Almost all women responded “definitely yes” (59.1%) or “probably yes” (37.6%), with 2.2% responding “might or might not” and 1.1% responding “probably not”. No women selected “definitely not”.The online video was effective in significantly increasing both knowledge and confidence around antenatal expressing of colostrum. The average knowledge score doubled in the post-video questionnaire, from 3.05 ± 1.70 to 6.32 ± 0.76, from a possible total score of 7. After viewing the video, the majority of women were able to correctly answer each knowledge question. The knowledge areas showing the largest improvements were when to start ACE (from 42.1% correct to 98.9% correct), and how often to express per day (from 26.3% correct to 94.7% correct). This observed increase in knowledge validates the most popular comments regarding what was liked about the video, which focused on the video being informative, detailed and interesting. If a learner finds the subject content interesting, this facilitates the learning process and makes them more likely to retain the information .Reported confidence in using ACE also showed a substantial increase, from a mean score of 2.56 to 4.32 out of a possible 5. It is important to see an increase in confidence alongside an increase in knowledge, as knowledge alone is not necessarily enough to result in a change to practice. Self-confidence in applying skills, also known as a sense of competence, is recognised in the literature as being important when implementing health-related behaviour changes . ImportaThe most common criticisms were that the video was too long and that it lacked some minor information, although these were an exception, with less than 20% of women expressing dislikes when prompted. When specifically asked about the length of the video, 17% reported that it was too long. The length of the video allowed for a complete demonstration and a relaxed atmosphere, which was noted as positive by some women, however it was possible to shorten it by speeding up some sections, particularly around the demonstration. Other aspects of video satisfaction indicated that it was well-received in terms of clarity of voices, quality of images and depth of information covered. We have since updated the video to cut out unnecessary and repetitive sections, reducing it to 15 min. We have also added additional information in the form of text notes at relevant times throughout the video.Overall, 97% of women in this video evaluation stated that they would be likely to recommend it to pregnant family or friends, if hand expression of colostrum was suggested by their healthcare provider. Family and friend recommendations can have an important impact on public health strategies. Eighty-three percent of online respondents across 60 different countries said that they completely or somewhat trusted the recommendations of friends and family, according to Nielsen’s Global Trust in Advertising Report in 2015 [An online video provides unique advantages for instruction over a traditional face-to-face format. Being online allows pregnant women to view the video at a time and location convenient for them. This is particularly valuable for mothers who already have children, along with those located in remote areas. Another advantage of a video is the ability to pause and replay certain sections according to the viewer’s needs and understanding. Videos have become increasingly popular in education, and many universities now offer online instruction, incorporating videos and recorded lectures. Disadvantages also exist with video instruction, notably technical issues with glitches in internet bandwidth and connectivity . In 2018Risk of self-selection bias was an important potential limitation of this study, with women who were interested in ACE being more likely to participate. In addition, the women who participated in our study had a relatively narrow age range. These factors limited our ability to generalise our results to a wider population. Our findings have important implications for the use of ACE video instruction for future research, and potential public health initiatives leading on from this. Many mothers introduce formula due to a perception of poor milk supply , and cit


Twenty male players (age: 20.4 ± 0.88 years) from the first handball league and 18 male players (age: 21.3 ± 1.61 years) from the second handball league were categorized as backs (8/8), pivots (5/4), and wings (7/6). The following variables were measured in both groups: peak power; vertical squat jump (SJ), and countermovement jump (CMJ); sprint times over 15 and 30 m; handball throwing velocity during the jump shot (JS); and 3 steps shot (T3 step); upper and lower limb muscle volumes; Yo-Yo Intermittent Recovery Test. Anthropometric data revealed significantly ( Team handball is classified as a high-intensity, body-contact sport that demands a high level of aerobic and anaerobic fitness  and anthropometric characteristics of current professional handball players. Examination of fitness profiles could be of great importance for optimal construction of training regimens to improve handball performance and in the orthopedic care of such players.The profiling of players can be a valuable tool when identifying talent, determining strengths and weaknesses, assigning playing positions, and optimizing the design of strength and conditioning training programs  and 18 second league male professional team-handball players  voluntary agreed to participate in this study. All athletes  were asymptomatic and had passed medical examinations prior to inclusion and participation in the study. Participants gave their written informed consent after receiving both a verbal and a written explanation of the experimental design and its potential risks. Subjects were free to withdraw from the study without penalty at any time.This study examined if anthropometric and physical fitness parameters are different between male handball players of different competitive levels and playing positions. Two distinct groups of handball players were identified consisting of players from the first and second leagues. The subjects were carefully familiarized with the testing protocol, as they had been previously tested on several occasions in season for training prescription purposes. All of the players within a given team were assessed on the same day, and the tests were performed in the same order.All tests were conducted in the middle of the pre-seasonal training and ahead of the competitive season. Furthermore, testing sessions were carried out at the same time of the day, and under the same experimental conditions, at least 3 days after the most recent competition. To reduce the influence of uncontrolled variables, all participants were instructed to maintain their typical lifestyle and diet habits before and during the study. Players maintained their normal intake of food and fluids, but abstained from physical exercise for 1 day before testing. They also drank no caffeine-containing beverages for 4 h before testing, and ate no food for 2 h before testing. Strong verbal encouragement was provided to all subjects to promote maximal effort throughout testing.The muscle volume of the upper limbs was estimated as detailed previously, using circumferences and skin-fold thicknesses measured at different levels of the arm and the forearm, the length of the upper limb, and the breadth of the humeral condyles , corresponding to the distance from the acromion to the minimum wrist circumference, and the mean of five limb circumferences  according to the formula:2 is the sum of the squares of the five circumferences of the corresponding limb.where ΣCSkin folds were assessed using a standard Harpenden caliper . The fat volume was calculated as:where ΣS is the sum of three skin folds for the upper limb , and “n” represents the number of skin folds measured on each limb.Bone volume was calculated as:where D is the humeral intercondylar diameter, F is a geometric factor (0.21 for the upper limb), and L is the limb length as measured above.Standard equation equations were used to predict the percentage of body fat from the biceps, triceps, subscapular, and suprailiac skinfold readings , and Circumferences and skin-fold thickness at different levels of the thigh and the calf, the length of the leg and the breadth of the knee condyles were measured to estimate the leg muscle volume.The total limb volume was estimated as the volume of a cylinder determined by: the distance (L) from the trochanter major to the external malleolar of the ankle. The basal area of the cylinder was based on the mean area of five limb circumferences (C) .2 is the sum of the squares of the five circumferences.where ∑Cwhere ∑S is the sum of four skinfolds , as determined with a Holtain skin fold caliper and where n is the number of skinfolds measured.r = 0.94; p < 0.01) . The accuracy of this anthropometrical method was previously validated by comparison with dual-energy x-ray absorptiometry  and 2 min of jumping exercises. Players performed the stretching exercises twice holding each stretch for 15 s and alternating between each leg in order to give adequate recovery before the next repetition. Jumping exercises included skipping (6 m), double limb ankle hops (6 reps), split squat jump (5 reps), and standing jump and reach (5 reps). Characteristics of the squat jump (SJ) and the countermovement jump (CMJ)  were determined by force platform . Jump height was determined as the center of mass displacement, calculated from the recorded force and body mass. Subjects began the SJ at 90 degrees of knee flexion, avoiding any downward movement, and performed a vertical jump by ballistically extending their legs. In the CMJ, they began from the upright position (0 degree knee angle), making a downward movement to 90° of knee flexion and simultaneously beginning the push-off into full extension of the legs. We recorded the largest of three jumps for each test.Prior to sprint testing, each subject performed a 5 min warm up, which consisted of 3 min of running, change of direction activities and dynamic stretching. The last 2 min of the warmup, consisted of two practice sprint starts of 3–4 s duration. Force–velocity measurements for the lower limbs were performed on a Monark cycle ergometer   that were located 1 m above the ground at the start and finish lines. Three trials were separated by 6–8 min of recovery, with the fastest times being used in analyses.Handball-specific throwing velocity was evaluated by a 3-step running throw and a jump throw. A 15 min warm-up was completed prior to test, that included jogging, lateral displacement, dynamic stretching, and jumping. For testing, participants threw a standard handball  toward the upper right corner of the goal positioned 9 m from each subject. Each individual continued until three throws had been recorded, to a maximum of three sets of three consecutive throws. A 1 to 2 min rest was allowed between sets and 10–15 s between individual throws. In the jump-throw, players took a preparatory three-step run before jumping vertically and releasing the ball while in the air. In the running throw, a preparatory run of three regular steps was made before releasing the ball. Throwing time was recorded with an accuracy of 1 ms, using a digital video camera  positioned 2 m above and perpendicular to the ball release. Data processing software  converted handball displacement to velocities. The validity of the camera and data processing software was previously verified . The Yo-Yo-IR1-test is known to have a coefficient of variation (CV) of 3.6% with an ICC of 0.94 , minimum, maximum, and 95% confidence intervals (95% CI)] were ascertained for all variables. Mean differences of anthropometric and performance parameters between performance levels (first league vs. second league) and playing positions (pivots vs. wings vs. backs) were tested using a two-factor univariate general linear model Bortz, . Differep = 0.012 and The first league players (20.4 ± 0.88 years) were significantly younger than the second league players  was also larger than the second league players .Similar results were provided for sprinting performance . Except There was a significant difference in running performance for the 15 m sprint  was also found to be higher among the first league players compared to second league players .The difference was higher in SJ [two significant differences: power  and the backs (lower limb) showed the highest power peak performance.The aerobic capacity (Yo-Yo-IR1) was the only performance that displayed a significantly higher performance level .Profiling studies in comparable designs like this one have been used in a variety of sports in an attempt to develop reference data and to standardize test procedures. Two major conclusions emerge from the present study: (1) performance characteristics  differed significantly among leagues in male handball players; (2) body height was different between groups with the first league players being significantly taller than second league players; and (3) different results were provided for sprinting performance however, the wings, and all first league players were faster than the second league players.p = 0.003 and n = 25) were over-represented in the group examined in this study.The anthropometric data revealed significantly  achieved higher values of thigh muscle than pivots (200 ± 2.41 cm2) and wings (180 ± 6.60 cm2). The cross-sectional area, differ significantly between level and ranking of players reflected neuronal adaptations, a well-accepted response to regime of training . The throwing velocity data revealed that the first league players have a higher throwing velocity than the second league players. However, the difference was only significantly for running throw  were similar to those for throwing performance with first league players performing better than the second league athletes. Except the wings (4.06 ± 0.10 s vs. 3.83 ± 0.18 s), all first league players were faster than the second league players. The performance difference was significant for sprint 15 m (n et al.  reportedThis difference may be explained by the exclusive assessment compared to the current study, where the sprint was measured during the 15 and 30 m protocol separately. In addition the players evaluated in the study of Haugen et al.  were NatAdditionally, the competitive athletic training in the third league team may be more sufficient than in the first league sample. This hypothesis is in line with the information regarding the first league team, that the main part of the athletic training was conducted in a CrossFit® studio. A sprint performance and technical training of running was lacking in the first league team. Maybe, the strength training in a CrossFit® studio induced fatigue effects for the upper limb and reduced the flexibility of the throwing arm.The CMJ scores of our players are higher than those previously reported (Hermassi et al., Team handball is characterized by explosive actions performed at high velocities; therefore, success in competition depends essentially on a well-developed muscular strength (Aloui et al., Thus, similar to other team sports, handball involves activities that require well-developed aerobic and anaerobic qualities. Povoas et al.  reportedThe main limitation of this study, especially regarding positional subgroups, is the small sample size. Therefore, these data should be interpreted with caution and in comparison with similar investigations. It is evident, that this sample size is not powerful enough to generate statements about anthropometrics and positional success for an entire sport. Furthermore, it might be considered, that the motivation of some first league players were limited. It could be an explanation for the lower performance level of first league players compared to third league players.This study provides a detailed analysis of movement patterns in relation to physiological profiles in elite professional handball athletes. These findings provide information for the assessment and evaluation of talents and should help to develop and optimize position training regimes. These findings may also be beneficial in the prevention, evaluation, and treatment of injuries commonly sustained by handball players. In this work, second league players showed a lower performance level regarding throwing, sprinting, and jumping than first league players, which underscores the challenge and difficulty of a valid performance and diagnostic program. Performance capacities clearly differ across playing positions, and coaches should thus develop position-specific training concepts.However, further profiling of handball players is required before definitive reference data can be presented. Scientists should also be encouraged to study factors that contribute to the progressive deterioration in performance over the course of a game; the optimal tactic in sustaining performance will likely improve endurance specific to the individual's playing position, plus the avoidance of unnecessary rapid movements early in the game. Furthermore, the results should encourage thinking about a sufficient performance diagnostic concept in team handball. Coaches and scientists should recognize the unique nature of training regimen with the different physical profiling level positions and match these to the demands of team handball practice and training prescription.All datasets generated for this study are included in the manuscript and/or the supplementary files.SH and RS: formal analysis and methodology. SH: investigation, project administration, and supervision. KL and RS: writing–original draft. SH, KL, and RS: writing–review and editing.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.


To assess the imaging properties of two different designs of a new concept of corneal inlays whose working principle is based on diffraction.  The quality of the retinal images provided by Diffractive Corneal Inlays (DCIs) was evaluated theoretically in comparison with Small Aperture Corneal Inlay (SACI). ZEMAX OpticStudio software was employed for the simulations in an eye model with different pupil diameters (3.0 mm and 4.5 mm). The employed merit functions in the analysis were the Modulation Transfer Function (MTF), the area under the MTF (MTFa), and the Point Spread Function (PSF). Comparison was made with the SACI at different defocus conditions.  The bifocal nature of the DCIs was demonstrated in a model eye for the first time. It was shown that the intensity of the near focus depends on the radius of the central zone. Retinal image quality of the DCI was equal to or exceeded the SACI in the majority of visual conditions as was demonstrated with simulated images.  A new customizable type of corneal inlays has been evaluated using objective numerical simulations. Improvements in imaging of near objects and in light throughput compared with the popular small aperture inlays were demonstrated. These findings open a new technical branch of minimally invasive surgical solutions for the treatment of presbyopia. Presbyopia affects almost all adults over 45 years of age, and it has been estimated that globally there are more than 1.8 billion people with presbyopia, 820 million of whom had near visual impairment because they had no, or inadequate, vision correction [At present, the minimum invasive surgical option for presbyopes who do not want glasses or contact lenses is to implant a corneal inlay. By means of a femtosecond laser, the surgeon creates a pocket inside the corneal stroma where the inlay is inserted, rendering the surgical procedure fast, simple, and importantly reversible.μm diameter. Unfortunately, although SACI implantation can result in improved intermediate and near vision, it has several important intrinsic drawbacks. Firstly, only about twenty percent of the incident light passes through the disc's central aperture. Secondly, as much as five percent of incident light is diffracted by the disc's microholes. Thirdly, as the SACI is implanted monocularly, the interocular asymmetry induced by anisocoria combined with monovision deteriorates binocular summation [Based on the working principle, different options have been launched in the market in the last years: corneal reshaping device, refractive corneal device, and small aperture corneal inlay (SACI) . The lasummation  and sterummation .In an effort to avoid these drawbacks, our group recently proposed a new concept of corneal inlays that take profit of the diffraction phenomena originated in the micropores of the SACI . The reshttp://www.zemax.com/os/opticstudio). The phakic model eye employed in the simulations was the Eye Retinal Image.zmx included in the Zemax software  for MTFs in a frequency range from 9.5 cpd to 59.9 cpd. These spatial frequencies correspond approximately to the sizes of letters of visual acuity charts between +0.5 logMAR and –0.2 logMAR.Additionally, simulated images of a visual acuity test chart were obtained from the PSF provided by ZEMAX by means of the numerical convolution using a Matlab  code. The simulations were performed with polychromatic light using 5 wavelengths as previously mentioned.Note that, except for the distance focus and 3.0 mm pupil diameters, the performance of both models of DCI is superior to the SACI, even though the diffractive effects of the SACI  have not been considered in the simulations. A better MTF curve was achieved by DCI #2 at the far focus for both pupils but with minimum differences. On the other hand, DCI #1 provides a better near focus than DCI #2. These results can also be verified in terms of area under MTF. For 3.0 mm pupil diameter, bigger differences can be observed between the three designs. DCI #1 has the lower values for the far focus, but the higher values for the near focus. These differences are attenuated for 4.5 mm pupil. In this case, all the three inlays have a comparable performance at the far focus, but both DCIs maintain an effective near focus.Figures These images have been obtained as the convolution of the corresponding PSF with the test object. In this way, the relative intensity of the images and the spatial extension of the PSFs can be directly compared, except for the SACI at the near focus; in this case, the image intensity has been multiplied by a factor of 4 because otherwise this image would be almost black. Note that in binocular distance visual acuity with a monocularly implanted SACI induces a binocular summation, the visual acuity for near distance seems to be close to the near distance acuity of the eye with SACI [The image quality and the relative image intensity between them can be clearly observed in Figures ith SACI .In conclusion, we performed an optical simulation on a new customizable treatment option for correcting presbyopia, the DCI. We found that the larger transmission of DCI compared with the SACI makes the proposed inlay highly luminous efficient, and its diffractive structure provides a near focus. Moreover, by using different models of the DCI, we have shown that the intensity ratio between the far and near foci can be controlled by adjusting the diffractive structure, which seems to be clinically relevant taking into account the particular patient's visual needs. In fact, in this study, we studied two different designs and demonstrated that the intensity of the foci of the DCIs depends on the radius of the central zone, being more intense in the near focus for the DCI #1 than for the DCI #2, but the opposite happens for the far focus. The PSFs and the simulated images show the improved performance of the DCI in comparison with the SACI, especially in near vision.


Mage = 23.06, SDage = 5.91). Results revealed a medium-sized negative correlation between problematic video gaming and psychological functioning with regard to psychological symptoms, affectivity, coping, and self-esteem. Moreover, gamers’ reasons for playing and their preferred game genres were differentially related to psychological functioning with the most notable findings for distraction-motivated players as well as action game players. Future studies are needed to examine whether these psychological health risks reflect the causes or consequences of video gaming.Video gaming is an extremely popular leisure-time activity with more than two billion users worldwide . However Video gaming is a very popular leisure activity among adults . The amoA video game is defined as “a game which we play thanks to an audiovisual apparatus and which can be based on a story” . In the behavioral addiction, its status as a mental disorder has been clarified since the release of the DSM-5 in 2013. In the DSM-5, the Internet Gaming Disorder with diagnostic criteria closely related to Gambling Disorder. Generally, this decision has been supported by many researchers  are cognitive enhancement  problematic video game use, (b) the reasons for playing, to (c) the preferred game genres. This strategy prevented us from making potentially invalid generalizations about video gaming in general and allowed us to examine the spectrum of gaming habits and the respective relations between such habits and a diverse set of variables representing psychological functioning.Playing video games excessively should be appealing to individuals with poor psychological functioning because games allow people to avoid their everyday problems and instead immerse themselves in another environment . MoreoveN = 2,891 individuals  with a mean age of 23.17 years  participated in our study. Of these participants, N = 2,734 (95%) confirmed their use of video games and were thus included in further analyses . The distribution of participants with regard to sex and age mirrors the findings of past research with males and younger individuals being more likely to play video games  to 5 (very often). The final score  is computed using weighted scoring  were identified as regular gamers, and N = 469 (17%) as problematic gamers. We used the AICA-S as a continuous variable for all further analyses . The instrument has been validated for different age groups in the general population and in clinical samples (r = 0.17∗∗∗) and age (r = –0.15∗∗∗). On average, participants played video games for M = 4.09 hours per weekday , and M = 4.21 h per day at the weekend .The AICA-S, the Scale for the Assessment of Internet and Computer game Addiction , was use samples . Cronbacnever) to 4 (very often). The most prevalent reasons were relaxation , amusement , and because of the storyline .Gamers indicated how often they played video games for certain reasons. They rated each of 10 reasons separately on Likert scales ranging from 1 (never) to 4 (very often). Using M = 2.54, SD = 0.84), strategy , role-playing , and simulation . A cluster for unclassified subgenres  was added to additionally account for such subgenres as jump’n’runs and games of skill. Descriptive statistics and intercorrelations for all measures (including sex and age) are presented in Gamers were asked how often they usually played various video game subgenres such as first-person shooter, round-based strategy, massively multiplayer online role-playing games (MMORPGs), life simulations, and others. Ratings were made on Likert scales ranging from 1 . The 9 items were answered on 5-point Likert-type scales ranging from 1  to 5 (agree completely). Cronbach’s alpha was satisfactory (α = 0.77).The SCL-K-9 , a shortnever) to 5 (very often). Intercorrelations of the two items per subscale ranged from r = 0.32, p < 0.001 for positive reframing to r = 0.78, p < 0.001 for substance use .We assessed 10 coping strategies with the Brief COPE , which igeneral affect as a trait and affect during video gaming as a state using the German version  to 5 (completely), participants rated the intensity of 20 adjectives. Cronbach’s alpha was α = 0.78 for general positive affect, α = 0.83 for general negative affect, α = 0.85 for positive affect while playing, and α = 0.83 for negative affect while playing.We measured  version  of the P version . On a 5-not at all) to 5 (completely). Cronbach’s alpha was excellent (α = 0.86).The measure for the assessment of shyness in adults  consistsWe administered the German version  of the Nnot at all) to 6 (completely). Cronbach’s alpha was excellent (α = 0.86).A 10-item measure of preference for solitude  was answnot at all) to 4 (completely).Participants answered a one-item life satisfaction measure on a 4-point Likert-type scale ranging from 1  to 4 (completely). Cronbach’s alpha was excellent (α = 0.88).We administered the German version  of the Rnot at all) to 4 (completely). Cronbach’s alpha was excellent (α = 0.86).We administered a 10-item generalized self-efficacy scale , which wnot at all) to 5 (completely). Cronbach’s alpha was excellent (α = 0.94). Participants indicated how many offline friends and offline acquaintances they had  as well as how many online friends and online acquaintances they had . Due to left-skewed distributions, we logarithmized the data before aggregation.We administered the perceived available social support subscale from the Berlin Social Support Scales BSSS; . The 8 iexcellent) to 6 (insufficient). Thus, higher scores indicate worse grades.Participants reported their grade point average. German grades are assessed on a scale that ranges from 1 , the strongest correlation between general psychopathology and game genre emerged for action , followed by role playing , and unclassified . For females (n = 357), the strongest relation between general psychopathology and game genre emerged for simulation . Differences were also found regarding the strength of the relation between number of friends online and the genre action: r = 0.06, p < 0.01 for males, and r = 0.27, p < 0.001 for females. Similarly, preferred game genre was related to participants’ age . In sum, our results speak to the idea that individuals with different levels of psychological functioning differ in their choices of game genres and vice versa.Third, we examined whether players’ preferences for different video game genres were differentially associated with the measures of psychological functioning.  age see . HoweverIn a final step, we entered all of the investigated psychological functioning variables as well as sex and age as predictors of the potentially problematic use of video games. By employing this procedure, we were able to determine the unique contribution of each psychological functioning variable when the influence of all other variables was held constant. As With this study, we aimed to shed light on the association of diverse video gaming habits with gamers’ psychological functioning. Drawing on a large sample, our results revealed a medium-sized relation between potentially problematic video game use and poor psychological functioning with regard to general psychological symptoms, maladaptive coping strategies, negative affectivity, low self-esteem, and a preference for solitude as well as poor school performance. These findings are in line with those of prior work e.g., . Also, rThe presented results are generally in line with previous work that has identified a connection between video gaming and psychological health, academic problems, and social problems . HoweverHow can the findings on differential relations between video gaming and various indices of psychological functioning – ranging from beneficial results  to unfavWhen is it appropriate to speak of video game addiction? More and more researchers have suggested a continuum between engagement  and pathIn sum, it seems relevant to assess not only the extent of video game use but also the reasons behind this behavior  and the concrete rewards that come from playing  to fully understand the relation between video gaming and psychological functioning.With the present study, we aimed to uncover the association between video gaming and psychological functioning. Our approach was cross-sectional and warrants interpretative caution because correlations cannot determine the direction of causation. It remains unclear whether potentially problematic gaming is a factor that contributes to the development of psychological dysfunction or whether psychological dysfunction contributes to potentially problematic gaming. Also, a third factor  may produce both psychological dysfunction and potentially problematic gaming. Thus, longitudinal studies that are designed to identify the causal pathway may provide a promising avenue for future research. Future studies may also answer the question whether the link between video gaming and psychological functioning is moderated by sex, age, the reasons for playing, or the preferred game genre. In addition, it is important not to forget that the present results are based on a self-selected sample in which potentially problematic video gamers were overrepresented e.g.,  to objecThe current study adds to the knowledge on gaming by uncovering the specific relations between video gaming and distinct measures of psychological functioning. Potentially problematic video gaming was found to be associated with positive affect and social relationships while playing but also with psychological symptoms, maladaptive coping strategies, negative affectivity, low self-esteem, a preference for solitude, and poor school performance. Including gamers’ reasons for playing video games and their preferred game genres helped deepen the understanding of the specific and differential associations between video gaming and psychological health. This knowledge might help developing adequate interventions that are applied prior to the occurrence of psychological impairments that may go along with potentially problematic video gaming.In our online survey, participants were given information on voluntary participation, risks, confidentiality/anonymity, and right to withdraw. Whilst participants were not signing a separate consent form, consent was obtained by virtue of completion. We implemented agreed procedures to maintain the confidentiality of participant data.BB, BE, JH, and KM conceived and designed the study. BB, JH, and KM collected and prepared the data. JH analyzed the data. BE and JH wrote the manuscript.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.


Using mouse models with increased or no formation of Tau protein and increased production of 24OHC, we have also tested the hypothesis that there is a direct association between neuronal turnover of 24OHC and Tau. The levels of 24OHC are increased, at a group level, in patients with PD or CBS. We found significant correlations between levels of 24OHC and Tau or P-Thr181-Tau in CSF from patients with PD, CBS or CBD. There were no similar correlations between 24OHC and Aβ42 in CSF from these patients. The neuronal levels of 24OHC were not altered in Tau knockout or Tau overexpressing mice. Vice versa, Tau species levels were not changed in Cyp46 overexpressing mice with increased neuronal levels of 24OHC. We conclude that the strongly correlative fluxes of 24OHC and Tau from neuronal cells to CSF are likely to be secondary to neurodegeneration and not due to direct interaction between the two factors. We suggest that this high correlation reflects a rapid neurodegeneration of specific neuronal subtypes with simultaneous release of 24OHC and Tau into the CSF.24S-hydroxycholesterol (24OHC) and Tau are produced in neuronal cells and neurodegeneration leads to increased flux of both of them into cerebrospinal fluid (CSF). In the present study, CSF levels of 24OHC and 27S-hydroxycholesterol (27OHC) along with those of Tau, P-Thr In contrast to cholesterol itself its side-chain oxidized metabolites 24S-hydroxycholesterol (24OHC) and 27-hydroxycholesterol (27OHC) are able to pass the blood-brain barrier. 24OHC is exclusively formed in neurons and is continuously fluxed into the circulation . 27OHC i181-Tau and 24OHC in CSF from patients with Alzheimer's disease and mild cognitive impairment. This finding was confirmed in a later study by another group , which is a synucleinopathy, but associated with genetic polymorphisms regulation tau expression  Memory and Aging Center. All the investigations of the patients and the analyses of their CSF were approved by the ethic committees of the respective institutions. Informed consent was obtained from the subjects.In experiment 1, CSF from controls , patients with early PD  or CBS The CSF samples were obtained by lumbar puncture and collected into polypropylene-tubes and subsequently centrifuged . The supernatant was carefully pipetted off and dispensed in 500 μl aliquots before storage at −80°C. The time interval from collection to freezing was less than 60 min.All the animal experiments were approved by the local Animal Experimentation Ethics Committee.Twelve weeks old male wildtype, tau KO and hTau OE mice on a C57Bl6 background were used. Both mutant Tau lines are deficient of murine Tau, but hTau OE mice overexpress all six human Tau isoforms, leading to gradual Tau pathology and behavioral deficits . Mice weTen weeks old male mice with overexpression of CYP46 under the β-actin promotor on a C57Bl6 background were used . CYP46 iThe analyses of 24OHC and 27OHC in CSF and mouse brain tissue were performed by isotope dilution mass spectrometry as described previously , 13. In 181 Tau (commonly referred to as phospho-tau) and Aβ42 analyzes in CSF samples from Karolinska were made with enzyme-linked immunosorbent assay (ELISA) kits from Innogenetics NV Ghent Belgium. CSF samples from USCF were analyzed with the INNO-BIA AlzBio3  platform to measure Tau, P-Thr181 Tau and Aβ42 and the Uman Diagnostics ELISA kit  to measure neurofilament (NFL).Tau, P-Thr202 Tau in cortical brain tissue from wildtype and CYP46 OE mice were determined by Western blotting and chemiluminiscence as previously described .Data are presented as mean ± S.D. Data was tested for normality using the Kolmogorov–Smirnov test. When two groups were compared, unpaired Student's F 10.6; p < 0.001] higher levels of 24OHC in CSF than those of the control subjects    Figure . The datr = 0.6, p < 0.001) in CSF from patients with PD   , correlation between 27OHC and Tau and P-Thr181 Tau in CSF from PD patients  correlation between 27OHC and Aβ42 in these patients  as well as P-Thr181 Tau  in patients with CBS  correlation between 24OHC and Aβ42 , P-Thr181 Tau  or Aβ42  in the CBS patients    correlation between 24OHC and Aβ42  a significant correlation to 24OHC , P-Thr181 Tau , Aβ42  or NFL   Figure  and a st) Figure . There w2 Figure . MeasureC Figure . There wr = 0.29, p = 0.38), P-Thr181 Tau  or Aβ42  in control subjects. There was no significant correlation between 24OHC levels and age in controls , PD  or CBD  subjects, whereas there was a positive correlation in CBS patients .There was no correlation between 24OHC and Tau (202 Tau (CP-13) or 4R-Tau in cortical brain tissue  or increased (Tau OE) levels of Tau. As shown in Supplementary Figure F 0.07] different between these groups. There was neither any significant  alterations in the levels of 27OHC in the genetically modified Tau mice , a frontotemporal behavioral variant (FTD-CBD) and a variant with progressive non-fluent aphasia (PNFA-CBD). Due to this heterogeneity in presentation, a clinical diagnosis of CBD is often difficult and many patients will receive an ante mortem diagnosis that is altered upon post mortem examination (The strongest finding here is the high correlation between 24OHC and Tau or P-Thrmination . In our The very high correlation between 24OHC and Tau led us to test the hypothesis that there is a direct interaction between the neuronal production of the two factors. Indeed, based on experiments with mouse models the possibility has been discussed that there may be a causal link between CYP46A1 protein content and memory impairment that result from Tau pathology .vice versa, Tau is not likely to directly determine the production of 24OHC. It is noteworthy that young mice were used in our studies to avoid indirect influence of aging, but it may also turn out that reciprocal changes in 24OHC and Tau are only evident in older mice. Nonetheless, it seems likely that the correlation between the two factors in the patients is secondary to neurodegeneration, in PD as well as CBD patients. In theory, a high correlation between 24OHC and Tau can be expected if there is a very rapid decomposition of individual neuronal cells with a simultaneous release of both 24OHC and Tau. Accordingly, a higher correlation was seen in CBS/CBD than in PD patients, likely to reflect the more aggressive neurodegeneration in CBD/CBS.However, experiments with a mouse model with high levels of 24OHC and mouse models with increased or no levels of Tau did not give support for this hypothesis. Thus, 24OHC is not likely to be a driving force for increased production of Tau and, In conclusion, CSF levels of 24OHC are elevated, at group level, in PD, CBS, and CBD, and show a very strong correlation to Tau. Future studies will evaluate whether 24OHC and Tau interact synergistically in pathophysiological events underlying PD or CBD. It will also be interesting to study whether there is a correlation between 24OHC and α-synuclein and to measure 24OHC in the same individual at different disease stages in longitudinal cohort studies.This study was approved by the Research Ethics Committee of the Karolinska University Hospital and University of California, San Francisco. All subjects gave a written informed consent in accordance with the Declaration of Helsinki before the measurements.IB: study planning, sample measurements, and manuscript writing. KP: sample measurements, data analysis, and manuscript writing. AB: patient and sample recruitment and manuscript writing. PS: study planning, data analysis, and manuscript writing.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.


Multiprofessional ward healthcare providers are generally unprepared to assemble and engage in the initial resuscitation of pediatric inpatients. This is important as the performance of these first-responders, in the several minutes prior to the arrival of acute care support, may have significant effects on overall patient outcome. Accordingly, we aimed to develop and pilot a training program intended for non-acute care inpatient providers, relevant to their working context. Using the latest theory and evidence in medical education, we created an interprofessional, entirely in-situ, simulation-based small-group activity. The activity was then piloted for four months with the goals of assessing perceived usefulness, as well as implementation factors such as participant accessibility and overall resource requirements. A total of 37 interprofessional (physician and nursing) staff were trained in 16 small group sessions over four months. Post-participation questionnaires revealed that the activity was perceived to be highly useful for their practice; especially the rapid cycle deliberate practice instructional method, and the increased focus on crisis resource management. Resource requirements were comparable to, and perhaps less than, existing acute care training programs. This project describes the preliminary steps taken in creating a curriculum intended to improve interprofessional resuscitation performance across an institution. Pediatric inpatient cardiopulmonary arrests are uncommon, but have significant health implications. Despite some improvements over time, a recent multi-center review of pediatric inpatient arrest events showed that rates of survival to hospital discharge were below 50% . In respWith infrequent clinical exposure to deteriorating or acutely ill patients, there are limited relevant and accessible ways for pediatric ward providers to maintain basic acute care skills. While there are structured educational opportunities provided by the American Heart Association, these courses  are geneBuilding on the existing literature, our goal was to develop an updated simulation-based, context-specific, interprofessional training program specifically for ward-based pediatric providers. We also aimed to pilot the activity for perceived usefulness, as well as to understand potential implementation obstacles such as participant accessibility and resource requirements.The program was developed at a stand-alone children’s hospital. The facility is part of an academic health sciences centre, with 166 inpatient beds, and approximately 6000 admissions per year. Outside the acute care units, patients are cared for by over 60 residents and fellows, 200 staff physicians, 30 respiratory therapists, and 500 nurses. Pediatric residents participate in acute care training and simulation during their residency curriculum. The remaining providers, however, have no regular acute-care curriculum nor training requirements. Ward-based simulated mock codes, similar to those described by van Schaik et al. . are helAn organizing group of interprofessional staff (see author list) undertook the six-steps of curriculum development . FollowiA concept map was created to assist learners in attaining knowledge and process objectives see . The conThe educational literature was then reviewed for pertinent instructional methods. Appropriate planning is essential for successful interprofessional educational activities . EmployiFrom a simulation perspective, the program objectives required training individuals to perform specific critical tasks competently (e.g. pulse-check), as opposed to engaging in abstract thinking or problem-solving. Accordingly, we facilitated the sessions using Rapid Cycle Deliberate Practice (RCDP), whereby performance is directly observed, and learners are provided immediate feedback with the opportunity to repeat until mastery is achieved. RCDP has become a central element in resuscitation learning , and hasNext, guided by the implementation principles of the resuscitation education science literature , we prioThe program was run by two instructors, beginning February 2017, with one instructor being experienced in mannequin transport and setup on the ward. Individual one-hour sessions consisted of 45-minutes of instructional time with an additional 5-minutes of built-in feedback and evaluation time, and 10-minutes of instructor cleanup and setup (see Program participants were ward physicians (attending physicians and trainees) and ward nurses. At least one physician and one nurse were required per group, with a goal of three to four participants total. Physicians scheduled their session ahead of time, while ward nurses on-shift were invited to participate. Of the 45-minutes of instructional time, instructors spent the first five minutes performing introductions and reviewing the program objectives and rationale. The next 15 minutes were spent demonstrating and then observing participants perform technical skills by retrieving and using equipment identical to those found on the ward. Participants were coached until each skill was done correctly. The remaining 20–25 minutes was spent running RCDP arrest simulations with the entire group . In eight sessions (50%), a ward nurse was not available, and a ward nurse educator participated instead. A total of 37 individuals participated in the pilot sessions, and 31 evaluation forms were submitted for a completion rate of 84%. Respondents were: ward nurses ; residents ; staff general pediatricians ; and staff subspecialty physicians .Most participants indicated that all parts of the program were either ‘very useful’ (should be kept in the program), or ‘extremely useful’ (definitely keep in the program) . ParticiCardiorespiratory arrest is uncommon in pediatric inpatients , and pedExisting literature has shown improvements in individual and team performance using simulation and the RCDP technique , and is From an effectiveness standpoint, the program was well received by participants. Most exhibited high degrees of self-motivation as they recognized the relevance of the content and skills being taught to their direct patient care environment. Practicing CRM skills through ad-hoc interprofessional team formation was also perceived as valuable.From a resource perspective, the activity appears to require similar and possibly fewer human and equipment resources compared to existing simulation acute care training activities. No specialized simulation space is required aside from an empty existing ward room, and a single low-technology mannequin is adequate. Compared to existing programs, and presuming full attendance, two instructors each spending 45-hours per year would be able to train up to 36 learners in PALS , up to 60 learners in PEARS , and up to 180 learners in our program . It should be acknowledged that these numbers simply reflect the reach to a learner audience, and not necessarily equivalence in training or scope of practice. Forty-five hours of individual instructor time per year equates to approximately 4-hours  of simulation work per month. Feedback from program instructors suggested the investment was reasonable given their existing clinical and academic commitments, especially since sessions required little to no extra pre- or post-work. Finally, although the scale of our pilot phase would be inadequate to train large numbers  of staff, including additional sessions and instructors could potentially accommodate larger learner populations.Considering accessibility, participants considered the short, 50-minute sessions on the inpatient units to be desirable and more easily accessed than standard pediatric resuscitation courses. However, there were identified challenges with accessibility, notably with ward nurse recruitment. The plan for ad-hoc on-shift ward nurse participant recruitment led to several cancellations. It seems that in order to maintain consistent ward nurse participation, deliberate plans for duty coverage and/or protected time are required on planned training dates. Alternatively, training dates may be scheduled to coincide with nurse orientation and education dates. In either case, given that ward nurse participation is a vital part of the interprofessional activity, seeking involvement as well as support from nurse managers and administrators at the outset is recommended.Overall, we developed and piloted a targeted and specific interprofessional resuscitation training activity for pediatric ward providers, that participants perceived to be highly useful. Resource requirements are not insignificant, but are comparable to or less than existing acute care training activities. Future steps include improving the capacity for participant attendance and measuring the program’s impact on learning, behavior, retention, and patient outcomes.


DEAR EDITORBody contouring surgery after massive weight loss is becoming very common all over the world and more so in our part of world. The contouring procedures need an extensive preoperative planning and correct marking of the incisions and areas of resection. The marking fades sometimes after scrubbing the patient and use of tumescent fluids. Intraoperative precise marking can be done by use of sterile surgical markers . The sca1 At the end of the procedure the pen is removed from the pouch and recapped, and can be used in this way for multiple times. This method is cost effective, and we have an option of using multiple colors. Moreover, the Sharpie markers have ink, which dries on the surface of patient instantaneously and marks don’t fade. We did not notice any infection in these patients, which could have been related to use of these markers.The circulating nurse hands over the pen to scrub nurse who puts it in a pouch made from sterile drape. Putting steri strips over it tightens the pouch . The wriThe authors declare no conflict of interest.