Using videoconferencing for consulting with patients in the mental health services has been shown in interventions to be similarly effective as when meeting in person. In practice, it often makes more sense to use video consultations with patients in a more flexible way than interventions permit. The aim of this study was to investigate what constitutes a professional video consultation from the perspectives of mental health professionals and explore what is of importance for the establishment and realization of video consultations in practice.A Grounded Theory methodology approach based on Corbin and Strauss was used. Data collection consisted of participant observations of introductory events followed by individual interviews with mental health professionals who had used video consultations with patients.Mental health professionals believed that a professional video consultation was one that was not inferior to an in-person consultation but offered something else, such as more and easier access, accommodating patients’ needs and wishes. At the same time, it should not interfere with the treatment quality, e.g., by hampering communication and therapeutic tasks. The expected treatment quality was based on an individual assessment of the patient and varied from clinician to clinician. The implementation process and support which the organization provided affected the clinicians’ attitudes as well as the clinicians’ experiences and hence how the clinicians assessed the quality of the service.Perceived usefulness, patient demands, and close IT support will positively impact the establishment and realization of video consultations whereas high workload and technical problems would hamper it. The use of home-based video consultations in the mental health services has several benefits. Aside from increasing access, as was the case during the COVID-19 restrictions , it has Framework refers to the organizational factors such as working procedures, support, and culture; and content refers to what is happening via the video consultation. It further explores what is of importance for the establishment and realization of video consultations to make it accepted among the clinicians. The investigation took place in a Danish setting and is based on an exploration of what considerations and experiences early adopters from a public mental health hospital had with video consultations used with adult outpatients. This will strengthen our understanding of the circumstances where video consultations will be considered meaningful and guide policymakers’ and managers’ decisions regarding initiatives to implement it in practice.The aim of this study is to investigate what constitutes a professional video consultation with regard to its framework and content from the perspectives of mental health professionals. 2 with approx. 1.2 million people in 2021. The region has a large rural population  What do you think about video consultations? (2) How was it introduced to you? (3) How do you choose to whom you offer video consultations? And (4) How did you experience communicating with the patient via video and how did that affect the therapeutic relationship? Interviews were conducted at each clinician’s office and lasted around 1 h. After each interview, initial concepts were noted down and used to direct specific focus in the coming interviews. All interviews were recorded and transcribed. After all interviews were collected, data from each interview were analyzed to refine the established categories . ExampleThe first author conducted all the interviews. She has a background in science of public health and has, therefore, no experience with consultations of mental health patients. This gave her an outsider perspective, which perhaps created a more objective look at practice but also made her naïve to informal cultural practice and jargon. The outsider perspective may have changed over time. She was employed within the organization and was seen by the participants as a colleague from a different department. This may have increased the participants’ trust in the interviewer.15 clinicians were invited via e-mail to participate in the individual interviews. 11 responded to the request and consented. In the final interviews, no new substantial concepts in relation to the research question emerged, and no more clinicians were contacted. Participant characteristics can be seen in The Regional Committee of Health Research Ethics for Southern Denmark was queried for ethical approval (no. S-20162000-29) and the project was reported to the Danish Data Protection Agency. Department managers were notified about the project, and team managers and local research coordinators approved of the study. During field work, the researcher who did the data collection presented herself as a researcher. Participants in interviews were informed in writing of the purpose of the study in their invitation to participate and orally before the interviews. They were assured anonymity, voluntary participation, and the right to withdraw their consent. They all gave written informed consent before the interviews began.From the analysis, the core category, “assessment of the most beneficial treatment,” was generated. It derived from the following categories: “expected treatment quality,” “assessment of the patient’s problems and needs,” “clinicians’ attitudes to video consultations,” “available organizational resources,” and “experienced treatment quality.” The categories are connected as follows: When the clinicians decided whether they wanted to offer a video consultation to a patient, they assessed how they expected this would affect the treatment quality of this particular patient. The assessment was based on the patient’s problems and needs. They balanced barriers and advantages, and when the total quality was expected to be better than without it, they offered it. It can be complex to counterbalance barriers with advantages; hence, it varied from clinician to clinician. Variations were based on the clinicians’ different attitudes toward video consultations, which were both guided by individual qualities, such as preferences and technical skills, and organizational conditions, such as the way video consultations were implemented in the system. The available organizational resources, such as support, working conditions and the videoconferencing system, restricted the scope of what was feasible. As the clinicians acquired experience with using video consultations, their attitudes became more positive or negative with regard to what video consultations were able to accomplish. The clinicians assessed that the use of video consultation could improve the treatment quality when the patient experienced that access to their treatment became easier and more readily available. With increased accessibility, the clinicians expected the patients to be more satisfied and that there would be fewer no-shows. This could safeguard continuity in the treatment course, which would strengthen the therapeutic process. An example:A: Do you also use it to have more frequent contact?I: Yes, with some of them, so you can follow up on them more often, yes. And I think you can say it’s also that frame of reference that we sort of work within, you may say, when you mainly work cognitively, then preferably not more than a month should pass between [sessions], or else there’s just too much, then there will be too much spam in the intervening period, so, the more often you actually can have a conversation, the better, then you can speed up the course a bit and help them (…). Participant 5, psychiatric nurse.In addition, video consultations could be offered as extra consultations since they are less resource-demanding and hence serve as an expansion of the existing offering. Conversely, the clinicians found the quality deteriorated when video contact prevented or hampered significant treatment components and when the technology was unstable, since access to the consultation would be reduced and the offering became unreliable.The clinicians’ point of departure when considering using video consultations was that the patient experienced a problem that complicated or prevented physical attendance at the clinic. This was both related to the lack of specific transportation options, expenses, and the time spent on the transport; mental problems patients might experience during transportation or their stay at the clinic; and social and cognitive difficulties with remembering the appointment and organizing transportation. This was the main reason why the clinicians considered offering video consultations. An example:I: But I can easily imagine that after the first personal [in-person] conversation that I continue the diagnosing [over video], but that would require that the patient said: ‘I find it difficult to turn up’, then I would order a [video] license. If the patient doesn’t mention anything, then they’ll just receive their next appointment to turn up here. Participant 6, psychiatrist.In this case, the psychiatrist only offered a video consultation to patients who expressed an obstacle to access the clinic. Given that the psychiatrist believed that he could make a better assessment of the patient in person, he did not suggest it proactive to patients who might from their perspectives have benefited from its use. Subsequently, the clinicians assessed how they thought the video consultations would affect the patients’ course of treatment, based on the patients’ mental condition and social competencies. For example, suicidal patients, psychotic patients, and patients with a substance abuse problem were mentioned as among those patients the clinicians deemed unsuited for video consultations for fear that they would be unable to observe the patient sufficiently and hence unable to intervene if necessary. Another example included patients with social phobia. When the patients could not leave their home, video consultations could be used at the beginning of the course of treatment, and then they could practice showing up at the clinic in due course. Furthermore, the patients with social phobia were more relaxed at home, which made it easier for them to work with some issues. These elements suggested that video consultations could improve the quality of treatment. An example of where the quality was restricted included patients with a major depression. They are typically affected socially and tend to isolate themselves. In these cases, the clinicians typically considered it important that the patient show up at the clinic to maintain certain functional abilities. That is, when the patient has poor social capability, it is not considered beneficial for the patient to meet over a video link, unless it is the only option for therapy. Some clinicians chose for that reason to first consider video consultations after social competencies have been practiced. Of other social competencies, the way the patients communicate also impacted on how the video consultations were assessed as beneficial. For example, a clinician mentioned that she did not want to offer video consultations to those of her patients who were very taciturn since the communication with that patient would be more supported by non-verbal language, which is less available via video. To some degree, it varied from clinician to clinician how they assessed the beneficial effect that meeting in person has on the patient’s social competencies and the need for exposure.The patient’s interest in video consultations was also decisive for whether a video consultation was established. Most of the patients who were offered a video consultation wanted to make use of it, presumably due to the clinicians’ careful selection of patients they offered video consultations to. Some patients requested video consultations, which the clinicians in general were willing to meet to secure the patients’ engagement in their treatment and make them feel that their needs were met. In several cases, this was the reason why the clinician started to use video consultations with a patient. The clinicians were in general attentive to the patients’ requests, such as here:A: Of those you told about video, did anyone say that they didn’t want to?I: No, not at all. These people, they’re very positive about it… especially when there’s a long journey to get here and it’s difficult… (…) so I have several [patients] who write: “well couldn’t we, could we possibly meet up on video today?” because some transport scheme went pear-shaped for them. And then we do it [video consultation]. So, it’s always at the patient’s request, if we end up using video. Participant 7, Psychotherapist.The clinicians’ experience with what affected the patients’ interest was, among other things, the patients’ IT skills. Especially younger patients under the age of 40 who are used to IT did not encounter any challenges with the technology. For patients who were less IT-savvy, the combination between IT challenges and the cognitive challenges their mental disorder may cause could be the reason why they were unable to cope with video consultations. However, the patients could bring their devices and get help from the clinician, or they had relatives who could help with the technology. A limitation was, though, that some patients did not have the right IT equipment and hence were excluded. These were often patients with severe disorders who were unable to work and hence had a low socioeconomic status. Some of these patients received home visits, and they may not be interested in changing those encounters to video. Nevertheless, some clinicians were able to offer consultations in addition to the usual care, which they would not have had the resources to do if they had to make a house call.In summary, the clinicians assessed the patient’s total situation before they decided whether to offer a video consultation. They considered problems regarding transport, mental issues, personality, and interest, and how these things would affect the treatment quality.The clinicians’ individual attitudes toward video consultations also affected how they assessed the treatment quality. Their attitudes were affected both by their individual competences (such as IT skills as well as their knowledge about and experience with video consultations) and the manner in which they were introduced to them.When the clinicians were introduced to video consultations, many of them were initially skeptical and saw it as a threat to their patients, their integrity, and their working environment. At joint meetings, they expressed their frustrations and asked many questions about whether it really was the best option for their patients, and whether they as clinicians would be able to figure out the technical parts. This was also expressed in the interviews:A: And what did you think about it at that time [when she was introduced to video consultations]?I: Ahh… I thought it was confusing and, ehm, I thought a lot about that with the relationships, how will it be when you do it over the computer, that is, how will your relationship be with the patients that you see on video? And then I was very scared about the technical stuff because I’m not very technology savvy, ha ha, when it comes to computers and plugs and headsets and webcam and stuff like that, so that, I was a bit, well actually scared of too. So, I think I was a bit skeptical, actually. Participant 3, psychiatric nurse.This participant was initially skeptical about how video consultations would affect her patients’ treatment. She also feared that she could not handle the technical part of the videoconferencing system which reinforced her skepticism. Many clinicians mentioned that they did not have good experience with the available IT support in other regards, and this might have intensified the fear of not being able to handle it. Other clinicians had a more pragmatic approach and expressed that video consultations gave them various options. An example:I: (…) so I feel sort of, I take it very from above and down, yes, when something new is coming. So, I don’t think: ‘oh no, something new is coming’. I think that it’s a way to keep up with reality of what’s happening IT-wise and what opportunities we have today. Participant 1, medical social worker.Whether the clinicians were skeptical or pragmatic influenced their decision to offer video consultations. Of those who were skeptical, some chose not to offer video consultations to anyone, while others picked out patients under specific conditions, e.g., if the patient had wanted the video option, or where video was the most clear-cut solution to a transportation issue. Those with a more pragmatic attitude offered video consultations to all with transportation difficulties, but also to patients who had several cancelations or no-shows, and they saw possibilities in offering additional video consultations consisting of follow-up conversations. The correlation is depicted in The clinicians’ attitudes were, among other things, influenced by the workload they experienced before the video consultations were introduced and their coping strategies. Some therapists felt that they did not have the mental capacity to acquaint themselves with something new, even though it could potentially save time in the end. By turning down new things, they avoided additional workloads. Among the interviewees, those who defined themselves as having good IT skills felt less insecure using video consultations since they could acquaint themselves with the program and solve any difficulties faster, so they were less skeptical. However, more than half of the clinicians who already had tried video consultations described in the interviews that they did not have good IT skills. They often had more difficulties getting IT support when technical difficulties arose. Further, when the clinicians heard from colleagues that something did not work, they were less inclined to try it out themselves. They did not find it professional to offer something to the patients that would turn out to not work, and hence they stopped offering video consultations. They felt that they appeared unreliable, and they feared how that would affect the patients’ trust in their therapist and their course of treatment, which is important for the treatment effect.The available organizational resources  set the framework for what was possible, which influenced the clinicians’ attitudes and affected their practical experiences with video consultations. At the mental health hospitals, the clinicians had, in general, great autonomy over their consultations, and for that reason, the management’s enthusiasm had little impact on the clinicians’ attitudes. However, the management’s level of support had a major impact on how well the video consultations were implemented. It affected the clinicians’ trust in whether video consultations were possible, and that the treatment quality would remain the same, and in their willingness to change their existing practice. For example, the hospital management decided that video consultations should be reimbursed better than in-person consultations. Since phone calls did not receive any reimbursement, this incentive structure specifically made some clinicians consider whether they should convert some phone calls to video calls, still in consideration of the treatment quality. In that way, they could increase their productivity without increasing their effort because they were making the call regardless. An example:I: (…) It’s also a performance positioned system we are in, right, so you can say that many of the phone consultations you have, you can redefine to actual performance output [when using a video consultation]. I find that it’s a bit of a shame that it has to be like that, but it’s a fact. Participant 5, psychiatric nurse.Despite some incentive structures, video consultations were implemented in an experimental way where no guidelines were defined, and each clinician had to decide on their own what potentials they believed that video consultations could have, without being aware of the existing evidence in the field. Because of that, it has been challenging for the clinicians to know what to be guided by, which may have caused them to be more restrictive in their selection. The insecurity was, among other things, expressed as follows:I: The problem here is that you may not be that pressured, because when we got Cosmic [electronic patient journal], we had no other option but to use it. With Jabber [the video program], if you’re scared of it, you don’t mention it as an option to your patients. It is better if you show up in person, and I prefer that. So, maybe it isn’t used as much as it could and what seems sound, due to anxiety and how you deal with that. Participant 6, psychiatrist.At the same time, the clinicians worked under a service system where the throughput to a great extent was measured on the number of patient consultations. For that reason, the clinicians considered the patient consultations as productive, whereas training and problem solving in regard to the video program were considered counter-productive. Patient consultations can take place without video, and hence video consultations are not essential for the clinicians’ productivity. To the extent that the clinicians experienced that the training and problem solving took time away from patient consultations, they did not prioritize it unless they deemed it particularly beneficial to the patient that the conversation was over video. An example:I: (…) But then there has really been a long period where I didn’t use it because it’s so frustrating in a busy weekday that you actually have to spend even more time sometimes on such a [video] conversation than you have to on a regular conversation where people arrive in here due to that the technical stuff doesn’t work (…). Participant 9, psychiatric nurse.It has therefore been decisive for the use of video consultations that sufficient IT support was available and that the video program worked. The amount of IT support available was an important factor in how secure the clinicians felt when offering video consultations. When they knew who to contact to resolve technical issues, they need not feel nervous about how well the technology would work or whether they would have to spend time on their own troubleshooting issues. In general, it was important that the IT support was available immediately, since technical difficulties often occurred during an appointment with a patient. When the problems were not solved immediately, the clinicians had to change the appointment to a phone call. When the clinicians experienced difficulties, they often used the IT support physically closest to them, such as a clinical colleague. Some teams appointed superusers whose responsibility it was to help others with technical difficulties, and that worked well:I: And it’s, at any rate, nice as a therapist that I don’t have to struggle a lot with something technical, and there is a sort of service about it, and I can approach the conversation as any other conversation. Instead of fetching the patient in the waiting room, well then I just need to open my computer and open Jabber [the video program] (…). Participant 8, psychologist.Others had to find out on their own how to get help, which delayed the time span before a solution was found, during which they could not use video consultations:I: Well, I have some [patients] where we simply couldn’t get the tech working, and without finding out how that is interrelated. Well, that’s what I sometimes think, that we, as nurses, we’re left with this, to find out about all this technical stuff. (…) It takes time, and if you do call and can’t get through… or the patient’s equipment doesn’t work, or… there it becomes a time-waster, and we finally had to give up. Participant 11, psychiatric nurse.Reliable performance of the videoconferencing program, close IT support, and incentive structures all affected the clinicians’ attitudes toward video consultations and the experiences gained.The experience the clinicians gained with using video consultations has either strengthened or changed their attitudes toward video consultations and how they assessed how the video format would affect the treatment quality. This was both in regard to what type of patients they would use it with and what type of conversations they wanted to use it for. A clinician who was asked which advice she would give to those of her colleagues who had not used video yet, replied:I: Well, that you don’t have to be so skeptical, ha ha, as I was; I think, that is, that it actually works well, ehm, and that it’s a good supplement to them coming here; that is, to outpatient conversations, it’s a really good supplement, and the patients are happy about it. At least those I’ve had; they’ve been happy that there has been this offering (…). Participant 3, psychiatric nurse.Experience not only improved the clinicians’ technical skills so that IT difficulties took up less time; it also improved their way of communicating and interacting with the patients via video. In general, the clinicians had good experiences with using video consultations when all of the technical aspects worked and claimed that video consultations held a bigger potential than before they tried it.Some of the experiences that the clinicians gained was that they often felt that the video consultations were more formal than in-person consultations. This was, among other things, because the clinician and the patient typically would sit straight in front of the screen where they would be able to see a passport photo segment of each other. In addition, they would typically use less small talk, which could shorten the conversations. Most often, the clinicians who did psychotherapy had made an agenda that both they and the patients would follow closely, and for that reason, they felt that the video conversations were more focused and effective compared to in-person consultations. The clinicians also felt that they did not get to know the patient as well. Small talk and how the clinicians acted in front of the screen could both be changed and tried out in new ways until they found an effective style. A clinician who had seen several patients via video explained that over time, she experienced that the video consultations in regard to content and timewise became more like the consultations she had in person.The clinicians also experienced that some of the communication was attenuated and had to be replaced verbally. It put more of the responsibility for the communication on the patients, since it would be easier to disguise emotions. This made the clinicians worry whether they would be able to observe enough to interact most considerately in regard to the treatment. For that reason, they nearly always chose to use video consultations with patients with whom they already had established a relationship, allowing them to feel able to read the patient correctly and ensure a safe treatment. Two of the clinicians had tried a video course with one patient each where they did not meet in-person first. They both felt that they did not get to know their patient as well as their other patients, which made them feel insecure and led to a decision of not doing it again. Both clinicians experienced that their patients seemed pleased, that they were equally candid as their other patients, and that the patients improved so much that they were discharged from the hospital. The clinicians’ insecurity is thus not due to specific inexpedient events but rather because they felt less in charge of the treatment. Another clinician saw a potential in giving the patients more control and chose actively to offer video consultations to some of her patients who were gamers and hence used to using video for conversation. She told them that she was less IT-savvy than them and that she thought she could ask them for help in the event of any technical issues, effectively shifting the balance of power in their relationship. She believed the patients would feel that they were creating value for her in that it was not just them who needed help. Video consultations further allowed new opportunities since it sometimes was possible to get more information about the patients in their home. While some patients chose to display their home via the webcam, most of the time they would sit in front of the screen.Several clinicians found that it was difficult to use the slate in therapy over video. They used the slate to draw and visualize cognitive models to explain how the cognitive therapy worked and how it applied to that individual’s problems. Instead, they chose to be more verbal and visualize cognitive models less. One therapist explained that it made the sessions shorter since they spent less time reflecting over concepts than they would if they looked at the visualized models on the slate. For that reason, several therapists decided to use video consultations for sessions with topics that had already been introduced. Then they could refer to models the patient was already familiar with:I: Sometimes I use the slate a lot, with models and stuff like that, and then I find it challenging because so far, we can’t run the video consultation while sharing our screen, (…) So thus, the level, also the quality of it, is not the same as if they were sitting inside the office. So, therefore, I must also choose: Should it be a consultation that’s a supporting conversation where you listen to how things have been since the last time, and how can you kind of work with them without there being too many slate projects? Participant 2, psychiatric nurse.In conclusion, the clinicians’ experiences showed that using videoconferencing with patients is a different way of communicating together. Having gained experience, the clinicians were able to adapt their sessions to the new modality and became more knowledgeable of how video consultations can be used in a meaningful way.During the COVID-19 crisis, many therapists have been compelled to cancel or virtualize sessions with patients. Concurrently with the relaxation of COVID-19 restrictions, psychiatric hospitals or community mental health centers, may want to continue some of these services to increase accessibility, and it is therefore relevant to look at which factors need to be available for it to be successful. In this study, factors that mental health professionals believed constitute a professional video consultation were investigated. It further explored what is of importance for the establishment and completion of video consultations in practice. The present study found that mental health professionals believed that a professional video consultation should not be inferior to an in-person consultation but should offer something else, such as more or easier access to the clinician. How the treatment quality is assessed to change over video varied between clinicians, and was, among other things, dependent on their attitudes, which again were shaped by the implementation process and the experiences they gained. Technical challenges and available IT support also played an important role in terms of deciding on whether or not to use video consultations.Our overall findings are in alignment with previous studies of mental health providers’ attitudes toward video consultations. Similarly, the studies found that clinicians believed video consultations could be effective and useful, since it facilitated access and met patient demands, but also that the medium was more impersonal and made it more difficult to detect non-verbal cues , 18. In In this study, the providers voluntarily decided to whom they offered video consultations, and little has previously been studied in this context . We founAnother factor to be attentive to when considering offering video consultations to patients is that there needs to be a balance between the patient’s need and the clinicians’ assessment, which must rely on a mutual acceptance. However, there is the risk of one part being trumped. It can be difficult to assess the patient’s need, and they may disagree. In some cases, in this study, the patients exerted pressure on the clinicians to get a video session. Even though the clinicians had to be attentive to whether using video consultations would have any negative effect on the patients’ treatment course, the hospital managers had repeated that video consultations is something the hospital offer to all patients. For that reason, the clinicians felt that they had to offer it when a patient requested it. In most clinics there were pamphlets in the waiting rooms describing that it would be possible to get a video consultation. Therefore, their requests were always met unless technical issues prohibited it. However, therapists found that they needed to establish a relationship in person; nevertheless, they acknowledged that this was their personal need and they were uncertain of the patients’ needs, since those who only met via video seemed satisfied and at ease with the format. However, patients often express that they, too, prefer knowing the therapist before having a video consultation , and cliFinally, consultations via videoconference may potentially facilitate access to mental health services; however, this does not apply for everyone. Home-based consultations require the right equipment and digital literacy, which is not always present among people with low socioeconomic status, socially marginalized people, ethnic minority groups, and the elderly , 24. WitParticipants were early adopters and the clinicians who opposed the most did not participate in the interviews. It was apparent, though, that several of the interviewees were skeptical and much less accepting of the modality than others. Understanding what made them adopt teletherapy might help understand the personal clinician barrier that needs to be overcome. Another limitation is that the clinicians had little experience with video consultations in general and hence were unable to take the full impact on the treatment and the relationship with their patients into consideration. The present study only focused on video consultations with patients in outpatient psychiatric hospital settings. The findings may therefore not be generalized to social psychiatry, and neither to support nor training between clinicians. However, we did include a range of professionals dealing with different types of treatment, from different teams as well, including treatment of a variety of patient categories. We did not find any diagnoses where video consultations would be of particular relevance or of no use. To understand when video consultations are meaningful for the individual, the study could be further strengthened by triangulation of the findings with other stakeholders in the mental health services, including patients and healthcare administrators using interviews, focus groups, and surveys.Our findings show that when clinicians are asked to voluntarily adopt video consultations with their patients, their decision to offer the service is based on an assessment of the most beneficial treatment for the individual patient. Both the patients’ problems and characteristics, as well as the clinicians’ attitudes, have an impact on the assessment. The clinicians’ attitudes are affected by the implementation process. In a system with high workload, the need to invest in extra training may outweigh the benefits of improved service delivery and will in that case negatively affect the clinicians’ attitudes toward the introduction of a new practice. The perceived usefulness and patient demands combined with close IT support will positively affect the clinicians’ attitudes. Overall, the clinicians had positive experiences with consulting the patients via video and maintaining a good working relationship with them. Consequently, the clinicians became more positive toward video consultations after having tried it, although technical challenges interfered with the process. Future research should further examine what education and training are needed and the effect on clinicians’ attitudes, and further investigate how video consultations can be used meaningfully, differentiated between patient groups.The datasets presented in this article are not readily available because of ethical and privacy restrictions. Requests to access the datasets should be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.AM: conceptualization, investigation, data curation, formal analysis, and writing—original draft. JH and PA: formal analysis, supervision, and writing—review and editing. All authors contributed to the article and approved the submitted version.


Tenacibaculum maritimum. This ulcerative disease causes high mortalities for various marine fish species worldwide. Several external clinical signs can arise, including mouth erosion, epidermal ulcers, fin necrosis, and tail rot. Research in the last 15 years has advanced knowledge on the traits and pathogenesis mechanisms of T. maritimum. Consequently, significant progress has been made in defining the complex host-pathogen relationship. Nevertheless, tenacibaculosis pathogenesis is not yet fully understood. Continued research is urgently needed, as demonstrated by recent reports on the re-emerging nature of tenacibaculosis in salmon farms globally. Current sanitary conditions compromise the development of effective alternatives to antibiotics, in addition to hindering potential preventive measures against tenacibaculosis. The present review compiles knowledge of T. maritimum reported after the 2006 review by Avendaño-Herrera and colleagues. Essential aspects are emphasized, including antigenic and genomic characterizations and molecular diagnostic procedures. Further summarized are the epidemiological foundations of the T. maritimum population structure and elucidations as to the virulence mechanisms of pathogenic isolates, as found using biological, microbiological, and genomic techniques. This comprehensive source of reference will undoubtable serve in tenacibaculosis prevention and control within the marine fish farming industry. Lastly, knowledge gaps and valuable research areas are indicated as potential guidance for future studies.Tenacibaculosis occurs due to the marine bacterial pathogen  ApproxiRelatively few pathogenic bacteria account for most of the financial losses incurred by the industry. However, new “emerging” diseases arise biannually and constantly impose health challenges limiting fish production. Classically, pathogenic bacteria are classified as extracellular, facultative intracellular, and obligate intracellular . The surTenacibaculum species . Most available studies involving Tenacibaculum species associate disease in marine fish with infection caused by Tenacibaculum maritimum  and blackhead (Acanthopagrus schlegelii) seabream in Japan . Finally reported are findings elucidating the virulence mechanisms of pathogenic T. maritimum isolates through biological, microbiological, and genomic techniques. The compilation of this information will prove invaluable for tenacibaculosis prevention and control in marine fish farming. Lastly, emphasis given to still existing knowledge gaps and valuable research areas will serve as guidance for future investigative efforts.Most published reviews on 2Flexibacter bacterium was a topic of controversy and confusion until T. maritimum, in addition to adding Tenacibaculum ovolyticum and two other species to the newly formed genus. Today, T. maritimum is the type species of the Tenacibaculum genus, which includes 33 validly and 3 invalidly published species (https://www.bacterio.net/genus/tenacibaculum). All are exclusively found in marine environments attached to or associated with the surface of marine organisms such as macroalgae, various invertebrates, and fish. In addition to T. maritimum, seven other Tenacibaculum fish pathogens have been identified – T. ovolyticum from Atlantic halibut (Hippoglossus hippoglossus)    (T. finnmarkense from rainbow trout (Oncorhynchus mykiss) (T. singaporense (T. piscium (Symphodus melops). Hereinafter, this review will focus only on T. maritimum.The original taxonomic classification of the previously mentioned glossus) ; T. disccarifer) ; T. solealensis) ; T. diceo salar) ; T. finn mykiss) ; and T. aporense  and T. p piscium  from CorT. maritimum are as follows: filamentous; Gram-negative; usually sized 2 – 30 µm in length with a diameter of 0.5 µm; gliding motility; and positive growth on media containing ≥ 10% seawater   . Severalpositive . As a poolyticum  and T. fmarkense , T. mari the dye .T. maritimum isolates may aid in taxonomic identification when compared to other Tenacibaculum species pathogenic to fish. Indeed, some of the above-mentioned morphotype and physiological properties can serve as initial tube and plate analyses for species differentiation, in addition to the application of traditional, ready-made identification systems   . HoweverI 50 CH) . The phe plasmid . Some of3T. maritimum, including the slide agglutination test; the dot-blot and immunoblotting assays; multiplex PCR (mPCR) serotyping; the randomly amplified polymorphic DNA (RAPD) method; the multi-locus sequence analysis (MLSA); and assembled draft genomes, among others. These methods confirm the existence of intra-specific diversity among T. maritimum isolates. In the early 2000s, three serotypes were identified through immunoblot analyses of lipopolysaccharides with varying degrees of relation to host fish species  the design of primers directed at constitutive genes of the pathogen and (ii) the characterization of population diversity. While an advancement, these evolved developments naturally limited the use of random amplification techniques, such as those previously proposed by Tenacibaculum genus, including T. maritimum isolates reflecting the global diversity of this species. The proposed method is based on eleven loci located within single-copy protein-coding genes conserved across the Flavobacteriaceae family were used to design generic degenerated PCR primers for the Tenacibaculum genus. T. maritimum group and recommended the use thereof to monitor infections caused by Tenacibaculum species. However, not all primer sets given by At the genetic level, cluster analyses of the RAPD-PCR profiles for 29 isolates and 3 reference strains of erotypes . ElucidaT. maritimum has been demonstrated with field isolates , the available investigative techniques for isolates of interest within the T. maritimum population, including mPCR-serotyping and MLSA, represent a significant and robust advancement towards commercial vaccines.Confirmation of the MLSA scheme as a powerful tool for taxonomic affiliation and isolate identification of isolates . Such pontrarchi  and seventrarchi . In this4T. maritimum are unclear as little ecological data for this microorganism exist. However, the propensity of T. maritimum to survive for a prolonged time in different seawater microcosms  of crocosms , as wellh stocks . Some reater see .T. maritimum. To this end, jellyfish  blooms could conceivably provide both a colonization site  and a source of Tenacibaculum infection  might serve as an organic substrate capable of extending Tenacibaculum persistence in seawater. More recently, S. salar skin surface microbiota throughout a complete L. salmonis infection cycle, finding that the Tenacibaculum genus was perhaps the most abundant taxon across all mucus and water samples. Indeed, the ability of T. maritimum like member of Flavobacteriaceae family to survive in host skin mucus and cope with the bactericidal activity of the skin mucus reflects the potential of this tissue to act as a major reservoir  using immersion and dilution methods. These authors observed high mortality rates between 17 and 26 °C but not below 17 °C or above 26 °C. In contrast, T. maritimum. In turn, the rising seawater temperature around Tasmania has increased tenacibaculosis frequency (Neoglyphidodon melas), Picasso triggerfish (Rhinecanthus assasi), and broomtail wrasse (Cheilinus lunulatus) during winter but no T. maritimum infections during summer. Likewise, Dicologlossa cuneata) cultured at 20.5°C in southwestern Spain. The winter water temperature ranged mainly from 15-20°C, which, as concluded by the authors, is perfect for the growth and propagation of T. maritimum. Taken together, these reports could explain the explosive appearance of tenacibaculosis outbreaks worldwide, since, as is known, climate change has increased the temperature of seawater globally  . Adversenfection . Likewisaritimum . Given aindustry .5T. maritimum isolates is presented in depth by Natural Reservoirs and Prevalence Factors, T. maritimum is a mesophilic microorganism that grows well between 15 and 34°C, a range representative of aquatic environments in which fish are farmed   . Marine n ulcers . UnderscT. maritimum has now been retrieved and recognized in more geographies and hosts than those described up to 2006. In Europe, T. maritimum has been isolated in Italy from farmed tub gurnard (Chelidonichthys lucerna L.) and wild turbot  (Cyclopterus lumpus) (P. olivaceus) (Sparus aurata) and European sea bass (D. labrax)   (T. maritimum and the respective geographic origins are briefly summarized in These advancements in isolation and culturing mean that maximus) ; and in  lumpus) . In Asiaivaceus) . In Afri labrax) . Tenacibin Egypt . In Frencularis) . Despitec salmon  and rainc salmon , and outs nerka) . Suscept6T. maritimum was, for a long period, based on clinical signs associated with diseased fish. However, field experience indicates that assigning a specific diagnosis based solely on this criterion is quite difficult as the same signs could also be attributable to other pathogens  or T. dicentrarchi   . An errottsiosis . These clla spp. . Similarlla spp. , Australlla spp. , and Canlla spp. .T. maritimum infection based on age, and lesions vary greatly between affected fish species  specimen showed moderate erythematous hemorrhaging at the base of the anal and pelvic fins and septicemic lesions manifested as severe congestion in the gills, kidney, and other visceral organs, with bloody hemorrhagic exudates , but d yellow . HoweverT. maritimum as a filamentous bacterium presents many obstacles to laboratory work. Cells aggregate and adhere tightly to different substrates, thus impeding the recognition of T. maritimum colonies   , reverseR-ELISA) , and DNAR-ELISA) . The inc species . Småge e species Table 4.Tenacibaculum species, but also for the specific identification of T. maritimum from pure cultures . An adequate level of nucleotide diversity was observed in the most conserved domains (~0.0071 bp−1). The conducted molecular analyses further evidenced remarkable recombination (r/m ≥ 7) and categorization into various subgroups. Moreover, MALDI-TOF-MS was used to detect biodiversity among the recovered 25 T. maritimum strains. The sequence analyses revealed various mass peaks that resembled ribosomal proteins. Furthermore, variation in one or more amino acids was demonstrated, illustrating the mass shift in the bacterial ribosomal proteins. These detected peak shifts greatly associated with the specific genotype defined by MLSA. Consequently, both MALDI-TOF-MS and MLSA are proposed as techniques highly specific for the diagnosis of T. maritimum when pure bacterial isolates are studied.Most PCR protocols are (a) time-consuming; (b) liable to produce multi-sized and nonspecific amplicons for environmental and field samples; and (c) require thermal cycling devices . A recen species . A recen7T. maritimum among fish species other than those indicated by T. maritimum shows a lack of strict host specificity, thus expanding previously described geographical and host distributions, as described in depth in section 5 Geographical Distribution and Host Susceptibility. Tenacibaculosis may therefore be a risk for many species of anadromous and marine fish, including in species in which the disease has not yet been described or, unfortunately, simply ignored. Controversy arises in cases where serotypes  supports scientific research that T. maritimum could be an opportunistic pathogen that primarily causes extensive skin damage and gill abrasion with subsequent systemic infection. Current scientific evidence supports disease transmission through seawater, but limitations presented by the initial variability of inoculum of T. maritimum during growth in microbiological cultures – that is, the formation of bacterial aggregates  (T. maritimum isolates (regardless of dosage or serotype) did not cause disease when injected intraperitoneally but did cause significant mortality in turbot after an18 h bath challenge. This first approach to establishing a robust challenge model using advances in knowledge of T. maritimum virulence properties has resulted in decreasing bath-challenge exposure times to just a few hours   , and Atlapiriña)  found vaubation) .T. maritimum, but other routes of entry to the host cannot be ruled out, such as direct contact with marine invertebrates colonized by the bacterium . This was ascribed to the capacity of the microbes to deliver extracellular polymers or slime, which permit a solid connection to hydrophobic surfaces. Most invading pathogens recognize and bind to fish mucus through sugar-binding proteins such as lectins. This is the first step in initiating defensive responses  in the T. maritimum genome. This gene cluster is responsible for the synthesis of the bisucaberin-class siderophore  and 10 spr genes that encode for various proteins needed for the gliding motility , iron-dependent sodB, and zinc-dependent type (sodC), the last of which is only found in virulent strains  encoding a PL8_3 family chondroitin AC lyase. These were very similar to those produced by another fish pathogen, Flavobacterium columnare . By contrast, Not all genetic information on T. maritimum type strain provided valuable insights into the existence of many predicted genes potentially implicated in the virulence and pathogenicity of T. maritimum. Through the analysis of 24 T. maritimum-strain genomes recovered from different hosts and geographical areas, T. maritimum virulence. Therefore, further physiological research is necessary to understand the pathogenesis of tenacibaculosis.The genome sequences of the 9T. maritimum is for turbot, specifically strain LPV1.7 serotype O2Tenacibaculum species and the antimicrobial.To date, the only commercially available vaccine for in vitro study using disk diffusion susceptibility testing on FMM plates, showed that 63 T. maritimum isolates from several hosts and geographical regions were resistant to oxolinic acid but susceptible to amoxicillin, nitrofurantoin, florfenicol, oxytetracycline, and trimethoprim-sulfamethoxazole (T. maritimum strains were resistant to oxolinic acid but highly susceptible to amoxicillin and trimethoprim-sulfamethoxazole (T. maritimum strains examined from diseased Haffara bream (Rhabdosargus haffara) and marbled spinefoot (Siganus rivulatus) were sensitive to erythromycin, cephalothin, ampicillin, and chloramphenicol but showed high resistance to ofloxacin and tetracycline. More confounding is that field results are not always the same, even if the tested bacteria show a higher sensitivity to the chosen drug in vitro  can be effective in killing pathogenic Tenacibaculum species, including T. maritimum  . This haaritimum . Similararitimum , as wellaritimum , showed in vitro susceptibility studies indicated potential antimicrobial activity of carvacrol, a derivative of the oregano plant  that are applicable to pure cultures as well as in early detection through infectious signs occurring in farmed fish. Advancements in genome sequencing have paved the way for developing methods invaluable to the genetic  and serotype  tracking of T. maritimum. Both tools could be useful in creating new species-specific vaccines. Other significant advancements include those related to disease replication under laboratory conditions, specifically through the immersion of fish with the pathogen, thus simulating natural conditions. This tool is indispensable in the search for new products for the treatment  and prevention  of tenacibaculosis. Unfortunately, understanding remains lacking regarding the reservoirs for this bacterium and for the risk factors that influence bacterial appearance. Particularly unclear is the influence of environmental factors , an important point considering the context of globally increased temperatures due to climate change. The genome has provided information on the existing mechanisms of pathogenicity in T. maritimum, but physiological studies demonstrating the participation of proteins, and not just the presence of the gene, are deficient. Research has also advanced knowledge of the fish response to T. maritimum, but much remains to be explored. This situation is likely the driver behind antibiotics remaining the most used measure to control T. maritimum. As such, there is an urgent need to establish best-practice sanitary measures, to develop new vaccines and autovaccines, and to search for other control measures besides antibiotics, which potentially include herbal-based medications, phages, or probiotics. Lastly, more research is needed to determine why T. maritimum and other Tenacibaculum species are generally considered opportunistic pathogens. This point takes on particular relevance when considering that some Tenacibaculum isolates possess a larger virulence arsenal than other isolates, as specifically due to the diversity within this bacterial genus. Consequently, we must be open to understanding that fish are farmed intensively, and bacterial infections are not restricted and specific to a single microorganism. Rather, coinfections occur, whether with different bacteria or, in many cases, with the same bacterial species but of different genotypes/serotypes. The presence of T. maritimum or other Tenacibaculum species in the aquatic environment can therefore be a factor in the health of farmed fish, regardless of the pathogen being primary, secondary, or, simply, a coexisting microorganism. Future research should focus on resolving the pending questions raised by our review.Tenacibaculosis has risen over the past five years to become one of the most devastating bacterial infections impacting various species of farmed fish and geographical regions. The abrupt re-emergence of disease caused by MM, AA, HH, ES, AF and RA-H participated in writing and editing of the manuscript. BA, SA and RA-H constructed the contents of the figures and tables. CR and RA-H participated in and supervised the thorough review of the manuscript. All authors contributed to the article and approved the submitted version.


With the development of radiology and three-dimensional (3D) printing technology, custom-made 3D-printed titanium augments have been more widely used. However, the radiological and clinical outcomes of custom-made augments lack reports. To better understand the clinical effect of using 3D-printed titanium augments and the significance of accurate placement, the aim of this study was to assess the outcomes when using custom-made 3D-printed titanium augments and to validate the idea that surgical simulation should be done before designing custom-made augments.A retrospective review was conducted on 31 surgical simulations and revision total hip arthroplasties using custom-made 3D-printed titanium augments. The safe zone, cup position, and hip rotation center were measured on anteroposterior radiographs. Clinical outcomes were assessed with a mean 21.1 months of follow-up.All patients were positioned within the safe zone, and none of the acetabular cups nor the custom-made augments had any evidence of migration at the latest follow-up. A strong correlation was found between the planned cup position and the postoperative position. The average vertical position of the center of rotation was significantly increased from 3.55 cm to 2.35 cm. The mean Harris Hip Score was increased from 40.81 preoperatively to 65.46 postoperatively. Complications included gait abnormality, groin pain, fracture of the greater trochanter, and partial palsy of the sciatic nerve. However, patient satisfaction reached 92.3%.Surgical simulations help to design custom-made augments accurately and improve surgical plans. Acetabular components supported with custom-made 3D-printed augments is a useful method to bridge severe bone deficiencies. In this study, both the radiologic results and clinical outcomes were favorable.Level 4.The online version contains supplementary material available at 10.1186/s10195-022-00656-5. Revision total hip arthroplasties (rTHAs) in the presence of severe acetabular defects can be a big challenge. In this circumstance, the use of a large cementless hemispheric cup is the first choice for most investigators, and has become even more versatile with the introduction of the extra-large hemispheric cup –7. When Recently, with the development of radiology and three-dimensional (3D) printing technology, custom-made 3D-printed titanium augments have been more widely used. The custom-made augment inherits the advantages of the porous metal augment and is more accurate than it. The strengths of custom-made augments include avoiding excessive reaming of the acetabulum due to a poor match, which can preserve the bone stock and simplify the surgery; matching the bone defects perfectly and providing the acetabular component with sufficient initial stability; and their ability to be printed according to the anatomical features of the patients. Thus, they also serve to reconstruct the hip rotation center and restore the hip biomechanics after THAs. Additionally, 3D-printed augments have personalized screw trajectories. Full-length insertion screws can be used, helping to avoid neurovascular bundle damage. Theoretically, custom-made 3D-printed titanium augments should have a more promising outcome than porous metal augments.However, in the study of Baauw et al. , they foAfter institutional review board approval, we retrospectively reviewed our revision THAs from August 2017 to November 2021. Patients were included if they received custom-made 3D-printed titanium augments (pore size 600 to 800 μm and porosity 60% to 80%), but they were excluded if they had prefabricated augments besides custom-made augments. Finally, 30 patients (31 hips) were included in our cohort. None of the patients were lost to follow-up.2. Among the cohort, four patients were followed up for less than 3 months. Due to their short recovery times, they were still taking NSAIDs, and two of them still could not get off their crutches. Those four patients were not included in our clinical outcome assessment, and the mean follow-up was 21.7 months (4.3 to 51.2).Demographic data were collected on all patients, as described in Table Acetabular bone deficiencies were categorized according to the method of Paprosky et al.  using prSurgical simulation was performed by the surgical performer in each case. Standard instruments for THA were prepared. The surgeon reamed the acetabulum to the appropriate size in successive increments, replicating the intraoperative process. Post reaming, a trial cup was secured and impacted where possible to achieve sufficient contact area with the host bone and to acquire adequate component stability. In unstable cases, plasticine was shaped and inserted into the acetabular bone deficiencies. Finally, our engineer redesigned custom-made augments according to the shaped plasticine. During this procedure, we checked the match between the 3D-printed augments and pelvic model several times Fig. : case 16The 3D-printed pelvis model and custom-made 3D-printed titanium augments were sterilized and prepared for use in surgery. After preoperative preparation, the failed acetabular component was removed through a posterolateral hip approach. The lead surgeon debrided the remaining acetabulum and reassessed acetabular bone defects by comparison with the 3D-printed hip model. Then the custom-made augments were inserted into the patient and fixed with screws as planned. After that, the acetabulum was reamed with the planned degrees of inclination and anteversion in successive increments from a smaller size to a diameter that was 1 mm or 2 mm less than the planned acetabular cup size. Post reaming, the grinding debris was removed and a trial cup was tested. If the cup position, stability, and contact area with the host bone were thought to be acceptable, bone cement was applied to the surface between the cup and augment and then a porous-coated cementless acetabular shell was secured and impacted with adequate press-fit and screws. Finally, the stability of the cup was evaluated. Table On the first day after surgery, patients were encouraged to walk with crutches and partial weight-bearing was allowed. A full weight-bearing gait was permitted at 6 weeks postoperatively. In the meantime, short-term antibiotic prophylaxis with a third-generation cephalosporin and low-molecular-weight heparin were applied to all patients.Standard AP radiographs and lateral radiographs were done before the revision THA, at 3 postoperative days, and routinely at every visit. The safe zone  and the Interobserver and intraobserver reliability were assessed by intraclass correlation coefficients (ICCs) for the measurements. Two observers who did not participate in the operations and were blind to the clinical results measured all the parameters. For the intraobserver reliability, the interval between measurements was at least 1 month. Both the intraobserver reliabilities were more than 0.9. The interobserver variance also had an ICC of more than 0.8, which indicated high agreement between all the measurements.The mean values and ranges were calculated for demographic data and are presented as the mean ± standard deviation with the range. Categorical variable values are presented as percentages. The pairedMeasurements using the AP radiographs taken on postoperative day 3 indicated that all the patients were positioned within the safe zone . The mean LLD was 0.337 cm, but in one case the LLD exceeded 1 cm. One patient presented with sciatica when the operative hip was flexed beyond 90°, but this symptom was gradually improving. One patient had a fracture of the greater trochanter during surgery. Three patients had slight groin pain occasionally. However, no infections, dislocations, aseptic loosening, or acetabular periprosthetic fractures were found in our study. In the gait assessment at the latest follow-up, 23 patients had a limp, of which 14 were classified as slight, 3 as moderate, and 6 as severe. However, at the end of the follow-up, patient satisfaction reached 92.3%.As outlined in Table In our study, we found that surgical simulation provided support for the approaches and techniques required. Figure The implant positions play a major role in THA instability . In 1978The restoration of the COR to an anatomic position is related to satisfactory functional outcomes –31. In oAmong the cohort, six patients had a severe gait abnormality. Gait abnormality is influenced by many factors, including leg length discrepancy, poor gluteus medius strength, and pain , 33. ConThere are several limitations of this study. First, being a retrospective study design, it is never as ideal as a randomized controlled trial for comparisons of this technique with other reconstruction techniques. Second, the small sample size and relatively short follow-up duration may have limited the interpretable power. However, this is one of the largest studies on 3D-printed augments in terms of sample size. Third, the femoral side also has an impact on postoperative gait, but in this study we paid more attention to the relationship between the position of the COR and lameness. Fourth, further follow-up of our patients is needed to demonstrate the long-term efficacy of our custom-made 3D-printed augments. Finally, there is no clear definition of “complex revision THA;” instead, each surgeon decides when to print a hip model and simulate a surgery based on his or her clinical experience and skill level.Surgical simulations aid the accurate design of custom-made augments and improve surgical plans. Acetabular components supported with custom-made 3D-printed augments are a good way to bridge severe bone deficiencies. In our study, most patients showed satisfactory results in both radiologic and clinical assessments, but further follow-ups are needed to demonstrate long-term results.Additional file 1. Intraobserver and interobserver evaluations.


Researchers working with administrative crime data often must classify offense narratives into a common scheme for analysis purposes. No comprehensive standard currently exists, nor is there a mapping tool to transform raw descriptions into offense types. This paper introduces a new schema, the Uniform Crime Classification Standard (UCCS), and the Text-based Offense Classification (TOC) tool to address these shortcomings. The UCCS schema draws from existing efforts, aiming to better reflect offense severity and improve type disambiguation. The TOC tool is a machine learning algorithm that uses a hierarchical, multilayer perceptron classification framework, built on 313,209 hand-coded offense descriptions from 24 states, to translate raw descriptions into UCCS codes. We test how variations in data processing and modeling approaches affect recall, precision, and F1 scores to assess their relative influence on model performance. The code scheme and classification tool are collaborations between Measures for Justice and the Criminal Justice Administrative Records System. A schema and trained machine learning model are introduced to translate raw criminal offense descriptions into standardized codes. Criminal justice systems across the world are tasked with responding to a wide range of activity deemed to be illegal and against public interest. These offenses range from driving while intoxicated to vehicular manslaughter, from possessing illegal narcotics to possessing stolen property, and from conspiracy to commit murder to capital murder offenses. Subtle distinctions in offense descriptions reflect deep differences in offense severity, potential motive, risk to public safety, and optimal responses by law enforcement. As such, organizing and classifying criminal activity is a core premise of a well-functioning system of criminal justice  tool to map unstructured offense description information to the Uniform Crime Classification Standard (UCCS) charge codes. Prior schema efforts have been inadequate due to their exclusive focus on felony-level offenses, lack of internal consistency, or lack of specificity on emerging crime types . The UCCS schema addresses a comprehensive set of violent, property, drug, traffic, and public order offenses at all levels of criminal severity, with modifiers to distinguish among completed, attempted, and conspired acts.To use the UCCS schema, one must identify how to map a specific text of an offense description to a corresponding UCCS code. While there are only 257 potential UCCS values, the set of potential offense descriptions is boundless, for instance, the Criminal Justice Administrative Records System (CJARS), which currently holds data on more than 175 million criminal justice events from 25 states and has roughly 4 million unique offense descriptions  model, which we refer to as the TOC tool, trained on 313,209 hand-coded observations from 24 states, including Alabama, Arkansas, Arizona, California, Colorado, Connecticut, Florida, Illinois, Indiana, Kansas, Maryland, Michigan, Minnesota, Mississippi, North Carolina, North Dakota, Nebraska, New Jersey, Ohio, Oregon, Pennsylvania, Texas, Utah, and Wisconsin. In the TOC framework, there are three levels of classification: (i) broad offense code, (ii) specific offense code, and (iii) offense modifier. Together, these constitute what we refer to as a full offense code.Our approach helps leverage meaningful common descriptors that otherwise might be ignored by the algorithm . We find the TOC tool generates F1 scores, which equally weight precision  and recall  metrics, in the range of 0.957 to 0.995 for broad offense type  and 0.845 to 0.991 for full offense codes . Out-of-state predictions yield similar performance levels, suggesting that the TOC tool will perform well when applied to the 26 states not currently covered in the training sample.We explore a range of factors that contribute to our realized performance statistics, including text preprocessing, feature construction and selection, hierarchical versus flat models, random forest versus neural network machine learning approaches, and the size of the training sample. Training sample size and feature construction have the largest relative impact on performance statistics, while variations in preprocessing, feature selection, and classification approaches yield more minor gains in performance in this context.https://cjars-toc.isr.umich.edu/. This system will especially be useful for processing big data, in which a large workforce would otherwise be needed to manually classify thousands of offense descriptions.The UCCS schema and the TOC tool are intended to be used as an open-source system and thus provide administrative users, the research community, and the general public with a common classification system to ensure reproducible statistics for conducting comparative analysis. Any interested users can access the TOC tool by registering for a free account at The National Academies of Sciences, Engineering, and Medicine  satisfy many of the aforementioned design choices, no single schema meets all of the recommended criteria. As a result, we developed the new UCCS scheme, which is built from adopting key features of existing schemes while satisfying all four design principles recommended by the National Academies of Sciences, Engineering, and Medicine  Uniform Crime Reporting (UCR) Program has collected data from more than 18,000 participating agencies since its inception in 1930. Historically, the UCR Program collected aggregated monthly reports using the UCR’s Summary Reporting System (SRS) that collected information for only 10 “Part I offenses,” which are described in table S1. Meanwhile, “Part II offenses” are designated for less severe crimes that may not always be captured by the police. In effect, SRS collects information for Part II offenses only from recorded arrests.However, these reports using the SRS were compiled using a hierarchy rule such that only the most severe crime for a given incident was reported. In an effort to improve the quality of data collection, the Bureau of Justice Statistics (BJS) and the FBI began a multiyear study in the early 1980s to reevaluate the SRS for user needs, to identify potential improvements in the existing system, and to design a new data collection system that accounts for system changes  collects offender-level data on prison and supervision admissions and releases. Similar to NIBRS, the NCRP is also composed of multiple data files but one distinct characteristic of this data collection system is that it also provides a standardized offense classification schema and crosswalks for each state . In effect, users without all of the identifying variables such as the statute code of the offense description will have to rely on subjective deduplication for consistent offense classification in their data. As a result, the inconsistent charge codes for a given description and the redundant offense categories  in the NCRP scheme does not make it the ideal classification scheme.To address shortcomings of prior schemas, we created the UCCS schema. It is grounded in the original offense-type delineations developed for the NCRP in the early 1990s but with modifications including adding clarifications to the NCRP codes to ensure coding consistency , reclassifying driving under the influence of alcohol or drugs (DUI) to its own offense type, reclassifying many of the “other” and “public order” offenses to more specific definitions, and adding new codes for previously omitted offenses including human trafficking, amphetamine drug offenses, opiate drug offenses, and other prescription drug offenses.UCCS is operationalized as a four-digit offense code that is hierarchical in nature (see table S5). The first digit represents the broad crime type, which can take on the following values: 1, violent; 2, property; 3, drug offense; 4, DUI; 5, public order; or 6, criminal traffic. For each broad crime type, offense category codes are generated by enumerating from 01 to 99 where 99 is reserved for the “other” category within the broad crime type . The final digit is reserved as an offense modifier. This can be used to delineate whether an offense was committed (0), an offense was attempted (1), or an offense was conspired (2).Because UCCS offense categories are generated by enumerating from 01 to 99, the scheme satisfies Principle 1, as there are unmapped category codes in each broad crime type for adding new offense categories . It satisfies Principle 2, given that broad crime types and offense categories are defined as mutually exclusive and exhaustive categories. Furthermore, the four-digit UCCS codes preserve the hierarchical data taxonomy such that the last three digits are used to provide additional context to the offense. Last, UCCS codes fulfill Principles 3 and 4 by using an attribute-based approach, distinct from statute numbers or leveraging other local features that might limit cross-jurisdiction comparisons, through being generated from text descriptions of offense types. A summary of the differences between the offense classification schemas compared against the National Academies of Sciences, Engineering, and Medicine  preprocessing, (ii) tokenization, (iii) feature selection, (iv) classifier, and (v) classification framework.et al. , punctuation, capitalization, and grammatical tense . This is a crucial step in text classification, since the reduction in the overall size of input data can improve classification performance. For instance, Uysal and Gunal , which scores each term through an inverse proportion of its frequency in a description to the percentage of descriptions the term appears in. For a given feature f in description d from document D, TF − IDF is then calculated as the product of the term frequency, TF, and the inverse document frequency, IDF. These terms are defined belowf) is the number of descriptions in the document that contains the term f and N is the total number of descriptions in the data.In feature selection, each token or feature is scored using a selection metric. Then, a subset of the best The selected features are then used as inputs for classification. We use a hierarchical MLP model to generate the mapping from selected features to predicted full offense code. MLP is a type of artificial neural network that consists of interconnected network of nodes, or neurons, in three different layers: an input layer, one or more hidden layers, and an output layer. In MLP, each node is associated with a weight, which is adjusted during the training phase to minimize classification error, or the difference between the predicted class and true class. In our application, we use the default parameters for MLP model in the scikit-learn Python package using one hidden layer with 100 neurons. For the activation function and weight optimization, rectified linear unit function and stochastic gradient-based optimizer were used, respectively.To leverage the taxonomic characteristic of UCCS schema, we induced class hierarchy to the TOC tool using local classifier per parent node method where one or more classifiers are trained at each level in the hierarchy. As a result, the TOC tool starts by training an MLP classifier at the parent level for classifying broad crime type (first digit of UCCS). Then, for each broad crime type, a different MLP classifier is trained to predict the offense category (second and third digits of UCCS) at the subparent level. As the last step, a single MLP classifier is trained for each offense category to predict the offense modifier (fourth digit). In total, the TOC tool consists of a group of 100 MLP classifiers  that together provide a predicted UCCS classification. To summarize, The overall out-of-sample case-weighted performance of the TOC tool is presented in At the full UCCS code level, the TOC tool yields weighted F1 scores in the range of 0.845 to 0.991. The largest declines in performance from broad to full code is observed within the drug broad crime type. This is perhaps expected given the prevalence of similarly described but distinct offense types within this category , which the algorithm has a difficult time differentiating between. Overall, however, out-of-sample performance statistics remain high, suggesting promising opportunities from the widespread adoption of the TOC tool.An important concern that remains is how well the TOC tool will perform when applied to additional states not contained in the training data. The TOC tool is built off of administrative data from 24 states in the United States, and we observe that some offense descriptions are unique to specific states. This could be due to state-specific abbreviations or data entry practices, or the inclusion of state-specific statute numbers when describing the offense in the free entry text field. While we do not hold data from the 26 remaining states, we can explore performance stability when excluding individual covered states from estimating the TOC tool, making predictions for those excluded states, and evaluate the resulting out-of-scope performance. The results of this exercise are presented in We find that there is only modest performance degradation when applying the TOC tool to other states not included in the training data. Comparing results from www.icpsr.umich.edu/web/pages/NACJD/guides/ncrp.html), and the National Crime Information Center (NCIC) crosswalk (www.dps.texas.gov/section/crime-records/appendix-k-offense-codes). While TOC and UCCS deliver classifications that cover the vast majority of charges and align with federal statistical reporting on the composition of criminal court caseloads  training data size, (ii) feature unit and selection method, (iii) number of selected features, and (iv) machine learning algorithm type and classification method. The goals of these exercises are to identify the parameterizations that yield the strongest out-of-sample performance measures and to better understand which choices are more or less consequential. For each perturbation of the model, we ran 20 bootstrapped iterations, sampling the fixed 75% training data sample with replacement in each iteration. All other features of the model described in the “Parameterization of the TOC tool” section remain unchanged.We first explore the role of the size of the training data. We have the luxury of having hundreds of thousands of training observations available to build the TOC tool, yet if other researchers were interested in building their own classification tool for other topics  or jurisdictions , this would be important information for assessing how much should be invested in developing an original training dataset.Both measures of performance monotonically improve with additional training sample observations, in terms of both better average performance and more consistent performance. The largest gains in average performance accrue from 1000 through 50,000 training observations, yet some improvements persist beyond that point, especially with regard to decreasing performance variability across the bootstrapped iterations. Predicting the full UCCS code also benefits from substantial numbers of training observations, which is expected given the more challenging goal of predicting offense type at such a fine-grained level of detail compared to just the broad crime type. Weighted performance is always higher than unweighted performance, reflecting the fact that rarely used descriptions usually represent poor-quality offense descriptions .We examine several aspects of how tokenization and feature selection influence the overall performance of the TOC tool. In the first exercise, we eliminate the prepocessing stage of the TOC tool, leaving all other aspects of the model untouched. N-grams (one to six characters), introducing a bag-of-words option, and allowing feature extraction to be determined by either the TF-IDF or CountVectorizer (CV) algorithm. CV selects features by using the most frequently occurring terms in the entire document. Given a list of offense descriptions, D, CV generates x by y sparse matrix, F, where x is the number of offense descriptions in the data, y is the total number of unique features found in D, and xyf  is the total number of times yth feature appear in xth description. By summing the columns, CV is then able to generate total frequency for yth feature in DThe second exercise in this theme explores variations in tokenization and feature extraction through varying the size of the Performance peaks at 4-grams for both feature selection approaches , indicatThe final exercise holds tokenization (4-grams) and feature extraction method (TF-IDF) constant but varies the number of features extracted to use as inputs to estimate the MLP models see . We examModel performance improves significantly as features increase from 100 to 1000 without a meaningful difference in computing time. Additional gains accrue with 5000 features, especially at the full UCCS code level of prediction but with a corresponding fourfold increase in time to train the model. At 10,000 features, model performance declines, and processing time is substantially longer, indicating that the feature space has potentially been oversaturated.Last, we compare the role of classification along two dimensions. We first evaluate the relative performance of MLP and random forest classifiers, followed by hierarchical versus flat modeling approaching. In random forest models, an ensemble of individual decision trees is used to generate predictions for each tree. Then, a vote is performed across the predicted results, and the model selects the final prediction value using the majority vote rule. In flat classification, a single classifier is used to assign a class . As a reBoth the UCCS schema and the TOC tool are intended to evolve over time. Additional crime types (or differentiating important differences within existing pooled groups of offenses) will be incorporated at regular intervals into UCCS to ensure that the schema remains current and valuable. Receiving feedback on the schema will be critical for ensuring that the categorization matures with the criminal justice system.As the UCCS schema evolves, the TOC tool will necessarily need to be updated. In addition to adding emerging offense types, there are several additional features that may improve the TOC tool’s performance and utility, which have not yet been incorporated.First, the out-of-state exercises suggest that there can be fundamental differences between states in how illicit behavior is described. This raises the question of whether the TOC tool should incorporate geographic information on the location of the offense into the prediction model or alternatively build state-specific tools that focus exclusively on predictions generated from within-jurisdiction training data. Given that not all jurisdictions in the United States are yet incorporated into the corpus of training data for the TOC tool, pursuing these options come with the trade-off of potentially decreasing the utility of the TOC tool when applying to noncovered jurisdictions or national-level data.The second feature would be to leverage the implicit information contained within cited statute numbers in offense descriptions. Statute numbers are entered into a number of observed offense descriptions as shorthand for more lengthy information on classes of criminal activity defined in statute, which supplement free entry offense description fields. The challenge in leveraging this information is twofold. First, statute numbers are cited irregularly in inconsistent formats, requiring the need to develop a technique to identify and interpret a statute number when it appears in an offense description. Second, there does not currently exist a comprehensive database that maps statute numbers to their offense descriptions, and so additional effort would be required to translate the statute numbers into a structure that the TOC tool could interpret.https://cjars-toc.isr.umich.edu. These initiatives promote inclusive research dialogs on pressing social policy issues through providing researchers without a background in data science with the opportunity for automated classification systems at their disposal. We also hope that these contributions will help encourage consistent and reproducible research in the field through encouraging researchers to use common definitions of offense types and minimizing the need for researcher discretion in wrangling administrative records for research purposes, a process that can be opaque and have minimal oversight.The UCCS schema and TOC tool lower barriers to working with cutting-edge data from the U.S. criminal justice system; the production tool is currently publicly available at no cost through our online portal at To generate the TOC model, we pool two sources of hand-coded offense description information and caseload count data from Measures for Justice (MFJ) and the CJARS. MFJ is a nonpartisan nonprofit with a mission to make reliable criminal justice system data available at the county level to spur dialog and reform. CJARS is a partnership between the University of Michigan and the U.S. Census Bureau, creating an integrated data repository to track involvement in the U.S. justice system that is linkable with socioeconomic data. Together, the pooled set of data draws on multiple decades of electronic criminal justice records from across the United States.We use the universe of MFJ offense descriptions that could be legally redistributed to CJARS. To ensure adequate coverage of uncommonly occurring UCCS codes, we supplement this bank of coded records with additional offense descriptions only found in the CJARS data, which then were also hand-coded to the UCCS schema.Overall, we use 313,209 hand-coded unique offense descriptions to create the TOC tool. Each individual description was categorized by a human reviewer, who has been trained on the charge coding schema, the ordering logic, and the nature of inchoate classification. This training is overseen by senior staff. Additional training occurs as needed when consistent errors are identified in classification audits. Additional oversight of the resulting classification for every description occurs through validation within the coding tool and through audit by a senior staff member. Last, once individual descriptions are added to the overall coded repository, a final round of auditing occurs to ensure classification consistency in the context in which they were originally provided and across disparate data sources.In addition, we use caseload counts per offense description to weigh observations according to their relative prevalence in the estimation procedure. Because of the free-entry nature of many of the text fields in the data that were collected, rare typos and obscure abbreviations represent a nontrivial share of the unique offense descriptions but a negligible number of cases overall. Together, the 313,209 unique offense descriptions represent 439,534,275 total criminal justice events that have occurred in the United States over recent decades. The criminal justice events leveraged in this study involve a range of distinct interactions that individuals have with the U.S. justice system. These can reflect arrest and bookings reported by law enforcement. They can also reflect charges and convictions conducted by criminal courts of law. As such, offense descriptions record alleged illicit activity at varying degrees of progression through the formal legal justice system. Examples of offense descriptions range from “hit run injury” to “driving under the influence and causing damage or injury wit 0 00 not in fdle statute 316 193 2 a dui alcohol or drugs 2nd off,” demonstrating the range of specificity across the pool of events that together encompass what we refer to as the criminal justice system.While the production version of the TOC tool leverages the full set of data described above, to evaluate model performance and identify optimal parameterization, we subset the data into mutually exclusive training and test datasets to avoid overfitting biases. To generate the training and test data, we use a 75%–25% mutually exclusive split of the unweighted unique descriptors. The goal of this mutually exclusive split is to eliminate the risk of data leakage, which is an important concern that has undermined the reproducibility and performance of machine learning models in a range of contexts [see Kapoor and Narayanan (