The proposal of the global leadership initiative in malnutrition (GLIM) criteria has received great attention from clinicians. The criteria are mainly used in the research environment and have the potential to be widely used in the clinic in the future. However, the prevalence of malnutrition and risk of future malnutrition based on a current diagnosis of malnutrition are worth exploring.A systematic search of PubMed, Embase, and the Cochrane Library was performed from the earliest available date to 1 February 2023. According to the diagnostic criteria of the GLIM, we analysed the prevalence of malnutrition by directly adopting the GLIM criteria for diagnosis without a previous nutritional risk screening (one-step approach) and by adopting the GLIM criteria for diagnosis after a nutritional risk screening (two-step approach). The main outcome was the prevalence of malnutrition based on the one-and two-step approaches. Secondary outcomes were the future risk of malnutrition based on the GLIM diagnosis, including mortality within and beyond 1 year. primary outcomes were pooled using random-effects models, and secondary outcomes are presented as hazard ratios (HRs) and 95% confidence intervals (CIs).I2 = 77.1%) and beyond 1 year  of patients diagnosed with malnutrition by the GLIM criteria was double that of patients with normal nutrition.A total of 64 articles were included in the study, including a total of 47,654 adult hospitalized patients and 15,089 malnourished patients based on the GLIM criteria. Malnutrition was diagnosed by the one-step approach in 18 studies and by the two-step approach in 46 studies. The prevalence of malnutrition diagnosed by the one-and two-step approaches was 53%  and 39% , respectively. The prevalence of malnutrition diagnosed by the GLIM criteria after a nutritional risk screening was quite different; the prevalence of malnutrition diagnosed by the Nutritional Risk Screening 2002 (NRS2002) GLIM tool was 35% ; however, the prevalence of malnutrition diagnosed by the Mini Nutrition Assessment (MNA) GLIM tool was 48% . Among the disease types, the prevalence of malnutrition in cancer patients was 44% , while that in acute and critically ill patients was 44% . The prevalence in patients in internal medicine wards was 40% , while that in patients in surgical wards was 47% . In addition, the mortality risk within 1 year (HR, 2.62; 95% CI, 1.95–3.52; The prevalence of malnutrition diagnosed by the GLIM criteria after a nutritional risk screening was significantly lower than the prevalence of malnutrition diagnosed directly by the GLIM criteria. In addition, the mortality risk was significantly greater among malnourished patients assessed by the GLIM criteria.Systematic review registration: identifier CRD42023398454. Malnutrition is a global problem, and studies have shown that malnutrition can lead to adverse clinical outcomes, including increased morbidity and mortality . PreviouCurrently, the prevalence of malnutrition in adult hospitalized patients based on the GLIM criteria is unclear, and the future malnutrition risk based on a current malnutrition diagnosis is also unknown. This study mainly explored the prevalence of malnutrition based on the GLIM criteria and the future risk of malnutrition based on a current malnutrition diagnosis.The meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) list, the Guidelines for Meta-Analysis of Observational Epidemiological Studies, and the study protocol . We perfThe following inclusion criteria were adopted in this study: (1) the study was a randomized controlled trial, cohort study, case-control study, or cross-sectional study. (2) Based on the complete GLIM diagnostic criteria , there wvia preestablished forms. Disagreements were resolved through discussion. The collected information mainly included author, year of publication, country or region, one-or two-step approach, initial nutritional risk screening tool, disease type, research design, and nutritional risk  of malnourished patients.Two junior researchers independently collected data A total of 64 articles were included in the study. We assessed nonrandomized studies using the Newcastle-Ottawa Quality Assessment Scale. Studies were assessed using three categories: study group selection (0–4 points); comparability (0–2 points); and exposure (0–3 points). A total score of ≤3 was considered to indicate low quality; 4–6, medium quality; and ≥7, high quality. These scores were used only to facilitate the interpretation of the meta-analysis results and not as criteria for the inclusion or exclusion of studies. Q test and the I2 statistic. All p-values were two-tailed, and the results of all analyses were considered statistically significant at p ≤ 0.05, except the results of the heterogeneity and publication bias tests. If I2 > 50%, indicating large heterogeneity among different studies, we applied a random-effects model to calculate the pooled effect value and 95% confidence interval (CI). We also performed subgroup analysis by nutritional diagnostic tool, region and disease type. All statistical analyses were performed using STATA 17.0.The primary objective of this meta-analysis was to investigate the prevalence of malnutrition and the nutritional risk in adult hospitalized patients based on the GLIM criteria. We calculated heterogeneity among studies using Cochran’s The relevant characteristics of the included literature are shown in I2 = 77.1%). I2 = 59.9%).The rates of malnutrition according to different screening tools cannot be compared equally as different tools were used in different cohorts. We simply report the malnutrition risk across cohorts, in each of which a different screening tool was used. As shown in We diagnosed malnutrition as a complete diagnosis based on the GLIM criteria and excluded relevant studies without a complete diagnosis. In fact, the results show that the current diagnosis of malnutrition based on the GLIM criteria is confusing and that most studies do not report a complete diagnosis. Usually, according to the GLIM diagnostic criteria, the diagnosis of malnutrition first requires a nutritional risk screening, followed by a diagnosis according to the GLIM criteria (two-step approach) ; howeverInvoluntary weight loss, which is the most definitive diagnostic indicator of malnutrition, topped the GLIM framers vote. BMI is also a relatively clear quantitative index, and it is easy to obtain and convenient to apply. However, when the GLIM criteria were released, it was also pointed out that there are substantial regional differences in using BMI as a diagnostic standard for malnutrition . ReducedIn the relevant studies included in this paper, malnourished patients diagnosed according to GLIM criteria may have reported discharge or five-year mortality risk, and we extracted pooled effect values directly from the original papers and pooled them. In addition, in the relevant studies included in this article, most of the mortality rates of malnourished patients diagnosed based on the GLIM criteria were reported using the HR, but a few studies used the odds ratio (OR) to indicate the effect size. Considering that the HR includes the time factor, we partially replaced the ORs reported in the studies with HRs, which may have caused minor bias.It has been reported that malnutrition diagnosed by the GLIM criteria is significantly associated with a poor prognosis , 15, 78;The results of this systematic review and mate-analysis need to be interpreted with caution. First, the GLIM criteria were mainly studied based on a complete diagnosis; although the included articles had clear phenotypical and aetiological criteria, the results may have been biased due to differences in the assessment of BMI and muscle mass loss among studies. Second, regarding the assessment of mortality, most studies reported mortality data using the HR, while a few articles used the OR. We used the HR to indicate the pooled effect size for the articles, which may introduced a small bias. Finally, most articles were from Asia, and these conclusions may not apply to other geographic regions and populations.The prevalence of malnutrition diagnosed by the GLIM criteria after a nutritional risk screening was significantly lower than the prevalence of malnutrition diagnosed directly by the GLIM criteria. In addition, the risk of mortality was significantly higher in malnourished patients assessed by the GLIM criteria. In the future, it is necessary to explore the effectiveness of the combination of different nutritional screening tools and the GLIM criteria for the nutritional diagnosis of relevant groups in a large cohort.The original contributions presented in the study are included in the article/WB and PZ contributed to the conception and design of the work. WB, YW, YiL, YuL, and HJ collected information and analyzed data used in the systematic review and meta-analysis. LD polished this article. PZ and HJ substantively revised it. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.https://www.frontiersin.org/articles/10.3389/fnut.2023.1174945/full#supplementary-materialThe Supplementary material for this article can be found online at: Click here for additional data file.


A pedagogical innovation backed by an online device using 360° video had been devised to train young team sports referees  to be more reflective. The objective of this exploratory research was to investigate the ways young student referees use 360° videos in allo-confrontation when carrying out some exercises involving open questions about their viewing experience.Student referees' answers were recorded. A grounded analysis of these answers enabled us not only to identify their main focuses when viewing the 360° videos but also to distinguish different cognitive stances.The grounded analysis revealed (1) idiographic differences between student referees in the video sequencing, although the participants seemed to share the same reference points, (2) two kinds of focus, one on the unfolding of the game and another one on the referee peer's activity, and (3) different perspectives according to which student referees use video and to initiate a reflection on a differentiation of several types of immersion: empathetic, simulation, exploratory.This study highlighted the conditions under which referees' reflectivity was fostered by the use of 360° video during allo-confrontation. Some perspectives for the evolution of 360° video supports for designing training courses for referees are proposed. Over the past few years, video has been used increasingly in sports for performance optimization in both game and training contexts  What use(s) do referees make of a 360° video of a sequence refereed by a peer in terms of reflectivity? What are their spontaneous reflective uses? (2) What are their reflective uses in relation to exercises that encourage them to project themselves in different ways in the videos? (3) What are the cognitive, normative, and/or reflective “stances” they take while watching the video? (4) How do they put different points of view on a peer's activity into perspective, and what can this perspective suggest for them in terms of reflectivity? These four questions were used as the basis for designing a training tool that could help understand whether and under what conditions referees make reflective use of 360° videos.First, we have specified the objectives of the training device set up for referees, the videos used, and the exercises related to them. Second, we have outlined a grounded analysis of how each exercise's objectives were experienced by the participants. We then present the results, which allow us to characterize how referees apprehended video according to the reflective exercises' objectives and ultimately initiate a reflection on the differentiation of several types of immersion. Finally, we conclude with proposals for the development of 360° video media to design training courses for referees.The elaborated device is part of an educational program designed to help student referees move away from a purely normative stance on the use of video and to introduce them to other uses of video, especially reflective uses, to progress in refereeing. This program was designed with the French Federations of Football and Rugby as a complement to the technical work they carry out. An online training tool for video viewing and asking questions was designed for a group of young referees in three team sports . Several caveats from the literature on immersive video training systems were considered when developing the exercises for the training device. First, it is not necessarily “natural” to access one's own activity through that of someone else, as video viewing tends to produce in the first place an extremely normative gaze, paradoxically often anchored in institutional normativity, that blurs the understanding of the intrinsic logic of the activity  To help the referees articulate how they spontaneously engaged with the 360° video viewing. To achieve this, we proceeded in two steps by asking the referees to (a) sequence the excerpt to grasp the way they spontaneously constructed units in the temporal flow and (b) describe each sequence to approach their spontaneous understanding of what was occurring in the video.(2) To make the student referees aware of their judgment in allo-confrontation with the 360° video.(3) To invite students to step out of the normative perspective they are used to when they are watching a video. In fact, within the federal framework, they are trained in a normative perspective, in which refereeing practices are qualified as “good” or “bad” according to the head of refereeing prescriptions.(4) To encourage student referees to put themselves in the referee's shoes to see if a 360° video would allow them to immerse themselves in their refereeing role in a game context. We asked the student referees to describe the visual and auditory elements they were paying attention to during the viewing.(5) To get the student referees to analyze how they use video, to open them up to different ways of using video, and to make them identify when and how they detach themselves from a normative perspective at certain moments.To implement the proposed exercises in a training session, an audiovisual recording of a 360° video media tool was set up during university football matches. A referee wore two 180° high-definition 4K cameras as follows: a front-facing camera on his chest and a rear-facing camera on his back refer to , 2. A spOnce the recordings were collected, a technical operation was carried out to join and synchronize the two 180° shots to obtain a 360° visual and embedded audio recording. This recording made it possible to perform 360° visual scans in all directions in the video.As the participants of the study (refer to section 2.4) were rugby, handball, and football student referees, and the sport chosen for the exercises was football, we selected the audiovisual recordings according to the interest the student referees would have in viewing them.To select the video clips used for materials and exercises, the research used criteria that were transversal to refereeing activities in rugby and football. Mascarenhas et al.  identifiWe selected five excerpts from one university match. A referee officiated in the 360° recorded match. This referee had a non-professional national refereeing level. In these excerpts, verbal exchanges are clearly audible, and the player(s) is (are) clearly visible on the screen. The following criteria were established to select images:Optimal viewing quality in terms of clarity and brightness of the image.The high sound quality of the recording made.One of the four recorded matches was selected as the best possible recording. The specific sequences were then selected to build the training tool according to the abovementioned criteria.The exercises presented to the student referees for viewing were conceived and formulated to meet the training objectives. These formulations were designed to support referees in stepping back from their spontaneous judgments while watching a 360° video of a peer officiating on the field. To do so, this research used the reflectivity inherent in referees' judgments. In fact, Van Manen , using tThe participants were also asked to adopt different cognitive stances during the viewing (1) by starting with the stance of restating aspects of the spontaneous viewing (according to our hypothesis involving a spontaneous judgment); (2) by asking them to explicitly produce a judgment as if they were the referee of the game to make them express a conscious judgment, and this step was necessary for students to abandon their normative stance; (3) by beginning to step back from this judgment by describing the clues that enabled them to make this judgment; (4) by putting themselves in a comprehensive stance, i.e., to be in the peer referee's shoes; and (5) by confronting them with the answers of other student referees carrying out the exercises and the questions.The exercises were conceived to solicit the following cognitive stances by asking questions after the viewing of each 360° video:(1) To immerse themselves in a refereeing sequence to collect aspects of the viewing experience as spontaneously as possible,(2) To act as if they would be the referee in place of the peer: invite the student referees to officiate in place of the referee. This invitation could lead to a normative stance on the peer referee's activity and, if it occurs, make the student referees aware of it,(3) To “observe and describe” with the aim of encouraging the student referees to step back and suspend judgment on the peer activity,(4) To “put yourself in the referee's shoes” in a way to suggest an empathetic attitude with the experience of the peer referee. This exercise asked the participants to put themselves in the shoes of the referee as if they had acted in the same way as the peer ,(5) To step back from one's own perspective by having access (anonymously) to the answers of other student referees.For each exercise, the participants were asked to answer several questions, with the open questions guiding the student referees to the significant points to be described in terms of sensorial focus and sequences of the game. The last questions for each exercise provided the possibility to look at other student referees' answers and to put their own understanding into perspective as well as to put their own understanding into perspective with the sport federation instructions. Some closed questions were addressed to support the students' analysis, which was more constrained and less open.The student referees had three possible ways of viewing the video and could perform 360° screen sweeps in all directions: on a computer by performing the screen sweeps using the mouse pointer, on a smartphone or a tablet by performing sweeps tactilely, or with a smartphone inserted in a virtual reality mask by performing the sweeps using head movements.To access the video, the student referees scanned a QR code placed before the viewing instructions. This QR code then gave access to the video available on the chosen medium, a YouTube channel dedicated to the training device.The exercises for viewing the 360° videos and the questions were displayed online on the digital workspace of the University of Clermont Auvergne on the Moodle platform . The stuThe study included 12 student referees . These referees had between 2 and 5 years of experience in refereeing a team sport. They were four football referees, seven rugby referees, and one handball referee.The procedures were approved by the ethics review board of the university, and each official who participated in the study provided informed consent.The referees' answers were processed question by question. Each set of answers to a question was processed in a grounded theory style Böhm, . We used▪ What (What is at stake)?For example, the continuity of the game, the placement of the peer referee, and the communications between the players or between the referee and the players▪ Who (Who are the people involved and how do they interact)?e.g., the players on the field, the players of one team, the specific player(s) of one team, and the peer referee.▪ How (What aspects of the phenomenon are addressed or not addressed)?About how a behavior manifests itself, e.g., the kind of verbal communication .▪ Which context (When? How long? Where? What was the intensity?)?e.g., the amount of time to resume the game.▪ Why (What reasons are given or may be deduced)?The reasons enabling the continuity of the game, such as an advantage.▪ For what reasons? With what intentions and for what purpose?e.g., because it is a request by the heads of the refereeing.What does it mean in terms of methods, tactics, and strategies to achieve the goal? Böhm, .Open coding was applied to each response of each exercise. Researchers proceeded by grouping significant units to formalize categories according to the contents used by the different student referees to answer. No axial coding, which serves to refine and differentiate concepts, was processed because the data did not make it necessary Böhm, . In factin-vivo codes are taken directly from the language of the field of investigation. Therefore, the researchers' background knowledge about the fieldwork enabled them to specify different characteristics of the phenomenon investigated.The researcher sought to identify a continuum between particular characteristics in the corpus of the student referees' answers. The authors produced memos based on the coding notes and based on broad interrelations between the different cases of referees' answers. The writing of memos requires researchers to step back from the data and proceed with each set of answers as a case. Iterative steps in the writing of the memos were taken to ensure the reliability of the data Weed, . A constResearchers used their background knowledge as experts in the refereeing fieldwork in football. Their research activities led them to know not only the rules but also the philosophies, the contents of arbitration training, and the prescriptions of good practices.The results are organized into two parts. The first one characterizes the viewing activity of the students step by step according to the different exercises, and the second one opens some discussions about the pedagogical uses of a 360° video as an immersive medium in referee training.The analysis of the student referees' different responses shows points of focus in video viewing and different cognitive stances. In this section, we focused on the contributions of each exercise to characterize the viewing activity.First, it is worth noting that, when given the choice of viewing modality, only two out of 14 students used the VR headset. After analysis of the responses, no significant differences in students' stances or perspectives related to the type of use chosen were noted. Thus, the kind of use of the virtual reality (VR) headset was not a relevant analysis category concerning the written content produced by the student referees.The reference points used to define the sequences were regularly of the same type: start of the match, throw-in, and peer referee's whistle. The student referees' understanding of the sequencing of play was based on how the play stopped and restarted. Play stopped in two ways as follows: either when the ball went out of bounds or when the peer referee stopped play by calling a foul. The significant elements mentioned in the responses were related to the understanding of how play stopped and how it was resumed. The significance of restarting the game was linked to how the rules would be implemented, i.e., the direction of a throw-in, a direct or indirect free kick, a corner kick, or a goal clearance.Although when the reference points used were regularly similar, faced with the same video, each of the student referees cut up the time flow differently and proposed different extensive sequences. More specifically, the number of sequences varied from one referee to another: one referee identified 2 sequences, three referees identified 3 sequences, two referees identified 4 sequences, three referees identified 5 sequences, one referee identified 6 sequences, two referees identified 7 sequences, one referee identified 8 sequences, and one referee identified 10 sequences. Thus, there are idiographic differences in the sequencing although the participants seemed to share the same reference points. These results raise the question of whether the referees, who are new to the use of a 360° video, can clearly perceive in the viewing what they seemed to share.The following results are presented regarding each research question. For each research question, the results are grouped into thematic categories that emerged from the treatment of the student referees' comments in relation to each viewing, question, or exercise. We, therefore, highlight the perspective adopted by the referees during the viewing or in response to the questions asked.The student referees' descriptions of the game spontaneously involved two types of focus as follows: one focuses on the course of the game and the other on the referee's activity. Referees generally alternated between these focuses in their descriptions.The focus on the game was characterized by a focus on possession, i.e., which team had the ball. This focus was linked to a concern to identify possible changes in possession of the ball possession to understand the continuity of the game. Some student referees linked the possession of the ball to an analysis of the balance of power at the moment. The notions of “ball carrier” and “change of side” (to characterize possession) were regularly used in the descriptions. As mentioned earlier, descriptions of global movements, particularly offensive movements, were regularly made; the identification of the team in possession of the ball was used in these descriptions.When student referees were focused on the peer's activity to describe the video, they focused on the peer referee's communication with the players. More specifically, they noted (1) the communication of the decision through words, whistles, and gestures and (2) the explanations of the decisions given to the players by the peer.(…) the first foul appears; the referee tells the players not to commit too many in order to keep the game flowing”.Example 1: Participant number 11: “The student referees' focus was on the way the interactions with players could influence the continuity of the game.More occasionally, the descriptions took the peer referee's gaze into account by considering the orientation that allowed him to follow the ball in its successive locations. This characterization was therefore based on a targeted focus.From 1'35 to 2'33: Once the referee has approached, he looks at the players to check if there is a foul”.Example 2: Participant number 2: (…) “However, the description of the peer referee's gaze could also be made more global by considering that the peer also integrated elements that were peripheral to the location of the game by taking a step back.In phase 1, we see that the referee is in a continuous run, and that he has a vision of the whole game”. Example 4: “[the referee] (…) positions himself to be in the best position possible to watch the outcome of the free kick”.Example 3: “When they were asked to project themselves into the context of the peer referee in order to “referee in his or her place”, the participants implicitly remained in a stance of exteriority in relation to the performance of the peer referee on the screen, i.e., in a stance of observation of the performance of the peer referee on the image. For example, when they described what they heard, they listened to the peer referee: they did not officiate in his place by focusing solely on what they would do according to what they perceived, e.g., the communications between players. They took into account and wrote what they would have done differently than the peer referee.The student referees did not project themselves in the context of the referee on the screen but constructed a normative stance of optimization. In three cases out of the 12 participants, they produced an evaluation of the placement of the peer referee in the 360° video.The participants were also able to identify what they based their statements on, namely:- Detecting disruptive physical behaviors in players or physical behavior that could disrupt the continuity of play. The referees would then pay attention to the relationships between players  to upcoming duels.- Communication between players. The aim was to understand the tensions between opponents and between partners to understand the game.- The referees put the peer referee's activity on video into perspective with the practices recognized as good refereeing practice, i.e., federal practices and the theories built on these practices.When they are subsequently asked for factual information about the placement of the peer referee, participants expressed the following concerns:- Does the peer referee interfere with the game or not? Does he or she alter the “normal” continuity of the game?- Is it possible to have better proximity to the game?- Is it possible to have a better angle of vision (distance)? This angle is sometimes necessary to understand (1) who has the ball, i.e., if a change in the possession is possible and where on the field, or (2) the upcoming foul on the carrier.- Is the positioning on the restart of the game suitable to follow the continuity of play?This was followed by a stance of optimizing the activity of the peer by offering their point of view.These results should reflect the reasons why students have a game focus. In fact, the student referees' focus on ball possession more deeply (refer to Section 3.1.1) could reflect prioritizing making a good decision or checking actions in the game that might affect the game's flow. In addition, these results provide some insights about the reason why the students were focused on the peer referee's behavior, i.e., placement or actions that give information about the game's unfolding. They had some expectations concerning the information they need on the field regarding the prescriptions of their tasks.When the student referees were asked to “put themselves in the peer referee's shoes”, the analysis identified two types of stances, which corresponded to two kinds of dynamics:- An analytical stance in relation to the performance of the peer referee: they studied the referee's choice again and then evaluated the other possible choices by projecting themselves into the best possible one. These student referees (two participants) never took an empathetic stance but rather adopted an extrinsic, analytical, and normative stance regarding the peer's activity. For example: “The video of a referee allows you to put yourself in his place and identify the different points of the video. Thus, we pay attention to his choices, his performance, as well as his movement”.- A direct normative stance that subsequently led them to project themselves into the choices they would have made in the place of the peer referee while indicating their understanding of the choices comprehensively made by the referee. The participants were then either, on the one hand, in an empathetic stance (two participants only evoked their emotions and feelings when viewing the peer's activity) or, on the other hand, in a normative analytical stance.Asking the student referees to put themselves in the shoes of the peer enabled 10 out of 12 participants to step back from their usual normative stance by empathizing with the peer. For example: “as referees we can feel things similar to our games, such as when he or she calls the red n°8 to caution him. We feel the physical effort the referee has to make to keep track of the action and the ball.”via the video). However, even if it seems difficult for the referees to adopt a non-normative stance, the introduction of several types of questions and exercises leads to changes in stance.These results show that, despite the instructions, the student referees only partially adopted the stance expected by the exercises .Nevertheless, the analysis of the student referees' responses to the proposed exercises led us to reflect on the different types of possible immersion and to discuss the issue of enriching 360° videos.If an exploratory immersion could become an interesting support within the framework of technical training owing to the technological enrichment of the 360° camera, the 360 currently does not appear to easily achieve an empathic stance. In fact, an empathetic immersion seems to require a preliminary work of detachment from a normative stance, the referees understand the position of the peer owing to their embodied knowledge and adopting a normative stance spontaneously on this basis. However, we must notice that, if it seems difficult for the referees to adopt a non-normative stance, it could be linked to how the exercise instructions were interpreted and to the fact that a written report was requested.In fact, the enrichment of the 360° video with visual explicit cues in space to situate oneself  representative of the refereeing activity to train the officials?The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.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.SB: conceptualization, methodology, investigation, writing—original draft, writing—review and editing, visualization, supervision, project administration, and validation. NR: interpretation of the data, revision, and writing. GR-L: conceptualization, methodology, investigation, writing—original draft, writing—review and editing, visualization, supervision, project administration, and validation. All authors contributed to the article and approved the submitted version.


Young men with Duchenne Muscular Dystrophy benefit from palliative care that supports their psychosocial needs. Acknowledging the sub-cultures they engage with can support their wellbeing. Anecdotal reports suggest video gaming is a sub-culture engaged with by young men with Duchenne Muscular Dystrophy.To explore the lived experience of video gaming from the perspective of young men with Duchenne Muscular Dystrophy.Interpretative Phenomenological Analysis approach involving in-depth interviews using a topic guide that focused on social media broadly, with reference to video gaming. Sequential interviewing was undertaken to support participation regarding fatigue and tiredness, symptoms of Duchenne Muscular Dystrophy.Participants were purposefully recruited from a hospice in the North of England. Twitter was used to support recruitment. Eight young men with Duchenne Muscular Dystrophy were recruited to the study.Five themes were developed; ‘gamer as a shared and accepted identity’, ‘an existential and bodily escapism’, ‘introspection through video gaming’, ‘video gaming as a release’ and ‘when life gives you few choices-video game’. Motivations for engagement with video gaming are diverse and reflective of the situated perspectives of young men with Duchenne Muscular Dystrophy.An awareness of the popular sub-cultures that young men with Duchenne Muscular Dystrophy engage with is key to building a therapeutic alliance, establishing rapport and recognising personhood in interactions between professionals and persons in palliative care settings. This study highlights the value of video gaming, offering professionals valuable insight into its placement in the daily lives of young men with Duchenne Muscular Dystrophy. What is already known on the topicAnecdotal reports suggest video gaming is an important activity in the daily lives of young men with Duchenne Muscular Dystrophy.Previous literature reports findings related to accessibility challenges and their impact on video game experience, gamer demographics and motivations for video game engagement.Video gaming facilities are increasing in clinical and hospice settings thanks to charity organisations.What this paper adds?Video gaming supports young men with Duchenne Muscular Dystrophy to engage with other peers based on a shared and accepted identity.Young men with Duchenne Muscular Dystrophy are able to escape their everyday lives through video gaming and engage in activity otherwise unavailable to them.Young men with Duchenne Muscular Dystrophy face barriers to engaging in social activity outside of video gaming.Implications for practice, theory or policyVideo gaming has value both in and outside of clinical settings to support the wellbeing of young people with Duchenne Muscular Dystrophy and disabled young people more broadly.While we advocate for video gaming as a meaningful and enjoyable activity, it is not a solution to the challenges young men with Duchenne Muscular Dystrophy can face to living fulfilling young adult lives.An awareness of the popular sub-cultures such as video gaming that young men with Duchenne Muscular Dystrophy engage with can support rapport building and recognition of personhood in interactions with professionals and persons in palliative care settings.14 In this paper, we draw on the findings of an Interpretative Phenomenological Analysis (IPA) study with eight young men with Duchenne Muscular Dystrophy to understand their experiences of video gaming.Since its inception, video gaming has become a popular activity shared by children and adults worldwide. Much has been written about player motivations for gaming, however relatively little attention has been given to the experiences of disabled gamers, despite anecdotal reports suggesting a significant proportion regularly engage with video gaming.6 The condition almost exclusively effects males and is characterised by progressive muscle degeneration and weakness due to a defect in dystrophin, a protein necessary for muscle cells to function correctly. Typically, by the age of 12, children diagnosed with Duchenne Muscular Dystrophy are non-ambulant. Relatively recent advances in respiratory, cardiology and gene therapy have significantly increased their life expectancy, with people with Duchenne Muscular Dystrophy now likely to live into their 30s and 40s, and potentially beyond.9 However, living with Duchenne Muscular Dystrophy is challenging, and requires multidisciplinary health and social care input to support young men living with the condition to have meaningful and fulfilling lives.Duchenne Muscular Dystrophy is a life-limiting neuromuscular condition with an estimated prevalence of 15.9–19.5 per 100,000 births.Video and computer gaming are congruous with forms of social media, including social networking sites and interactive blogging, in their capacity to bring people together through their online functionality and player connectivity. Research into video gaming, and social media use more broadly by young men with Duchenne Muscular Dystrophy is limited. In 2018, we published the findings of an integrative review of research that focused on social media use by adolescents and young adults with life-limiting and life-threatening conditions. Of the 15 studies identified, 14 reported findings on social media use by adolescents and young adults with cancer. End-stage renal disease was addressed by the remaining article. No other illnesses representative of life-limiting or life-threatening conditions were found, despite a comprehensive search of multiple databases. No studies on social media use by young people with neuromuscular conditions such as Duchenne Muscular Dystrophy were identified.1113 Of these studies, two were survey-based,13 and one interview-based. Findings primarily related to accessibility challenges and their impact on video-gaming experiences, understanding the demographics of disabled gamers and understanding motivations for video game engagement. A separate body of literature has explored the potential utility of gaming to support physical assessment and physiotherapy of Muscular Dystrophy and related conditions.1416 However, no studies within this evidence base have focused specifically on the experiences of video gaming from the perspectives of young men with Duchenne Muscular Dystrophy.An expanded search of the literature identified an additional three studies on video gaming use by young people with physical disabilities.14 For example a young man with Duchenne Muscular Dystrophy, who was an active blogger, poignantly summarised the meaning of video gaming as: ‘my chains are broken and I can be whoever I want to be. In there I feel normal’. To support the wellbeing of men with Duchenne Muscular Dystrophy, it is necessary to understand their experiences of engaging in daily activity such as video gaming. To address the dearth in evidence into video gaming use by this patient group, this study aimed to explore the lived experience of video gaming from the perspectives of young men with Duchenne Muscular Dystrophy.Despite a paucity in empirical evidence, anecdotal and social media reports suggest video/computer gaming is a popular and meaningful activity undertaken by young men with Duchenne Muscular Dystrophy. Ethical approval was granted by the University of Leeds School of Healthcare Research Ethics Committee (Reference: HREC17-009).Interpretative Phenomenological Analysis (IPA) underpinned the study and informed the methods and rationale for recruitment, data collection and analysis. IPA was appropriate because it is fundamentally concerned with how a particular phenomenon (video gaming) comes to mean something to a particular person/group (young man/young men with Duchenne Muscular Dystrophy), in a particular situated context (the everyday life living with Duchenne Muscular Dystrophy).In the United Kingdom (UK), young men with Duchenne Muscular Dystrophy and their families are typically offered hospice care, which provides a range of support including psychosocial support and respite care. A hospice in the North of England supported the study and recruitment. The social media platform Twitter was also used to support recruitment.Young men with Duchenne Muscular Dystrophy were included if they met the criteria defined in Young men aged 18–35 with Duchenne Muscular Dystrophy with an interest in video gaming were eligible for the study. Purposive sampling was undertaken by professionals at a children and young persons hospice, as per the study inclusion criteria. Relatedly, purposive sampling was undertaken by GP to identify eligible participants who responded to the Twitter advertisement.The lead nurse sent recruitment packs to potential participants 1 month prior to a planned respite stay at the hospice, that included an invite letter, information sheet, and a copy of the consent form. Those interested in participating were asked to contact the lead researcher (GP) using details provided in the information sheet. Email dialogue between potential participants and GP was established prior to the interview, with a date/time for interview subsequently agreed. To support recruitment, @Twitter  was utilised with tweets (messages) posted to advertise the study, developed in consultation with patient and public involvement (PPI) representatives. Profiles of relevant charities and organisations were added to the tweets to increase tweet visibility. The tweets received a total of 88 engagements, including 18 retweets and 12 likes. Contact details of GP were provided in the tweet and people who expressed an interest in taking part in the study contacted GP and were then sent a recruitment pack by email. To support participation in the study, interviews were offered to be undertaken sequentially at more than one time point. An interview guide was developed from the literature, theory, the findings of a Twitter Chat and in consultation with two PPI representatives and a young person’s advisory group. Topics included the placement of video gaming in the daily lives of participants, the value and utility of video gaming and the barriers or challenges to engagement with video gaming. Most interviews took place face-to-face at the participant’s home, or at the hospice where they were receiving respite care, with one participant interviewed online (via Skype following university protocols). Video gaming was used in several of the initial interviews to develop rapport with participants and to support the elicitation of video gaming experiences. All interviews were undertaken by GP. With participant’s consent, interviews were audio-recorded and transcribed verbatim. Interviews took place between October 2018 and July 2019.Data were collected by semi-structured in-depth interviews to explore participants’ experiences of social media broadly, with video gaming a featured topic. Fatigue and tiredness are common symptoms of Duchenne Muscular Dystrophy. An initial case-by-case approach was adopted, whereby each participant account was analysed individually. To aid data familiarisation, interview recordings were listened to and transcripts read multiple times, with initial thoughts noted. A process of developing descriptive, linguistic and conceptual codes followed. Descriptive codes highlighted content that appeared to ‘matter’ to participants. Engaging in descriptive coding helped to structure participant narratives. Linguistic coding identified how participant’s utilised pronouns, laughter, pauses and repetitive discourse to convey their narrative. Finally, conceptual coding involved an interpretive probing and questioning of the data. Descriptive, linguistic and conceptual codes were then grouped into themes that summarised participant accounts. The stages of familiarisation, coding and theme development were repeated for each participant account. Prior to moving to the next account, interpretations  developed through engaging with the previous account were documented to support the analysis of each account. On completion of the case-by-case analysis, an iterative process of identifying patterns and divergence across cases followed, resulting in new cross-case themes. Cross-case themes were then grouped to develop superordinate themes that structured the overall findings. Superordinate theme development was debated and subject to on-going refinement through regular meetings between GP, AR and JS.Interpretative Phenomenological Analysis was undertaken.Prior to developing the study, GP had no experience of engaging with young men with Duchenne Muscular Dystrophy or similar life-limiting/threatening conditions. During study development, GP spent a period of time at a hospice, to understand the needs and priorities of young men with Duchenne Muscular Dystrophy. GP has a background in psychology, with experience in qualitative methodology and methods. The study was undertaken as part of a PhD qualification. GP enjoys video gaming as a hobby, and was therefore able to share experiences with participants, supporting rapport. GP regularly journaled throughout the study, questioning and bringing to fore his assumptions/presuppositions about the sample and topic area.The study was supported by two PPI representatives who held senior nursing roles at a children and young adult hospice/s and were able to appropriately guide and inform the study. AR and JS both have extensive experience of delivering research in the field of young person’s palliative care/long-term conditions and could offer GP relevant support. Therefore, to support their engagement, the sample were interviewed at more than one time point. This also engendered rapport with participants that supported in-depth discussions about their experiences. In total, 18 interviews were undertaken with each interview lasting on average 40 min. The characteristics of the sample are outlined in A sample of eight young men with Duchenne Muscular Dystrophy were interviewed. Young men living with Duchenne Muscular Dystrophy experience greater fatigue in comparison to typically developing males.The meaning of video gaming is illustrated by five themes; ‘gamer as a shared and accepted identity’, ‘an existential and bodily escapism’, ‘introspection through video gaming’, ‘video gaming as a release’ and ‘when life gives you few choices-video game’.. . .would probably put gamer and the types of games I play, that would be it really. Lee.Video gaming provided a sense of identity that could be shared with others without prejudice. Participants described themselves as ‘gamers’ and opted to prioritise their ‘gaming self’ when describing themselves to others:‘other things than just your disability’ (Vivek). Avatars and gaming characters appeared as modalities that offered choice and freedom over aspects of self revealed to others:Well I think it is easier to kind of not allow them to see your disability straight away. To see you as a person and a gamer. I realised that you formed friendships that are about a lot of other things than just your disability. Vivek.Video gaming offered an alternate landscape for self-presentation. Participants described the social benefit of being able to ‘hide’ their disability from other gamers, and form friendships with others based on ‘summet wrong with them’ (Tom).Participants described challenges in presenting a self in line with how they wished to be viewed by others outside of video gaming. Periods of bullying and teasing targetted at their disability were associated with difficult times where they were considered as Beings with In summary, gaming facilitated additional identity formation without an association to their disability, allowing them to feel fully participant in the virtual world and not judged by those with ableist ideologies.‘forget’, ‘shut-out’ or ‘escape’ from life outside of the video game. In this sense, escapism was experienced existentially, with gaming providing a pause from life as lived outside of gaming:. . .gaming kind of helped me to take my attention away from negative things all the time about my weakness, because it felt like I was grieving each time I had a little bit of deterioration but having the game there to play I forgot about that (deterioration). Vivek.Engagement with video gaming offered participants existential and bodily experiences of escapism. Video gaming provided a space where they could ‘that I (they) wouldn’t be able to do in real life’ (Simon). Participants described a range of activities including driving, horse riding and sports such as football and mixed martial arts that were perceived as outside their reach. Other activities outlined included more intimate experiences such as washing and grooming:I like the driving ones obviously I don’t drive so it’s like a thing I get to know exactly what it is like to drive, well ye know not quite exactly but. . . Simon. . .but when you fall you get muddy, yeah and then you can wash yourself, whereas I wouldn’t be able to do that in real life, so it is just experiencing new things. VivekOn an interrelated level, participants video gamed to experience activity ‘astral projection’ (Vivek).Escapism in these instances therefore appeared to mean a departure from the body as experienced outside of video gaming, to a transformed bodily existence, akin to an In summary, participants found meaning in the ability of video games to offer them a haven and space to escape to during periods of difficulty. Likewise, the activity offered a medium to experience activity otherwise perceived as out of reach in their offline worlds.‘a bit more exciting than mine’ and therefore wished ‘to be some of the characters that I am in games’ (Simon).Yeah would I drive like I do on GTA (video game) and do the stuff I am doing in the game. Ye know what I mean. . .cos in my case I have never been able to walk. Ye know what I mean I have never had that. So there is always that thing of what would I be like if I could walk? Mohsin.I think with everything I do like gaming. . .I kind of start to understand myself more, it is kind of a way to like create an identity and kind of shape it. So yeah I think that is what gaming is, it is shaping you as a person. Vivek.Gaming provided a space for participants to make sense of and ponder their sense of self and identity. Participants described looking inward to question, ponder and evaluate their self. Exposure to activities through video gaming otherwise unavailable provided participants with a different world view. Participants reflected on how life would appear differently if activities accessible through gaming were present offline, for example the ability to walk. Relatedly, participants compared their lives to those of gaming characters. Some participants perceived that the lives of gaming characters were In summary, video gaming offered participants’ experiences otherwise unavailable outside of gaming. Access to these experiences promoted introspection that in turn supported them to make sense of their identities and lives.‘vent out’, ‘taking out’ and ‘get rid of’ to describe the cathartic quality of video gaming:. . .and I used it (video gaming) as a coping mechanism as I got older. Mainly because as a kid I was confused, I had a lot of anger, ye know about myself and the position I am in. I just didn’t understand why, so I used Tekken (game) to vent out my frustrations. Mohsin.Video gaming offered participants a space to release emotions that otherwise would negatively impact their wellbeing. Participants used discourse such as Ye know cos they (parents) might think I don’t know they’ve failed you or something like that. When they haven’t but. . .. Tom.Participants identified video gaming as a viable space to make sense of emotions associated with their daily lives. Participants perceived that discussing daily stressors and challenges to significant others such as their parents may have upset them, opting instead to process these emotions through video gaming:‘vent out’ challenging or difficult emotions.In summary, video gaming appeared to be a crucial activity to support wellbeing, offering a space to make sense of emotions that manifested in participants’ everyday lives, and ‘. . .isolated from the real world’ (Mohsin), something they attributed to few avenues to socialise and family dynamics they described as over-protective:I mean you don’t understand if you’ve got a disability, and you’ve got an overprotective family, that don’t let you play out because they are scared that you are going to get hurt, or that you are going to get picked on, or ye not going to fit in, the only thing you can do is gaming. MohsinYeah because people who can go to the gym or do sport and things you get to know people through that stuff ye know going out, but I can’t really go out on nights out and stuff like that. Cos there is just no facilities or disabled access and stuff it all comes down to that. . . TomThe presence of video gaming in participants’ lives was associated with a dearth in opportunities outside of the activity. Participants described being ‘from whatever time I get up till I go to sleep’ (Lee). Participants’ were aware of their reliance on video gaming for everyday meaning, and voiced that if opportunity for other activities existed, their relational dynamic with video gaming would be significantly altered:If I could I would not just game, if I could get out and do all that stuff I would hardly ever go on my Xbox. Tom.Video gaming held a consistent and daily presence in the lives of several participants In summary, the presence of video gaming in participants lives existed not always through choice, but through a belief based on experience that few other opportunities existed for meaningful activity and engagement.Young men with Duchenne Muscular Dystrophy cite a range of motivations for daily engagement with video gaming. However, they were unanimous about its significance and importance in their everyday lives. to compete as equals and interact with peers. In addition, we found that video gaming can act as a space of solace and refuge for young men with Duchenne Muscular Dystrophy from the challenges of their everyday lives. The ability to transcend their everyday lives and immerse themselves within video games can aid wellbeing, offering the opportunity to process and make sense of troubling emotions.Our findings highlight how young men with Duchenne Muscular Dystrophy can tap into the shared and accepted identity of a gamer to portray a ‘narrative of non-difference’,Video gaming occupied a significant space in the lives of participants, with some stating it was their main daily activity. While citing the benefits of video gaming to their wellbeing, participants also recognised a balance between gaming life and life outside of gaming should exist. However, participants felt that few options exist other than to video game. Therefore, while our findings illustrate the benefits of video gaming to young men with Duchenne Muscular Dystrophy and those with life-limiting/threatening conditions more broadly, they do not underplay the importance of support and provision to enable young men with Duchenne Muscular Dystrophy to live fulfilling and meaningful young adult lives both in, and outside of video gaming.1014 Adopting an in-depth phenomenological approach, this study adds new insight to the evidence base, highlighting the varied benefits of video gaming, demonstrating its placement and significance in the daily lives of young men with Duchenne Muscular Dystrophy.Previous study on video gaming use focused on accessibility barriers, gamer demographics and gamer motivation, with an underrepresentation of young men with Duchenne Muscular Dystrophy despite anecdotal reports suggesting the utility of the activity in their everyday lives.22 Leisure and social activities are often family-centred, with few opportunities to develop independent and active social lives.22 Furthermore, societal abliest ideologies have ‘othered’ and marginalised disabled young adults, confounding physical barriers such as poor accessibility to hinder social participation. Our findings concur and highlight experiences of bullying and derogatory behaviour experienced by young men with Duchenne Muscular Dystrophy. To negate physical and societal oppressions of social self, our findings show how young men with Duchenne Muscular Dystrophy tap into a popular gaming culture to engage with others based on the shared identity of a gamer. It is important that video gaming is recognised as an anchor into a popular shared identity that young men with Duchenne Muscular Dystrophy, and those with disabilities more widely, can utilise to support social interaction.Opportunities to socialise and connect with others can often be limited for young men with Duchenne Muscular Dystrophy.1416 Whilst not underplaying the value of these studies, we found gaming has cathartic and therapeutic qualities that can support the emotional wellbeing of young men with Duchenne Muscular Dystrophy. Living as a young person with a degenerative condition can be challenging. At a time when other young men are becoming increasingly independent, those with Duchenne Muscular Dystrophy experience increasing dependence on both technology such as mobility chairs and ventilation equipment, and people to support their daily needs.2124 We found video gaming offers a space for young men with Duchenne Muscular Dystrophy to make sense of their everyday experiences. Identifying the capacity of video gaming to support emotional wellbeing is significant, particularly because the population are at increased risk of anxiety and depression.Studies have to date focused on the physical benefits of video gaming in areas such as physiotherapy. and internationally. To maximise the potential of this equipment, clinicians need to be aware of the therapeutic, cathartic and social benefits of video gaming, illustrated in our findings. Furthermore, we also found video gaming supported rapport between participant and researcher prior to and during interview/s, a finding also reported elsewhere. There is a growing emphasis on including young people with life-limiting/threatening conditions in discussions about their care. Clinicians may look to utilise video gaming as a tool to connect with patients and support involvement in discussions about their care. Further study is warranted to explore the potential utility of video gaming within clinical settings.The presence of video gaming equipment in clinical settings has increased in recent years largely due to the work of charity organisations both in the UK We found that participants recognised the need to balance gaming with other social activities. Nevertheless, participants consistently faced barriers to meaningful activity outside of video gaming, increasing their dependence on the activity. Our findings therefore complement a call for a ‘systemic cultural shift’ in the way young men with Duchenne Muscular Dystrophy and other children and adults with special educational needs and disabilities are viewed and supported.To support the wellbeing of young men with Duchenne Muscular Dystrophy, a balance should exist between video gaming as a source of enjoyment and occasional refuge, and ensuring it does not claim superiority over other realities. Extended periods devoted to video gaming can isolate young men with Duchenne Muscular Dystrophy from social groups and settings outside of video gaming realities. More so, the testimony of the study sample is supported by anecdotal reports of gaming use by this patient group, and previous study into gaming use by people with physical disabilities.1113 Consequently, it is likely that the findings of the study are transferable to the wider population.To the best of our knowledge, this is the first UK study to explore video gaming use by young men with Duchenne Muscular Dystrophy. This is significant because to support young men with Duchenne Muscular Dystrophy to live fulfilling and meaningful lives, it is necessary to better understand their daily lives and activities. A limitation of this study was the sample size recruited. However, the sample recruited was in keeping with an interpretive phenomenological approach.Young men with Duchenne Muscular Dystrophy engage with video gaming to situate themselves as part of a popular sub-culture, to experience escapism, for a cathartic release, to make sense of their Being, and because few other opportunities for meaningful engagement exist. These findings can be implemented into practice, utilising gaming equipment available in hospital and hospice settings to connect, engage and provide escapism for young people in palliative settings. Relatedly, an awareness of the popular sub-cultures that young men with Duchenne Muscular Dystrophy engage with is key to building therapeutic alliance, establishing rapport and recognising personhood in interactions between professionals and persons in palliative care settings. More broadly, while we advocate for video gaming as a meaningful and important activity, it is not a solution to the challenges faced by this group to live fulfilling lives. Young men with Duchenne Muscular Dystrophy should not feel such an urge to escape or forget, nor should they require a space to release negative emotion, and nor should they compare themselves to software constructed characters and find themselves wanting. Future research and practice policy should be directed towards supporting the population to live fulfilling lives.Click here for additional data file.Supplemental material, sj-pdf-1-pmj-10.1177_02692163231172246 for ‘It is easier to not allow them to see your disability straight away, to see you as a person’: An Interpretative Phenomenological Analysis of video gaming from the perspectives of men with Duchenne Muscular Dystrophy by George Peat, Alison Rodriguez and Joanna Smith in Palliative Medicine


Comparisons were made between W1ADF and W2ADF, W2ADF and W2OvF, and W2OvF and W3OvF. The waves were numbered 1, 2, or 3 based on when the waves emerged relative to the preceding ovulation. W1ADF emerged closer to the preceding ovulation, and W2ADF emerged in the late luteal or early follicular phase. The interval from emergence to maximum diameter was shorter for W2ADF than W1ADF and for W3OvF than W2OvF. Selection of W3OvF occurred at a smaller diameter compared to W2OvF. W1ADF regressed at a faster rate than W2ADF. Also, W1ADF were associated with lower mean follicle stimulating hormone (FSH) and higher mean estradiol than W2ADF. In contrast, W3OvF were associated with higher FSH and luteinizing hormone (LH) compared to W2OvF. However, W2OvF were associated with higher progesterone than W3OvF. This study contributes to the understanding of the physiologic mechanisms underlying selection of the dominant follicle, ovulation, and pathophysiology of anovulation in women, as well as optimization of ovarian stimulation protocols for assisted reproduction.Growth patterns and associated endocrine profiles were compared between dominant anovulatory (ADF) and ovulatory follicles (OvF) developing from different waves within and between menstrual cycles in women. Follicular mapping profiles of 49 healthy women of reproductive age and blood samples were obtained every 1–3 days during one interovulatory interval. Sixty-three dominant follicles were classified into wave 1  develop within 2 or 3 waves during the human menstrual cycle. Typically, only one follicle in each cycle releases an egg during ovulation. The rest of the follicles grow then regress. In this study, we characterized differences in the growth, regression, and associated hormone production between follicles that ovulated and those that did not, developing from different waves within and between menstrual cycles. Differences regarding follicle growth patterns and hormone concentrations were found when comparing different waves and whether a follicle ovulated. Results from this study improve our understanding of the processes underlying follicular growth and ovulation, which in turn may assist in improving fertility and birth control treatments. Despiteet al. 2003a,et al. 2003a,Follicular dynamics in women comprises a combination of minor and major waves throughout the interovulatory interval (IOI). An IOI is the period of time from one ovulation to the subsequent ovulation. In women of reproductive age (range: 19–43 years), major ovulatory waves develop in the follicular phase , and follicle stimulating hormone (FSH) has been demonstrated in women of reproductive age with two-wave cycles compared to three-wave cycles .Early studies byThe objective of the present study was to compare the intervals, growth rates, diameters, and associated systemic endocrine profiles of ADF vs OvF, developing from different types of follicular waves  within and between menstrual cycles.Data evaluated in the present analyses were collected from a previous study  was approved by the Biomedical Research Ethics Board of the University of Saskatchewan, Saskatoon, SK, Canada, and the Strategic Planning and Priorities Committee of the Saskatoon Health Region. Secondary analyses were approved by the Institutional Review Board of Southern Illinois University, Carbondale, IL, USA.The growth and regression profiles of individually identified antral follicles were retrospectively characterized following transvaginal ultrasonography of the ovaries every 1–3 days during one IOI ; Wave 2 anovulatory dominant follicles (W2ADF), which emerged in the late luteal to early follicular phase in women with three waves (n = 6 women);Wave 2 ovulatory follicles (W2OvF), which emerged in the early follicular phase in women with two waves (n = 33 women); and Wave 3 ovulatory follicles (W3OvF), which emerged in the early–mid follicular phase in women with three waves (n = 16 women). Examples of follicular waves  in women with two- or three-wave cycles as well as the association with ADF and OvF evaluated during the IOI are shown in Minor waves, characterized by the absence of dominant follicles . Tukey's multiple range tests were used for post hoc analyses. Data are presented as mean (± SEM), while categorical data are presented as percentages. Significant differences are indicated by P < 0.05.Data were evaluated for normality using Shapiro–Wilks tests and were transformed to ranks when not normally distributed. Student's P < 0.05) on the days of emergence, deviation, and maximum diameter compared to OvF.Mean growth profiles for ADF and OvF, irrespective of wave, centralized to days of emergence, deviation, and maximum diameter are shown in P < 0.0001) for ADF than for OvF. The intervals from emergence to maximum diameter and deviation to maximum diameter were longer (P < 0.0001) for OvF than for ADF. The maximum diameter was greater (P < 0.0001) for OvF than for ADF. The growth rates from emergence and deviation to maximum diameter were greater (P < 0.0001) for OvF than for ADF. In addition, both OvF and ADF had faster (P < 0.0001) growth rates from deviation to maximum diameter than from emergence to deviation.Intervals between various follicular events, diameters, and growth rates for ADF vs OvF, irrespective of wave, are shown in P < 0.05) was first observed 6 days after emergence of ADF (P < 0.05) before deviation of OvF but did not increase in ADF  9 days after emergence of OvF; however, no increase was observed in ADF. LH concentrations associated with ADF and OvF did not change around the time of deviation (P < 0.05) from 3 days before to 3 days after the maximum diameter of OvF compared to ADF (LH increased (eviation . Howeverd to ADF .P < 0.0001) after emergence (P < 0.05) 3 days after emergence of ADF but decreased 3 days after emergence of OvF.Estradiol increased after emergence of ADF and OvF , after dmergence , at and mergence , and befmergence . ProgestP < 0.003) at emergence of OvF compared to ADF. Similarly, LH was lower (P < 0.004) at emergence of OvF when compared to ADF. LH was higher (P < 0.003) at maximum diameter of OvF vs ADF, but no differences at deviation were observed between groups. Although estradiol at emergence did not differ among groups, estradiol was greater (P < 0.0002) at deviation of ADF compared to OvF. However, estradiol was greater (P < 0.01) at maximum diameter of OvF compared to ADF. Progesterone did not differ between groups at emergence but was greater (P < 0.006) at deviation and maximum diameter of ADF in comparison to OvF. Maximum LH and estradiol concentrations were greater (P < 0.04) for OvF compared to ADF. Maximum and overall mean progesterone concentrations were lower (P < 0.0001) for OvF than for ADF.Mean concentrations of hormones associated with follicle emergence, deviation, and maximum diameter of ADF vs OvF, irrespective of wave, are shown in P < 0.0001) than W2OvF when data were centralized to emergence, deviation, and maximum diameter. Moreover, the mean diameter of W2OvF was greater (P < 0.02) than W3OvF when data were centralized to deviation.Follicle growth profiles centralized to the days of emergence, deviation, and maximum diameter of anovulatory or ovulatory waves are shown as follows: W1ADF (in women with two or three follicular waves) vs W2ADF  compared to W2ADF. The growth phase was longer (P < 0.02) for W1ADF vs W2ADF. In contrast, the regression phase was longer (P < 0.03) for W2ADF, even though the static phase was longer (P < 0.03) for W1ADF vs W2ADF. The mean follicle diameters and growth rates did not differ between W1ADF and W2ADF. A slower regression rate (P < 0.02) was observed for W2ADF. An earlier (P < 0.03) emergence relative to ovulation was observed for W2ADF compared to W2OvF, leading consequently to shorter intervals from emergence and deviation to the maximum diameter  for W2OvF than for W2ADF. An earlier (P < 0.0001) emergence relative to the first ovulation was observed for W2OvF compared to W3OvF (P < 0.03) to ovulate than the W3OvF. The diameter of W3OvF at deviation was smaller (P < 0.02) when compared to W2OvF. Although the overall growth rates did not differ (P > 0.05) between W2OvF and W3OvF, the mean growth rates after deviation were greater (P < 0.02) in both W2OvF and W3OvF compared to those before deviation.Intervals between various follicular events, diameters, and growth rates of anovulatory or ovulatory waves are shown as follows: W1ADF (in women with two or three follicular waves) vs W2ADF (in women with three follicular waves), and W2OvF (in women with two follicular waves) vs W3OvF  when data were centralized to emergence, deviation, and maximum diameter (P < 0.05) at emergence of W2ADF vs W2OvF, and the overall concentrations of estradiol were lower (P < 0.0001) when normalized to maximum diameter of W2ADF than W2OvF. Overall, concentrations of FSH, LH, estradiol, and progesterone did not differ (P > 0.05) when data were centralized to emergence, deviation, and maximum diameter of W2OvF vs W3OvF (P < 0.05) at emergence of W3OvF than W2OvF.FSH and LH consistently decreased after data were centralized to emergence  and D, ddiameter , and L ovs W3OvF , and L. P < 0.003) for W1ADF than for W2ADF. In contrast, at deviation and maximum diameter, FSH was greater (P < 0.0002) for W2ADF compared to W1ADF. Estradiol and progesterone were greater (P < 0.03) at emergence, deviation, and maximum diameter of W1ADF vs W2ADF. Similarly, maximum and mean concentrations of estradiol and progesterone from emergence to maximum diameter were greater (P < 0.0003) for W1ADF than for W2ADF. FSH concentrations were greater (P < 0.05) at emergence and maximum diameter of W2ADF vs W2OvF (Supplementary Table 2). Estradiol and progesterone were greater (P < 0.04) at maximum diameter and maximum concentration of W2OvF than W2ADF. Moreover, the mean concentrations of LH, estradiol, and progesterone were greater (P < 0.01–0.09) from emergence to maximum diameter for W2OvF compared to W2ADF. Greater (P < 0.01) FSH concentrations were observed at emergence, maximum diameter, and ovulation in W3OvF compared to W2OvF (P < 0.04) in W3OvF compared to W2OvF. Mean FSH and LH were greater (P < 0.03–0.08) from emergence to maximum diameter of W3OvF vs W2OvF. Progesterone concentrations at emergence and from emergence to maximum diameter were greater (P < 0.05) in W2OvF compared to W3OvF.Mean concentrations of hormones at follicle emergence, deviation, and maximum diameter of W1ADF vs W2ADF, W2ADF vs W2OvF, and W2OvF vs W3OvF are shown in to W2OvF . At ovulTo our knowledge, this is the first comprehensive evaluation of intervals, growth rates, diameters, and associated systemic endocrine profiles of ADF and OvF that developed from different waves  within and between menstrual cycles. From these analyses, we were able to document differences in growth and endocrine profiles between ADF and OvF, as well as between the different types of anovulatory vs ovulatory waves.This study provides insight into the growth dynamics of anovulatory and ovulatory follicles developing in spontaneous ovulatory menstrual cycles. However, because ADF and OvF emerged at different times from the preceding ovulation , differences in endocrine profiles were expected based on the presence or absence of corpus luteum . TherefoWithin ovulatory cycles, W1ADF (in women with two or three follicular waves) grew for a longer period of time than W2ADF (in women with three follicular waves). This finding supports results from earlier reports demonstrating shorter inter-wave intervals for three- vs two-wave cycles in women and heifers c. We inAn increased growth rate after deviation was observed in W1ADF (in women with two or three follicular waves) compared to W2ADF (in women with three follicular waves). Although growth rates did not differ between W1ADF and W2ADF, W2ADF and W2OvF, or W2OvF and W3OvF, W1ADF regressed more quickly compared to W2ADF. Differences in growth rates of dominant follicles between anovulatory and ovulatory waves were not reported in the original study  and W2ADF (in women with three waves) revealed that FSH and LH concentrations decreased throughout W1ADF but were consistently higher in W2ADF. Decreasing FSH concentrations after emergence and before and after deviation of the future ovulatory follicle has been reported previously in women  FSH surge has been detected prior to the preovulatory FSH surge in association with the emergence of the first luteal phase follicular wave   . HoweverIn summary, progressively decreasing gonadotropins, slower growth rates, longer growth phases, and more rapid regression rates were observed for W1ADF (in women with a two- or three-wave cycle) compared to W2ADF (in women with three waves). FSH was greater and estradiol lower in W2ADF compared to W1ADF. W2OvF in women with two waves was associated with lower mean FSH and higher estradiol compared to women who had W2ADF in a three-wave cycle. Late luteal phase-early follicular phase emergence of W2ADF results in regression, enabling the emergence of a third follicular wave in the cycle. Greater serum FSH concentrations were detected in association with the growth of W3OvF compared to W2OvF. The data were interpreted to mean that there is a potential role of FSH in the development of three vs two follicular waves. Collectively, this knowledge may be applied to the future optimization of ovarian stimulation protocols for assisted reproduction and hormonal contraceptive formulations and provide directions for future studies to elucidate the physiologic mechanisms underlying selection of the dominant follicle, ovulation, and pathophysiology of anovulation in women.The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.Health Researchhttp://dx.doi.org/10.13039/100005622. Trial registration number: ClinicalTrials.gov Identifier: NCT01389141.No external funding sources were used for this study. Funding for the original study from which the data were obtained was provided by an operating grant from the Canadian Institutes for The data underlying this article are available in the article and in its online S T B and E L G conceived the study, analyzed and interpreted data, and wrote the manuscript. M O G helped with data processing, statistical analyses, and manuscript preparation. A R B and R A P helped to plan the study and participated in data collection, interpretation, and manuscript revision. All the authors critically reviewed the manuscript.


Internet scams are fraudulent attempts aim to lure computer users to reveal their credentials or redirect their connections to spoofed webpages rather than the actual ones. Users’ confidential information, such as usernames, passwords, and financial account numbers, is the main target of these fraudulent attempts. Internet scammers often use phishing attacks, which have no boundaries, since they could exceed hijacking conventional cyber ecosystems to hack intelligent systems, which emerged recently for the use within smart cities. This paper therefore develops a real-time framework inspired by the honeybee defense mechanism in nature for filtering phishing website attacks in smart cities. In particular, the proposed framework filters phishing websites through three main phases of investigation: PhishTank-Match (PM), Undesirable-Absent (UA), and Desirable-Present (DP) investigation phases. The PM phase is used at first in order to check whether the requested URL is listed in the blacklist of the PhishTank database. On the other hand, the UA phase is used for investigation and checking for the absence of undesirable symbols in uniform resource locators (URLs) of the requested website. Finally, the DP phase is used as another level of investigation in order to check for the presence of the requested URL in the desirable whitelist. The obtained results show that the proposed framework is deployable and capable of filtering various types of phishing website by maintaining a low rate of false alarms. An internet scam is a common social engineering attack used to disclose private and sensitive data by misleading users without being found out . The ultAn Anti-Phishing Working Group Organization statistics report  indicateIn particular, a phishing website attack is executed through several steps, as illustrated in Several research studies have been carried out recently to identify the phishing website attacks. Such studies, however, cannot avoid the advanced hacking of phishing websites adequately. Moreover, the utilization of different media communication, including social networks, raises the amount of web-based assaults. In , JagaticThis paper develops a real-time framework for phishing website detection (ScamFree), mimicking the honeybee’s defense nature mechanism. ScamFree is basically an enhancement for the PhishSys system, which we have previously proposed in  for the The rest of this paper is structured as follows: This section critically discusses the most related work of phishing website attacks. Several studies on phishing website attack have been conducted over the past few years. The main aim of such studies is to achieve the most effective and accurate detection of phishing website attacks. The existing studies that used in phishing website attack prevention are mainly categorized into three classes: heuristic-based, blacklist-based, and machine-learning-based approaches, as illustrated in Heuristic-based approaches elaborate on the HTML or URL signature in identifying the phishing websites. Many researchers have conducted studies on phishing website detection based on this type of approach. For instance, in , Chou etStudies in ,14 analyThe similarity-based index among the original website and the spoofed ones could be identified using content-based approaches. This type of approach calculates the similarity between websites that have overlapping contents. Generally speaking, we can achieve an adequate level of accuracy with low false alarms in identifying the phishing websites by using the content-based approach. In , Zhang eDunlop et al. in  have proSpoofguard , which rA recent work was proposed in  for the As another strategy that is widely used nowadays in identifying phishing websites, a blacklist-based approach has been implemented as an anti-phishing technique. Using this approach, the system should obtain an up-to-date blacklist for the common phishing websites. Altogether, entries that are denied access are allocated in such a phishing blacklist ,18. AccoAs a representative of phishing detection techniques based on the blacklist approach, Net Craft Toolbar  is discuIn , Rao, R.In the literature relatingphishing website detection, there are a numerous number of machine learning techniques that can be directly utilized in the context of phishing URL identification, such as Decision Trees , Naïve BFor machine learning, the main requirement for training a model is training data. The identification of phishing URL is definitely subjected to the numbers of URLs that are used in the training process. Moreover, the precise process of extracting the optimal features for both phishing and genuine URLs to be used as training data will increase the detection accuracy. The more common lexical features used include the statistical properties of the URL string, its length, and the length of each component  . PhishArA number of research studies, such as ,32, haveIn the honeybees’ colony, there is a tiny entrance guarded by a particular part of the honeybees, called colony guards. The colony guards are responsible for checking incomers on the entrance to the colony and for preventing them from entering the colony if they do not belong to the colony . In 37]37], StabOur previous work, named PhishSys, has been presented in  for detePhishing website attacks happen when the victim is directed to the spoofed website using forged URLs. This section describes the agents and algorithm of ScamFree as a proposed framework for phishing attack detection. In particular, ScamFree consists of three main agents: PM agent, UA agent, and DP agent. Further details about ScamFree agents are provided in the following subsections.This agent is used to investigate the suspicious URL by checking if it exists in the blacklist of the PhishTank database. PhishTank is one of the public databases of phishing URLs . The PhiThis agent is responsible for further investigating the content of the URL, which was filtered by a PM agent in the previous phase. Its main aim is to check if the URL contains one of the undesirable features. Ahmed and Sadiq  demonstrhttp://www.legitimate.com//http://www.phishing.com (accessed on 20 February 2018). This feature checks the position of the “//” symbol in the URL. It would mean that the “//” symbol will appear in the sixth place if the URL begins with “HTTP.” However, if the URL requires “HTTPS,” the mark “//” is in seventh place.Several phishing site URLs are inserted in front of the actual URLs. An instance of this is Given the features of the zero-day attack usually not included in the signature databases, a potent defense system should use an alternative strategy to detect the new attacks. The ScamFree framework provides an agent for further investigating a suspicious URL, which does not exist in the blacklist of the PhishTank database, and verifying if that URL is a new phishing website. Checking the whitelist of legitimate URLs, which is the opposite of a blacklist and contains a list of known trusted sites, does this. More details about the anti-phishing methods using a whitelist database are described in . ScamFreThe ScamFree framework is implemented and tested in Google Chrome explorer. Chrome extension allows for adding functionality in Google Chrome without diving deeply into native code. Nowadays, Chrome provides extensions with many purpose APIs for developers to enhance the user browsing experience. This method requires the Chrome platform APIs to perform their function. Those platforms applied in this method are JavaScript APIs Manifest File format and Permission warnings. A JSON-formatted manifest file, named manifest.json, was included as part of the Chrome extension package. The use of JavaScript code is to check the URL link, it either being for a secure page or a genuinely suspicious URL site. The function of checkURL is to send a POST request to PhishTank in order to use their API. The function will then process the returned response and determine whether the page is a verified phishing website or not. The function would then return true if the URL is verified as belonging to a phishing website, and false if not. The PhishTank database is one of the familiar public crowd-sourced databases of phishing URLs, containing blacklist data collection . Upon suThe outcome of this method is displaying pop up alert as the result to notify the user that the targeted website is either a secure page or a suspicious URL site. When the page is safe, Chrome will notify “safe” page only in the console and redirect to the targeted page, which allows the user to continue browsing. If the URL website is suspicious, Chrome will notify the user with pop up alert with message “This is a suspected phishing page!!!” This to make the user aware that the targeted page is a suspicious website that is probably a phishing site, luring the user to give their personal information. For detecting URL phishing websites by using Chrome extensions, the extension is loaded into the user’s browser, as illustrated in The proposed framework, ScamFree, is examined to validate its ability in identifying the spoofing website. To this end, a set of 200 URLs is used, in which 150 are phishing websites and 50 are genuine webpages. The utilized URLs are picked up randomly by PhishTank  and GoogThe obtained result demonstrates that ScamFree classifies 49 of the URLs as genuine websites and the other 151 URLs as phishing websites. The obtained result is illustrated in The performance of ScamFree is evaluated by measuring the accuracy of phishing attack detection and the percentage of false positive alarms. The detection accuracy is measured using Formula (1) as described in .(1)Accufound in . The falfound in .(2)FalsThe results shown in The proposed framework is evaluated in this section by comparison with existing methods, which have been previously discussed in the related work section. The criteria listed in ScamFree detects the phishing websites through three cascading filtration phases, which are performed by the three main agents: PhishTank-Match (PM), Undesirable-Absent (UA), and Desirable-Present (DP). These agents inspect the suspicious URLs using a set of features to ensure that the visited website is genuine. In particular, the suspicious URLs are inspected to discover if they are included in the PhishTank blacklist, any undesirable symbol encompassed within their content, or they are matched with the whitelist of genuine websites. The advantage of ScamFree is its ability to mitigate the limitations of the existing approaches. ScamFree could actively mitigate the high false rate by using several phases of investigation. On the other hand, ScamFree avoids the high overhead against system performance by considering the filtration strategy. In ScamFree, there is no need to investigate all requested URLs, instead, only the suspicious ones that will be filtered and investigated accordingly. Furthermore, investigation of the suspicious URL against the whitelist websites is only required for short-listed URLs to detect the zero-day phishing websites. The findings of this paper have demonstrated our proposed framework’s ability to identify the fake webpages based on their URLs.For future work, we are planning to improve the method of investigating the URL content, which is through the UA agent. Investigation of the undesirable features will be improved using an intelligent method, which will train the framework to detect the undesirable features based on desirable and undesirable patterns.