Shigella transmission, populations at increased risk, or importance of antibiotic susceptibility testing (AST). This study assessed HCP knowledge and clinical practices regarding shigellosis and antibiotic resistance.Shigellosis is an acute diarrheal disease transmitted through contaminated food, water, objects, poor hand hygiene, or sexual activity. Healthcare providers (HCP) may not be aware of the multiple routes of Porter Novelli Public Services administered a web-based survey  to HCP in the United States. Pediatricians, primary care physicians, nurse practitioners, and physician assistants completed questions about knowledge and clinical practice of acute diarrhea and shigellosis.Shigella transmission; fewer recognized person-to-person contact (40%) and sexual activity (18%). Men who have sex with men (MSM) were identified as being at risk for shigellosis by 35% of respondents. Most reported counseling patients to wash hands (86%) and avoid food preparation (77%) when ill with shigellosis; 29% reported recommending avoiding sex. Many HCP reported treating shigellosis empirically with ciprofloxacin (62%) and azithromycin (32%), and 29% reported using AST to guide treatment.Of 2196 HCP contacted, 1503 responded (68% response rate). Most identified contaminated food (85%) and water (79%) as routes of We identified several gaps in shigellosis knowledge among HCP including MSM as a risk group, person-to-person transmission, and appropriate antibiotic use. Improving HCP education could prevent the spread of shigellosis, including drug-resistant infections, among vulnerable populations.The online version contains supplementary material available at 10.1186/s12875-023-02213-3. Shigella genus, infects approximately 450,000 people annually in the United States [Shigella may infect any human host, children 1–10 years of age have the highest rates of culture-confirmed Shigella infection in the United States, and between 2009 and 2018, 54.5% of shigellosis outbreaks occurred in childcare facilities [Shigella can spread through person-to-person contact, food, water, fomites, and sexual contact, and it is one of the most contagious enteric pathogens, requiring as few as ten organisms to cause an infection [Shigella outbreaks reported to the National Outbreak Reporting System (NORS) between 2009 and 2018 were thought to occur through person-to-person contact, and sporadic cases of Shigella are most commonly attributed to person-to-person contact, international travel, and foodborne transmission [Shigella cases in the United States may be water-related [Shigellosis, an enteric disease caused by bacteria of the d States , 2. Althcilities , 4. Othecilities . Shigellnfection . Unlike smission , 6. WateShigella infection experience a gastrointestinal illness with diarrhea, abdominal pain, and occasionally fever, but severe complications can also occur [Shigella isolate. All patients with shigellosis should receive guidance to avoid swimming, food preparation, and sexual activity while ill and practice frequent handwashing [Most people with symptomatic so occur . Testingso occur . Althougso occur –12. If adwashing .Shigella is now considered a serious threat to human health by the Centers for Disease Control and Prevention (CDC) [Shigella isolates tested with AST, 28% were resistant to ciprofloxacin and 44% were resistant to azithromycin [Shigella have been implicated in multiple outbreaks and have been frequently reported among MSM [Antimicrobial resistance is increasing to antibiotics used to treat shigellosis, including fluoroquinolones and macrolides, and drug-resistant on (CDC) . CDC surhromycin . Drug-remong MSM –19. Inapmong MSM .Shigella in their communities. Previous studies have found gaps in HCP knowledge of E. coli and other foodborne bacterial pathogens [Healthcare providers (HCP) are uniquely positioned to take an active part in controlling the spread of athogens –23. The Shigella and acute diarrhea. Obstetricians/gynecologists were not included in this section of the survey due to scope of practice.DocStyles is a web-based survey developed by Porter Novelli Public Services and administered twice yearly to samples of HCP that includes questions about providers’ knowledge of several health issues . The panCDC licenses access to results of the DocStyles surveys post-collection from Porter Novelli. Porter Novelli is not subject to CDC institutional review board review; however, they adhere to all professional standards and codes for market research. Survey respondents were informed that their answers were being used for market research and they could exit the survey at any time. No personal identifiers were included in the data file provided to CDC. This secondary analysis was reviewed by CDC in accordance with CDC policy, pursuant to applicable US regulations.Shigella, including questions about knowledge and perceptions of Shigella transmission and prevention, as well as clinical practice regarding diagnostic testing and treatment (Supplementary Table The DocStyles survey contained 15 questions about acute diarrhea and N = 1287). Likewise, analysis of questions meant to characterize behavior regarding HCP treatment of patients with shigellosis (questions 13–15) were restricted to providers who reported seeing at least one patient per month with laboratory-confirmed Shigella infection (N = 391).The outcomes evaluated were percentages of participants who selected each response option, and the percentages of correct answers for the knowledge-based questions (questions 1–3). For questions 1–3, a correct answer was considered as any answer except “none of the above”. Answer choices were analyzed overall, by demographic characteristics, and by provider specialty. Analysis of questions meant to characterize behavior regarding HCP diagnosis and treatment practices among patients with acute diarrhea (questions 8–11) were restricted to providers who reported seeing at least one patient per week with acute diarrhea .The cohort was described overall and by provider specialty. Frequency of answer choices by specialty were compared using Chi square difference of proportions. Fisher exact tests were used for comparisons in which ≥ 25% of cells were expected to have counts of < 5. Statistical significance was determined at Of 2196 HCP who were eligible to answer questions about acute diarrhea and shigellosis, 1503 HCP completed the survey (68% response rate), primarily consisting of family practitioners and internists , contaminated water (79%), fomite transmission (33%), person-to-person contact (44%), and sexual activity (18%) (Table Respondents correctly identified possible routes of %) Table . Many pr%) Table .Table 2HSexual activity was the least frequently selected route of transmission (18%) and MSM were the least frequently identified group at-risk for shigellosis (35%). Approximately one third of providers endorsed encouraging their adult patients with shigellosis to avoid sex. Among 1,042 providers who see adult patients with acute diarrhea at least once weekly, 22% report asking about sexual practices upon the initial consult, and 10% provide sexual health education. The most common barrier to discussing shigellosis with patients was that shigellosis is often diagnosed after the patient encounter has ended (32%). Less frequently perceived barriers included lack of time (17%) and lack of access to educational resources (17%).Shigellosis knowledge varied by provider specialty; more pediatricians identified children as an at-risk population compared with others (78% compared with 49–57%), while more internists correctly identified MSM as an at-risk population (40% compared with 27–35%). In addition to provider specialty, age was found to be associated with shigellosis knowledge. More HCP aged 45–64 years chose all correct answers for knowledge-based questions compared with providers in younger or older age groups.Among 1287 HCP who reported seeing patients each week with acute diarrhea, 29% reported routinely using a culture-independent diagnostic test and 64% reported routinely requesting a stool culture, 20% of whom reported routinely requesting AST Table . EighteeShigella compared with HCP treating patients presenting with acute diarrhea. Among 391 providers who regularly treat patients with confirmed shigellosis, 52% usually prescribe antibiotics to returned international travelers with shigellosis; similarly, 47% of providers who regularly treat patients with acute diarrhea prescribe empiric antibiotics to international travelers with acute diarrhea. A higher proportion of HCP report prescribing antibiotics for children (38% vs 10%), MSM (30% vs 14%), hospitalized patients (56% vs 33%), or other adults (47% vs 18%) diagnosed with Shigella infection, the most commonly reported antibiotics were fluoroquinolones  (67%), followed by scientific articles, textbooks, or professional organizations (45%), and AST results (39%)  Now: Human Data” platform provides updated antibiotic resistance surveillance data for many enteric pathogens at the national and state level and can be utilized by HCP when they are considering treatment options for patients with shigellosis [Emerging resistance to first-line drugs threatens available treatment options , 16, 35 nfection , 36. Altnfection , given hnfection , HCP shogellosis ., as disease severity and geographic distribution varies among different species of Shigella and may impact testing and prescribing practices [This study is subject to several limitations. First, the cross-sectional survey design, which asks about one point in time, may not represent HCP practice over time and could be impacted by several factors, including recent patient encounters, recent shigellosis outbreaks, testing availability, survey fatigue, and disruptions to the healthcare system during the COVID-19 pandemic. Similarly, social desirability bias may have influenced the results, as the source of information was self-report; however, antibiotic use reported in this study was consistent with previously described prescribing practices . The surractices , 30. AltShigella infection. However, this study suggests that providers’ knowledge of shigellosis transmission, risk groups, and treatment considerations could be improved by focused educational initiatives. Specific gaps in knowledge were identified surrounding MSM populations and risk of transmission through person-to-person contact. HCP, especially those providing care to individuals at increased risk of shigellosis, can contribute to stopping the spread of this infection in vulnerable populations by improving their knowledge of shigellosis transmission, prevention, and treatment.Healthcare providers are essential in the prevention and control of shigellosis in the United States as they diagnose, treat, and educate those with symptomatic Additional file 1.


Over the last two decades a growing number of neuroscience labs are conducting behavioral assays in rodents. The equipment used to collect this behavioral data must effectively limit environmental and experimenter disruptions, to avoid confounding behavior data. Proprietary behavior boxes are expensive, offer limited compatible sensors, and constrain analysis with closed-source hardware and software. Here, we introduce PiE, an open-source, end-to-end, user-configurable, scalable, and inexpensive behavior assay system. The PiE system includes the custom-built behavior box to hold a home cage, as well as software enabling continuous video recording and individual behavior box environmental control. To limit experimental disruptions, the PiE system allows the control and monitoring of all aspects of a behavioral experiment using a remote web browser, including real-time video feeds. To allow experiments to scale up, the PiE system provides a web interface where any number of boxes can be controlled, and video data easily synchronized to a remote location. For the scoring of behavior video data, the PiE system includes a standalone desktop application that streamlines the blinded manual scoring of large datasets with a focus on quality control and assay flexibility. The PiE system is ideal for all types of behavior assays in which video is recorded. Users are free to use individual components of this setup independently, or to use the entire pipeline from data collection to analysis. Alpha testers have included scientists without prior coding experience. An example pipeline is demonstrated with the PiE system enabling the user to record home cage maternal behavior assays, synchronize the resulting data, conduct blinded scoring, and import the data into R for data visualization and analysis. Modern neuroscientific tools have enabled the manipulation of molecular and cellular function to then evaluate the effect on behavior. As the acquisition and analysis of awake and freely moving behaviors become more widespread, video capture becomes a critical mode of data collection in neuroscience.The acquisition of this behavioral data introduces a number of challenges that must be overcome. It is now well established that environmental disruptions and experimenter presence can contaminate behavioral assays . There iMany commercially available home cage behavioral systems are available, yet, these are often expensive, difficult to scale, and provide limited flexibility to incorporate the requirements for a particular behavioral experiment. As an alternative, a growing number of custom-built home cage monitoring systems have been developed . One strOnce behavioral data is collected, it must be analyzed to extract the desired measurements and metrics required for a given assay. To achieve this, there are a growing number of video annotation software systems (See review: Here we present PiE (a Raspberry Pi Experiment), an open-source and user-configurable home cage behavior pipeline from video capture to scored behavior for researchers with little to no programming experience. This system is inexpensive to build, will work equally well for just one home cage, and will scale easily to any number of home cages. A key advantage of this system is that the open-source software and accessible hardware affords the user flexibility to expand the behavior box function to meet the customized goals of their experiments. Using the provided browser-based software, the PiE system reduces environmental and experimenter disruptions by providing fully remote control and monitoring of home cage behaviors. Finally, the provided desktop GUI video annotation software, VideoAnnotate, streamlines manual and unbiased annotation of video recordings.To test the PiE pipeline, we examined a complex social behavior by acquiring video recordings and then analyzing maternal behavior of mouse dams from two inbred mouse lines and their pups over the course of weeks using eight behavior boxes, recording simultaneously. Our PiE pipeline provides a robust end-to-end system for a range of behavioral analyses.ad libitum.All animals were DBA/2J  or C57BL/6 J  mice obtained from Charles River. Females (6–8 weeks old) used in behavior experiments were bred to males (8–10 weeks old) of their same strain. Female mice were group housed before and after breeding until approximately E17, when they were moved to single housing in a behavior box home cage prior to birth. All experiments were approved by the Animal Care and Use Committees of Johns Hopkins University. Animals were housed on a 12:12 light/dark cycle. Food and water were available Behavior boxes were designed to enclose standard mouse cages (maximum of 5 mice per cage). The box was constructed with an aluminum frame  and plastic walls . Each box was equipped with a hinged door on the front, large enough to accommodate the cage and water bottle. Holes were drilled in the walls of the box to allow wires for sensors and actuators. Care was taken to make the boxes light tight and gaffer tape  was used when necessary.For our experiments, we included a number of sensors and actuators. Additional experimental components can easily be added as needed. We included (1) a ceiling mounted, downward facing, infrared (IR) video camera (Pi NoIR) to allow both daytime and nighttime video recording, (2) white and IR LEDs to illuminate the behavior box , (3) a temperature and humidity sensor, and (4) a circulating fan for climate stability. The IR camera has a flex cable connecting it directly to the Raspberry Pi computer. The white and IR LEDS as well as the fan were powered via a quad-channel relay allowing them to be independently turned on and off by the Raspberry Pi computer. The tops of the home cages were replaced with a clear acrylic panel to provide an open field of view and improve the quality of the video recording. Mirrors were placed on either side of each mouse cage to allow the ceiling-mounted camera to capture side view video as well. These strategies greatly improved the over-all video quality and allowed the precise scoring of complex maternal behaviors.We used boxes of approximately 24” W × 24” D × 24” H, but strongly recommend setting up the mouse cage, water bottle, and mirrors to confirm width and length dimensions. Likewise, we recommend setting up the ceiling mounted IR camera to determine the video field-of-view before deciding on the height of the box.All components including suppliers, price, and additional notes are provided in Materials and Equipment .Each behavior box had a dedicated Raspberry Pi computer  to control the sensors and actuators within the box and to provide a web- and file- server to remotely control the experiment. Each Raspberry Pi computer included the computer itself, a 5 V/2A AC/DC power adapter, a 16–32 GB micro SD card for the operating system, a 64–256 GB USB thumb drive to locally store recorded files including video, and an ethernet cable. Each computer also had a ribbon cable to connect the camera to the computer . One dedicated Raspberry Pi computer was attached to the back side of each behavior box.Each Raspberry Pi computer used the Raspberry Pi OS operating system (version Buster). This OS is based on the Debian operating system which provides stable and efficient operation, making it well suited for the demands of long behavioral experiments and running on low-cost hardware such as the Raspberry Pi.All software is open-source and available on GitHub.We implemented custom software to control all aspects of a behavioral experiment. This software runs on a Raspberry Pi computer and once the hardware is configured can be installed with simple to use installation scripts. Implemented with a client/server architecture with a backend written in Python, a webserver (Flask), and a frontend web interface written in Javascript. We provide a point and click graphical user interface (GUI) that can run in any web-browser including on desktops, tablets, and smart-phones. All aspects of the software can be configured and controlled through a RESTful application-programming-interface (API) using Uniform Resource Locators (URLs) directly from a browser or with a programming language such as Python, R, or Matlab. Video acquisition to save files was implemented with the PiCamera Python package and video streaming was achieved using the UV4L software. Video files are initially saved in the h264 format and automatically  converted to the mp4 video file format. A half-hour video at 1296 by 972 resolution with 30 frames per second creates a file just under 3 GB. With this file size, approximately 42.6 h of video can be stored on a 256 GB USB drive.One important consideration when acquiring video with a Raspberry Pi camera is the possibility of dropped frames during a recording. For our maternal behavior video recordings, this was not an issue as the behaviors are relatively slow and dropped frames do not affect our analysis or results. If one seeks to use this system to record fast behaviors such as whisker movements or forepaw reaching, then dropped frames could potentially impact the analysis and results.The Swarm software is designed to provide a web interface for the control of all aspects of any number of behavior boxes equipped with a Raspberry Pi running the PiE server software. All functionality of one behavior box with a PiE server is included in the Swarm software. The Swarm software can be run on any remote  computer including Raspberry Pi, macOS, and Windows operating systems. The Swarm software connects to individual PiE servers over the internet or a local area network (LAN) and itself provides an easy-to-use web interface.The Swarm software will automatically  copy recorded video files from the Raspberry Pi to a remote analysis machine for further analysis and safe storage. Thus, video can be recorded continuously for an arbitrary amount of time, regardless of the local storage limitations on a Raspberry Pi. In addition to full experimental configuration and control, the Swarm software allows experimenters to review recorded files and view real-time live video streams. With this design, fully remote control and review is possible, thus reducing potentially confounding experimenter interaction with animals and allowing experiments to be controlled from remote locations such as other labs, while at home, or even abroad.Once installed on a local or remote computer, the Swarm software runs a web-server (Flask) and provides a point-and-click GUI in a browser (JavaScript). All communication with individual PiE servers is through their built-in RESTful API.We have implemented desktop software, called VideoAnnotate, to perform behavioral analysis. Importantly, VideoAnnotate will work with any video, it is not dependent on video acquired with the PiE server software. At its core, VideoAnnotate provides video playback including play, pause, playback rate, and random access to any time within the file. As video is reviewed, the keyboard is used to indicate the start and stop of any number of different behavioral events. Point behavior event markers are also provided. All events within a video are presented in an intuitive GUI for review and curation. For example, clicking on an event will play the video corresponding to just that event.A key design feature of the VideoAnnotate software is that it includes a randomization algorithm to reduce experimenter bias. This also allows random sampling of longer videos to reduce analysis time while not losing statistical power. In addition, this randomization is important because behavior often depends on the sequence of events such as ‘just placed in a cage’. By presenting the video in a random sequence of Chunks (see below) to the analyzer, we reduce bias as the analyzer does not know the sequence of events they are viewing. Once analyzed, all VideoAnnotate events are saved as a comma-separated-value (CSV) text file that can easily be opened and further analyzed with custom analysis scripts in almost any language.As an example, we divided video files for our behavioral experiments into three Pieces of 10 min each, then 10 Chunks of video (10 s/Chunk) from each Piece were randomly selected, to total 30 Chunks of behavior video analyzed per 30-min recording. With this system, a 30-min behavioral video can be analyzed blind, while only having to score 5 min of video. These parameters are all user-configurable in the VideoAnnotate desktop application.Lactation day 0 (LD0) was demarcated as the first day live pups were seen in the cage by 12 PM. Behavior experiments were conducted on Lactation Days 1, 3, and 5  during the first hour of the light cycle from 09:00–10:00 AM. Immediately prior to the Maternal Behavior Test, the mouse dam was removed from the cage and placed in a clean separation chamber for 15 min. The cage was then cleaned, and food and water removed for the assay. Just before the start of the assay, the pups were returned to the cage and placed in the three corners opposite a new nestlet. The video recording was begun at the dam’s moment of return to the cage, which commenced a 30-min video capture period.The 30-min Maternal Behavior Test video was scored blind, consistent with standard maternal behavior testing . Nine paAll behavior data was analyzed using the Wilcoxon Rank Sum Test, a non-parametric test of distribution differences in continuous data between two groups.The PiE system allows for the monitoring and recording of mouse behavior while housed inside a home cage. Each home cage is enclosed within a behavior box. The individual behavior box design enables individualized light:dark cycle control, isolates behaving mice from neighboring cages, and reduces mouse exposure to the experimenters. Early versions of the PiE system were successfully used to monitor home cage wheel running  and actiThe PiE system is modular, starting with an individual behavior box, its sensors and actuators, and a dedicated Raspberry Pi computer running the PiE server software . BecauseTo scale up a behavioral experiment, one needs to include any number of behavioral boxes such that independent measurements can be made simultaneously over a large number of individuals, or in our case, mouse dams (mothers) with their pups. To achieve this, we implemented the Swarm web interface to remotely control any number of boxes running the PiE server software . The SwaThe web interfaces, including the PiE server and Swarm interfaces, can be accessed using several different network topologies. In one topology, all computers are connected to the same residential router to create a LAN. In another topology, all computers are connected to an information-technology (IT) managed network. If working in an environment where the network is managed by IT (such as a college or university), all PiE server computers need to be authenticated on the network which normally must be performed by IT.We constructed light-proof boxes with off the shelf components designed to enclose a home cage ,B. Each To ensure stable temperature and humidity within the enclosed (light tight) behavior boxes, we implemented a system of cooling fans and lightproof air vents. By continuously measuring temperature and humidity (using the PiE server software), we were able to ensure a stable environment.The PiE system is a software pipeline that takes a behavioral experiment from raw data collection, to data organization and storage, to final analysis and plotting of the results. Here we describe each piece of this modular design including (i) PiE server software, (ii) Swarm software, and (iii) video annotation software.This software runs on an individual Raspberry Pi computer and provides both a web- and file- server. Throughout the development of this system, we performed extensive testing and modifications to ensure it performs reliably and that it captures the general needs of a remotely controlled behavioral experiment. The provided web interface allows all aspects of the behavioral data acquisition to be remotely controlled . This inAs video and sensor data is acquired, it is saved locally on the dedicated Raspberry Pi computer attached to each behavior box. The PiE server software provides additional web interfaces to monitor this information and download it to a remote analysis computer. This includes a web interface to download recorded video files and textual logs of sensor data such as temperature and humidity . FinallyThe PiE server software implements a web-based API to provide access to all its functions. This is called a RESTful API and basically provides a set of URLs to get and set all data and features of the provided web GUI. This includes an API to, for example, start and stop video recording, control actuators such as LEDs and fans, and to download acquired data. With this API, others can extend the capabilities of the PiE server software by creating customized scripts to implement novel behavioral data acquisition and control of the sensors and actuators included in the behavior box.Once an individual behavior box is configured and controlled with the PiE server software, a key feature of our pipeline is to extend this functionality to any number of behavioral boxes. This is achieved with the Swarm software that allows full control of any number of PiE servers to be remotely controlled . The SwaA key feature of the Swarm software is its ability to copy all raw data from any number of PiE servers to a remote analysis machine. This can be done while other experiments are running on the PiE servers and has an alarm-clock feature such that files can be automatically transferred at a given time or times per day. This is a requirement of our behavioral pipeline as just using 8 behavior boxes, we found manually collecting all the raw video data was tedious and error prone.For the analysis of the raw video recorded and organized by the PiE server and Swarm software, we provide a desktop GUI for video annotation and scoring . Unlike The video annotation software is designed for the manual scoring of events within a recording. As the video is played, keyboard shortcuts allow the user to mark the beginning and ending of different behavioral events. This interface also allows the user to mark single time point behavioral events. All events are tallied and displayed in a GUI resembling a video editor interface.Because behavioral experiment analysis has the potential for experimenter bias, the video annotation software includes a randomization algorithm . For exaAll behavioral events are saved as CSV text files which facilitate additional analysis and plotting by end users in any number of scripting languages. Importantly, the video annotation software does not require video to be acquired with the PiE server, it is designed to open, display, and analyze several common video formats including mp4.To demonstrate the flexibility of the PiE system, we collected and analyzed home cage data using maternal behavior tests, a complex social behavior requiring simultaneous scoring of many behaviors  but also components designed by other researchers and made available on public resources such as OpenBehavior and Hackster. By choosing the Raspberry Pi as the main hardware controller, this is also open-source and extendable as the not-for-profit Raspberry Pi foundation is dedicated to educating new and seasoned users in using their computers and associated software.Behavioral analysis is often fraught with reproducibility errors. This is partially due to small sample sizes but also attributed to unintentional changes in an animal’s environment including interactions with the experimenter and neighboring researchers and moving animals to a novel and stressful environment. It is important that confounding variables be reduced, controlled, and eventually abolished. With the PiE system, we have addressed these concerns by keeping mice in their home cage in a dedicated environmentally controlled box that is remotely controlled through a web-browser, allowing the experimenter to be in another room, out of earshot. An additional concern is that the Raspberry Pi computer, sensors, actuators, and other electronic equipment may produce sound that could disrupt mouse behavior. Depending on the experimental needs, the PiE system is a platform where these potential confounding sources of noise can be measured and then a new version of the system can be iterated where they are controlled.Our behavioral analysis of recorded video is manual. While machine learning algorithms for scoring maternal behavior and other complex social behaviors are continuously improving, for many experiments the data scale and time required to train a machine learning algorithm is not efficient. For example, an 87% accuracy with machine learning algorithms to identify pup retrieval may not be sufficient . AgreemeWe have used the PiE system to record and analyze maternal behavior, a complex social behavior. Due to the sensitivity of rodent dams to stress , maternaTaken together, the PiE system is an end-to-end behavior pipeline from home cage animal housing, to data capture and management, to behavioral scoring and analysis. Its modular design allows others to extend any component including the design of behavioral boxes, environmental control, behavior box data acquisition, and behavioral analysis of recorded video. These features make this open-source, remotely controlled, and user-configurable rodent behavior pipeline a logical choice for a low cost, flexible, and easy to use behavioral analysis pipeline.https://github.com/cudmore/pie.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found at: JB and RC designed and implemented all aspects of the project. RC wrote all server code. JB performed behavioral experiments. All authors contributed to manuscript revision, read, and approved the submitted version.RC was supported by the NIH (1RF1MH123206).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.


Blinding drugs through simulation techniques is an important means to control the subjective bias of investigators and subjects. However, clinical trials face significant challenges in the placebo production of drugs, and many trials cannot be double-blinded.This study was conducted to ascertain the consistency between non-blind and blind evaluation results in clinical trials and to pioneer strategies to control information bias, particularly in trials where double-blinding is not feasible.In this investigation, a randomized controlled trial (RCT) studying diabetic foot infections (DFIs) was utilized as a representative case. In this trial, the grading of DFIs, as per guidelines by the Infectious Disease Society of America (IDSA) and International Working Group on Diabetic Foot (IWGDF), was used as the primary efficacy indicator. A sample of sixteen patients was randomly chosen from the RCT, and DFI grading was assessed jointly by both non-blinded investigators and blinded center-reading investigators. A consistency test was then deployed to compare the evaluation results, forming the basis for our proposed strategies for effective blinded evaluation. In addition, other perspectives were collected at the end of this study, including with those involved in designing and conducting the recent blinded evaluation trial.p=0.384). In the experimental group, three cases were judged as grade 1 in the non-blinded evaluation and grade 2 in the central reading blinded evaluation; in the control group, three cases were judged as grade 2 in the non-blinded evaluation and grade 1 in the central reading blinded evaluation. The sum of these two cases in 22 post-treatment determinations was 27% (6/22). Furthermore, researchers propose several strategies for implementing blinded evaluations in clinical trials after this trial, which encompass aspects such as staff allocation, training, participant management, trial drug administration, efficacy indicator collection, and safety event management.Five subjects were excluded due to the quality of photos or the lack of post-treatment visits. The post-treatment IDSA/IWGDF grading results were compared in 11 subjects , and the consistency test showed inconsistent results between the non-blinded and center reading blinded evaluations (Kappa=0.248, The study highlighted that evaluations from non-blinded site investigators may potentially exaggerate the efficacy of the experimental group and that deep wounds can present challenges for observation via center-reading photos. These findings underline the vital necessity for objective assessment in open clinical trials, especially those where wound observation serves as the primary efficacy indicator. The study suggests the adoption of independent blinded investigators at each site, complemented by a comprehensive set of standard operating procedures for blinding evaluation. These measures could serve as an effective counterbalance to subjective bias, thereby augmenting the credibility and consistency of results in open clinical trials. The implications of these findings and recommendations could be of great significance for the design and execution of future open clinical trials, potentially bolstering the quality of clinical research in this area.ChiCTR2000041443. Registered on December 2020The online version contains supplementary material available at 10.1186/s13063-023-07652-y. The application of the most reliable evidence to address individual clinical issues underpins the core principle of evidence-based medicine . The rigHowever, due to the particularity of certain interventions, it becomes challenging to blind participants and investigators in some clinical trials. Recent investigations have highlighted that traditional Chinese medicine (TCM) clinical trials encounter significant obstacles in placebo production, rendering some medications unsuitable for double-blind controlled trials , 6. In rIn this study, we use an open randomized controlled trial of TCM as an example to compare the outcomes of unblinded and blinded evaluations. Furthermore, we propose several strategies for implementing blinded evaluations in clinical trials, which encompass aspects such as staff allocation, training, participant management, trial drug administration, efficacy indicator collection, and safety event management.A multicenter RCT on diabetic foot infections (DFIs) was taken as an example. This trial evaluated the efficacy and safety of a Chinese patent medicine. Patients with DFI, aged between 18 and 75 years, and IDSA/IWGDF grade 2 were included . The degThere is a greater risk of using a placebo control for patients in this trial. Furthermore, placebos are challenging to match the investigational drug in terms of color, texture, and odor . ExperieTo ensure the objectivity and consistency of the test results, using objective evaluation methods to evaluate the efficacy indicators is necessary. We envisioned a blinded evaluation of efficacy indicators using a center-reading blinded method. The center-reading blinded method refers to using a digital camera to take pictures of the condition of the subject’s foot and using the image analysis software ImageJ to analyze the trauma area. We compared the differences between unblinded and center-reading blinded evaluations to investigate whether this method better reflects an accurate picture of efficacy. In addition, other perspectives were collected at the end of this study, including with those involved in designing and conducting the recent blinded evaluation trial.N=16, Nexperimental group VS Ncontrol group = 1:1). The study evaluators were divided into non-blinded and blinded investigators who performed the evaluation were associate chief or chief vascular surgeons. And the blinded investigators consisted of three clinicians who were not involved in the clinical study. All unblinded and blinded investigators in this study received training in IDSA/IWGDF grading.This was an exploratory study, and we randomly selected only about 10% of the completed clinical trial subjects for blinded and unblinded evaluations  were referenced .P ≤ 0.05 will be regarded as significant. A 95% confidence interval will be utilized. The Kappa consistency test will assess the results of the non-blind and blind evaluations, and the inferential statistics  will be displayed as descriptive results.An independent statistician will carry out statistical analysis using the SPSS 25 software. All statistical tests will be two-sided, Among the 16 randomly enrolled patients, one was excluded due to a lack of post-treatment follow-ups, and 4 were unable to be analyzed as the central reader could not discern the deeper parts of the wounds from the photographs. The randomization and follow-up process for patients is illustrated in Fig. P=0.384). Subsequent comparisons of post-treatment IDSA/IWGDF gradings were carried out within the experimental and control groups separately.The post-treatment IDSA/IWGDF gradings were compared across 11 subjects, revealing inconsistencies between non-blinded and center-reading blinded evaluations according to the consistency test .Within the experimental group, three cases were deemed grade 1 by the non-blinded evaluation and were rated grade 2 by the center-reading blinded evaluation. Inconsistencies were also observed within this group between non-blinded and blinded evaluations . Detailed information is provided in Tables In the control group, three cases considered grade 2 in the non-blinded evaluation were rated as grade 1 in the center-reading blinded evaluation. Here too, inconsistencies between non-blinded and blinded evaluations were detected  for blinded evaluation. The ensuing considerations for blinded evaluation are explored from three perspectives: safeguarding participants' rights, minimizing bias, and optimizing clinical operability.We advise establishing clearly delineated roles among the research team, which may include treatment investigators, blinded evaluation investigators, research nurses, quality control officers, medication administrators, and documentation managers.The investigator responsible for efficacy evaluation remains blinded throughout the study, while all other personnel are unblinded. Staff roles should be defined and authorized prior to the trial  the treatment investigator and study nurse should remove all dressings, document any purulent discharge from the wound, and perform routine disinfection and cleaning of the wound; (ii) the study nurse should then notify the blinded evaluation investigator; and (iii) the blinded evaluator should proceed with the efficacy evaluation and capture the necessary photographs.The responsibility for collecting and assessing safety events in this study fell to the blinded investigator, who made determinations of causality based on the five principles of adverse event-drug causality assessment . In the In the present study, there were two independent evaluations of each subject at different time points of the visit after treatment, which can be considered a sample size of 22. If we assume that Kappa=0.7 represents a better agreement, while we evaluated the blinded and non-blinded state, we found Kappa=0.248 (about 0.25). With α=0.05, proportions=0.4, 0.6, and according to the above parameters, we used PASS 22 to calculate power=0.75. The findings from our study suggest that even with a relatively small sample size, the outcomes are notably indicative of similar future investigations.p=0.384). In the experimental group, three cases were judged as grade 1 in the non-blinded evaluation and grade 2 in the central reading blinded evaluation; in the control group, three cases were judged as grade 2 in the non-blinded evaluation and grade 1 in the central reading blinded evaluation. The sum of these two cases in 22 post-treatment determinations was 27% (6/22), and the results suggest that the non-blinded determination may have a subjective bias to exaggerate the efficacy of the test group. This is consistent with the results reported in several previous studies [The current study showed that the post-treatment IDSA/IWGDF grading results were compared in 11 subjects, and the consistency test showed inconsistent results between the non-blinded and center reading blinded evaluations  for blinded evaluation should be implemented. We have described above the basic requirements for blinded evaluations by setting up standard processes: separation of duties for investigators, subject management, collection of efficacy and safety indicators, and management of trial drugs. In some studies, when scientificity and operability permit, we propose that blinded evaluation can be conducted by taking photos and centralized evaluation by an independent evaluation committee to ensure the objectivity and consistency of the results. For some of the objective result data  for which there is a risk of blinding, we suggest that blinded management can be used, where the personnel blinded to the evaluation of efficacy and safety indicators are not exposed to these data results. Meanwhile, research team members at the back of the data chain  should also be in a blinded state to reduce bias. Research quality control personnel should follow the PDCA cycle model  for all phases of quality management-related work. Through the above process, ensure the maintenance of blinded evaluation throughout the trial and improve the quality of open clinical trials.Although we have proposed various measures to mitigate bias in open clinical trials, further exploration and innovation are necessary to enhance the reliability of trial outcomes. For instance, introducing objective efficacy evaluation tools, like sensor-equipped insoles, can provide unbiased, quantifiable data . In addiDespite these strengths, our study is not without limitations. The relatively small sample size may raise questions about the reliability of the results. Future research should validate our findings with larger sample sizes and further explore the best practices for maintaining blinded evaluation in clinical trials.In open clinical studies, minimizing information bias represents a significant challenge. Our findings indicate that implementing blinded evaluations can effectively reduce information bias, thereby ensuring the authenticity and reliability of trial outcomes. We strongly advocate for the appointment of an independent blinded researcher at each trial site and the implementation of a series of standard operating procedures (SOPs) for blinded evaluations. For this purpose, we propose a comprehensive set of SOPs encompassing divisions of labor among researchers, subject management, collection of efficacy and safety indices, and trial drug management. By doing so, we aim to achieve effective blinded evaluations and enhance the quality of open trials to the greatest extent possible.Importantly, our study provides a practical strategy for future clinical trials to mitigate potential biases, thereby strengthening the evidence base for clinical decision-making.Additional file 1. Study Center Grading Results Evaluation Form.


People often try to improve others’ emotions. However, it is unclear which interpersonal emotion regulation strategies are most effective and why. In 121 candid dyadic conversations between undergraduate students via video conferencing, target participants recounted a stressful event to regulator participants. Three strategies used by regulators during these conversations to change targets’ emotions were obtained from the regulator after the conversation: extrinsic reappraisal, extrinsic suppression, and extrinsic acceptance. Perceived regulator responsiveness was obtained from targets to examine the social consequences of extrinsic emotion regulation and its mediating role in successful extrinsic emotion regulation. We found that regulators’ extrinsic reappraisal use was associated with improved target emotions measured across two distinct classes of outcomes: targets’ emotions during the conversation and targets’ perception that the regulator improved their emotions. Regulators’ extrinsic suppression and acceptance, in contrast, were not related with improved target emotions or perceptions of improvement. Instead, all extrinsic regulatory strategies were associated with improved targets’ emotions when mediated by targets’ perceptions of regulator responsiveness. Finally, observer-ratings of regulators’ extrinsic reappraisal and suppression use were found to be consistent with regulators’ self-ratings and follow the same pattern of results on the outcome measures. These findings provide insight into why the social regulation of emotions can succeed or fail and hold implications for interventions aimed at guiding people toward more successfully improving others’ emotions.The online version contains supplementary material available at 10.1007/s42761-023-00183-4. Overwhelmed with his new job, Tyler divulges his fears and doubts to his coworker Rebecca. Tyler fears failing the people who gave him this job opportunity, and he doubts that he can keep up with the accumulating workload. When Rebecca hears about his distress, she considers using three different strategies to help him. She could remind him that many people struggle at first in a new job, so it is okay to feel this way , she could scold him for being so negative at work because it looks bad for him , or she could suggest that he reframe his situation as a learning experience in which it is okay to make mistakes . Ultimately, she chooses the latter strategy, which proves effective in easing Tyler’s negative emotions.This example highlights the importance of interpersonal emotion regulation, a process in which one person’s emotions are regulated by another person  as in the case of the social sharing of emotions Rimé,  or may bSimilar to intrapersonal cognitive reappraisal which works through the reinterpretation of an emotion-eliciting situation Gross, , 2015, eWhen using extrinsic suppression, a regulator signals for a target person to hide their emotion expression through indirect means  or direct means . By suppressing a target’s expressions of negative emotions, a regulator may improve a target’s emotions by preventing detrimental social behaviors such as co-rumination Boren,  or ventiIn the case of extrinsic acceptance, we conceptualize this strategy as one in which a regulator embraces the emotions of the target without attempts to control the target’s emotions which may or may not result in the target also accepting their own emotions. Extrinsic acceptance may result in greater emotion awareness and expression ; these instructions/signals can influence the target’s cognitions and regulatory actions, potentially improving the target’s emotions. For example, a regulator may try to help a target downregulate their negative emotions due to a recent breakup by telling them that they “will regret” feeling like this later . For instance, if extrinsic reappraisal is associated with worse perceived regulator responsiveness, we would also expect it to be associated with worse target affect. To determine target emotion improvement, we measured two types of outcomes from the targets: their emotions during the conversation and their perception of the regulators’ success at improving how they feltf = 0.3 with 80% power. We thus aimed to collect data from at least 120 dyads and more if possible, terminating data collection at the conclusion of the academic quarter. Twenty-six participants were excluded due to internet connectivity issues or other technical issues during the study. Four participants were excluded due to knowing the other participant in the dyad. All other participants were paired with stranger participants. The final sample consisted of 242 participants .Two hundred seventy-two undergraduate students at the University of California, San Diego participated in this social interaction study in same-gender dyads. Participants received course credit. A power analysis, using G*Power, indicated that a sample size of 120 dyads (40 dyads per cell) would be sufficient to detect a medium effect size of f2 = 0.08 with 80% power.Within each dyad, one participant was randomly assigned a regulator role, and the other participant was assigned a target role. To examine questions about extrinsic emotion regulation, we used multivariate linear regression models to determine the extent that independent variables from the regulator participants influenced the dependent variables from the target participants. A sensitivity analysis using G*Power indicated that for a two-predictor linear regression model, the present sample size of 121 dyads would be sufficient to detect a small effect size of We originally intended a between-subject design with three extrinsic prohedonic goal conditions for the regulator participants . However, the manipulation of regulator goals was deemed to have failed because it did not influence regulators’ self-reported goals or their use of extrinsic emotion regulation strategies . Given this, and because of the rich nature of the dataset, which involved real, ecologically valid extrinsic emotion regulation actions that participants self-generated to improve targets’ emotions alongside measurements from both dyadic members, we decided it was most appropriate to analyze the data based on participants’ natural variability in interpersonal emotion regulation actions collapsing across the originally intended manipulation.https://osf.io/kazep/.Data, code, and online supplemental materials are available on OSF at To get comfortable with the experimental environment and with each other, each pair of participants first interacted together in a 5-min fast friends task  nor did they significantly predict any of the outcome measures . After these instructions were given, the target was moved to a private Zoom breakout room for 5 min to brainstorm what they wanted to discuss during the stress sharing conversation.For the stress sharing conversation, participants were randomly assigned to be the regulator or the target. In the instructions given to the participants, the regulator was referred to as the friend, and the target was referred to as the sharer to minimize any demand effects. Both participants were told that the role of the target is to speak about a stressor they are experiencing in their life right now, to discuss the details of why that experience happened, and to share how they feel. The stressor could include anything they perceive to be stressful at work, school, or home. Then, both participants were told that the role of the regulator is to talk with the target about that stressor. All regulators were given the goal to have a natural conversation with the target participants, and they were encouraged to share their thoughts and impressions, give advice, and ask questions. Participants who were not in the control condition were also told to either increase the positive emotions or decrease the negative emotions of the target participants. Compared to the control condition, these instructions did not successfully change regulators’ extrinsic prohedonic goals (Regulators rated the following three extrinsic emotion regulation strategies that they used to manage the emotions of targets during the stress sharing conversation on 1 (strongly disagree) to 7 (strongly agree) scales: extrinsic reappraisal  to 5 (strongly agree) scales (“The other participant succeeded in making me feel more positive emotions” and “The other participant succeeded in making me feel less negative emotions”). In figures and tables, these two items are referred to as extrinsic positive emotion upregulation and extrinsic negative emotion downregulation, respectively.Targets rated the responsiveness of the regulators using adapted items from the Perceived Partner Responsiveness Scale  to 5 (strongly agree) scales.Both regulator and target rated their closeness and their motivation to affiliate at the end of the conversation. Closeness was measured using the Inclusion of Other in Self scale  to 5 (strongly disagree) scale.Regulators rated to what extent they believed they successfully improved the targets’ positive and negative emotions on 1 (strongly disagree) to 5 (strongly agree) scales (“I succeeded in making the other participant feel more positive” and “I succeeded in making the other participant feel less negative”).In order to account for targets’ emotions potentially influencing the regulators’ extrinsic strategy choices, at the beginning of the study, targets rated how much they felt positive and negative affect in general (in their daily life) on 1  to 5 (very much) scales. The five items for the positive emotion composite (α = .74) were “proud / good about yourself,” “compassionate / sympathetic / touched,” “grateful / appreciative / thankful,” “inspired / uplifted / elevated,” and “happy / pleased / joyful.” The six items for the negative emotion composite (α = .85) were “angry / irritable / frustrated,” “anxious / nervous,” “distressed / upset,” “guilty / embarrassed / ashamed,” “sad / down,” and “resentful / bitter / annoyed.”We obtained observer ratings of regulators’ strategy use from three trained behavioral coders. Behavioral coders watched videos of the entire conversation and rated both extrinsic reappraisal and extrinsic suppression on 1  to 5 (behavior is very frequently present) scales . We assessed inter-rater reliability on 13% of the data for extrinsic reappraisal (ICC = .75) and extrinsic suppression (ICC = .78). Six dyads were excluded due to improper recording or uploading of the video data.Additionally, we attempted to obtain observer ratings of two forms of regulator extrinsic acceptance: regulators attempt at accepting the targets’ emotions (measured through self-report) and regulators attempt to lead the targets to accept their emotions (not measured through self-report). Due to low inter-rater reliability, we did not proceed with coding these variables.b = 0.32, t(119) = 3.72, 95% CI , p < 0.001, and at downregulating their negative emotions, b = 0.21, t(119) = 2.32, 95% CI [0.03 0.39], p = .022.First, we tested the relationship between regulator extrinsic reappraisal use and extrinsic emotion improvement using univariate linear regression models without control variables  = 2.69, 95% CI , p = .008, and less negative emotion, b =  − 0.12, t(119) =  − 2.47, 95% CI , p = .015, during the stress sharing conversation.Then, we tested the relationship between regulator extrinsic reappraisal use and target emotions using univariate linear regression models without controls. When regulators used more extrinsic reappraisal, targets experienced significantly more positive emotion, b =  − 0.32, t(117) =  − 2.04, 95% CI , p = .044. Target trait negative affect was not significantly associated with regulator extrinsic reappraisal use, b =  − 0.08, t(117) =  − 0.62, 95% CI , p = .54. This suggests that regulators used more extrinsic reappraisal on those who entered the study in a worse affective state and, on average, successfully uplifted them during the conversation. Finally, we controlled for target trait affect in our main analyses. When we did, we still found that when regulators used more extrinsic reappraisal, targets experienced significantly more positive emotion, b = 0.27, t(117) = 3.45, 95% CI , p < .001, and less negative emotion, b = 0.12, t(117) =  − 2.49, 95% CI , p = .014, indicating that targets’ affect at the start of the study could not explain the main results.Additionally, we examined the alternative explanation for these results in the other causal direction—that regulators used more extrinsic reappraisal on targets with better affect . We did not find any support for this alternative explanation. To examine this, we tested how target trait affects predicted regulator extrinsic reappraisal use. We found that targets with less positive affect at beginning of the study received significantly greater extrinsic reappraisal from regulators, Neither extrinsic suppression nor extrinsic acceptance was significantly associated with targets’ emotions or extrinsic emotion improvement  = 9.08, 95% CI , p < .001, and lower negative emotion, b =  − 0.20, t(119) =  − 2.51, 95% CI , p = .013. When targets perceived greater regulator responsiveness, they also reported that regulators were significantly more successful at upregulating their positive emotions, b = 0.63, t(119) = 4.85, 95% CI , p < .001, and at downregulating their negative emotions, b = 0.71, t(119) = 5.64, 95% CI , p < .001.When targets perceived greater regulator responsiveness, they experienced significantly greater positive emotion, b = 0.13, t(119) = 2.24, 95% CI , p = .027, and more extrinsic acceptance, b = 0.20, t(119) = 3.47, 95% CI , p < .001, whereas targets perceived less regulator responsiveness when regulators used more extrinsic suppression, b =  − 0.14, t(119) =  − 2.44, 95% CI , p = .01 , sense of connection , and regulator empathy  and regulator extrinsic suppression use  positively correlated with regulators’ self-ratings of these strategies, respectively (r(113) = .40, p < .001 and r(113) = 0.38, p < .001). Furthermore, we obtained similar results when using observer ratings to predict emotion outcomes and perceived partner responsiveness  interpersonal goals. Thus, attempts at changing targets’ emotions may have been conversational-directed depending on the targets’ disclosure instead of goal-directed. This raises the question—what trigger regulators to have these goals? In future research, it would be useful to examine whether regulators set these goals because of their own motivations or because of the type of disclosure by the target. For example, a target person may seek emotional support but receive problem-oriented support Below is the link to the electronic supplementary material.


PhDs in Nursing and PhDs in Social Communication with experience in the production of educational videos participated in the process. After editing, the video was validated by three nursing professors and assessed by students of the undergraduate nursing program at a public university.the video was validated by the examiners with 100% agreement in three rounds for script validation and in two for video validation after editing. The duration of the video was 9 minutes.after validation by the examiners, students assessed the video and considered it suitable for learning. We This video is expected to aid in the training of nursing professionals and the enhancement of patient care. In addition to pain and anxiety, possible harms include the occurrence of sterile abscess, infection, tissue irritation, periostitis, fibrosis, muscle contracture, necrosis, gangrene, and hemorrhage-4. Other adverse events associated with the procedure include decreased drug efficacy, lower drug absorption rate, and delayed drug action, particularly when the injection site is incorrectly delimited-6.Although the IM route has advantages over the oral and other parenteral routes, such as the potential to increase drug absorption and bioavailability. The Z technique or Z-track technique-9, which reduces the risk of administering the drug to a tissue other than the muscle, thus preventing loss or extravasation of solution after its introduction, is one of the techniques capable of minimizing the risks and injuries associated with the procedure-11.Some authors emphasize that IM injection injuries can be prevented with the proper techniques-13; according to other authors, a significant number of nursing professionals reported not knowing the procedure and only a few performed it routinely-14.Despite the literature demonstrating that the Z-track technique is the most appropriate for drug administration via the IM route, it is rarely used in practice. According to studies conducted with nursing professionals, more than half of the team members had never used the Z-track technique.This impediment to the use of the Z-track technique in the daily routine of health services, particularly by nursing professionals, may be related to deficiencies in the professional training process. It is advised that the teaching of skills-based techniques be coordinated with evidence-based applications and enhanced learning technologies.In this context, educational resources should be developed to improve the safety of drug administration via the IM route, as the occurrence of harm can be reduced by acquisition of scientific knowledge and technical skills. From this perspective, traditional learning methods and skill laboratories should be enhanced with the use of information and communication technologies-17. Educational videos stand out among the various teaching-learning tools that have been used for this purpose.Digital information and communication technologies (DICT) integrate pedagogical practices through digital resources, resulting in the creation of new, innovative, and collaborative learning spaces with the goal of promoting autonomy and interactivity in the teaching-learning process. Furthermore, it has several advantages, such as being a practical method, having a good cost benefit, allowing information to be easily understood, and allowing scenes to be watched multiple times-20. It can be used in a variety of teaching settings, including classrooms, simulation laboratories, and distance education, to promote the acquisition of new skills and improve the learning process of students.Educational videos can represent a level of sophistication in the teaching-learning relationship because it can capture the public’s attention while also arousing their curiosity about the topics addressed, stimulate creativity, and develop educational practice in a straightforward and objective mannerTo produce and validate an educational video on IM drug administration using the Z-track technique.The research project was submitted to a human research ethics committee and data collection began after the project was approved.. Before the production stage, the script was validated by specialists, and after the post-production stage, the video was validated by specialists and evaluated by the target population-24. The video was produced in the practice simulation center of a public teaching institution in the state of São Paulo, and it was assessed by the target population at a public university in the state of Minas Gerais.This is a methodological study that was conducted from September 2021 to July 2022. The steps for producing the video were as follows: pre-production (script development), production (video recording), and post-production (video editing)The inclusion criteria for content validation were being a professor who taught the Fundamentals of Nursing course discipline or an assistant nurse with experience in IM drug administration for content validation, and the inclusion criterion for technical validation was being a social communication professor with experience in producing educational videos. Experts who did not hold at least a doctorate were excluded.Three professors and two nurses participated in the content validation, and two professors participated in the technical validation. and technical validation were sent, along with a characterization questionnaire on the participants’ qualification and professional background,27. All instruments provided space for the examiners to record their thoughts and/or suggestions about each item evaluated.An email invitation was sent to the experts outlining the objectives of the study and providing information on the material to be evaluated. The email included an informed consent form. After the examiners agreed to participate in the study and signed the informed consent form, the initial version of the video script and the instruments for content.The content validation instrument examined six categories: objectives, content, relevance, environment, verbal language, and topic inclusion. Each item in the six categories was assessed by a four-point Likert scale. .An instrument containing the following categories was used for audiovisual technical validation: concept of the idea; dramatic construction ; rhythm ; characters ; dramatic potential, dialogues (dramatic time), visual style (aesthetics), referring audience, production estimate, functionality, usability, efficiency, and final analysis results. Each item was rated as: 4. Excellent; 3. Very good; 2. Good; 1. Regular; 0. Less regular. The examiner chose one of the four options as the final result: 4. Approved, 3. Approved with modifications, 2. Rejected with positive aspects, or 1. Rejected,21,24. The Delphi technique is an expert evaluation method aimed at obtaining successive suggestions, criticisms, and opinions on items in a questionnaire. Each round draws on information and comments from previous rounds, which are analyzed and integrated into the next round to generate new suggestions, with the goal of reaching a consensus among the examiners.The Delphi technique, which has been used in other studies, was used to validate the video script.The Delphi technique has several advantages: it can be conducted via e-mail and does not require specialists to meet in person; the anonymity of the process prevents an opinionated examiner from dominating the process and influencing the opinion of the group; it allows the accumulation of different opinions reaching consensus among experts.For this validation stage, the percentage of expert agreement was set at 100%The results were analyzed descriptively using average scores and presented in tables.The final version of the script was created after analyzing the data and reaching a consensus among the experts, both in terms of content validity and audiovisual communication.The educational video was recorded in the practice simulation center of a public educational institution in the state of São Paulo. Following the validated script, the scenes were filmed repeatedly over a four-hour period. Two participants took part, one acting as a nurse and the other as a patient.Following the completion of the filming, text, image, and sound graphic animation resources were included. The video was narrated by a professional with voiceover experience and was recorded using the “recorder” application available on the iPhone 7® with iOS 15.5 operating system, and images were edited using Adobe Premiere and Adobe Photoshop by communication technicians who were experienced in video development. It took 25 days of editing to cover the content of the validated script, adjust the image, audio, and soundtrack sequences, and make the necessary adaptations for the target population. The video was sent to three Nursing Fundamentals professors for face and content validation after the sixth version..The instrument with six categories, related to functionality, usability, efficiency, audiovisual technique, environment, and procedure, was used to validate the educational video. Each item of the categories was rated as “4. strongly agree,” “3. agree,” “2. disagree,” and “1. strongly disagree”The data analysis technique and the criteria for agreement values among the experts were the same as in the script validation stage.The video was assessed by fifteen students from a non-probabilistic sample of the undergraduate nursing program at a public university in the state of Minas Gerais.. Choosing an odd number of participants avoids a tie in dubious answers and questions.Some authors recommend six to twenty subjects for technology/instrument validationThe inclusion criteria were as follows: a) being regularly enrolled in an undergraduate nursing program; b) having completed the theoretical and practical modules of the Fundamentals of Nursing discipline; and c) being 18 years old or older. Students enrolled in a special learning regime and those who had not been approved for the Fundamentals of Nursing discipline were excluded.The students were invited at random via an electronic address and in descending order from the most advanced periods of the program. They were taken to an appropriate and silent environment to watch the educational video individually through a laptop after consenting to participate in the study and signing the informed consent form. The date and time were chosen based on the students’ availability and that of the room..After watching the video, the students were given the educational video assessment tool by the target population called “Assistive Technology Assessment Questionnaire” for their assessment. This validated tool consists of four items to verify the understanding of educational assistive technologies: objectives, clarity, relevance, and interactivity. Students assigned a score from 0 to 2 for each attribute, with (0) Inadequate, (1) Partially adequate, (2) Adequate, and a space was provided for the students to comment, criticize, or suggest the aspects they considered positive or negative, if applicableThe results of the assistive technology assessment questionnaire were organized based on the synthesis of the responses, and they were analyzed descriptively using mean, median, standard deviation, maximum and minimum values, and the Statistical Package for the Social Sciences software - SPSS for Windows, version 25.0.The video script was validated by seven experts, five from the nursing field and two from social communication. The experts were professors of the Fundamentals of Nursing discipline, nurses, and professors of social communication with experience in the development of educational videos, aged 31 to 65 years old (mean of 41.3 years), all with a PhD. Professional experience in the area ranged from 8 to 20 years, with a mean of 13.3 years.Items that did not achieve the maximum value (score 4 or “strongly agree”) were reformulated based on the suggestions of the experts, and a new script was submitted for reevaluation in subsequent rounds.The video script was validated after three rounds of content validation and two rounds of technical validation over a four-month period.The experts in the nursing field made the following suggestions in the first round: adding information on the need for traction on the plunger to verify venous return; replacing the seven “rights” framework in drug administration with the nine “rights” framework; changing the terms “prescription” to “medical prescription” and “medication” to “drug”; adding information on packaging disposal in recyclable waste; signaling the anatomical structures in the actor’s (patient) body in order to guide the injection site; correcting the positioning of the non-dominant hand in the figure showing skin traction.Only the addition of the word “ventrogluteal” to the video title was suggested in the second round.Only in the first round did the experts make changes to the video script’s technical  validation, namely: adding more images, vignettes, and videographics; revamping the soundtrack to something more rhythmic; including duration time of each scene; dynamizing the action times of each scene; modifying the excessive freezing of scenes; not repeating many types of shooting plans; describing the type of light used in the compositions of the plans; estimating the time of the final product; using an average time of 10 seconds for each scene; using other transition effects (scene freeze) such as fade in, fade out, dry cut, and overlay.Following script validation and video production, the video validation stage was carried out by three professors of the discipline of Fundamentals of Nursing aged 31 to 42 years, with an average of 35 years and professional experience in the area of 12 years.Video validation took two rounds. The following suggestions were made in the first round: adjusting the speech/narration with the action in one of the scenes, changing the moment of presentation of the check of two “rights”, form and action of the drug, inserting the information of disinfection with alcohol 70% of the bottleneck of the ampoule at the time of preparation of the drug, and adding speech/narration for better understanding of some steps presented in text form.The examiners strongly agreed  with all items of the instrument in the second round, with no new recommendation/suggestion.Following the completion of the validation and reaching 100% agreement among the experts, the video was completed with a duration of nine minutes.Fifteen students from the fourth to tenth periods of the undergraduate nursing program participated in the video evaluation stage, ranging in age from 22 to 46 years, with an average of 25.2 years..Videos and films have been used extensively as a didactic resource in education over the last few decades. This has been observed in health education, particularly in nursing education, because it brings students closer to real-world service settings through procedure illustrations, promoting the understanding of clinical competencesThe video created and validated in this study depicted all steps of a nursing professional in a hospital unit administering drugs via IM in the ventrogluteal region using the Z-track Technique., we decided to use a proportion of 100% of consensus between experts due to the rigor in the pre-production phase, a criterion also adopted by other studies,24.Although existing studies consider a proportion of agreement between experts equal to or greater than 80% for video validation,22, because the duration interferes with the students’ level of attention. However, there have been reports of videos lasting between 16 and 37 minutes in the literature,24,35. The duration of the video in this study was within the limits recommended by the literature.According to some authors, the duration of educational videos should not exceed 10 to 15 minutes.Three rounds of assessment were required for script validation by experts in the nursing field, two rounds for the examiners in the technical field, and two rounds for the final validation of the video in the post-production stage. One of the precautions to be taken before using the Delphi technique is to avoid excessive rounds, limiting them to a maximum of fourOnly suggestions in terms of content and relevance were made of the seven categories addressed in the script validation instrument assessed by nursing experts. The main recommendations focused on the need to better demonstrate the anatomical boundaries of the injection site in the ventrogluteal region.. Thus, in order to best simulate reality and comply with the experts’ recommendations, the procedure of IM injection using the Z-track technique was performed using the actor’s own body (patient), except at the time of needle insertion, when an anatomical piece created by the researchers was fixed on the delimited area to simulate the injection site.Using a realistic simulation scenario in health provides a favorable learning environment, assisting in the development of essential competences and skills for professional trainingThe main categories addressed by the experts in the field of social communication for the validation of the video script were visual style (aesthetics) and production estimate.-39.Following the suggestion of the examiners in the first round of video validation, the narration of all steps of the Z-track technique procedure was included to the presentation, which was previously only in text format. Language adequacy in instructional material production is required to improve understanding of the topic and is widely recommended in the production of materials for health education.In addition to boring viewers and causing abstraction, the use of confusing language with difficult-to-understand terms and incorrect concepts can impair the performance of the procedure and, as a result, compromise patient safety. Therefore, it is critical to obtain agreement between the examiners and the target population on the concept, clarity, and language used in the video to ensure understanding of its content while making it more appealingAlthough all students thought the video was adequate for learning how to administer drugs via IM using the Z-track Technique, the items “offers interaction, active participation in the educational process” and “reproduces the content addressed in different contexts” received the lowest scores from the participants..The fact that some students considered the video as unfavorable to active participation in the educational process, despite being dynamic, interesting, stimulating, and reflective for learning the content addressed, may be due to the characteristics of the videos, which are aimed at viewers receptive to information in order to demonstrate procedures, as opposed to educational games, which have the potential to provide students with opportunities to participate more actively-43.The evaluation of the reproduction of the content addressed in different contexts confirmed that the scenario depicted in the video depicts the hospital environment. However, it does not mean that the procedure cannot be replicated in other healthcare settings. All IM injections should be administered using the Z-track techniqueThe validation process represented a limitation in the development of the study as the content validity was only completed due to the time established to fulfill the research schedule. Despite the study’s limitations, the video was positively assessed by the examiners and the target audience during the validation process, achieving the goal for which it was proposed.The educational video created in this study potentially collaborates to the training of scholars and health professionals, with the benefits of strengthening the theoretical-practical foundation in the critical educational process aimed at improving the quality of care through educational strategies capable of guiding the achievement of safety goals and promotion of safe care.This study is expected to serve as a catalyst for further research on the subject, promoting scientific research in the field.Both the examiners and the target audience found the educational video to be valid in terms of content.


Full-body motion capture is essential for the study of body movement. Video-based, markerless, mocap systems are, in some cases, replacing marker-based systems, but hybrid systems are less explored. We develop methods for coregistration between 2D video and 3D marker positions when precise spatial relationships are not known a priori. We illustrate these methods on three-ball cascade juggling in which it was not possible to use marker-based tracking of the balls, and no tracking of the hands was possible due to occlusion. Using recorded video and motion capture, we aimed to transform 2D ball coordinates into 3D body space as well as recover details of hand motion. We proposed four linear coregistration methods that differ in how they optimize ball-motion constraints during hold and flight phases, using an initial estimate of hand position based on arm and wrist markers. We found that minimizing the error between ball and hand estimate was globally suboptimal, distorting ball flight trajectories. The best-performing method used gravitational constraints to transform vertical coordinates and ball-hold constraints to transform lateral coordinates. This method enabled an accurate description of ball flight as well as a reconstruction of wrist movements. We discuss these findings in the broader context of video/motion capture coregistration. Motion capture systems have been widely used to track human movements as they provide important scientific data. Out of several technologies that capture body motion, marker-based motion capture has been the standard and most spatiotemporally accurate, though requiring the attachment of physical markers. Markerless video-based motion capture is a promising alternative used in situations where physical contact may not be possible ,2,3. It There is a third situation that has had little discussion, which is when a hybrid of the two approaches provides the best performance, such as in ball sports where it is not possible to place active markers on the ball, and passive markers may interfere with the handling and flight of the balls. In such a task, humans interact with physical objects, and thus, both human and object movements must be recorded precisely. While a coarse video-based estimation of human movements has been used in sports such as basketball , volleybSpecifically, we apply the hybrid system to the understanding of the motor control of juggling, a new paradigm for computational neuroscience of complex motor skill learning that builds on the simpler tasks that have dominated the field. Its study is possible via the method of Mobile Brain/Body Imaging (MoBI) , which uIn this study, we seek to develop a practical system to integrate commodity video cameras into a marker-based mocap that does not rely on a priori calibration nor on precise knowledge of the camera position and lens characteristics. Such a system could be computationally efficient enough to learn coregistration in real time, which is especially important when the participant is moving relative to the video image plane. In the case of manipulating objects that are alternately held and thrown, two primary constraints are available to be used in coregistration: a positional constraint during holding  and gravitational dynamics during ball flight. Several additional challenges of motion capture during juggling had to be overcome. Ball position estimation from the video may be inaccurate because of partial occlusion of the ball by the hand, and it was not possible to know the actual hand position because active markers on the hand would be occluded, and thus, hand position was estimated from forearm and wrist markers. Our coregistration method had the secondary benefit of enabling us to estimate the correct hand position, including wrist bending movements that are important for throwing and catching.Here, we compare multiple methods for the coregistration of video and marker-based motion capture, each differing in their use of hand positions and gravitational constraints. Coregistration methods were evaluated by (1) the difference (error) between the estimated hand position and the estimated ball position during the hold phase and (2) the vertical acceleration of the balls. We chose linear methods for simplicity, assuming that the video plane was spatially linear, but these methods could be easily generalized to use nonlinear scaling methods. The proposed algorithms differed in their use of physical constraints and assumptions to reconstruct the ball trajectory from video, producing trajectories in body space. We provide guidance on the optimal reconstruction of object positions from video that are widely applicable to hybrid video/motion capture scenarios. We expect this discussion to be useful to researchers who used to use marker-based motion capture and vision-based motion capture simultaneously, even in a limited hardware environment.We recruited healthy subjects who can already juggle. Their age was 28.69 ± 5.66 (mean ± standard deviation). The subjects performed three-ball cascade juggling with internally illuminated balls with a diameter of approximately 7 cm for five 10 min sessions with a 3 min break session between sessions. All participants provided informed consent, and this study was approved by the IRB of UCSD and carried out complying with the Declaration of Helsinki. We used a PhaseSpace motion capture system  with a sampling rate of 480 Hz to track nine markers on left/right shoulder, left/right upper arm, left/right forearm, left/right wrist, and chest, as shown in of 60 Hz B. MotionFor motion capture data, juggling trials were first isolated, and all coordinate signals were manually inspected to eliminate abnormal discontinuous points (noise) and interpolate short missing intervals with spline interpolation. Missing intervals that lasted over 0.2 s were not corrected and were discarded in further processing. Then, using the interpolation function interp1 in MATLAB, the motion capture data were downsampled for the purpose of finding the ball coregistration transformation and aligned with the 60 Hz video sample times. Ball positions on a pixel scale were estimated from the video frames by applying an automatic circle-finding algorithm using the circular Hough transformation , which iTo define the body plane, we tracked a rigid body formed by the coordinates of the two shoulder markers and the chest marker. The position and angle of the body plane relative to the video image plane can be used to trigonometrically correct ball coordinates so that they lie in the body plane A. In praIt was not possible to track the hand using active markers due to occlusion of palm-side markers by the ball and invisibility of markers on the back of the hand. While this could be solved in future studies using inertial sensors or placing mocap cameras below the hands, it was a limitation inherent in this data, and thus, recovery of hand position was a secondary aim of our method. We proceeded by estimating the hand position using wrist and forearm markers by extending a line connecting the two markers by 10 cm . Since misalignment of events could misclassify the phase of motion samples near the throw and catch, we removed 3 samples (~50 ms) at the beginning and end of each phase. This had the side effect of eliminating any frames in which ball occlusion by the hand may have led to ball position estimation errors.Ball coordinates derived from the video data on the lateral and vertical axes are on a pixel scale, and the aim of coregistration is to match these to the real-world scale. The units can be converted using a linear equation, as we confirmed the validity of linearization in the previous section. Linearity enables us to compare methods with ease and has high generalizability in general.As there is no a priori best method for reconstructing the ball position from video, we explored the following task-dependent constraints: (1) the ball position during the hold phase should be identical to the hand position; (2) during free flight, the ball is subject to gravitational acceleration of approximately 9.8  . For theOne reason for the poor performance of the naïve Ind solution is that the hand position used in the coregistration was an imperfect estimate based on forearm and wrist markers due to the impossibility of using active markers on the hand itself. Simply minimizing these errors does not result in optimal estimates. Rather, the errors shown in The models were designed under several assumptions for simplicity that might affect the accuracy. First, we assumed the ball position extracted from the video was accurate. However, we have potentially unaccounted for error in ball position due to hand occlusion. In a situation where a minor error is acceptable, such as a soccer game, occlusion can be detected to estimate an occluded object . HoweverFinally, uncertainty about the throw and catch times also should be considered because those times were used to segment the data into hold and flight phases, which were used differently in coregistration. We evaded this potential trouble by eliminating three frames at both ends of each phase. This conservative way might unnecessarily lose useful parts of the information. We inserted the throw and catch times manually, watching all frames on video. Alternative methods that have been used in the past are inserted events based on ball kinematics, such as changes in vertical acceleration . In our In this present study, we demonstrated methods that were able to successfully coregister free-flying thrown and caught objects in video with marker-based motion capture. The best method (the LV model) utilized a combination of physical constraints during flight and ball holding as well as hand motion constraints to result in a coregistration that allowed us to accurately quantify ball flight and with the additional benefit of enabling the accurate recovery of unmeasured wrist movements. The methods (L and V) that partially employed the availability of the constraints and applied homogeneous scaling across dimensions were suboptimal. The methods developed here, which combine the fitting of constraints and reverse reconstruction of unobserved variables could be broadly applicable to other studies of movement dynamics in which not all objects can be instrumented with active markers. A number of general lessons can be drawn from this work. First, simple least squares fitting is not the best approach because the object/body ‘error’ will often, in fact, contain important behavioral information. Considering the least square fitting is likely to be exploited in general, defining task constraints should be prioritized. From this work, we developed several recommendations for future experimental studies of complex object/body interactions that can be difficult to study using marker-based motion capture alone and for which currently available markerless motion capture is not accurate enough. Such cases can benefit from a hybrid approach with the addition of video capture to marker-based systems. The recommendations are as follows: (1) identify task constraints ; (2) design a method to maximize the use of constraints, such as the LV model in our case, considering the importance of scaling different dimensions using different constraints; (3) avoid simple error minimization as fitting errors may contain behaviorally relevant information; (4) examine and extract meaningful information from the errors.