In digital forensics, video becomes important evidence in an accident or a crime. However, video editing programs are easily available in the market, and even non-experts can delete or modify a section of an evidence video that contains adverse evidence. The tampered video is compressed again and stored. Therefore, detecting a double-compressed video is one of the important methods in the field of digital video tampering detection. In this paper, we present a new approach to detecting a double-compressed video using the proposed descriptors of video encoders. The implementation of real-time video encoders is so complex that manufacturers should develop hardware video encoders considering a trade-off between complexity and performance. According to our observation, hardware video encoders practically do not use all possible encoding modes defined in the video coding standard but only a subset of the encoding modes. The proposed method defines this subset of encoding modes as the descriptor of the video encoder. If a video is double-compressed, the descriptor of the double-compressed video is changed to the descriptor of the video encoder used for double-compression. Therefore, the proposed method detects the double-compressed video by checking whether the descriptor of the test video is changed or not. In our experiments, we show descriptors of various H.264 and High-Efficiency Video Coding (HEVC) video encoders and demonstrate that our proposed method successfully detects double-compressed videos in most cases. The price of digital imaging systems today has become considerably low, and the use of devices equipped with cameras has become a fact of daily life. Numerous surveillance cameras on roads and streets are constantly recording our surroundings, and when an accident or a crime occurs, video becomes important evidence for digital forensics ,2. For eA video basically consists of a sequence of images (or frames). The forgery video can be detected by applying image tampering detection methods ,7,8 to eThis paper presents a novel method to detect a double-compressed video under conditions that are slightly limited but frequently occur in practice. There are two assumptions in our study. The first assumption is that the model name of a camera that took a test video is known. Here, the test video denotes the video to be checked for tampering. Since the test video is submitted as evidence of a crime, the model name of the camera that took the test video is generally known. The second assumption is that an attacker is not enough of a video coding expert to develop his (or her) own software video encoder. Therefore, when compressing a forged uncompressed video, the attacker utilizes a software video encoder available either publicly or on the market. In other words, the software video encoder shown in The contributions and novel parts of our study are as follows. First, this paper introduces a new approach in the field of detecting a double-compressed video. While most existing methods analyze only the test video itself, the proposed algorithm considers the characteristics of the hardware video encoder that took the test video. This approach is one of the novel parts of our study. Second, the proposed method can complement the existing method to further improve detection accuracy. For example, the proposed method first checks a test video to see whether it is tampered with or not. If the proposed method fails to detect anything, the existing methods can be applied to further examine the test video. Finally, if the proposed method decides a test video is a forgery video, the probability of a wrong decision is extremely low, which can be used for strong evidence in a crime. There is no risk that an unforged video is determined to be a forgery video.The rest of the paper is organized as follows. A video encoder for international video coding standards, such as using H.264  and HEVCgiven in . The vidit (CTU)  whose siThere are two approaches to the implementation of a video encoder: software and hardware. Software-based video encoders are inherently very flexible in modifying and upgrading algorithms. Further, there is no limitation on the size of input videos. As the size increases, the processing time increases only. This flexibility makes the software-based encoder adaptable to various types of applications. As the software-based encoder does not guarantee real-time processing, it is suitable for offline applications. Meanwhile, since the processing blocks in a hardware-based encoder run in parallel, its processing speed (or throughput) is generally faster than that of a software-based encoder. However, the hardware video encoder cannot process a video larger than the designed hardware specification due to limitations of memory size, operation frequency, etc. Once the video encoder is implemented in an application-specific integrated circuit (ASIC), it is very difficult to modify or upgrade the encoding algorithms. Hence, hardware-based video encoders are suitable for consumer electronics where real-time encoding is an essential feature.This paper proposes a method to detect a video forged from a video shot with a camera, such as a car DVR (or a black box). Here, the camera encodes input frames using a hardware video encoder. Hence, this subsection examines the hardware implementation of video encoders.To achieve high coding performance, video encoders generally need to examine all possible prediction modes and choose the best mode among the candidates. For example, HEVC video encoders need to examine 35 intra-prediction candidates and choose the best one among the 35 candidates. Recent video coding standards are so complex that even hardware-based video encoders are not practical to carefully check and evaluate all possible prediction modes in real-time. Therefore, many researchers have proposed new hardware architectures with novel fast algorithms to efficiently reduce the processing speed and implementation cost while maintaining the coding efficiency. Video encoders need to determine many parameters, such as block size, block partition, intra prediction mode, and so on. Top-tier hardware vendors can develop all new advanced algorithms that run in real-time for high-performance video encoders. However, since the development of the new advanced algorithms increases the development cost, other hardware vendors may find it difficult to develop all new advanced algorithms to determine encoding modes. These hardware vendors may need to consider a trade-off between the development cost and the encoder performance. Therefore, some hardware vendors often consider simple and straightforward methods to efficiently reduce the development cost while the performance degradation is not significant.One of the simple and straightforward methods is to use only a subset of encoding modes among all possible ones. Since three intra predictions of modes 0 , 1 , and 2 (DC) for For a video decoder to comply with the video coding standard, the decoder should have the capability to decode all encoding modes defined in the standard. On the other hand, if the bitstream generated from a video encoder is decodable by the standard decoder, the video encoder is considered to generate the bitstream that conforms to the video coding standard. Hence, the video encoder can comply with the standard even if only some of encoding modes defined by the standard are implemented. For example, an H.264 video encoder that uses only three intra prediction modes for the As mentioned in the previous section, some hardware video encoders support only a subset of encoding modes among all possible ones. Which encoding modes are included in the subset can vary from video encoder to video encoder. Hence, the subset can be used as the descriptor of a video encoder. Let us first examine the descriptor of an H.264 video encoder. There are many encoding modes to be determined by the H.264 encoder. The proposed descriptor includes the intra prediction modes and inter block partition. The profile, level, and group of pictures (GOP) are also included in the descriptor. The proposed HEVC descriptor basically includes some parameters from the video parameter set (VPS), sequence parameter set (SPS), and picture parameter set (PPS), such as CTU size, minimum coding unit (CU) size, and GOP size. The descriptor also includes the intra prediction modes and block decomposition types, such as the descriptor of the H.264 video encoder. Since the block partitioning structure in the HEVC standard is very complex, the definition of the HEVC descriptor is not simple. Let us review its block partitioning structure in brief. As explained in the previous subsection, the basic processing unit of the HEVC is CTU, whose size is from It is not easy to organize the proposed HEVC descriptor into a single table due to the complex coding tree structure, which consists of several tables. The proposed method constructs the descriptor according to the size and type of the CU that is a leaf node of the coding tree rather than the coding tree structure of the CTU. Hardware video encoder manufacturers usually provide the basic specifications of video encoders, such as the profile and level, which are some of the components of the proposed descriptor. Even if the manufacturers do not provide the specification, these values for the descriptor are directly readable from VPS, SPS, and PPS. However, most values of the descriptors in The descriptor analyzer monitors the process of decoding video clips. Whenever a mode in the proposed descriptor is found in the video clip, the analyzer increases the variable to record the number of how many times the corresponding mode is used in the video clip. For example, let us assume that an H.264 decoder processes an MB in a video clip. If the MB is an intra Let us assume that a test video (or an evidence video) is submitted to check whether the video is forged or not. Conventional methods usually focus on the test video itself. They carefully analyze the test video to find out tiny changes due to double compression. Meanwhile, the proposed method takes a different approach from the previous methods. It does not analyze only the test video but compares the test video with other videos shot by the same video encoder from the viewpoint of the proposed descriptor. Since the test video is submitted as evidence of a crime, the model name of the camera (or video encoder) that took the test video is generally known. We can generate new videos using the same camera if necessary. Hence, the test video can be compared to other videos shot with the same camera.Model b. Then, the proposed method searches the descriptor of the corresponding model (Model b) in the model database. If the descriptor for the corresponding camera model is not in the model database, new videos are taken using a camera of Model b. Then, the proposed method predicts the descriptors of the new videos and stores them in the video database. In the figure, two videos, #3 and #4, were taken, and their descriptors are In There is an important issue. We mentioned in When comparing the descriptor of the test video to the descriptor of the video encoder, there are three types of comparison results. i software.If the test video is not double compressed, the descriptor of the test video should be consistent with or included in the descriptor of the video encoder used to shoot the test video   is a newIn experiments, eight models of car DVR (or black box) cameras, four models of smartphone cameras, and one GoPro camera were used to evaluate the proposed method. We took many videos using the above cameras to build the model database. The total running time of videos shot by each camera model was more than 5 min (9000 frames). Video resolutions from the car DVR cameras are d do not consider modes 33 and 34, respectively. In fact, camera model c in Four a considers only b utilizes c can be considered to support all block partitions in As described above, the hardware video encoders used in our experiments support a subset of encoding modes rather than the full set of encoding modes. According to our analysis, the descriptors of camera models used in our experiments are unique to each other. However, there are many camera models in the commercial market and it is very likely that different camera models with identical descriptors exist. It should be noted that uniqueness is not required to detect double-compressed videos in the proposed method. Details will be shown in Section 4.4In our experiments, 11 models of car DVR cameras (or black boxes) were used to evaluate the proposed method. B, D, E, and F support all The above experiments show that since H.264 hardware video encoders used in our experiments support a subset of encoding modes rather than the full set of encoding modes, the subset of encoding modes can be used as descriptors of H.264 video encoders. On the other hand, these H.264 descriptors are not completely unique to each other, unlike the HEVC descriptors. Models B, C, F, G, H, I, and K were unique to each other. The descriptors of models A and J were identical. Models D and E also have the same descriptors. Again, uniqueness is not required to detect double-compressed videos in the proposed method.After going through the procedure in B in Next, we conducted another simulation using an authoring tool (FFmpeg ). It is In the same way, the experiments were performed on HEVC camera models using two software video encoders. One is HM software , which iNot detectable’, the existing methods are applied to further examine the target video. Since the proposed method is complementary, it does not matter whether the proposed method is superior to the existing methods or not. Therefore, only the experimental results of the proposed double compression detection are presented in this paper. In practice, the performance of the proposed method is highly dependent on the combination of encoders used for the first and second compressions.The proposed method does not replace the existing methods but complements them. For example, a target video is first examined using the proposed method. If the target video is determined as ‘b is identical to the descriptor of the open-source authoring tool based on H.264. Hence, the proposed method cannot judge whether the test video from camera model b is tampered with or not; the test video is categorized as ‘Not detectable’. The remaining videos from ten camera models are correctly detected. The accuracy of the detection results for the ten detectable camera models is 100%. The proposed method basically checks whether the descriptor of the original video (compressed) is changed to the new one or not. It does not matter for detecting double compression that two descriptors from different camera models are identical.Not detectable but unforged. However, we believe that this case is very rare for the following reason. Since the open-source encoder is free and public, it is very likely that the new software (Now, let us consider a situation of tampering with a test video using the new software video encoder (s FFmpeg . Then, DIn this paper, we present a new approach to detecting double-compressed videos using the proposed descriptor that represents the characteristics of each video encoder. Unlike human fingerprints, each video encoder’s descriptor is not completely unique enough to discriminate all video encoders. Nevertheless, we experimentally show that there are many types of descriptors according to video encoders. Specifically, the descriptors of hardware video encoders are different from those of software video encoders in most cases. Therefore, the proposed descriptor can be utilized to detect double-compressed video like human fingerprints.The accuracy of the detection results is very important in digital forensics. Specifically, the untampered video should not be decided as a forgery video in order for the innocent not to be punished. The proposed method guarantees that the test video judged to be a forgery is indeed double compressed. In other words, the proposed method never determines a single-compressed video as a double-compressed video. We believe that this work is very meaningful for digital forensics. If an attacker is a video coding expert, one can easily find a way to neutralize the proposed method. For example, by modifying the test models such as HM or JM software, a software video encoder whose descriptor is identical to a specific hardware video encoder can be developed.The proposed descriptor only includes whether a particular encoding mode is used. Not only whether the encoding mode is used but also the probability that the encoding mode is selected may be utilized in a descriptor of the video encoder. For example, according to our experiments, some hardware video encoders have a very high selection probability of modes 0, 1, and 2 among the 35 modes in HEVC intra prediction, but other encoders do not. The probability distribution of the chosen encoding modes is also an important characteristic of video encoders. We expect that considering the probability distribution will further improve our study.


This study aimed to assess and update the content, reliability, and information quality of content related to root canal treatment (RCTx) on YouTube and evaluate the correlation between each evaluation index.YouTube was searched using two terms related to RCTx . A total of 240 videos (120 for each search term) were screened. Exclusion criteria were as follows: no sound or visuals, non-English, irrelevant to the search term, longer than 15 min, duplicate, or old (uploaded before 2016). After exclusion, 50 videos of “root canal treatment” and 45 videos of “endodontic treatment” were analyzed. Video length, total number of views, likes, dislikes, comments, and days since upload were recorded using descriptive video data. Viewers’ interaction, reliability and information quality of the video, and quality of video content were measured using nondescriptive video data. The interaction index and video power index were used for viewer interactions, and the modified DISCERN index, JAMA criteria, and Global Quality Score were used to assess the reliability and information quality of the video. The quality of the video content was measured using the completeness score.p < 0.05), and videos of the “endodontic treatment” group showed a higher interaction index, completeness score for the procedure (p < 0.05). Videos for dentists had significantly higher completeness scores for the procedure, while videos for laypersons had higher completeness scores for etiology, anatomy, symptoms, and prognosis (p < 0.05). Furthermore, the total completeness score and the interaction index of the videos for laypersons were significantly higher (p < 0.05). The videos uploaded by the university had a significantly higher modified DISCERN index (p = 0.044), and the JAMA score was significantly higher in the commercial group (p = 0.001).The videos of the “root canal treatment” group had a significantly higher completeness score for the etiology and symptoms (Although the accuracy of videos related to RCTx was higher in videos by universities and professionals, the total completeness of YouTube videos was low regardless of the video source. Therefore, professionals should be responsible for providing more accurate and reliable videos. Conventionally, health-related information is provided through direct communication with health care providers. However, with the growth of information technology, access to the Internet has become easier than in the past, and as a result, 80% of Internet users obtain medical or dental information through online searches .YouTube is the most widely used content hosting site where users can freely upload videos, and is the second most visited website after Google . YouTubeRoot canal treatment (RCTx), a very common dental procedure, preserves natural teeth by removing bacteria and cleaning the infected root canal to prevent reinfection. It is difficult to know how many root canal treatments are performed in actual dental procedures, but data from the National Health Insurance Company indicate that RCTx is performed on hundreds of thousands of teeth every year in the USA . As the Therefore, the purpose of this study was to assess and update the reliability and information quality of content related to the RCTx on YouTube and to evaluate the correlation between each scoring tool.On November 13, 2021, we searched YouTube for relevant videos using two related search terms: root canal treatment and endodontic treatment. The search was carried out by deleting cookies and caching with Google Chrome, using the default settings without filters. Previous studies have shown that 90% of people watch the top 60 videos several times a day ; the topSince the number of YouTube users has increased significantly compared to 2016 when a previous study assessing YouTube content on RCTx was reported , videos A second-year resident evaluated the videos and their characteristics in the endodontic department. Thirty videos for each search term, which were randomly selected, were reanalyzed by the same observer to evaluate intra-observer agreement at a 2 month interval. The following features of the video were recorded: length of the video, total number of views, likes, dislikes, comments, and days since upload.The video upload sources were divided into five categories: 1) dentists, 2) specialists, 3) commercials, 4) universities, and 5) others. The videos were divided into two groups depending on the subject: 1) information for dentists and 2) information for laypersons. The video forms were categorized into three groups: 1) real procedure, 2) clinician explanation, and 3) animation. If the video forms overlapped, the main video form was selected.After categorization of the videos, the viewers’ interests were calculated using the interaction index  , video pTo assess the content of the videos, the investigator assessed the completeness of each video by numerically scoring  for all six contents of “etiology,” “anatomy,” “symptoms,” “procedure,” “postoperative course,” and “prognosis” with a maximum score of 12 .The three evaluation tools used in this study are illustrated in Fig. The quality of educational information was assessed using the GQS , with a p < 0.05). The comparison between the two groups for continuous variables with nonnormal distribution was analyzed with the Mann-Whitney test, and the Kruskal-Wallis test was used to compare three or more groups. Pearson’s correlation coefficient was used to examine possible correlations of completeness score, modified DISCERN index, JAMA score, GQS, interaction index, and VPI.SPSS Statistics software  was used for statistical analysis. The Shapiro-Wilk and Kolmogorov-Smirnov tests were used to analyze the normality of quantitative data , and it was shown that the parameters did not represent a normal distribution , and “endodontic treatment” videos had a significantly longer duration of videos (p < 0.05). However, the number of total views, likes, and dislikes was not significantly different between the search terms (p > 0.05).In this study, a total of 240 videos (120 for each search term) were screened; however, 70 videos of “root canal treatment” and 75 videos of “endodontic treatment” were excluded. The reasons for the video exclusion are listed in Table The characteristics of the video, including the source, subject, and form, are summarized in Table p < 0.05), and “endodontic treatment” had a higher interaction index and procedure score (p < 0.05). However, there were no significant differences in VPI, completeness score , modified DISCERN index, JAMA score, and GQS (p > 0.05).The viewers’ interaction, completeness, and reliability scores by search terms are presented in Table p < 0.05), etiology, symptoms, and prognosis scores in clinical explanation (p < 0.05), and anatomy score in animation (p = 0.024) were significantly higher. Videos for dentists had significantly higher procedure scores, while videos for laypersons revealed a higher etiology, anatomy, symptoms, and prognosis score (p < 0.05). Furthermore, the total completeness score and interaction index of the videos for laypersons were significantly higher (p < 0.05). Uploaded videos by the university had a significantly higher modified DISCERN index (p < 0.05), and the JAMA score was significantly higher by commercial (p < 0.05). The correlations of all scores that involve total completeness, VPI, interaction index, modified DISCERN index, JAMA score, and GQS are shown in Table r = 0.654) and the modified DISCERN index (r = 0.676), and the GQS revealed a high correlation with the modified DISCERN index (r = 0.728). The JAMA score showed a low correlation with the modified DISCERN index (r = 0.264).The evaluation of completeness, viewers’ interaction, and reliability scores regarding the video source, video subject, and video form is reported in Tables Although dentists and laypersons have different purposes for finding information, they are interested in RCTx, commonly performed in dental procedures. Several sources, such as papers, conferences, Internet searches, and social media, provide information on RCTx. YouTube, the second most visited website and can be easily accessed, often provides information to people who want to know about health-related content, and people also upload their opinions. As YouTube content is not evaluated by experts in the relevant field, the reliability and educational quality of health content has become an important issue . The avaIn this study, the search terms were selected from a wide range of terminologies . This is because if the search term becomes more detailed, the contents related to a specific procedure can be focused.r = v-0.07). The number of likes and dislikes was positively correlated with the total number of views (r > 0.09). There were no differences in the video sources according to the search terms. When YouTube was searched using the term “endodontic treatment,” the main subjects of the videos were dentists (82%), and the majority of the video forms were actual clinical procedures (62%). The average length of the video was also significantly longer than that of videos searched using the term “endodontic treatment.” This means that videos of the search term “endodontic treatment” contain more details on the RCTx procedure than “root canal treatment.”In the analysis of the descriptive data and characteristics of the videos in this study, the most viewed video was over 5 million, but there were also videos with less than 100 views. Although older videos are generally expected to have higher views, there was no correlation between total views and dates in this study . This was inconsistent with the results of previous studies, in which videos by professionals were more beneficial [The average overall completeness score for this study was 4 ± 2.33, showing a low level of approximately 1/3 of the total. This means that the video information related to RCTx is insufficient and may provide YouTube viewers with incorrect information. Furthermore, the completeness scores of the video content by upload source were not significantly different . Videos by professionals were considered to contain clearer references, which had higher accuracy. Furthermore, the JAMA score of the commercial video (3.67 ± 0.52) was the highest, which means that more reliable information was included in the video to enhance the advertisement effect.Three video evaluation scoring tools were used for objective analysis. The JAMA score focuses on evaluating the reliability of the video, while the modified DISCERN index evaluates both accuracy and reliability. Additionally, the GQS is a gradation of the educational degree of a video. In this study, the mean of the modified DISCERN index by video source was 2.57 ± 1.13, 2.41 ± 0.98, and 1.93 ± 1.27 for universities, specialists, and dentists, respectively, which were significantly higher than those of the non-professional . The interaction index and VPI, which indicate the popularity of a video, were not correlated with other video rating tools. This means that even if the video is popular and has many viewers, the quality of the video may not be good (− 0.2 < r < 0.2). However, more studies are needed because few studies have investigated the correlation between video evaluation indices, and the standardized evaluation tool for comprehensive video evaluation remains unclear. A limitation of this study was that only the top 120 videos were analyzed, so not all videos on YouTube regarding root canal treatment could be evaluated. In addition, due to the features of YouTube, many videos are continuously uploaded, and only analysis at a specific point in time is possible. Therefore, an ongoing evaluation of YouTube videos is required. Finally, in addition to YouTube, an additional evaluation of information on social media used by many people, such as Twitter, Facebook, and Instagram, is also necessary, and these previous evaluation tools can be used for analysis.Although the accuracy of videos related to RCTx was higher in videos by universities and professionals, the total completeness of YouTube videos was low regardless of the video source. Therefore, it is important for professionals to provide more accurate and reliable videos to reduce the risk of misinformation by viewers. In addition, as there is no standardized index for evaluating YouTube videos, future studies should be directed toward the development of new evaluation tools for more objective and comprehensive video evaluation.


Mobile phones are increasingly used in community health programmes, but the use of video job-aids that can be displayed on smart phones has not been widely exploited. We investigated the use of video job-aids to support the delivery of seasonal malaria chemoprevention (SMC) in countries in West and Central Africa. The study was prompted by the need for training tools that could be used in a socially distanced manner during the COVID-19 pandemic. Animated videos were developed in English, French, Portuguese, Fula and Hausa, illustrating key steps for administering SMC safely, including wearing masks, washing hands, and social distancing. Through a consultative process with the national malaria programmes of countries using SMC, successive versions of the script and videos were reviewed to ensure accurate and relevant content. Online workshops were held with programme managers to plan how to use the videos in SMC staff training and supervision, and the use of the videos was evaluated in Guinea through focus groups and in-depth interviews with drug distributors and other staff involved in SMC delivery and through direct observations of SMC administration. Programme managers found the videos useful as they reinforce messages, can be viewed at any time and repeatedly, and when used during training sessions, provide a focus of discussion and support for trainers and help retain messages. Managers requested that local specificities of SMC delivery in their setting be included in tailored versions of the video for their country, and videos were required to be narrated in a variety of local languages. In Guinea, SMC drug distributors found the video covered the all the essential steps and found the video easy to understand. However, not all key messages were followed as some of the safety measures, social distancing and wearing masks, were perceived by some as creating mistrust amongst communities. Video job-aids can potentially provide an efficient means of reaching large numbers of drug distributors with guidance for safe and effective distribution of SMC. Not all distributors use android phones, but SMC programmes are increasingly providing drug distributors with android devices to track delivery, and personal ownership of smartphones in sub-Saharan Africa is growing. The use of video job-aids for community health workers to improve the quality delivery of SMC, or of other primary health care interventions, should be more widely evaluated. During the COVID-19 pandemic, it was important to ensure that core malaria prevention strategies continued. Seasonal malaria chemoprevention (SMC) is the monthly administration of chemoprevention drugs to children to prevent malaria in areas with highly seasonal malaria transmission. In partnership with 13 National Malaria Control Programmes in West and Central Africa, we developed a user-friendly training video to support safe delivery of SMC during COVID-19. The use of the video was evaluated through a case study in Guinea and an online workshop with the programme coordinators. SMC drug distributors found the video covered all the essential steps and was easy to understand. However, not all key messages were followed as social distancing and wearing masks were perceived by some as creating mistrust. Programme coordinators found the video useful as it reinforces messages and can be viewed many times. Video content needed to be adapted to the local setting and narrated in local languages. Not all distributors use android phones but many SMC programmes now provide drug distributors with android devices to use during SMC delivery, so that video job-aids could be more widely used. Community health worker (CHW) programmes rely on effective training and supervision . The incSMC involves intermittent administration of the antimalarial drugs sulfadoxine-pyrimethamine and amodiaquine (SPAQ) to children to prevent malaria. It is used in areas with highly seasonal malaria transmission in West and Central Africa where the majority of malaria cases, especially severe cases, occur in young children during and shortly after the rainy season . SMC invSMC campaigns require substantial human resources. For example, the ACCESS-SMC project in 2016 used about 60,000 people  to treat about 7million children in seven countries  can use so as not to make mistakes"" IDI, Regional Health OfficerSupervisors felt the video could support their work, drug distributors could refer to the video in the first instance to check the procedures, without needing to ask the supervisor.… it will also facilitate the work of the supervisors. A supervisor who has to supervise several shifts, and if this video is available [with distributors], this may decrease supervisors’ workload ""IDI, SMC national supervisorSome distributors in Labé said they generally followed all the steps mentioned in the video, but many other distributors in Labé and in Siguiri acknowledged that, although they knew the correct procedures, they did not observe all the video’s recommendations. Distributors said that respecting all the steps recommended in the video was time consuming, therefore following all the steps was not practical in terms of the target number of children to cover with SMC per day. Each pair of distributors are expected to cover 80 children during an eight-hour day, which is an average of six minutes per child. The shortest time observed for a single administration was four minutes, and the longest time sixteen minutes, and these figures do not include time to move from one household to the next. The shorter administrations, were instances where the child’s caregiver accepted the SMC immediately without extended discussion, and the child was present. In longer administrations, which were the majority, either the caregivers had a long discussion with the distributors before agreeing, or the child was absent or could not take the drugs immediately . Given the daily targets of 80 children, distributors would often not follow all the procedures as they are time consuming."You know that we [are taught] everything [all the recommendations] during the training, but in the field it’s different, we can’t respect everything. If you respect all the instructions, the procedures as they say in training, you’re going to delay a lot, and if you come back from the field in the evening, they’re going to scold you that you’re not working well. It’s very tricky indeed…"Informal conversation, SMC distributer, male, Labé, 13th December 2020The procedures that should be followed to deliver SMC drugs safely during the COVID-19 pandemic, were not always followed. Adherence to these procedures was problematised in the Guinea context due to mistrust of health workers and in disbelief in the existence of the COVID-19 virus. There was widespread mistrust in Guinea of government healthcare services and workers following the 2013–2015 Ebola crisis ,11. ThisThe [distributors] who came here the first time were all wearing masks. When they came, I couldn’t recognise them with the mask. I did not want to accept what them [their service] because I could not know who they are. But when the girl [one of the distributors] took off her mask, I immediately recognised her and finally, I allowed them to give the drugs""Informal conversation with a Caregiver"…I have my face mask in my packbag, but as you know it is not cautious to take it out…"Informal conversation, SMC distributorSome drug distributors found it hard to follow the guidance on social-distancing in the video, physical distancing when visiting a household, in particular towards those who are older than the distributor, can be considered disrespectful.“…people sometimes, if you distance yourself from them, they will feel offended, and it is difficult to observe social distancing; shaking hands is a much-appreciated custom and to fail to do so is to disrespect the elders”Informal conversation, SMC distributorA key aspect of the social distancing guidance was that the distributor should pass the blister pack to the caregiver, and ask them to administer the medication while observed by the distributor, rather than the usual practice which was that the distributor administers the medicine. In Guinea, distributors were advised not to let the caregivers suspect that this change was due to COVID-19. Instead they were told to explain this change so that caregivers could learn to administer the SMC whilst being observed, so that they know how to do this when they administer the remaining doses unsupervised on each of the next two days.We said again, we must not tell the parents that we ourselves do not give the medication because there is Covid-19, that we must not say that. That we must say, as we do every year, so you are going to distribute this time, we will see if you have understood how we do it.”“SMC Drug distributorDistributors were issued with alcohol-based hand rubs, or ‘gel’ rather than needing to use soap and water, but were advised to use the gel out of sight of the community. The video showed distributors asking for soap and water to wash their hands, but in Guinea this could be considered impolite especially if asking an older member of the household. Some distributers therefore preferred not to ask, and so did not wash their hands before providing the SMC drugs. The video was adapted to remind the drug distributors to wash their hands at the start but the instruction to ask households to provide soap and water was omitted. This allowed the drug distributors to choose how best to clean their hands in a given context.Smart phones are increasingly used in community health programmes ,12–17, bThe videos were short and could be distributed easily via Whatsapp or Bluetooth, with the potential to be cascaded to large numbers of distributors in a short time, and not requiring significant battery power to be expended during viewing, so that they could be used in the field during delivery as a job-aid, as well as during pre-campaign training.Careful consideration was needed in defining the video content, to ensure it reflected WHO guidelines and consensus good practice, while also recognising certain differences in procedures country to country. Piloting content is an important step to ensure content is consistent with cultural norms and is not overly prescriptive with respect to actions that may need to be adjusted in particular settings. For example, in Guinea, some COVID-19 safety measures could not always be followed due to negative perceptions by communities.Some community members thought that SMC distributors may bring COVID-19, or wished to test for COVID-19. In Nigeria, the SMC teams were also charged with looking for COVID-19 and reporting any suspected cases and this created some mistrust. However, methods that improved trust and helped distributors to adhere to safety measures in the video included, in The Gambia, training on how to communicate to the community about the importance of wearing a mask, and in Ghana, the use of volunteers well known in the local community to delivering SMC.Most drug distributors are members of rural communities and may not speak the official national language. Video versions were needed with narration in a range of languages to improve understanding. The accent may also be important. In Togo, the French accent in the video was difficult to be caught by local people, and so ideally the video needs a Togolese French accent. It has been estimated that out of 1200 different languages spoken in West Africa, 130 are commonly used among 80% of the population . Voice-oLimitations of the video job-aids include that when the training is not in the classroom, it can be difficult to ensure that everyone has participated in the training, and there is no opportunity to ask questions. However, local coordinators can use the videos to enhance supportive supervision and can respond to questions. Videos can be effective in complementing classroom training , the SMCA limitation of our evaluation was that not all distributors had a smart phone. However, SMC programmes are increasingly using ‘digital’ delivery whereby distributors are provided with android devices to track delivery, these devices can be used to view the videos.During the 2020 campaigns, three countries used digital data collection, The Gambia, Ghana and Benin. In 2021, a further three countries piloted digitalisation, Nigeria, Burkina Faso and Guinea [We used animation rather than live action, this has the advantage of being effective across diverse cultural groups with only the voice-over needing to be modified for different audiences. The animation depicted key messages clearly through the images as well as through the narration. There is evidence that watching aminated videos can enable better retention of information than face-to-face training .SMC involves door-to-door distribution during 4 to 5 months each year to over 30 million children in 13 countries, by tens of thousands of drug distributors. Ensuring quality of drug administration on such a scale is a major challenge. We have shown that video job-aids can be used to promote adherence to good practice guidelines but care is needed to ensure content is appropriate to the local context. Their use in community health programmes should be more widely evaluated.S1 File(DOCX)Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(DOCX)Click here for additional data file.


The most promising representative L3 resulted the best performing sensor for Mg2+ both in solution and embedded in an all‐solid‐state optode, especially towards real samples of drinkable water.A new series of ligands containing the 2‐(2‐hydroxy‐3‐ naphthyl)‐4‐methylbenzoxazole (HNBO) fluorophore showed selectivity for Mg PVC‐based solvent polymeric membranes uploaded on cellulose‐based Color Catcher absorbent sheets were doped with a fluorescent chemosensor containing a polyamine unit decorated with the 2‐(2‐hydroxy‐3‐ naphthyl)‐4‐methylbenzoxazole (HNBO) fluorophore to develop user‐friendly disposable all‐solid‐state devices for the selective detection of Mg2+ in real samples of commercial and tap drinking water, without the interference of Ca2+and other Alkali (A) and Alkaline‐Earth (AE) metal ions. Nevertheless, taking into account that the amount of Cd2+ and Zn2+ ions in drinking waters is commonly low and must be well controlled according to the WHO guideline for potable water,2+ assessment by the developed optodes.At higher concentration . The results revealed no significant pH influence on L3‐based optodes luminescence response to Mg2+ ions in the entire tested concentration range  and for all the calibration curves the linear trend and the slope remain indeed the same .Moreover, since the pH of drinking water may vary in a quite wide range (from 5 to 8.5 pH units), the pH influence on 2+ content in solutions simulating natural waters and containing all A and AE in various concentrations  as far as in mineral waters. Disposable CC strips (approximately 0.9 x 3 cm size) with deposited a small sensor array formed by four sensing membranes  replicated in two spots, were employed in these analyses . A clear difference in the optical luminescence response of the sensor array in multicomponent model solutions in the presence of Mg2+ was observed . Moreover, the application of a PCA analysis to the numerical outputs of sensor array luminescence response in terms of RGB intensities permitted to clearly identify all multi‐component model solutions in the presence and absence of Mg2+ ions .The disposable fluorescent sensors were hence employed for the detection of the MgL3.2 membrane, preliminarily calibrated in individual solutions of Mg2+ (10−6–10−1 mol dm−3 range), was tested for the Mg2+ assessment in tap, distilled and mineral waters featuring high and low magnesium content  should be addressed to the authors.Supporting InformationClick here for additional data file.


Higher education institutions are uniquely placed to introduce emotional coping skills to promote resilience in pre-registration nurses in order to reduce anxiety and increase confidence before they enter clinical placement for the first time. In this qualitative study, we will explore the use of a 360-degree video in developing skills for coping. The participants will be mental health nursing students. We will develop a 360-degree video in collaboration with a mental health service user. All participants will watch the video. A sub-group will receive a supportive clinical supervision discussion within a cognitive reappraisal/solution-focused/VERA framework. We will record the experiences of the participant to explore: (1) how students felt about the use of 360-degree video, as an education tool to build skills of resilience; (2) whether the students involved felt more confident and less anxious about the situation in the video as a result of participating in the cognitive reappraisal/solution-focused/VERA supervision discussion. In U.K. healthcare settings, there are a number of factors that might contribute to nurses’ experiences of stress at work such as excessive workload, shortages of time, staff and resources ,2, ineffIn mental health settings, there may be additional psychological and emotional stressors for nurses which are distinct from other health settings, by their nature and degree . Within It is clear that in mental health nursing, more research is needed to help staff develop resilient dispositional, psychological and social attributes, which are fundamental in forming effective therapeutic working relationships with patients . We alsoThe 360-degree video as an educational tool: This qualitative study protocol will outline an approach to explore the combined use of simulation-based and experiential learning approaches to support student nurses to learn about how to handle and respond to emotional distress. The beneficial value of simulation in dealing with psychosocial challenge and potential confrontation is established [ablished , but it ablished . In thisDeveloping emotional coping skills: techniques to reduce anxiety and build confidence in student nurses: There are a number of studies which show a more positive adjustment to stress if an individual is able to reappraise their emotional responses [esponses ,14,15, wesponses ,17,18.In this study, the clinical supervision strategy will focus on reducing anxiety using cognitive reappraisal, an evidence based therapeutic principle which draws from cognitive behavioural therapy (CBT)  and builMost cognitive behavioural approaches aim to build skills that individuals can apply to new situations . CognitiStudents will also be taught a communication strategy based on the validate, emotion, reassure, action (VERA) cycle for communication; an existing model of training and supervision to promote confidence ,31 which(1)To provide validation for behaviour or communication and to avoid negative and unhelpful assumptions that may create barriers to engagement;(2)To engage with the emotional content of what is communicated;(3)To offer reassurance and to promote a sense of safety;(4)To take the communication forwards into meaningful activity or to reflect on the interaction.The VERA cycle for communication has four key stages :(1)To prPreparation work: an immersive video scenario will be developed using 360-degree technology. The film will be approximately 5 min in length and will be set in an in-patient unit/ward. Actors will play the role of service users and nurses on the ward. The main focus will be on a mental health service user exhibiting emotional distress and the viewer will have the opportunity to follow this character around inside the ward.Permission to film in a vacant ward setting will be sought from a hospital setting in a UK healthcare Trust.Involvement will be sought from an individual who has lived experience of the mental health services during the creation of the video to ensure that the final product is sensitive, appropriate, well rounded and upholds ethical standards .Study Aim: The overall aim of this study is to help prepare mental health students for potentially stressful experiences in practice. Participants will experience an immersive 360-degree video showing a service user experiencing emotional distress within a mental health setting and a subgroup will be supported by a tutor to explore, appraise and reappraise their feelings and emotional responses, within a cognitive reappraisal/solution-focused/VERA framework.Objectives:To evaluate the use of 360-degree video as an educative tool.To evaluate whether using a clinical supervision discussion builds confidence and reduces anxiety in relation to stressful clinical interactions, using a combined cognitive reappraisal/solution-focused/VERA framework.Procedure see :Sample: Two cohorts of first year student nurses, enrolled on a BSc Mental Health Nursing course and yet to experience a practice placement, will be invited to participate. The intention is to recruit around N = 30 participants. Demographic data will be collected from the sample . Whether participants had prior exposure to mental health settings will also be assessed.To meet objective 1, participants will follow a service user showing signs of emotional distress in a ward setting, using an immersive 360-degree video to create a real-life experience. Participants will be video-recorded to provide both visual and audio data.These data will allow an exploration of whether 360-degree video is an effective learning tool. All participants will view the video, and answer questions on the 360-degree experience, which will provide an opportunity to reflect on the technology and the immersive experience.To meet objective 2, a subgroup of around half the recruited participants will be randomly selected to receive the supportive clinical supervision, within a cognitive reappraisal/solution-focused/VERA framework. Participants will be supported to consider what skills they already have to help them produce effective responses to the distressed service user. This group of students will watch the video, then participate in the supportive clinical supervision discussion, and then watch the video again.The procedure for the supportive clinical supervision will be as follows:Identify emotions: as part of the process of cognitive reappraisal, the participants will describe how they felt whilst watching the scenario. They will rate the intensity of their emotional responses using a scale from 0  to 10 (the most intense I have ever felt).After viewing the film for the first time, the supervisor will ask participants to:-What is going through my mind as I am feeling this emotion?-What am I telling myself about this situation?-What am I afraid might happen?After the film, the supervisor will support the students to evaluate their thoughts. At this stage, prompts will include:Next, participants will be asked to rate how strongly they hold these beliefs on a scale of 1–10.-How anxious do you feel about this situation on a scale of 0–10?-What would move your anxiety levels down the scale?-How confident are you that you would be able to deliver an intervention that would help the service user move on from this situation on a scale of 0–10?-What would move your confidence levels further up the scale?Then participants will be asked to rate their levels of confidence and anxiety. Scaling questions will be asked :-Why might the service user in the video be feeling this way?-What do you think they are trying to communicate?-What response might you give to this distressed service user?-What clinical decisions might you undertake based on the scenario?Participants in the subgroup will also be supported to explore how they might respond in the situation using solution-focused brief therapy skills guided by the supervisor based on the VERA framework ,31. The The cognitive reappraisal and solution-focused evaluation will be recorded by the supervisor using a worksheet ,34 see .Whether pre-registration mental health nursing students consider 360-degree video to be an effective learning tool.How pre-registration nursing students interpret and respond to stressful clinical situations.Whether working through a process of cognitive appraisal and clinical supervision (to introduce concepts of SFBT and the VERA framework) helped students to cope better with a stressful interaction (in terms of reduced anxiety and increased confidence).Social interaction is a key element of mental health nursing and, given this study concerned an interaction between pre-registration mental health students and a distressed client in an acute setting, this study was underpinned by social phenomenological theory . QualitaThis study is also concerned with using video to capture pseudo real-world data. The audio-visual data allows comparisons between visible conduct as well as verbal content to inform our understanding of how student nurses respond in complex, stressful social interactions which include a distressed client. Given the data will provide an opportunity to explore body language, actions, movements and spoken words, all will be transcribed and analysed using a thematic content analysis which has the flexibility to cross data formats . GreaterThe findings of this study will be written up for publication.Outputs: An interactive digital overlay, containing additional didactic information, questions and multimedia, will be added to the 360-degree video. This will be developed into an online educational tool for nursing students. This tool will be fully compatible with Canvas, a course management system that supports online learning and teaching.This research involves human participants, that is, student nurses enrolled on the BSc Mental Health Nursing course. We will not require a gatekeeper for this research as the students are known to the department. There will be no financial incentives to participate in this research; however, students will benefit educationally from the experience of participation. Ethical approval has been awarded for this study (reference: NNM-SREP-18-012). Approvals were sought through the University ethics application system.We are mindful that participation in this research could reveal a health/mental health issue. As we are interested in how stress might be remediated to improve students’ clinical experiences in practice, this will not be considered an incidental finding. Details of internal and external support agencies will be provided to the participants.Service users will facilitate the creation of the 360-degree video. A service user researcher experienced in facilitating service user involvement in research will provide support for those involved.In this study, the 360-degree scenario will be focused on a mental health service user in a state of emotional crisis, to enable student nurses in the field of mental health to explore what skills they have to enable them to cope and offer support. However, if successful, this approach might be tailored to other fields of nursing to allow the exploration of stressors in different settings. It may also beneficial in providing insight into how to work with mental health crisis for all fields of nursing.


Background and aimWard-round documentation is important for clinical communication and patient safety. Standardized checklists have improved ward-round documentation in surgical and medical settings. This quality improvement project aimed to introduce a standardized ward round proforma to improve documentation in a UK specialist stroke unit.MethodsWard round entries were assessed against internally agreed standardized criteria. A stroke-specific ward round proforma was designed and introduced with input from the multidisciplinary team. A repeat audit was performed, including assessment of the use of different proforma sections. Multidisciplinary team members were invited to provide feedback via an anonymous online survey.ResultsA total of 111 ward round entries were reviewed before the proforma was introduced. Ninety-five ward round entries were reviewed following introduction of the proforma, and 84.2% of these used the proforma for documentation. Overall documentation of standardized criteria improved from 48.7% to 62.1% with substantial improvement seen in documentation of neurological examination, presence/absence of mechanical venous thromboembolism prophylaxis, and blood test results. Multidisciplinary team feedback was positive.ConclusionsThe stroke-specific ward round proforma improved the quality and consistency of documentation in the unit. An updated proforma was designed using these results and multidisciplinary team feedback. Ward rounds are a focal point of hospital care facilitating multidisciplinary review of patients and management planning. They serve as a vehicle for communication within the multidisciplinary team (MDT) and between the clinical team and patients. The Royal College of Physicians (RCP) considers clear documentation of ward rounds "essential" for communication . Ward roStructured ward round approaches, including standardized checklists, are recommended by the National Institute for Health and Care Excellence (NICE), along with other professional bodies, as an intervention to improve patient outcomes ,3. ExtenSimilarly, multiple studies have demonstrated improvement in documentation, when measured against set criteria, following the introduction of a proforma for medical post-take ward rounds -7. OtherStroke is the leading cause of death and adult disability worldwide and occurs over 150,000 times a year in the United Kingdom (UK) . The NatThere is limited evidence to support the use of structured checklists in specialist stroke units. A 2015 study introduced an admission proforma in a stroke unit and found an improvement in the quality of clerking when measured against the RCP acute stroke management guidelines . AnotherWycombe General Hospital (WGH) houses a regional specialist stroke unit incorporating a hyper acute stroke unit (HASU) and a specialist rehabilitation unit. This quality improvement (QI) project aimed to introduce a ward round proforma to improve the consistency and quality of documentation in WGH Stroke Unit.Audit standardThe audit was approved by the Stroke Unit in Buckinghamshire Healthcare NHS Trust. The audit standard was a list of documentation parameters devised through internal consensus Table . These wProforma designAn initial draft of the ward round proforma was designed considering the consensus documentation criteria. The layout was modeled on a previously existing medical ward round proforma used in the same NHS Trust. Feedback was obtained through discussion with MDT stakeholders (as previously described) and the proforma was re-drafted multiple times in an iterative process. Wide-ranging changes were made, including adding dedicated space to document mood, electrocardiogram (ECG) results, cannula plan and current treatment escalation plan (TEP), items not included in the initial documentation consensus criteria Figure . The forThe proforma design was circulated electronically to junior medical staff and administrative staff to ensure printed copies were available on the ward. Documentation on daily medical ward rounds was performed primarily by junior medical staff who were encouraged, but not mandated, to use the proforma.Sampling of clinical notesAll patients admitted to the stroke unit between February 1, 2021, and February 15, 2021, were identified and their retrospectively uploaded paper clinical notes were accessed electronically. A maximum of three consecutive ward round entries were reviewed for each patient. Documentation of the consensus criteria was recorded for each ward round entry in yes/no format . The questionnaire comprised a combination of Likert scale, multiple choice, and free-text questions.Documentation standards pre-proformaA total of 111 ward round entries were reviewed during the initial audit , before the introduction of the proforma. Ninety-five ward round entries were reviewed following the introduction of the proforma . Prior to the introduction of the proforma, documentation of the date (99.1%), clinician leading the ward round (99.1%), signature of the documenting clinician 97.3%), and clinical issues/diagnosis (93.7%) were high. The least frequently documented parameters were discharge plan (18.0%), bowel function (18.0%), presence/absence of mechanical venous thromboembolism (VTE) prophylaxis (10.8%), and catheter plan (2.7%). No entries included documentation of hydration status  of ward round entries were documented using the proforma following its introduction and mean documentation of all criteria improved from 48.7% to 62.1%. All parameters improved except for nutritional status and signature, which fell from 27.0% to 14.7% and 97.3% to 95.8%, respectively , date (98.8%), clinical issues/diagnosis (98.8%), and observations (98.8%) Figure . The leaMDT feedbackAt least 39 MDT members were invited to complete the anonymous online survey. A total of 11, 28.2% of those invited, responded, including senior medical staff (2), junior medical staff (7), and nursing staff (2). All respondents were aware of the new ward round proforma and the majority felt it was either very easy (54.5%) or easy (27.3%) to find in the patient notes. All respondents reported that the proforma made documentation of patients’ medical issues more clear (81.8%) or much more clear (18.2%), and the majority agreed that key patient information including blood tests, scan results, and examination findings was easier (45.5%) or much easier (45.5%) to find in the patient notes, and that documentation of patients’ medical plans was more clear (27.3%) or much more clear (36.4%). Junior medical staff felt the proforma was very easy (44.4%) or easy to use (55.6%). The majority also felt the proforma had made ward-round documentation faster (44.4%) or much faster (11.1%). Free-text feedback about the proforma was positive and praised its clear structure, stating that it served as a prompt to check key information including VTE prophylaxis prescription, electrocardiograms (ECGs), and blood results. Respondents also provided suggestions to improve the proforma layout, including increasing the size of the neurological examination box and adjusting the placement of the column containing blood results.Introduction of the proforma resulted in improvement in documentation of the consensus criteria, with the greatest improvement seen in documentation of blood test results, day of admission, drug chart review , and presence/absence of mechanical VTE prophylaxis. More modest improvement was seen in documentation of observations, neurological examination, general examination, hydration status, and discharge plan, however, the neurological examination and discharge plan sections of the proforma were infrequently used. Feedback from the MDT was generally positive, with respondents reporting that the proforma made ward-round documentation clearer and easier to find in patient notes.The consensus documentation criteria generated in this QI project are broadly similar to those employed in similar studies, including observations, examination findings, and diagnosis ,6,7. SomThe proforma design resembles the traditional SOAP  framework utilized in similar QI projects ,18. ThisThe most important implication of these results is more comprehensive patient assessment during ward rounds. This is suggested by the considerable improvements seen in documentation of neurological examination and presence/absence of mechanical VTE prophylaxis, and more modest improvements in documentation of drug chart review, general examination, and hydration status. Daily physician ward rounds are associated with reduced mortality following stroke , and betMDT feedback was positive, suggesting the ward round proforma has made the documentation of medical issues and management plans clearer. Previous QI studies have suggested positive perceptions of ward round checklists amongst junior medical staff . A smallSeveral factors may explain the low rates of documentation of discharge plan, nutritional status, hydration status, bowel function, and catheter plan. Discussions around discharge planning may not have been appropriate for every patient, depending on numerous factors including stroke acuity, other active medical issues, and social circumstances. Hydration and nutritional status may have been poorly documented due to uncertainty among junior medical staff about the level of detail required. Data about the number of patients who were catheterized during admission were not collected. However, patients were not routinely catheterized on admission to the stroke wards, therefore the low completion rate of the catheter section of the proforma likely reflects a low percentage of patients with a urinary catheter during their admission. Furthermore, information about catheter care and bowel function was primarily nurse-held, and nursing documentation about these parameters may not have been routinely reviewed on the medical round.Using the results of this study, including survey feedback provided by the MDT, an updated proforma was designed with changes including multiple choice options for nutrition and hydration status, and removal of the catheter and discharge planning sections (Appendix). The size of the neurological examination box was increased as, although 71.3% of ward rounds documented a neurological examination following introduction of the proforma, only 28.8% used the section provided, with survey feedback suggesting this was due to insufficient space. The project was handed on to subsequent rotations of junior medical staff for repeat audit.This study is limited as it does not report the direct impact of improved documentation on patient outcomes. Furthermore, evaluating documentation fairly between the initial and repeat audit following proforma introduction was challenging for some parameters. For example, any evidence of drug chart review was accepted as sufficient for the initial audit, whereas the majority of ward rounds reviewed during the repeat audit documented VTE prophylaxis prescription (78.8%) and antiplatelet prescription (80.0%) in the relevant proforma section. These results, therefore, are likely to under-represent the impact of the proforma on the quality and specificity of ward-round documentation.In conclusion, we report the impact of introducing a ward round proforma in a specialist stroke unit in the United Kingdom for the first time. This resulted in improvements in the quality and consistency of documentation which suggested more comprehensive patient assessment during ward rounds. The greatest improvements were seen in documentation of blood test results, neurological examination, presence of mechanical prophylaxis, and day of admission. Documentation of nutrition status fell and documentation of bowel function, hydration status, and catheter plan remained disappointingly low, although improved. We have introduced an amended proforma using the data presented and MDT feedback.


Abdominopelvic arteriovenous malformation is an uncommon congenital vascular lesion, for which the diagnosis and treatment are usually difficult. Though embolization and sclerotherapy are the primary treatment strategies, traditional surgical resection remains a valuable option.Herein, we present a 32-year-old female diagnosed with a massive abdominopelvic arteriovenous malformation that originates from the splenic artery and drains into the portal vein. The vascular lesion was evaluated with multiple imaging modalities and then surgically resected successfully. The patient was discharged post-operatively on day 6 and free of symptoms during the 12-month follow-up.To our knowledge, the presented abdominopelvic arteriovenous malformation is the first to be reported in the literature, with such a rare condition originating from the splenic artery and draining into the portal vein. Abdominopelvic arteriovenous malformation (AVM) is an uncommon vascular lesion, for which the etiology is usually congenital, and the diagnosis and treatment are difficult. The AVM is characterized by abnormal connections between supplying arteries and draining veins . It may Most pelvic AVMs are supplied by internal iliac arteries, inferior mesenteric artery, or the median sacral artery –9, and aA 32-year-old woman was admitted to our center due to the finding of a pelvic mass with hypervascularity 2 years ago. She was generally asymptomatic and had no related family history. On physical examination, her mass was not palpable, but vascular bruits could be easily auscultated on the abdomen, especially in the peri-umbilicus area. The ultrasound revealed a pelvic mass with an abundant blood flow signal . CT angiArteriovenous malformation (AVM) belongs to the entity of vascular malformations, which are generally classified into slow-flow  and fast-flow malformations  . AVM is Pelvic AVM may be asymptomatic in some patients, and present as a pulsatile or vascularized mass on pelvic imaging. However, AVMs often progress throughout life, and a variety of symptoms could occur, such as urinary frequency or dysuria, pelvic pain, life-threatening hemorrhage, and high-output cardiac failure. It is well-known that the growth of AVM could be stimulated by various factors, such as puberty, pregnancy, and trauma. According to the Schobinger classification system, there are typically four stages for AVM lesions: stage I (quiescent), stage II (expansive), stage III (destructive), and stage IV (cardiac decompensation) . The curvia transarterial, transvenous, and sometimes direct percutaneous access could profoundly evaluate the AVM. The successful treatment of AVM depends largely on the diagnostic imaging, which needs to provide information on the location, extension, composition, vessel diameters, and hemodynamics of AVM.The pelvic AVMs are usually first detected and evaluated by color Doppler ultrasound, which could offer an impressive overview of the lesion with hypervascularity signals . MR angiTreatment of AVM is notoriously challenging, as inappropriate treatment could stimulate the AVM lesion into an aggressive growth state . AlthougHere we presented a condition of AVM that might not have been described in the literature before, which had a massive vascular nidus in the pelvic cavity with feeding artery from splenic artery and draining veins into portal vein. The AVM was profoundly evaluated with color Doppler ultrasound, CT angiography, and catheter angiography, and it was demonstrated as a well-localized lesion that did not involve other organs or the pelvic wall. For this case, surgical resection was considered to be a superior strategy to endovascular therapy. As the AVM had relatively simple angioarchitectures without involving vital adjacent vital organs, surgical resection could provide a definite and effective treatment, while interventional therapy had the risk of incomplete or ectopic embolization.The patient was treated successfully with surgical resection of the AVM and ligation of the feeding artery and draining veins. A major concern of the surgery was that removal of the AVM might significantly decrease the blood flow into the liver and cause ischemic liver injury. Fortunately, the patient recovered well and showed no signs of liver injury after the operation. The post-operative CTA showed no evidence of residual arteriovenous connections, and she lived uneventfully during the 12-month follow-up.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the institutional Ethics boards of the Second Xiangya Hospital. The patients/participants provided their written informed consent to participate in this study.XL and JL drafted the manuscript. CS and QL designed the study. HH and ML revised the manuscript. MW, JW, and LW were responsible for the collection of data or analysis. All authors read and approved the final manuscript.This work was supported by the National Natural Science Foundation of China (grant numbers: 81870345 and 82120108005) and the Natural Science Foundation of Hunan Province, China (grant number: 2020JJ2054).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.


Representatives for dentists are required for many governing committees, local and national, that contribute to many aspects of the profession related to politics, the workplace, education, or community-building. Developing skills as a representative can begin as an undergraduate in student representation systems as part of UK university governance structures. At one UK dental institution, there was a plan to explore the learning and skill development of current student representatives, review the training, identify any areas where there were gaps or where they should be strengthened, and consider whether a new training programme could be developed. Training gaps in the representation process and preference for peer mentoring in training were identified as students acknowledged learning 'on the job' through observation of experienced peers. Current representation training also fell short of highlighting the relevance to their future dental profession. Staff and students co-designed a bespoke programme of training to help students develop their representation skills, as well as align them to the development of professional skills which were determined to be relevant for their future dental career. Outlines a selection of representation opportunities in the UK dental community.Explores professional skills developed by students through representation activities.Outlines a method for developing representation skills and the relevance of these. This paper outlines representation opportunities in the UK dental profession and considers development of skills for dental students to support representation roles. Dental student opportunities in academic representation are described, together with a description of training that was co-designed and delivered by students and staff.1 This involves liaising with those who they represent and clearly articulating their views. The expectation is that positive outcomes will typically result for both the profession and patients.2Speaking or acting on behalf of another in representation is found throughout dentistry in various guises. The British Dental Association (BDA), as the trade union for dentists, primarily describes representation as involving elected individuals working to present the views of the electorate as the 'voice of members', thereby furthering their cause.1 However, there are multiple other organisations and structures which support representation within dentistry. These are grouped into those most closely aligned with recently qualified dentists  in dental schools; dental foundation training scheme representatives on Health Education England and deanery committees soon after graduation; and Royal College committees throughout training. These committees focus on optimising educational and training experiences for their electorate and promoting the cause of the areas they represent.Workplaces offer a range of representational structures and committees. Roles such as the BDA Accredited Representative act in a trade union capacity to support employed dentists within their workplace.4 but those same representatives sit on the BDA Students Committee delivering political representation. BDA Young Dentists Groups and branch councils include community-building representation regionally, in addition to organising educational events.The representation opportunity categorised as building community comprises mainly elected roles, where the priority is to support networking, support and social opportunities. There is significant overlap with other categories of representation. The British Dental Students Association serves this purpose, with its representatives organising social events for dental students5With many representation roles available, awareness of the need of representation, encouragement to participate and appropriate training is warranted. It has been recognised that diversity in representative roles must be improved, which includes greater involvement of newer members of the profession, who may require additional training.6,7,8The Newcastle University's academic representation system, overseen by Newcastle University's Students' Union (NUSU) is part of this quality assurance process that is supported through SSC meetings where student representatives in the School of Dental Sciences gather peer opinion on the quality of their programme, bring items for resolution and feedback actions to their cohort  and subsequently analysed by thematic analysis.The two student interns considered secondary data in the form of training material provided to student representatives: the NUSU training lecture slides and the Course Representative Handbook material was reviewed for content related to the development of professional learning opportunities.In response to findings in Phase 1 and Phase 2, a new programme of training was co-designed by the student interns, the dental school's staff facilitator and the NUSU representation and research coordinator. A series of meetings led to design and development of lesson plans for two workshops, creation of workshop activities and presentation slides, practice sessions and workshop implementation followed by debrief. A University Research Ethics Committee ethical review application (no. 13512/2016) determined the project low-risk. Participants provided written consent to participate in the focus group and to be audio recorded. They could withdraw at any time. The project was supported through an internal university-wide Education Innovation Fund and a Faculty Educational Research and Development Project grant.Five students took part in the focus group (age range of 18-25 years). Participant role, sex and length of involvement in the Academic Representation system are shown in most professional way' and supporting others in meetings. They also recognised the responsibility to others within the system and the importance of this in the success of the meeting: have responsibility for your reps. I think it's just a little bit more of a leadership, communication kind of role'.'Participants discussed their representation role responsibilities: ensuring preparation for meetings, conducting the role in the 'how you represent your year') and how their role meant they had a 'place in the system' which could be developed:I felt a bit out of place about bringing things up with senior members of staff but I feel like now it's quite a friendly atmosphere'.'Examples related to the identity of themselves and others in the representation system, what they brought as individuals  and there was some confusion as to what should be shared:An individual came to me and asked me about a specific thing which I brought to the SSC on Wednesday and do I just tell that individual the result of it or do I spread it year wide?''Students faced challenges in mechanisms of feeding back to share meeting outcomes with their peers  and that this did lead to actual change:When [anonymous] chairs the Board of Studies meeting, you sort of pick-up tips and advice as you go along'.'Learning about the role revealed the importance of observation of others and that they were also learning from observing staff in staff-led education meetings:I sort of learn on the job I guess, it's quite good to have that awful SSC meeting quite early, sort of like, get it out of the way. I can't imagine it would get any worse than that'.'Participants spoke of learning from earlier, less successful attempts at meetings. Students agreed that going through the process makes them learn but disliked the negative feelings when they began and refer to some early experiences as 'awful'. Conversely, students feel these difficult situations help them progress:Not everyone agrees with what you think, [we] should be honest. You also have to defend a statement if you think it's in the patient's best interest'.'There were elements of learning that linked to professionally relevant contexts; working in the best interests of students and, for clinical year students, 'the patients'' best interests:It's quite interesting to be able to kind of adapt the way you speak about things and think about things depending on where you're placed in a particular situation'.'Participants also talked about understanding the confidentiality and discretion associated with representing someone's views, raising concerns and being impartial:12 related to representation activity, the group were confident that most, if not all professional principles aligned to aspects of the representation process:I'd honestly say possibly all of them, you could apply it to everything. Like patients' interests first, we had the discussion about patient confidentiality, things like that''Communication, complaints procedures, I mean that's basically what it is isn't it?''When asked if they thought the professional principles set out by the General Dental Council (GDC)Some felt that their professional skills were developed directly when patient-centred discussions took place within the SSC forum. There was also a feeling that professional principles could be developed further by applying them to indirect situations not relating to patient care; in essence, those relating to professional dealings with student colleagues and staff.This review found only brief mentions of the benefits of involvement in student representation, mainly focusing on achievements in influencing the educational experience rather than personal development. Training did not significantly encourage continued involvement in representation and as such, student turnout at meetings had a tendency to reduce as the year progressed. Nothing was mentioned about specific skill development and potential influence for future career.Structured representation activities, such as agenda writing, that are interactive and include skills practiceInvolvement of current representatives in the training, for example, as mentors - a personal development and progression opportunity for themIncrease recognition of professional skill development in representationInformation about professional representation opportunities at different career stages.From focus group findings and training review, potential opportunities to improve training were identified:A pilot programme was developed to supplement the training lecture. This was optional and limited to those with an active role in the representation system. A key design element was that training would be student-led and supported by staff.Two interactive workshops were developed and spaced apart in the academic year to allow practical meeting experience between training workshops.Designed to explore the meaning and importance of representation and the process required to enable effective representation. Each activity was underpinned by real examples from SSC meetings and the student lead for the workshop supported participants by sharing their own experiences, guiding discussion and activities.Students worked through actual SSC scenarios and aligned experiences with professional principles. The workshop highlighted opportunities for representation at different career stages. This was delivered by a dentist with experience in local and national committees. This was illustrated with examples from the speaker's own career and achievements secured through those representative structures.Participants were assessed after each workshop by a reflective piece of writing. Successful programme completion resulted in a Newcastle University Students' Union 'Professional learning through Representation Award'.Gave me an idea of where our representation roles can take us in the future. Also that our skills can be used outside of the university and dental school in a vast number of roles that we can make a difference''I think I definitely benefited from the workshops and they advanced my understanding of the workings of the dental school and the larger student body as well'.'A short pilot-programme evaluation was disseminated to all participants. This highlighted appreciation of the interactive nature of the workshop and the opportunity to have open discussion of their experiences with students from other stages:8 There is an acknowledged paucity in the dental literature on the benefits to students in engaging with these processes compared with other professional courses, such as medicine and nursing.13 Effective representation can be transformative by empowering voices and there is evidence that effective student representation not only benefits the students involved, but also education providers and society.14 Where dental students are discussing issues around patient care alongside their curriculum, this also supports the requirements outlined as part of the GDC's Standards for education15 where education providers should attain multi-source feedback (including student feedback) on quality assurance aspects of the programme. As well as this, education providers should have a variety of mechanisms to ensure concerns about patient safety aspects can be raised.Academic representation is an extracurricular activity that allows students to feedback on behalf of their peers to the institution about their learning experience and provides opportunities for the student voice to influence education.1 Through developing an understanding of the art of representation, a dentist can help to support and represent colleagues in their dental practice or other workplace. They can also ensure that systems are in place to enable the views of patients to be adequately represented, such as through a patient forum, which can enhance service development and outcomes.16 Other skills which are developed through being a representative, such as communication skills and leadership skills, bring additional benefits and opportunities to progress throughout careers.12The skills involved in representation and the act of representation in itself are highly valuable post-graduation, during a dental career.1 Through influencing policy, these undertakings will benefit many dentists, frequently including the representative themselves. Representation opportunities exist via trade unions such as the BDA and also Royal Colleges, learned societies and other representative structures and networks.At a national, regional or local level, using these skills to become involved in political representation, or representation in an educational setting, can yield powerful results for the profession and oral health.17 Through supporting the next generation of dental students to gain representation skills, it is hoped that the numbers and diversity of dentists involved in such representational structures will increase in future, thereby improving that representation. It is also important to acknowledge that those students who take part in representation and moreover, the training programme, are likely to be actively engaged students. Widening access to the training and encouraging more student voices to take up representation roles will be an important commitment going forward to ensure diverse voices are heard and opportunities afforded to more.18These representative structures are not always aligned with the demographics of the population being represented and there are frequently gaps.Within Newcastle University School of Dental Sciences, the workshops have now been delivered for three consecutive academic years with a total of 15 students completing the award. With the COVID-19 pandemic, workshops moved to a similar but online format in the academic year 2020-2021, which complemented the fact that all SSC meetings were held online. Students who have completed the award also now take a role in leading the training programme.Workshop participants have progressed in their roles in the representation system from course representative to student chair and school representative. They have also moved into other roles including equality, diversity and inclusion representatives. Participants have also gone on to achieve NUSU's 'Academic Rep' Awards and 'Pride of Newcastle' Awards. Other outcomes have included dental graduates taking on representation roles during their foundation year, including involvement in the Deanery Representation Programme and the local BDA committee.A limitation of this work was that only one focus group, with five participants, took place. Participants had different levels of experience, ranging from only a year in a representation role to four years of experience. While this divided the group demographic, it did mean that there were perspectives from those who had recent training and those who had more experience to reflect on the applicability of the training.7,8,18 Further exploration of this would be useful, along with evaluating the direct relevance of this training programme to future practice.The programme is available to those who wish to further develop their skills. A future direction would be to include all student representatives with an overall aim to enhance engagement and quality in representation. Motivation for undergraduates to become involved in representation can include many reasons, such as to get to know and help people, personal gains and opportunities to make their CV stand out.By exploring the learning students experienced by taking part in representation and identifying training needs, we designed a bespoke programme to help develop representation skills and understanding of future opportunities.