Malnutrition mortality in older adults is underrepresented in scientific literature. This obscures any recent changes and hinders needed social change. This study aims to assess malnutrition mortality trends in older adults (≥ 65 years old) from 1999 to 2020 in the United States (U.S.).Mortality data from the Centers for Disease Control and Prevention’s (CDC) Wide-Ranging Online Data for Epidemiology Research (WONDER) database were extracted. The ICD-10 Codes E40 – E46 were used to identify malnutrition deaths. Crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) were extracted by gender, age, race, census region, and urban–rural classification. Joinpoint regression analysis was used to calculate annual percentage changes (APC) of AAMR by the permutation test and the parametric method was used to calculate 95% confidence intervals. Average Annual Percentage Changes (AAPC) were calculated as the weighted average of APCs.Between 1999 and 2020, 93,244 older adults died from malnutrition. Malnutrition AAMR increased from 10.7 per 100,000 in 1999 to 25.0 per 100,000 in 2020. The mortality trend declined from 1999 to 2006 , plateaued till 2013, then began to rise from 2013 to 2020 with an APC of 22.4  and an overall AAPC of 3.9 . Persons ≥ 85 years of age, females, Non-Hispanic Whites, residents of the West region of the U.S., and urban areas had the highest AAPCs in their respective groups.Despite some initial decrements in malnutrition mortality among older adults in the U.S., the uptrend from 2013 to 2020 nullified all established progress. The end result is that malnutrition mortality rates represent a historical high. The burden of the mortality uptrends disproportionately affected certain demographics, namely persons ≥ 85 years of age, females, Non-Hispanic Whites, those living in the West region of the U.S., and urban areas. Effective interventions are strongly needed. Such interventions should aim to ensure food security and early detection and remedy of malnutrition among older adults through stronger government-funded programs and social support systems, increased funding for nursing homes, and more cohesive patient-centered medical care. Malnutrition is a complex multi-factorial condition defined as a decrease in body fat and/or muscle mass due to diminished intake or absorption of nutrients . MalnutrMalnutrition can impact people of all ages. However, older adults (≥ 65 years old) can be particularly susceptible due to a combination of risk factors . Aging cEstimates show that around 25% of older adults are malnourished or at risk of malnutrition with an expected rise as the population continues to age . By 2030This study used data produced by the National Center for Health Statistics (NCHS) available through the Centers for Disease Control and Prevention Wide-Ranging On-Line Data for Epidemiologic Research (CDC WONDER) database . Data arP value of < 0.05 denoted statistical significance. Institutional review board approval was not required as all data used are in the public domain and de-identified.To analyze mortality trends from 1999 to 2020, Joinpoint Regression Program V 5.0.0.0, provided by the National Cancer Institute (NCI), was used . This pr. Mortality rates were highest in females , Non-Hispanic Blacks , persons aged ≥ 85 years , residents of the South region , and small metropolitan counties  From 1999 to 2020, AAMR increased from 10.7 to 25.0 . There was a significant gradual decrease from 1999 to 2006 . This was followed by a near-plateau from 2006 to 2013 , which was followed by a significant increase from 2013 to 2020   in the 65 – 74 age group, 21.1  in the 75 – 84 age group, and 118.9  in the ≥ 85 age group. On the other hand, the age groups with the highest AAPC were the ≥ 85 age group  and the 65 – 74 age group , followed by the 75 – 84 years age group   compared to 9.5  in males. Furthermore, Females had higher AAPC  from 1999 to 2020 , Non-Hispanic Whites had the highest AAPC . Non-Hispanic Asians had an AAPC of 3.7 . Hispanics had an AAPC of 3.2 . Lastly, Non-Hispanic Blacks had an AAPC of 2.9 . A detailed summary of the results is provided in Fig. Trends for regions and counties mirrored the trends for the overall population, with an initial decline in malnutrition AAMR which was subsequently nullified by a strong uptrend. The rate of increase differed by different regions and counties. Overall, the West had the highest AAPC  as its AAMR increased from 7.6 in 1999 to 27.4 in 2020, while Northeast had the lowest AAPC over the study period   while rural counties had an AAPC of 2.5 . Further subgroup analysis showed that small metropolitan counties had the highest AAPC. . Noncore counties  had the lowest AAPC  and the change was not statistically significant. The counties with the lowest significant AAPC were micropolitan . A summary of the subgroup analysis is provided in Fig. Our study highlights a worrying trend in malnutrition-related deaths among older adults. Although an initial period of decline in malnutrition mortality was seen from 1999 to 2006, this was not long-lasting. It was followed by a plateau between 2006 and 2013 and an eventual uptrend from 2013 to 2020, at a rate sharper than the initial rate of decline. The end result is that malnutrition mortality rates among older adults in the U.S. are at a historical high.The increase in mortality rates is likely attributable to a confluence of risk factors for malnutrition rather than a singular culprit. Further, we suspect the changing mortality trends between 1999 and 2020 were due to the delicate balance between risk factors and protective factors for malnutrition, which at different points in time, succeeded in outpowering the other.Because economic prosperity has long been established as a crucial determinant of population health , 18, theThe economic stressors that followed during the Great Recession may have placed tremendous financial and psychological stress on older adults, particularly the economically disadvantaged. This destabilization of protective factors for malnutrition was likely responsible for the plateau in the mortality trend from 2006 to 2013.After years of progressively waning, protective factors could not prevent the 2013 uptrend in mortality. While the U.S. continued its astronomical spending on healthcare, the value of healthcare spending in the older adult population has been decreasing over time . Upon clMoreover, the high spending on healthcare could be driving resources away from public health problems in need of funding and contributing to malnutrition. For example, despite several studies showing the training of nursing home staff on diet quality improvement and feeding assistance care leads to improvement of malnutrition indices of residents , 27, funMore broadly, the fall of protective factors for geriatric health is reflected in other indices: all-cause mortality in older adults only declined from an AAMR of 4267 per 100,000 in 2013 to an AAMR of 4074 per 100,000 in 2019. The initial decline in mortality rate from 1999 to 2006 (decline of ~ 600) far outpaced the decline seen from 2013 to 2019 (decline of ~ 200) . AdditioFurther contributing to the recent uptrend in malnutrition mortality are the rising risk factors for malnutrition. Among the number of potential culprits is a growing burden of comorbidities. For instance, depression is an established risk factor for malnutrition , due to Diseases, outside the realm of mental health disorders, have also been shown to increase the risk of malnutrition . ConsideThe growing utilization of nursing homes, whose utilization has more than doubled between 2000 and 2013  may alsoOther maladies that defy biomedical labels but which are nevertheless crucial in influencing geriatric health should also be considered. A previous study identified social isolation and subjective loneliness, two growing public health concerns , as indeFurther, recent data indicates that, although poverty rates among older adults declined significantly since 1975, this decline reached a plateau since approximately 2011 . It is pThe unequal distribution of modifiable risk factors, like poverty, is part of a larger problem of health disparity where certain socially disadvantaged groups systematically experience greater obstacles to health . TherefoThe steep mortality uptrend in persons ≥ 85 years of age is due to a rising average age in this subgroup . As prevAs for gender, female older adults were more affected by malnutrition than their male counterparts in other studies as well , 64, 65.Non-Hispanic Whites experienced the greatest rise in their malnutrition mortality trend. Indeed, they have multiple risk factors with reports of the highest rate of severe depression and decreased social contact compared to other races . FurtherFurther, the West was the census region with the steepest rise in its malnutrition mortality trend. There are likely many contributing factors as to why this may be. Recent data from the American Community Survey shows that 11.6% of all counties in this region experienced an increase in poverty among those aged 65 and above . HoweverThe higher uptrends of mortality in urban  areas may at first seem perplexing in light of known difficulties in accessing healthcare in rural areas and the consequently higher rates of mortality and shorter life expectancies , 74. ThiThis study has several limitations. First, the determination of the underlying cause of death by clinician adjudicators carries a risk of underestimation, as malnutrition may not be readily identified in clinical practice, particularly if the individual lacks access to healthcare services and does not have a long-established relationship with a primary care physician. Therefore, the number of deaths driven by malnutrition may be underestimated. A further limitation is that ICD codes in the ICD-10/9 systems may be less suitable for high-income settings such as the U.S. This is because the clinical picture of malnutrition has evolved and is no longer necessarily associated with absolute impoverishment and deprivation but is also commonly found in adults who may, in fact, be obese but still suffer the effects of malnutrition. This likely adds to the underestimation of malnutrition-driven deaths. Third, this study did not include American Indians/Alaska Natives in the analysis stratified by race/ethnicity due to several missing data points. This is because the relatively low number of deaths leads the CDC to censor the data due to fear of individual identification. Future analyses including older individuals from these ethnicities will shed more light on malnutrition deaths in these populations. Fourth, it may have been of interest to delineate these uptrends by additional factors such as income, employment status, and the presence of health insurance. However, as CDC WONDER does not contain data on these variables, we were unable to conduct these analyses. Future analyses linking CDC WONDER data to county-level characteristics may be helpful in understanding the drivers of these deaths and the counties that may be ideal to target with interventions aimed at curbing malnutrition among older adults.The delicate balance between protective factors and risk factors drove the fall and rise of the malnutrition mortality trend between 1999 and 2020. Despite some initial decrements in malnutrition mortality among older adults in the US, the recent uptrend from 2013 to 2020 outpaced the preceding decline. The end result is that contemporary malnutrition mortality rates represent a historical high. The burden of the mortality uptrends disproportionately affected certain demographics, namely persons ≥ 85 years of age, females, Non-Hispanic Whites, those living in the West region of the U.S., and those living in urban areas. Effective interventions are needed to ensure food security and the early detection and remedy of malnutrition among older adults. Such interventions may include stronger government-funded programs and social support systems, incentives that reward the detection of malnutrition, and more cohesive patient-centered medical care for older adults.


Here, extensive molecular dynamics simulations  predicted over 10 inner-shell Mg2+ ions in the SAM/SAH riboswitch. Six of them line the two sides of a groove to widen it and thereby pre-organize the riboswitch for ligand entry. They also form outer-shell coordination with the ligands and stabilize an RNA-ligand hydrogen bond, which effectively diminishes the selectivity between SAM and SAH. One Mg2+ ion unique to the apo form maintains the Shine–Dalgarno sequence in an autonomous mode and thereby facilitates its release for ribosome binding. Mg2+ thus plays vital roles in SAM/SAH riboswitch function.The SAM/SAH riboswitch binds S-adenosylmethionine (SAM) and S-adenosylhomocysteine (SAH) with similar affinities. Mg Molecular dynamics simulations reveal site-specific mechanisms of Mg2+ ions in conformational transitions of the SAM/SAH riboswitch for ligand and ribosome binding. Riboswitches, mostly found in bacteria, are located in the 5ʹ-untranslated regions of mRNAs and typically consist of two domains: aptamer and expression platform3. The aptamer domain binds ligands such as metabolites and triggers the expression platform to turn on or off gene expression5. S-adenosylmethionine not Fig. , which cnot Fig. . The nuc21. As just noted, G38 base-stacks with the ligand. G39 forms a base triple with two other nucleobases, G9 and C14  sequence (G38-G39-A40-G41) can be freed to bind with the ribosome and initiate translation when no ligand is presentC14 Fig. . As G9 i22. Due to its small size and double charge, Mg2+ is special for RNA structural stability, e.g., by forming bidentate coordination with two adjacent phosphates23. Moreover, Mg2+ has been implicated in many other roles, including promoting folding or conformational transition28 or rescuing misfolding29, mediating ligand binding36, and participating in catalysis37. In particular, although imino proton NMR spectra demonstrated that the env9b SAM/SAH riboswitch is capable of binding SAH in the absence of Mg2+, isothermal titration calorimetry measurements showed that Mg2+ significantly increases the binding affinities of the riboswitch for both SAH and SAM20. However, identifying Mg2+ ions in RNA structures by experimental approaches is very challenging. Although the diamagnetic Mg2+ in theory can lead to changes in NMR spectra of RNA, the effects may be small and challenging to resolve38. For example, the NMR structure 6HAG, though determined on samples in 2 mM Mg(OAc)2, has no information on Mg2+. For X-ray diffraction, because Mg2+, Na+, and water molecule all have the same number of electrons, distinguishing them is difficult and requires high resolution39. The total number of Mg2+ ions in non-ribosome RNA crystal structures at worse than 2.1-Å resolution is very low. The 1.7-Å structure 6YL5 of the SK209-2-6 SAM/SAH riboswitch, crystallized in a buffer containing 10 mM MgSO4 and 50 mM sodium cacodylate, resolved no Mg2+ but a few Na+ ions forming inner-shell coordination with the RNA21.Because electrostatic repulsion of the phosphate backbone of RNAs would lead to unstable tertiary structures, cations are essential to provide charge neutralization2+. For example, MetalionRNA  uses a statistical potential to predict metal ions inside RNA structures40; MCTBI (http://rna.physics.missouri.edu/MCTBI) predicts tightly bound ions by Monte Carlo sampling42; and MgNET is a convolutional neural network model trained on a set of crystal structures containing RNA and Mg2+ ions43. Molecular dynamics (MD) simulations have been used to predict or characterize Mg2+ binding sites in RNA51. When Mg2+ ions are initially placed in the solvent51, it can be difficult for them to form inner-shell coordination with RNA during typical MD simulation times, due to the high barrier for dehydrating Mg2+ 46. Different approaches have been developed to enable the sampling of inner-shell sites by Mg2+, including bias-exchange metadynamics45, the use of an effective potential27, and grand canonical Monte Carlo28. By initially placing Mg2+ ions at sites predicted by a structure-based method such as MCTBI, we have demonstrated success in achieving Mg2+-RNA inner-shell coordination in MD simulations48. MD simulations have also shown that Mg2+ can promote the conformational transition of an RNA26, quench conformational fluctuations50, and stabilize ligand binding48.A variety of computational approaches have been developed to predict metal ion binding sites in RNA structures or applied to elucidate the roles of Mg2+ mediates ligand binding and conformational transition. Eleven Mg2+ ions stably form inner-shell coordination with backbone phosphates of the riboswitch, whether it is in the apo form or bound with SAM or SAH; nine of these sites are common among the three forms. Six of the common sites line either side of a groove that provides the entryway for the ligand. In the apo form, Mg2+ ions at these sites widen the groove and thus pre-organize the riboswitch for ligand binding. Once the ligand is bound, three of these Mg2+ ions can alternately form outer-shell coordination with the carboxy moiety of the ligands and also stabilize an additional U16-ligand hydrogen bond. These interactions have the effect of diminishing the selectivity between SAM and SAH. A unique inner-shell Mg2+ ion in the apo form maintains a curved shape for the G38-G39-A40 backbone, thereby loosening their base-pairing with C15-C14-U12 and facilitating the release of the SD sequence for ribosome binding.Here we carried out 120 μs of MD simulations on the env9b SAM/SAH riboswitch ], enough to neutralize the charges on the RNA. In the above two protocols, Na+ ions  were placed into the solvent. The third protocol also relied on Leap but we added Na+ ions around the RNA and placed 41 Mg2+ ions into the solvent [Leap(41)]. We also studied the case where the RNA and ligand molecules were only neutralized by Na+ and no other ions were present (modeling the Mg2+-free condition).Our MD simulations used the SAH-bound NMR structure 6HAG as the initial structure. We replaced SAH with SAM to generate the SAM-bound form and removed SAH to generate the apo form. Following our previous study53  protocol, we ran four replicate 1-μs simulations of the liganded forms starting from each of the 10 models in 6HAG, and calculated the interaction energies of the 43 nucleotides of the riboswitch with the ligand by the MM/GBSA method53 Fig. . Consist53 Fig. , only fir) between the interaction energies from any two starting models  protocol closely match those from the Mg2+-free simulations  protocol is intermediate between those of the MCTBI and Leap(41) protocols (see next subsection), and correspondingly the nucleotide-ligand interaction energy results are also intermediate 20.Compared to the nucleotide-ligand interaction energies obtained from the simulations with Leap(41) protocol Fig. , the resons Fig. . The ext2+ and to draw the most contrast with the Mg2+-free condition. While the 5ʹ-deoxyadenosyl group of the ligand is buried in the binding pocket, the aminocarboxypropyl group and the sulfur center are exposed to a groove defined by nucleotides 5–8 and 12–16  in the SAH-bound form20  of the riboswitch throughout the simulations. With the Leap(21) protocol, the numbers of inner-shell Mg2+ ions reduced to 6, 9, and 8, respectively  of Mg2+ around oxygen and nitrogen atoms on the backbone and bases. Inner and outer-shell coordination can be identified from RDF peaks at 2.0 Å and 4.3 Å, respectively  but moderately reduced between either liganded form and apo (inset table). In Fig. 2+ ions around the RNA, superimposed on a representative snapshot of inner-shell Mg2+ ions.In Fig. 2+ ion, we identified its coordinating phosphates by calculating the distributions of their distances  harbors the last conserved inner-shell Mg2+ ion M9, and the 3ʹ strand of stem S2 harbors one last inner-shell Mg2+ ion, M10, only in the apo form. Below we present further details of these Mg2+ ions and their structural and functional consequences.For each inner-shell MgM10 Fig. . A few MdP6-P14, between the phosphorus atoms of A6 and C14, to measure the groove width . Mg2+ saturation also results in groove widening in the liganded forms.As presented above, the 5ʹ-deoxyadenosyl group of the ligand is buried in the binding pocket, with the groove defined by nucleotides 5–8 and 12–16 providing the entryway. We used the distance, dth Fig. . The grog2+ Fig. . Interes2+ ions widen the ligand-entry groove and thereby pre-organize the riboswitch for ligand entry. Six conserved inner-shell Mg2+ ions, M1–M6, line the two sides of this groove  of the four replicate simulations  for SAH but much less so (49.9%) for SAM, and hence a greater contribution of G17 to the binding energy of SAH. The O6-N1 contact does not always satisfy the angular requirement of a hydrogen bond (donor-H-acceptor angle > 120°), but the short distance still results in a significant van der Waals interaction.We have noted above that U16 and G17 also make a greater contribution to the binding energy for SAH than to the counterpart for SAM : in the U-shape conformation, N1 gets close to U16 O4 but C15 moves away, whereas in the L-shape conformation the opposite occurs. Therefore the methyl can interfere with U16-ligand amino hydrogen bonding, thereby explaining the much higher propensity of forming this hydrogen bond by SAH and the greater contribution of U16 to the binding energy of this ligand.For SAM, the methyl (C15 atom) on the sulfur center can potentially clash with the U16 O4 Fig. , in whicr = 0.87).When this hydrogen bond with U16 is formed, it places the carboxy moiety in a position to form outer-shell coordination with M6. Therefore, when the methyl of SAM interferes with U16-ligand amide hydrogen bonding, it simultaneously interferes with M6-ligand carboxyl outer-shell coordination. In simulation MD4, where SAM forms M6-ligand carboxyl coordination with 94.9% probability  from the center of the binding pocket   Fig. . The disdpk-B37 ~ 4.7 Å) or far away from the binding pocket , spending roughly equal times in the two positions  line the ligand-entry groove to widen it, thereby pre-organizing the riboswitch for ligand binding. M2, M5, and M6 alternately form outer-shell coordination with the ligands. In addition, M6 stabilizes U16 and G17-ligand amide interactions. These interactions occur with reduced probability for SAM due to the interference of its methyl, thereby countering the general favorability of this ligand over SAH and diminishing the selectivity between these two ligands. One Mg2+ ion, M10, unique to the apo form maintains the SD sequence in a curved conformation and weakens its base-pairing with upstream nucleotides, thereby facilitating its release for ribosome binding.We have carried out extensive MD simulations to investigate the essential roles of Mg1H-13C hetNOE data20. The mobility of the ligand carboxy moiety seen in our MD simulations is supported by its different orientations in the NMR structure 6HAG and crystal structure 6YL521 ; this Na+ is similar to our M2. The second Na+ ion forms inner-shell coordination with G20 and outer-shell coordination with C19, close to our M8. The third Na+ ion forms inner-shell coordination with G39 and outer-shell coordination with A40 (via both phosphate and N7). Interestingly, this Na+ ion is very much like our M10, except that ours is found in the apo form. Comparing backbone shapes of the nearby nucleotides, we find that 6LY5 is more curved than 6HAG  of the riboswitch, four types of Mg2+ initial placement were applied  addition of 25 Mg2+ ions at sites predicted by MCTBI42; (iii) addition of 21 Mg2+ ions  around the RNA as part of the solvation step using Leap; and (iv) addition of 41 Mg2+ ions in the solvent using Leap. Type (iv) was applied to all the 10 models in 6HAG for the two liganded forms; in all other cases only model 5 was prepared. In the solvation step, the RNA [plus Mg2+ in the case of type (ii)] was placed in a truncated octahedron periodic box of TIP3P54 water molecules. The number of water molecules was approximately 15580. Neutralizing Na+ or Cl− ions and 0.15 M NaCl [except type (i)] were also added. In (ii) and (iii), Mg2+ was added around the RNA whereas Na+ was placed into the solvent; in (iv), the opposite was true: Na+ was added around the RNA whereas Mg2+ was placed into the solvent. The distance from the RNA molecule to the edge of the box was at least 12 Å.The initial SAH-bound structure of the SAM/SAH riboswitch was from the NMR structure 6HAG55, with correction for α/γ dihedrals (bsc0)56 and correction for χ dihedrals (χOL3)57. The parameters for Mg2+ were from Li et al.58; those for Na+ and Cl− were from Joung and Cheatham59. To generate force-field parameters for the ligands, the structures of the ligands were optimized using the Gaussian16 program60 at the HF/6-31 G* level. The atomic partial charges were assigned using the restrained electrostatic potential (RESP) method61; other parameters were taken from the general Amber force field62.The force field for RNA was an improved version of AMBER ff9952. To start, each system was minimized by the steepest-descent and conjugate-gradient methods, each for 2500 steps. The preparatory stage of the simulation consisted of 50 ps of temperature ramping from 100 K to 300 K at constant volume, 50 ps at 300 K and constant volume, and 50 ps at 300 K and 1.0 atm pressure while restraining the RNA and ligand atoms with a force constants of 5 kcal/(mol·Å2). The equilibration stage was 1 ns at constant temperature and pressure (without restraints). The production run was carried out in four replicates for 1 μs at constant temperature and pressure. The temperature (300 K) was regulated by the Langevin thermostat63, and pressure (1.0 atm) was regulated by the Berendsen barostat64. Long-range electrostatic interactions were treated by the particle mesh Ewald method65 with a direct-space cutoff of 12 Å. Bonds involving hydrogen atoms were constrained by the SHAKE algorithm66. The time step was 2 fs. Frames were saved at 100 ps intervals for later analysis.Energy minimization and MD simulations were carried out using the AMBER18 package53 using AMBER18. Results were obtained for 5000 frames in the second 500 ns of each replicate simulation, and then averaged over four replicate simulations (or further over 10 starting models).The interaction energies were calculated by the MM/GBSA method2+ ions within a distance bin (0.05-Å width) from a given RNA atom, normalized by the expected number of Mg2+ ions in that bin assuming uniform density. RMSFs, RDFs, distances, and hydrogen bond formation were calculated by the CPPTRAJ program67. Hydrogen bonding criteria were: donor-acceptor distance <3.5 Å and donor-H-acceptor angle >120°.All other analyses were done on 10000 frames in the entire 1000 ns of each replicate simulation and then averaged over four replicate simulations. RMSFs were calculated by first aligning using backbone atoms  of the riboswitch to obtain an average structure and then finding the deviations of a specific set of atoms from the average structure. The set of atoms was: (i) H1′ and C1′; or (ii) H6 and C6 (C and U nucleotides) or H8 and C8 (A and G nucleotides). RDFs were calculated from the number of Mg2+ions was calculated using a Tcl script in VMD68, based on distances between the phosphate OP1 or OP2 atom and any Mg2+ion, with cutoffs at 2.5 and 5 Å, respectively. The 2.5-Å cutoff was chosen because it falls well into the gap between the first and second peaks of the RDFs around OP1 and OP2 (Supplementary Fig. 2+ were determined using a python script importing the MDAnalysis package69.The fraction of frames where a nucleotide made either inner or outer-shell coordination with MgMolecular dynamics simulations were carried out in four replicates for each system, for one NMR model as starting structure in most cases but for 10 NMR models in one case (Supplementary Table Further information on research design is available in the Peer Review FileSupplementary MaterialsDescription of Additional Supplementary FilesSupplementary Movie 1Reporting Summary


Considering the need to improve patient knowledge, awareness, and compliance for peri-implantitis prevention, and patients’ demand for better, quick, and convenient access to medical information, the present study primarily assessed the reliability and accuracy of YouTube videos on peri-implantitis and secondarily evaluated their educational value for the patients, and the related suitability, as part of population-based preventive strategies, to deliver valid information, potentially capable of improving patient knowledge and educational skills. This study’s protocol was developed in advance, and computer history and cookies were cleared to avoid limitations based on preferred user histories. The search term “peri-implantitis” was defined using the Google Trends website, and videos were searched on YouTube on 5 December 2022. Video inclusion and data collection were conducted by independent pre-calibrated investigators. Descriptive statistics were performed on the videos’ characteristics, source, category, target audience, popularity, source reliability, video information and quality (VIQI), content, and educational value. Pearson’s correlation between educational value and all parameters was calculated. Videos with very low/low and medium/good/excellent educational value were compared using the Mann–Whitney U test. A total of 44 videos with medium values for popularity, VIQI, content, and educational value were analyzed. Most videos covered peri-implantitis treatment rather than etiology and prevention, about half were uploaded by dentists/specialists, and only 10% specifically targeted patients. Only 2% of YouTube videos about peri-implantitis had excellent educational value, and 5% had good educational value. Video educational value was correlated with VIQI and content beyond video length and source reliability. When comparing the very low/low and medium/good/excellent educational value YouTube videos on peri-implantitis, a significant difference was found in the Video Information and Quality Index, VIQI, and video content. Peri-implantitis is a destructive inflammatory process that affects the tissues surrounding dental implants and is characterized by mucosal inflammation and bone loss ,2.The prevalence of peri-implantitis ranges from 1% to 85% when considered at the patient rather than implant level , and theStrategies to prevent peri-implantitis include routine clinical assessment and screening of peri-implant soft and hard tissues, periodontal maintenance care , and patPatient education and motivation, as well as treatment compliance, rely on effective communication with healthcare professionals . For comSeveral studies have been conducted to evaluate the impact of social media on oral health literacy, e.g., including fixed orthodontic treatment , orthodoMoreover, YouTube allows people to broadly network, collaborate, and share knowledge and experiences ,24. The Furthermore, social media is able to combine the credibility of interpersonal persuasion with the echo chamber effect of mass media, resulting in desirable behavior among a large group of people ,28, and In turn, however, any YouTube user can upload content, regardless of background and reliability. As a result, the quality of information is not guaranteed, and inaccurate content may mislead patients, negatively affecting preventive as well as therapeutic interventions . For thiTherefore, this study was conducted considering the need to improve patient knowledge, awareness, and compliance for peri-implantitis prevention ,32,33.The present cross-sectional evaluation of Internet-based video media did not require approval from the Local Research Ethics Committee, as it contains only public data.This study’s protocol was developed before the search. Before searching, the computer history and cookies were deleted to prevent restrictions based on preferential user history.http://www.youtube.com) (accessed on 5 December 2022) was searched for relevant videos uploaded until 5 December 2022. The search keywords “peri-implantitis treatment” were defined through the Google Trends Web site (freely available at https://trends.google.com/trends/), with “worldwide” and “last 5 years” settings, and no related queries available. The filters applied to the YouTube search were the following: video duration between 4 and 20 min, ranking based on the “level of relevance”.YouTube  with experience in oral medicine and oral surgery independently screened eligible videos. Multipart videos were considered single videos.-Video quality: ≥240p.-Video language: English only.-Primary video content: peri-implantitis treatment.The inclusion criteria were as follows:-Video quality: <240p.-Video language: non-English.-Video duplication.-Videos without sound or written explanation.-Advertisements from YouTube.The exclusion criteria were as follows:The calibration of 10 videos randomly chosen was performed by three investigators  with experience in oral medicine and oral surgery.▪Characteristics: link, length of video (minutes); number of views; number of likes; number of dislikes; number of comments; number of subscriptions; time elapsed since upload.▪Source: classified as dentist/specialist; hospital/university/scientific dental associations; commercial; other.▪Category: education; people and blogs; science and technology; film and animation; others.▪Target audience: classified as laypersons; professional; both.▪Video Power Index (VPI) ,21.▪Video Information and Quality Index (VIQI) .▪Video content .▪Video source reliability .▪Video educational value (GQS) ,35,36.The following data were independently extracted, computed, and collected by the two investigators  involved in the pre-calibration on a standardized extraction form for each video included in the present study:The Video Power Index, assessing video popularity, was computed as follows: Like ratio (Number of likes + Number of dislikes/Number of views × 100) × View ratio (Number of views/Number of days since the video was uploaded × 100)/100 ,16,21.The video information and quality index (VIQI) examined the videos’ general quality, scoring 1–20 .❖“Flow of the information.❖Accuracy of the information.❖Quality .❖Sensitivity (the consistency level between the video title and the content)”.A five-point Likert-type scale  was employed to evaluate each of the following criteria:❖Definition/diagnostic criteria.❖Etiology.❖Diagnosis.❖Prevention.❖Treatment (any).The content of the videos was evaluated, providing a total content score of 1–5, according to the coverage of the following topics:❖“Authorship ❖Attribution ❖Disclosure ❖Currency (dates that content was posted and updated should be indicated)”.The reliability of the source of the medical information retrieved through videos was determined using four criteria, known as the Journal of American Medical Association (JAMA) benchmark criteria, suggested by Silberg et al. ,34❖“Aut❖Score 1 = Poor quality; very unlikely to be of any use to patients.❖Score 2 = Poor quality but some information present; of very limited use to patients.❖Score 3 = Suboptimal flow, some information covered but important topics missing; somewhat useful to patients.❖Score 4 = Good quality and flow, most important topics covered; useful to patients.❖Score 5 = Excellent quality and flow; highly useful to patients.The videos’ educational value was rated based on the five-point Global Quality Scale (GQS) criteria ,35,36:❖SVideos rated <3 were classified as having very low/low educational value, and those rated ≥3 as having medium/good/excellent educational value for patients’ education, as part of population-based preventive strategies.p value < 0.001). The descriptive statistical analysis was performed for all of the YouTube videos included. The correlation between the educational value and videos’ characteristics, popularity, Information and Quality Index (VIQI), content topics and score, and the video source reliability was computed through Pearson’s correlation test.The normality of the data distribution was determined through the Shapiro–Wilk test  and medium/good/excellent (≥3) educational value videos, analyzed, and compared with the Mann–Whitney U-test.Out of the 120 videos initially retrieved, a total of 44 YouTube videos on peri-implantitis compliant with the eligibility criteria were considered in the present study, mainly due to the inconsistency between the title and content and the lack of information provided on peri-implantitis.Related data extracted, computed, and collected are available as a The median length of the videos was 5.58 (4.02–19.3) mins. The videos were uploaded between 27 and 2842 days (median time elapsed since upload 974) before the search and received a median number of views of 684, with a median number of likes of 6.5 (0–333), no dislikes, and a Video Power Index VPI of 1.09.The median Video Information and Quality Index VIQI (0–20 score) was 12.0.The median video educational value (0–5 score) was 2.0; thus, on average, the videos included were considered to be of low to medium educational value.The included videos’ length, number of views, likes, dislikes, comments and subscriptions, the time elapsed since upload, the Video Power Index (VPI), the video source reliability, the Video Information and Quality Index (VIQI), the video content, and the video educational value (GQS) are detailed in The median video source reliability (0–4 score) was 2.5 and dentists/specialists uploaded 53.2% of the videos. Approximately 40% of the videos fell into the “education” category. About 10.6% of the videos were produced for laypersons.The source, category, and target audience of YouTube videos on peri-implantitis are shown in The median video content score (1–5 score) was 2, indicating that, on average, YouTube videos covered at least two of the five relevant topics .Peri-implantitis treatment was the most frequently covered topic (88.63%), followed by definition/diagnostic criteria (47.72%), etiology (36.33%), prevention (31.81%), and diagnosis (29.54%).The content topics of the videos are shown in The educational value of the videos assessed using the five-point Global Quality Scale (GQS) criteria was distributed as follows: 7% of the videos had very low and 43% low value, whereas medium, good and excellent value was assigned to 34%, 11%, and 5% of the videos analyzed, respectively.Pearson’s correlation coefficients measuring the strength of the linear association between the videos’ educational value and the videos’ characteristics of popularity (VPI), general quality (VIQI), content, and source reliability are listed in p-value = 0.016), the number of likes  and video source reliability , but not specifically related to the uploading dentist/specialist .Video educational value was significantly related to the length of the video  and the video content score ; specifically, the video educational value was significantly correlated with the “Definition/Diagnostic criteria”  and the “Diagnosis”  content topics, but not with “Prevention” and “Etiology”, nor with “Treatment” ones.A highly significant correlation was found among the video educational value, the Video Information and Quality Index .Variables of very low/low and medium/good/excellent educational value videos are reported in p-value < 0.001) and video content .When comparing the very low/low and medium/good/excellent educational value YouTube videos on peri-implantitis, a significant difference was found in the Video Information and Quality Index  , suggestThe popularity of the videos, although no dislikes were recorded, was even more modest, with a median number of likes of 6.50 and a median Video Power Index of 1.09 , suggestLess than half (40.4%) of the YouTube videos on peri-implantitis were in the “education” category , and onlMoreover, the most frequently covered content was the treatment of peri-implantitis (88.63%), followed by definition/diagnostic criteria (47.72%), and less so by etiology (36.33%) and prevention (31.81%) , which iFurthermore, 53.2% of the videos were uploaded by dentists/specialists, while only 6.4% were uploaded by recognized institutions, such as universities or hospitals , with a ® and Yahoo!® by providing easier-to-understand visual content to improve patient knowledge and awareness of population-based prevention strategies, potentially playing a key role in conveying medical and dental information to patients and improving their understanding [® and Yahoo!® [Monje et al.  advocatestanding . Convers Yahoo!® , was fouUnfortunately, half of the YouTube videos on peri-implantitis were of very low/low educational value (GQS < 3), and the other half were of medium/good/excellent educational value (GQS ≥ 3); specifically, 34.09% of the videos had a medium educational value, and only 11.36% and 4.54% had a good and excellent educational value, respectively. Thus, the majority of the YouTube videos on peri-implantitis analyzed were rated as poor for patient education.These results are consistent with those of YouTube videos on other medical and dental content. Indeed, the information quality of YouTube videos on orthopedics  and allep-value = 0.016)  , suggest= 0.016)  as well p-value = 0.008)  were often more popular and preferred among YouTube users, probably because they were easier to understand for people without a medical background ,19. In c= 0.008) . This is= 0.008) , who finp-value = 0.034)  .p-value < 0.001) and video content score   , possiblhttps://en.wikipedia.org/wiki/List_of_languages_by_total_number_of_speakers) (accessed on 5 December 2022).The main limitations of the present cross-sectional analysis of the reliability and accuracy of YouTube videos in improving patient knowledge, awareness, and compliance may be ascribable to the dynamic nature of the platform, where videos are uploaded and deleted daily, and the restriction of the language of the videos to English, considering that other languages, especially Chinese, Hindi, and Spanish, are even more widely used (data available free online at: However, the present study may be the first to examine the popularity, information and quality, content, and source of YouTube videos on peri-implantitis and to evaluate the associated content accuracy, source reliability, and educational value. In addition, the results presented were compared with those of a recent study assessing the intelligibility of educational content on peri-implantitis websites to comprehensively assess the suitability of available patient-centered Internet information for population-based peri-implantitis prevention strategies .Further cross-sectional analyzes should be conducted without language restrictions, including other social media platforms, and should be continuously updated. Indeed, dentists should be aware of the information available on the Internet and refer patients to appropriate sources with accurate and up-to-date content to improve the suitability of YouTube videos as an educational resource for patients in population-based prevention strategies against peri-implantitis.Future studies of patient-centered, educational Internet information for peri-implantitis prevention should evaluate not only the accuracy of the information, but also its impact on patient knowledge, awareness, and compliance, as well as methods that are more engaging and effective for patients . A pool In addition to videos aimed at a professional audience , patientLess than half of the YouTube videos on peri-implantitis fell into the “education” category, and the language used was often technical and difficult for patients to understand, making it unlikely that they were uploaded for patient education purposes. The educational value of the videos was mostly rated as poor and was significantly related to video length, source reliability, the Video Information and Quality Index, and video content.Most of the videos covered the treatment of peri-implantitis rather than its prevention and etiology, which are critical for patient knowledge.


Video super-resolution aims to generate high-resolution frames from low-resolution counterparts. It can be regarded as a specialized application of image super-resolution, serving various purposes, such as video display and surveillance. This paper proposes a novel method for real-time video super-resolution. It effectively exploits spatial information by utilizing the capabilities of an image super-resolution model and leverages the temporal information inherent in videos. Specifically, the method incorporates a pre-trained image super-resolution network as its foundational framework, allowing it to leverage existing expertise for super-resolution. A fast temporal information aggregation module is presented to further aggregate temporal cues across frames. By using deformable convolution to align features of neighboring frames, this module takes advantage of inter-frame dependency. In addition, it employs a hierarchical fast spatial offset feature extraction and a channel attention-based temporal fusion. A redundancy-aware inference algorithm is developed to reduce computational redundancy by reusing intermediate features, achieving real-time inferring speed. Extensive experiments on several benchmarks demonstrate that the proposed method can reconstruct satisfactory results with strong quantitative performance and visual qualities. The real-time inferring ability makes it suitable for real-world deployment. Video is a widely used multimedia format combining image frames with audio. However, the quality of video often is limited by factors such as capture, storage, and transmission . Video sRecently, deep learning-based methods have shown promising performance in video SR tasks  and imagFurther, numerous video SR models ,14,15,16In this work, a novel video SR method is proposed to address these limitations. To exploit spatial information, the proposed method incorporates the architecture and well-trained weights of an image SR model as the foundational framework. A fast temporal information aggregation module is introduced to effectively leverage inter-frame dependency. Since moving objects exist in different positions, deformable convolution  can effeThe main contributions of this paper are as follows: (1) A novel video SR model is proposed to fully incorporate a pre-trained image SR model and achieve a trade-off between accuracy and real-time efficiency. (1) A novel video SR model is proposed that can be inferred in real-time while providing high-quality SR video frames. (2) A fast temporal information aggregation module is introduced where deformable convolution is adopted to extract the information of a moving object. The channel attention is also employed for adaptively capturing important information. (3) A redundancy-aware inference is developed for video SR. By avoiding repetitive feature extraction, the computational cost is significantly reduced.The remainder of this paper is organized as follows: The image SR problem is a typical ill-posed problem. In 2014, Dong et al.  were theIn this study, the IMDN  is emploRecently, there has been a growing interest in the video (SR) problem, leading to the proposal of numerous deep learning-based models . Given tThe first category includes methods that utilize optical flow. These methods make use of optical flow to align neighboring frames or features. For instance, VESPCN  aligns nThe second category contains methods based on 3D convolutions. Three-dimensional convolution is capable of extracting spatial and temporal information simultaneously from multiple input frames. For example, Kim et al.  applied The third category consists of methods employing deformable convolutions, which have gained popularity recently. Deformable convolutions were proposed in . The leaIn addition, there are attention-based approaches. These methods extract spatio-temporal information via various attention mechanisms. For example, Yi et al.  and Li eFor better performance on video SR reconstruction, the proposed method incorporates both deformable convolution and channel attention. The proposed fast temporal information aggregation is achieved through two stages: spatial aggregation and subsequent temporal aggregation. In the spatial aggregation stage, the deformable convolution is employed to align neighboring features. In order to effectively aggregate information from neighboring video frames, channel attention is used. Further, both stages significantly contribute to reconstruction performance.t. The model consists of three key components, i.e., the spatial feature extraction module, the fast temporal information aggregation module, and the upsampler module. The spatial feature extraction module is based on a pre-trained image SR model called IMDN 7], and SIn addition to the Vid4 benchmark, comparisons on the SPMCs-30  benchmarThe qualitative comparison is shown in The temporal consistency of the proposed model is evaluated following the methodology in a prior study . The temThe efficiency is analyzed from four aspects: number of parameters, number of computational operations, inference latency, and quality of SR results. The float point operations (FLOPs) and latency of each model are evaluated by producing 100 SR frames with a resolution of In this section, ablation studies are presented to examine the impact of key components. IMDN establishes a baseline for comparison, which takes one LR frame as input. Subsequently, the spatial aggregation and temporal aggregation are evaluated. They are key stages in the fast temporal information aggregation module. For measuring the performance of the model with spatial aggregation only, the spatially aggregated features are fused using concatenation and a On the Vid4 benchmark, the baseline model without temporal information achieves a PSNR result of 25.3254 dB and an SSIM result of 72.49%. By incorporating spatial aggregation, there is a noticeable improvement of 0.6499 dB and 3.96% in terms of PSNR and SSIM. Notably, the temporal aggregation in this variation is a simple Furthermore, an additional analysis is conducted to evaluate the impact of well-trained parameters from the image SR model on the video SR task. As shown in Although the proposed method can infer 720P video frames in real-time, there are some limitations. First, the LR video frame is synthesized by bicubic degradation. This may deviate from the degradation of actual low-resolution video. Secondly, the performance of the proposed method can be further improved. In In this paper, a novel approach for real-time video super-resolution is presented. The method incorporates a pre-trained image super-resolution model as its foundational framework to effectively exploit spatial information. To further leverage inter-frame dependencies, a fast temporal information aggregation module is introduced with the utilization of deformable convolution. This temporal modeling extracts motion cues across frames to enrich the spatial details. Additionally, a redundancy-aware inference algorithm is developed to minimize redundant computations by reusing intermediate features. It reduces the inference latency, enabling real-time performance for 720p video super-resolution with a minimal impact on accuracy. Experiments on several benchmarks show that the proposed method produces high-quality SR results quantitatively and qualitatively. The real-time inference capability makes the proposed method suitable for practical applications requiring live video enhancement. In the future, the efficient video super-resolution approaches can be improved by but not limited to the following directions: advanced degradation model for real-world low-resolution video; attention mechanism for better spatial-temporal feature extraction; novel techniques for efficient inference.


Educational videos are a potent resource for the learning of surgical skillsamong different study cohorts. However, there is limited evidence on theeffectiveness of different educational video interventions and theirfeatures.A systematic search of MEDLINE (via PubMed), Embase (via OVID), Cochranelibraries and Clinicaltrials.gov was performed from inception to 28/02/21.Studies included were not limited by date of publication, studies aiming toassess the impact of video-based interventions in the direct acquisition ofsurgical skill were included. Eligible studies were analysed based on studytype, type of video intervention, method of assessment and period ofeducation. The educational impact of the studies was also assessed as perMessick’s framework for testing validity of evaluation methods andMcGhagie’s model for analysing translational outcomes.22 studies were deemed suitable for inclusion, of which 14/22 (63.6%)demonstrated a significant improvement in knowledge/skills following thevideo-based teaching interventions, 3/22 (13.6%) studies demonstrated animprovement in trainee satisfaction scores. A recurrent limitation of theincluded studies was the lack of validation of selected assessment methods.None of the included studies scored on all 5 parameters of validity asdefined by Messicks validity framework. Furthermore, none of the includedtrials were conducted for long enough to indicate direct changes to patientoutcomes resultant from educational methods.Video-based surgical education is effective in learning surgical skillswithin different levels of surgical training; however, superior studyquality and follow-up is required to determine which aspects of video-basedinterventions are most impactful. Although surgicalexpertise is integral to healthcare, challenges exist in the training of competentsurgeons such as the implementation of work time directives, reduced opportunities for performing core procedures4 and budget cuts in healthcareorganisations limiting investments into surgical training.To date, the current model by which surgeons are trained relies heavily onapprenticeship-based Halstedian frameworks, The utility of videos in learning surgical skills became increasinglyapparent during the COVID-19 pandemic.With the advent of new video recording technologies, and improved computer systems,opportunity stands for innovation in surgical education. The use of educationalvideos offers many significant advantages including remote learning on demand, costeffectiveness, saved time and transport fees for healthcare professionals andstudents. Furthermore, with the development of validated checklists in theassessment of surgical skills, the opportunity lies for the extension of video-basedlearning to assessment and further.The aim of this study is to compare the effectiveness of video-based teachinginterventions to alternative teaching methods, such as text and live workshopdemonstrations. Moreover, it aims to evaluate the manner in which implementation ofvideo-based teaching interventions is most effective in the acquisition of surgicalskills by healthcare professionals. and registered on “PROSPERO” the international prospective register ofsystematic reviews prior to the study commencement (Registration ID:CRD42021233836).This review was conducted according to PRISMA  guidelinesInclusion for research analysed in this systematic review was limited to primaryresearch. All studies with original data relating to surgical skill acquisitionthrough the utilisation of video technology were included. Inclusion criteriafor study participants were medical students, surgical trainees, surgeons of allgrades and specialities, healthcare students and healthcare professionals. Thecontrol group was the cohort receiving alternative methods of training in theacquisition of surgical skills. Papers were included unrestricted by publicationdate however study inclusion was limited to those which could be obtained in theEnglish language if the mentioned criteria were met. Studies that did notutilise video in the direct demonstration and teaching of a surgical skill orprocedural steps were not included. Studies regarding the improvement ofsurgical skill following video-based feedback, patient education or livestreaming the surgical teaching were not included, as this review is assessingthe use of video in the initial learning and acquisition of surgical skill inhealthcare professionals/students.Clinicaltrials.gov wasalso searched for eligible ongoing studies. The search was conducted using theterms: Video* AND surgical AND teaching OR skill OR education. The listeddatabases were searched from inception date to 28/02/21. Effort was undertakenin analysing reference lists from articles meeting the inclusion criteria toidentify additional eligible studies.3 Databases were searched for this systematic review: MEDLINE (Via PubMed),Embase (via OVID) and Cochrane libraries, Study selection was performed by two independent authors and with a third moresenior reviewer to settle disagreements during study selection. Three levels ofreview were completed, firstly title screening and abstract screening toeliminate ineligible articles and lastly a full analysis of the manuscript,disagreements following discussion regarding eligibility were settled by thethird reviewer. Articles which met the eligibility criteria also had theirreference lists screened for additional eligible articles. Table 1The extraction of data from the eligible studies was completed and checked byboth authors, disagreements following discussion were resolved by the thirdreviewer. Information extracted from the studies included: study type, type ofeducational video, participant information, duration of education, method ofassessment and outcome data analysed for methodological validity and educationaleffectiveness using Messicks and McGhagie’s frameworks. For data extraction, astandard template was decided on prior to analysis of studies .Table 2.10 testingfor validity of the study assessments on five different facets: content,response processes, internal structure, relation to other variables andconsequences. Each of these parameters were graded according to the Beckman etal. rating scale  of the educational models in the respectivestudies were quantified using an adapted version of McGhagie’s translationaloutcomes, to serve video-based educational models as opposed to simulation basededucational models. In the present review McGhagie’s initial translationaloutcomes have been extended to five outcomes ,The search produced 2201 results, following duplicate removal 1688 studiesremained for screening. The 1688 studies underwent title and abstract screening,34 remaining studies underwent a full text screening, after a thorough analysisof the 34 articles, a further 12 articles were excluded, 22 articles remainedfor inclusion .Figure 1Of the included studies 20/22 were randomised controlled trials and 2/22 wereprospective observational studies. The number of intervention groups alsodiffered between studies. The total number of participants across the includedstudies within this systematic review was 797.34 general surgical skills 11/22 (50%)36 and simulated surgical procedures 5/22(22.7%).32 Studies also varied on method of assessment, somearticles assessed skills pre intervention and post intervention 12/22 (54.5%),whereas others solely examined skills post intervention 10/22 (45.5%).The surgical skill focus being learnt and tested varied between studies and canbe broadly divided into three categories : full surgical procedures 4/22(20%),24 a further 2/22 (9.1%) also used still images throughoutthe procedural video to augment certain instructional steps.32Multiple methods were used in the delivery of video-based interventions, the mostcommon simply included 2-dimensional video with narrations describing proceduralsteps which 11/22 (50%) mentioned to have utilised either through audio oron-screen narration. Animation technology was implemented in 2/22 studies(9.1%), 3/22 (13.6%), studies scored an LOE of 1 indicating positive traineesatisfaction relating to the intervention, typically recorded via feedbackforms.14/22 (63.6%) papers scored an LOE of 2 suggesting a statisticallysignificant improvement in surgical skill as quantified by a form ofexamination, either practical or knowledge based. 1/22 (4.5%) of studies scoredan LOE of 3, indicating an improvement of performance in the clinical context.Crawshaw et al. assessed the effectiveness of incorporating a comprehensive instructionalvideo prior to the performance of a right laparoscopic colectomy, which improvedoverall surgical performance and operative independence within surgicalresidents. Lastly, 4/22 (18.2%) of the included studies scored N/A, this wasallocated when no statistically significant positive outcome was reportedrelating to the administration of the educational intervention. None of thearticles included in this study reported a LOE of 4 or 5 whereby patientoutcomes were quantifiably affected or changes witnessed on a systemic level.This LOE requires an additional level of analysis, through widescale long termimplementation of the educational interventions, which was not conducted in theincluded studies. Rather studies assessed educational interventions on a moreimmediate level, such as in trainee satisfaction and improvement of knowledgeand skills.Of the 22 papers analysed according to McGhagie’s translational outcomes, Subjective student experience surveys, designed to assess the allocatedintervention on factors such as: student satisfaction, clarity of teachingmaterials and whether the participant deems the educational method effective were also incorporated in 7/22 studies. Of the 7 studies whichincorporated student surveys, 6 (85.7%) demonstrated favourable responsestowards the video-based teaching intervention.The majority of studies within this systematic review assessed outcomes throughvalidated practical examination checklists, completed by blinded expertexaminers testing multiple aspects of good surgical practice such as propermotion handling, knowledge of instruments, and flow of operation.21 Further benefits of the use of educational video werein the post recording edits, educational video can be enhanced through the useof narrated diagrams, physical demonstration and the ability to highlightspecific aspects augmenting understanding among participants.Conventional teaching methods were used in 9/22 (40.9%) studies within thissystematic review, defined in this context as: live workshops, textbook use andinstructor led teaching sessions/lectures. In 7/9 (77.8%) of the studiescomparing video-based interventions to conventional methods, a LOE of 1 or 2 wasrecorded, favouring video-based interventions. Overlying themes which madevideo-based interventions a superior modality, include the ability of theparticipant able to control replay speed, pause and advance to focus on certainaspects.36 Lohre et al. assessed orthopaedic residents in performing a reverse shoulderarthroplasty, results revealed that the immersive virtual reality had asignificantly higher mean OSATS scores than the video group . Yoganathan et al. demonstrated similar findings, although the study focussed on acquisitionof basic surgical skills as opposed to a complete procedure. Scores weresignificantly superior in the virtual reality (VR) group (median knot score 5.0vs 4.0 P = .04) than the video-based intervention group, with25% more of the cohort being able to construct a completed reef knot.Two of the included studies within this systematic review compared typicalvideo-based education to virtual reality,All the included studies above were graded according to the MERSQI tool which hasa maximum possible score of 18, although for certain studies adjustments weremade as not all assessment fields were applicable and a common denominator of 18was implemented. The mean MERSQI score across all studies was 11.66 (64.7%)(range = 9.5 -14.5 (52.7% - 80.6%), Standard deviation = 1.55 (8.6%)).Of the analysed studies within this systematic review, 14/22 (63.6%) studiesreported with data strongly supporting the validity of the evaluation instrument on atle and Ahmet et al. suggest a positive impact, however the eligibility criteria for both studieswas limited to medical students and residents, conversely this study analysedresearch relating to any healthcare profession. The analysis of students from arange of different academic backgrounds, was considered more reflective ofeducational effectiveness of the video-based methods in surgical skill acquisition,due to the variability in the study cohort.This systematic review has demonstrated that video-based teaching methods led toimproved surgical skills/trainee satisfaction in 17/22 of the studies. Previoussystematic reviews investigating the use of video in surgical education conducted byGreen et al.36 Sakamotoet al. comparing simulation-based teaching interventions for microsurgicalskills found video-based interventions to be inferior, improvement in thesimulation group may have been due to the opportunity for hands on rehearsal.An evident theme from this study was that video-based interventions whichutilised virtual reality and simulation-based education proved more effectivethan standard videos. The immersive nature of virtual reality may rendersuperior visuospatial awareness of technique, studies utilising virtual realitytraining had outcomes significantly superior to basic teaching video.21 thehighlighting of different anatomical structures, the imposition of schematicoverlays and the use of audio/text narrations. Furthermore, through video editing attention can be directed towards themost important aspects of the teaching via auditory and visual annotations,enabling learners to achieve a superior understanding of taught concepts. Videoediting also enables the removal of non-essential information reducingextraneous load, which by the cognitive load theory, would increase learningpotential.42Several features of video were markedly advantageous to conventional methods,themes identified upon analysis included: the ability to control replay speedand to navigate through videos directly to specific parts of focus, With advances in computer technology, trainees have access to highquality digital content at the click of a finger, creating opportunity forimprovement of access to surgical education. Traditional learning of surgicaltechniques relies heavily on workshop-based interventions and the apprenticeship model, however research suggests significant advantages of augmenting surgicalskills training with educational video through the ability to widely disseminatesurgical video via the internet, study remotely and control aspects of material review. Video is also documented to enhance retention in the learner to a greaterdegree, a person typically retains 10-15% of that which is read, 10-20% of whatis listened to, and 20-30% of what is viewed, however when audio and videomaterials are used in conjunction the retention of knowledge increases to 40-50%.Video-based teaching enables standardisation of educational materials, enablingnot only a consistent foundation for future clinical trials but alsoconsistently high-quality educational content for healthcarestudents/professionals. An example is the New England Journal of Medicine (NEJM)video series for learning surgical procedures. Videos are designed by multipleexperts, they then undergo peer review prior to dissemination. Through the useof this video series, Saun et al. proved the superiority of standardisedvideo-based teaching methods over didactic teaching for chest tube insertion,authors speculating the basis being due to the possible variability in theteaching approaches by different instructors, being overcome by standardised video. Further studies, assessing video-based interventions with additionalfeatures such as expert feedback during practicing of surgical skills andquestions and answers, may enable a more comprehensive comparison of teachingmethods.Although the employment of video-based teaching methods poses significantadvantages, surgical video to date may not be able to replace traditionalinteractive teaching methods. Interactive teaching sessions have the additionalelement of live feedback and the ability to ask questions which solely relyingon a teaching video would not provide. The extension of studies to assess surgical performance beyond asimulated environment can support the investment into video-based educationalresources and curricula for trainees. Conduction of such research could be inretrospective analysis of complications and operative time prior to video-basededucation and after. Alternatively, patient outcomes in a surgical setting couldbe investigated through a randomised controlled trial where video-basededucation is employed.Most studies included in this systematic review (17/22) demonstrated improvedexamination scores and positive trainee perceptions resulting from video-basedtraining. However, whether video-based education had advantages which translatedto improved performance in the clinical context was undocumented, except in astudy by Crawshaw et al. which scored high on content validity, with Dantas et al. which showed no evidence of content validity. Chien et al. used a scoring checklist with domains based upon predefined guidelines inpublished literature accounting for expert opinion, whereas Dantas et al. did not clearly define where test items were derived.In addressing low validity scores, the design of checklists and study protocols would have improved external validity ofincluded studies. The advantages of the sources of validity mentioned areevident, an example of this is in comparing a study by Chien et al.The establishment of a study protocol checklist, which accounts for validity andinvestigation of similar outcomes, would increase study quality and homogeneityallowing a more rigorous evaluation of video-based surgical education. Theliterature reports the existence of standardised educational video libraries,for example the NEJM video series. The uniformity in composition video features,if applied across multiple study groups, would further prove the utility ofvideo-based education.Numerous recurring weaknesses were identified within the studies, firstly the lowstudy quality as assessed by the MERSQI tool with the average quality quoted at64.7%, Secondly, the use of validated evaluation instruments was lacking, noneof the 22 studies reported validity on all five sources. Thirdly, none of thestudies in this systematic review achieved higher than an LOE of 3, suggestingthe lack of long term follow up. It may beneficial if future clinical trialscould attempt to assess translational outcomes in terms of clinical practice.Also, multiple studies failed to specify the type of video used, as well asadjunctive features which may have been causative in the witnessed change/lackof change of assessment scores, thereby preventing a holistic analysis of videofeatures which may have contributed to outcomes.Due to the heterogeneity in study methodology of included papers, quantitativeassessment of effectiveness of video-based interventions was not feasible andqualitative analysis of studies was performed. Studies differed drastically onmultiple measures such as outcomes assessed limiting comparability. This studylimited inclusion to papers which were in the English language.Video based interventions proved to have a positive effect in (17/22) 77.3% of thestudies analysed in this systematic review. With the advent of new videotechnologies, and the ease of accessibility of video-based teaching, based on thefindings of this review, the creation of standardised video programmes for theteaching of surgical skills is likely to enhance current teaching methods. It isevident from this study that video-based education overcomes many limitations inacquiring procedural knowledge and was favoured by trial participants. Althoughvideo may not be able to replace the interactive aspect of learning surgical skills,an analysis of the literature proved favourable outcomes in practical and knowledgeexaminations. Future research in the field should ensure evaluation tools arevalidated, ensuring reliability of any results, and aim to assess outcomes on awider scale outside of the immediate study setting.


VGT® was elaborated according to the Adlerian therapy vision and, consequently, the different phases of Adlerian therapy and VGT® match. Despite the use of video games in psychotherapy might have some adverse effects in specific cases, VGT® is currently used in three associations with positive results in promoting emotional experimentation and literacy, social feeling, sense of identity, and activating cognitive processes. Future developments include expanding the use of VGT® further to validate such results from a statistical point of view.Video games have been increasingly used as a form of therapy for various mental health conditions. Research has shown that video games can be used to treat conditions such as depression, anxiety, PTSD, and addiction. One of the main benefits of video games in therapy is that they can provide a sense of engagement and immersion that traditional therapy methods may lack. Additionally, video games can teach valuable skills such as problem solving, decision making, and coping strategies. Video games can also simulate real-life scenarios, allowing individuals to practice and improve social skills in a safe and controlled environment. Furthermore, video games can provide feedback and track progress objectively and quantifiably. This paper proposes an approach, the Video Game Therapy A video game is an electronic game that can be played on a computer or a gaming console. It typically involves a user interacting with a visual display, such as a television or computer screen, to control characters or objects within a virtual environment.Engagement: Video games are designed to be engaging and immersive, which can make them effective at keeping individuals focused and motivated during therapy sessions.Interactivity: Video games are interactive, allowing individuals to actively participate in therapy. This can be especially beneficial for individuals with difficulty in verbalizing their thoughts and feelings.Visual and auditory feedback: Video games can provide visual and auditory feedback, which can be used to reinforce positive behaviors and provide instant feedback on progress.Customization: Video games can be customized to suit the specific needs and goals of the individual. This can include tailoring the difficulty level, the type of game, and the session length.Variety: Video games offer a wide range of options, from action games to puzzles and simulations, which can help individuals find a type of game that they enjoy and are motivated to play.Accessibility: Video games can be accessed remotely, making the therapy more convenient for individuals who may have difficulty traveling to a therapy office.Assessment: Video games can be used to assess an individual’s cognitive abilities, such as memory, attention, and decision-making skills.Virtual Reality: Video games can be used in virtual reality environments, allowing individuals to experience immersive and realistic simulations of real-world scenarios. This can be particularly beneficial for individuals with phobias or other anxiety disorders.There is no consensus in the literature about the definition of a game . Philoso® (VGT). In the following lines, we describe the genesis of the approach, its use, and the psychological methodologies and tools employed to support the therapy process. The primary aspect of VGT® is the idea of having an integrated approach where the gaming experience of the patient is at the center of the therapy.All that said, there are different examples in the literature about how to take advantage of the use of video games to support  therapy . Still,® was created in 2019 by Dr. Francesco Bocci, taking inspiration from Geek Therapy . This gives us an indication for the therapeutic procedure: providing the opportunity for a formless experience and creative, motor and sensory impulses, which are the substance of play. On the basis of play, the entire existence of man is built as an experience” . TherefoThe therapist covers two main functions while playing in a psychotherapeutic setting. We use the term “function” in the sense of Propp, referring to the role and actions specific to a particular character within a story, without which it is impossible to predict the expected changes in the story .First, the therapist must ensure that psychotherapy is configured as a play space following the characteristics of playing, including its intrinsic pleasures, spontaneity, freedom, and uncertainty . This plConsequently, the therapist is the guarantor of flow and total immersion in the activity. This responsibility starts with choosing the suitable game for the patient, according to their lifestyle, personality, condition, and other forms of expression. However, as therapy involves a creative couple and not an individual, this function does not end with training the patient to reach the flow state. The therapist also puts themselves in the position to reach a flow state with the patient so that such “networked flow”  may amplTherefore, the therapist’s second responsibility is being available for the patient during play whenever they become more fragile and open to communicating about themselves and their trauma. That is why “the therapist must have a mind for two, energy for two, hope for two, imagination for two” , especiaIn short, the therapist’s responsibilities include creating and maintaining a good working alliance through an emotion-based relationship setting, as emotional change is often deemed necessary for long-lasting change in the patient’s well-being .As previously stated, the insight phase of Adlerian therapy consists of reflecting on the patient’s past experiences and how they might have shaped their current beliefs and behaviors. According to research, emotion is a fundamental source of information regarding their environment, personal goals, concerns, or needs ,126. BesWithin EFT, therapists act as Emotion Coaches, helping patients become aware of, regulate, and transform their emotional experience. It is crucial to notice that “coaching” implies the patient actively participating in the process, forming an empathic, highly collaborative, and validating relationship with the therapist, where both sides are held mutually accountable . Such a Through creating and maintaining a successful alliance involving relationship and setting, the therapist can effectively guide the patient’s attention toward their emotional processes, first and foremost, giving a name to otherwise unformulated personal experiences . After iThe therapist must resort to experiential methods as patients cannot be verbally taught new strategies for dealing with difficult emotions. The therapist begins by following the patient’s exploration of internal states, asking them to recount the emotional processing they are engaging in. By confirming their availability as open listeners, therapists provide a much-needed feeling of acceptance and validation of the patient’s inner states.® can represent a more efficient technique than enactment based on imagery and artistic performance, although maintaining similarities with improvisation theater [Then, the therapist can lead the patient towards novel emotions by directing their attention toward previously overlooked aspects of the situation. Focus shifting can be carried out through various techniques, including enactment . Social  theater . As prev theater , leading® represents not only a possible application of therapy through commercial video games but also an approach rooted in Flow experiences and in the unique role of the therapist in the creative couple as a fundamental characteristic of Individual Psychoanalytic Therapy.In conclusion, Video Game Therapy® organically and systematically. VGT® was defined in 2019 by one of the authors [®’s integrated approach compared to other methods that use video games as a therapeutic tool. In particular, the peculiarities of this approach originate from Adler’s Individual Psychology, where the therapeutic relationship is at the center, and the therapist becomes the guarantor of the flow. It is important to address the fact that the use of video games in psychotherapy might have some adverse effects in specific cases. It has been previously reported that excessive use of games led veterans to a lower perceived quality of life [® use and to make this approach more solid and standardized by defining guidelines established in collaboration with other professionals who use video games as a therapeutic tool in and outside Italy. Currently, experiences of VGT® use are underway in three different associations. These include the Hub Costa Volpino , where 20 young people are involved in a project on NEETs, and the Gaia Cooperative of Lumezzane , which is a residential community for gambling addicts (DGA), where eight users use VGT® for cognitive and emotional self-regulation. Both programs are weekly and are led by psychologists. Their focus is mainly on assessment (skill training) and insight, and, in the case of the Gaia Cooperative community, on storytelling as well. In addition, the programs are aimed at promoting Flow, starting from positive reinforcement, awareness of the characteristics of the Self that come alive in the video game, and observing the patients’ playful style (as considered by Briggs Type Indicator (MBTI) [® is the CAG Tok Tok Center in Travagliato  of Fraternità Community. In this center, VGT® is used for minor deviations and young people with court-ordered probation by the Juvenile Court of Brescia. The work carried out in this center involves five young people between the ages of 15 and 18 and focuses on cognitive and emotional self-regulation, insight, and creative function. Based on the growing body of literature and the encouraging results of these programs, introducing commercial video games in psychotherapy may be considered an effective integrated approach. However, according to a recent systematic review of the benefits of role-playing games in psychotherapy, only 16% of the studies were definable as experimental [This article aimed to present the integrated approach of VGT authors , taking  authors  and More authors ,136. How authors ), there  of life . Excessi of life , consider (MBTI)  and Bartr (MBTI) ). A thirrimental . Along trimental . Considerimental , there i


Omic BON is a thematic Biodiversity Observation Network under the Group on Earth Observations Biodiversity Observation Network (GEO BON), focused on coordinating the observation of biomolecules in organisms and the environment. Our founding partners include representatives from national, regional, and global observing systems; standards organizations; and data and sample management infrastructures. By coordinating observing strategies, methods, and data flows, Omic BON will facilitate the co-creation of a global omics meta-observatory to generate actionable knowledge. Here, we present key elements of Omic BON's founding charter and first activities. Analysis of these biomolecules can help us monitor biodiversity and understand how it is changing in response to human activities, environmental or biological pressures, or due to genetic drift or mutations. Molecular techniques, collectively known as omics is used by the biomolecular community to describe the study of DNA and RNA sequences, proteins, metabolites, and other biomolecules in (i) organisms  or (ii) environmental material samples .Referring to the holistic study of elements that compose a greater whole, Widely applied in biomedical research, omics has great potential in environmental and biodiversity studies , 2. VariAddressing these challenges will require global coordination of key actors; overcoming regional silos by ensuring compatibility of baselines, time-series, and reference libraries; developing concerted strategies and agreed-on common practices for managing biosamples; coordinating and maturing data, information standards, and strategies; and connecting to social benefit areas.The Group on Earth Observations Biodiversity Observation Network (GEO BON) endorsed the Omic Biodiversity Observation Network (Omic BON) to address the above challenges. Founding partners of Omic BON include observing networks, data/sample infrastructures, and standards and best practices organizations. Its overarching aim is to implement a meta-observatory of life at the molecular scale across earth systems Box .Box 1:Vision1A sustainable, responsive, and globally integrated omic meta-observatory that monitors biodiversity at the molecular level.MissionTo transition the fragmented observations of biomolecular diversity into coordinated contributions to a meta-observatory for collective insight and action.Meta-observatoryA distributed observatory to which anyone performing well-documented observations - from citizen science initiatives to established long-term observatories - can contribute. The observations conducted independently across time and space are integrated into a coordinated body of (meta)data through a harmonized community of practice, shared standards, and agreed-on methods. Benefits are shared among the contributors and with broader society for the common good.GoalsProvide a forum to discuss and coordinate omics methods, standards, and approaches among the land, ocean, freshwater, and human-health observing communitiesFacilitate standard protocol development to build reliable baselines of biomolecular diversityFacilitate calibration among partners as omic technologies develop, are adopted, and evolve, channeling innovations  into meta-observatory operationsSupport partners in overcoming regionalization and siloing of biomolecular observations, data, and applicationsFacilitate the establishment, sustainability, and interoperability of omic time seriesFacilitate sharing and sustained delivery of trusted biomolecular (meta)data and information products to global aggregators , compatible with specifications relevant to the essential biodiversity variables (EBVs), essential ocean variables (EOVs), and other biodiversity monitoring mechanisms at local to global scales and with proper respect for ethical, legal, and social issuesHighlight contributions of partners by establishing a regular global assessment of change in biomolecular diversity, reporting trends in biomolecular-based variables and indicators worldwideSupport mechanisms to detect sudden or consequential events that facilitate appropriate authorities in considering collective, targeted actions in response to emerging threats  or needs In order to achieve Omic BON's goals, we will start with three initial activities:Establish an operational Omic BON with funding, governance, and administrative supportDevelop Omic BON's data strategy to improve the availability, reusability, and interoperability of global omics biodiversity data and achieve the sustained delivery of key data/information products in support of the Omic BON goalsex situ access)Establish Omic BON's strategy for tracking/indexing samples to build the meta-collection pillar of the meta-observatory, including recommended practices  for accessing, tracking, and storing the biosamples that underpin omic observations and future analyses of those samples  localized omic observatories; (ii) networks of observing platforms; (iii) data infrastructures; (iv) curated, long-term stores of biosamples; (v) (meta)data standardization bodies; (vi) coordination and integration with other biological and environmental observing; (vii) documentation and coordination practices and standards; and (viii) identification and iteration on requirements to benefit science, society, and nature.Omic BON emerged through joint collaborations across existing initiatives. Omic BON was formed by the union of the Global Omics Observing Network  and the Genomic Observatories Network , Marine Global Earth Observatory (MarineGEO), Agriculture and Agri-Food Canada (AAFC), European Marine Biological Resource Centre (EMBRC), Australian Microbiome Initiative (AM), and MBONLong-term observatories and observation networks: National Science Foundation's National Ecological Observatory Network Data and sample infrastructures: GSC, Biodiversity Information Standards (TDWG), and Ocean Best Practices System (OBPS)Standards and methodology management organizations: GOOS) and Ocean Biomolecular Observing Network (OBON)Global ocean observing networking programs: Global Ocean Observing System , and similar but at present largely parallel efforts in the terrestrial, freshwater, atmospheric, and space/extra-terrestrial domain.Omic BON will continue to bring together observers and observatories across sectors and environments. We benefit from the coordination already occurring in the marine domain, in part due to the mobilization spurred by the United Nations Decade of Ocean Science for Sustainable Development (Figure To build a structural foundation for Omic BON's long-term success, it will operate with a defined governance structure with distributed responsibilities and terms. The initial governance structure of Omic BON is illustrated in Figure Ethical, legal, and social considerations are essential in omics biodiversity observation to ensure responsible and sustainable practices. An example of particular importance for omics is the Nagoya Protocol of the CBD, which aims to ensure fair and equitable distribution of benefits derived from the study and utilization of genetic resources . Recent Omic BON will serve the global omics biodiversity community through open, trusted, and inclusive coordination. This is crucial to help coordinate omics research and technology information to effectively and sustainably contribute to the global baselines and trusted indicators needed to address pressing threats to the biosphere and opportunities for conservation and sustainable development. We envisage that the Omic BON community will establish a meta-observatory with decadal strategies and interoperability models, forging sustained links to an ever-growing collection of stakeholders and global programs. This fundamental step in mainstreaming omic approaches will help build the collective capabilities and intelligence needed to address the grand scientific and societal challenges of our time.giad068_GIGA-D-23-00062_Original_SubmissionClick here for additional data file.giad068_GIGA-D-23-00062_Revision_1Click here for additional data file.giad068_Response_to_Reviewer_Comments_Original_SubmissionClick here for additional data file.giad068_Reviewer_1_Report_Original_SubmissionMelody Clark -- 7/18/2023 ReviewedClick here for additional data file.


Colour-related search tasks are common in many professional fields. The study investigated whether increasing chromatic saturation can enhance the visual performance of individuals with colour vision deficiency (CVD) in colour-related search tasks.10 normal trichromats  age: 23.1 (3.3) years) and 15 individuals with CVD [8 deutans and 7 protans identified by HRR plates]  years) participated in this study. Four naturalistic sceneries of everyday tasks/ birds, animals and flowers of 15 different colour combinations  were presented in ‘low’ saturation, ‘original’  and ‘high’ saturation condition using the Psychopy program on a colour-calibrated monitor. On each trial, the subject was asked to identify a specific-coloured target.-1) of the normal trichromats [Mean (SD):77.76% correct*s-1 (16.32)] was significantly higher than CVD [45.71% correct*s-1 (18.95)] in the “original” test images (p = 0.001), but in individuals with CVD, there was no significant difference between ‘original’ [45.71% correct*s-1 (18.95)] and ‘high’ saturation condition ([47.43% correct*s-1 (20.07)]; p > 0.05). However, colour-wise, increased saturation showed improvements (≥ 10%) in protans mainly for ‘red’ combinations with other colours such as white , purple, orange, grey, green, brown and black.Overall, the visual search performance index (expressed as product of accuracy and a reciprocal of reaction time (%correct*sThe study suggests that increasing the saturation of certain colour combinations can potentially aid in the visual search performance of individuals with CVD. This knowledge will help in better counselling and management of the patients. Colour-based visual search is a commonly encountered task in professions such as police , army, nIncreasing the chromatic saturation of the visual display may benefit individuals with CVD  becauseTwenty-five participants participated in the study. Out of which, 10 were normal trichromats  age:- 23.1 (3.3) years) and 15 individuals with colour vision deficiency [ years)]. The screening plates of Hardy Rand Rittler (HRR) pseudoisochromatic plates  distinguished normal trichromats from individuals with CVD, who were further tested using the Colour Assessment and Diagnosis (CAD) test  to identify the type and quantify the severity of colour vision defects. The test was performed according to the manufacturer’s instructions. The lighting for the HRR test was white light (standard office fluorescent lamp) with illumination of 300 lux. The individuals with CVD were subclassified as protans and deutans. All participants had a monocular visual acuity of at least 20/20 (logMAR– 0.0) with refractive correction in place. The participants were sourced primarily from patients who reported to the L V Prasad Eye Institute (LVPEI), Hyderabad campus. Individuals with CVD in staff and student cohorts were also recruited for the study. The study was conducted at the L V Prasad Eye Institute, Hyderabad. The participants were informed of the test duration and nature of the test. If the participants were interested, written informed consent was obtained prior to testing. This study adhered to the tenets of the Declaration of Helsinki. The study protocol was approved by the Institutional Review Board of the L V Prasad Eye Institute, Hyderabad (Reference no: LEC-BHR-P-09020-509).https://www.flickr.com/explore) and 500px (https://500px.com/) websites that represented 15 colour combinations: brown/black, red/purple, red/green, red/white, red/brown, red/orange, red/grey, red/black, green/yellow, green/blue, green/white, green/brown, green/grey, orange/brown, and orange/yellow. The colour combinations were chosen based on the common colours confused by individuals with CVD ). Further post-hoc analysis using Bonferroni correction, with regard to saturation, revealed that the visual search performance index in both the ‘original’ and ‘high’ saturation conditions was significantly better than the ‘low’ saturation performance condition in individuals with CVD. However, there was no significant difference between the ‘original’ (45.17% correct*s-1(9.44)) and ‘high’ saturation condition (46.9% correct*s-1(10.52); p = 0.71) in individuals with CVD.The overall visual search performance index in normal trichromats (mean (SD): 77.8% correct*sp2 = 0.040), and protans performed better than deutans. There was also a significant interaction between saturation and defect type  = 4.7; p = 0.009, ηp2 = 0.02). Similar patterns were observed for other visual search parameters, such as accuracy and reaction time, except for the absence of a significant interaction between saturation and type of defect. Overall, compared to deutans, all outcome variables of protans were significantly better   on the visual search performance index was significant  = 26.8, p <0.0001, η) Tables .The minimum and the maximum difference in the visual search performance index of the individuals with CVD compared to the normal trichromats was noted in the ‘green/white’ and ‘red/grey’ combination respectively . In protThe normal trichromat performance in the ‘high’ saturation category was not significantly enhanced compared to the ‘original’ category. In protans, there were numerous colour combinations  which improved upon increasing chromatic saturation . HoweverThere are four key findings of this study. First, the visual search performance index in individuals with CVD was significantly poorer compared to normal trichromats . Second,The poor visual search performance index of individuals with CVD relative to normal trichromats is consistent with several other previous studies , 16, 19.Overall, the visual search performance of individuals with protan deficiency was better than that of individuals with deutan deficiency. The visual search task in this study was not a threshold-level task. It is possible that starting ‘chromatic saturation’ used in the ‘original’ image condition may itself be representative of a suprathreshold task, where protans perform better than deutans . BesidesChromatic displacement is a concept used in the CAD test as well, where the target and background are initially separated by a small chromatic displacement in the CIE colour space which is either increased or decreased based on the performance of the individual. Increasing the saturation should make the task easier. However, there is a caveat: this improvement is noticed only when the chosen colours are in different confusion lines. This may also explain why the effect of increasing chromatic saturation did not improve the visual search performance index for some colour combinations. There are few specific colour combinations where the visual search performance index worsens , it would be relatively easier to estimate the chromaticity of the targets in the realworld and ensure that modified coloured targets are of specified recommendations. However, the results of this study cannot be generalised to objects in the real world. Nevertheless, it provides a framework regarding which colour combinations can be potentially modified to enhance the visual search performance index in individuals with CVD.As CVD is not treatable  thereforThe present study has some limitations. The selection of individuals included almost an equal percentage of protan and deutan deficiencies which is inconsistent with the prevalence of CVD . HoweverThe study concluded that increased chromatic saturation produces a differential effect across various chromatic combinations, especially protans benefitting from higher saturations in most combinations containing red. Therefore, this study is the first step towards potentially modifying colour-specific environmental settings in an occupational environment based on increased chromatic saturation to aid individuals with CVD.S1 DataThe combinations highlighted in yellow are demonstrated in (XLSX)Click here for additional data file.S1 File(PDF)Click here for additional data file.S2 File(PDF)Click here for additional data file.