A common problem among students is the problem of delaying important work activities, which is conceptualized as procrastination. Since procrastination can cause considerable costs for society, we would like to find a method to effectively alleviate the symptoms of this conditioning. It has been proven in an earlier study that staying in the forest environment increases vitality and reduces anxiety, and the negative state of these features can be associated with the intensification of procrastination symptoms. Therefore, it is likely that watching a forest video may decrease the probability or intensity of procrastination. To measure the impact of the forest environment on the level of procrastination of the subjects, a randomized experiment was carried out, in which the subjects watched in random order (on different days) one of two 15-min videos: one showing a walk in the forest area and one showing a walk in an urban environment (control). We measured the level of so-called ‘fluid procrastination’ including three aspects: ‘lack of energy to do the work’, ‘inability to get to work’ and ’pessimistic attitude to do the work’ with a set of questions the respondents completed before and after the experiment. The results showed that one aspect of fluid procrastination (‘pessimistic attitude to do the work’) can be effectively lowered by watching a video showing the forest environment. In contrast, watching a video of an urban environment increased the procrastination levels for two other aspects of procrastination . We also measured three other parameters before and after the experiment: mood state, restoration and vitality. Watching the video from forest area raised mood and restoration and watching the video from urban area, decreased mood, vitality and restoration. The study suggests that watching a video showing forest landscapes could be used as an effective remedy for problems related to procrastination among students. An increased amount of research has been carried out indicating the positive contribution of contact with nature to human health ,2,3,4,5.Forest visits are demonstrated to have positive effects on human psychological relaxation , mental In Finland, where the experiment was conducted, depression is a common problem, as in other European countries . For exaFive mechanisms have been identified  for explTo measure the positive health effects the forest environment has on humans, various methods have been used. The direct impact of the forest environment can be measured by staying in the forest. For this purpose, the simulation of various activities is used: using the forest environment during the camp , walkingRepresenting nature in the form of images, and video or virtual reality has been found to have a positive effect on human well-being, mental and physiological health ,53,54. VAs health benefits of nature are increasingly understood, it is worth paying attention to its possible use as a tool for helping people with difficulties in carrying out tasks. One of the problems individuals face every day is a problem doing tasks on time or delaying them, which results in various types of problems. This type of behavior, consisting of non-compliance with deadlines for psychological reasons, is called procrastination . The proProcrastination is often associated with anxiety , and somGeneral procrastination can be measured with a variety of tools. The tool, that is validated and measures accurately procrastination, is pure procrastination scale (PPS) . HoweverIt is also worth noting that by conducting the study with virtual videos, the method also allows assessing the suitability of not only the forest environment itself but also the video itself for reducing procrastination. If an individual would like to lower the level of procrastination, and the video would be useful for that, then it was enough for the individual to watch the video at home if a real forest environment is not easily accessible. Also, the key point is how to get nature exposure during work or studying, when participants need to get something done.The aim of this research is to study the restorative effects and current procrastination of videos presenting forest and urban environments on Finnish university students.A randomized controlled study was conducted, in which the subjects watched two types of video  with questionnaires measuring the fluid procrastination and other features filled before and after the watching.The purpose of the study described here was to test three hypotheses:Hypothesis 1. (related to the research methodology): Fluid procrastination will correlate with general procrastination. This will be manifested in the fact that people achieving higher values in the general procrastination questionnaire will also achieve higher fluid procrastination values.Hypothesis 2. Fluid procrastination is a measurable feature which value may change under the influence of stimulation of the subjects in the form of displaying a video film of a walk in an urban or forest environment. It is hypothesized that the forest video decreases more the procrastination than the urban video.To check if the forest environment has the potential to reduce the level of procrastination, an experiment is carried out, in which the forest environment is presented in the form of a video to the subject and the fluid procrastination is measured before and after watching the video.Hypothesis 3. Values achieved by study participants on other psychological scales , commonly used in forest well-being research after watching the video, will be similar to the results obtained on the fluid procrastination scale.In this study, we use three different scales to measure changes in mental well-being: profile of moods states (POMS), restorative outcome scale (ROS) and subjective vitality scale (SVS). Since these questionnaires allow measuring significant changes that are observed after exposure to the forest environment , therefoThe study participants were 42 healthy volunteer students , with an average age of 26.24 ± 6.23 (mean ± SD) years. Of these, 40 subjects studied at the University of Helsinki, and two studied at the University of Turku. We aimed at recruiting students that did not have a professional relationship with nature through their studies. None of the students participating in the study studied biology, forestry or landscape design. All of the respondents lived in cities, the majority in the Helsinki Metropolitan area (39 respondents), and three outside it. Students were recruited to this experiment in the city center in a building (Porthania) belonging to the University of Helsinki. The recruiters (18 students participating in the ‘Urban Forestry’ course and studying at the University of Helsinki) explained to the respondents what the study was about. If the students were interested in participating in the experiment, they were given a recruitment card with information about the study and with specified recruitment criteria. The title of the study was ‘Supporting student well-being in everyday life’.The recruiters explained that the respondents would be invited to two meetings, during which they would be presented with two videos (one 15-min video at one meeting). During the recruitment, it was explained that participants should complete a questionnaire regarding their well-being and also explained that both visits would take about half an hour.To participate in the study, a participant needed to meet the following criteria (listed on the recruitment card handed to subjects): (1) had to agree to participate in these study and sign a written consent; (2) having an age between 18 and 44 years old; (3) does not take any medication that may affect mood and feelings; (4) had to give consent to treat personal data confidentially and for research purposes only; (5) does not consume large amounts of alcohol or other drugs that may affect them on examination days; (6) had to know Finnish (the questionnaires were prepared in Finnish). If recruited students answered ‘no’ to any of the above questions, they could not take part in the study. The responses were anonymous. Recruitment was conducted during 10 days from 30 September 2019 to 11 October 2019 (on workdays).To determine the statistical power of the experiment, a statistical power analysis was performed using the free software ‘G * Power 3.1’ . Actual power (1-β error probability) for this research design was 0.977, assuming the presence of two groups and four repetitions, test with repeated measurements (two within-subjects factors), type of power analysis ‘Post hoc: Compute achieved power—given α, sample size, and effect size‘. The effect size was set at 0.25, α error of probability is 0.05. The number of 42 study participants was sufficient to identify significant differences between the compared levels.All data were processed anonymously and protected in accordance with the guidelines of the EU General Data Protection Regulation 2016/679 (GDPR). Personal data was kept separate from the material being analyzed. Personal data was removed from the data when it is no longer needed for data linking. This study was positively evaluated by the Ethical Review Board at the University of Warmia and Mazury in Olsztyn. The number of the ethical statement is 07/2019. All the procedures were performed in this study in accordance with the ethical standards of the Polish Committee of Ethics in Science and with the 1964 Helsinki Declaration’s later amendments. All research was carried out in accordance with the recommendations of the University of Helsinki Ethics Committee.Each subject watched a 15-min video showing a walk in the forest area and a 15-min video showing a walk in the urban area displayed in a room in the Porthania building.2 park that is popular among Helsinki residents. The Kruunuvuorenranta area of 1.42 km2 was also selected for recording in the forest environment. Three videos were used to make the video, the first video in the 15-min clip (0′:00″–4′:21″) showed a video shot in the Kruunuvuorenranta area (northern Helsinki). The video was shot in an area with canopy layer of a forest area with mature Scots pine (Pinus sylvestris) stands with some spruce and leafy understorey. The second video (4′:22″–8′:27″) was shot in the northern part of Helsinki Central Park, an area covered mature coniferous forests dominated by Scots pine and Norwegian spruce. Deciduous tree species and shrubs were found in the undergrowth. The third video (8′:28″–14′:58″) was shot in the southeastern part of Helsinki Central Park showing a forest walk on a path made of wooden beams. The walk led through a mature spruce stand with an admixture of birch and pine. The video shows picturesque landscapes enriched by lush developed undergrowth in this area.Helsinki Central Park was chosen to make a video of the walk in the forest. It is a 10 kmTillia).To create a video showing the walk in the urban environment, the suburb areas in the Rastila and Vuosaari areas located in East-Helsinki were selected. Altogether four videos were shot in these areas, two were near the metro stations ‘Rastila’ and ‘Vuosaari’ (0′:00″–5′:17″), (9′:55″–12′:50″) and two in the eastern part of the suburbs (5′:18″–9′:54″), (12′:51″–15′:00″). In addition, to depict the view of buildings and streets, the video contained elements of normal, everyday life in this area: people, passing subways and cars. The footage in the video also includes urban greenery, lawns, and small-sized trees and shrubs, e.g., lime trees . Areas of the city of Helsinki in which videos from the forest and urban area were shot are marked on the map . Shots fAll videos were prepared in HD quality , using a GoPro Hero 7 Black field camera  and using the image stabilizing gimbal during filming movement . During filming, the camera was kept at the operator’s eye level to recreate the experience as similar as possible to a walk in a forest or urban area. All videos were assembled using the iMovie application available for Mac OS . To maintain satisfactory sound quality in the assembled video, commercially available soundtracks from soundsnap.com were used with high quality soundtracks recorded in forest and urban areas. The video finally selected for presentation to the subjects was selected in a multi-stage process, during which the assembled clips that most closely resembled normal daily experience were selected.2 (1920 × 1080 resolution). The experimental room was built on a rectangular plan with dimensions of 370 × 345 cm. The study participants sat on comfortable, adjustable chairs at a distance of 250 cm from the screen. There were a maximum of five people in the room during the experiment on separate, comfortable armchairs with back and shoulder rests. The volume of the loudspeakers associated with the monitor during the display of the screen was the same for the video from the forest area as well as for the video from the urban area, but the volume of the sound depended on the type of video and thus, the volume of the film from the urban area was higher than the volume of the film from the forest area. The view of the experimental room during the experimental stimulation is shown in The videos were displayed to the subjects in the room using a high-resolution 55 “LCD monitor  with size of 71.4 × 124.4 cmBecause the aim of the study was to check how videos depicting two different environments affect the fluid procrastination of subjects, a randomized experiment was performed during which videos were used as experimental stimulation. After signing consent to participate in the study (recruitment card), the participants were randomly assigned to the time and date on which they were to watch the videos. The video display order was random, simple randomization was used for this by assigning a random number to each hour and day of display. The principle of participation in the experiment was that each study participant had to watch each video once, and the minimum time before watching the second video should be 24 h. Based on these principles, the recruiters established a schedule that contained information about when a person would come to watch one of these two videos. The subjects were sent an e-mail reminder the day before the scheduled video and a text message on the day of experimental stimulation. 44 people were recruited to see each of the two videos once, but two did not appear to watch the second video. On each day of the experiment, three videos were shown at different times in the room in the Porthania building, at 13:00, at 14:30 and at 16:00. The display order of the two videos was randomized. To balance the video display effect (for the first or second time), it was attempted to see the video in a random way, first or second .On the first day, before watching the video, each participant completed an extended questionnaire, which contained general information on the characteristics of the subject and his/her previous experiences related to visiting green areas. The participants were also asked to fill in the Pure Procrastination Scale (PPS), which measured the level of general procrastination. In addition, participants completed a questionnaire containing four sets of questions with psychological scales before viewing: fluid procrastination scale , profile of mood states (POMS), restorative outcome scale (ROS) and subjective vitality scale (SVS). These measures were conducted just before watching the video and were called ‘Pre’ measures that measured participants’ current psychological state. The subjects then watched either an urban or forest video for 15 min , and after the video the subjects completed another questionnaire, ‘Post’. On the other date, the person filled out the ‘Pre’ questionnaire again, then watched another video, after which the person filled out the ‘Post’ questionnaire. The course of the experiment on one experimental day is shown in Which of the following best describes your childhood (age under 16) environment? Circle the most appropriate number: from ‘1 = city center’ to ‘3 = rural’.How familiar are you with outdoor activities conducted in the woods? Circle the most appropriate number: from: 1 =‘not at all familiar’ to 5 = ‘very familiar’.How often do you go outdoors/in nature  Circle the most appropriate number: May-September from: 1= ‘never’ to 5 = ‘5 times a week or more’.How important do you feel that the residence is a half-mile radius close to one of the green- or nature area? Circle the most appropriate number: from 1 = ‘Not important’ to 5 = ‘important’.The first time (regardless of whether it was a forest or city video), the examined person received an extended questionnaire. In the extended questionnaire, the respondents answered their daily experiences and questions that characterized themselves. In addition to standard questions about age, sex, place of residence and place of studies, the following questions were asked:In addition, the background questionnaire contained the Finnish version of the pure procrastination scale (PPS), which makes it possible to measure the overall level of procrastination in the examined person. Procrastination is measured using questions relating to the life of the examined person or a certain period in that person’s life, which conceptualizes the procrastination as dysfunctional delay. The questions are for example ‘I am continually saying I’ll do it tomorrow’ or ‘I delay making decisions until it’s too late’. The original version of the questionnaire was developed by Steel , from whThe FPS scale was used for the first time in this study. The formulation of FPS scale was based on the assumption that procrastination can also be measured at the current moment. Therefore, 11 statements were proposed, which the respondents rated on a 5-point Likert scale . The statements were ranked in three proposed subscales, which measures three separate aspects: (1) On scale 1 (FPS1) ‘lack of energy to do the work’ containing 4 items of which were reversed when calculating the results: ‘I feel right now that I would be good at meeting deadlines’, ‘Now I could immediately start doing something that is approaching a deadline’, ‘I feel that I will be able to complete my tasks’ and ‘I feel ready to do tasks’; (2) on scale 2 (FPS2) ‘inability to get to work’ containing 4 items: ‘I cannot do my tasks right now’, ‘I feel that now I could not make a decision and I would waste time on trivial matters’, ‘I feel discomfort at the very thought of doing something’, ‘I feel that it would be best to say right now: “I will do it tomorrow!”; (3) on scale 3 (FPS 3) ‘pessimistic attitude to do the work‘ containing 3 items: ‘At the moment I am worried about my future’, ‘At the moment I feel like I would not complete any task on time‘ and ‘I feel that I will lose something because of my lack of motivation to perform tasks’. It was assumed that these scales can measure the psychological effect faced by persons experiencing procrastination but as a result of own analysis, it was found that these three scales can significantly reflect the actual ruminations occurring in people with a tendency to delay the implementation of tasks. Unpublished pilot studies identified three main factors corresponding to the sub-scales of fluid procrastination.The creation of the FPS scale was initiated in the pilot study launched before starting the actual field experiment. During these tests, questionnaire study was conducted in a room using a film from the urban and forest environment. The data was used to conduct exploratory factor analysis, during which, the statements based on factors were formulated and selected and to perform three subscales of the FPS scale. The subscales were named as presented already above ‘the lack of energy to do the work’, ‘inability to get to work’, ‘pessimistic attitude to do the work.’ When creating a group of items for potential use on an FPS scale, the practical significance of the items was assessed. To establish the FPS scale, only those statements were used that best correlated with the general procrastination and changed the most under the influence of viewing the video of urban and forest environment in the pilot study.The impact of video on the mood of the subjects was also measured using the POMS scale. The original scale contains 65 items . The scaThe study also used the six-item ROS questionnaire  to assesThe SVS questionnaire was also used to assess the level of vitality of the subjects after watching the video . The scaThe quality of the presented video was evaluated by subjects on a 5-point scale with two questions: ‘How pleasant the view of the displayed video was?’ and ‘How pleasant the sound of the displayed video was?’ However, many of the respondents understood the question differently than we had originally planned. They thought we asked about the content and not the quality of the videos, therefore we could not use these answers in our analysis.The FPS scale was invented in this study and the analysis of its reliability and validity are good, and its usefulness has been proven here. The POMS, ROS and SVS scales are widely used in research on the impact of nature on subjects, and these scales are widely recognized as valid and reliable.p value < 0.05 was considered significant. The analysis was performed in the SPSS Statistics Version 25 program  and in the JMP 15 program . During the analysis, it was noted that some missing data appeared which were replaced by matched variables using the winsorization technique [η2’: small = 0.01; medium = 0.06; and large = 0.14.Data are presented in the analyses as mean ± standard deviation (S.D.). Data analysis ‘variable by variable’ was adopted . Raw datechnique . Also, tTo check if there were correlations between subscales of fluid procrastinations scale and variables, a simple Pearson correlation coefficient was used. The results are summarized in N = 42): FPS1 r = 0.678 ***; FPS2 r = 0.600 ***; FPS3 r = 0.585 ***. Validity analysis of FPS is presented in the The value of Cronbach’s α for the FPS1 subscale in the experiment was 0.869, for the FPS2 subscale 0.779 and for the FPS3 subscale (containing only three items) 0.676. Correlations of fluid procrastination subscales with the PPS scale were as follows (for 2 ranged from 0.06 to 0.14).The scale of fluid procrastination consists of three subscales  of which each subscale indicated a different response of this scale to the type of video displayed. Therefore, these scales were analyzed separately rather than one, total scale analysis. Two main factors were assessed in the statistical analysis of these subscales: the impact of experimental stimulation (conditions: forest video vs. urban video) and the impact of exposure to a given factor (time: pre vs. post). We were most interested in how the subscales change in time between the two environments, forest vs. urban. Therefore, also the interactions between conditioning and time were analyzed in the model. These effects and their interaction, calculated for the three subscales  of fluid procrastination, were included in the two-way repeated measure ANOVA model. The results of these analyses are presented in p < 0.05, Urban: pre vs. post). In the case of the FPS2 subscale, the only significant difference was observed after watching a video depicting the urban environment compared to the situation before watching the video. This aspect of procrastination, ‘the inability to get to work’, got worse by watching the urban video . In the case of the FPS3 subscale, the value were significantly lower after watching a video of a walk in the forest landscape than before watching the video  and also after watching the forest video compared to the city video . This means that after watching a video of the forest environment, the aspect of procrastination ‘the pessimistic attitude to do the work’ lowered among participants.The mean values and standard deviations for each of the four measurement times  as well as the results of multiple comparisons by Tukey’s post-hoc test for the three subscales of fluid procrastination, are summarized in In the case of the POMS questionnaire, the main effects were also analyzed: conditions (forest vs. urban video) and time (pre vs. post) and the interaction of these effects. The results of the analysis of these factors and their interactions using the two-way repeated measure ANOVA model are presented in The result of multiple comparisons with the Tukey test  indicateScales ROS and SVS, are often used as good indicators of the effect of urban and forest environment on the subjects. They are often used together, so for the purposes of this description they are included in one chapter.In the case of the ROS scale and the SVS scale, two-way repeated measure ANOVA was used to examine the effect of the conditioning effect and the time effect, as well as the interaction effect on these variables . The conThe results of the Tukey’s multiple comparison tests for the ROS and SVS are included in η2 for each of the three subscales was in the range of 0.06 to 0.14). Compared to the effect size of other measured variables —the effect size was often two times smaller in the case of fluid procrastination.It is worth noting that in the conducted experiment the size of the effect in the case of tested fluid procrastination was not large  on the level of procrastination has not been studied before. To examine this impact, a measurement of ‘fluid procrastination’ or procrastination ‘at the moment’ was proposed, which, as expected, changed after watching the urban and the forest video. This measurement was possible due to simulation in controlled conditions of walking in the forest environment and walking in the urban environment—as a control. The created fluid procrastination scale consists of three smaller scales. The values of all three scales significantly changed under the influence of watching videos showing two environments. Subscale 1 and subscale 2 values  increased (got worse) significantly after exposure to video from the urban area.This confirms Hypothesis number 1—the values of fluid procrastination may change under the influence of the subjects’ experience and can be changed by stimulation. This means that the view of the urban area significantly increased the temporary tendency of the respondents to procrastination. When going for a walk, to reduce the worry associated with procrastination, individual should prefer the forest environment. This might be helpful especially if an individual lacks a positive attitude towards work and also if an individual cannot get work started. Subscale value 3  decreased significantly after exposure to a video of a walk in the forest. This result is of great practical importance as when a person cannot get down to the task, watching a video showing the forest landscape might help. This walk (or video watched) should significantly reduce the aspect related to the occurrence of negative thinking, which has been suggested to be a key factor responsible for problems with the impossibility to get on with tasks . The urbr = 0.678, which means, that these subscales of procrastinations did correlate within each other, but it did not reach the total correlation. Therefore, the use of fluid procrastination as a measurement tool for ‘at the moment’, is only legitimate. Furthermore, due to significant correlation, it is highly probable that fluid procrastination measures the aspects of procrastination as a phenomenon. This is due to the fact that fluid procrastination ‘at the moment’ is higher in people with higher values of general procrastination. This confirms “Hypothesis number 1”—these two types of procrastination are related to each other.Fluid procrastination in this study was significantly correlated with general procrastination, as expected. People achieving higher values in the general procrastination questionnaire, achieved higher values in the fluid procrastination subscales. However, correlation coefficients did not reach a value greater than The interaction between conditioning and time was significant in case of six of the examined mood states: tension, fatigue, forgetfulness, vigor, irritation, slackening. After watching the video showing the forest area, the four subscales of the POMS questionnaire significantly decreased: tension, fatigue, forgetfulness and irritation. In the case of subscale 3 (FPS3: ‘pessimistic attitude to do the work’) of fluid procrastination, decreased values were also observed. Therefore it can be concluded that the reduction of the four mentioned mood subscales are associated with a decrease level of fluid procrastination. This result is consistent with the results of other studies, in which general procrastination was associated with negative mood changes . The levThe impact of the forest environment (or in this case: its representation in video form) on the level of the ROS scale value was significant, which means that the presented video had a restorative effect on the subjects. A change under the influence of this video also occurred in the case of the subscale of FPSFPS1 fluid procrastination, which means that as restorative activity increased, pessimistic attitude to the work decreased. The SVS value did not increase significantly after watching a video of the forest area. This mirrors the results obtained for the POMS sub-scale “vigor’, which also did not change after watching the video from the forest area. After watching a video from the urban environment, both restorative and subjective vitality decreased. Of course, this is an unfavorable change, because it is desirable to increase the value of these features. A video from the urban environment turned out to be unsuitable for causing a restorative effect. As previous research has reported ,84, the In future studies, more understanding is needed about the dose-response relationships  of tUsing glasses for virtual reality  may alsoIt is also possible to refine the fluid procrastination scale to make the measured effect larger, for which the sensitivity of the scale should be increased. However, the impact of the natural forest environment on the values of fluid procrastination may be much greater than the impact of the displayed video. This would indicate that a more effective form of dealing with procrastination would be a walk in a real forest environment, in which case the sensitivity of the scale would not have to be increased.The content of the videos also reflected everyday environments for Helsinki residents. People may prefer different types of environments in their everyday life. For example, in the real natural environment, people with a stronger nature relatedness recover from stress more in the forest environment compared to the city center . In conThe significance of research results is great for societies living in cities. Contemporary society is struggling with the so-called ‘technostress’  caused bIn this study, the effects of two types of video on fluid procrastination, mood, restorative and vitality in young adults studying at the university were examined. Participants in the study saw a video showing a walk in a forest environment and a video showing a walk in an urban environment (as a control). Both videos were recorded in an urban area of the city of Helsinki. These two videos were shown to participants . The psychological questionnaire was completed by the subjects before watching the video (pre-test) and after watching the video (post-test). The results indicate that a video showing a walk in the forest environment can effectively reduce one aspect of the measured fluid procrastination—‘pessimistic attitude to do the work’. This video can also be useful for lowering negative moods, such as tension, fatigue, forgetfulness, irritation or raising the level of restoration. On the other hand, watching video from an urban area can increase two aspects of measured procrastination—it can worsen the lack of energy to do the work and the level of inability to get to work. Watching a movie from the urban environment can also lower vigor, restoration and vitality, and increase slackening. The results of the study are promising and suggesting that to reduce the level of procrastination it is worth watching a video showing nature. In addition, the study used the concept of the scale of fluid procrastination, the use of which proved to be justified—the scale logically changed its values under the influence of watched videos and correlation with subscales and general procrastination was observed, the scale was also reliable (good Cronbach’s α coefficients).


Child life therapists provide patient education for children undergoing radiation therapy to assist in coping with and understanding their treatment.This proof-of-concept study aimed to determine the feasibility of incorporating a 360-degree video tour via a virtual reality system for children scheduled to receive radiation therapy. The secondary objective was to qualitatively describe each subject’s virtual reality experience.Children aged ≥13 years scheduled to receive proton radiation therapy were included in the study. Subjects watched the 360-degree video of the radiation therapy facility in an immersive virtual reality environment with a child life therapist experienced in coaching children receiving radiation therapy and completed a survey after the tour.Eight subjects consented to participate in the study, and six subjects completed the 360-degree video tour and survey. All the enrolled patients completed the tour successfully. Two subjects did not complete the survey. Two subjects requested to pause the tour to ask questions about the facility. Five subjects said the tour was helpful preparation before undergoing proton radiation therapy. Subjects stated that the tour was helpful because “it showed [them] what’s to come” and was helpful to see “what it’s like to lay in the machine.” One subject said, “it made me feel less nervous.” Six subjects stated that they would like to see this type of tour available for other areas of the hospital, such as diagnostic imaging rooms. None of the subjects experienced nausea or vomiting.The 360-degree video tour allowed patients to explore the treatment facility in a comfortable environment. Participants felt that the tour was beneficial and would appreciate seeing other parts of the hospital in this manner. A course of radiation therapy consists of one simulation session followed by 10 to 35 daily radiation sessions. Each treatment session can last between 30 and 90 minutes, depending on the treatment setup and delivery. Radiation therapy protocols are carefully designed to match each patient’s condition.Patients must be placed in the same position and remain perfectly still to ensure the radiation beam targeting achieves the highest accuracy. Many children require an immobilization device, usually an individually molded plastic shell that fits tightly over the face. For young or anxious children, sedation or general anesthesia is often required, whereas adolescents and older children may undergo radiation therapy without general anesthesia -3.Individuals receiving radiation therapy without general anesthesia often work with child life specialists to learn about radiation therapy and the steps involved as well as to develop coping strategies . One of Virtual reality technology is becoming increasingly available to consumers for development and delivery of content. One of the leading developers for virtual reality consumer devices such as the Oculus Rift is Oculus . Oculus released the first consumer device in April 2016 . SamsungThe primary objective of this study was to determine the feasibility of using a virtual reality headset—the Oculus Rift Development Kit—to deliver a 360-degree video tour of the radiation oncology facility to patients scheduled to receive proton radiation who are eligible for radiation therapy without general anesthesia. The secondary objective was to qualitatively describe the patients’ impression of the 360-degree video tour through a virtual reality system.This single-site study was conducted in full accordance with all applicable research policies and procedures of the Children’s Hospital of Philadelphia, Hospital of the University of Pennsylvania, and Oregon Health & Science University Institutional Research Boards. The study was approved by the Institutional Review Boards in The Children’s Hospital of Philadelphia and the Hospital of the University of Pennsylvania. All patients and parents provided informed consent and assent to participate in the study.Study subjects and a parent or guardian provided informed consent and assent before enrollment. This proof-of-concept study evaluated the feasibility of delivering a tour of the Roberts Proton Therapy Center in the Perelman Center for Advanced Medicine  to pediatric patients with a virtual reality headset.After the tour, the subjects completed a questionnaire to describe their experience . The incA study member demonstrated the use of the equipment and headset to each subject. The subject then held the virtual reality headset over his/her eyes and experienced the 360-degree video tour of the radiation therapy facility in the presence of a child life therapist experienced in pediatric proton therapy . The chiThe 360-degree video tour was projected using an Oculus Rift Development Kit 2 (Oculus) and a MacBook Pro (Apple Inc). The Oculus Rift viewer has foam face pads that pose an infection risk. Per the hospital’s recommendations for infection control, we fitted a nylon cover on the foam pads . FurtherThe video tour was recorded using GoPro Hero 3 Silver Edition  and Kodak SP180  with guidance from a child life therapist who conducts the patient tours at the facility. Video editing was performed using Final Cut Pro . The video was displayed using Kolor Eyes 360 Video Player for Mac, version 1.4.1  . The vidA total of eight subjects consented to participate in the study, and six subjects completed the 360-degree video tour through a virtual reality system . Two subWe demonstrated that incorporation of a 360-degree video tour via a virtual reality system into patient orientation to a pediatric proton therapy facility is feasible. The patients who experienced the tour described the experience positively. All patients enrolled were able to complete the 360-degree video tour and used the virtual reality system. The 360-degree video tour and virtual reality system allowed the patients to experience what it is like to lay down in the proton therapy gantry and watch the machine move from a first person’s perspective. One patient expressed that “[the 360 degree video tour] made me feel less nervous.” Patients, particularly children and adolescents, undergoing radiation therapy may experience anxiety, especially before the treatment begins.Virtual reality experiences offer an opportunity to improve the patient’s experience. Child life therapists play an integral role in guiding patients through this process, which ultimately spares the patients from receiving general anesthesia for each radiation therapy session. One advantage of the configuration described is that the video footage is viewed simultaneously by the patient and the child life therapist. In this context, the child life therapist could coach the patient through the experience and answer questions as they come up. The child life therapist could also see what the child is looking at and answer questions accordingly as well as guide the child’s attention to details that may have been missed otherwise. Furthermore, the child life therapist had the ability to pause, rewind, and resume the video to allow more time for discussion. In this study, we successfully introduced a 360-degree video tour delivered through a virtual reality system to the child life therapist’s education tools in this field and are exploring other applications throughout the hospital.The 360-degree video tour and virtual reality system provide a unique first-person perspective of the radiation therapy room in a neutral environment. In addition, the tour allowed patients to experience laying down on the proton therapy machine and watch the machine operate. Five patients highlighted this as the most valuable part of the tour. The 360-degree video tour also offers access to the proton therapy room without interrupting the scheduled treatment sessions. The proton therapy rooms are always in high clinical demand, and patients have limited opportunities to visit the room before their treatment starts. We are exploring options to expand virtual reality tour access to adult patients in the proton therapy center as well as other parts of the hospital. The patients in our study cohort commented that they would also like to see other parts of the hospital in virtual reality. There are endless possibilities for patient-centered virtual reality-immersing experiences aimed at education, anxiolysis, or analgesia.The 360-degree video tour was designed specifically for the Roberts Proton Therapy Center at the Perelman Center for Advanced Medicine. One of the limitations we encountered was specific to the device used for the tour. The Oculus Rift DK2 projects a low-resolution image, which appears pixelated. However, the video is not limited to virtual reality viewers, as it is compatible with mobile phones, tablets, and computers. The 360-degree video tour is compatible with most commercially available virtual reality viewers. In this study, we limited the virtual reality tour to patients aged ≥13 years according to the device’s manufacturer recommendations. This age limitation is due to the fixed position of the eyepieces and limited range of interpupillary distance for adults. It is possible for younger children to use the device. However, they may not be able to experience the binocular view or may potentially see double images. In fact, a group in Toronto has designed the “Childlife VR” application to introduce the operating room to patients and have successfully applied it with younger patients by using a generic Google cardboard viewer ,15.Virtual reality viewers such as the Oculus Rift are designed for personal use; thus, they may not translate well to clinical environments or may not meet hospital infectious disease-control specifications. The Oculus Rift DK2 has a foam pad, which contacts the face around the eyes, and two elastic head straps, which cannot be easily cleaned or disinfected according to our hospital’s specifications. Hospital infectious disease specialists recommended placing a waterproof cover over the foam pad and cleaning it with hospital-grade disinfectant wipes. Generic single-use devices such as disposable cardboard or paper viewers based on the Google Cardboard model can circumvent the cleaning problem . HoweverThe device configuration described in this study is time consuming, requires a clean working surface to configure all the necessary equipment, and can take 5 to 15 minutes to set up. Portable virtual reality technology is evolving rapidly, and new devices are constantly entering the market. The virtual reality tour is available as a digital video file and is compatible with any commercially available virtual reality viewer, such as hand-held virtual reality viewers designed for mobile phones or hand-held devices. There are many options available in the market and more will become available. In the meantime, the 360-degree video tour can be delivered via a digital video player such as a computer or tablet in addition to any virtual reality device or 360-degree video player in the market.Health care providers are constantly evaluating emerging technologies to improve patient care and the patient experience. Virtual reality technology is becoming widely available for consumer use. This technology has great potential for various applications in health care, such as assisting health care providers in introducing patients to the hospital setting and therapy areas such as radiation therapy. Portable virtual reality technology is growing rapidly, and its role in healthcare is evolving quickly. This study provides an example of the feasibility of implementing virtual reality in a pediatric clinical setting to supplement child life efforts and dispel the fear of the unknown. Finally, the 360-degree video tour and virtual reality system provide access to a clinical area that is inaccessible to patients due to the high clinical demand and fast-paced schedules. As virtual reality technology continues to evolve, so will health care providers’ ability to understand its application and improve the patient experience.


We sought to contain a healthcare-associated coronavirus disease 2019 (COVID-19) outbreak, to evaluate contributory factors, and to prevent future outbreaks.Quasi-experimental cluster-control outbreak evaluation.All patients and staff on the outbreak ward (case cluster), and randomly selected patients and staff on COVID-19 wards (positive control cluster) and a non-COVID-19 wards (negative control cluster) underwent reverse-transcriptase polymerase chain reaction (RT-PCR) testing. Hand hygiene and personal protective equipment (PPE) compliance, detection of environmental SARS-COV-2 RNA, patient behavior, and SARS-CoV-2 IgG antibody prevalence were assessed.P < .001). RNA levels on the COVID-19 ward (where there were no outbreaks) and the outbreak ward were similar . Mean monthly hand hygiene compliance, based on 20,146 observations (over preceding year), was lower on the outbreak ward (P < .006). Compared to both control wards, the proportion of staff with detectable antibodies was higher on the outbreak ward .In total, 145 staff and 26 patients were exposed, resulting in 24 secondary cases. Also, 4 of 14 (29%) staff and 7 of 10 (70%) patients were asymptomatic or presymptomatic. There was no difference in mean cycle threshold between asymptomatic or presymptomatic versus symptomatic individuals. None of 32 randomly selected staff from the control wards tested positive. Environmental RNA detection levels were higher on the COVID-19 ward than on the negative control ward (OR, 19.98; 95% CI, 2.63–906.38; Staff seroconversion was more likely during a short-term outbreak than from sustained duty on a COVID-19 ward. Environmental contamination and PPE use were similar on the outbreak and control wards. Patient noncompliance, decreased hand hygiene, and asymptomatic or presymptomatic transmission were more frequent on the outbreak ward. These reports should be accompanied by an analysis of the specific infection control measures implemented.1 However, none of the major case series of COVID-19 patients from US hospitals, Italy, or China discuss infection control measures.8 Similarly, reports from skilled nursing facilities in the United States and London did not detail infection control measures beyond “restricting visitors, canceling communal events, and implementing COVID-19 transmission-based precautions.”11 Those reports did not explain those transmission-based precautions or evaluate other related factors such as compliance with personal protective equipment (PPE) and hand hygiene (HH), or the role of the environment in the outbreak.11An outbreak on a pediatric dialysis ward in Germany has also been described, but the details of the exposure are not provided. Other than saying that exposed staff were quarantined, specific infection control measures were not described.12Detailed descriptions of hospital-acquired coronavirus disease 2019 (COVID-19) and workplace transmission patterns are crucial to preventing outbreaks and improving patient safety.17 until most recently, most COVID-19 testing in the United States has been performed on symptomatic individuals. This situation complicates nosocomial outbreak investigations because the prevalence of asymptomatic infections and the baseline seroprevalence are not fully known. However, this information is important for differentiating nosocomial transmission from background positivity rates and assessing the degree of spread throughout the ward.Although presymptomatic and asymptomatic transmission is increasingly recognized,After the first nosocomial transmission of SARS-CoV-2 at our facility, we sought to contain the outbreak, to assess contributory factors, and to prevent future outbreaks using the information gained. In addition to those efforts, we describe the control measures implemented and their short-term impact.1 (online). Due to neurologic impairments in the patients, close physical contact with nursing and physical and occupational therapists occurs more frequently on this ward than on te general medical–surgical wards. Historically, nosocomial respiratory syncytial virus cases are more frequent on the ward compared to other wards. On average, 80% of the patients have intravenous catheters and 40% have indwelling or external urinary catheters.The outbreak occurred on a 39-bed acute-care stroke ward in a 528-bed teaching hospital. The layout of the ward and the sequence of secondary patient cases are illustrated in Supplementary Fig. The index case was a patient who had been on the stroke ward for 22 days before becoming acutely symptomatic with fever and lower respiratory tract symptoms. Her SARS-CoV-2 test was positive 20 hours later, and she required transfer to the intensive care unit (ICU) for endotracheal intubation. Prior to becoming symptomatic, the patient wandered throughout the ward visiting other patients and the nurse’s station without adhering to directions to wear a mask. To ameliorate nocturnal agitation that the patient suffered from, it was often necessary to place the patient in a geriatric chair at the nursing station. She was initially admitted for delirium and medication toxicity. During the admission, the patient also required continuous positive airway pressure and occasional bilevel positive airway pressure for chronic obstructive pulmonary disease.2 online). Both patients had a history of mental illness and were not compliant with requests to remain in their rooms or to use masks, despite repeated redirections from nursing staff. Subsequently, a second patient care technician became symptomatic and tested positive for SARS-CoV-2 .One day after the index case became ill, a patient care technologist also became symptomatic and tested positive for SARS-CoV-2 the following day. All staff with exposure to the index case in the 14 days prior to her symptom onset, were offered SARS-CoV-2 screening. Three days after the index case was identified, a second patient on the ward, who was a frequent visitor of the index patient, also tested positive for SARS-CoV-2  , or BD SARS-CoV-2 Reagents for BD MAX, . A hospital-acquired COVID-19 case was defined as a patient who had their first positive specimen collected after day 14 of their hospitalization.Prior to the outbreak, several COVID-19–specific infection control measures had already been adjusted to account for possible presymptomatic transmission. These included visitor restrictions, that is, no visitors allowed except in special circumstances, such as imminent death of the patient, and 1 birthing partner allowed. All such special circumstance visitors were interviewed in and questioned regarding symptoms and exposures, and their temperatures were measured. All healthcare workers were required to wear ASTM -Level 1 surgical masks. ASTM International, formerly known as American Society for Testing and Materials, is an international standards organization that develops and publishes technical standards. Staff who were positive for SARS-CoV-2 testing or symptomatic were restricted from working. SARS-CoV-2–positive patients were placed in cohorts on dedicated COVID-19 wards, and patients were required to wear masks when leaving their rooms. In addition to masks, all staff were provided face shields to wear when caring for COVID-19 or suspected COVID-19 patients. Face shields were required for COVID-19 patient care but were only recommended for non–COVID-19 patient care. Any patient having an aerosol-generating procedure was treated as a possible person under investigation. These aerosol-generating procedures required the use of N-95 filtering respirators and were performed in an airborne-infection isolation room whenever such a room was available.Historically and currently, all wards were and are required to report monthly HH compliance to infection control and leadership committees. Clandestine observations are performed by specially trained staff . The same procedures apply to PPE observations.Following the discovery of the index case, the entire outbreak ward was placed on quarantine precautions. As a result, gloves, face shield, and face mask were required for all patient contact on the ward (regardless of SARS-CoV-2 status) until 14 days after the last exposure. Patient assignments and work locations of staff were determined by interview and review of shift assignments. Quarantine information was given to the nurse manager and attending physicians from the ward to share with patients. Directly exposed patients (meaning patients who were visited by the index case or cared for by an employee who tested positive) were notified of their exposure and were placed in quarantine. Discharged COVID-19–exposed patients and their primary care physicians were notified by an ambulatory results nursing call center and were instructed to remain in home quarantine for the remainder of the 14 days following their last exposure. The list of exposed patients and staff was also reported to the local health department. New admissions to the stroke ward were restricted to patients with acute neurologic conditions.Staff break-room capacity was limited through staggering and distanced seating. In addition to the routine regular monthly assessments, additional PPE and cleaning assessments were conducted clandestinely . For an observation to be counted as compliant, the proper equipment had to be worn and worn correctly. For example, a cloth face mask covering the nose and mouth would not be considered compliant because staff were required to wear approved surgical masks. A surgical face mask covering the mouth but not the nose would also be considered noncompliant.The same authors also observed patient behaviors regarding mask use on the outbreak and control wards. Additionally, safety and incident reports that involved behavior deviations by inpatients, and patient exposures, were reviewed.Any employee who had spent time on the outbreak ward or had multiple interactions with patients and/or staff on that ward from 2 days before the index case became symptomatic to 7 days afterward was offered voluntary PCR testing for SARS-CoV-2. Staff were able to continue to work if asymptomatic while test results were pending . Staff who tested positive for SARS-CoV-2 were restricted from working until they were cleared by the employee health department . Staff who tested negative but had a defined medium- or high-risk exposure to a positive employee or patient were actively monitored for symptoms 14 days from exposure using the Datos Health Application .Before the outbreak occurred, the hospital had predesignated 1 of 4 ICUs and a general medicine floor as a COVID-19 unit in anticipation of the surge of COVID-19 patients. All patients testing positive for SARS-CoV-2 were admitted to this floor or ICU, and these were therefore selected as a positive control comparators. Two wards that had had no SARS-CoV-2–infected admission since the start of the pandemic, and that currently contained no such patients, were selected as the negative control comparators. These control wards and the outbreak ward are located on different floors. Patients and staff on the outbreak ward were considered the outbreak cluster.To assess the background point prevalence of asymptomatic SARS-CoV-2, every other patient across the negative-control comparator wards, and randomly selected staff on those wards were included and tested as ‘negative control clusters.’ Randomization was performed using a random number generator (1–26) corresponding to the first initial of the patient’s last name.In response to the nosocomial case, all patients on the outbreak ward were tested for SARS-CoV-2. All new admissions to the outbreak ward were tested for COVID-19, upon or before arrival to the ward. Patients without typical or atypical COVID-19 symptoms were randomly selected as ‘negative control cluster’ from the non–COVID-19 wards. These wards also acted as the negative controls for serological and environmental assessments.Nasopharyngeal specimens were analyzed on the cobas6800 System, (Roche Diagnostics), the BD MAX BioGX SARS-CoV-2 (Becton Dickinson), or the Simplexa COVID-19 Direct kit .Serology was performed 25–28 days after the index case was identified. Antibody binding to the SARS-CoV-2 spike and N proteins were detected in a standard 2-step enzyme immunosorbent assay using antibody-HRP-conjugate, goat anti-human IgG-antibody in an alkaline phosphatase substrate coated onto 96-well plates . All serum was screened at 1:1,000 dilution, and all samples with an optical density 2-fold higher than the control well were confirmed as positive by 8 2-fold dilutions.2 test surfaces in vacated patient rooms were spotted with 1,250 copies of SARS-CoV-2 genomic RNA (BEI Resources). After 10 minutes of drying time, these surfaces were sampled as positive controls. All such controls tested positive using the commercial assay described below.To ensure that the sampling method could reliably detect environmental RNA before formal sampling began, 100-cm20 Briefly, swabs were streaked over targeted high-touch surfaces for a minimum of 20 seconds in a rolling motion to ensure contact with the entire swab surface. The cobas PCR Media Uni swabs (Roche) were premoistened with the transport media (sterile 40% guanidine hydrochloride tris-HCl buffer) and analyzed on the cobas 6800 System (Roche).Environmental surface sampling was performed as previously described.Eight stationary surfaces were sampled in rooms on the outbreak and control wards: bed rails, call buttons and remote controls, over-bed tray tables, sinks and soap dispensers, chairs, windowsills, and floors. Three shared surfaces were sampled: walking computer workstations, handheld glucometers, and vital-sign machines. Staff break rooms, including microwaves and refrigerators, were also sampled.2 test, the Fisher exact test, and analysis of variance (ANOVA) tests were performed using R software  or Minitab 2020 software .The χ2 online). None of 32 randomly selected staff from the positive and negative control wards tested positive  (Table P < .001). However, there was no difference in the proportion of tested surfaces that were positive between the dedicated COVID-19 ward (where there had been no outbreaks) and the outbreak ward .Of 128 randomly sampled surfaces on the outbreak and control wards, 26 were positive. Floors, call buttons and remote controls, chairs, and shared equipment  were the surfaces most commonly positive for SARS-CoV-2 RNA. The proportion of tested surfaces that were positive for SARS-CoV-2 RNA was higher on the dedicated COVID-19 ward (positive control) than on the non–COVID-19 ward   across all wards at the hospital. The outbreak ward had lower mean monthly HH compliance than most other wards. Of the 20,146 observations, 4,626 were on the outbreak and control wards. Mean monthly HH compliance was significantly lower on the outbreak ward than the positive and negative control wards, averaging 61% on the outbreak ward compared to 79% and 74% on the positive and negative control wards, respectively (P > .05). There were no patient safety or incident reports, and 0 of 72 patients were observed without a mask on the positive and negative control wards.There were 354 clandestine observations for compliance with COVID-19–specific PPE recommendations immediately after the identification of the index case. Overall PPE compliance was 91% on the outbreak ward versus 79% on the positive control ward and 82% on the negative control ward, but the differences were not significant  in this report is lower than those in most available reports.25We found no other cluster control reports of a nosocomial outbreak in a US acute-care hospital that detailed specific control measures and also evaluated compliance with PPE recommendations, environmental surface contamination with SARS-CoV-2, and staff seroconversion. To our knowledge, this report appears to be the first such report. Furthermore, reports from non–university-based locations, such as this one, are underrepresented in research; most studies are carried out in large academic institutions. However, most health care in the United States is provided at non–university-based facilities. Additionally, the factors involved in this outbreak  have been associated with explosive outbreaks and sustained transmission (super-spreading events).17 and nearly all the transmission that occurred in this outbreak was either presymptomatic or asymptomatic .The observation that infection in staff, as measured by seroconversion, was not higher on a dedicated COVID-19 ward compared to wards that had no patients with SARS-CoV-2 infection suggests that the prevailing PPE practices described here were effective. However, unanticipated movements or events are known to be factors in workplace accidents, and those appear to have furthered this outbreak. Similarly, decreased HH compliance likely contributed as well. Presymptomatic and asymptomatic transmission is increasingly recognized,This report has several limitations. Because of its quasi-experimental nature, causality cannot be inferred. It is from a single facility, but the facility is typical of many hospitals and settings in the United States, so the findings are still relatively generalizable. The number of PPE observations was unavoidably small given the limited number of trained observers and competing duties. We did not have the ability to cultivate SARS-CoV-2 virus, so another limitation is that the infectivity of the environmental RNA is unknown.26Our findings raise several unanswered questions that are important considerations for future control efforts. These issues include the legal, ethical, and safety implications of managing noncompliant, infectious, or potentially infectious patients. These challenges and questions have particular implication for neurobehavioral wards where a patient’s understanding and behavior are degraded or risky, and for other vascular wards where symptoms of SARS-CoV-2 infection can overlap with or be mistaken for underlying cardiac and vascular conditions such as stroke, cardiac insufficiency, thromboembolism, or even syncope  remains challenging and merits further research aimed at creative solutions for increasing compliance. Going forward, we are evaluating the effectiveness of highly visible HH and PPE ‘ambassadors’ who roam the wards providing friendly reminders and answering questions. We are also evaluating the feasibility of using whole-genome sequencing at nonuniversity hospitals such as this one to enhance outbreak investigations.


With their demanding schedules, surgical residents have limited time to practice techniques. The aim is to evaluate the pedagogic model of self-directed learning using video in surgery residents.Informed consent was obtained from all the participants. A randomized controlled trial was conducted in 2018 at Hôpital Maisonneuve-Rosemont . Participants were general surgery residents. There were 27 eligible residents; 22 completed the study. They were filmed performing an intestinal anastomosis on cadaveric pig bowel. The self-directed learning by video (SDL-V) group was given an expert video, which demonstrated the technique performed by an experienced surgeon. The control group continued with their regular duties. Three weeks later, participants performed a second filmed anastomosis. Two attending surgeons evaluated the residents’ filmed anastomosis using the Objective Structured Assessment of Technical Skills scale. After their second anastomosis, all participants had access to the expert video and completed a survey.p = 0.99, presented as mean (SD)) or second filmed anastomosis procedure (control: 27.1 (3.9) vs. SDL-V: 29.6 (3.4) p = 0.28). Both groups improved significantly from pre- to post-intervention . Correlation between the evaluators for score was moderate . The pass/fail global evaluation exhibited poor inter-rater reliability . On the survey, all participants wanted more expert-made videos of specific surgical techniques.Score did not differ significantly between groups during the first (control: 23.6 (4.5) vs. SDL-V: 23.9 (4.5), Despite a higher final OSATS score for the intervention group, self-directed learning by video failed to produce a statistically significant difference on the overall OSATS scores between the two groups in this small cohort.The online version contains supplementary material available at 10.1186/s12909-021-02524-y. Throughout their surgical training, residents must acquire both theoretical knowledge and technical skills. These skills derive from the psychomotor development of residents, which links cognition to movement . DespiteSimulation is widely used in surgical residency programs. Notable examples include the “Fundamentals of Laparoscopic Surgery” (FLS) course , which eMore recently, studies have investigated the use of video coaching in surgical training. During a coaching session, the novice will receive directed feedback from an expert in the specific field. These studies have shown improved technical skills in intestinal anastomosis on canine models  and alsoAuto-didacticism refers to the process by which the students organize their thoughts, behaviors and emotions to maximally reap rewards from a learning experience . The leaTwo studies from the United Kingdom have compared the effects of personalized feedback from an expert versus a video made by an expert highlighting key points , 10. In With the proliferation and accessibility of new technologies, a wide range of e-learning tools have developed to improve medical and surgical education . These eThe goal of our study was to determine the efficacy of self-directed learning by video on the acquisition of a surgical procedure in surgical residents. The primary outcome was the impact of auto-didacticism on the Objective Structure Assessment of Technical Skills (OSATS) total score . The secThis project was approved by the “Comité d’Évaluation Scientifique en Santé Physique”  affiliated with Hôpital Maisonneuve Rosemont. Informed consent was obtained from all the participants. The inclusion criterion for participants in this project was being a surgical resident from the University of Montreal’s general surgery residency program, post-graduate year 1 (PGY-1) to PGY-5 who consented to participate. The exclusion criteria were not consenting or being unable to participate, due to scheduling issues, for instance. This study is a single blinded randomized controlled trial. There were two arms; a self-directed learning by video group (SDL-V) and a control group (C). The study took place in 2018 at the Surgical Simulation Laboratory at Hôpital Maisonneuve-Rosemont, a hospital affiliated with University of Montreal. All methods were carried out in accordance with relevant guidelines and regulations.SONY Handycam Exmor R) mounted on a tripod.Residents were asked to create an end to end, single layer intestinal anastomosis with interrupted sutures on a cadaveric pig bowel. The same surgical assistant was present for all the procedures to ensure uniformity. Participants were told that they should inform this person exactly how they needed to be assisted during the anastomoses; otherwise the assistant did not take any initiative. This assistant also started and ended the recording, using a camera . They were resected, divided into 15 cm long sections, and immediately frozen so that they could be thawed individually for each participant.The Audiovisual Department of Maisonneuve-Rosemont Hospital edited the recordings. The final videos had no sound and repetitive tasks, such as knot tying, were removed.After completing their baseline anastomosis, participants randomized to the intervention group received a Google Drive link  containing an expert video. This video was made prior to all baseline assessments. Producing the expert video took approximately 45 min. It demonstrates an end-to-end, single layer intestinal anastomosis using interrupted sutures on pig bowel. An experienced surgeon, who practices at the teaching hospital, performed the procedure. The video was finalized with voice-over narration by the same surgeon explaining key steps. The duration of this video was approximately 5 min. Residents were instructed to watch the video at their leisure and as many times as they wanted, they were also instructed not to share the video with other residents. Approximately 3 weeks after their baseline anastomosis, residents returned to the laboratory to perform the same procedure, which was also filmed.After completing their baseline anastomosis, participants randomized to the control group did not have access to the expert video and were also asked not to view any videos online or elsewhere. They continued their regular clinical duties and returned to perform the same procedure, 3 weeks after their baseline anastomosis. After completion of their second anastomosis, they received the Google drive link, so they could also benefit from the expert video.Residents, regardless of group, did not have access to the pig bowel between their baseline and second anastomosis to limit uneven skill acquisition through laboratory practice.All participants performed two anastomoses during two separate sessions approximately 3 weeks apart. All the anastomoses were performed on a 15 cm thawed pig bowel that had been cut in half by the same assistant. The interventions were filmed in the same manner, such that only the gloved hands of the participants, with their reference number written on them, could be seen. A video bank was created on a separate Google drive. The final videos had no sound.The primary outcome was the total score of the Objective Structured Assessment of Technical Skills (OSATS) scale . This opThe OSATS scale has been validated for construct validity, internal consistency and inter-rater reliability for evaluating open surgical simulation procedures. Given that we had two evaluators, who independently reviewed all the videos, we also looked at the inter-rater consistency in our study.Finally, two short surveys were created by the authors. They were sent to all the participants after they had completed the second filmed anastomosis; one was sent to the intervention group and the other to the control group. They were composed of questions with multiple choice answers , thus 22 residents participated in the study.After making their baseline anastomoses, participants were randomly allocated to either the control group or the intervention group. This was done using a 1:1 ratio and block randomization, stratified by the residents’ post-graduate year. Block size varied according to the number of residents per year who consented to participate. A sealed envelope method was used for the randomization process. The two surgeons who scored the videos were blinded to the randomization.p < 0.05 was considered significant. Statistical Analysis was done using PRISM 8.0 . Since we used a convenient sample, we retrospectively calculated the size of the between-group difference in total OSATS scores that the experiment was powered to detect (statpages.info/postpowr.html). Unless stated otherwise, data are presented as mean (SD).The PGYs of the participants of the two groups were compared with the Chi-square test. Spearman’s correlation coefficient was used to analyze the association between the OSATS scores  provided by the two evaluators. Cohen’s Kappa coefficient was used to determine the inter-rater reliability between the two evaluators in terms of pass/fail. The intervals between the two sets of anastomoses of the groups were compared with the unpaired student-t test. Repeated measures two-way ANOVA followed with post-hoc Sidak’s multiple comparisons test was performed to compare the OSATS scores  of the two sets of anastomoses within and between each group. A There were 27 general surgery residents in our program. Two residents were unable to participate due to away rotations and 3 were unable to participate due to scheduling issues. Thus, 22 participants were consented for the study. There were 11 participants that completed the study per group  or the second filmed anastomosis procedure (control: 27.1 (3.9) vs. SDL-V: 29.6 (3.4), p = 0.28), but both groups significantly improved their performances during the interval   vs. SDL-V: 23.9 (4.5) p = 0.28) in total OSATS scores between the groups for the second video, a retrospective sample size analysis showed that 36 participants would have been necessary to deem a variation of such magnitude as significant. With the 11 participants that were used, power was sufficient to detect a mean difference of 4.61.Having found a non-significant difference of 2.6 . OSATS score for each category were also significantly correlated, with the singular exception for “knowledge of instruments”  between the two evaluators, In the control group, 2 candidates reported watching a video on intestinal anastomosis and performing one during a real-case procedure. Every candidate in the control group wished they had had access to the video.In the intervention group, all candidates watched the video 1 to 2 times between the two anastomoses. This self-teach didactic activity was considered enjoyable and useful by all.Every candidate, regardless of group, reported wishing they had access to similar videos on various techniques throughout their residency.General surgery residency is a 5-year training program. During this time, the residents’ role is divided between being a healthcare provider and learner. In North America, residents can work between 70 to 100 h per week, depending on the specialty , 18. SurOur focus was to investigate a practical, focused learning method that was amenable to the residents’ schedule. E-learning encompasses a wide array of learning techniques, from online reading to interactive multimedia platforms. Its use to optimize medical pedagogy is under investigation as it has several advantages  , 23. StuIn this study, we designed our e-learning technique. We hypothesized that creating a short video, tailored specifically for a single technique, voiced over by an expert in the field, could provide a useful tool for the residents. The use of this method would give the residents flexibility in their learning; it could quickly and easily be viewed at any time, even on the ubiquitous smart phone. The material was made by a reliable source, and the narration provided key points. The residents universally appreciated the experience and all the candidates reported wanting more similar videos.The intervention group had a statistically significant improvement in all individual OSAT categories between their first and second filmed anastomosis, compared to the control group, which improved in only 4 of the 7 categories. Perhaps the intervention is a useful tool to hone those specific skills . This could be evaluated more closely in a follow up study.However, despite a higher final OSATS score for the intervention group, there was no statistically significant difference between those who had access to the video and those who did not. Since both groups improved, it is plausible that simply performing two anastomosis a few weeks apart was sufficient to improve the skill. This could also be due to the effect of mental imagery or mental rehearsal; that despite not having access to the expert video, the control group still improved on the skill . On the There are some limitations to our study. It is possible that the lack of significance is due to a small number of participants: there were 27 residents in our program, and 22 were randomized. The retrospective power analysis indicated a minimum of 18 participants per group to show a difference. Also, subtle technical differences may be lost in the quality of the filming, which was done with a stationary camera. The procedural task may have been too simple to show a significant difference. Finally, the intervention itself could have no impact in terms of acquisition of technical surgical skill.In terms of the inter-rater reliability, studies have previously shown a correlation coefficient for OSATS scores close to 0.8 . In our Given the positive response to this intervention, there may be a place for similar learning techniques in the surgical curriculum. With patient consent, real interventions  could be filmed, edited and narrated. A video library could be created for residents. This could be coupled with current technical workshops and lectures that several surgical programs usually offer.In our study, despite a global positive appreciation of the experience, self-directed learning by video did not prove to be a significant learning tool. It is conceivable that the number of participants was insufficient. With the widespread use of technology, there is certainly a role for video or e-learning in the surgical curriculum , and furAdditional file 1.


This article describes the process of selecting a collection of professional and amateur videos that elicit five basic emotions  and validating these videos in three groups of participants . In the video selection phase, professional videos, which were Western movie trailers, were selected from IMDb (Internet Movie Database) and amateur videos were selected from YouTube. The researchers selected videos that display five basic emotions, identified the time frames with the strongest display of emotion, and rated the emotional intensity of each video on a 5-point Likert scale. After the initial stage of selection, two other researchers performed an emotion recognition task by watching the videos without audio to ensure that the emotions can be elicited without understanding the language. This data was used to refine the final selection of 20 professional videos and 20 amateur videos. In the video validation phase, 30 participants were asked to identify and rate the intensity of emotion felt. This article includes a description of the video selection method, a detailed list of the videos selected, and participants' responses and ratings of emotional intensity for the 40 videos. The data is reported in 2Emotion recognition is an important social skill that allows individuals to understand others’ mental state and to respond appropriately in different social situations For professional videos, Western movie trailers were selected from IMDb, which is an online database of information related to films, by identifying scenes that displayed the common emotional triggers After the initial stage of video selection, two researchers performed the emotion recognition task, which was presented on the Psychopy 3.0 software and uploaded to Pavlovia. The videos were played without audio to ensure that the emotions can be elicited without understanding the language. Upon completion, this data was used to refine the final selection of 20 professional videos and 20 amateur videos see .In the video validation phase, 30 undergraduate and postgraduate students  enrolled in Universiti Malaysia Sabah were recruited. 10 participants were Chinese from China , 10 participants were Chinese from Malaysia , and 10 participants were Bumiputera from Malaysia . All participants, who had normal or corrected vision, were recruited through convenience sampling and snowball sampling. All participants gave informed consent prior to their participation.The video validation phase was carried out using the Psychopy 3.0 software, which was uploaded to Pavlovia. All participants accessed the videos via a link that was provided by the researcher and performed the emotion recognition task on their respective laptops. The 40 videos were presented randomly, and each video was followed by three questions . Participants who have watched more than 60% of the videos prior to the video validation phase were excluded from the data as they may have anticipated the content of the videos Upon completion, the data on the count and percentage of emotion detected and the rating of emotional intensity for each video were recorded on Pavlovia and then transferred to XLSX worksheet (.xlsx) to calculate the total count and total percentage of detected emotions and the mean of emotional intensity see . In TablEthics was approved by the ethical committee of the Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah [approval code: JKEtika 1/19 (20)]. Informed consent was obtained from all participants.The authors declare that there is no conflict of interest.


Nutrition plays a vital role in health and the recovery process. Deficiencies in macronutrients and micronutrients can impact the development and progression of various disorders. However, malnutrition screening tools and their utility in the clinical setting remain largely understudied. In this study, we summarize the importance of nutritional adequacy and its association with neurological, cardiovascular, and immune-related disorders. We also examine general and specific malnutrition assessment tools utilized in healthcare settings. Since the implementation of the screening process in 2016, malnutrition data from hospitalized patients in the Geisinger Health System is presented and discussed as a case study. Clinical data from five Geisinger hospitals shows that ~10% of all admitted patients are acknowledged for having some form of nutritional deficiency, from which about 60–80% of the patients are targeted for a more comprehensive assessment. Finally, we conclude that with a reflection on how technological advances, specifically machine learning-based algorithms, can be integrated into electronic health records to provide decision support system to care providers in the identification and management of patients at higher risk of malnutrition. Nutrition, a vital component of proper growth and development, plays an integral role in preventing disease, maintaining health, and facilitating faster recovery. Undernutrition remains a major public health concern for people of all ages. Nutritional deficiencies of essential macronutrients, including proteins, fats, and carbohydrates, in addition to micronutrients, including vitamins and minerals (as set by the US Department of Agriculture) , result In this work, we outline the deleterious effects of deficiencies of both macronutrients and micronutrients on the regression and recovery of neurological, cardiovascular, and immunological disorders. We summarize the assessment tools for nutrition in clinical settings. We also demonstrate how Geisinger, a large and integrated healthcare system with over one million active patients, has implemented a unified pipeline targeting malnutrition to improve care and outcome. Finally, we discuss how leveraging modeling and machine learning can help identify the most vulnerable population to better tailor care while optimizing resource utilization.The central nervous system and peripheral nervous system require sufficient nutritional resources to function optimally as major control centers of the body. Compensatory mechanisms during disease onset and progression rely heavily on macromolecules, coenzymes, and cofactors. Therefore, balanced nutrients are essential for appropriate recovery responses and disease regression. It is estimated that nearly 20% of patients with cerebrovascular accidents suffer from malnutrition . MalnutrAdequate intake of nutrition is important for blood vessel integrity, proper cardiac function, and sufficient myocardial mass . VitaminNutritional macromolecules can impact the electrophysiological properties of the heart , leading to the development of atrial fibrillation. Paradoxically, atrial fibrillation is associated with both underweight and overweight patients . In the Malnutrition is associated with immune dysfunction, characterized by chronic inflammation and infections . ImmunolPatients with nutritional deficiencies have depressed immune systems and are at a higher risk for infections. Specifically, malnutrition impacts the function of hematopoietic and lymphoid organs, including bone marrow, thymus, and spleen . When thMalnutrition assessment tools are utilized in clinical settings to identify specific nutritional deficiencies in patients. Assessment tools enable clinicians to gain a better understanding of the patient's condition and can promote targeted treatment strategies. American Society for Parenteral & Enteral Nutrition (ASPEN) is an example of a general approach to nutrition assessment. This toolbox considers family and medical history in addition to clinical diagnosis to determine the presence of inflammation and malnutrition. Clinical signs of fever, hypothermia, tachycardia, edema and weight gain/loss are used to recognize malnutrition. The ASPEN guidelines emphasize laboratory parameters consisting of serum albumin, C-reactive protein, white cell count, negative nitrogen balance for an objective confirmation. Further, strength tests, including handgrip dynamometer and physical performances  are employed for assessments in the elderly . In addiAs certain patient populations require a more tailored approach to malnutrition assessments, there are different toolboxes geared toward these specific patients. For example, Mini-Nutritional Assessment Short Form (MNA-SF) examines the cognitive problems of dementia and depression in the elderly , 51. PatASPEN promotes nutritional care through nutrition screening, assessment, and intervention . IndividWe have collected clinical data from the various departments across five Geisinger hospitals in central Pennsylvania. As shown in , the perTechnological advances could also aid in the fight against malnutrition. For instance, individualized recommendations about meal plans could be one of the ways to promote healthier food-consumption behaviors . In addiThe nutritional status of patients can be determined by performing laboratory testing, as we have outlined above. The use of these laboratory tests can enhance healthcare delivery by providing a quick and more efficient method of detecting nutritional deficiencies and prompting physicians to begin the process of in-depth assessment and intervention. However, these methodologies often fall short in identifying a larger patient population as well as following up on these patients. Artificial intelligence (AI) offers a scalable solution to these shortcomings when addressing malnutrition. Algorithms based on AI consist of various modeling strategies, including supervised learning, unsupervised learning, deep learning, and cognitive learning. While supervised learning is useful for classification and regression , unsuperAI could be designed to enhance the quality of care through early diagnosis, effective and personalized care plans, and risk identification and mitigation in some patients . StudiesNutrition impacts patients' general health, occurrence of diseases, and hospital systems at large. Although malnutrition screening tools exist, healthcare systems are not using these resources optimally and systematically. Modeling strategies, including the metamodel sensitivity analysis or machine learning-based approaches, can help identify a larger population of patients at risk for malnutrition. Our preliminary finding from one healthcare system shows the value of engaging physicians and care providers; however, more studies are warranted before malnutrition assessment tools could become truly transformative for already complex healthcare systems.VA and RZ designed the architecture of the study. VaS, ViS, and VA performed the searches. MS, VaS, and ViS assisted with the data collection and data analysis for the case study. DW, AK, RZ, RH, and JB-R provided critical feedback and contributed to the editing of various sections of the study. VaS, ViS, and VA wrote the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Forkhead Box N1 transcription factor. This transcription factor supports the development of TECs, the controllers of T cell fate, and defective TECs means no T cells.The thymus is a bi-lobed lymphoid organ localized above the heart whose primary function is to foster the development of the T cells of the adaptive immune system. T cells are a critical component of the cellular immune system, helping B cells produce antibodies, releasing cytokines to orchestrate effective immune responses, and killing infected cells and/or neoplasm/tumor cells. The recognition of an infected cell or tumor cell, and the ability to support B cell secretion of antibodies requires T cells express a cell surface receptor, termed the T cell receptor (TCR). This receptor selectively binds to peptides complexed to major histocompatibility complex antigens (MHC class I and II). MHC class I molecules are present on all nucleated cells in the body, while MHC class II is restricted to antigen presenting cells. In the thymus, thymocytes rearrange DNA loci comprising the genes encoding the TCR subunits. Using a process termed VDJ recombination, each thymocyte expresses a unique TCR with exclusive recognition specificities. However, only those thymocytes expressing TCRs that can engage self-peptides/self MHC complexes present on thymic epithelial cells (TECs) are “selected” to form the peripheral T cell repertoire. This involves processes coined positive and negative selection, with the ensuing repertoire of T cells capable of recognizing pathogen- or distinct tumor- derived peptides presented on self-MHC molecules without overt reactivity to self-peptides. The critical role of the thymus in this process is best exemplified with infants born with mutations in genes required for the formation of the thymus (22q11.2 deletion syndrome or DiGeorge). No thymus results in no T cells, leading to a severe combined immunodeficiency. A second excellent example pertains to the spontaneously arising nude mouse, which lacks a thymus and hair due to mutations in the Yet, as late as 1960, the thymus was a scientific conundrum. Dramatic variations in its size in humans and diverse species had been documented for over two millennia. Severe clinical repercussions based on these size differences ensued due to a complete lack of knowledge about its functions, which was not revealed until demonstrated in pivotal experiments performed by Jacques Miller using thymectomy and skin grafting. These experiments established the thymus as the site of T cell development. For this, Miller was awarded the Lasker Prize in Biomedicine in 2019 . Such anBhalla et al.; Giardino et al.). The contributions of key transcription factors such as T Box Transcription Factor 1 (TBX1) and FOXN1 in the patterning of the pharyngeal apparatus and the subsequent demarcation of the thymus anlage are discussed in conjunction with the differentiation and expansion of thymic epithelial cells. The formation of the two different populations of epithelial cells, cortical and medullary TECs and their selective roles in supporting and educating thymocytes to form the repertoire of T cells, which is unique to each individual, is described, revealing new subsets of these cells in the process .In the series of articles under the title “New Insights into thymic functions during stress, aging, and in disease settings” in this issue of Frontiers in Immunology, novel insights and findings by leading scientists in the field of thymus biology are presented. The articles include two reviews outlining recent discoveries into the mechanisms required for the formation and specification of the thymus within the 3rd pharyngeal pouch during embryogenesis . Such thymic hypoplasia is widespread in the population, and the different conditions leading to hypoplasia/aplasia of the thymus are presented in a combination of research and review articles in this series  For example, thymic hypoplasia is evident in pregnant women and infants born prematurely. The natural aging process causes a gradual and “permanent” hypoplasia of the thymus and this involves both loss of developing T cells and TEC subsets, with a greater impact evident in males than females, at least until middle-age . The epithelial tissue within the thymus undergoes adipogenesis and epithelial to mesenchymal transitions . Given these varied and damaging processes, improving and/or restoring thymopoiesis, from infants to the elderly, requires new therapeutic strategies. Several innovative approaches covered in this series include use of pro-T cells to improve T cell formation in the thymus  and the use of specific cytokines to restore TEC functions (Kinsella and Dudakov). Humanized mouse models and comparative mouse-human studies offer additional understanding and methodologies for improving thymus functions .As is well-recognized currently, in addition to aging, the thymus undergoes a transient and sometimes massive reduction in overall size and cellularity following infections, corticosteroid production through the hypothalamus-pituitary-adrenal axis or via injections, and chemotherapy treatments. The impact on thymocytes and stromal cell populations are presented herein . While the thymus is usually considered in the context of T cell development, there is evidence of some B cell development in normal and clinical settings. Two pronounced conditions, the autoimmune diseases, Systemic Lupus Erythematosus and Myasthenia Gravis, have substantial levels of B cell development/expansion . In the case of Myasthenia Gravis, thymectomy is actually done for patients to eliminate the autoreactive B cells in the thymus, improving their clinical outcomes. Alzheimer's Disease is another clinical condition where mouse models have established that intrathymic injections of TECs, derived from stem cells, can actually improve cognitive functions . In summary, we have come a long way from purposely destroying the thymus to focusing on its restoration and regeneration. These are nicely collated in our Frontiers in Immunology Topic.The emergence of checkpoint blockade immunotherapy to treat cancer patients has consequences as well, since the incidence of autoimmune complications with such a patient cohort increases dramatically due to the antibody treatments (All authors participated in the editorial reviews of the manuscripts. All authors participated in the writing and editing of the editorial article.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.