The current study assessed the appropriateness of the FIES for measuring FI in rural Bangladesh, followed by an assessment of FI prevalence and its correlates utilizing Bangladesh Integrated Household Survey (BIHS) data. The internal validity of the FIES and the prevalence of FI were investigated using the Rasch modeling approach. We utilized equating procedure to calibrate the study’s result to the global FIES reference scale and determined FI prevalence rates that were comparable across countries. The external validity of the FIES was evaluated by examining its association with other FI measures using Spearman’s rho correlation analysis. With an overall Rasch reliability of 0.84, the FIES met the Rasch model assumptions of conditional independence and equal discrimination, and as well as the fit statistics standards for all eight items. Infit statistics were within the allowed limit for all FIES items indicating good internal validity. However, we noted a high outfit (>2) for the “unable to eat healthy and nutritious food” item indicating the presence of some unusual response patterns. Our analysis found no significant (>0.4) correlation between FIES items. We also found a significant correlation between FIES and other FI proxies, e.g., the Household hunger scale (HHS), Food consumption score (FCS), and Household dietary diversity score (HDDS). Overall, the prevalence of moderate or severe FI was 18.92% in rural Bangladesh. Geographic areas, access to electricity, household ownership, access to sanitation, livestock ownership, family size, education level, and monthly per capita food expenditure significantly explained the variation in FI. Our analyses suggest that the FIES is internally and externally valid for FI measurement in rural Bangladesh. However, FIES questions may need to be reordered to more accurately evaluate lower levels of FI, and the item “unable to eat healthy and nutritious food” may need cognitive testing. Under SMore than 820 million people still go to bed hungry every night, and about 2.37 billion have moderate or severe food insecure . Asia isFood insecurity is a multi-dimensional problem resulting from diverse issues of individual, household, social, political, economic, and environmental factors. As shown by Chowdhury et al. 2016 , a low l“Access to adequate food,” a vital aspect of human welfare, is one of the crucial aspects of food security. Food insecurity experience scale (FIES) was developed by the Voices of the Hungry initiative of the United Nations Food and Agriculture Organization (FAO-VoH) to minimize complexity and to address the demand for a simple, universally acceptable, and comparable FI evaluation tool . The FIEThe FIES uses an experience-based metric, modeled as a latent trait to assess FI severity at the individual or household level. It pertains to eight questions about respondents’ experiences regarding access to adequate food, difficulties in accessing food, and coping strategies due to lack of money or other resources during a reference period . According to FIES, moderate FI exists when people face uncertainties about their access to food due to a lack of money/resources and are forced to adopt coping strategies, reducing the quality and/or quantity of food they consume. People with severe FI run out of food, experience hunger, and, at the most extreme, go days without eating .The FAO-VoH evaluated FIES’s psychometric properties using data from the 2014 Gallup World Poll (GWP) survey , Sub-Sah22.1We utilized the most recent BIHS survey data, carried out between 2019 and 2020 . The BIHBIHS is the country’s most extensive household survey to date. It provides detailed data related to various nutrition and development issue such as agriculture, food insecurity, dietary consumption, women empowerment, etc. . HoweverData Analysis and Technical Assistance Limited carried out the BIHS study with oversight from senior IFPRI researchers. Interviews were conducted with one adult male family member by a male interviewer and one adult female family member by a female interviewer.2.2Unlike the previous two surveys, BIHS 2018-2019 collected comprehensive data on household FI and resilience using the FIES . The FIE2.3Observations with missing responses to any FIES questions were excluded from the 5605 households in the BIHS data. The final analytical sample included 5603 cases with complete responses (meaning no missing response to any FIES question) for the psychometric analysis of the FIES.Although the BIHS survey module allowed for the recording of “don’t know” and “refused” responses to any FIES question, such responses were classified as “missing” for analytic purposes and were removed from the analysis. Then, 1s were assigned to affirmative responses and 0s to negative ones. Since the FIES consisted of eight questions, the raw score ranged from 0 to 8. We used the Voices of the Hungry project’s FIES app  to produce the parameter estimates and other outputs related to statistical validation . Followi2.42.4.1We analyzed the psychometric properties of the FIES by Rasch modeling based on the principles of Item response theory (IRT) . The keyRasch modeling output included item fit statistics (infit and outfit statistics), overall model fit statistics (Rasch reliability), and residual correlation matrix. An infit statistic between 0.7 and 1.3 was considered acceptable for adequate Rasch model building. A low infit value (below 0.7) indicates that the item is redundant with other items. In contrast, a high infit value (greater than 1.3) indicates an unusual response pattern, and items with high infit values are thought to be doing poorly . An outfWe also calculated the residual correlation matrix for each pair of FIES items. If the residual correlation between two items was significantly high (≥0.4), the responses to items were considered redundant, implying that they represent the same conditions caused by FI . Moreove2.5We identified the common items between the global and country scales by 1) examining equating plot of the two scale’s item parameters, 2) looking at the correlation between the common items’ adjusted item parameters, and 3) considering the absolute difference between the two scales’ item parameters for each item. Since we didn’t find any unique item, equating was performed with all eight items to the FIES global standard scale. After that, two globally-comparable indicators of the prevalence of FI at different levels of severity: moderate or severe FI (raw score = 4 to 6) and severe FI (raw score = 7 to 8), were calculated. All analyses were adjusted for sampling weights.2.6To verify measurement invariance and comparability of prevalence rates at the sub-national level, DIF analysis was conducted to ensure that the FIES scale performs similarly in subsets of the data. Each subgroup’s item severity parameters were plotted against each other to visually evaluate of how well they aligned. Alongside, fit statistics were calculated among different subgroups to inspect whether some items were problematic only in a certain context.2.7We considered numerous FI measures and development indicators for testing the external validity of the FIES. The proxy indicators were chosen exclusively based on the literature, and FAO-VoH used majority of them during the formulation of the global FIES threshold. Our analysis included Household dietary diversity (HDDS), Food consumption score (FCS), Household hunger scale (HHS), Months of adequate household food provisioning (MAHFP), household asset ownership, total cash monthly expenditure, and percentage of total cash expenditure on food, access to improved sanitation and water facilities, and child anthropometry for external validation.2.7.1HDDS measures the variety of food groups consumed throughout a certain time frame  as a proxy for household food access . The folThe respondents were asked whether anyone of the household consumed the foods from this list during the previous 24 hour. For each food group consumed, was coded as 1, otherwise coded as 0. The 12 food groups were then summed to compute HDDS, yielding a total HDDS score ranging from 0 to 12. Since there is no specific cutoff for HDDS, the present analysis treated the HDDS as a continuous variable.2.7.2The FCS is a proxy indicator to measure caloric intake and diet quality at the household level, indicating food security status . The sco2.7.3HHS, a household food deprivation scale, is a simple indicator for measuring household hunger in food-insecure areas. We estimated the proportion of households that fall into each of three hunger catagories: little or no hunger (HHS score 0–1), moderate hunger (HHS score 2–3), and severe hunger (HHS score 4–6) .2.7.4MAHFP is used to measure household food access, a simple sum of the number of months a household reports experiencing hunger in the previous 12 months .2.7.5Asset ownership is a good indicator for tracking changes in household resilience over time and monitoring progress toward increased household resilience . The agg2.7.6The improved water source was defined as water piped into the dwelling from a tube-well or borehole, protected dug wells, or rainwater. Water from unprotected dug wells and surface water  was considered unimproved. Households with pour-flush toilets or flush-to-piped sewer systems/septic tanks or pit latrines with slabs were considered improved sanitation facilities. In contrast, an unimproved sanitation facility was defined as a flush/pour flush to an open drain or pit latrine without a slab or hanging toilet or no toilet facility .2.7.7Anthropometric data was collected using height and weight scales . WHO Anthro software (version 3.3.2) was used to determine the three anthropometric indices: Height-for-age z score (HAZ), Weight-for-age z score (WAZ), and Weight-for-height z score (WHZ). Based on the World Health Organization’s (WHO) growth standard, children were categorized as stunted (HAZ -2 SD), underweight (WAZ - 2 SD), or wasting (WHZ -2 SD) . Subject2.8IBM SPSS Statistics version 25  was used for performing multiple logistic regression analysis to identify predictors of FI. The outcome variable food security was categorized as a binary variable (food secure and food insecure) based on the FIES raw score cutoff . A houseA set of demographic and socioeconomic factors such as geographic area, access to electricity, household ownership, access to sanitation, livestock ownership, family size, education level, and monthly per capita food expenditure were considered as explanatory variables identified a priori based on the literature review. At a significance threshold of 0.05, univariate analyses were performed for each explanatory variable. Variables whose p-values in the univariate analyses were less than 0.05 were included in the final model, which was built using the stepwise method (forward entry). The underlying assumption of the logistic regression model was investigated prior to the final model building.The regression model’s validity was examined using Pearson goodness of fit. The degree of multicollinearity in the model was evaluated by calculating the Variance inflation factor (VIF), with a VIF larger than two indicating multicollinearity . AdjusteWe used the Tobit regression model to analyze the predictors of FI severity, in addition to multiple logistic regression. In the Tobit regression model, the raw FIES score (from 0 to 8) served as the dependent variable. The raw score was concentrated at 0, which led to the selection of Tobit regression as the appropriate method. Therefore, the raw score was left-censored at point 0. The model used the same covariates as a multiple logistic regression analysis.2.9The Institutional Review Board at the International Food Policy Research Institute in Washington, DC, USA (Ref: 2014-44-PHND-D) granted BIHS ethical approval. The Bangladeshi government's Ministry of Agriculture approved the survey after reviewing the questionnaires. All participants gave their informed verbal agreement for participation in the study.33.1A total of 5603 rural households were included in this study. The majority of the households had access to electricity, but only approximately half of them had better sanitation facilities . Almost all rural households had their dwelling place, with more than half of them rearing livestock. In approximately half of the household'sper capita food spending was below 25 USD.3.2The item parameter or relative severity of the item was estimated based on the distribution of responses as a whole. Parameter values that are lower indicate less severe experiences, while those that are higher indicate more severe ones. There was a range of −4.77 to7.14 (11.91 logits) in FIES item severity parameters . The perThe proportion of affirmative responses declined as the severity of the items rose. Even if the severity parameters of the items assessing less severe FI (items 1–5) were inconsistent, their percentage of affirmative responses was still lower than those indicating more severe FI (items 6–8).3.33.4The residual correlation matrix shows the residual correlation among FIES items . However, there was no evidence of multidimensionality in the FIES, as correlation across items was within the acceptable range of |0.4|.3.53.6All divisions had infit statistics values in the acceptable range (0.7–1.3) for the first seven items . A zero Infit value for “Whlday” shows that the item does not provide significant information to the measure and is relatively redundant with other items, with Chittagong and Dhaka being the exceptions.3.73.8In rural Bangladesh, 18.92% of rural households experienced moderate or severe FI, whereas only 0.84% were severely food insecure . The pre3.9The results of logistic regression analysis show that the odds of FI were lower in all divisions than Sylhet . This re4Using a nationally representative large dataset, the present study sought to evaluate the internal and external validity of the FIES for measuring household FI in rural Bangladesh. We conducted a Rasch analysis to assess the performance of the FIES in the rural Bangladesh context. The statistical validity of FIES data was examined using item fit statistics, Rasch reliability, and residual correlations of items. It was found that the FIES met all of its assumptions regarding equal discrimination and conditional independence; thus, it is a valid measure of FI for Bangladesh. FIES was also significantly associated with all of the most important FI proxies. However, the prevalence of FI was estimated at 18.92% in Bangladesh. Various demographic and socioeconomic factors contributed to FI, such as geographic area, access to electricity, household ownership, access to sanitation, livestock ownership, family size, education level, and monthly per capita food expenditure.Statistical validation is the fundamental screening tool for evaluating the quality of self-reported, experience-based FIES data and determining whether the data are compatible with the assumptions of the measurement model. It also assesses whether a given measure of FI has a strong enough statistical foundation for its intended policy and research uses. Rasch is one of the most invaluable statistical tools for developing and validating survey instruments by assessing individual items and their functionality . In addiSelf-reported experiences and actions regarding food access due to a lack of money or other resources are elicited by FIES over the course of a year. One of the most important characteristics of experiential FI measures is that the FIES items vary widely in terms of the degree of FI. It is a latent feature, which means it is not directly visible. The cognitive content of the items also intuitively demonstrates the severity of the conditions detected by the items. Moreover, less often confirmed items have greater severity. However, The Rasch model provides standardized statistical methods for measuring the severity of each item by formalizing the concept of item severity ordering. By predicting their position on the same underlying continuum of severity of FI, Rasch modeling provides a theoretical basis for linking the FIES indicator items to the FIES responses ,35. EachFit statistics are chi-square type statistics  and wereAlthough the main statistic focuses on infit, the outfit statistic is also important. In contrast to infit, the outfit statistic is highly case sensitive; even a few cases with highly improbable response patterns  can elevate outfit value. Items that cause cognitive issues or have distinctive meanings for small subpopulations can be identified using outfit statistics. A comparatively higher outfit value (3.6) for the “healthy” item in our analysis reflects that some respondents gave improbable responses. In line with our findings, “healthy” item was shown to be relatively higher (>2) in Ethiopia  and the The Rasch model also presupposes that all item-to-item correlations in the FIES should arise from items' shared association with the latent trait. Residual correlations were not high for any pair of items, indicating that the FIES was unidimensional, measuring only one construct of FI. In addition, the total Rasch dependability was within acceptable limits. Therefore, it follows that the FIES is a reliable and valid instrument for application in rural Bangladesh, with excellent psychometric qualities.Equating procedure is necessary to compute internationally comparable prevalence rates of different levels of FI among the study population by calibrating the study’s results to the global FIES reference scale. Furthermore, this technique, make reliable comparisons of FIES results between subpopulations within a country .When the severity of an item in a country is less than 0.35 points off the global standard, we classify it as “common” . Even thWe found some discrepancies in the conceptual ordering of FIES items, particularly those that measure less severe FI. The severity of FI was ranked in reverse order by the items “skipped” and “ateless”. This disarray had no effect on the overall FI measurement in this study because both items were classified as moderately FI . In addiThe current study used FIES to investigate the prevalence of FI at the household level in rural Bangladesh. The level of moderate or severe FI (18.92%) reported in the current study is quite similar to that found in a telephone survey conducted in rural Bangladesh by IFPRI and Cornell University (16%) during the COVID-19 pandemic . The IFPSimilar to previous studies conducted in Bangladesh , Latin ARegarding the educational level of respondents, -those with lower educational levels (never attended school and primary school or below) were more likely to be food insecure than those with higher educational levels (secondary or higher). This finding was similar to findings of studies performed in Iran  and sout4.1The study’s key strength is its use of a nationally representative large dataset, which enables us to generalize our findings to rural Bangladesh. We employed multiple logistic and Tobit regression models, which indicate the robustness of the study findings. Moreover, the results of one model are confirmed by the results of another, suggesting the independence of our study findings from the model selection for statistical analysis. However, the study is not beyond limitations. We could not rule out a certain degree of response bias due to the nature of the FIES data. Measurement of the seasonality of FI was also beyond the scope of the study due to the cross-sectional nature of the BIHS survey.Similarly, the study design did not allow for investigating FI causality, although policy decisions at all levels of government can benefit from the information gleaned from a cross-sectional study . Apart f4.2Our study analyses ensured the internal and external validity of the FIES in the context of rural Bangladesh. Future research may use the FIES to assess the state of FI as required for SDG 2.1.2, set national goals, and monitor the progress of interventions on FI at national and local levels.5The results of the current study suggest that the FIES is a reliable and valid tool for measuring food insecurity in rural Bangladesh. Our results also imply that the FIES questions may need to be rearranged in order to more correctly assess moderate and low FI. We recommended cognitive testing of the “healthy” item because of its high outfit value to possibly guide improvements of this item. In this study, 18.92% of study subjects experienced moderate or severe FI, and 0.84% experienced severe FI. A set of demographic and socioeconomic factors, i.e., geographic area, access to electricity, household ownership, access to sanitation, livestock ownership, family size, education level, and monthly per capita food expenditure, were significantly associated with FI.No public, private, or not-for-profit organization provided a grant in support of this study.Ahmed Jubayer, Md. Moniruzzaman Nayan: Conceived and designed the study; Analyzed and interpreted the data; Wrote the paper.Saiful Islam: Performed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper.Abira Nowar: Contributed reagents, materials, analysis tools or data; Wrote the paper.Md. Hafizul Islam: Performed the experiments; Analyzed and interpreted the data.https://dataverse.harvard.edu/dataset.xhtml?persistentId=doi:10.7910/DVN/NXKLZJ).Data associated with this study has been deposited at Harvard Dataverse (The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


GABBR2 in bladder cancer cells. Meanwhile, GABBR2 expression was significantly elevated in a cisplatin-resistant bladder cancer subline, compared with control cells. In AR-positive bladder cancer cells, knockdown of GABBR2 or treatment with a selective GABA B receptor antagonist, CGP46381, considerably enhanced the cytotoxic activity of cisplatin. However, no additional effect of CGP46381 on cisplatin-induced growth suppression was seen in GABBR2-knockdown cells. Moreover, in the absence of cisplatin, CGP46381 treatment and GABBR2 knockdown showed no significant changes in cell proliferation or migration. These findings suggest that GABBR2 represents a key downstream effector of AR signaling in inducing resistance to cisplatin treatment. Accordingly, inhibition of GABBR2 has the potential of being a means of chemosensitization, especially in patients with AR/GABBR2-positive bladder cancer.The precise molecular mechanisms responsible for resistance to cisplatin-based chemotherapy in patients with bladder cancer remain elusive, while we have indicated that androgen receptor (AR) activity in urothelial cancer is associated with its sensitivity. Our DNA microarray analysis in control vs. AR-knockdown bladder cancer sublines suggested that the expression of a GABA B receptor GABBR2 and AR was correlated. The present study aimed to determine the functional role of GABBR2 in modulating cisplatin sensitivity in bladder cancer. AR knockdown and dihydrotestosterone treatment considerably reduced and induced, respectively, GABBR2 expression, and the effect of dihydrotestosterone was at least partially restored by an antiandrogen hydroxyflutamide. A chromatin immunoprecipitation assay further revealed the binding of AR to the promoter region of  Urothelial carcinoma in the urinary bladder has represented a commonly diagnosed malignancy, especially in men, and the global number of bladder cancer-related deaths has indeed increased from 165,100 in 2012 ). MoreovDespite the availability of novel therapeutic options, such as immunotherapy with checkpoint inhibitors, cisplatin (CDDP)-based chemotherapeutic regimens remain the first-line systemic treatment for locally advanced or metastatic urothelial carcinoma ,6,7,8. IThe molecular mechanisms underlying CDDP resistance are still far from being fully understood ,16,17,18GABBR2 expression, which was at least partially blocked by antiandrogen ) treatment  assay . A bioinUsing its inhibitor and knockdown, we assessed the impact of GABBR2 on the growth of bladder cancer cells. Western blot showed that a selective GABA B receptor antagonist, CGP46381 (50% inhibitory concentration (IC50): 4.9 μM ), inhibiWe then determined if GABBR2 could modulate sensitivity to CDDP treatment in bladder cancer cells. The MTT assay was first performed in UMUC3-control-shRNA and UMUC3-GABBR2-shRNA sublines treated with various doses of CDDP covering its pharmacological concentrations . GABBR2We further assessed the effects of CGP46381 on CDDP cytotoxicity. In UMUC3 A, 5637-AGABBR2 expression in bladder cancer. Data obtained from GSE32894 [GABBR2 tumor  and cerWe obtained anti-AR (441), anti-GABBR2 (H-10), and anti-GAPDH (6c5) antibodies from Santa Cruz Biotechnology . DHT and HF, CGP46381, and CDDP were obtained from Sigma-Aldrich , Thermo Fisher , and Santa Cruz Biotechnology , respectively.2. The cells were then cultured in phenol red-free medium supplemented with 5% FBS  at least 24 h before actual assays.A human urothelial carcinoma cell line, UMUC3, was originally obtained from the American Type Culture Collection and recently authenticated by the institutional core facility. Human urothelial cancer sublines stably expressing AR-shRNA  or control-shRNA  , as well® Green Supermix , as we described previously [GABBR2 ; and GAPDH .Total RNA isolated from cultured cells by TRIzol  was reverse transcribed using oligo (dT) primers and Omniscript reverse transcriptase . Real-time PCR was then performed using iQ™ SYBReviously ,24. The Equal amounts of proteins (30 µg) extracted from cell extracts were subjected to electrophoresis with 10% sodium dodecyl sulfate-polyacrylamide gel, which was transferred to polyvinylidene difluoride membrane electronically. After blocking with 5% nonfat dry milk, the membrane was incubated with a primary antibody at 4 °C overnight, followed by 1 h incubation with an HRP-conjugated secondary antibody  at room temperature. Chemiluminescent signals were then generated by Clarity Western ECL Substrate and detected by ChemiDOC™ MP (Bio-Rad).https://biogrid-lasagna.engr.uconn.edu/lasagna_search/ [We first performed a bioinformatic search for potential AR binding sites in the GABBR2 promoter  seeded in 96-well tissue culture plates were cultured for 48 h and then incubated with 0.5 mg/mL of MTT -2,5diphenyltetrazolium bromide; Sigma-Aldrich) for 3 h at 37 °C. MTT was dissolved by dimethyl sulfoxide, and the absorbance was measured at a wavelength of 570 nm with background subtraction at 630 nm. IC50 was calculated using the web-based tool .The MTT assay was used to assess the cell viability. Cells  was quantitated using ImageJ software .https://hgserver1.amc.nl/cgi-bin/r2/main.cgi, accessed on 7 August 2023) was used to assess the prognostic role of GABBR2 expression in patients with bladder cancer. Data were obtained from the Gene Expression Omnibus repository (GSE32894; https://www.ncbi.nlm.nih.gov/geo/query/acc.cgi?acc=GSE32894 [The R2 Genomics Analysis and Visualization Platform (GSE32894 , accesset-test was used to compare numerical data. p values less than 0.05 were considered to be statistically significant.Student’s We identified GABBR2 as a key downstream effector of AR in modulating CDDP sensitivity in bladder cancer. Our data suggest that not only concurrent antiandrogen therapy but also GABBR2 inhibitor treatment has the potential of being a means of chemosensitization, especially in patients with AR/GABBR2-positive bladder tumor. Nonetheless, further studies are warranted for elucidating molecular mechanisms responsible for AR/GABBR2-mediated chemoresistance.


Physiotherapeutic telerehabilitation in various musculoskeletal and internal diseases, including back pain, might be comparable to face-to-face rehabilitation or better than non-rehabilitation. In Germany, a standardized back school for patients with chronic back pain is provided in outpatient rehabilitation centers. The effectiveness of this standardized back school was shown in a randomized controlled trial in face-to-face rehabilitation. This study examines non-inferiority of a hybrid rehabilitation applying a digital version of the standardized back school against a rehabilitation applying the face-to-face back school.We recruit 320 patients in eight German outpatient rehabilitation centers. Patients are randomized equally to the intervention and control groups. Patients aged 18 to 65 years with back pain are included. Patients lacking a suitable private electronic device and German language skills are excluded. Both groups receive the standardized back school as part of the 3-week rehabilitation program. The control group receives the back school conventionally in face-to-face meetings within the outpatient rehabilitation center. The intervention group receives the back school online using a private electronic device. Besides the back school, the patients participate in rehabilitation programs according to the German rehabilitation guideline for patients with chronic back pain. Hence, the term “hybrid” rehabilitation for the intervention group is used. The back school consists of seven modules. We assess data at four time points: start of rehabilitation, end of rehabilitation, 3 months after the end of rehabilitation and, 12 months after the end of rehabilitation. The primary outcome is pain self-efficacy. Secondary outcomes are, amongst others, motivational self-efficacy, cognitive and behavioral pain management, and disorder and treatment knowledge. Guided interviews with patients, physicians, physiotherapists and other health experts supplement our study with qualitative data.Our randomized controlled trial aims to demonstrate non-inferiority of the online back school, compared to conventional implementation of the back school.German Clinical Trials Register .The online version contains supplementary material available at 10.1186/s44247-023-00013-4. Over the last decade, the usage of technology in rehabilitation has grown exponentially, paving the way for the development of telerehabilitation and the opportunity for more flexible implementation of rehabilitation . The benA survey from 2019/2020 showed that 61.3% of German adults suffered from back pain during the last 12 months. Low back pain occurred more often than neck pain in a ratio of two-to-one. Women were affected more often by low back pain (60%) and neck pain (54.9%) than men (56.4% and 36.2%). Around 15.6% of German adults develop chronic back pain (women 18.5% and men 12.4%) . Due to Physical exercise can reduce pain and improve mobility, which is why it plays an important role in today’s pain rehabilitation programs . HoweverAlthough a systematic review of exercise-based telemedicine in patients with chronic pain found no difference in physical activity, activities of daily living, and quality of life , telerehWhilst considerations on the implementation of telerehabilitation in Germany have so far been largely limited to rehabilitation access , 19 and The study we are planning compares a hybrid rehabilitation program that implements an online back school with conventional face-to-face back school. The back school curriculum developed by the Federal German Pension Insurance  is the sWe hypothesize that patients receiving the hybrid rehabilitation program achieve as comparable pain self-efficacy as patients receiving the back school within a conventional rehabilitation program. Additional comparable outcomes are expected for other variables. Guided interviews explore the structure and processes of the hybrid rehabilitation program.Our study is a randomized controlled trial. We recruit participants in eight outpatient rehabilitation centers. Each center provides 40 patients. In total, we recruit 320 patients. Within each rehabilitation center, participants are randomized equally to the intervention and control group. Randomization schedules were stratified for each rehabilitation center and used block randomization. Four measurement points are planned . We examine the non-inferiority of the hybrid rehabilitation program. Primary outcome is pain self-efficacy at the 12-month follow-up . We alsoEight centers for outpatient rehabilitation are involved in recruitment, data collection, and implementation of the rehabilitation program. All centers are located in seven different German cities . The intervention and control groups are recruited in the same rehabilitation center, but the online back school of the intervention group is used at the patients’ homes and is provided by a web-based rehabilitation provider .Rehabilitants aged 18 to 65 years and with back pain  are included. Patients without stable internet, an appropriate electronic device for using the internet or executing app-related videos, and a suitable camera for communication are excluded. We also exclude patients not speaking German.The intervention group receives a hybrid rehabilitation program, during which a standardized back school is delivered digitally. The standardized back school developed from the Federal German Pension Insurance consists of seven modules and is based on the health action process approach and the fear-avoidance beliefs model , 26. TheThe control group receives a conventional rehabilitation program, during which the standardized back school is provided in face-to-face meetings. Table No harm due to study participation is expected. Therefore, no ancillary and post-trial care are intended.All outcomes, including measurement points and expected scaling, are shown in Table The primary outcome is pain self-efficacy, which is measured by the German adaption of the Pain Self-Efficacy Questionnaire  , 44. TheHealth and health-related outcomes: The current health status is assessed through one item of the COPSOQ  [onnaire) . The parMental health, functional capacity, and pain are assessed with the IRES-24 questionnaire, which was developed as a comprehensive generic tool to measure outcomes of rehabilitation in Germany . For menCognitive and behavioral pain management are determined by six subscores of the FESV questionnaire (Fragebogen zur Erfassung der Schmerzverarbeitung) : action-Motivational self-efficacy is determined by ratings of three statements based on Schwarzer et al. . ParticiParticipants are expected to accumulate disorder and treatment knowledge on back pain during the rehabilitation. This knowledge is rated by ten self-developed questions  A 6-point scale is provided for every question . The questions refer to all modules of the back school. The scores of the ten questions are added up to an overall score, which ranges from 0 to 50 points. A higher score indicates more disorder and treatment knowledge.Participants are expected to improve their self-efficacy in practicing gained knowledge. Self-efficacy in practicing gained knowledge is tested by four self-developed questions  A 6-point scale is provided for every question . The questions are based on modules three and six of the back school. The scores of the four questions are added up to an overall score, which ranges from 0 to 20 points. A higher score indicates more self-efficacy in practicing gained knowledge.Electronic health literacy is measured by the eHEALS  . Eight qSelf-informing behavior is assessed using a self-developed question, which asks how frequently the participant informed themself about back pain or chronic pain in the past 3 months. Six potential answers are provided .To assess how well the patients adhered to the exercises from the back school after the rehabilitation ended, we ask them the self- developed question: How often did you do the exercises from the back rehabilitation after the end of the rehabilitation? Five potential answers are provided .To assess how well the patients adhered to the knowledge learned from the back school after rehabilitation ended, we ask them the self-constrcuted question: How often did you apply the knowledge you learned from the back rehabilitation to everyday life after the end of the rehabilitation? Five potential answers are provided .Work functioning outcomes: Work ability is measured by three questions of the work ability index [ty index , 36. Thety index , 38.Sickness absence is measured by self- developed questions, which assess if people are currently on sick leave and how many weeks patients were on sick leave during the last 6 months (baseline and 12-month follow-up) or 3 months (3-month follow-up).Employment is assessed by a self- developed item, which allows a distinction between employed and non-employed persons. Additionally, we ask for the employment contract  and shift work.Patient satisfaction: Patient satisfaction is assessed by the German version of the Client Satisfaction Questionnaire  [, ZUF-8) , 45, whiUse of the digital intervention: The digital intervention is rated by the intervention group only. The system usability of the Caspar application is determined using the System Usability Scale (SUS) [le (SUS) . ParticiAn overall assessment of the Caspar application is assessed by grades from 1 to 5  .The way of using the Caspar application is clarified by two self- developed questions. The first question asks how frequently participants make use of the Caspar application during the last 3 weeks. Six potential answers are provided . An additional question asks what electronic device was used. Multiple responses are possible .Rehabilitation aftercare: Three self- developed questions on rehabilitation aftercare assess which physical activity options were used in the last 3 months  , which services were used in the last 3 months? , and reasons for not participating in an aftercare program . For each question multiple responses are possible.Sociodemographic information on age, gender, language skills, partnership, number of children, level of education, and professional qualifications are collected by self- developed questions.Therapeutic treatments during the rehabilitation program are recorded according to the classification of therapeutic services . We deriFESS: Pain Self-Efficacy Questionnaire (German: Fragebogen zur Erfassung der schmerzspezifischen Selbstwirksamkeit), COPSOQ: Copenhagen Psychosocial Questionnaire, IRES-24: Indicators of Rehabilitation Status (German: Indikatoren des Rehastatus), FESV: Questionnaire for the Assessment of Pain Processing (German: Fragebogen zur Erfassung der Schmerzverarbeitung), eHEALS: eHealth Literacy Scale, ZUF-8: Client Satisfaction Questionnaire (German: Fragebogen zur Messung der Patientenzufriedenheit), SUS: System Usability Scale. All instruments except the FESV were freely available and/or licenced with permission to use, share, adapt and reproduce. The FESV has to be purchased. Our self-developed items and questions can be used, shared, adapted and reproduced. Participant timeline.A timeline of enrollment, intervention, and assessments is shown in Table n = 160; control group: n = 160), which result in 20 participants for both arms of the study within each outpatient rehabilitation center. The sample size is sufficient for a secondary analysis including only patients with complete follow-up. The anticipated flow of participants is shown in Fig. A difference of four points for pain self-efficacy  was deteThe recruitment is conducted in eight different outpatient rehabilitation centers. Study assistants recruit new study participants as follows: First, every new arriving patient is informed orally about the study. Second, eligible and interested study participants are handed a patient information leaflet as well as a consent form. Third, potential study participants are asked for their informed and written consent. The patient information letter and the consent form are accessible as additional file Randomized allocation is done in a one-to-one ratio. The principal investigator at the University of Lübeck generated all randomization sequences using Stata 16.1 . For each outpatient rehabilitation center, 40 assignments were randomly combined in blocks of four and eight, and the University of Lübeck provided the rehabilitation centers with 40 identical, non-transparent, sealed envelopes numbered from 1 to 40. The envelopes contain the information about the group allocation and personal identification number. Before opening the envelopes, the content of the envelopes was unknown to everyone, excluding the principal investigator. The envelopes are handed out consecutively from 1 upwards to the participants, after informed consent was given. A study assistant in each outpatient rehabilitation center enrolls the participants and registers the group allocation in the study list (Microsoft Excel) using the personal identification number. Due to the nature of the intervention, there is no blinding in the study.Quantitative data are collected with questionnaires and standardized rehabilitation discharge reports. Qualitative data are collected with interviews by phone. An overview of the collected data and measurement time points is shown in Table The first and second questionnaires, together with a prepaid and preaddressed envelope to the University of Lübeck, are given to the participant by a study assistant in the outpatient rehabilitation center. Questionnaires are marked with the personal identification number of the participant only. The participant completes the questionnaires, puts them in the envelope and returns the sealed envelope to the study assistant. The study assistant sends the envelope to the University of Lübeck. For the third and fourth questionnaires, participants are contacted by mail through the University of Lübeck directly. Participants send the completed questionnaires back by again using a prepaid and preaddressed envelope. Patients whose follow-up questionnaires have not been received at the University of Lübeck two weeks after completion are reminded once by mail with new questionnaires, as well as a prepaid and preaddressed envelope to the University of Lübeck. The standardized medical discharge reports are sent to the University of Lübeck after the recruitment phase is over and contain all documented therapeutic treatments during rehabilitation. Researchers from the University of Lübeck conduct the guided interviews between the second and third measurement time points. Participants can withdraw their consent at any time and all collected data will be deleted accordingly.Data from the questionnaires are entered into computers by trained research assistants or researchers from the University of Lübeck using Microsoft Access forms. The Microsoft Access forms contain the exact set of questions and values from the questionnaires. Data entry is done directly after the questionnaires arrive at the University of Lübeck.Documented in the study list of each outpatient rehabilitation center is whether the first and second questionnaires were given to the participant, the personal identification number, name, surname, year of birth, address, and gender, as well as the start and end date of rehabilitation. The study list is transferred to the University of Lübeck.In the monitoring list at the University of Lübeck, all study lists are combined and received questionnaires from all participants at all measurement time points are documented. It is also documented whether the third and fourth questionnaires were sent to the participant from the University of Lübeck, and if written consent was received. Additionally, the University of Lübeck uses the monitoring list is to send out reminder letters to the participants in case of missing questionnaires.An external data monitoring committee is not implemented. Short-term and long-term effects are analyzed and published separately. No further interim analyses are planned. No criteria for early study termination have been established.Every 2 weeks, the status of recruitment, response rates of the questionnaires, other announcements, and current events are discussed through a video conference between the University of Lübeck and the outpatient rehabilitation centers.Every new study participant is entered into the study list at each outpatient rehabilitation center. All documentation is done by study assistants from the outpatient rehabilitation centers. The study list is password protected. This list is stored on a computer at the outpatient rehabilitation center, and only the study assistants have access to it. Every two weeks, the study assistants send an electronic encrypted copy of the study list to the researchers at the University of Lübeck. After the last enrolled participant finishes the second questionnaire, the study assistants delete the study list.All received study lists from the outpatient rehabilitation centers are incorporated into the monitoring list at the University of Lübeck. Each received study list is deleted immediately at the University of Lübeck after the content is transferred to the monitoring list. The monitoring list is password protected and stored on the computers at the University of Lübeck. Only researchers involved in the study have access to it. The monitoring list itself will be deleted after the third follow-up is complete (anonymization of the data).The data from all questionnaires are pseudonymized by the personal identification number on the questionnaire. All completed questionnaires are sent to the University of Lübeck. At the University of Lübeck, the questionnaires are stored in folders and locked in lockers that belong to the office rooms of researchers who are involved in the study. The questionnaires are only accessible to researchers who are involved in the study. All questionnaires will be destroyed in accordance with data protection regulations upon completion of the study.The interviews are recorded and stored on the computers at the University of Lübeck. The files of the audio recordings are password protected and pseudonymized immediately after the interview is finished. Transcripts of the interviews are also pseudonymized. The audio recordings are deleted after the interviews are transcribed.Medical discharge reports are pseudonymized by the personal identification number and sent electronically to the University of Lübeck by the study assistant at each outpatient rehabilitation center.All digital data is stored on password protected computers that require authentication of users. The computers are located in the researchers’ office rooms at the University of Lübeck, which are locked when left. Access to the computers can be tracked. Only researchers at the University of Lübeck have access to the digital data. The network in which the computers are integrated is protected against external access and manipulation by a regularly updated firewall system.Ten years after the end of the study, all digitalized data from the questionnaires will be deleted.All authors of the study protocol will have access to the final and fully anonymized data set.We analyze the short-term effects (end of rehabilitation and 3-months follow-up) and long-term effects (12-months follow-up) to show non-inferiority of the hybrid rehabilitation program. The results of the short- and long-term effects will be published separately.To test the primary hypothesis of non-inferiority, the confidence interval method is applied , 48. We The estimate of the treatment effect is adjusted for the baseline scores of the dependent variable, as well as for the treatment center (outpatient rehabilitation center). To estimate group differences for continuous and binary outcome variables, linear or logistic regression is calculated. Regression coefficients or odds ratios and their 95% CI are determined. Confidence intervals are two-sided for all secondary outcomes.Age, sex, level of education, electronic health literacy, and motivational self-efficacy are considered as moderators of the treatment effect on our primary outcome variable. The interaction effects are assessed through p-values. All secondary outcome variables are tested on superiority of the intervention group, and we present p-values. We test superiority to identify potential group differences that, in the case of non-inferiority, can be used to formulate a preference for one of the two treatments .In order to perform an intention-to-treat analysis, missing values are imputed by multiple imputation using 20 independent data sets , 52. TheA sensitivity analysis also calculates unadjusted estimates for the intention-to-treat analysis. An additional sensitivity analysis is conducted as complete case analysis. Like in the primary analysis, we adjust for the baseline scores of the dependent variable and for the treatment center. We also conduct a per-protocol analysis, including only individuals in both groups who participated in six of the seven back school modules.Withdrawal from consent leads to deletion of the participant’s data.The analyses are performed with Stata 16.1 . A two-tailed p-value of less than 0.05 is considered statistically significant.Our randomized controlled trial compares a hybrid rehabilitation that implements an online back school with a rehabilitation that conventionally provides a face-to-face back school. We aim to demonstrate non-inferiority of the hybrid rehabilitation. All findings of this study will be published in peer-reviewed journals and presented at conferences. The authors of this present study protocol will also write the publication of the findings. No professional writers will be included in the process.The SPIRIT checklist  was used when drafting the study protocol .Recruitment has started and is still ongoing.Additional file 1. Items from the World Health Organization Trial Registration Data Set.Additional file 2. Full description of the intervention according to the TIDieR checklist and the TIDieR-telehealth checklist.Additional file 3. Patient information.Additional file 4. Model consent form.Additional file 5. Self-developed instruments.


The rapid development of information and communication technology has fostered a natural integration of technology and design. As a result, there is increasing interest in Augmented Reality (AR) business card systems that leverage digital media. This research aims to advance the design of an AR-based participatory business card information system in line with contemporary trends. Key aspects of this study include applying technology to acquire contextual information from paper business cards, transmitting it to a server, and delivering it to mobile devices; facilitating interactivity between users and content through a screen interface; providing multimedia business content  via image markers recognized by users on mobile devices, while also adapting the type and method of content delivery. The AR business card system designed in this research enhances traditional paper business cards by incorporating visual information and interactive elements and automatically generating buttons linked to phone numbers, location information, and homepages. This innovative approach enables users to interact and enriches their overall experience while adhering to strict quality control measures. A business card is a professional introduction, displaying one’s name, address, phone number, company name, and title. As a crucial marketing tool for establishing connections between businesses and potential customers, business cards represent a company’s brand and its products. Traditional paper business cards aim to make a strong first impression during business meetings, emphasizing simplicity and conveying essential information. As a result, unique and differentiated design business cards and digital business cards have emerged .The rapid development of information and communication technology has led to the rise of digital science, technology museums, and exhibitions featuring virtual books, digital Olympic halls, voice recognition robots, virtual architectural expressions, interactive illusions, and camera games . SmartphToday, characterized by the fourth industrial revolution, the proliferation of mobile devices has resulted in better connectivity and segmentation between customers compared to traditional mass marketing and internet marketing. Mobile marketing has emerged as a popular tool for targeted marketing, with companies developing branded applications and leveraging mobile device capabilities for various marketing activities . ConsequPaper business cards, though widely used, face limitations in conveying information in the digital age and have a restricted role in public relations. AR business cards, which employ AR technology, can address these challenges. AR technology involves object recognition and location-tracking capabilities, as exemplified by the popular AR game “Pokémon Go” which utilizes location-tracking technology . The widAugmented Reality technology merges the natural environment with virtual space in real time, providing users with an immersive and realistic experience. Users can access information intuitively by overlaying information on actual locations, enhancing their engagement and interaction . Recent Quality control is essential to many industries and products, ensuring businesses deliver consistent and reliable goods and services to their customers . BusinesAugmented Reality (AR) is technology that utilizes video devices to recognize objects in the real world from a human perspective. It seamlessly integrates the real and virtual worlds by displaying virtual information, such as text, as well as 2D and 3D objects, in real time on the recognized objects . AR can The widespread use of mobile devices, such as smartphones, has led to the emergence of location-based AR content. Location-based AR leverages mobile device GPS  data to measure the user’s latitude, longitude, and altitude. It uses geomagnetic sensors to determine the user’s direction and accelerometers to establish the device’s orientation. However, GPS sensors struggle to accurately calculate the user’s position indoors or underground, limiting their functionality to navigation pointing towards the target location .Marker-based AR utilizes square markers with high recognition rates to calculate the position and orientation of the camera, as video processing technology is significantly affected by external factors such as lighting and shading. Markers enable the efficient creation of coordinate systems for the real and virtual worlds by selecting classes to extend 3D objects. Marker-based AR processes the original image into a binarized image using a threshold, recognizes the marker’s edge to determine its orientation and position, and then augments objects accordingly .Traditional AR technology relies on markers to augment virtual objects, requiring users to possess these features. The presence of markers in the output video may conflict with the real world, reducing user immersion and realism. To address these challenges, research is being conducted to determine the camera’s orientation based on natural environmental information in the real world. This approach, known as non-marker-based AR technology, has already led to commercial services ,13.AR technology offers the advantage of synthesizing and displaying virtual information in real space rather than merely providing virtual content within a virtual background. This expands users’ interaction capabilities and enhances their implicit knowledge. As a result, the technology holds significant potential for increasing utility value, enabling skill acquisition, and creating new high-value opportunities through integration with other industries .Various industrial sectors are exploring new content services incorporating AR technology across different content, platform, network, and device (CPND) ecosystem levels . Figure Business cards primarily promote business success, products, brands, and users. Offline business cards fulfill this purpose and are generally easier to use than digital alternatives, such as mobile business cards. The rapid development of information and communication technology has led to a natural combination of technology and design, resulting in an increased appreciation for analog sensibility. This trend has driven the demand for offline business cards.Moreover, the emergence of various content-providing services has created a growing need for alternative information delivery methods, such as digital product catalogs, brand advertisement introductions, and location information provision through offline business cards.Recently, tangible media technology has gained traction, providing users with virtual experiences that resemble reality by bringing virtual information directly into the real world . This teAR technology enables the display of virtual information data consistent with real-world experiences, blending reality and the virtual world. It involves the real-time synthesis of information with virtual objects based on reality ,20. AR tThis increased interest is due to the diversification of mobile AR platforms resulting from the widespread use of smartphones. The advancement of core technologies, such as the Internet of Things (IoT), computer vision, realistic content, and artificial intelligence, has led to the development of AR and the selective provision of reliable information. Consequently, expectations for utilizing AR technology in various business fields have risen.Augmented Reality (AR) is technology that utilizes video devices to recognize objects in the real world from a human perspective. It seamlessly integrates the real and virtual worlds by displaying virtual information, such as text, as well as 2D and 3D objects, in real time on the recognized objects . AR can The design quality of AR business cards plays a significant role in effectively communicating information and capturing users’ attention. Focusing on clarity, creativity, and relevance is essential to ensure high-quality design. Clarity refers to the legibility of text, discernibility of graphics, and unambiguous presentation of information. Creativity is crucial for capturing attention and differentiating the card from competitors, involving unique and innovative uses of AR features that highlight the brand identity. Relevance entails ensuring that the AR content aligns with the target audience’s interests and expectations while fulfilling the primary purpose of a business card.Quality control when producing AR business cards involves robustness, compatibility, and seamless integration. Robustness pertains to the reliability and resilience of the AR technology to perform under varying conditions, such as lighting, camera angles, and environments. Compatibility addresses the ability of the AR business card system to function across different devices and platforms, maximizing accessibility for users. Seamless integration focuses on creating a smooth and intuitive user experience that effectively merges the physical or digital business card with AR content.Ensuring a high-quality user experience is vital to the success of AR business cards. This involves ease of use, engagement, and effectiveness. Ease of use pertains to the simplicity and intuitiveness of the AR business card system, allowing users to access and interact with AR content without unnecessary complexity. Engagement refers to the level of interest and interaction the AR content elicits, driving users to explore further or to act . Effectiveness measures the extent to which the AR content achieves its intended outcome, such as promoting a brand, conveying information, or establishing connections. By focusing on these aspects of user experience quality, AR business cards can provide value and contribute to successful business relationships.The demand for business communication linked to the real world using analog sensibility has grown. Services utilizing QR codes on paper business cards have emerged to cater to this need. However, such methods provide content designated by the user by redirecting to a site linked to the QR code, resulting in limited interaction between the content and the user and, ultimately, a less engaging experience.Business cards that employ Augmented Reality (AR) technology offer a more interactive experience by providing 3D animations, 2D videos, sounds, and other integrated content within the real-world context. These AR business cards facilitate brand and user promotion and ease any initial awkwardness in offline meetings. They enhance traditional paper business cards by adding visual information and engaging features and automatically generating buttons that link to phone numbers, location information, and websites. This approach enables various interactions for users.AR business cards can be converted into digital business cards through a camera, allowing users to form business-centric community platforms, e.g., by exchanging business cards and engaging in chats by registering and managing business card information. This approach offers high scalability.Furthermore, the business market using AR is expanding, and AR-based business card systems have become increasingly marketable. It is anticipated that such techniques will integrate with various offline printed materials. Since many businesses already employ post-processing and multiple options for efficient transactions with business cards, creating AR-based business card systems could enable efficient product promotion without incurring additional marketing costs.To invigorate Augmented Reality (AR) products, providing exceptional content that caters to customer needs is crucial. Developing emotionally engaging, high-quality content templates based on storytelling is vital for promoting the widespread adoption of AR content. As diversity and a sustainable, regular content supply should be prioritized, this research aims to explore efficient AR business cards that can enter the market.This study seeks a content creation template that enables users to develop various AR content tailored to their business cards. The objective is to design a user-participation business card content provisioning service and operating system which enhances and delivers content matched with business cards through mobile devices.Cross-platform-based system environment and efficient interface:The advanced business card information provisioning service design encompasses the following five technical areas:The design should enable the transmission and reception of pattern information, content resources, and template information through a web server. It should also allow business card management and content provision regardless of location. The interface layout should be designed as a Multi-Document Interface (MDI) to accommodate complex tools.2.Development of pattern detection and storage technology:A unique pattern must be applied to offline business cards and stored in a database, allowing for the detection of the business card’s unique ID based on stored pattern information.3.Development of user-participation content enhancement technology:Users should be able to create extended objects by combining multiple content types based on the content production template. The extended objects should support various interactions, including 3D models, 2D images/videos, animation buttons, and URL links.4.Development of comprehensive content resource registration technology.In this research, a viewer can provide 2D content through streaming services. A template can be created by arranging 3D content in a virtual space, specifying the content created by the 3D modeling operation as an Asset, and storing the virtual coordinate information of the object file so that the user can retrieve it from the content template when creating an enhancement object. Then, we developed technology that makes it possible to link with mash data.5.Development of integrated content generation technology:Instead of augmenting simple characters or 2D images, this research aims to develop a template that allows users to synthesize desired content and generate a single enhanced object. The technology should enable users to create extended objects by inserting various content into the template.6.Development of integrated content resource registration technology:This technology should allow viewers to provide 2D content through streaming services and create templates by arranging 3D content in a virtual space. Users should be able to call upon the content created by the 3D modeling operation as an Asset when creating an enhanced object. The virtual coordinate information of the object file should be passed in XML tag format to enable linkage with mash data.As illustrated in The module employs a series of steps, including route calculation, map information verification, user position display, business card holder position display, and real-time navigation assistance. The route calculation step computes a path from the user’s position to the address of the business card holder using advanced routing algorithms. This ensures that the most efficient route is selected, considering real-time traffic data and other factors that might impact travel time.The map information verification step involves transmitting map information containing the calculated route from the server and confirming it. This allows the user to preview the suggested route and adjust it if needed, e.g., by adding intermediate stops or avoiding specific areas.The user position display step shows the user’s location on the transmitted map, providing real-time updates as they move. This ensures that users can easily track their progress along the route, make necessary adjustments, and access their current position at all times.In contrast, the business card holder position display step presents the business card holder’s location on the transmitted map using the 3D face model of the business card holder stored in the 3D object database. This unique feature enhances the user experience by providing a personalized representation of the destination, making it easier to recognize and remember.The real-time navigation assistance step guides the user along the calculated route using audio and visual cues, ensuring a seamless and efficient journey to the business card holder’s location. The system can also dynamically adjust the route based on changing traffic conditions or user preferences, offering a truly adaptive navigation experience.This comprehensive approach ensures accurate and user-friendly location information for enhanced business communication and networking. By integrating advanced mapping technology, personalized visualizations, and real-time navigation assistance, the location information provision service offers a powerful tool for professionals looking to strengthen connections and facilitate in-person meetings in an increasingly digital world.This research has demonstrated the feasibility of implementing cost-effective pricing policies by adopting a low-cost approach to content production, system maintenance, and upkeep. The developed system enables users to generate augmented objects tailored to their specific business content needs, leveraging the existing business card market infrastructure, including QR codes and mobile business cards.By prioritizing quality control and offering superior content compared to traditional Augmented Reality business card systems, this research presents a distinct technical advantage that can significantly enhance the user experience. This innovation is anticipated to promote the widespread adoption of Augmented Reality business card services, with consumers taking on more engaged roles as content creators rather than merely passive consumers.The system developed through this research exemplifies a pioneering approach to business card systems utilizing Augmented Reality technology. It provides diverse business content through paper business cards, empowering users to create customized content tailored to their business meetings or marketing strategies. This innovative approach effectively addresses the contemporary business card market’s needs, offering considerable potential for widespread adoption and commercial success.Furthermore, by emphasizing quality control at every stage of the AR business card development process, the system ensures a consistently positive user experience. This focus on quality control and the system’s cost-effective and user-friendly nature can revolutionize the business card industry and set new standards for future developments in Augmented Reality applications.This research has explored an inventive, user-centric approach to AR business cards that prioritizes quality control and affordability. By providing a seamless, engaging experience that meets the demands of the contemporary market, the system holds great promise for transforming how business professionals connect and communicate in the digital age.A crucial aspect of realizing AR in business cards is marker recognition technology for image marker detection, including pre-processing technology for marker detection and pattern matching technology for marker pattern detection. Ensuring quality control during these processes is vital for providing a reliable and engaging AR experience. Moreover, user content control necessitates advanced object control technology that guarantees a seamless AR experience while maintaining high quality.Additionally, this research supports location information services that enable users to obtain a business card holder’s location using address information stored in the business card information database. Quality control ensures accurate and reliable location information, enhancing the user experience.To promote the widespread adoption of AR content, this research has developed an emotionally engaging, high-quality content template based on storytelling. By maintaining strict quality control standards, users can generate a range of AR content tailored to their business cards through a content creation template. Recipients of these AR-enhanced business cards can access and interact with the augmented content via mobile devices, ensuring a memorable and engaging experience.This research’s business implications and anticipated effects include increased user loyalty through appropriate discounts on selected AR business card content and the option for content upgrades, all while maintaining quality control. This approach can enhance content provision, maintenance, and sales management. Furthermore, developing a business concept character within the AR business card content template theme allows for the creation of a 3D animation series, enabling expansion into collaborative businesses such as production, webtoons, and virtual reality content.In conclusion, this research has designed and explored an innovative, user-centric approach to AR business cards with a strong focus on quality control. This emphasis on quality control paves the way for enhanced marketing and business communications in the digital age, ensuring an engaging, effective, and memorable experience for users.


P = 0.0057). From this result, it can be inferred that patients diagnosed AR have lower risk of periodontitis.The increase in fine dust levels in the atmosphere has been associated with a growth in the incidence of environmental diseases, including allergic rhinitis (AR). Nasal obstruction caused by AR can impact the conditions in the oral cavity. The aim of this study was to determine the association between AR and periodontitis in the Republic of Korea. This study was based on data from the Seventh Korea National Health and Nutrition Examination Survey , which was conducted by the Korea Centers for Disease Control and Prevention. The study included 6129 adults older than 19 years. Sociodemographic information and medical variables including history of treatment of periodontitis (HTP) reflecting diagnosis of periodontitis and diagnosis of diseases such as AR were extracted from the data. HTP and AR were reported for 22.81 ± 0.84% (weighted percentage ± standard error) and 15.32 ± 0.63% of the studied population, respectively. A diagnosis of AR was reported for 11.07 ± 1.28% of those with HTP and for 17.55 ± 1.84% of those without HTP. From these, it was inferred that the prevalence of HTP was 1.536-fold higher in the non-AR group than in their counterparts with AR. Significant association was found between AR and HTP among those aged ≤ 64 years and the odds ratio (OR) of AR group for HTP was 0.62 (95% confidence interval:0.44–0.87;  Airborne allergens are generally considered to be the most common trigger2. Statistical data from the Korean Ministry of Health and Welfare indicate that the number of patients affected by AR in the Republic of Korea has increased over the past 10 years. This may in part be attributable to the recent finding from the Health Effects Institute in the USA that the annual average fine dust concentration in Korea ranked second to Turkey among nations in the Organization for Economic Co-operation and Development. Moreover, there has been a trend toward increasing fine dust concentration in Korea since 2011.Allergic rhinitis (AR), which is one of the more prevalent respiratory diseases, can cause sneezing, runny nose, postnasal drip, and nasal congestion concomitantly with eye symptoms such as redness and watery eyes1, which has been reported to have adverse effects by changing composition of saliva and oral normal flora inducing gingival inflammation, halitosis, and an altered dentofacial growth pattern5. In particular, periodontitis, which is characterized by inflammation of the periodontal tissue , is associated with a significantly higher gingival inflammation index in patients with mouth breathing than in their counterparts with closed-mouth breathing7. Thus, there appears to be a connection in AR patients between periodontal diseases and mouth breathing induced by nasal congestion. The oral cavity is anatomically adjacent to the nasal airway, which may allow conditions in one to impact those in the other. For example, especially for maxillary molars and sinus floor located in maxilla with anatomical proximity, odontogenic maxillary sinusitis is one of the common diseases8.Nasal congestion, one of the common symptoms of AR, can induce the obstruction of nasal airway, leading to mouth breathing9. Periodontitis is a major cause of tooth loss among middle-aged people and older, and can influence quality of life while simultaneously conferring a large social cost for treatment10. In this context, given that AR is an emerging and tentative risk indicator for periodontitis, investigations of the association between AR and periodontitis may contribute to improved public welfare. There have been very few studies of this association, and there is no consistency among these studies. For example, Hung et al. reported that there was increased risk of periodontal disease in patients with AR in Taiwan11, whereas Friedrich et al. demonstrated an inverse association between periodontitis and respiratory allergies including AR12.According to position paper from the ‘Journal of Periodontology’, the prevalence of periodontal disease in the adult population has been reported to be more than 20% including 50% of those who aged 55–64 suffering from moderate to severe periodontitisThe purpose of the present study was to determine whether an association exists between AR and periodontitis among the population of Korea, adjusting for the impact of exogenous variables, which can have influence on the outcome variable, including sociodemographic features, systemic health status, and oral hygiene behaviors.13. The characteristics of the study population, which are listed in Table Based on previous studies, there may be an association between sociodemographic variables and factors related to systemic diseases, and periodontitisP = 0.0002). The proportions of subjects with HTP among those with (AR group) and without AR (non-AR group) were calculated as 0.1572 and 0.2416, respectively , and AR . In addition, the ORs for this association for education level (higher than high school) and OP among those aged younger than 65 years were 0.65 (P = 0.0241) and 1.99 (0.0108) with statistical significance, respectively. No such association was found for the older age group.One of the characteristics of this study population was the distribution of education level according to age Table . More th12. Moreover, Grossi et al. reported a negative association between history of allergies and the severity of bone resorption based on a cross-sectional study of 1361 patients16.The findings of these analyses of data from 6129 subjects extracted from the Seventh Korea National Health and Nutrition Examination Survey  demonstrated that for patients aged younger than 65 years, HTP was less prevalent among those with a diagnosis of AR, indicating that patients with AR had a lower risk of periodontitis. This finding is supported by that of a similar study by Friedrich et al., which suggested that there was an inverse association between periodontitis and allergic respiratory diseases17. Furthermore, OP is considered as a risk factor for the progression of preexisting periodontitis18.The present study also revealed associations between HTP, education level, and presence of OP. This is in line with the finding in another study finding a significant inverse association between education level and risk of periodontitis19. There are three types of Th cell: Th1, Th17, Th2, and Treg19.These statistical phenomena can be interpreted in the context of the T-cell-mediated immune response. Upon recognizing an antigen, naïve T cells differentiate into several kinds of T cells, including T-helper (Th) cells and regulatory T cells (Treg)20, in which they act as cross-inhibitors for each other, thus maintaining a balance in their activities21. Th1/Th2 immune responses can account for various diseases22. Th1-related cytokines are connected to autoimmune-related pathology20. They promote inflammation pathways through secretion of the cytokine interferon gamma (IFN-γ), which activates macrophages, in turn suppressing Th2 activity20. In some studies it was suggested that Th1 cells and IFN-γ contribute to the breakdown of periodontal tissue by stimulating monocytes and macrophages23. Meanwhile, Th2-related cytokines are involved in the genesis of allergic diseases22. Th2 cells inhibit Th1 cells via the production of interleukin (IL)-10; they also stimulate antibody formation by B cells through the production of IL-4 and IL-521. One of the main roles of Th2 cells is the production of the immunoglobulin E (IgE)-synthesizing cytokines IL-4 and IL-13; IgE is involved in the allergic reaction24.The Th1/Th2 hypothesis is one of theories regarding the mechanism of immune regulation and is based on homeostasis between the activities of Th1 and Th2 cells25. Subgingival pathogens can interact with and invade periodontal tissues25. Although bacterial pathogens are considered to initiate the periodontal disease, the host response appears to be related to destruction of gingival tissue and bone26. Invasion of these antigens can cause an inflammatory reaction and generation of immune responses, including innate and adaptive immune responses26. Periodontal tissue breakdown occurs mainly via cellular immune responses together with proinflammatory mediators such as tumor necrosis factor, IL-1β, and IL-17, which promote degradation of gingival tissue and bone resorption27. As a part of this mechanism, activated lymphocytes including Th1 and Th17 play important roles in the loss of bone through a RANKL-dependent mechanism28.Periodontitis is regarded as an infectious pathology of periodontal tissue with several specific characteristics29. The pathogenesis of AR starts with the dendritic-cell-induced activation of Th2 cells, which themselves induce the production of IL-4 and IL-13, and ultimately IgE30. Specific IgE antibodies formed by B cells become attached to mast cells to enable cross-linking between the two31. This results in release of histamine, leukotrienes, and prostaglandins from mast cells, causing typical immediate reactions of AR such as sneezing, itching, and running of the nose or blockage of the nasal epithelium30. As mentioned above, overactivation of Th1 or Th2 cells can cause disease, and either pattern may inhibit the other20. In this context, AR with a Th2-dominant state may cause the down-regulation of the Th1 pathway, resulting in suppression of periodontal tissue destruction by proinflammatory cytokines.AR, a symptomatic pathologic state of the nose caused by exposure to allergens, is an IgE-mediated hypersensitivity reaction34. Conversely, several studies suggest that the prevalence of periodontitis increases with age37. The differences in the distribution of AR and periodontitis prevalence with age may support the explanation for the present findings. It can be hypothesized that diagnosed AR in young age may affect the occurrence of periodontitis in older age. In the context of immunology, a statistical association between periodontitis and Th2-related diseases such as asthma and atopic dermatitis is required to support that found in the present study between AR and periodontitis.Children account for almost 40% of all AR patients, with adults accounting for only 10–30%20.The Th1/Th2 theory is just one of the ways of explaining and understanding the process of immune regulation; however, that theory is still considered controversial, with limitations and discrepancies. Further research based on large-scale human studies are needed to support its validity39. In Table In conclusion, statistical analysis of data extracted from KNHANES VII-1 (2016) revealed that there was a significant association between AR and HTP, suggesting reduced risk of periodontitis in the AR group compared with the non-AR group particularly among those younger than 65 years. Higher education level was associated with decreased risk of periodontitis and presence of OP was associated with increased risk of periodontitis. The limitation of this study was that supplementary statistical analysis about secondary effects of variables should be included in multivariate statistical analysis although subanalysis based on the distribution of education level according to age was performed. In addition, the association between variables should be considered and reflected on statistical modeling. Variables in this study were selected from the KNHANES VII-1 (2016) raw data, which were known to have association with periodontitis according to the previous studies40. The study included 6129 subjects, all of whom were adults older than 19 years. This study was approved by Institutional Review Board (IRB) of Ewha Womans University . The research was performed in accordance with relevant guidelines and regulations.This study was based on data from the KNHANES VII-1 (2016), conducted by the Korea Centers for Disease Control and Prevention39. As previous studies suggested, diagnosis of periodontitis was defined based on the HTP42. HTP included periodontal treatment other than scaling such as subgingival curettage, periodontal flap operation, and gingivectomy. Education level was divided into three groups: lower than high school, high school, and higher than high school. Income was classified into four grades (quartiles). Alcohol consumption was defined as a history of alcohol intake on one or more occasion per month within a 1-year period. AOHD, including floss, interdental brush, mouthwash, electric toothbrush, water flosser, tongue cleaner, and end-tuft brush, was ascertained by questionnaire (the “not using” group included only subjects who did not use any AOHD).Data on HTP, education level, income, alcohol consumption, smoking, AOHD, diagnosis of diseases such as AR, DM, HTN, COPD, RA, OP, and cardiovascular disease, and BMI were extracted from the data for the included individuals. AR was defined based on the self-report of diagnosis experience of AR by doctor ever. In case of HTP, it was also defined based on self-report of history of periodontal treatment. Investigation of medical history included in the present study were examined by questionnaire. Other factors except BMI such as age, sex, education level, and income were also examined by questionnaire. BMI was calculated by measuring height and weight of individuals. These variables except HTP and AR were selected as exogenous variables based on the previous studies suggesting that they had association with periodontitisStatistical estimations were made for the Korean population based on samples from KNHANES VII-1 using a complex sample design. Statistical analysis of this study was proceeded according to the analysis guideline from Korea Centers for Disease Control and Prevention. The sample weights, assigned to each variable, were set for sample participants to reflect the Korean population. Weighted percentages were used to express the proportions of each variable among the total population. Proportion of patients with HTP among patients with and without AR was calculated based on weighted percentage of HTP and AR group. Multiple logistic regression analysis was used to analyze associations between HTP and the other variables, with adjustment for exogenous variables, providing ORs. Univariate analysis was performed before multiple logistic regression and only variables with P value less than 0.1 were included in multiple logistic regression. Confidence level for multiple logistic regression analysis was set to 95%. P-value less than 0.05 was chosen as threshold for statistical significance. Additional sub-analysis, dividing population into two group based on age 65, was performed because population with lower education level was concentrated in aged over 65 group. There was no remarkable uneven distribution among other variables. SAS for Windows  was utilized.


To explore the factors affecting the quality of accelerated rehabilitation for patients with cervical spinal cord injury, therefore, to propose targeted improvement strategies and provide reference for promoting the quality of nursing care for accelerated rehabilitation.This descriptive qualitative inquiry followed the COREQ guidelines.From December 2020 to April 2021, 16 subjects including orthopaedic nurses, nursing management experts, orthopaedic surgeons, anaesthesiologists and physical therapists experienced in accelerated rehabilitation were selected by objective sampling method to conduct semi‐structured interviews. Thematic analysis was used to analyse the interview content.Through analysis and summary of the interview data, the following two themes and nine sub‐themes were finally extracted. Factors related to the quality of accelerated rehabilitation structure include: construction of multidisciplinary teams, thorough system guarantee and adequate staffing. Factors related to the quality of accelerated rehabilitation process include: inadequate training and assessment, lack of medical staff's awareness, incapability of the accelerated rehabilitation team members, poor multidisciplinary communication and collaboration, lack of patient's awareness, and ineffective health education.Quality of implementation of accelerated rehabilitation can be improved by maximizing the role of multidisciplinary team, establishing a flawless accelerated rehabilitation system, increasing allocation of nursing resources, enhancing knowledge of medical staff, improving their awareness of accelerated rehabilitation, establishing personalized clinical pathways of accelerated rehabilitation, increasing communication and collaboration among multidisciplinary disciplines, and improving health education of patients. It refers to a multidisciplinary collaboration in which healthcare professionals (HCP) implement a series of evidence‐based perioperative management measures aiming to reduce traumatic stress reaction and promote the recovery of patients It requires multidisciplinary, physician‐led collaboration, including the anesthesiologists performing the preoperative evaluation, and the orthopedic surgeons completing the preoperative examination and assessment. Physicians could evaluate conditions such as hypertension, diabetes, cardiac disease, etc. There should be nutrition doctors to evaluate the nutritional status of patients and provide nutrition guidance and so on. Some participants emphasized the importance of building an accelerated rehabilitation team to improve quality. This requires multidisciplinary HCP including orthopaedic surgeons, physicians, orthopaedic nurses, anaesthesiologists, operating room nurses, physiotherapists, and dieticians to perform their respective roles and collaborate effectively.(P2)It is important for patients to be actively involved. Nurses play an important role in the evaluation and early identification of rehabilitation and postoperative complications, which is directly related to the overall nursing quality of patients, and is also the inspector of the patients' knowledge of rehabilitation. Also, some participants emphasized that nurses play an important role in the accelerated rehabilitation team and have a direct impact on the quality of accelerated rehabilitation. In addition, patient participation plays a crucial role in improving the quality of rehabilitation.4.1.2(P1)It is very necessary for us to establish a comprehensive rule and regulation, so as to better regulate the behaviors of the members of accelerated rehabilitation team and facilitate the inspection of the work standards of the HCP. (P6)There should be a clinical pathway for diagnosis and treatment of cervical spinal cord injury. I think the establishment of this standard is very critical, which mainly includes regulations, process, nursing routine, medication routine and follow‐up rehabilitation guidance routine. Only by establishing standardized diagnosis and treatment norms can we carry out homogenous diagnosis and treatment in a systematic and process‐based way. Some participants expressed that only by establishing standard guidelines, policies for clinical pathways related to accelerate rehabilitation of cervical and spinal cord injuries can the behaviours be regulated. The implementation of accelerated rehabilitation work can therefore be better guided and the homogeneous diagnosis and treatment be achieved.4.1.3(P3)For patients who can urinate spontaneously, the urinary catheter should be removed on the day after surgery according to idea of enhanced recovery. However, sometimes when patients return to the ward after surgery, it is during night shift, with less staffing and larger workload. If the patient cannot urinate  after the catheter has been removed, the catheter must be re‐inserted. Therefore, the nurse usually removes the catheter during day shift the next morning, so the enhanced recovery cannot be implemented due to the shortage of nurses. (P6)The workload of nurses is too heavy now, and there is no time to supervise whether patients are doing rehabilitation exercises properly, such as training time and standard movements. Allocation of human resources is considered to be a structural factor affecting quality of accelerated rehabilitation. Adequate resources are the prerequisite. Some participants expressed that due to the implementation of accelerated rehabilitation, workload of nurses has increased, resulting in a relative shortage of human resources, which was a hindrance to the implementation of accelerated rehabilitation measures by nursing staff.4.24.2.1(P4)I think both the awareness and implementation process of enhanced recovery need to be relearned. Due to the different comprehension ability of each nurse, the implementation effect of enhanced recovery is different. Therefore, managers need to train nurses repeatedly, so that all people can really master the enhanced recovery and specific implementation methods. The leaders of our department usually send some key nurses to participate in the training of enhanced recovery on a regular basis, but this kind of training only enables a small number of people in the department to understand the relevant knowledge of enhanced recovery. In my opinion, in order to truly promote the application of enhanced recovery, all nurses should be trained. Only with full understanding of enhanced recovery can we actively implement nursing measures. Medical staff with necessary knowledge of accelerated rehabilitation is the premise. Inadequate training of HCP was identified as an important factor affecting the quality of accelerated rehabilitation process. Some participants expressed that medical staff's awareness of accelerated rehabilitation would directly affect the accuracy, timeliness and effect of implementing accelerated rehabilitation measures.(P13)ERAS is a new concept, and it is difficult for medical staff to thoroughly understand the importance of enhanced recovery. Therefore, training on enhanced recovery should be strengthened and courses related to enhanced recovery should be set up to improve team effectiveness. In addition, assessment of HCP' knowledge of accelerated rehabilitation is considered to be an important factor to ensure the quality of accelerated rehabilitation, so as to promote HCP' awareness of accelerated rehabilitation and ensure the provision of homogeneous care for patients.4.2.2(P2)In the process of promoting enhanced recovery, some medical staff have outdated cognition, takes a long time to accept new concepts, and are skeptical about the concept of enhanced recovery. In addition, the short‐term benefits of enhanced recovery are not obvious, so that some medical staff still take conventional nursing measures, delaying the promotion of accelerated rehabilitation. Recognition of the importance and the expected benefits of ERAS by HCP are considered to be contributing factors. Some participants said that some medical staff had outdated concepts and could not realize the importance of accelerated rehabilitation, which would affect its promotion and effect.(P6)At the beginning, people didn't know much about enhanced recovery, but our medical team saw the benefits of enhanced recovery to patients through the implementation of enhanced recovery measures in the past three years, and constantly increased our understanding of enhanced recovery. In addition, some participants indicated that medical staff's recognition of the benefits of accelerated rehabilitation during practice could strengthen their awareness of its importance.4.2.3(P12).The competence and experience of the nurses in the team will influence the implementation of the accelerated rehabilitation program. Firstly, it needs to be above average (P8).In the process of postoperative rehabilitation for patients, nurses should not implement the same rehabilitation plan for every patient, but should timely adjust the rehabilitation plan based on the accelerated rehabilitation process and according to different patients' conditions and tolerance degrees The lack of capacity of accelerated rehabilitation HCP is considered to be a factor affecting the process quality of the accelerated rehabilitation. Some interviewees indicated that the lack of HCP's ability would affect the implementation of accelerated rehabilitation programs for patients and the development of personalized accelerated rehabilitation clinical pathways, thus affecting the quality of accelerated rehabilitation.4.2.4(P1)Enhanced recovery cannot be completed by one department. It requires the cooperation of multiple departments. There may be some problems in the process of cooperation. The anesthesiology nurse said that the patient could only drink water six hours after returning from the operating room, but we taught the patient two hours. (P2)Generally, first day after surgery involves mainly bed function exercise, on second day patients can wear braces, sit up by the bed, encourage patients to get out of bed for early activities if no symptoms of dizziness or limb weakness. At this time reducing unnecessary infusion is required, as well as increasing the time spent out of bed by patients, but it is necessary to communicate with the doctor in charge. In the process of implementing accelerated rehabilitation, it is necessary for multidisciplinary HCP to reach a consensus on the requirements of implementation of accelerated rehabilitation, so as to carry out homogenized management for patients. Some participants mentioned that providing patients with adequate and consistent information is an important factor affecting the implementation of accelerated rehabilitation. Good multidisciplinary communication can promote the implementation of accelerated rehabilitation, but inconsistent information or poor communication is an obstacle to the effective operation of accelerated rehabilitation.4.2.5(P1)Enhanced recovery requires patient's cooperation, but due to the patients' fixed thinking in the past, they may not believe in the concept of enhanced recovery. Some patients are conservative and do not accept enhanced recovery. (P14)Some patients believe muscle and bone injuries takes about 100 days to recover. They believe that they should remain in bed to reduce physical activity during recovery. Therefore, the compliance is very poor when we tell patients to do rehabilitation exercise, and it is very difficult to complete the enhanced recovery program. Patients' compliance to accelerated rehabilitation program is an important factor affecting the quality and effectiveness of accelerated rehabilitation. Some participants indicated that due to the influence of traditional concepts, some patients are not aware of the benefits and safety of accelerated rehabilitation. They tend to adopt a conservative attitude towards accelerated rehabilitation and cannot strictly implement the measures related to accelerated rehabilitation, thus affecting patients' compliance.4.2.6(P6)We should begin to teach patients regarding enhanced recovery from admission. We should let patients and their family know what is enhanced recovery, what is good for them, and make them fully understand about the benefits. It then might be easier for us to carry out the work. (P14)Most patients do not know much about enhanced recovery, so the whole team needs to carry out standardized propaganda and education for patients. After repeated propaganda and education, patients will form a positive perception of enhanced recovery. If propaganda and education are not in place, patients will not cooperate actively, and the rehabilitation effect of patients will be poor. Health education is considered to be an important factor affecting the quality of accelerated rehabilitation. Some participants indicated that education for patients and family members about the benefits of accelerated rehabilitation could improve their awareness of the benefits and thus patient compliance. Therefore, the quality of accelerated rehabilitation can be enhanced.4.3Through the analysis of interview data, we extracted the conceptual framework affecting the quality of accelerated rehabilitation, as shown in Figure 5qualitative studies .The purpose and significance of the research were fully informed to the interviewees before the interview.