We used a Picture Selection Task and found that Mandarin-speaking preschool children with ASD performed significantly worse than their TD peers with regard to their understanding of the presuppositional content of sentences containing this presupposition trigger. Additionally, in contrast with previous results, TD preschoolers’ understanding of this presupposition trigger was found to be adult-like. We attribute this to an improved experimental design.Individuals with autism spectrum disorders (ASD) have been reported to be widely impaired in their understanding of linguistic expressions that rely on elements of the context or norms of communication. The accurate interpretation of sentences conveying presuppositions often relies on such content, however, little previous research has investigated the ASD population’s understanding of these sentences. The present study attempts to remedy this by exploring the understanding that Mandarin-speaking preschoolers with ASD and their typically developing (TD) peers have of sentence containing the presupposition trigger  Over the last few decades, a great many studies have revealed that individuals with autism spectrum disorder (ASD) are impaired in their ability to accurately comprehend certain types of linguistic meaning , as wellInterestingly, a number of recent studies have found that there are a few types of linguistic meaning that individuals with ASD appear to understand as readily as their TD peers, despite them also being thought to rely on contextual/social knowledge. Specifically, the performance of people with ASD has been found to match their TD peers when it comes to accurately interpreting indirect requests and scalar implicatures . ConsideThe present study attempts to further investigate language impairments in the ASD population by focusing on their understanding of the presuppositions conveyed by certain lexical items . To understand how presupposition triggers contribute to linguistic meaning, a hearer has to be able to distinguish the presupposed information introduced by the trigger from any non-presupposed information  and also understand how these various components interact and contribute to the final meaning of a host-utterance .In recent years, a small but growing number of acquisition studies have investigated presuppositions in TD populations . HoweverAs far as we know, ye “also”, but no work has looked at the understanding that any individuals with ASD have of this trigger. Therefore, this investigation has the potential to provide important insights into the linguistic competence of children with ASD as well as the ASD population more generally.The presupposition trigger “also” is a focus particle, meaning that it associates with some other constituent in the sentence and its exact contribution to sentence meaning is determined by the set of alternatives in the discourse model. That is, in order to accurately understand a sentence containing the presupposition trigger “also”, one has to be able to identify and access the relevant shared information between the speaker and listener, i.e., from the linguistic context, the situational context, and world knowledge . Given t1 My hat is yellow.According to a traditional analysis , when 1.The lexical items or phrases that engender presuppositions are called “presupposition triggers” . As ment(2) a.Mary also played tennis.b.Assertion: Mary played tennis.c.Presupposition: There is an x ≠ tennis, and Mary played x.d.Presupposition: There is an x ≠ Mary, and x played tennis.ye, partitions sentence meanings into the same presuppositions and assertions  presupposes that someone other than Zhangsan watched a movie; when stress is put on the verbal phrase kanle yichang dianying “watched a movie”, the sentence in (3) presupposes that Zhangsan did something else, in addition to watching a movie , it often involves the integration of prosodic content as well as content from the immediate situational context. That is, given the context in (4), deriving the correct presuppositions for the sentences in (4a) and (4b) requires an accurate perception of the prosodic contours of the utterance in order to identify which element is the focused constituent. Moreover, in (4) the presuppositions associated with (4a) and (4b) are satisfied, not from the previous linguistic discourse, but from the immediate situational context.(4)Anne and Bill are attending a work party. They run into each other out the front of the building where the party is being held. Anne is holding a packet of chips and a bottle of wine. Bill is only holding a packet of chips, but he also has a bottle of wine in his backpack.(4a)F also brought a bottle of wine.Bill: Oh hi Anne. [I]Presupposition: Someone else  brought a bottle of wine.(4b)F.Bill: Oh hi Anne, I also brought [a bottle of wine]Presupposition: Bill brought something else .In this way, determining both the nature of the presuppositions conveyed by (4a) and (4b), as well as whether they are satisfied in the context, requires integrating information from different sources .Previous studies .It is worth noting, however, that many of these previous comprehension-based studies adopted Picture Selection/Judgment tasks, which presented test sentences, like (5), in isolated, “out of the blue” contexts, that is, with no/minimal introduction or leading sentences.(5)The boy is also patting a dog.ook “also”. Finally, a study with the same experimental design, auch “also”.Following this, participants were required to select a matching picture or to judge whether the presented picture matched the utterance . For exaOne thing these previous studies have in common is that they presented the test sentences in quite an isolated and unnatural manner, which is very different from the way they would be presented in a “normal” discourse. For example, in a typical conversation, an utterance like (5) would often be produced after there had either been some mention of the fact that someone else had patted “a dog”, or some mention of “the boy” having done something else, that is, after the content presupposed by the additive particle had been clearly added to the common ground.In contrast, many of the studies investigating TD children’s understanding of the additive particle e.g.,  presenteIn fact, this interpretation of the previous literature is supported by a more recent study by In contrast to the large numbers of studies which have investigated “also” in TD children, to the best of our knowledge, no existing research has investigated atypical children’s understanding of this presupposition trigger. That is, Both (6)a. Daaiman’s sister will be 10 years old next year. That is to say,b. Daaiman has a sister.c. Daaiman doesn’t have a sister.One thing worth noting at this point is that  research on TD children’s understanding of presuppositions has found substantial variation in children’s performance between methodologies and between triggers e.g., . Moreoveye “also”. This trigger has not been included in any previous investigations of the ASD population, as far as we are aware. Moreover, existing research that studied the acquisition of the presupposition trigger “also” in TD children reported mixed findings, which may have been caused by differences in the experimental methods. The unique experimental design in this study is expected to provide a better chance for children to demonstrate their knowledge of the presupposition trigger “also”. Furthermore, the present study targets Mandarin-speaking preschoolers with and without ASD, whose age, receptive language ability, intelligence, working memory, inference ability, and executive function will be measured and controlled for.The present study contributes to this effort by using a novel method to examine Mandarin-speaking children with ASD’s understanding of the presuppositions associated with sentences containing the trigger ye “also”. Moreover, as noted above, the experimental design in previous acquisition studies, which used isolated sentences as test stimuli, might not have provided a felicitous context for the production and comprehension of this trigger, and thus, may not represent an accurate picture of TD children’s knowledge of “also”. In an effort to improve the experimental design and give children the best chance of accessing the adult-like interpretation of “also”, this study presented the target sentences in contexts where the relevant presuppositions were plausibly satisfied in the preceding clause, and where accessing the presupposition was integral to successfully completing the task. Presenting the stimuli in this manner allows us to address a secondary research aim: to test whether TD preschoolers are capable of interpreting the presupposition trigger “also” in the same way as adults, when the salience of the elements satisfying the presupposition is increased and the overall felicity of the utterance within the experimental context is improved.This study’s primary aim is to further investigate the understanding that children with ASD and individuals with ASD more broadly have of presuppositions. The current study does this by testing how participants from this population interpret sentences containing the presupposition trigger Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , and hear many sentences. In each sentence, there is a part you cannot hear because there are cars passing by. Your job is to figure out what the unheard parts are and find the corresponding pictures for the sentences. When you find the correct pictures, you may tell me its number or point it out.3 were of the same structures and presented similarly to the trials in the main part of the experiment, but with the verb phrases in the second clause being replaced by the sounds of “cars passing by”. This was to make sure that participants were capable of processing compound sentences that were made up of two simple clauses. Corrective feedback was given to participants when they chose the wrong pictures.The practice trialsalso. In this case, picture ③ is a possible answer, in addition to picture ①. We coded responses that correctly selected picture ① as also-correct and responses that selected picture ③ as also-without-presupposition. Answers as ② or ④ were coded as also-false. The positions of the target pictures were counterbalanced.In the main part, participants were presented with filler and test trials, as exemplified in (7) and (8), in which the verb phrases of the first clauses  were made inaudible by playing sounds of passing cars. post hoc pairwise multiple comparisons. The ANOVA revealed significant differences among the three groups with regard to also-correct answers, F = 12.53, p = 0.000, η2 = 0.28, and also-without-presupposition answers, F = 11.95, p = 0.000, η2 = 0.28. No significant difference was found for also-false answers, F = 1.53, p = 0.23, η2 = 0.04.Participants’ answers to the test trials were evaluated by conducting a one-way ANOVA, with the adoption of Tamhane’s T2 test for also-correct answers (p = 0.01) and more also-without-presupposition answers (p = 0.009) than TD children. Both groups performed at a similar level in their choices of also-false answers (p = 0.99). Moreover, to control for the effect of age, receptive language ability, non-verbal intelligence, verbal intelligence, working memory, inference ability, and executive functions, we further compare the performance of both groups with a general linear model. The above-mentioned potential influential variables were treated as covariances. After controlling for the effect of the variables, we found that TD children provided significantly more also-correct answers than ASD children group (p = 0.006). Moreover, ASD group chose significantly more also-without-presupposition answers than TD group (p = 0.004). Both groups performed similarly with regard to their choice of also-false answers (p = 0.97).Specifically, ASD children chose significantly less also-correct answers (p = 0.16), also-without-presupposition answers (p = 0.48), and also-false answers (p = 0.28).Finally, TD children and adults performed very similarly. That is, we found no difference between the two groups with regard to their choices of ye “also” as their TD peers. A secondary goal of this experiment was to investigate whether TD preschool children would readily access an adult-like interpretation of sentences containing this presupposition trigger.The present study set out to further our understanding of the linguistic competence of ASD individuals by exploring ASD children’s understanding of the additive particle. We primarily examined whether Mandarin-speaking preschoolers with ASD had the same level of knowledge of the presuppositional content associated with sentences containing the presupposition trigger ye. To put it another way, presenting our test sentences in a context where the content satisfying its presupposition was presented in the immediately preceding clause reduced the ancillary demands associated with accessing an adult-like interpretation of these sentences. Therefore, we take our results to be a more accurate representation of TD children’s understanding of the presuppositional content of sentences containing the presupposition trigger “also”.4As for the second goal, our experiment found no difference in the interpretations of our test sentences accessed by TD adults and TD children. This finding differs from the series of previous studies  that fouThis aspect of our results seems to support the argument, proposed by ye “also”, even after controlling for the effects of age, language ability, verbal intelligence, working memory, inference ability, and executive function. This study is the first investigation of ASD children’s  understanding of this specific presupposition trigger and this result identifies another respect in which the linguistic abilities of people with ASD appear to be impaired. This naturally raises the question of why children with ASD’s understanding of the presuppositional content of sentences containing “also” should be worse than that of TD children.The main novel contribution of this study was the finding that preschoolers with ASD demonstrated impairments in their understanding of the existential presupposition associated with the additive particle As we mentioned in the Literature Review section, accessing an adult-like interpretation of a sentence containing the focus particle “also” involves identifying the focused constituent within the host-sentence and picking out the set of alternatives related to this focused constituent from the discourse context. The successful identification of these elements and the derivation of the associated presupposition can involve, among other things, the integration of information from different sources. For example, our experiment was designed so that participants would be facilitated in achieving an accurate understanding of the presuppositional content of our test sentences if they understood the relationship between them and the preceding clauses. That is, if they took note of the mentioning of “a boy” in the first clause of (7), this should facilitate the accurate identification that the focused constituent in the second clause was “a girl” and not “riding a bicycle”. This aspect of our test sentences is notable because it has been suggested that when processing information, individuals with ASD demonstrate a unique processing style called “Weak Central Coherence” WCC; , which mye “also”, which is a lexical presupposition trigger (Another point we should discuss is a certain contrast between our results and those obtained by  trigger . NotablyOne possibility is that differences in matching criteria between our study and Finally, this study provides further evidence of difficulties that individuals with ASD have in understanding elements of linguistic meaning that rely on contextual/social knowledge or abilities. However, it is interesting to note that quite different results have been found in recent work investigating people with ASD’s understanding of another type of linguistic meaning that has been suggested to involve similar knowledge and abilities, namely, “scalar implicatures”. Specifically, studies by ye “also”. We found that children with ASD performed significantly worse than their TD peers in understanding the presuppositional content of sentences including this trigger. We further found that TD 4–6-year-old children’s interpretation of this trigger is adult-like.The current study aimed to advance the knowledge of linguistic impairments in ASD people by examining how Mandarin-speaking preschoolers with ASD interpreted sentences containing the presupposition trigger All datasets presented in this study are included in the article/The studies involving human participants were reviewed and approved by the Guangdong University of Foreign Studies. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.SA conceived the study, designed, carried out the experiments, and drafted the manuscript. SA analyzed the data with the assistance of QY. SA and QY interpreted the data and discussed the structures of writing with each other. CB contributed to the writing and revision of the Introduction, Literature Review, Discussion, and Conclusion part of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Part 1 discusses definitions, a pre-history of heat and temperature, and steam engine efficiency, which motivated thermodynamics. Part 2 considers in detail three heat conservation-based foundational papers by Carnot, Clapeyron, and Thomson. For a reversible Carnot cycle operating between thermal reservoirs with Celsius temperatures  This was in an 1849 article by William Thomson referring to “thermo-dynamic engines”, by which he meant devices—in particular, steam engines—that convert heat (thermo) to motion (dynamics) , a power of resisting, by which every body, as much as in it lies, endeavours to persevere in its present state, whether it be of rest, or of moving uniformly forward in a right [straight] line.” Among other things this definition permits the dissipation-free inertial “resistance” to changes in motion to be distinguished from true dissipative frictional forces that oppose any motion relative to some medium. Inertia“limits” acceleration, but is not really a force.Newton defined Newton’s last four definitions characterize attractive central forces  and their properties; Newton had magnets and gravity in mind.vis viva (living force) for In 1668, Wallis, Wren, and Huygens independently showed that, in one-dimensional collisions, what we now call momentum is conserved. Wallis discussed inelastic collisions, and Wren and Huygens discussed elastic collisions, with Huygens using rules equivalent to momentum and energy conservation. In 1686, in treating collisions, Leibniz introduced c energy ,25. ThisAnalytical Mechanics (1788) Lagrange employed the symbol V but did not call it the potential energy.The modern terms energy, kinetic energy, and potential energy all had to wait years to be defined, even when symbols for them existed. Sometimes an equation used the modern symbol and definition, but not the modern name. In his quantité de travail (quantity of work) for travail mécanique  for vis viva for mathematical convenience, and that he “coined the word ‘work’ for the product of force and distance.” Thus, for a time ‘work’ meant both work and vis viva.Coriolis employed (1829) the term r states  that CorU, which is opposite in sign to the modern potential energy: Hamilton wrote H is not given a name. He wrote U the force function   should be attributed to the friction of the molecules of the metal ...that is, the heat is set free just where the moving force is expended.” “Wherever there is destruction of motive power there is, at the same time, production of heat in quantity exactly proportional to the quantity of motive power destroyed” . He alsoMany translations include these notes as Appendices ,13. We gClapeyron (1834) expands on Carnot’s work . He doesp-v space (Watt’s ‘indicator diagram’). Had he known to employ ‘heat absorbed minus work done’ as conserved, his approach would have—except for entropy—led to modern thermodynamics. Most of his detailed results are correct. He discusses the ideal gas before steam.Clapeyron gives the first graphical representation of the Carnot cycle in We discuss his Sect. III on the ideal gas, and his Sect. IV on the vapor-liquid (steam) system, including a derivation of what is now known as the Clausius-Clapeyron equation. He also considers other single phase systems, such as iron, in his Sect. V.In his Sect. III Clapeyron considers the ideal gas as his working medium, with units, as for Carnot, taken to satisfyp vs. v for the ideal gas and for steam, but he labels the axes as Y and X.Clapeyron gives figures of t and Within the text Clapeyron gives, for two thermal reservoirs at p-v space, although tilted relative to one another, are straight.He uses “quantity of action” for work, so we here we include Clapeyron next assumes that there is a well-defined heat function d in air . Hence, By the caloric theory Clapeyron needs only consider t constant, as applies when the working medium is in contact with either thermal reservoir, Equation vQ is a true function of p and v, then the solution is, for another unknown function t. Since there is no such thing as a heat function Q, this result is not trustworthy. Nevertheless, Clapeyron applies  t,Second, from Equation  one obtaQ itself, but Q is not a state function.Further, withncorrect . This ret at either constant p or v one obtainsThird, at the end of Sect. III Clapeyron notes that on differentiating Equation  with resWith , these ldifference, due only to work, this result is valid.Because it involves the v or p.Mendoza comments that these equations make y wrong” . This isWater, when heated, has appreciable amounts of each of two fluid phases at relatively high and low densities; the gaseous (vapor) and liquid phases, as in steam. Since Carnot gave steam engines little detailed consideration, much of the analysis that follows may originate with Clapeyron.v of vapor is formed, then it comes at the cost of liquid volume Clapeyron takes the vapor to have mass density k per unit volume of gas formed, if a gas volume v is formed, then the amount of heat produced is C is the same unknown function introduced earlier for the ideal gas. Thus he obtainsTherefore the “quantity of action”  4 result  written 4 result  is what T from t. At either thermal reservoir In Sect. V of his paper, Clapeyron considers the general case of a Carnot cycle, but in this section he (or the type-setter) changes to Thus  that the above equation implies that “olutely” .In other words, Clapeyron argues that net work done and the heat input are proportional. Nevertheless, the idea that something is conserved, so that the heat output is less than the heat input, does not yet appear.Having read Clapeyron, but not yet Carnot’s difficult-to-obtain book, Thomson argued that from the material-independent thermodynamic efficiency of reversible heat engines operating between the same two temperatures, an “absolute thermometric scale can be founded...” . He alsoT, and t for what we call the Kelvin temperature T.As already noted, Thomson was later to introduce a different temperature scale, now known as the Kelvin scale, which is identical to what I have called the ideal gas temperature scale Thomson in 1848 defined the scale t from the air thermometer. Regnault had both accurate values for the air thermometer, and accurate values for the work produced by the steam engine, at fixed volume. Table I of Thomson’s later multi-part 1849 paper presents his results, expressed in terms of mechanical efficiency, for which he there develops the theory. Although the 1848 paper contains no equations, in a reprint of this 1848 paper , Thomson indicates his reasoning. At Joule’s suggestion, the efficiency With this discrete Here In the end the ideal gas scale In the early 1840s, James Joule, with little initial recognition or support, was developing experimental evidence that heat converts to work, and in a specific and universal ratio. He and Thomson became friends after meeting at the 1847 British Association Meeting at Oxford. Within weeks they met by accident on a tour of Mont Blanc. There they tried to measure the temperature rise of fallen water at a waterfall; unsuccessfully, because of the water spray .totally converted to work. This prevented him from accepting conservation of energy to the extent needed to formulate a thermodynamics based on it. In the steam engine and the Carnot cycle only some of the heat is converted to work.Although convinced by Joule’s numerous demonstrations of the mechanical equivalent of heat, Thomson had reservations about the total inter-convertibility of heat and work. In particular, he correctly did not believe, all other things the same, as in a cyclic process, that heat can be In 1849, Thomson wrote that: “When ‘thermal agency’ is thus spent in conducting heat through a solid, what becomes of the mechanical effect which it might produce? Nothing can be lost in the operations of nature, no energy can be destroyed. What effect then is produced in place of the mechanical effect which is lost?” Thomson’s biographer, Silvanus P. Thompson, comments that in this phrase the word ‘energy’, “then unknown in its modern signification, here bursts forth in the intuitive utterance” ,53.However, in 1849 Thomson could not push beyond this objection, even to accept that in a heat engine the waste heat is less than the input heat. Nevertheless, he suggests that there may be a need “for an entirely new basis of the theory of heat” .In 1850, Clausius used conservation of energy as that ‘new basis’ of the theory of heat. In 1851, Thomson turned his lemon of an objection into lemonade, making his disbelief that heat can be completely converted to work into his form of the Second Law of thermodynamics. Later Clausius accounted for the “loss” of (useful) “mechanical effect” in developing the concept of entropy and recognizing the principle that it cannot decrease .After discussing an important side work, we discuss that 1849 work by Thomson, which was published in two parts.Knowing that near the melting temperature the density of water decreases on melting, Thomson was concerned that providing heat to an ice-water mixture would, paradoxically, also cause work to be done as the mixture compressed. His older brother James, an engineer, resolved the contradiction in early 1849 by predicting the new result that, as temperature increases, the ice-water melting pressure decreases, so that on heating more solid appears and the mixture volume can expand without having more work done on the mixture .p (in lb/ftJames reasoned as follows. He noted that for a (ft)t units, which for this system is 4925t in Celsius. He wrote that one “thermic unit” is equivalent to 4.97 ft-lb.  HenceTo remain on the ice-water line this also must correspond to a temperature change of ice by Setting t here is a change in temperature, p is a pressure, not a pressure change.This does not quite have the form of the Clausius-Clapeyron equation. Although In a separate paper, William Thomson reports his observation of the predicted effect . For u=1tm≈p, so  approximp-v diagram, and analyzes the Carnot cycle in detail.Thomson (William) organizes with numbered paragraphs. The Introduction is very general, with three numbered paragraphs. Part I (paragraphs 4–45) is “On the nature of Thermal agency, considered as a motive power.” It first considers the Seebeck effect , but quickly moves on to Carnot’s work. Part II (paragraphs 46–51) deals with making “thermal agency available as a source of mechanical effect, by means of the expansions and contractions of bodies.” He then illustrates the Carnot cycle with a W done in a cycle, or “mechanical advantage”, or “mechanical effect”, or “duty”, or M,H from the hot reservoir to the cold reservoir in this heat-conservation-based work (this differs from Laplace and Clapeyron’s use of Q for heat) and takes latent heat k “in a unit [volume] of saturated steam at temperature t”. With H, then it will produce a volume Unlike Clapeyron, Thomson discusses the steam engine before the ideal gas. For steam the pressure depends primarily on temperature and little on volume. He writes, for the net work S and T. For small Thomson takes upper and lower temperature reservoirs to be at This echoes what we have labeled Clapeyron’s [4.4], or .Thomson next considers the air engine. Treating it as an ideal gas Thomson writes, using pressure a is the temperature offset between the Celsius and Kelvin scales, taken much earlier as 262 by Amontons, as 267 by Carnot and by Clapeyron, and somewhat later as 273 by Clausius.Here p-v space. With volume changes With H this M must be the same for the air engine as for the steam engine.Thomson then obtainsq and temperature difference Thomson’s (4), not shown, involves an integral for finite heat This echoes what we have labeled Clapeyron’s [3.15], or .J the mechanical equivalent of heat, By Carnot, Equation  is the mality in  becomes ality in ).t in Celsius to compute Thomson goes on to use Regnault’s steam data at a given air data temperature on. Ref.  providesPart I. This deals with the values of Part II. This considers the heat produced by compressing air. By rearranging t, the heat produced by a given amount of work, Thomson then turns to the corresponding work done in an isothermal process . He finds that Noting that Joule had performed experiments measuring, for the compression of air at fixed reservoir t, from t, from  gases. By  and steam engines, and of water wheels. He notes that with water wheels the fall of water can be converted completely to work if done properly , but this cannot be done with air-engines or steam-engines. Further, noting that air engines (at that time) operated at a higher temperature than steam-engines, with waste heat at about the same temperature, he observes that air engines can be more efficient than steam-engines. We note an analogy to the efficiency of falling water that reaches its lowest value, and thus 100% efficiency, in a succession of discrete steps: consider a sequence of thermal reservoirs with waste heat being re-used at the next lowest temperature reservoir until one reservoir is practically at zero temperature.Part V. In “On the Economy of actual Steam-Engines” Thomson considers steam engine efficiency in theory and in practice. He notes that the theoretical efficiency is determined by the boiler temperature and the condenser temperature, so the boiler temperature should be made as high as possible relative to the furnace temperature, and the condenser temperature as low as possible . He estimates the “duty” of seven actual steam engines, with values from 8.6% to 57.5%.Although from his work on the dependence of the freezing temperature on pressure Thomson is aware of the ideas embodied in the Clapeyron equation, he does not seem to derive that result. It must be kept in mind that Thomson was an extremely busy researcher in many areas. For example, in a personal letter, in 1850 he informed Stokes of what is now known as Stokes’s Theorem .This concludes our history of thermodynamics prior to the acceptance of conservation of energy.Much of the following discussion is taken from secondary sources, especially Ref. . For a mMayer. Mayer, a physician, in 1842 developed a theoretical argument for the mechanical equivalent of heat, based on the difference in specific heats at constant volume and at constant pressure. He attributed this difference to the work done at constant pressure as the volume expanded  gas expands at a constant temperature, it absorbs only as much heat as is necessary to the exterior work produced by expansion”. That is, at fixed a vacuum ). From  a function only of t, , so Then, by ,(59)cdtt satisfiesFrom this he shows that the heat absorbed from a reservoir at fixed  Laplace ,46. Howet is constant, Clausius notes thatConsidering that This is to be compared with Clapeyron’s 3.21  he defines:(1)(2)(3)(4)r as the latent heat per vapor mass (rather than Clapeyron’s latent heat per vapor volume k).Expanding on Clapeyron, Clausius also develops the theory for fluid-vapor mixtures . At common vapor and fluid temperature Then for temperature increase This is to be compared with what in  we have r (both per mass) he hasAccounting for the liquid-vapor specific heat difference A  to the net heat, which corresponds to no change in the energy of the system, Clausius obtainsEquating work times We do not show details of this complex Carnot cycle, with mass changes Equation , it is nPart II of Clausius’s Memoir applies Carnot’s efficiency definition to steam. He has already applied it to the ideal gas, deriving . Recall With dQ from , dW from an an72) anh is negative, a seemingly extraordinary result that was simultaneously noted by Rankine  and G.[ay-Lussac], so much regularity as to lead us to the notion that the mutual attraction of the particles which takes place in solid and fluid bodies is in their case annulled.”Nevertheless, Thomson goes on to note that “Mayer’s hypothesis’ was “at least approximately, verified by his [Joule’s] experiments” up to December of 1848, and goes on to cite the Joule-Thomson porous-plug experiments as having shown Joule’s conjecture “to be not rigorously, but very approximately true” .I think it fair to say that Mayer is the first to publish the idea of energy conservation and to obtain a value for the mechanical equivalent of heat. However, without further experimental support, as in the independent and extensive and careful work of Joule, it would not have served as a foundation for others to build upon. On the other hand, the underlying implication, not stated by Mayer, is that the constituents of the gases are so weakly interacting that volume changes due to expansion or compression do not affect their interactions.all thermodynamics courses, in part because it so readily yields a value for the mechanical equivalent of heat. Further, as argued above, the relationship Thomson expended great effort in the laboratory to test his friend Joule’s “conjecture” that in integral form to develop the entropy [S. Thompson, in his biography of Kelvin, condemns Clausius as arriving at a “vague statement” that heat tends to pass from hot to cold . However entropy .Although I have read comments attributing to nationalism the priority jockeying between Thomson, Tait and Joule, on the one hand, and Clausius and Mayer on the other hand, I think it is more likely that it was a matter of personal loyalty in the staking of claims. To my knowledge, of all of the participants during the development of thermodynamics, only Thomson and Joule were friends. On the contrary, in 1862 the English Tyndall supported the German Clausius, likely simply out of a sense of fairness; after this Kelvin’s friend Tait entered the fray. I believe that Thomson had it within his ability to call off the polemical Tait; if Thomson had done so, various disagreements would have been more amicable, but perhaps in that case neither Joule nor Thomson would have had their eponymous units of energy and temperature. Not until somewhat later did Thomson and the German Helmholtz (a distant relative of the American William Penn) become good friends.By 1860 Maxwell, and by 1873 Gibbs, had entered the picture. These two had a calming influence. Gibbs wrote:“in the memoir of Clausius ...the science of thermodynamics came into existence”. However, he goes on with “In the development of the various consequences of the fundamental propositions of thermodynamics, as applied to all kinds of physical phenomena, Clausius was rivaled, perhaps surpassed, in activity and versatility by Sir William Thomson” . Here GiAs I hope this article shows, Clausius’s work is still not fully appreciated as forming the basis for both entropy and temperature. The unit of temperature is indeed the Kelvin, and to Kelvin we owe a great debt for early thermometry. However, it was Clausius who rigorously established that the ideal gas, or Kelvin scale, is the unique thermodynamic temperature.Although in the late 1850s Clausius did fundamental work in the kinetic theory of gases by developing the concept of the mean-free-path, thermodynamics still occupied his mind. In 1862 he introduced the term “disgregation” , a measuOn the other hand, Clausius’s 1865 introduction of “entropy” (from a Greek root for transformation) and his explanation in terms of reversible and irreversible processes, has become part of the terminology of daily life .Although for a time Clausius’s terminology of entropy, disgregation, ergal, and virial “were for Maxwell the butt of jocular barbs” , all werFor my knowledge of the contributions of Rankine, works by Hutchinson and Marsden were extremely valuable ,84,85. THutchinson writes of Rankine that “I shall conclude that apart from his taking the extremely important step of introducing the entropy function, Rankine’s contributions to theoretical thermodynamics as it finally emerged were minimal.” “Even with the entropy function, it was left to Clausius to discover the law of entropy increase, a law which Rankine argued against”. The “somewhat negative conclusions I reach and the positive conclusion about the entropy function are of considerable importance in the historiography of thermodynamics, where Rankine’s theoretical thermodynamics has often been misrepresented” .The same objection to his thermodynamic function  can be made to his “metabatic” and “metabaric” functions; all three of these, as defined, are not true state functions . Rankiner phrase .This author would prefer to credit Rankine only for obtaining a mathematical form that gave the appearance of entropy.Nevertheless, Rankine often had impressive physical intuition, and knew where thermodynamics was needed in developing the steam engine. It is perhaps not coincidental that some five years after publication of his work on the steam engine, steam engines improved significantly in efficiency. Much of Rankine’s work used a questionable vortex model of the atom, but one that was sufficiently close to the truth that it served him as a useful heuristic device. Moreover, Rankine, as a prolific writer of engineering textbooks, surely did not have the time for rigor, and perhaps rigor was not part of his mind-set. The word over-committed comes to mind.Rankine’s works are available online . In RankFor a work with a higher opinion of Rankine’s contributions, see Ref. . Gibbs, My own, semi-informed, view of Rankine is a bit like Churchill’s famous commentary on Russia: “It is a riddle, wrapped in a mystery, inside an enigma.” Those who have worked on, or will work on, disentangling the diverse thermodynamic contributions of Rankine deserve commendation.The theory of irreversible processes in bulk, as in Thomson’s studies of heat flow, had to wait until Onsager’s work of 1931 . Callen’By the time loss of “mechanical effect” by juxtaposition of two materials with surface temperature difference nsidered ,98,99, tnsidered . One res [(∇→T)2 , so the p-v space, and thus to the entropy function This work traces the origins of thermodynamics, with an emphasis on the logical order of the concepts. We note that the material-independent efficiency of a reversible heat engine defines only a well-ordered set of numbers corresponding to temperature, consistent with Thomson’s proposal of two distinct material-independent temperature scales, the second being the ideal gas scale in Kelvin units. We further note that, with the ideal gas temperature U.We conclude that, despite Thomson’s great efforts to establish a reliable theoretical basis for temperature, it was not until 1854, when Clausius defined the equivalent of entropy, that a unique thermodynamic temperature could be defined. Despite its abstractness, it appears that entropy is more fundamental than the more accessible temperature. Another way to see the primary nature of entropy is from Boltzmann’s statistical definition


Thus, all utilizations of “S. epidermidis RN and S. epidermidis RN TC” in the article should be replaced with “S. capitis RN” and “S. capitis RN TC”, respectively.The authors wish to correct an improper bacterial species designation in the original article. Post publication, whole genome sequencing and targeted Additionally, a correction has been made to Keywords, (specific changes are underlined):Staphycoccus aureus was changed to Staphylococcus aureus due to a misspelling.A correction has been made to Keywords, (specific changes are underlined):Chlorhexedine digluconate was changed to Chlorhexidine digluconate due to a misspelling.A correction has been made to Introduction, Paragraph Number 5 (specific changes are underlined). In the original edited stage, a sentence was incorrectly pasted into the introduction. This sentence should be removed and has a strikethrough to designate the deletion.qacC, which is also known as smr, was previously found to be carried on conjugative plasmids as well as on small rolling circle plasmids , QacB appears to offer little/no protection to divalent organic cations (Paulsen et al., The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.


This article is inspired by a pseudo Oxford-style debate, which was held in Tel Aviv University, Israel at the International Conference on Virtual Rehabilitation (ICVR) 2019, which is the official conference of the International Society for Virtual Rehabilitation. The debate, between two 2-person teams with a moderator, was organized by the ICVR Program committee to address the question “Will virtual rehabilitation replace clinicians?” It brought together five academics with technical, research, and/or clinical backgrounds—Gerry Fluet, Tal Krasovsky, Anat Lubetzky, Philippe Archambault, W. Geoffrey Wright—to debate the pros and cons of using virtual reality (VR) and related technologies to help assess, diagnose, treat, and track recovery, and more specifically investigate the likelihood that advanced technology will ultimately replace human clinicians. Both teams were assigned a side to defend, whether it represented their own viewpoint or not, and to take whatever positions necessary to make a persuasive argument and win the debate. In this paper we present a recapitulation of the arguments presented by both sides, and further include an in-depth consideration of the question. We attempt to judiciously lay out a number of arguments that fall along a spectrum from moderate to extreme; the most extreme and/or indefensible positions are presented for rhetorical and demonstrative purposes. Although there may not be a clear answer today, this paper raises questions which are related to the basic nature of the rehabilitation profession, and to the current and potential role of technology within it. But first, we must define virtual reality (VR). Jaron Lanier, who is credited with first coining the term virtual reality, has defined it in many ways, some more poetic than others ),A final but alarming point is safety: what happens when things go wrong? HMDs, for example, have the advantage of providing 3D, stereoscopic vision, increasing realism and sense of presence. However, a still unsolved issue is the possibility of appearance of symptoms of cybersickness, such as nausea, vertigo and disorientation . AlthougTo summarize the “no” side, despite the incredible advancement of technologies in recent years, we can safely state that “technologies are only as good as their makers” . The issTechnology has been advancing at an exponential rate for many decades (Moore’s Law), hence where we will be in 10–20 years in not yet known. For the rehabilitation field, it is unknown whether we will have a contemporary Luddite rebellion in our future or instead an age of technophilia, which will allow for a rapid adoption of virtual rehabilitation. The points raised in this debate highlight the complexity of the issues surrounding this question. Prior to the debate, 100% of the clinicians, scientists, and technologists in the audience all voted ‘no’. However, a post-debate vote revealed the audience was split in their support for either side. We believe that this is due to the fact that while the current state of affairs clearly supports a “no” (as evidenced by the fact that VR has not replaced clinicians), considering the possibilities, the future state of affairs may suggest a “maybe” (Fig. are the driving force [In the process of technological change, humans ng force . Clinica


Aesthetic Surgery Journal (ASJ) has been the platform that many have chosen over the past several decades to describe their techniques and innovations.The artistry of aesthetic surgery continues to evolve and relies heavily on plastic surgeons’ constant search for perfection and better ways to accomplish safe and predictable outcomes. The ASJ used several creative ways to highlight contributions to the field. “Panel Discussions” and “My Way” were published teleconferences allowing authors to share their techniques to solve many of the challenging problems we faced in our practices. “My Practice to Yours” and “Surgical Strategies” were published articles by experts in the field, dedicated to sharing the technical details of specific procedures.1In the mid-1990s, ASJ, Malcolm Lesavoy and Joel Feldman both shared their approach in correcting “Witch’s Chin.” 3 Dr. Lesavoy preferred a dermal flap technique to Dr. Feldman’s direct excision approach. Both described the rationale for their preferred choice and the details of the procedure. These papers exemplified articles found in the “Practice Forum” of the then known Aesthetic Surgery Quarterly. The clinical relevance and desire to learn technical details made this section quite popular.For example, in the March 1995 issue of 4 Dr. Jamil Ahmad was appointed Section Editor and has done an excellent job at inviting, curating, and in some cases coauthoring “My Way” articles to ensure that they remained true to their original intent. Since this section’s inception, we have had 23 articles published in ASJ, many of which have included video content. The evolution of My Way articles has been underpinned by the increased popularity (and availability) of video content and has created an even greater opportunity to learn the author’s techniques in the explicit detail.In his Editorial in 2014, Dr. Foad Nahai acknowledged the historical importance of “how to” articles and developed a new section of the journal entitled “My Way.” As he described it, “My Way” content will include tips, tricks, and innovations that may not be lengthy enough for a full-length article yet are useful and worth sharing with our readers.” No longer does one have to hire a production company to film a procedure. Most of our phones have high-quality cameras, allowing us to easily film “teaching moments,” bringing our procedures to life for our reader, enabling us to teach our colleagues and to help educate plastic surgery residents and Fellows. These articles are technique-centered and include a small series discussion and an accompanying video.Aesthetic Surgery Journal Open Forum. I am honored to serve as Editor in Chief of ASJ Open Forum that has already become known for rapid peer review and broad dissemination of articles to a global audience. ASJ Open Forum is a sister journal to ASJ and is a peer-reviewed, open-access journal that targets preliminary work, case reports, Reviews, and technique-based submissions such as Featured Operative Techniques, My Way, and Video Review articles. During the first year of the journal, we published 3 My Way articles educating our readers on vaginoplasty and breast surgery.Last year, we saw the launch of a new open-access journal, https://academic.oup.com/asjopenforum/pages/General_Instructions. To submit your My Way manuscript, please visit https://mc.manuscriptcentral.com/asjof.We hope you will consider the opportunity to publish your technique and expertise in My Way so that our global readers can learn from your expertise. The opportunity to share your experience in written and video formats has never been easier. Given the recent limitations of travel and meeting presentations, video articles and detailed reviews in My Way provide our readers with opportunities to learn the nuances of surgical procedures for our patients. My Way articles should include a video and photographs (a minimum of 1 pre and postoperative photographs) and generally include 1000 to 1500 words, up to 5 figures and tables, and up to 35 references. More information can be found at These past few months have been challenging times for us all. We are grateful that our publisher, Oxford University Press, has provided several resources that make publication easier.https://academic.oup.com/journals/pages/librarians/developing_countries/participating_countries. Also, ASJ Open Forum reviewers will also receive a 5% publication discount as our thanks for supporting the journal. We remain committed to publishing high-quality content and if we’ve learned one thing during COVID-19, it’s that video, Zoom, and other online educational tools are the future and an excellent accouterment to traditional learning.5Authors in many developing countries may be eligible for free or discounted publication charges. A complete list of countries can be found here: ASJ Open Forum, and I’m calling on you share your greatest learning moments so together we can pay that knowledge forward and continue this educational cycle.The Department of Plastic Surgery at UT Southwestern, where I have the privilege to serve as Professor and Chair of Plastic Surgery, has a long-established history of education and I have personally had the honor of working with some of the brightest residents and fellows in their earliest years. As their careers evolve and I watch them move from training into practice, present at national and international meetings, and begin to share what they’ve learned with the next generation, it gives me joy to see their professional development and evolution. In the same way, I am excited to carry the baton and help the My Way section continue to evolve in its new home,


The COVID-19 pandemic has impacted the lives of expectant parents and parents of young babies, with disruptions in health care provision and loss of social support.This study investigated the impact of the COVID-19 pandemic and its associated lockdown on this population through the lens of users of the UK National Health Service–approved pregnancy and parenting smartphone app, Baby Buddy. The study aims were threefold: to gain insights into the attitudes and experiences of expectant and recent parents (with babies under 24 weeks of age) during the COVID-19 pandemic; to investigate whether Baby Buddy is meeting users’ needs during this time; and to identify ways to revise the content of Baby Buddy to better support its users now and in future.A mixed methods study design combining a web-based survey with semistructured telephone interviews among Baby Buddy users in the United Kingdom was applied. Data were collected from April 15 to mid-June 2020, corresponding to weeks 4-13 of the lockdown in the United Kingdom.A total of 436 expectant  and recent  parents responded to the web-based survey, of which 79.1% (n=345) were aged 25-39 years and 17.2% (n=75) spoke English as their second language. Of the 436 respondents, 88.5% (386/436) reported increased levels of anxiety around pregnancy, birth, and being a new parent, and 58.0% (253/436) were concerned about their emotional and mental health. Of the 244 pregnant respondents, 43.4% (n=106) were concerned about their physical health. Telephone interviews with 13 pregnant women and 19 recent parents revealed similarly increased levels of anxiety due to reduced health care provision and loss of support from friends and family. Although a minority of respondents identified some positive outcomes of lockdown, such as family bonding, many telephone interviewees reported feeling isolated, disregarded, and overwhelmed. Recent parents were particularly anxious about the impact of the lockdown on their baby’s development and socialization. Many interviewees were also concerned about their physical health as a consequence of both limited access to face-to-face medical appointments and their own poorer dietary and physical activity behaviors. Across both samples, 97.0% (423/436) of respondents reported that Baby Buddy was currently helping them, with many commenting that its role was even more important given the lack of face-to-face support from health care and parenting organizations. Greater speed in updating digital content to reflect changes due to the pandemic was suggested.The COVID-19 pandemic has created heightened anxiety and stress among expectant parents and those with a young baby, and for many, lockdown has had an adverse impact on their physical and mental well-being. With reductions in health care and social support, expectant and new parents are increasingly relying on web-based resources. As a free, evidence-based app, Baby Buddy is well positioned to meet this need. The app could support its users even more by actively directing them to the wealth of existing content relevant to their concerns and by adding content to give users the knowledge and confidence to meet new challenges. The COVID-19 pandemic has impacted people’s lives in ways that few could have predicted. With health care services channeling resources to patients with COVID-19 and face-to-face contacts being reduced to limit the risk of contagion, antenatal, birth and postnatal care have all been affected. Moreover, due to the COVID-19 pandemic and its associated lockdown, expectant parents and parents of young babies have lost their usual support networks.In recent years, the use of pregnancy and parenting apps has become widespread ,2. A 201t 24 weeks of parenthood and to reduce inequalities  and anxiety. The disruption to normal life has affected the progress I had been making.Free textA small minority of respondents painted a more positive picture of their state of mind, finding their home-based life relaxing and less stressful than “normal” life.Not having to go out the house as much has made me more relaxed.Free textThe qualitative findings indicated three main causes of these negative emotional states: fear of contracting COVID-19, current disruption, and future uncertainties. The contribution of these causes to anxiety and stress levels appeared to change over the course of the research; current disruption and fear of contracting the virus were responsible for raised anxiety and stress levels during the early weeks (April), but future uncertainties showed more impact later (May). Similar shifts were apparent in the web-based survey, which showed levels of anxiety decreasing slightly over time among pregnant respondents but increasing slightly over time among postnatal respondents see . PossiblDuring April, when the pandemic was peeking in the United Kingdom, anxiety over contracting COVID-19 was high. Pregnant women expressed anxiety over the impact their contracting the virus might have on their unborn child. Those close to delivery were particularly anxious about contracting COVID-19 in hospital when giving birth. Indeed, over two-thirds of the pregnant web-based survey respondents  said that staying safe when giving birth was worrying them more than normal at the moment, and over half  were worried about staying safe at antenatal appointments see .I’m scared of the unknown- how much does it affect pregnant women and unborn babies, will my new-born be at huge risk?Free textWhile the most common concern for postnatal respondents was their baby’s health, qualitative insights showed that respondents’ concerns did not revolve around their baby contracting the virus but around the potential impact on their baby should they themselves contract COVID-19, such as whether they would still be able to breastfeed and who would look after their baby.I don’t want my baby to catch anything while he is so little. I don’t want to catch coronavirus and leave my child without a parent.Free textQualitative findings suggested that for many respondents, fear of contracting COVID-19 diminished during May, perhaps because death rates fell and respondents felt safer because lockdown and social distancing measures were well-established.I am happy with lockdown as I feel my baby and I are protected.Free textThe exception was respondents whose risk of contracting COVID-19 was above average, including respondents who were of Black, Asian, or minority ethnicity, those with underlying health conditions, and those whose partners were health care workers.It’s a worrying time to be health care professionals and being pregnant. I worry that my husband will get coronavirus and infect me and that could result in FGR [fetal growth restriction] or worse.Free textDuring the first weeks of the research (weeks 4-6 of lockdown), the respondents’ focus appeared to be on current disruptions caused by the pandemic and proximate uncertainties such as accessibility to food and medicines, job insecurity, and financial worries. Current disruption seemed to be greater for pregnant respondents for a number of reasons. For some pregnant women, there was considerable confusion as to whether they should be going to work if employers were not necessarily aware of or adhering to government advice.I’m a community care worker. I’ve had problems with work as they won’t pay me sick pay and they haven’t fired me, they just aren’t giving me any shifts so I’ve lost my income.Pregnant 8 weeks, age 21-24 years, White BritishMany pregnant respondents stated that the changes to their antenatal care schedule were unsettling, with some appointments being cancelled. Some women struggled to make contact with their midwives, especially in the early days of lockdown. For those whose due date was imminent, disruption of birth plans was a major source of anxiety, with the single greatest fear being having to go through labor and give birth without their partner. However, later survey responses and interviews suggested that some of these fears had subsided as reports circulated of good birth experiences, quiet labor wards, and partners being allowed to be present. Although 69.0% (78/113) of pregnant respondents said they were more worried than usual about staying safe when giving birth in the first two weeks of the survey, this proportion dropped to 57.9% (22/38) in the last two weeks of the survey see .Over the course of the research, a shift appeared to occur from focusing on current disruption to future uncertainties. Postnatal respondents were particularly anxious about the longer-term impact of the pandemic, such as limited access to support services to monitor their baby’s development, the impact of lockdown on their baby’s socialization, and how both they and their baby would cope with returning to work. Whereas 42% (78/187) of all respondents said they were more worried than usual about caring for a new baby under the "stay at home advice" in the first two weeks of the survey, this had risen to 55% (44/80) in the survey’s last two weeks see .Worried about the world – thinking ahead how’s it going to be – a massive change that we are all going to have to go through – it’s quite an anxious time really.Baby 3 months, age 30-34 years, Black, Asian, minority ethnicityFree text comments from the web-based survey and telephone interviews showed that the impact of loss of support on the respondents’ mental and physical well-being was substantial. Several sources of support were identified by respondents: family and friends, health care professionals, and government.Although modern technology enables video calls with family and friends, the respondents, especially those with young babies, felt that they were suffering considerably from the loss of face-to-face interaction. Without antenatal and postnatal groups and visits to family and friends, respondents felt that they were missing out on opportunities to share experiences and learn from others. Many reported increased usage of digital pregnancy and parenting resources, and some had found online support groups and classes. In practical terms, the loss of informal childcare support (such as grandparents babysitting) meant that mothers no longer had time to themselves for mental revival or physical exercise. Several postnatal respondents remarked that their intended postpartum fitness regime had been put on hold as a consequence of having no help with childcare.A frequently voiced concern for postnatal respondents was the stress of 24/7 parenting. They were not only struggling with the strain of having no time to themselves but were also worrying about having to be more self-reliant and responsible for monitoring their baby’s health and development. This impact was particularly magnified for those whose partners were working long hours at home or out of the home, as well as for single mothers.My partner is working from home, so I am trying to keep him (baby) quiet. I’d just like a break. He is literally with me 100% of the time.Baby 6 months, age 35-39 years, White BritishFor many, the loss of face-to-face interaction with family and friends created feelings of isolation and loneliness. For those with pre-existing mental health issues, this could be particularly challenging.My maternity leave has not been what I had hoped. I have not been able to access help with the baby from family or friends because of social distancing. I have not had the benefits of meeting up with other mums and have felt isolated and very lonely at times.Free textThe survey findings showed that for pregnant respondents, there had been an equal number of face-to-face and telephone midwife appointments . For postnatal respondents, health visitor appointments had been largely by telephone . Over 53% of pregnant respondents  and postnatal respondents  reported that they were worrying more than usual about being able to see their health care professional if they needed to see . Many reIn the telephone interviews and free text sections of the survey, pregnant respondents often expressed their concern and disappointment at receiving what they regarded as suboptimal antenatal care. Although some respondents pointed out that telephone appointments reduced their risk of contracting COVID-19, many worried about the aspects of care they might be missing. Indeed, a common sentiment was that of being disregarded or sidelined.My antenatal care is now much more rushed and stressful. There is no time to talk to the midwife and it very much feels like a quick process to check my urine and blood pressure only. This makes me feel less connected and more anxious.Free textI’ve had days when I break down and cry. We aren’t getting as much support from the midwives. I am out of vitamins and the children's centres are closed. I’ve had 6 different midwives and when I call them I never get a reply, just a message, sometimes saying they are no longer working.Pregnant 21 weeks, age 21-24 years, Black, Asian, minority ethnicityI want to hear my baby’s heartbeat – a phone call’s not the same.Pregnant 7 weeks, age 35-39 years, White otherWhile there was no evidence that pregnant women themselves chose to avoid antenatal appointments, many talked about their initial reluctance to visit a hospital, especially since their partner was unable to accompany them. However, their experiences had generally been positive, and separate areas or entrances for antenatal patients had reassured respondents.In most instances, reduced health care professional support did not appear to have impacted the safety or health of the pregnant women. However, in a number of more concerning cases, the absence of face-to-face consultation had impacted the respondents both mentally and physically.I had a bladder infection. They were like you can’t come in to the doctor’s, so everything was by phone and they didn’t test it and then I had to make a choice, if I wanted to just take the lower tablets which would cover the bladder infection but not kidney, or the kidney ones but the kidney ones had a chance of miscarriage … stuff like that I find quite scary.Pregnant, 13 weeks, age 30-34 years, White BritishQualitative findings suggested that the reduced support from health care professionals had a greater impact on postnatal respondents. A widespread lack of face-to-face appointments with health visitors and general practitioners (GPs) meant that many respondents were worried about their baby’s health and development.They were worried that he wasn’t putting on weight…he was referred to the GP for acid reflux but we only had a telephone consultation…. the health visitor isn’t coming any more. When I asked what I could do, she said check whether he is growing out of his baby grows [all-in-one sleep suits].Baby 8 weeks, age 40-44 years, White BritishMy baby was on a feeding plan but I can’t have her weighed anymore and the doctor has diagnosed reflux over the phone but the medication we’ve tried isn’t working. I feel quite tearful and less supported than at first.Free textAlthough some respondents had been able to speak to their health visitor on the telephone, others reported having no health visitor service at all. Concerns about the baby’s weight gain were frequently voiced, as were breastfeeding issues by those who had given birth just before or during lockdown.I was struggling breastfeeding. I would have gone to breastfeeding group, but that’s been cancelled…. I was in pain and I felt let down, but I felt really guilty asking for help.Baby 7 weeks, age 30-34 years, White Britisht 24 hours anymore.Feeding is a challenge at the moment….it’s been painful. I was engorged and he was crying, and I was upset that he was upset, so my partner went to get some formula, but Tesco’s isn’Baby 7 weeks, age 30-34 years, White BritishSeveral respondents talked about their threshold for seeking medical or developmental advice for their baby being higher, both as a result of their concerns about burdening an already stressed health service and the safety of visiting a GP surgery or hospital. The resulting greater self-reliance in monitoring and diagnosing issues with their baby was worrying and stressful.You can’t get things now – you can’t get a thermometer…. if you are a bit anxious because the baby is unwell that ramps up 20 times because you can’t do anything.Baby 7 weeks, age 30-34 years, White BritishNo-one has seen him in 2 months. What if there’s something he’s doing that’s not right?Baby 5 months, age 25-29 years, White BritishA small but meaningful number of respondents had experienced postponed or cancelled hospital appointments for themselves or their baby, which had caused substantial anxiety.He’s got a cows’ milk allergy and kept being sick…with what’s going on, I think he’s been forgotten – I feel as if it’s been left. We were supposed to have an appointment with the pediatrician in March, they were going to weigh him, but I still haven’t had my appointment….I think its affected my mental health a bit. I feel overwhelmed.Baby 6 months, age 35-39 years, White BritishI’ve been recommended to attend the ‘birth afterthoughts’ service to deal with my feelings over difficult birth but am wary of attending any hospital appts that are not absolutely necessary. Similarly baby is supposed to be referred to paediatric cardiac specialist- I’ve heard nothing...and hesitant to chase for same reasons.Free textMany postnatal respondents questioned the cancellation of 6-week postnatal checks. Although for most respondents, this had little impact beyond reinforcing the sense of being disregarded by the NHS, a small number of respondents felt that their recovery had been hindered by not being able to see their GP.I had an episiotomy and I’m still in pain 7 weeks later. The doctor said no six-week checks … eventually the doctor gave me a call but I haven’t had an examination. I feel as if I have been short changed.Baby 7 weeks, age 30-34 years, White BritishI didn’t get the aftercare I was expecting and I’m in agony but not able to get real help from the NHS. Just feels like I had my baby and then abandoned.Free textOne exception to postnatal respondents’ general dissatisfaction with health care services was baby vaccinations. Respondents reported positive experiences of visiting GP surgeries, remarking on reassuringly high levels of hygiene and social distancing precautions.A lack of clear guidelines from the government led some respondents to feel that they were a forgotten sector of the population. Although initial guidelines had suggested that pregnant women should shield, there was confusion as to whether this meant staying indoors or being allowed out to exercise and whether it was still applicable (by May) or had been superseded by new advice. Postnatal respondents were not aware of any advice directed at them as parents of young babies, and many were critical of its absence.I just feel like new moms and parents have just been completely left out of the Government’s mindset and their exit strategy really.Baby 3 months, age 30-34 years, White BritishI don’t think I am being supported. The Government should be giving us more information, like where do you go to get your baby weighed…there were 8 weeks when she wasn’t weighed – quite a worry really.Baby 12 weeks, age 30-34 years, White BritishAs talk of easing lockdown restrictions began (mid-May), postnatal respondents were particularly frustrated by the lack of consideration given to their circumstances.I would like someone to be representing our needs to politicians so that priority is given to measures like “bubbles” that would help new families SO much rather than people being allowed to have a cleaner come!Free textUnsurprisingly, lockdown had an immense impact on all aspects of the respondents’ lives. Within the context of pregnancy and parenting, four subthemes emerged from the qualitative analysis: missing out, lifestyle disruption, couple relationships, and impact on baby.The greatest disappointment for pregnant respondents appeared to be that their partners were missing out on antenatal appointments. Women worried that less involvement might adversely affect their partner’s bonding with the baby. Missing out on antenatal groups was also disappointing for women, although some were attending existing groups on the web or had found new online support groups or forums to compensate.We’ve looked at the videos (on Baby Buddy) of the baby moving in the womb. It’s good for my husband as he can’t go to my scans. He hasn’t even heard the heartbeat …. I worry he isn’t bonding with the bump.Pregnant 21 weeks, age 21-24 years, Black, Asian, minority ethnicityThe sense of missing out was expressed much more strongly by postnatal respondents who felt that they were being deprived of all the fun activities they had looked forward to doing during maternity leave, such as play dates, baby classes, and seeing more of family and friends. Some respondents thought a UK-wide extension to maternity leave was needed, while those who were able to extend their maternity leave were considering doing so.I’m due to go back in November, but I am thinking of taking the full 12 months as I haven’t been able to do stuff with her.Baby 3 months, age 30-34 years, Black, Asian, minority ethnicityA small minority expressed more positive views of the benefits of a quieter life.No pressure to go to groups, no need to go places at specific times, no stress of public feeding or changing nappies in public toilets. He has 100% of my attention and is very happy and settled.Free textBoth pregnant and postnatal respondents talked about disruption to routine adversely affecting their physical health. Their physical health was the third  and fourth  most highly rated concern at the moment see  for pregI don’t get out of the house for days, weeks on end….there are too many people outside….it’s getting difficult walking from room to room.Pregnant 34 weeks, age 25-29 years, Black, Asian, minority ethnicityWe’re not getting out much – we are super cautious because of the hole in her heart….so many people around it wouldn’t have been possible to do any distancing.Baby 16 weeks, age 30-34 years, White BritishAt the time of the research, the government guideline was to go out to exercise only once per day, and many parents were choosing to take their baby out over exercising themselves. For some respondents, the lack of physical activity had become self-perpetuating, with energy levels decreasing to a concerningly low level.I hadn’t been out (from mid-March) until the end of April. I went for a very short walk – I was really tired.Baby 4 months, age 30-34 years, White otherSimilarly, many respondents talked about changes to their diet. On the positive side, some respondents reported doing more home cooking during lockdown, although they were more likely to bake than cook nutritious meals. However, 35.3% (83/235) of pregnant respondents and 28.2% (53/188) of postpartum respondents were concerned about healthy eating. A reduction in consumption of fruit and vegetables was reported widely in the telephone interviews, as many respondents were attempting to visit shops as infrequently as possible and delegating grocery shopping to their partner. Reports of more frequent snacking and treat-eating due to boredom, misery, or simply a lack of other treat options were widespread.Physically I am a wreck. My back hurts, I never do any exercise as my baby doesn’t sleep during the day. My ligaments hurt, my breasts hurt. I want to lose some weight, but I am stress eating – I’m not hungry I just eat because I want something sweet.Baby 16 weeks, age 30-34 years, White otherHere, experiences were divisive; many respondents with a partner working from home really appreciated the additional time spent together. Postnatal respondents pointed out the practical benefits of sharing childcare and household tasks as well as the emotional benefits of the greater opportunity to bond as a family.My baby is having the best start to life! Full undivided access to her mummy and her daddy!! For 2 months!Free textHowever, for a small number of respondents, lockdown had created tensions within the couple’s relationship. Those whose partners were working hard, either from home or outside, could find themselves resenting their partner’s seemingly “normal” lives when they were feeling isolated, alone, and bored. Respondents also talked about arguments about levels of hygiene and adherence to lockdown guidelines; this seemed more prevalent in couples in which the partner was working outside the home.There have been a couple of occasions where there have been cross words…. I am sat in this house all day alone ….with the hours he is out of the house I don’t have another adult to speak to – it’s made it a bit more isolating.Baby 7 weeks, age 30-34 years, White BritishLess than half of pregnant respondents  felt that the changes that the pandemic was causing in their lives were affecting their baby. Several telephone interviewees expressed concern that their stress might transfer to their baby in the womb and adversely affect its development. In contrast, over three-quarters of postnatal respondents  felt that the changes were affecting their baby, and this high level of concern was voiced strongly by telephone interviewees. They worried that their baby was missing out on interactions with other people, experiences, and activities, which would have a detrimental impact on the baby’s development and socialization. Respondents frequently expressed concerns that their baby might forget their grandparents and other family members or become clingy and reluctant to interact with others.My baby has been unable to meet family and I am anxious that she will be fearful of others when it comes to the time she needs to go to nursery.Free textLockdown had also affected some babies’ routines, with changes in sleeping patterns reported most frequently. Although some postnatal respondents viewed lockdown to be an ideal time to develop new routines, others found it challenging to cope with the changes and felt that their baby had become more unsettled and cried more frequently.The only way I used to be able to get him to nap at lunch time was to go for a walk in the buggy … I was unable to go out at all at the start because he had a temperature so I couldn’t get him to sleep so there were about 3 weeks that were kind of hellish.Baby 6 months, age 35-39 years, White BritishWhile the majority of survey and telephone interview respondents felt they were using the Baby Buddy app about the same amount during the pandemic , nearly a quarter of the survey respondents said they were using the app more . Comments from the free text boxes and telephone interviewees showed that many women were finding Baby Buddy to be particularly valuable in the absence of support from health care professionals and baby groups.I have had very little contact with my midwife and I really like how much information I can get from the app given that I can’t seem to get any support from anywhere else.Free textWithout groups to go to I’ve found having these apps to be even more useful and helpful.Free textI have enjoyed using Baby Buddy throughout pregnancy and these early months and find it even more reassuring now that external input is so limited.Baby 7 weeks, age 30-34 years, White BritishI look forward to the little bit of advice every day. It is written in such a non-judgemental way, encouraging but not patronising. I feel like it’s giving me some of the general knowledge I’d be picking up from other mums at baby groups.Free textBecause it’s linked to the NHS it’s not like googling.Baby 3 months, age 30-34 years, Black, Asian, minority ethnicityReliable, trustworthy and ad-free source of information. Great videos.Free textOf the respondents who reported which Baby Buddy features they were finding most helpful at the moment, 97% (377/436) identified Today’s Information see . SimilarIt’s reliable – like the people who are writing it are knowledgeable. Today’s message is always more or less in line with what I am thinking.Baby 16 weeks, age 30-34 years, White otherI’m not the best at researching stuff and reading a big book in advance so this gives me nice little bite-size chunks of things I need to know.Pregnant 16 weeks, age 40-44 years, White BritishOther features were helping a smaller number of Baby Buddy users at the moment. This could be explained by the finding that interview respondents frequently reported that they rarely explored the app beyond the Today’s Information section. For those who did, the videos were singled out as being very helpful. Typically, respondents had viewed videos that had been highlighted in Today’s Information. Fewer respondents had explored the videos by category, although those who had appreciated the number and variety of videos available.The information is so useful – I share it with my husband. We’ve looked at the videos – the baby moving in the womb. It’s really good for my husband because he didn’t get to go to the scan and I worry he is not bonding with the bump. He hasn’t heard the heartbeat.Pregnant 21 weeks, age 21-24 years, Black, Asian, minority ethnicityI like to see the videos – they’ve helped a lot to see that other women are struggling too.Baby 16 weeks, age 30-34 years, White otherOther app features specifically praised by interview respondents included Ask Me, Your Appointments, You Can Do It, and You and Your Partner. Only one respondent was aware of Get Help. The idea of a 24/7 text helpline was widely appreciated; however, Get Help was not necessarily felt to be a good descriptor of this feature.I love the partner’s advice. A lot of apps don’t bring the partner into it…it’s brilliant. It’s (pregnancy) a stressful time and two people don’t always react the same.Pregnant 8 weeks, age 21-24 years, White BritishThe main criticism from the 10.1% of users (44/436) who felt that Baby Buddy was not helping them during the pandemic was its slowness to adapt to the new situation. Recommending courses of action that were no longer available under current circumstances, such as ask your health visitor, join a play group, and have a baby shower, were both unhelpful and a sad reminder of activities that respondents were missing out on.One of the things that came through was a video saying keep your distance from people with colds and ‘flu and there was this pregnant woman sitting on a bench next to a man coughing. I laughed at it, but not to acknowledge when we are in a middle of a pandemic is a bit of a blunder I would say.Pregnant 16 weeks, age 40-44 years, White BritishSometimes I won’t check because it reminds me of all the things I’d like to be doing but can’t because of social distancing.Free textViews on whether Baby Buddy should be providing COVID-19–specific information were mixed. While some respondents felt that this information should be prominent within the app, others expressed a keen desire that Baby Buddy remain a safe haven from the pandemic. Clarity around the guidelines and links to websites providing recommendations and advice were generally thought to be helpful.Several respondents identified additional information and advice needs as a consequence of the pandemic. This included how to ensure your baby is gaining the right amount of weight and meeting developmental milestones ; ideas for stimulating and entertaining babies (in the absence of classes); ways to calm a crying or fractious baby; ways to reduce one’s own anxiety and stay calm; and making sure you are getting enough vitamin D with limited time outdoors.Things to do with him when you are stuck inside – keeping him entertained, what’s best for his development.Baby 5 months, age 25-29 years, White BritishAn additional suggestion was the inclusion of self-made videos from Baby Buddy users with their tips for coping with pregnancy, birth, and parenting a very young baby during the pandemic.Beyond content relating to the current circumstances, another notable demand for additional information came from respondents who had one or more other children. These respondents were keen to receive advice specific to their circumstances, such as how to cope with tiredness in pregnancy when you have an active toddler, how to prepare a child for the birth of their sibling, and how to avoid sibling rivalry.The thing that I would find even more useful would be if they designed a section for 2nd or 3rd time mums…how to explain to your kids they’ve got another brother or sister coming, things like that….that would be amazing.Pregnant 34 weeks, age 30-34 years, White otherFirst-time mothers suggested adding new functionalities, usually those they had found in other parenting apps. These included features to allow mothers to record feeding information  or diaper records and chat rooms for parents to share tips and provide mutual support.This service evaluation study aimed to understand the attitudes, experiences, and needs of Baby Buddy app users in the United Kingdom during the COVID-19 pandemic, with a view to identifying ways in which Baby Buddy could further support its users. The web-based survey in conjunction with the follow-up telephone interviews revealed heightened levels of anxiety and stress around being pregnant, giving birth, and parenting a new baby during the pandemic. Reduced support, especially from health care professionals, and the impact of the lockdown clearly affected the mental and physical well-being of pregnant women and parents of young babies. Baby Buddy users appreciated having access to a source of easily accessible, reliable, and trustworthy advice, and some users felt that the app helped to compensate for the loss of face-to-face advice and support. A small minority felt that greater speed in adapting the content to reflect the new situation would have been beneficial.Reports of insufficient support for new parents in the United Kingdom with health and parenting issues have been reported elsewhere . This reThe heightened levels of anxiety and stress during the COVID-19 pandemic found among Baby Buddy users are consistent with research among the general UK population  and periThis study also found physical health to be an important concern, especially among pregnant women. With lockdown limiting women’s ability to exercise, restricting their access to healthy foods, and leading to more snacking on foods high in fat, sugar, and salt, there may be a long-term impact on mothers and babies as a result of increased risks associated with excessive gestational weight gain ,31. ThesThe vast majority (90%) of Baby Buddy users in this study reported finding the app helpful during this period, especially given the reduced support from health care professionals, family, and friends. However, while Baby Buddy provides a wealth of information to support its users, many users were not finding all this information. It is especially important during these times of reduced support and heightened anxiety to actively encourage Baby Buddy users to explore beyond the daily information feature, Today’s Information, to find additional content and functionality. The addition of new video content featuring expectant and new parents during the COVID-19 pandemic may help to support users by normalizing feelings and experiences they are having during these unprecedented times. It may also help reduce feelings of “missing out” by exemplifying that many other young families are facing the same challenges.With the pandemic limiting access to their usual support networks and health care professionals, Baby Buddy users have had to become more self-reliant in their roles of parenting a young baby. This has created additional information needs, particularly around baby stimulation, socialization, growth, and development. Although the app already contains written and film content covering these issues, adding new content to further meet these needs could improve the support Baby Buddy provides to its users and help increase new parents’ confidence in monitoring their baby’s well-being and development while reduced access to professional support continues.This study was a precursor to a UK-wide survey of expectant parents and parents of children under 2 years of age, Babies in Lockdown, commissioned by Best Beginnings, Home-Start UK, and the Parent-Infant Foundation and undertaken by Critical Research . The finA strength of this study was that it was conducted during the height of the COVID-19 pandemic, with data collection beginning within three weeks of the start of lockdown in the United Kingdom. As a mixed methods study, the research was able to deliver statistically robust findings alongside detailed qualitative insights.A limitation of this study is because the survey focused on Baby Buddy users, the findings cannot be generalized to all pregnant and new parents in the United Kingdom, although its findings were highly consistent with the follow-up survey described above . A furthThe COVID-19 pandemic has created heightened anxiety and stress among expectant parents and those with a young baby. This study found that for many expectant and new parents, lockdown has had an adverse impact on their physical and mental well-being. With reductions in health and social supports, expectant and new parents are relying even more on web-based resources. As a free, evidence-based app, Baby Buddy is well positioned to meet this need. The app could support its users even more by actively directing them to the wealth of existing content relevant to their concerns and by adding content to give users the knowledge and confidence to meet the new challenges facing them. As the longer-term impact of the COVID-19 pandemic becomes apparent, it will be necessary to add to and update the content of the Baby Buddy app to meet new needs.