Concerns have been raised over the quality of evidence on the performance of medicalartificial intelligence devices, including devices that are already on the market in theUSA and Europe. Recently, the Medical Device Regulation, which aims to set high standardsof safety and quality, has become applicable in the European Union. The aim of thisarticle is to discuss whether, and how, the Medical Device Regulation will help improvethe safety and performance of medical artificial intelligence devices entering the market.The Medical Device Regulation introduces new rules for risk classification of the devices,which will result in more devices subjected to a higher degree of scrutiny before enteringthe market; more stringent requirements on clinical evaluation, including the requirementfor appraisal of clinical data; new requirements for post-market surveillance, which mayhelp spot early on any new, unexpected side effects and risks of the devices; andrequirements for notified bodies, including for expertise of the personnel andconsideration of relevant best practice documents. The guidance of the Medical DeviceCoordination Group on clinical evaluation of medical device software and the MEDDEV2.7guideline on clinical evaluation also attend to some of the problems identified in studieson medical artificial intelligence devices. The Medical Device Regulation will likely helpimprove the safety and performance of the medical artificial intelligence devices on theEuropean market. The impact of the Regulation, however, is also dependent on its adequateenforcement by the European Union member states. Owing to these shortcomings, the performance and safety claimed by the developers ofthe tested AI systems may be overestimated. This may, in turn, translate into the risk ofharm to patients, and wasteful use of healthcare resources, if the devices are used inmedical practice.Artificial intelligence (AI)-based technologies are being developed to improve variousareas of medical care, including diagnostics, surgery and healthcare systemmanagement.1016 Educationalarticles and guidelines for healthcare professionals have also been published to aiddecision-making on the use of AI tools.1721In response to these issues, the academic community has been working on standards for thevarious types of studies in which AI systems are developed and tested. has also been of interest to regulators. In January 2021, the US Food and DrugAdministration (FDA) issued the ‘Artificial Intelligence/Machine Learning (AI/ML)-BasedSoftware as a Medical Device (SaMD) Action Plan’. In this document, the FDA declares supportfor, among other things, efforts to develop ‘methodology for the evaluation and improvementof machine learning algorithms, including for the identification and elimination of bias,and on the robustness and resilience of these algorithms to withstand changing clinicalinputs and conditions’. Meanwhile, in Europe, a new Medical Device Regulation (MDR) applying to medical AIdevices became applicable on 26 May 2021.24 A few authors have examined the impact ofthe MDR on medical AI devices, and the requirements that have to be met under thisRegulation.2527 To date no published article, however,has specifically discussed whether, and how, the MDR will improve the safety and performanceof medical AI devices entering the market. The aim of this article is to address thisquestion. After providing a brief overview of the MDR, the article focuses on the changesintroduced by the MDR that seem most relevant to improving the safety and performance ofmedical AI devices. These include changes in risk classification (and consequently theapplicable conformity assessment procedures), clinical evaluation, post-market surveillanceand notified bodies (NBs). These issues (or some of their aspects) are underlined in the MDRpreamble as the ‘key elements’ of the regulatory system that should be reinforced ‘toimprove health and safety’ . The impact of changes in riskclassification, clinical evaluation and post-market surveillance on medical AI devices wasalso highlighted by other authors.27The question of standards for medical AI devices24 The new Regulation is a response totechnological progress in the development of medical devices. It also addresses problemswith the previous regulatory system revealed in scandals involving unsafe medical devices,and it harmonises the rules for medical devices in the EU. Unlike directives, regulations apply directly in the EU member states, that is,without being implemented in national law. This means that after the four-year transitionperiod, from 26 May 2021, new medical devices must comply with the MDR if they are to bemarketed and sold. However, certificates of conformity  issued earlier, under the MDD, will remain valid as indicated on thecertificate, but no longer than until 27 May 2022 or 24 May 2024 .The MDR entered into force in May 2017, replacing the Medical Device Directive (MDD) andthe Active Implantable Medical Device Directive. The MDR applies from 26 May 2021, with theexception of some provisions (Article 123).Core elements of the MDD are maintained in the MDR. Under both, medical devices must meet aset of requirements to enter the market. In the MDD these are termed ‘essentialrequirements’, while in the MDR they are referred to as ‘general safety and performancerequirements’. Both documents require devices to achieve the performance claimed by themanufacturer, and that the safety risks are acceptable in relation to benefits. Compliancewith the requirements is verified in a conformity assessment procedure. Both MDD and MDRcategorise medical devices into risk classes. The conformity of devices with the lowestrisks can be self-declared by the manufacturer. In the case of higher-risk devices,compliance with the requirements needs to be verified by a notified body – that is, aprivate company designated to conduct conformity assessments. Conformity assessmentprocedures in the MDR are similar to those in the MDD. Manufacturers of higher-risk devicescan choose among different conformity assessment procedures, depending on the risk class ofthe device. Devices passing the conformity assessment receive a CE (Conformité Européenne)mark and can be placed on the market or put into service.Although the main principles of MDD and MDR are similar, there are important differences inthe requirements set by the documents. The MDR addresses risk classification of software in a separate rule (Rule 11),although other classification rules may also apply . This risk categorisation for software is in line with the International MedicalDevice Regulators Forum approach, which factors in ‘A. [s]ignificance of the informationprovided by the SaMD [Software as a Medical Device] to the healthcare decision, and B.[s]tate of the healthcare situation or condition’. Both these factors depend on the intended use defined by the manufacturer and not onthe technology used. Rule 11 in the MDR states that::- death or an irreversible deterioration of a person's state of health, in whichcase it is in class III; or- a serious deterioration of a person's state of health or a surgical intervention,in which case it is classified as class IIb.Software intended to provide information which is used to take decisions with diagnosisor therapeutic purposes is classified as class IIa, except if such decisions have animpact that may causeMany devices that under the MDD fell into the lowest risk class will now shift to a higherrisk class.Software intended to monitor physiological processes is classified as class IIa, exceptif it is intended for monitoring of vital physiological parameters, where the nature ofvariations of those parameters is such that it could result in immediate danger to thepatient, in which case it is classified as class IIb.All other software is classified as class I.  and unlike Class I devices they will therefore be required to undergo conformityassessment by a notified body. In other words, under the MDR more devices will be subjectedto a higher degree of scrutiny before entering the market. This, in consequence, willideally help to ensure that devices entering the market demonstrate the performance andsafety claimed by the manufacturer.Based on this rule, most AI devices will probably be classified as Class IIa or IIb,In the MDR, clinical evaluation is required regardless of the risk class of the device. Thegoal of this evaluation is to verify compliance with the general safety and performancerequirements (Article 61). The requirements include, among other things, the ability of thedevice to deliver its intended performance, its safety, and the acceptability of thebenefit–risk ratio in the context of the state-of-the-art (Annex I). In comparison with theMDD, the MDR raises the level of the requirements to be met in clinical evaluation andplaces more emphasis on clinical evidence collected after the device has been placed on themarket. MEDDEV 2.7/1 (rev. 4) is the most recent guideline on clinical evaluation and it isin keeping with the requirements of the MDR. It explains general principles of clinicalevaluation and describes each stage of the clinical evaluation process. The steps ofclinical evaluation for medical devices outlined in the MDR and described in more detail inthe MEDDEV 2.7 include (1) preparation (and updating) of a clinical evaluation plan; (2)identification of relevant clinical data (both generated by the manufacturer and availablein scientific literature) and of gaps in the available evidence through a systematicliterature review; (3) appraisal of the available data, including the methodological qualityand scientific validity, as well as their relevance to the clinical evaluation of thedevice; (4) clinical investigation (involving human subjects), which is mandatory for classIII and implantable devices, but necessary for other devices only if it is needed to addressgaps in the evidence; (5) analysis of all relevant clinical data to evaluate whether theydemonstrate conformity with the general safety and performance requirements (Annex XIV ofthe MDR). Both the MDD and the MDR allow manufacturers to claim equivalence of their deviceunder evaluation to a device that is already CE-marked and use clinical data of thatCE-marked device for clinical evaluation. The requirements of the MDR (Annex XIV) are,however, higher than in the MDD, and it seems unlikely that manufacturers of medical AIdevices will use this option. Results of the clinical evaluation should be presented in a clinical evaluationreport, which is part of the technical documentation required for conformity assessment(together with other elements that depend on the risk class of the device) .The requirements for clinical evaluation in the Regulation, in particular the requirementfor the appraisal of clinical data, may increase the attention paid by manufacturers and NBsto the quality of clinical evaluation and contribute to its improvement.The Regulation provides more detailed requirements for clinical evaluation than thoseimposed by the MDD. It does so in part by incorporating elements of a non-legally bindingguideline on clinical evaluation issued in 2016 under the MDD (MEDDEV 2.7/1 (rev. 4)).MEDDEV 2.7/1 (rev. 4), in section ‘9. Appraisal of pertinent data (Stage 2)’ offers furtherguidance on the evaluation of the methodological quality of studies. It mentions that thepossibility of confounding influences, bias, random error, lack of transparency in reportingand misinterpretation should be considered in the evaluation. It also outlines specificissues that should be critically appraised, such as the appropriateness of sample size, thepower of calculations, the endpoints and controls used, and the validity of conclusions. It was developed by the Medical Device Coordination Group (MDCG) established byArticle 103 of the MDR. The guidance also applies to medical AI devices. The drafting heredraws on the approach developed by the International Medical Device Regulators Forum and outlines three components of clinical evidence for medical device software: validclinical association, technical performance and clinical performance. Data supporting thesethree types of clinical evidence need to be identified or generated, to show compliance withthe applicable general safety and performance requirements. The document provides generalrecommendations on the type and quality of the studies that may be involved here, as well asmeasurements that can be used to demonstrate valid clinical association, technicalperformance and clinical performance.There is also another guidance document on clinical evaluation, which specificallyaddresses the clinical evaluation of software qualifying as a medical device .Were the type and the design of the study/ test appropriate to meet the researchobjectives? Was the data set appropriate and actual (state of the art)? Was thestatistical approach appropriate to reach a valid conclusion?Where the quality of the studies is concerned, the MDCG guidance proposes questions thatcan be used in their evaluation. For example:Attention to these aspects may indeed help users to conduct methodologically sound studies.On the other hand, these are rather general recommendations..If the MDSW [medical device software] is used for the determination of a patient'sfuture state  or if the output of the MDSWimpacts clinical outcomes (e.g. treatment efficacy) or patient management decisions,then a prospective study may be required as part of the device's clinical evaluation(MDR)/performance evaluation . Inother situations, retrospective analysis may be more appropriate to generate thenecessary data to support compliance with the GSPRs [general safety and performancerequirements], as there is no impact on patient management and the research does notintroduce any risks to the patients. Such an approach is only possible under conditionthat there is an adequate access to data sets of sufficient amount and quality andobtained from the target populationImportantly, the document also explains when prospective studies may be required andstresses that data for retrospective analyses should be of appropriate quantity and quality:34 Therefore, as claimed byTopol, ‘[p]rospective trials that are representative of patient care are essential’, while‘[r]etrospective studies of AI in healthcare must … be considered hypothesis generating,often a best-case scenario, and unacceptable as definitive proof points’. The MDCG's guidance also does not specify further what kind of prospective studiesshould be conducted  and when. The document, however, does not focus on AI devices and is notlegally binding; it is, therefore, understandable that it was formulated to allow forflexibility.The document then presents a few examples to illustrate different strategies for theclinical evaluation, including the use of prospective and retrospective studies. Theserecommendations may help address the lack of prospective studies on medical AI. However, onecould argue that in the context of medical AI devices, a stronger stance in favour of theneed for prospective studies would be needed. Retrospective studies might not adequatelyreflect real-world clinical settings and consequently might overestimate the performance ofthe device. The standard outlines two types of evaluation of interactions by users with the userinterface: formative and summative. Formative evaluation is conducted iteratively at thestage of the device's design and development, while summative evaluation should be performedonce the user interface is developed to test hazard-related use scenarios and obtainobjective evidence of the safety of the user interface. Summative evaluation should beconducted ‘in a simulated or actual user environment’ (Annex II). Such an evaluationprovides insight into the interaction of a clinician (or another intended user) with thedevice and, in the context of medical AI devices, in some respects may compensate for a lackof prospective studies in real clinical settings.Although the guidance document states that retrospective studies may be sufficient in somecases, it also outlines that the usability assessment is part of clinical performanceevaluation. Indeed, in the MDR, requirements on usability are a subset of the general safetyand performance requirements. They, in part, overlap with the requirements of the MDD, butin the MDR they are more extensive. Manufacturers should, among other things, assess risksrelated to the intended use as well as potential misuse of the device and minimise the risksrelated to ergonomic features of the device and the environment in which it is supposed tobe used (Annex I). Characteristics of users of the device, for example, their technicalknowledge and training, should also be accounted for in the design. To demonstratecompliance with these requirements manufacturers can implement international standard IEC62366: ‘Applications of usability engineering to medical devices’.To recapitulate the MEDDEV 2.7 guideline and the MDCG's guidance, both emphasise issuesrelated to the quality of research on the performance and safety relevant to medical AI.They directly address several weaknesses of studies that have been identified by theacademic community. Drawing the attention of both manufacturers and notified bodies to theseissues may help address them. However, the documents do not specifically address someproblems connected to AI research, such as the lack of an adequate, external validation ofthe systems deploying a dataset other than the one used for training, as well as the lack ofrandomised clinical trials and multi-site evaluations. Rather, they provide generalrecommendations. Furthermore, they are not legally binding, and the extent of theirimplementation is uncertain.Post-market surveillance is mentioned in the MDD. However, it is not defined there, and theDirective offers limited guidance on it . The MDR, by contrast,introduces more detailed and stringent rules on post-market surveillance.The MDR requires manufacturers to establish a post-market surveillance system that should‘be suited to actively and systematically gathering, recording and analysing relevant dataon the quality, performance and safety of a device throughout its entire lifetime, and todrawing the necessary conclusions and to determining, implementing and monitoring anypreventive and corrective actions’ (Article 83(2)). In particular, the data should be usedto update the benefit-risk determination, the clinical evaluation, the summary of safety andclinical performance, and other matters (Article 83 (3)).The post-market surveillance plan should be included as part of the technical documentationrequired for conformity assessment. The plan should address, for example, how the relevantdata will be collected and evaluated, information about the benefit–risk reassessment,methods for the investigation of complaints and management of incidents, and the post-marketclinical follow-up plan (Annex III). The post-market clinical follow-up plan, in turn,should, among other things, describe how clinical data will be collected and evaluatedthroughout the lifetime of the device, how new side-effects, emergent risks and off-labeluse of the device will be identified, and how the acceptability of the benefit–risk ratiowill be ensured .. The reportshould be updated with a frequency that depends on the class of the device (Articles 85 and86).The manufacturers should prepare a report containing a summary of the results and theconclusions of post-market analysis together with ‘a rationale and description of anypreventive and corrective actions taken’ (Articles 85 and 86)To facilitate the traceability of devices and post-market surveillance, the MDR introduceda Unique Device Identification system (UDI system) within which each device receives aunique identifier (Article 27).The post-market surveillance system required by the MDR should help manufacturers ofmedical AI devices to spot early on any new, unexpected side effects and risks of thedevices and take corrective actions, which may improve the overall safety of devices on themarket. the European Commission issued two documents concerning NBs.37As mentioned earlier, NBs are private companies designated by national authorities toassess conformity with the Regulation of a given type of medical device. In comparison withMDD, the MDR tightens the requirements on NBs. Some of the provisions included in the MDR,however, were introduced when the MDD was the applicable legislation. In 2013, in a responseto the breast implants scandal,In the MDR, Articles 35–50 consider NBs. They describe what the designation process andoversight of NBs should look like, referring to the roles of both the national authoritiesresponsible for NBs and the European Commission. The authority responsible for NBs, forexample, should review clinical evaluation assessments conducted by NBs to verify theirconclusions (Article 45). In addition, Annex VII details requirements that should be met byNBs. The first section of this annex specifies organisational and general requirements thatare meant to ensure, among other things, the independence and impartiality of NBs. Forexample, the MDR prohibits offering consultancy to the manufacturer regarding the deviceunder assessment ). The subsequent dozen or so pages of Annex VII aredevoted to requirements on quality management, personnel and conformity assessmentprocedures in NBs. Importantly, in the section devoted to conformity assessment activitiesit is stated that ‘[t]he notified body shall, where relevant, take into considerationavailable CS [common specifications], guidance and best practice documents and harmonisedstandards, even if the manufacturer does not claim to be in compliance’. This means that NBsshould be aware of and refer to relevant guidelines on medical AI devices. Adherence to thisprovision may help to prevent common deficiencies in studies on medical AI devices. have argued, however, that delegation of the conformity assessment to privateentities (i.e. manufacturers and NBs) is a key weakness of the existing regulatory system, and that the recent reforms do notadequately address this. They argue that since the manufacturers are free to choose NBs forthe conformity assessment, NBs ‘evolve in a competitive market, compete against each otherand adopt market behaviours, which can go against their fundamental public healthrole’. Jarman et al. also suggest that the incentives for public bodies to oversee the work of NBsadequately are insufficient, that this gives NBs a relatively weak incentive to conductappropriate surveillance of manufacturers, and that as a result, the motivation formanufacturers to ensure the safety of their devices is limited.In sum, then, the MDR improves oversight and imposes more detailed requirements on NBs thatmay help to improve the quality and thoroughness of conformity assessments and preventabuses. This may, in turn, prevent medical devices of unproved safety or performance fromentering the market. Jarman et al. and common specifications (Article 9); the requirement of a ‘person responsible forregulatory compliance’ appointed by the manufacturer within their organisation (Article15);and provisions regarding devices developed by health institutions for in-house use(Article 5(5)). Furthermore, the MDCG guidance on clinical evaluation of medical devicesoftware, and the MEDDEV2.7 guideline on clinical evaluation of medical devices, attend tosome of the problems identified in studies on medical AI devices. These documents addressthe issues mostly in general terms, however, and are not legally binding. Some deficienciesthat quite commonly impair studies presenting evidence of the performance of medical AIdevices, such as the lack of an adequate external validation of the systems, the lack ofrandomised clinical trials and multi-site evaluations are not directly addressed in thecurrent guidelines. However, the more stringent regulation of NBs imposed by the MDR,including requirements on adequate expertise of the NB personnel and consideration of bestpractices, may contribute to a more thorough evaluation of the studies submitted for theconformity assessment and increase the attention paid to the above-mentioned problems. Theimpact of these provisions depends also on adequate enforcement by the national authoritiesresponsible for NBs.The MDR introduces regulatory changes that may contribute to better performance and safetyof medical AI devices on the market. The most important modifications appear to centre onnew rules for risk classification of the devices, which will result in more devicessubjected to a higher degree of scrutiny; more stringent requirements on clinicalevaluation, including the requirement for appraisal of the methodological quality andscientific validity of clinical data; new requirements for post-market surveillance, whichmay help spot early on any new, unexpected side effects and risks of the devices and takecorrective actions; and requirements for NBs including for expertise of the personnel andconsideration of best practice documents. Other changes, not discussed here, which may alsopositively impact safety and performance include new harmonised standards (Article 8) The recently proposed Artificial Intelligence Act may help address some of theproblems presented by the development of medical AI. For example, Article 10 of thelegislative proposal directly addresses the quality of training data and bias. However, the final version of this regulation, yet to be agreed upon, will take a fewyears to develop. At this point, a quicker, but not legally binding, option that could helpaddress the problems discussed above might be a guideline issued by the MDCG. This couldfocus specifically on methodological and reporting standards for studies on medical AIdevices and draw on existing guidelines developed by the academic community. The MDCG indeedplans to develop a guideline ‘Artificial Intelligence under MDR/IVDR framework’. Its content, however, is not yet known.What steps can be taken to further ensure the safety and performance of medical AI deviceson the market? One approach, taken recently by the European Union, is to develop a separateregulation specifically focusing on AI.Importantly, we should keep in mind that regulatory solutions designed to achieve givengoals  may negatively impact other important values or cause somepractical problems. For example, a legally binding document outlining detailed rules on thequality of studies on medical AI devices could quickly become outdated due to technologicalprogress and could potentially hamper the development of new, unanticipated technologicalapproaches. Legislators have, therefore, the difficult task of balancing the aims of a givenlaw against any negative impacts of the mechanisms utilised to achieve these aims.Methodological and reporting shortcomings in studies on medical AI devices seem rathercommon. Since such shortcomings may lead to inaccurate conclusions about safety andperformance, and consequently to the presence of unsafe or low-quality medical AI solutionson the market, recent changes in the requirements introduced by the MDR may be justifiable.Yet there may be costs and negative impacts of each of these new requirements, for example,costs for the companies and public authorities , delays in implementation of innovative and beneficial solutions andothers, discussion of which is beyond the remit of this article. It is therefore importantto keep in mind this broader perspective – including trade-offs between different goals,values and costs – when discussing different regulatory solutions aiming to ensure thesafety and quality of medical AI devices.


Sport climbing is enjoying growing popularity—on rock in the great outdoors and especially indoors on artificial climbing walls in inner-city gyms. Increased enthusiasm and participation in the sport has led also to greater interest in competitive climbing—ultimately leading to sport climbing being included as an Olympic discipline in Tokyo 2020 and beyond. It is hoped that the sport being showcased on the international stage will result in increased participation around the world.Along with participation in climbing, interest in and research on the science of the sport has increased considerably. In 2011, the International Rock Climbing Research Association (IRCRA) was founded, which holds an international congress on research in climbing every 2 years. This Research Topic is the outgrowth of the last meeting of IRCRA in Chamonix in the summer of 2018, organized by its current president Pierre Legreneur.Two strands with different objectives are emerging in climbing research. The first strand focuses on understanding and improving climbing performance. Performance-determining factors are sought and found, and a wide variety of training procedures are examined for their effectiveness. Conversely, the second strand focuses on climbers as a special population to be studied in terms of their perceptions, stress processing, and other personality traits. Such characteristics are examined to determine whether the practice of climbing promotes outcomes that are educationally or therapeutically desirable or just scientifically interesting. This Research Topic is predominately focused on the first strand.Gibson-Smith et al. assessed the dietary intake, body composition, and iron status. While the authors did not find significant differences between climbing ability groups (intermediate-advanced/elite-higher elite) for any of the parameters analyzed the results suggest experienced climbers are at risk of energy restriction and iron deficiency and monitoring of nutritional intake in training experienced athletes would be of benefit. Similarly, Joubert et al. surveyed a larger number of climbers using a web-based questionnaire and found that climbers are not immune to disordered eating, especially elite female climbers.Related to both the health and performance of climbing athletes, Reveret et al. analyzed the body motion of speed climbers  in 3D. The ability to observe and quantify the velocity profile of speed climbers may help to highlight potential deviations from an optimal climbing path and shows the points where the upward movement stalls, providing coaches and climbers with actionable feedback on climbers speed performance.Concerning the technical movement performance, Hill et al. presented a procedure to develop individual load-response profiles comparing difficulty with the number of attempts required, creating a system which may help coaches to find the optimal stress level in training for their athletes.Many athletes have to deal with stress and climbing is no different in this respect. For instance in bouldering competitions, a problem must be mastered in as few attempts as possible within a 4 or 5 min window, and the movements required often involve a high risk of failure. In their paper, Limonta et al. were interested in climber's route preview capacities and their ability to recall movement sequences. Analyzing both parameters in on-sight (without prior knowledge and practice of a route) and red-point (following practice) climbing the authors reported that, even for advanced climbers, the on-sight style is more physiological and psychological demanding than red-point climbing. The results highlight the interaction between perceptual, physiological, and psychological factors and the importance of psychological performance in on-sight climbing. Developing on the theme of the cognitive demand of on-sight climbing, Garrido-Palomino et al.'s study investigated the relationship between attention and self-reported climbing ability. The authors found that attention is positively related to on-sight but not red-point climbing ability, suggesting that higher level on-sight climbers are better able to attend to the task of climbing and not to external factors  which may affect performance.Considering the cognitive demands of the sport, Gajdošík et al. They studied climbers with different expertise as they climbed through an identical climbing route, one close to the ground and one at height. They were able to show that the perceived exertion for advanced climbers was in good agreement with the objective measurements. However, less proficient climbers overestimated their actual exercise intensity when climbing at height.Research of the second strand is reported by Fuss, Weizman et al. investigated the climbers abilities to perceive the roughness and grippiness of climbing holds. The construed holds from different materials that differed in these properties. They found that climbers mainly use grippiness for the evaluation of the holds. They use the estimated grippiness in planning the force they use to achieve the necessary friction efficiency and not slip off the hold.Sas-Nowosielski and Kandzia report the positive effect of post-activation potentiation on upper-body climbing-specific power exercise, Fuss, Tan et al. examine the behavior of heart rate during speed climbing, and Mitchell et al. examine the visual search strategies of experienced climbing coaches.In addition to the eight original research articles, the Research Topic is supplemented by three short reports. In anticipation of the approaching Olympic Games and climbing's debut, in this Research Topic, we have brought together research articles that predominately focus on improvements in the athletic performance of climbers. While developments in this area continue to be important and relevant the “second strand” of educationally and/or therapeutically relevant outcomes should be given more weight at future meetings and may become dominant content in a later Research Topic.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.DG was employed by company Lattice Training Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Traumatic vision is an important factor that causes people to have a vision. In our country, the vast majority of vision is caused by trauma. To understand the role of optic nerve decompression in the treatment of traumatic visual disturbances based on the pathological states of traumatic visual disturbances and intelligent Internet of tumors medical nasal endoscopy optic nerve decompression. This article collects relevant information by investigating patients, investigating relevant literature, interviewing professionals, etc., constructing a case template and using a comprehensive quantitative and qualitative analysis method to create a damage assessment matrix. The results of the study found that most traumatic vision disorders occur in the young and middle-aged stage, which is more than three times that of other age groups. The permanent blindness rate of patients reaches 8%, which is extremely harmful. Optic canal decompression surgery can play a great role in the treatment of patients. It can greatly reduce the patient's neurological damage. The effect is about 30% higher than that of general treatment methods, and it can also play a certain role in the prognosis of rehabilitation. It can effectively prevent related postoperative complications. This shows that optic canal decompression in the treatment of traumatic vision disorders should attract people's attention and increase research and development efforts and promotion efforts so that optic canal decompression can be used in the diagnosis and treatment of patients with traumatic vision disorders based on smart Internet of things China can play a greater role. Cognitive function is an important prerequisite for people to perceive the peripheral world and to adapt to the objective environment. A specific injury factor, such as a head injury and stroke, causes damage to the brain tissue, often causing cognitive dysfunction in the patient, resulting in difficulty in perceiving the patient and adapting to the external environment. Life and society can live independently, work hard, and even constitute obstacles , 2. VariWith the development of science and technology, especially the application of imaging technology in the medical field, it provides a reliable guarantee for doctors at the risk of optic canal decompression surgery . In ordeRegarding the impact of traumatic visual impairment on patients, experts at home and abroad also have many studies: Cheng and Jia believe that traumatic visual impairment causes extremely serious damage to people. After treatment, more care should be given to patients. Patients admitted to a hospital in northern Anhui received relevant psychological care for one year to study whether they had a positive effect on the prognosis of traumatic visual impairment. The results showed that after psychological care, the patient's neurological deficit score increased significantly, indicating that psychological care is effective. Traumatic visual impairment can play a role in promoting the recovery of patients' neurological function and daily living ability ; Li et aThis article is primarily to study the impact of optical nerve decompression surgery visualization on the treatment of traumatic vision through the visualization of medically assisted Internet surgical design, reducing the risk of surgery. Combining medicine, biology, computing, instrumentation, and mechanics related disciplines, relying on computer graphics and image technology, segmentation and reconstruction technology, virtual roaming technology, etc., display the patient's information according to the doctor's requirements, and help the doctor to plan the operation. Provide great help to doctors in surgery, reduce the risk to patients, reduce unnecessary pain for patients, and increase the success rate of surgery.Visual acuity is a more accurate function of form perception. It can be divided into central visual acuity and peripheral visual acuity. Central visual acuity is obtained through the center of the macula. Peripheral visual acuity refers to the functions of the retina other than the macula. Therefore, vision is one of the specific manifestations of visual function. The visual impairment, although very slight, also shows that the visual function is affected.Mono's Internet uses information recognition techniques such as sensors and runs through a wireless network between patients and medical staff, medical institutions, and medical devices. Through the comprehensive application of handwriting recognition, identity recognition, sensor wireless network, and other Internet of Things technologies, identification, local positioning, monitoring, and management of special populations in hospitals, medical equipment, medical waste, and medicines have been carried out. You can play the following aspects in this process: diagnostic and treatment entry points, patient ID line bar codes, mobile doctor orders, mobile test sample management, mobile drug management, infant theft prevention, medical records, data dialing and storage, nursing program management, and so on . It can Scope: the scope of neuroendoscopy includes rigid endoscope, flexible endoscope, and observation peeling mirror . Rigid eLight source: the brightness of the light directly affects the quality of the image, from the first endoscope using candle light to the later invention of the light bulb and the use of incandescent bulbs, and then to the widespread use of metal halide lamps and ultrahigh voltage short-arc lamps in the 1960s. For applications, neuroendoscopy lighting systems are constantly evolving .Imaging system: the imaging system includes a camera, a camera system, and a display. The camera is connected to the eyepiece of the neuroendoscope, and the image is transmitted to the display through the camera system host; the display shows that the image collected by the camera is the “eye” of the surgeon, and it is mostly placed directly in front of the surgeon's operating position. The distance should not exceed 2 meters to facilitate observation .Storage system: image recording device and computer management system. The image recording apparatus can be used to record and store full information, including video devices, optical discs, hard disk storage media and printing devices and can be used to convert an operating image to a digital signal or directly print to a photo to store, display, or expose data . Some caAs shown in Aiming at the problem that the Snake algorithm will not converge when the initial position is not appropriate, and the search range is limited, this paper uses the GVF model to make up for the above shortcomings. This model uses the gradient vector on the image to diffuse outward to increase the capture area, a recessed area that is deep in the contour of the target. Therefore, the GVF field can expand the range of target detection.f as the edge-mapped image of the image I, the f general value here is |∇∗I)|2, define GVF as a vector field V=, v), and minimize energy generalization as follows:Set According to the principle of variation, GVF satisfies Euler's equationu is a time-varying function, which changes continuously with time t, so we can get the following:In the formula, Visualization is a theory and a technique that can be used to convert data into graphics or images by displaying image processing techniques and computer graphics techniques –18. The s approaching 0When ΔAs the conditions change, the image will also change with the discoveryFrom this, we can see the following:s approaches zero, use the following differential equation to illustrate the change in light intensity:When ΔFor the application of diagnostic imaging in medical treatment, we generally adopt the following formula:The quadratic performance indicators are as follows:Before the emergence of visualization technology, medical staff can only use two-dimensional images as a basis for judgment, and there are three ways of observation: axial, sagittal, and coronal . In thisAt present, there is no software system specifically for visualizing optic canal decompression surgery at home and abroad. Doctors can only perform analysis based on a two-dimensional CT image or a regular image workstation and can make a decision based on their experience. They cannot provide more accurate and accurate analyses to doctors. Careful help, and because optic canal decompression surgery is highly dangerous, and the location of the optic canal varies from person to person, so far, few doctors at home and abroad can undertake such an operation . In ordeManagement of restlessness and pain: severe restlessness and pain lead to an increase in the body's stress response. Pain is an important cause of delirium. These factors increase the burden of vital organs and affect the prognosis. Sedation therapy can prevent the increase in blood pressure and reduce rebleeding, and the protective effect of brain tissue has also been clinically recognized . PatientBlood pressure management: the fluctuation of blood pressure is closely related to the expansion of hematoma and poor prognosis, so the management of postoperative blood pressure is particularly important. At present, the optimal decision for blood pressure management is still unclear, and there is no large study that can confirm that an exact blood pressure target value can benefit widely or that rapid blood pressure reduction is absolutely harmful; some exploratory studies have shown that excessive blood pressure variability indicates a poor prognosis and it is recommended to avoid excessive fluctuations in blood pressure as the goal of blood pressure management. It is recommended that the blood pressure does not drop too fast or too low.Management of blood sugar: in neurosurgery, due to stress reaction, elevated blood glucose is common in patients. Hyperglycemia has a positive correlation with a head injury. Initial elevation of blood glucose is an index that reflects the severity of the head injury and suggests a poor prognosis. Hyperglycemia worsens brain edema simultaneously. Blood glucose damages the immune function of the body and increases the probability of infection. Therefore, hyperglycemia is associated with a poor prognosis and an increase in mortality. At present, the best management methods and target values for blood glucose in patients with cerebral hemorrhage are different, and it remains to be studied . After tLiquid management: fluid management is an important part of the management of critically ill patients, involving the resuscitation and maintenance of the patient's volume, as well as the control of intracranial pressure. After the operation, patients need to be given supplementary fluids and adequate nutrition for physiological needs . In geneBody temperature management: elevated body temperature is a powerful vasodilator, which can increase intracranial pressure and increase brain metabolism rate, and may also lead to hematoma enlargement, which is extremely unfavorable for the prognosis of patients with cerebral hemorrhage. The duration of fever is also closely related to the prognosis. Actively search for the cause of fever and treat it. Physical cooling is a simple, effective, and safe way to cool down. Warm water baths, alcohol cooling, etc., are given, and an indomethacin suppository is given to the anus –31.Imaging examination: CT should be reviewed as soon as possible after the operation, which can improve the accuracy of the calculation of hematoma clearance rate and reduce the error caused by postoperative bleeding; it also reduces the confusion caused by residual hematoma after hematoma or rebleeding. The CT reexamination time in this study was all after the patient's spontaneous breathing recovered and the reexamination immediately, no more than 24 hours after the operation.All patients were admitted to the neurosurgical intensive care unit for postoperative follow-up, and statistical analysis showed that sending the patient to the intensive neurosurgery intensive care unit could allow the patient to receive good treatment and improve prognosis. Provide patients with vital signs, neurological function assessment, continuous cardiopulmonary monitoring, vital signs, and other monitoring . The posHuman cells have plasticity and functional reorganization. This is theoretical support for superior rehabilitation effects of neurological disorders that are recognized in the rehabilitation circle. Rehabilitation therapy occupies an important place in the treatment process, and the recovery time window has attracted people's attention. As a medical staff, in the process of preventive medication for patients, the patient's own economic situation should be fully considered. When the economic level permits, patients should be advised to take cost-effective and effective drugs as much as possible, and patients should be encouraged to take the drugs for a long time. Medication compliance shortens the distance between clinical practice and prevention guidelines.Before the operation, fasting water, routine CT examination, CT scan with a thickness of 0.5 cm to obtain CT images, give ECG monitoring to monitor vital signs, continue to inhale oxygen, give nicardipine 5–15 mg/h continuous intravenous infusion to reduce blood pressure, if necessary, and give 20% mannitol dehydration to reduce intracranial pressure. Perform routine fasting and drinking before surgery, establishing intravenous access after entering the room, monitoring blood pressure, heart rate, breathing, pulse, and other vital signs, and administer dexmedetomidine, propofol, sufentanil, and other anesthetics.(1) Make a small side nasal incision on the affected side first, and then cut the area from the inner end of the brow arch to the upper part of the alar, but do not cut the alar. (2) Open the nasal bone plate and enlarge the bone hole to ensure that the bone hole is in the area between the nasal root and the lacrimal sac. Then, use curettage to remove the ethmoid sinus anterior and posterior groups, and the scraping range is from the lamina to the upper jaw. The area between the upper boundary of the sinus will reach the anterior boundary of the sphenoid sinus after the above operations. (3) Remove the anterior inferior wall of the sphenoid sinus and open the sphenoid sinus cavity. If you encounter edema mucosa and blood clots, you can directly clear them. (4) After opening the sphenoid sinus, there will be a posterior obliquely upward skeletal protrusion called the optic canal. (5) Determine whether the optic nerve sheath needs to be cut according to whether there is edema in the optic canal. Generally, a scalpel is used to make a few tiny openings on the sheath to relieve pressure.The data in this article are mainly obtained from the clinical data of the inpatient's diagnosis, the patient's understanding of the scene and the statistics of the telephone interview. The newly diagnosed patients with visual impairment in our hospital from November 2019 to March 2020 were selected. Then statistical data is categorized, analyzed, and simulated by computer software. We conduct investigations on doctors and patients, respectively, and conduct nursing work for the treatment of traumatic visual impairment by optic canal decompression under the intelligent Internet of Things medical nasal endoscopy. The evaluation method is based on the entropy method and comprehensive quantitative and qualitative analysis.P < 0.05 is considered significant. The statistical results are displayed as mean ± standard deviation (x ± SD). When the test data obey the normal distribution, the double T test is used for comparison within the group, and the independent sample T test is used for comparison between the groups. If the regular distribution is not sufficient, two independent samples and two related samples will be used for inspection.All data analysis in this article uses SPSS19.0, and statistical test uses two-sided test, significance is defined as 0.05, and We have collected statistics on people who have undergone treatment for visual impairment in city hospitals, classified patients who have been treated for visual impairment in recent years, and classified patients according to the causes of visual impairment, as shown in From From We examine different patients and count the various parameters of the patients to check the severity of the visual impairment of the patients and divide them into four categories: congenital, benign, trauma, and internal trauma. The classification parameters are shown in As shown in 4We classify the patients with visual impairment, collect statistics on the patients' living habits and physical conditions, and obtain the causes of the patients' visual impairment, and then carry out targeted rehabilitation and prognosis so that the patients can recover. The details are shown in Tables From the table, we can see that bad living habits are an important reason for the difficulty in nursing and rehabilitation of patients. Most patients have the habit of smoking and drinking, which causes the patients' own high blood fat and high blood pressure to be more serious, which greatly hinders them. We compare the rehabilitation prognosis of patients with normal schedules and patients with bad habits, as shown in From The internal carotid artery is close to the optic canal and is located in the cavity of the sphenoid sinus. The structure is complex. The method of realistically rebuilding the structure is the study task of this article. Since the internal carotid artery around the optic nerve has a C-shaped structure, it is difficult to obtain the structural image. It is relatively large, so this article adopts sampling based on the smart medical Internet of Things. All the structures of the internal carotid artery around the optic canal are presented on a two-dimensional image. The technology of mapping the two-dimensional space position to the three-dimensional space is a good realization of the operation. Connecting optic canal decompression surgery with smart medical care cannot only achieve surgical planning but also real-time observation, effectively reducing surgical risks. High technology promotes the rapid development of this medical device. 3D endoscopy has a three-dimensional effect. It has been invented and used in clinics and will gradually replace ordinary endoscopes. The combination of nasal endoscopy and intraoperative imaging technology will make the effect of endoscopic surgery more obvious. The combination with artificial intelligence in the future is also a development trend, and there may be more minimally invasive new surgical methods used in the clinic.


Beyond its devastating consequences for public health, the COVID-19 pandemic had a major impact on gender inequalities, labour markets and families. Compared to many European countries, the French approach to lockdown was among the more stringent, although the measures taken by the French government to support employment, to some extent, mitigated the worst effects of the crisis on families. This article analyses the implications of COVID lockdown restrictions on gender equality and well-being for couples with children in France. The study adopted a multidimensional approach to gender inequalities associated with paid work and various dimensions of living conditions, involving gender-differentiated access to personal work spaces in the home, personal leisure time outside the home, and local support networks during the first phase of lockdown (March−June 2020). Drawing on data from the COCONEL survey, carried out by the Institut national d’études démographiques on a quota sample of the French adult population in April/May 2020, the authors controlled for variables including socio-economic status, age, family structure and place of residence. The survey data were complemented by a longitudinal set of in-depth interviews enabling the research team to capture the differential effects of the pandemic within couples. The main findings indicate that, despite the frequency of dual-employment arrangements for heterosexual couple households with dependent children, French mothers were nevertheless more likely to reduce their working time and/or withdraw from the labour market. Within the households surveyed, mothers were less likely than fathers to leave the home during the day, particularly for personal leisure activities. The presence of children in households increased gender inequality in both employment and living conditions across all socio-economic categories. In conclusion, the authors consider whether the pandemic might have a long-term impact on gender norms and inequalities within families, and how the findings about changes in gender inequalities could be used to inform public policy development. The COVID-19 pandemic had a major impact across the world, not only on health, particularly for older people and those with underlying health conditions, but also on social life and labour markets, where it caused mass layoffs, job dislocation, and income loss. The effects of the crisis were highly uneven both between and within countries, depending on working arrangements and workers’ characteristics , as well as on the public policies implemented.France occupies an intermediate position in Europe regarding the socio-economic impacts of the COVID-19 crisis. It was one of the EU member states hardest hit during the first wave of the pandemic and was characterised by the stringency of the measures implemented . From 6 Three types of mechanisms have been highlighted in studies to explain the rise in gender inequalities during the COVID-19 crisis and the diverse effects of the pandemic across and within countries. The first is linked to the form and intensity of labour market segregation. In Europe, women are over-represented in the public-facing service sectors  that were disproportionately affected by closures due to social distancing and lockdown measures, and in cases where they were less able to work from home . MoreoveThe second mechanism refers to the social norms determining acceptable roles for women in society and the household. Although the dual-breadwinner family model has become dominant in Europe, the share of unpaid work within households remains largely unequal . In mostThird, cross-country gendered disparities depend on the public policies implemented, such as school closures, and financial support for workers with children. Employees in Germany, which has a well-established short-time work scheme (Kurzarbeit), were, for example, much less likely to be affected by the crisis than in France or the United Kingdom, where furlough measure were widespread . Short-tIn France, women and men who were unable to work owing to workplace, school and childcare service closures, or other lockdown measures, could claim employment insurance or social security payments. Short-time work compensation was high—at the rate of 84% of the previous net salary—and extended to non-standard employment. More than a third of those employed prior lockdown were on short-time work during this period . MoreoveIn spite of the socio-economic measures taken by the French government at national level to support employed workers, the impact of the pandemic on households varied according to age, socio-economic status  and gender . In FranThe research reported in this article explores the impact of lockdown on working-age mothers in two-adults households with the aim of understanding the interactive effects of gender and parenthood. The study contributes to the literature on COVID-19 and gender inequalities in two ways. After explaining why the French case is of interest for an analysis of the interactive relationship between COVID-19 and the experience of working mothers during the pandemic, the research team sought new evidence demonstrating how the pandemic affected gender inequalities in heterosexual families in France. In contrast to much of the previous literature, the project team adopted a multidimensional approach in analysing developments in gender inequalities during the first wave of the COVID-19 crisis, taking account of paid and unpaid working and living arrangements, and social well-being.The first research question considers whether, despite substantial public aid in France aimed at preventing mass unemployment and the exit of salaried parents from the labour market, working-age women with children were more adversely affected by the crisis and lockdown measures than men in the same situation, regardless of social category. The second question concerns the negative impact of lockdown on the family and social lives of mothers, and consequently on their well-being. It leads onto an analysis of the relationship between housing conditions, private space and activities outside the home, and the sharing of educational and domestic tasks between parents.The study draws primarily on cross-sectional data collected in the sixth round of a longitudinal online survey . This round of the survey was designed and conducted by the Institut national d’études démographiques (INED), focusing on housing and living conditions during the first wave of the pandemic. A sample of 2,003 adults living in metropolitan France were questioned online between 30 April and 3 May 2020, using a quota sampling method covering age, gender, education, occupation, and category of municipality. Data collected included socio-demographic characteristics, household composition, a detailed description of housing conditions, employment characteristics, and perceptions of well-being.The COCONEL survey has three advantages compared to other national surveys. It contains information about the situation pre- and post-lockdown, meaning that changes in individual situations can be compared over time. Its approach to living conditions during the crisis was not limited to employment and the division of household work, which were the particular focus in the international literature and several ad hoc surveys in France, such as EpiCOv . COCONELSupplementing the COCONEL survey, the article draws on in-depth interviews and qualitative longitudinal analyses of families in different types of housing arrangements and social class, enabling an analysis of the subjective experience of the crisis and the mechanisms leading to greater inequalities within couples. The interviews focused on the changes that occurred during the crisis in terms of housing, family, work, and day-to-day life. 21 in-depth interviews were carried out in April and May 2020 by the COCONEL study group by telephone or online owing to the physical distancing measures imposed at that time. They were all recorded and fully transcribed. It is important to note that the interviewees had already been followed and interviewed in person as part of earlier qualitative surveys, which meant that their “regular” living conditions were well known and documented.This mixed methods approach enabled the authors to reconstitute the dynamics of inequalities in the longer timespan of the life course. Furthermore, by focusing on the domestic sphere, they were able to gain a better understanding of family dynamics and a firmer grasp of the trade-offs made by families in confronting the gendered experience of lockdown.The analysis presented in this article shows that the deterioration in employment and working conditions during lockdown was more pronounced for mothers than for fathers, thereby confirming the observations made in some other countries. In addition, it shows that living conditions were more difficult for mothers than for fathers during this period, in particular because they spent less time outside the home during the day than did fathers. Working-age women with children also complained more often than fathers about their housing conditions. Similarly, experiences of teleworking differed by gender, particularly in better-off households where housing conditions were more amenable to home working.The odds ratios from the COCONEL data analysis in The additional household work was performed entirely within the home. Housing conditions and the ways in which domestic space is shared appeared to be decisive in the assessment made by mothers and fathers of the effects of lockdown on the well-being of family members. Overall, the women in the sample population lived in smaller dwellings than the men, with an average of 45 square metres of living space compared to 51 square metres for men, factoring in the number of individuals in the household. This disadvantage was aggravated by the health crisis since more women than men were living with dependent children during lockdown: 36.7% of women lived with at least one dependent child during the period, compared to 29.4% of men. In addition, exposure time to poor housing conditions increased owing to restrictions on leaving the home.The COCONEL survey showed that women in couples with children had more negative perceptions of their housing conditions during lockdown than men in the same situation. Whereas 13% of all female respondents said their home lacked space, compared to 9% of men, the percentage rose to 18% for women in couples with children, compared to 12% of men in the same situation. Among women and men in couples without children, gender differences are almost non-existent. This differing perception of housing conditions can be attributed to the fact that more women than men stopped work or reduced their working hours during lockdown. They took on greater responsibility for daily household tasks and the material aspects of daily life — cleaning, washing up, laundry, preparation of meals — which meant that they were more sensitive to the lack of living space in everyday life.This perception gap also stems from differences between women and men in couples with children in terms of life outside the home. Daily outings were stringently regulated in France during the eight-week lockdown in spring 2020. A list of exemptions applied for work, exercise, essential shopping and health visits; a maximum period of one hour within a radius of one kilometre from the home was enforced for physical exercise, and shopping was confined to basic necessities. But these legal restrictions did not prevent major differences between population categories. In the sample of respondents to the COCONEL survey, respectively 40% of men and 53% of women on average said they did not leave their home on the day preceding the interview. The gender gap was largest among couples with children, with 37% of men in couples with children not having left their home the day before the survey, compared to 53.5% of women see .The origin of these inequalities can be discerned in the reasons given for leaving the home. Men and women with no children were equally likely to leave the home to go to work, but among couples with children, men left the house to go to work more often (+7.5 points) than women. Gender differences were much more pronounced for recreational and sporting activities. The gap in each case was greater among couples with children. The number of men in couples with children engaging in sporting activities outside the home was three times higher than for women in the same situation. Outings were also longer for men than for women (231 and 184 min per day respectively). The regression model presented in These findings are supported by qualitative data providing information about the organisation and reasons for leaving the home by members of the same household. Interview data showed that men more often than women continued to leave the home for personal leisure: for example, hunting for the partner of a female farmer, or jogging for an airline pilot living in the city. Sometimes they left the home to complete tasks that they did not usually carry out before the pandemic, such as shopping for food. Their outings sometimes infringed the new rules, for example by exceeding the authorised distance from the home. They generally described these activities as necessary for personal well-being, or sometimes, among older couples, as a way of protecting the health of a female partner who was self-isolating. The leisure practices of men were also more likely to be justified as part of a daily or weekly schedule, serving as a refuge, whereas the personal leisure activities of women were organised during any time that remained after they had carried out their work-related, domestic and parenting tasks.In addition to the data provided by the statistical survey, the interview narratives also captured the experience of mothers living through lockdown. Although they mainly regretted the lack of leisure and personal time, they rarely disproved of their partner’s activities outside the home. Moreover, if they went out for a reason other than work, women did not go as far as their partner. They most often stayed at home, including for rare leisure activities, such as reading or watching television, or they remained in the vicinity of the home , whatever their social milieu. This was the case for Rosa, a checkout assistant on short-time work and mother of three children, who said she shut herself up in her home with her children while her partner went out to work. Stéphanie, an unemployed administrative worker living with her husband and her 18-year-old daughter, reported that she suffered from boredom while her husband could go out almost every day for professional reasons and shopping activities. Agnès, a mother of four children, whose husband had a higher-level occupation, said that she went no further than the outside of her apartment block or remained in the neighbourhood to help her aunt. In a wealthy couple confined to the countryside during lockdown, recreational outings were organised to visit a neighbour or to have a drink with friends, generally in the presence of the male partner. This was the case for Delphine, an assistant producer who had stop working and had more time available than Christophe, a human resources manager, who was then teleworking.The home became not only a place for leisure pursuits and family life, but also a place for paid work activities. While telework was not a widespread practice in France before the pandemics, it spread considerably during the first lockdown, but in a very unequal way according to the type of work and the level of education . The anaCOCONEL was one of few surveys in France to provide information about the conditions of teleworking at home during the pandemic. By May 2020, 29% of the population in employment before lockdown worked from home. This was the case for 86% of those in higher-level occupations. Telework was presented in the public debate as an advantage for well-qualified workers . But it In the interviews with respondents in higher and intermediate level occupations, men were found to have appropriated certain rooms in the home, for example a bedroom or study for their work, and sometimes for their leisure. This situation was observed, as anticipated, both among hypergamous couples, where the women did not work or had stopped working, and among homogamous couples, where the women worked in an occupation of a level similar to that of their partner, which was more unusual, for example, in the case of a couple who were both teachers. The interviews showed that the re-distribution of domestic space, whether for work or leisure, often occurred informally, without prior negotiations, thereby revealing the internalisation of male precedence in the use of space:I had to prepare for my job interview, but I had the opportunity to do so because my husband was at work. So I was able to prepare in the living room, comfortably installed at my desk .He comes to see us at lunchtime; he pretty much has lunch with us, 20 min. My husband is mainly in his room and in general doesn’t come out. I see him at 1 pm and then towards 9 pm .He’s started making sculptures, carving wood, so he spends almost all his time on the patio, morning to evening. Sometimes I tell him: “I need you here, cut that stuff out!” .Some women were able to throw off the shackles of conjugal pressure by choosing not to live with their partner during lockdown, appropriating the entire domestic space for themselves and some of their children. But this option was exceptional, a result both of real-estate ownership and a shared understanding of equality within couples. Overall, these indicators show that mothers have a specific relationship to the home environment, which can be qualified as “domestic imprisonment”. Lockdown, therefore, had a profound impact on living conditions for mothers, with negative consequences for their well-being.The COCONEL survey addressed the subjective experience of lockdown for the well-being of working-age mothers. Respondents were questioned about the difficulties they experienced in everyday life. As shown in The interviews showed that women felt more vulnerable for two main reasons. Firstly, because they were the principal caregivers for young children during the day, they felt overwhelmed by the situation. Secondly, during lockdown, female respondents who were teleworking or economically inactive found that their partners who continued working contributed little to housework and remote schooling. This was true for Agnès , who handled almost all the housework while her partner shut himself up in the bedroom to work. It was also the case for Jeanne , who finished her teaching work late at night after spending the day looking after her two young children. She explained: “We don’t have the same daily lives”. Her husband, also a teacher, reported not feeling fatigued at the time of the interview. The second reason for women on short-time work or unemployed with older children lies in their sense of domestic boredom. For example, Rosa , a checkout assistant, who was carrying out some household tasks to pass the time, said: “I try something new every day. My children are older and can take care of themselves.” The men interviewed reported fewer cases of personal difficulties, because they were less involved in the additional housework and parenting tasks during lockdown, while also being constrained by gender norms from expressing emotions that might undermine their virile image .Lockdown resulted in an increased feeling of social isolation, captured by the question in the COCONEL survey: “Do you currently (during lockdown) feel isolated in your neighbourhood or home?” Women were less likely than men to feel isolated during lockdown because they were living closer to family members and were able to provide mutual support. The COCONEL survey showed that 38% of women in couples with children had a relative living within 1 km from their home, the authorised geographical limit for outings, compared to 27% for men in couples with children. This percentage was even higher for women with low socio-economic status: 48%, compared to 27% for women with high socio-economic status, confirming that the family played a key protective role among the lower socio-economic group.The qualitative study underscored the importance of women’s residential preferences in the organisation of daily life among families in lower socio-economic categories. This was the case for Marie-Claire, an employee and remarried, whose house had been rebuilt in part by her father, and for Séverine, 55, a farmer in Burgundy, who had inherited the family farm. Women were also more involved in maintaining local relationships and sociability . The facFor men from all social class, lockdown caused a greater disruption in their lifestyle since the increased amount of time spent with children did not compensate for the lack of sociability outside the family. The combined findings from the survey and interviews confirmed that male sociability was more likely to be structured by professional life and work colleagues, whereas women more often maintained contacts with their relatives. Women were also more likely to receive friends and relatives in their homes or meet at private or semi-private venues.One of the aims of the study was to explore whether the pandemic might have increased gender inequalities in France due to its impact on working arrangements and living conditions, including teleworking, access to personal space, leisure time and activities, and to family support networks. In seeking to achieve this aim, the researchers adopted two working hypotheses to frame their analysis. Firstly, they asked whether, despite substantial public support in France to avoid mass unemployment and the exit of working parents from the labour market, working-age women with children had been more adversely affected by lockdown measures than men in the same situation across socio-economic categories. Secondly, they analysed the impact of lockdown on dimensions of social life other than employment, and asked how lockdown had affected the quality of life and well-being of working mothers.COCONEL is among the few sociological surveys to be conducted using a random sample of national population that simultaneously takes into account working arrangements, living conditions and well-being, and allows for an intersectional analysis of social inequalities by gender and socio-economic status. The results presented in this article are based on the sixth wave of the survey documenting employment, living conditions and well-being during the first wave of the pandemic and lockdown. The findings showed that working-age mothers were more likely than their male counterparts to stop working during lockdown. When controlled by age, socio-economic category and place of residence, belonging to the lower socio-economic groups was found to be associated with a higher risk of stopping work during lockdown. Highly educated women were less affected by firm closures than women with a low level of education, since they were more often able to work from home. These results are in line with findings from other literature about the gendered impact of COVID-19 on the labour market .Data on living conditions and social well-being were included in the analysis as potential factors exacerbating gender inequalities. The authors measured the gendered access to personal spaces for women and men working from home, gendered access to personal leisure time and activities, and the legitimacy of this differential access, and gendered and class-based access to family support networks during lockdown. The study found that men left the home more frequently during the day than women during lockdown, and that these differences increased when children were present. When controlled for employment, household composition, age and socio-economic status, men were found to be 1.6 times more likely to go out during the day than women. The same pattern was observed for well-being. Working age mothers more often than their male counterparts reported difficulties during the day, but they less frequently felt isolated. These findings suggest that mothers’ difficulties during confinement were more likely to be related to the additional domestic and parental work at home and less to psychological distress, while fathers’ new difficulties were related to the disruption of social contacts with family and others.The design of the COCONEL survey did not allow a textured analysis of all the variables of interest to the researchers. Like all national population-based surveys, the data failed to capture the experience of highly vulnerable groups such as lone mothers who were particularly affected by the pandemic. In addition, the analyses were based on cross-sectional data limited to the period April−May 2020 rather than longitudinal data. Nor did COCONEL enable comparisons to be made of the situation between men and women within couples. The authors used the findings from in-depth interviews carried out during the first lockdown to address some of these limitations and better understand the mechanisms that contribute to the deterioration of the situation of working-age mothers. They were able to use a panel of respondents who were already being followed prior to the pandemic to complement the quantitative analyses by providing biographical and longitudinal data.The respondents’ narratives suggest two main mechanisms – socio-economic and employment status − that contributed to the deterioration of the situation of working-age mothers. Among the higher socio-economic groups, with their more spacious dwellings, women mainly kept their jobs and worked from home, generating a dual domestic−occupational workload that eroded their well-being, given that the customary outsourcing of domestic work was no longer possible. They tended to feel overwhelmed by the lack of time for themselves or their leisure activities. However, they did not reproach their spouses for appropriating the domestic space and for their limited contribution to domestic work. It seemed that the crisis delegitimised any expression of female protest.In the lower socio-economic groups, where housing conditions are less amenable to homeworking, more women stopped working or were put on reduced hours. Despite the loss of income, the impact on the deterioration of individual and family well-being appeared to be mitigated by their closer family networks and their lesser reliance on paid housework and childcare services before the pandemic. Women with a lower level of education complained less about additional domestic and parenting tasks and more about being bored at home after being required to stop working for several weeks. They were eager to return to work for the benefits of socialisation and social identity that it conveyed.The findings from the study shed new light on the dynamics of gender inequality and its underlying mechanisms during the COVID-19 pandemic. While most of the available economic literature emphasises the role of sex segregation on the labour market and public policies, this study highlights the importance of gender norms and their impact on the appropriation of space and family resources by men in the private sphere . It alsoBy calling into question the gender inequalities that occurred in the private sphere, and not only employment outcomes, these findings about changes in gender inequalities during the early stages of the pandemic have broader policy implications beyond the current pandemic. They suggest the importance of reconsidering and value of the major role of women in creating and maintaining close ties with the family and in the neighbourhood, and more broadly their role in providing emotional support to the family during the health crisis. It also suggests the need for enterprises to strengthen professional equality policies that fully recognise parenting time and the support for dependants. They touch on how society supports women’s autonomy and well-being in the longer term, through childcare facilities and work−life balance policies, and are, therefore, important in informing future public policy development.


In the 21st century, the internet and particularly social media have become essential platforms for the spread of health information (including misinformation and disinformation). One of the distinguishing features of communication on these platforms is the widespread use of emojis. Though seemingly trivial emojis are now used by many if not most public health figures and organizations alongside important health updates. Much of that information has had to do with vaccination. Vaccines are a critical public health tool but one surrounded by falsehoods, phobias, and misinformation fueling vaccine hesitancy. Part of that has to do with their lack of positive representation on social media . We thus argue that vaccination deserves an entirely new emoji to communicate vaccine confidence and discuss a design proposal for a vaccinated emoji that has gained traction in the global public health community. Yet this does not address the fact that for many people needles themselves come with a host of negative associations. Needle phobia affects some 25% of adults [Communicating online has reached an all-time high for both scientists and the public, and has been catalyzed by public health and social measures in the context of the COVID-19 pandemic. The potential value of emojis in the context of medical communication and care has recently come into the limelight . These ek emoji . As the e emoji  . Howevere emoji  ,5,6. Sevf adults , often cThis is no small problem. In 2019, the World Health Organization (WHO) listed vaccine hesitancy, or the reluctance to vaccinate despite availability, among the top 10 threats to global health . This waVaccine hesitancy becomes an especially pressing problem in the context of pandemics, such as the 2009-2010 H1N1 (hemagglutinin type 1 and neuraminidase type 1) novel influenza A pandemic and the current COVID-19 pandemic. This is especially costly given that the COVID-19 vaccines offer an extraordinary degree of protection against severe clinical outcomes, including death. In 33 countries across the WHO European Region, an estimated 470,000 lives have been saved among those aged ≥60 years in 2021 alone .drop of blood emoji . In another case, Apple decided to change its pistol emoji to a water pistol emoji  [Improving vaccine confidence, whether in Europe or elsewhere, will require more effective messaging. In the social media age , this mel emoji  ,15. Thismosquito emoji  was proposed in 2016 in the context of the Zika virus outbreak [mosquito emoji  design has been added to the permanent collection of the Victoria and Albert Museum in London [With regard to public health, the creation of emojis is not a new idea. For example, the n London .vaccinated emoji to meet the current public health need for better digital communication on vaccine confidence.In this viewpoint, we build the case for a vaccinated emoji  and often used to indicate strength, success, overcoming a struggle, or rolling up your sleeve to receive a vaccine [adhesive bandage emoji  over the deltoid to couple this symbol of strength with one of protection and care. Their combination enables the user to communicate the benefits of vaccination in an intuitive, playful way. The initial design of the vaccinated emoji by author GD, introducing the relatable and protective image of an arm with a bandage, was posted on Twitter by January 6, 2021 [crying face emoji  has a relatively large tear because it would not be visible otherwise. The emoji was designed using the graphics editor and design programs Photoshop (Adobe Inc) and Illustrator (Adobe Inc).We aimed for a generic arm as a base for the emoji, representing all ages, genders, and skin tones, based on the  vaccine . We thenvaccinated emoji, TSB and GD have submitted the design proposal to the Unicode Consortium—who formally manages emoji approval and implementation across devices, platforms, and languages—in 2021. The Unicode Standard can ensure global access to the emojis across all platforms through the associated license agreement [To enable universal and international access to the greement :Submitter hereby acknowledges and agrees that they are submitting the Proposed Emoji for inclusion in the Standards, and further acknowledges and agrees that, if included in the Standards, the Proposed Emoji will be freely licensed by Unicode to all users around the world under the Unicode Licenses.mosquito emoji  [hijab (person headscarf) emoji , as well as the infectious disease prevention–related emojis for soap and microbe [The Unicode Emoji Subcommittee only selects a limited number of emojis that can be encoded and unfortunately did not select the vaccinated emoji proposal to move forward in 2021. Nonetheless, we are currently revising the emoji proposal for resubmission in 2022. It is not uncommon for emojis to be proposed multiple times before successful implementation, which was also the case for the o emoji  . To ensumicrobe .To increase uptake where vaccines are available and affordable, thoughts, feelings, and social processes can motivate getting vaccinated . People #WhyIVax on Twitter where trusted doctors and public health professionals gave positive examples, often with a photo of a loved one they were protecting through vaccination. The idea behind the campaign—which author NLF played a role in—was to give other users the courage to speak up about vaccines. The powerful flex of the vaccine emoji conveys confidence in one’s convictions and helps animate the important yet dry facts that comprise many provaccine posts [The vaccine emoji was created by TSB, a health scientist and field epidemiologist, and GD, a designer. After posting the design proposal to Twitter on January 1, 2021 , it quicne posts . People ne posts . An emoj#WorldEmojiDay, July 17 . International attention skyrocketed, and within a day, the proposal had been endorsed by many, including senior leaders at the WHO including Dr Tedros Adhanom Ghebreyesus  and Dr Maria van Kerkhove  [vaccinated emoji is driven by its accessibility, ease of use, and universal appeal, winning praise from commentators as diverse as Heidi Murkoff (the author of the What to Expect When You’re Expecting series of pregnancy guides) and Toyin Saraki . The emoji going viral on Twitter spilled over to media coverage in the United States [Later, NLF, who was a social media specialist for the Task Force for Global Health, began to help popularize the emoji. We reached out to a number of people through Twitter and rallied the global and public health community for al lead) ,32. The d States  and the d States . We see vaccinated emoji has become a fixture in the space of digital health advocacy. By August 2021, the emoji was selected for presentation at the Stanford Infodemic Conference on Social Media and COVID-19 Misinformation [vaccinated emoji  has been integrated into health promotion materials by national and international public health institutes with large reach, such as the Robert Koch Institute (Germany) [Since World Emoji Day 2021, the ormation . In Octoormation ) to visuGermany) , the US Germany) ,38, and Germany) , as wellGermany) .Vaccines for All WhatsApp Sticker Pack in collaboration with the WHO [#vaccinated [One year after its initial design, the proposal to add an emoji for vaccination gained international support from public health and medical professionals, national and international nongovernmental organizations, the infodemic management community, and the public. We endorse previous advocacy for expanding the available set of medical emojis and wish to amplify the need for emojis for public health by our proposed vaccinated emoji . Big tec the WHO  and the cinated . Furthercinated . These mEmojis are here to stay in our societies and have played a role not only in the fields of computer science and communication but also in marketing, behavioral science, linguistics, psychology, medicine, and education ,45. Impo