Precautionary measures  to limit the transmission of the Coronavirus 19 (COVID-19) have been put in place worldwide. However, a limited understanding of precautionary measures and low compliance with them has been observed in older adults with neurocognitive disorders, persons with intellectual disability, or mental illness. The objective of this study is to create and evaluate a robot-mediated activity to deliver information on COVID-19 precautionary measures in an accessible and engaging way using the humanoid robot Nao. An interactive scenario explaining and demonstrating COVID-19 precautionary measures is created using the verbal and non-verbal behaviours of the robot. The scenario (≈5 min) is presented to 124 users of a geriatric hospital, including the following: older patients (n = 45), accompanying persons (n = 39), and health professionals (n = 40). The data regarding perceived usefulness, acceptability, and accessibility are collected using a questionnaire. A video analysis of the participants’ behaviour during the interaction with the robot is performed to examine the quality of engagement in the activity. The results show a good acceptance, satisfaction, and perceived usefulness of the robot-mediated activity. These findings suggest that robot-mediated interventions using humanoid robots can be an effective tool for the delivery of health promotion information. Persons of all age groups are at risk of contracting Coronavirus Disease 19 (COVID-19) infection. However, older adults (65+ years old) have a significantly higher risk of developing severe forms of the disease due to physiological changes that come with ageing and other potential underlying health issues . The prePublic health organisations around the world have implemented and made mandatory the application of such precautionary measures . Since tSome studies have shown that older adults generally respect COVID-19 precautionary measures ,11. In cGeneral guidelines for communicating effectively with older adults with NCDs include using simple sentences, speaking clearly and slowly, giving the person enough time to understand and respond, offering simple choices, and using non-verbal communication , or visual prompts  to convey meaning ,17,18.Many initiatives around the world have been taken to make COVID-19 related information accessible to persons with intellectual or developmental disabilities, such as older adults with NCDs. For instance, in North America, the Centers for Disease Control and Prevention (CDC) has provided a list of accessible resources including guidelines and tools to help people with disabilities protect their health, for instance, as follows: easy-to-read materials, social stories , posters, and video series . Most ofSome researchers from the field of robotics have developed COVID-19 related interventions either to transmit information or to support preventive measures using robots . RoboticSocial robots are an innovative tool that could be used to provide accessible information on COVID-19 precautionary measures, encourage their imitation, and motivate compliance among the public with intellectual disability or cognitive disorders. The possibility of adapting the robot’s communication style  makes them suitable for use by persons who have communication and comprehension difficulties . HumanoiIn the field of healthcare, various studies have shown the benefits of “robotic mediation” for older adults in geriatric settings. A robot-mediated intervention uses the social robot as an intermediary between the older adult and the therapist or facilitator. A few publications have described the use of humanoid social robots to encourage older adults to participate in adapted physical activity programmes ,23,24. TThe study reported here aimed to develop an interactive informational activity for older adults in geriatric facilities to encourage the learning or recall of COVID-19 precautionary measures, using a humanoid robot as a mediation tool. The robot-mediated activity was intended to be simple, engaging, and accessible. To this end, particular attention was given to aspects facilitating understanding and imitation of precautionary measures . This work was carried out in two stages:(1) Phase 1 “Design and development of the informational scenario”: The objective of this phase was, on the one hand, to define the message on precautionary measures for COVID-19 that would be transmitted during the robot-mediated activity. The accessibility of the message and its relevance to the public of geriatric facilities were central issues at this stage. On the other hand, the verbal and non-verbal behaviours of the robot were defined and programmed to convey the information in an interactive and engaging way using the concept of “embodied cues”. Embodied cues refer to behaviours such as gaze, gestures, proximity, and vocal cues that help encompass meaning. Embodied cues used in human-robot interaction have been shown to contribute to significant social, cognitive, and task outcomes, for instance, improved learning  that an activity with a robot can be very instructive.” (accompanying person), “I learned that with a robot, you can educate yourself.” (patient), “I learnt about social distancing.” (patient), “I learnt about taking off the mask by the rubber band.” (patient), “This activity complements the action of professionals.” (accompanying person).Regarding the perceived usefulness of the activity, 66% of the older patients and 46% of the accompanying persons answered that they had learned something about COVID-19 precautionary measures or about the interest in robot-mediated health promotion , “This activity should be done on a regular basis.” . A single professional who provided a negative answer insisted on the necessary presence of a human person for health prevention activities.Out of 33 hospital professionals who answered the question, “Do you think the robot can be useful in transmitting preventive health information?” 97% (n = 32) answered positively. “For the 20 participants who were filmed, the analysis of videos using the observation grid showed that 75% of them asked questions about the robot, 65% imitated the robot , 25% asked the facilitator or the robot to repeat some instructions, 60% laughed (smiles were not counted because of the mask), 90% nodded during the intervention as if acknowledging the sense of the presentation, 85% responded to the robot , 80% kept their gaze fixed on the robot for the duration entire activity, and 25% repositioned or checked that their mask was correctly positioned on their face.Most participants made comments that entailed the identification of barriers and enablers for the robot-mediated intervention. They are reported in Making the robot available in a waiting room while waiting for test results to provide some distraction for patients and accompanying persons and reduce boredom;Offering various types of relaxation and leisure activities using the robot to help reduce anxiety and stress for patients and families who come to consult or visit;Organizing robotic mediated activities to deal with loneliness and isolation of patients in geriatric or paediatric departments;Using social robots to support healthcare workers and reduce their workload;Using social robots in the framework of rehabilitation therapies,  or for monitoring vital functions;Integrating social robots into educational activities at school with younger audiences.This study had the following two objectives: (1) To develop an interactive informational activity to encourage the learning or recall of COVID-19 precautionary measures for older adults in geriatric facilities, using the humanoid robot Nao as a mediation tool, and (2) to assess the feasibility, acceptability, and perceived usefulness of the robot-mediated activity. The barriers and facilitators for this kind of intervention were also identified. In this section, we discuss the main results observed in this experimentation, describe its limits, and formulate some practical recommendations for the implementation of informational activities for health prevention using the mediation of a social robot.Regarding the feasibility, in terms of the design process, we succeeded in developing and implementing an interactive informational scenario to present the main COVID-19 precautionary measures using the Nao robot. This experience confirms the flexibility of the Nao robotic platform to develop different sequences of behaviours associating the verbal and non-verbal dimensions.iconic gestures  by the robot was limited, we observed that it was possible to compensate to a certain extent for this limitation by trying to use deictic gestures  to elicit the comprehension of the gesture within the framework of a discourse associated with it. In this case, we chose to program the robot to make a pointing gesture associated with the precautionary measure “wearing a mask correctly”, for which the robot showed the mask on its head using its hands. Our study confirms the findings from previous studies that reported the benefits of including different kinds of gestures  to support and enrich the robot’s speech in human–robot interaction (HRI) [However, some technological barriers were identified during the development of the activity. We found it difficult to implement certain gestures for the robot. For example, with Nao having only three fingers, it was not possible to make it wear its mask by itself  or even to simulate the gesture . Although the representation of such on (HRI) .Another important issue regarding HRI was the understanding of the robot by the participants. One person did not find the content  of the activity easy to understand, and 25% of the participants asked the facilitator to repeat at least one instruction. This could be due to the robotic voice itself or to the sounds the robot makes when it moves, for instance when walking or moving its arms. These sounds may obscure the robot’s voice sometimes. These technical problems using robotic applications, particularly regarding speech recognition and production, have already been noticed in previous works ,43,44. FAnother technical limitation was observed regarding the automation of the robot’s dialogues. When designing the activity, an autonomous interaction was planned between the participants and the robot. At the end of the session, the robot asked the participants if they had understood the prevention messages and if they had any other questions. Depending on the answer of the person , the robot had to enunciate a predetermined sentence. During tests conducted in the laboratory, a rather quiet environment, the robot appeared to understand the user’s speech and respond accordingly. However, during a field test in the hospital waiting room, a noisier environment, this autonomous interaction was not possible since the robot could not understand users’ speech. Autonomous interactions were then removed and replaced by moments of improvised speech controlled by the person in charge of the robot .The Wizard of Oz technique, used to control the robot in real-time, seemed effective for small-scale tests, but since it requires the participation of a professional, its use would be expensive for a permanent and/or wider implementation. A suggestion could be to create a digital application to launch the informational script with the complete staging, including the sequences of verbal and non-verbal behaviours, and an option for improvised simple dialogues and gestures. Such an application would allow the implication of a single facilitator instead of two, which could help with a wider implementation of robot-assisted activity sessions.The feasibility of the intervention was also dependent on certain human factors. For instance, the presence of severe neurocognitive disorders in older adults was a limiting factor for their participation in the activity. The researchers stopped the intervention for two persons with major NCDs who did not seem to understand the activity or participate in it in a satisfactory way. This point has already been emphasized by other works ,46, whicSeveral factors favoured the feasibility of the intervention. The activity was carried out in good conditions. The environment was pleasant, calm, and favourable to the performance of the activity . The activity was short and could easily be performed by older adults. As previously shown in the literature ,47,48,49Regarding the acceptability of the robot, the results from the questionnaires and the video analysis showed that most participants from the three groups  appreciated the intervention and showed strong engagement in the activity. Indeed, all the participants had at least one verbal or non-verbal interaction with the robot. Some of them responded directly to the robot by saying hello or greeting with their hands. Others imitated the robot when the latter showed that it was necessary to sneeze into its elbow or even put its mask over its nose and mouth. These verbal and non-verbal responses observed contribute to validating the hypothesis that the use of the robot promotes engagement during health prevention activities. Our results confirm the results of other works as well, which found that the Nao robot captured older adults’ attention and facilitated communication ,30,50. ABefore taking part in the robot-mediated activity, most of the participants in the three groups  declared having learned the COVID-19 precautionary measures by different means. Nevertheless, some persons, particularly older patients (40%), declared a lack of information regarding COVID-19 prevention. Several authors have noted that common disorders observed in older adults  may negatively impact access to and use of health information ,55. SincFor older adults with NCDs, one of the issues that make access to health information more difficult is the use of complicated language and/or many medical or technical terms . D’Cruz We formulated the hypothesis that the activity with the Nao favoured the engagement of the participants in a health prevention activity. Our results showed that participants found that the robot was an enjoyable and engaging tool. Most participants accepted the robot as a mediating tool for the transmission of health information. This kind of support may be useful as well for other audiences with intellectual or developmental disorders who may struggle understanding traditional health information supports ,58.The results of our study showed that humanoid robots, such as Nao, can be used as interactive, engaging, and useful supports to promote health information for older adults. Other technologies have been used to improve health literacy in this population. For instance, some works ,60,61 hadeontological approach for ethical analysis that involves the following three main points: (1) respecting the autonomy and dignity of older adults when implementing robot-assisted care; (2) identifying the risk of deception when introducing care robots that may pretend to be something they are not , making the best to communicate about them in a truthful way; (3) considering the risk of social isolation that the use of social robots may entail for older adults, promoting instead care practices that favour social connectedness.Ethical questions are important and need to be addressed when implementing a robot-mediated intervention in the field of healthcare. A literature review of publications on the ethics of the use of robots for geriatric care  describeThe fact that everyone was free to participate or not in the activity;Each person who accepted to participate in the activity, could decide to interact with the robot at the level of involvement he or she wanted ;The nature of the robotic tool and the presence of the Wizard of Oz person who handled the robot were clearly explained;A methodological limitation in that, overall, ethical issues were not explicitly addressed in the evaluation protocol.In our study, we noted a very limited number of comments by participants linked to ethical issues. Some reasons why these issues were not further discussed or pointed out by the participants may be the following:Nevertheless, one older patient noted that he did not want to trust the robot, a remark that can refer to the first deontological point regarding the respect for the autonomy of the person , but also to the second point, about not considering the robot as a reliable entity. In another case, an accompanying person underlined that the robot should not replace the human presence, illustrating the third deontological point. These views and opinions were heard and respected.Participation in a robot-mediated activity should always be voluntary and enjoyable for the participant. In this study, the free nature of the participants encouraged the respect for the autonomy of the person about his choice of taking part in the activity or not. Moreover, it is worth keeping in mind that the robot-mediated activity was conceived in such a way that the facilitator was highly involved in the scenario. This choice was made to reduce the concerns about the replacement of healthcare workers by robotic interventions. We consider that associating the professional with the implementation of activities using social robots is a key factor for the smooth and respectful integration of this form of mediation into professionals’ care practices. With this aim, the sequences of dialogue and actions in our script were structured to alternate the intervention of the facilitator and the robot. With respect to this point, our study is in line with the “care triangle” approach for robot-mediated care interventions, which we have implemented in a previous work  and thatThe results of this study enabled us to suggest some recommendations for the development and implementation of robot-mediated activities to improve the accessibility of health information for older adults as follows:Preparation of robot-mediated activity sessionsDefine the target population as follows: Inclusion in this kind of activity must privilege older adults who are cognitively healthy or have mild or moderate cognitive impairment, according to the type of information to be provided and the objectives of the activity. The participation of persons with significant communication and/or comprehension impairments should be examined on a case-by-case basis;Identify audience needs as follows: Examine the needs of older adults in terms of health information  and prepare the contents of the message accordingly;Develop HRI scenarios as follows: Develop scenarios combining robot’s speech and gestures. Prepare short, precise, and simple key messages and associate them, if possible, with embodied cues . Sound effects can be useful to encourage participants’ attention and motivation;Preparation of the robot as follows: Program the robot in advance and adapt its voice, speech, and volume for people with potential hearing loss. Make the objects that support the informational message visible and identifiable . Plan to start the activity with the robot located at 2.50 m away from the participant to allow for a gradual familiarisation with the robot’s presence. After introducing itself, the robot can approach the participant to facilitate visual access to the gestural explanations, up to 1.50 m. Before each activity session, verify the technical aspects that are necessary for the correct use of the robot ;Feasibility/acceptability/usefulness testing as follows: Test the feasibility, acceptability, and usefulness of the scenarios with some older adults and implement necessary adaptations to the activity before proposing a large-scale deployment of the activity.Conduct and assessment of robot-mediated activity sessionsCreate a positive context as follows: Create a pleasant atmosphere between the participant, the facilitator, the Wizard of Oz (if available), and the robot.Check consent as follows: Before starting the activity, explain the context and objectives of the session, make sure that participants feel at ease with the robot, and verify that they agree to take part in the activity at its beginning and throughout its course;Facilitate understanding and learning as follows: The facilitator plays a key role in promoting participation in the activity session. To favour participants’ understanding and learning, the facilitator should articulate well and observe a sufficiently slow rhythm, check participants’ reactions to verify understanding throughout the session, and rephrase or imitate what the robot says or does when needed. A few simple questions addressed to participants can be integrated throughout the presentation to keep their attention and to encourage the retention of the message;Assess pre-and post-learning as follows: in cognitively fit older adults who appreciate challenges, assess knowledge in the health domain before and after the robot activity.The study has some limitations that should be considered when interpreting the results. First, although some participants in our study (the older patients’ group) obviously presented cognitive and hearing disorders, the assessment of these health conditions was not performed in our protocol. It is noteworthy that cognitive, hearing, or visual impairments can affect the interaction of users with the robot, influence the activity impact, and, therefore, should be considered in future studies.Second, we did not ask the patients and accompanying persons about their prior experiences regarding social robots. Some participants mentioned that they had already seen the Nao robot on television or in other contexts, but most participants did not comment on this point. Therefore, one cannot exclude that the results showing good acceptance of the Nao robot were biased by novelty effects. In future studies, it would be useful to include questions about participants’ prior knowledge of social robots to assess the potential novelty effect of the Nao robot.A third limitation of our study is that a formal evaluation of health literacy in the domain of precautionary measures in COVID-19 infection before and after the robotic intervention was not conducted. In our study, most older patients declared having understood and learned the prevention-related information during the activity, but one could argue that this positive answer carries a bias of social desirability . Future A fourth limitation concerns the choice of the robot used in this study. The Nao robot is small and, in some ways, fragile. This can present some challenges if used in crowded environments or with a lot of people moving around . In our study, the fact that participants were seated during the demonstration, and that the experience was conducted in a one-to-one or very small group format, ensured its execution without any incidents of this type. However, the implementation of the activity in more complex environments needs to be examined in terms of safety for both the participants and the robot.Finally, in future studies on health information delivery in older adults, we could incorporate artificial intelligence. For instance, the robot could be programmed to verify if the health prevention information has been correctly learned . It would also be useful to develop robot-mediated interventions that convey health information to a wider spectrum of people and regarding other health education topics.Understanding and compliance with preventive measures have been a major issue during the COVID-19 pandemic. The results of this study showed that a social humanoid robot can be used as an innovative communication tool to promote COVID-19 precautionary measures in older adults with and without cognitive impairment. The importance of working to improve health literacy among older adults and individuals with cognitive impairment, intellectual disability, or mental illness is, nowadays, widely acknowledged. This new intervention modality for health prevention can be added to the existing range of accessible support for audiences with special needs.


Live commerce is a phenomenally innovative form of social commerce in China. In this paper, the authors aim to explore the authenticity of live commerce. By employing a qualitative approach using in-depth interviews and grounded theory, 21 initial categories are classified into six core categories. Among them, authenticity-associated concepts are classified into explicit concepts and implicit concepts. Explicit concepts of authenticity are associated with objectively authentic cues, while implicit concepts of authenticity are associated with subjectively authentic experiences. Moreover, the study explores the relationship between explicit concepts of authenticity and product commitment, as well as the relationship between implicit concepts of authenticity and affective commitment. Both of these paths are found to influence consumers' shopping-related behaviors. Although consumers can more easily perceive explicitly authentic cues than implicitly authentic experiences, this study suggests that the latter may be more effective in inducing shopping behaviors. In addition, the effect of streamer attractiveness on opinion leader building is addressed, while authenticity is found to be an alternative approach to attract consumers both for attractive and nonattractive streamers. Finally, the study addresses theoretical implications and practical implications as well as suggestions for future research. According to the 47th survey report of the China Internet Network Information Center (CNNIC), the user size of live streaming in China had reached 703 million as of December 2021, accounting for 68.2% of all Internet users. Meanwhile, the user size of live commerce in China had reached 464 million, accounting for 44.9% of all Internet users. The CNNIC's report summarized three reasons for the rapid development of live commerce in China: (1) local governments encourage the development of the industry; (2) active enterprises provide technical support for the development of the industry; and (3) extensive participation of Internet users accelerates the development of the industry , while Facebook and Instagram are trying to allow users to browse products and place orders directly within their social media he is more beautiful or attractive. Physical attractiveness was found to correlate positively with happiness and self-esteem, especially for women . Authenticity has been an issue for tourism studies for nearly 50 years, ever since MacCannell introduced this museum-related concept into sociological studies of tourist experiences  and professional self-disclosure   is the most popular live-streaming celebrity in China. She has been contributing to charity since 2016 by live promoting agricultural products for villagers and farmers from the central and western provinces of China   was chosen for a number of reasons to explore the authenticity concepts in live commerce , which is enabled by the AI technology to transcribe Chinese speech into text. Although the transcription machine has a very high recognition precision, the textual outcomes were double checked and corrected by a human transcription assistant to increase the accuracy. Finally, the output texts were entered into NVivo 11.0 for further qualitative analysis  will show you the color after using.” Many cosmetic consumers worry about the actual effect on themselves after using the product, even if the advertisement gives a wonderful display. They need to know the details before placing an order. Alternatively, Taobao consumers are used to inquiring about product details from online customer services before shopping. One informant said this is time-consuming. They prefer to learn, feel, and anticipate by following the camera during live streaming. Trustworthiness is the outcome of the expertise and source credibility of the authenticity in live commerce. Therefore, the consumers will increase their product commitment because of the explicit authentic cues.The audience can also perceive the authenticity from scene settings. The authentic scenes and atmosphere involve the audience through the environmental settings attached to the products. Corresponding to existential authenticity, the implicit concepts of authenticity bring the audience into an elaborate atmosphere to connect with the authentic environments, which were classified as the “telepresence experience” in this study.In this study, five categories of telepresence experience were identified, i.e., interaction, physically experiential simulation, telepresence, sense of involvement, and sense of reality. Referring to Wang , existenExplicit concepts of authenticity were more easily perceived by the informants than implicit concepts. The informants had different levels of understanding of the academic term of “authenticity.” We need to explore the dimension of implicit concepts with the help of authenticity theories  was convenient and easy to operate. In addition, the products recommended in streaming are practical and useful. From the perspective of emotional motivations, affective commitment will induce consumers to make purchases. One informant reported that he placed an order because he was persuaded to have a try. One informant also stated that she often made impulsive purchases if she felt good. Another informant stated that she wanted to support the streamer because she knew the streamer worked hard, in a type of supportive purchase.Finally, the core categories of actualization and induced demand are related to shopping behavior. Most consumers participate in live commerce because of utilitarian motivations. One informant said that he could afford the product promoted in the live commerce because it is cheap. Another informant stated that shopping The qualitative exploration in this paper provides a deeper understanding of the influence of streamer attractiveness and authenticity on consumers' purchase intention in live commerce. These insights partially answered the questions posed at the beginning of this paper. Using a qualitative approach, we found that attractiveness indeed has an effect. However, most celebrities tend to present a “homogeneous beauty” to the audience, resulting in “aesthetic fatigue” , Philosophy and Social Science Planning Foundation of Zhejiang Province (Grant No. 21NDJC080YB). This research was also supported by the Special Project for International Student Education & Management Service of Zhejiang Gongshang University and the Teaching Platform Project of Zhejiang Province.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.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.


Clinical data on 61 patients (grouped by their treatment with MVD or RHZ) with glossopharyngeal neuralgia were analyzed retrospectively. A summary analysis of the effective rate and surgical complications of MVD and RHZ in the treatment of glossopharyngeal neuralgia was performed to observe the new surgical options for GN.From March 2013 to March 2020, 63 patients with GN were admitted to our hospital by the professional group of cranial nerve diseases. Two patients diagnosed with tongue and pharynx pain secondary to tongue cancer and upper esophageal cancer, respectively were excluded from the group. The remaining patients all met the diagnosis of GN, some of them were treated with MVD and others were treated with RHZ. The pain relief rate, long-term results, and complications of the patients in the two groups were well-organized and analyzed.Of the 61 patients, 39 were treated with MVD and 22 were treated with RHZ. In the early-stage patients (the first 23 patients), all of them were operated on with the MVD procedure except one patient without vascular compression. In the later-stage patients, MVD was performed for evident single arterial compression according to the intraoperative situation. And for compression of arteries with greater tension or PICA + VA complex compression, RHZ was performed. It was also performed in cases where vessels with tight adhesions to the arachnoid and nerves could not be easily separated, or where it was easy to damage the perforating arteries after separating the blood vessels, causing vasospasm, which affects the blood supply to the brainstem and cerebellum. RHZ was also performed if there was no clear vascular compression. The efficiency of both groups was 100%. In the MVD group, one case recurred 4 years after the initial operation, and RHZ was performed for reoperation. Complications related to the operation included one case of swallowing and coughing in the MVD group, and three cases in the RHZ group; two cases of uvula not centering in the MVD group, and five cases in the RHZ group. There was 2 patients in RHZ group lost taste in 2/3 of the backing of the tongue, though these symptoms mostly disappeared or decreased after follow-up. One patient in the RHZ group had developed tachycardia by the time of the long-term follow-up, but whether it was related to the surgery is still uncertain. In terms of serious complications, there were two cases of postoperative bleeding in the MVD group. Based on the clinical characteristics of the patients' bleeding, it was judged that the cause of the bleeding was ischemia and was related to an intraoperative injury to the penetrating artery of the PICA artery and vasospasm.MVD and RHZ are effective methods for the treatment of primary glossopharyngeal neuralgia. MVD is recommended for cases where vascular compression is clear and easy to handle. However, for cases with complex vascular compression, tight vascular adhesions, difficult separation, and without clear vascular compression, RHZ could be performed. Its efficiency is equivalent to MVD, and there is no significant increase in complications such as cranial nerve disorders. There are few cranial nerve complications that seriously affect the quality of life of patients. RHZ helps to reduce the risk of ischemia and bleeding during surgery by reducing the risk of arterial spasms and injury to the penetrating arteries by separating the vessels due to separation of vessels during MVD. At the same time, it may reduce the postoperative recurrence rate. Glossopharyngeal neuralgia (GN) accounts for ~0.2%−3% of all cranial neuralgia –4. The m* were very similar to those of GN, characterized by severe pain in the right pharynx and tongue root for 3 months. The pain of patients treated with carbamazepine can be partially alleviated. Before admission, the patient had undergone laryngoscopy and CT examination of the nasopharynx and no abnormality was found. When the head MRI showed that there were blood vessels around the right glossopharyngeal nerve, the patient was admitted as GN. After the MVD of the right glossopharyngeal nerve, the pain of the patient was reduced only for 1 day, and the patient could only continue to be given carbamazepine, oxycodone, pregabalin, and clonazepam to alleviate the pain. One month later, the patient found sublingual ulceration and was diagnosed with tongue cancer by pathology  patients felt pain in the external auditory canal, of which only 6 (9.8%) patients had pain in the external auditory canal alone.In this group, oral carbamazepine was used in the early stage. Forty-five patients were on carbamazepine in remission, 35 (57.38%) were in complete remission, and three (4.92%) were in partial remission (decrease in VAS pain score ≥ 3), effective in the early stage (within 3 months) in 7 patients (11.47%). Another 16 (26.23%) took carbamazepine without remission . The sidvia retrosigmoid is adopted, with a horizontal or vertical incision  brain scan. There is communication in detail before the operation, explaining that MVD or RHZ operation may be adopted according to the intraoperative conditions, and explaining the risks of the operation. The patients and their families must fully understand and approve.Microvascular decompression was performed in the early stage. Before patient No. 23, only one patient was treated with RHZ as the exact vascular compression was not seen during the operation. The concept of operation was changed in the later stage, and MVD was generally performed for simple arterial compression. RHZ was applied to patients with high tension artery compression or PICA + VA complex compression, which made it difficult to lift up the blood vessels, risked blood vessels bouncing back to their original position, and relapsed easily. It was also performed on patients whose blood vessels tightly adhered to the arachnoid membrane and nerve and were not easy to separate, or those where it was easy to form an included angle of blood vessels after forcibly separating them, easily damaged the brain stem and cerebellar perforating arteries, easily caused vasospasm leading to brain stem ischemia, and had no obvious blood vessel compression . In thisDuring the operation, we found that the inferior cerebellar artery (PICA) was the most common, accounting for 39 cases, with no definite vascular compression seen in two cases and vertebral artery (VA) compression in eight cases. The anterior inferior cerebellar artery (AICA) compressing in four cases, and the remaining eight cases were combined impressed by the VA + PICA complex.Postoperative pain disappeared in two groups. Two patients in the MVD group experienced postoperative hemorrhage , so urgeThe patients in this group were followed up continuously after operation. As of March 2022, the patients in this group were monitored for between 24 and 108 months. Five patients were lost to follow-up; however, all of them had been monitored for more than 24 months after surgery. The main reason they could not be monitored was death from other diseases or severe disability, or because they were unable or unwilling to participate in follow-up. In the MVD group, one patient had a recurrence 46 months after surgery, and RHZ was performed for reoperation. Patient No. 5 with bilateral glossopharyngeal neuralgia, with the left side being the most severe, and after decompression of the left glossopharyngeal nerve, the patient's pain disappeared bilaterally.One patient with coughing and swallowing problems in the MVD group experienced partial relief 3 months later. In the RHZ group, five patients with uvula deviation improved partially after 6 months of follow-up. In two out of three patients, problems with coughing and swallowing disappeared 3 months later, and one patient's symptoms were significantly alleviated, with only occasional coughing and swallowing problems. The two patients who lost their sense of taste did not feel any confusion.In 1910, Weisenburg  describeGN was often misdiagnosed due to low incidence and clinical uncommonness especially in the early stage of the disease. Patients preferred to seek clinical help in otorhinolaryngology, and many were misdiagnosed with inflammatory lesions in the oral cavity. Nine patients in this group were misdiagnosed with pharyngitis, two patients were diagnosed with hypertelorism, and four patients were misdiagnosed with trigeminal neuralgia. In fact, misdiagnosis of glossopharyngeal neuralgia as trigeminal neuralgia was relatively common because in addition to the symptoms of the two being very similar, there was often an overlap and confusion at the site of the attack . In thisTwo patients excluded from the group were misdiagnosed with primary GN due to esophageal and tongue cancer, and pharyngeal and upper esophageal cancer also displayed a group of lesions that could be easily misdiagnosed as GN, as mentioned in Bharti et al. . TherefoThe age and lateral distribution of patients in this group are roughly consistent with the previous literature , 18. TheMVD was generally performed for treatment in early cases, and individual approaches were used in later cases. The use of the MVD or RHZ procedure shall be determined according to the situation of vessel compression of the patient. In the MVD group, two patients developed delayed hematoma on the second and the fourth day after operation, respectively. It should be noted that the surgeon had previously performed over 1,500 cranial nerve surgeries and had extensive clinical surgical skills and experience. There were only two cases where a late postoperative hemorrhage occurred, one case of facial spasm, and one case of trigeminal neuralgia. In this group, the cases of two patients with a postoperative hemorrhage were probably caused by vasospasm or injury to the penetrating arteries. Both patients with hemorrhages involved the PICA. The PICA had an extremely important role and position among the three arteries of the posterior circulation. The PICA artery was complementary in function to the AICA, and was particularly important because of its proximity to the brain stem, and there were multiple perforating arteries supplying blood . Once thSome studies also reported several patients with GPN caused by an adhesive arachnoid , 25. TheThe operations in the two groups were all effective; the efficiency was 100%. At follow-up, one patient in the MVD group had a recurrence 46 months after surgery and underwent RHZ surgery again. There was no recurrence in the cut-off group at the time of follow-up. Complications unrelated to the operation mode are not discussed here. In terms of complications related to the surgical approach, although the group in which nerves were cut had slightly more dysfunction than the MVD group in terms of non-centralization of the uvula and loss of taste in the posterior 1/3 of the tongue, the patients themselves did not experience any significant dysfunction. Regarding the swallowing function, one case in the MVD group and three cases in the RHZ group had swallowing and coughing problems after the operation. However, after 3 months of follow-up, only one patient in the RHZ group described having an extremely slight cough occasionally, and the other patients had no swallowing or coughing problems. One patient in the RHZ group displayed tachycardia after 1 year of follow-up. Whether this was related to the surgery was hard to determine, and there were no relevant reports in the literature. However, the glossopharyngeal nerve supplies the CB and carotid sinus (1). It conveys chemoreceptor and stretches baroreceptor information centrally for respiratory and circulatory reflex function . This maFor glossopharyngeal neuralgia, there have been different views on decompression or amputation. In a report on a series of 37 patients with GN, 22 underwent MVD, and 15 underwent MVD + GNR. Between the two groups, there was no significant difference in postoperative efficacy, while the incidence of postoperative hoarseness and a cough when drinking in the MVD + GNR group was higher than in the MVD group . In termScranton  reportedRHZ was safer in terms of surgical risk compared with MVD, which included the risk of injury to the penetrating artery, vasospasm, and angulation. These risks may lead to more serious short-term life-threatening complications such as postoperative ischemia and bleeding. Compared with cranial nerve dysfunction, more attention should be paid to risk reduction.Limitations of this study include the retrospective nature of the analysis . Patients were not randomly assigned to a procedure, and there was no blinding of the procedure to clinicians or patients. Indeed, there is a major need for more randomized controlled trials in the neurosurgical treatment of GN, though randomization poses its own challenges. Compared with previous literature, this study showed that RHZ did not significantly increase the patient's extension dysfunction. As for the difference in recurrence rate, a longer follow-up period is needed.We believe that both MVD and RHZ are very effective in treating GN. RHZ did not increase the patient's cranial nerve dysfunction excessively. There was no need to be too concerned about whether there would be neurological dysfunction, but more attention should be paid to the situation of vascular compression, and whether it is easier to separate intraoperatively. In order to reduce the potential risk of delayed postoperative ischemia and hemorrhage as much as possible, we suggest that either MVD or RHZ should be carried out according to the patient's intraoperative compression to reduce the complication.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the patients/participants or patients/participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.LW: responsible for the overall design, data collection, and writing of the article. XD: patient follow-up and communication. JW: responsible for statistical work and article translation. QL: responsible for clinical related work. All authors contributed to the article and approved the submitted version.


Privacy in the context of electronic health records (EHR) is an incredibly complex and multi-faceted topic within the LIS field. We conducted a narrative literature review and selected twenty-five articles published over the past fifteen years, which explore this topic from the perspectives of patients, doctors, medical librarians, informatics experts, records managers, and archivists. We identified themes that appeared consistently across the literature, as well as issues that differed across healthcare systems with varying levels of IT infrastructure. Significant changes have also taken place over time, especially with the development of technologies meant to protect privacy and make the widespread use of EHR possible. However, despite technological advances, many of the same problems of privacy ethics remain. Diverging opinions exist in the literature regarding how, and if, EHR systems should be established in light of these unresolved issues. This has been predicted since the 1960s and 70s when university medical centres began developing EHR systems that were a hybrid of digital and paper records systems [Health records have moved from the basement storage room under lock and key of major hospitals to digital clouds and hard-drives to increase accessibility and utility. Electronic health recordsOne of the most profound impacts of EHR is the delocalization of health records, and quick delivery of information to any medical site . Other cWe performed a narrative review with the aim of having a broad array of sources from a variety of viewpoints, and from different countries. We selected the articles for our literature review through searching the databases: Library and Information Science Abstracts (LISA), and Library, Information Science and Technology Abstracts (LISTA). We chose these two because they are the most popular databases for Library and Information Science literature.Similar to other traditional literature reviews, we did not use an exhaustive list of conceivable terminology or databases for the literature search. Instead, we opted to use the most relevant search terms to provide a general review of the subject. The Boolean OR functions allowed for the broadest possible recall of the two main concepts, which we hoped would provide a higher recall of results for our overall search. We combined the first concept, , with the second concept, , using the Boolean AND function, so that the overall search would specifically retrieve literature containing both core subjects.We restricted the results to the last fifteen years, from 2005 to 2020. We chose this date range because we wanted to represent and review recent literature, but we also wanted sufficient time depth to be able to analyze how the issues have developed over the years, as well as observe trends and changes. The starting year of 2005 was selected because EHR began to receive national attention and feature in federal policy in the United States, where the majority of selected papers originate. The authors agreed that limiting results to the last five or ten years was overly restrictive, and would ignore the time depth of the issues, and how they have evolved with technology.We selected a total of twenty-five articles to review, which came from a variety of countries, including Canada, the United States, the United Kingdom, Germany, Sweden, India, Iran, Zimbabwe, Uganda, Australia, China, and Singapore. We decided to include literature from around the world, because we consider health information to be a universal need, and recognize that research on the topic of privacy and EHR has been conducted around the world. Because of the universal aspects of health information and privacy, it was appropriate to include studies from multiple countries, in order to identify commonalities and differences, and to present a more complete review of the literature on this topic.Although a certain degree of selection bias is inherent in the process of choosing literature for a review, we aimed to provide a fair representation of how EHR and privacy have been researched in the LIS field, and the ways this has changed over time. We selected an approximately equal number of articles from LISA and LISTA, to avoid any biases that could arise from LISTA's stronger technology focus. We included papers about specific technologies, security analyses for existing EHR systems, articles focused on ethics, qualitative studies of patient and healthcare provider communications, as well as archival and records management papers. Although the papers we selected represent diverse perspectives and areas of research within LIS, they all share electronic health records and privacy as their core themes. We excluded articles that were outside of our date range, and that only focused on one or the other theme (only privacy or only EHR), because these were outside of our review’s purview.One of the most consistent themes across the literature is the potential of EHR to revolutionize multiple aspects of healthcare. This can be seen in the majority of articles in this review. In many of the articles published between 2005-2015, the role of information in 21st century healthcare is the main focus. Many of these papers describe how an EHR system can improve how patients are diagnosed and treated, and improve healthcare delivery in emergency rooms [McClanahan 2008) describes how quick access to medical records through a universal EHR system could save thousands of patient lives each year in emergency rooms, due to a reduction of medical errors . Other a008 descrDinh-Le et al. (2019) note how EHR in the United States are overwhelmingly provided by private vendors, such as Epic, Cerner, and Meditech selling directly to doctors and patients. This paper focuses on wearable EHRs, and states that “a secure network, separate from the main hospital network, would need to be established to protect the privacy of wearable EHR” . A task Patient and doctor communications in the context of EHR is another distinct theme that emerges in the literature. Baskaran et al. (2013) explore staff concerns about EHR, privacy, and patient consent at a maternity hospital in the United Kingdom. An EHR system for patient records could improve health outcomes and provide a means to assess healthcare quality for mothers on a national scale. However, the staff surveyed by Baskaran et al. express concern over the fact that sensitive health information could be illegally accessed by hackers . This woCampos-Castillo & Anthony (2014), Patel et al. (2015), and Walker et al. 2017) all focus on how patients perceive the privacy of EHR, and how this influences their communication with their doctors  all focu. They exConcerns about EHR privacy are not only held by patients, but also by healthcare providers. Risks to patient-doctor confidentiality is cited as a drawback by Furusa & Coleman (2018), as well as by Shahmoradi et al. (2017). Doctors and other hospital staff interviewed in both studies expressed concerns over patient privacy risks, as well as the possibility of EHR disrupting normal workflow ,12. HoweA third theme that appears is technology advancements to improve EHR privacy. This is especially prominent in the more recent literature (2015-2020). A variety of information technologies and strategies are presented. Vimalachandran et al. (2016) propose a hierarchical role-based authentication for EHR, which allows different levels of access to different roles within hospitals. This would reduce the risk of data leaks by restricting those who are not the patient or a medical professional from accessing the record . Alaqra A study similar to Alaqra et al.’s (2018) paper is by Rodrigues et al. (2013). Both studies examine ways to improve security for EHR stored on the cloud. Public and private key encryption, as well as role-based authentication are presented as possible solutions , 15. CloHylock & Zeng (2019) write about ways to enhance the privacy of EHR through public and private key encryption. They propose blockchain as a way to store vast amounts of data while encrypting it. This could prevent information leaks resulting from unauthorized access. This study notes the potential of blockchain technology to improve privacy through detailed, public tracking of access. This could theoretically advance privacy beyond even paper records . HoweverHong et al. 2018) review the issue of big data in healthcare around the world, as well as the privacy issues arising from big data EHR systems. They discuss a variety of challenges, including the difficulty of sharing medical information between hospitals in China, controlling EHR access in the cloud, ethical questions of using EHR for population health research, and practical questions of storing unprecedented volumes of data [ review tDuan et al. 2020) develop a mathematical algorithm to transfer health data from EHR while keeping patient information private. They demonstrate how this algorithm could allow for large-scale statistical analysis of EHR data for health research . Another20 develoA final theme emerges in the LIS literature in the question of EHR ownership. The utility of EHR over the years have expanded beyond the delivery of healthcare itself, to include the ability to analyze population health through data analysis and informatics. Hong et al. 2018) explore how EHR can be used to study population health and epidemiology  explore . HoweverThe article by Dong et al. does not focus on the ownership question explicitly, because it is an archival paper, which focuses on historical patient records and the potential benefits of digitizing them . HoweverA paper by Chorley (2017) illustrates the ethical conundrum when a government owns hospital data, including EHR, and has the right to publish such data on the internet through Freedom of Information laws . The greUncertainties around privacy obligations complicate the question of ownership. Tardif (2020) discusses the complex responsibilities of “healthcare information custodians” . He descA unifying opinion among the reviewed papers is the potential for the improvement of healthcare by the further development and implementation of EHR. However, EHR is fraught with both technical and privacy ethics limitations, which complicate its realization across different countries and healthcare systems. EHR requires a relatively strong and robust IT infrastructure in the hospital it is being implemented in; something not always available in developing economies . AdditioEHR has an inconsistent implementation across countries, partially due to variations in cultural attitudes on information collection and privacy. This extends to societies with the same laws governing information and privacy protections such as countries in the European Union. In Sweden there are higher levels of trust and implementation of EHR. However, in Germany there are lower levels of both patient trust in EHR and medical professionals’ confidence in them . This hiAnother challenge that arises in the research is the resistance to EHR by both patients and medical professionals due to privacy concerns. The concern over privacy is a consistent and unifying feature in all papers in this review. There are significant ethical questions as to how much, and whether, patient privacy is worth risking. There appears to be a general consensus that accurate, accessible and detailed records have an inverse relationship with privacy. Although technology has advanced enormously over the past fifteen years, leading to improved data capacity and security measures, nearly all authors of the included papers acknowledge that the privacy risks of EHR is never zero. As a result, privacy remains the most significant barrier to a universal EHR system. It will be interesting to observe how privacy technology continues to develop over the coming years, and if privacy can be sufficiently protected to allow for such a system.The question of EHR and ownership is highly complex, and has significant implications for privacy and ethics. We believe this is an area of the literature that merits further research. Firstly, the ownership of individual EHR brings up questions of content control and accuracy. One of the clear benefits of EHR is the facility of transferring information. However, maximum benefit from this requires the health information itself to be accurate and complete. In the literature we reviewed, there was limited discussion of the problem of human error, and how potential misinformation, including misdiagnoses and doctor bias, could be transmitted through EHR. This is one potential problem that can arise through hospital or clinic ownership of EHR. Further, patient ownership could create other problems, such as critical information being altered or removed due to patients misunderstanding of specialized medical terminology , 23.Another challenge of ownership is the fact that many modern-day EHR are dependent on privately owned software and hardware to store, format and encrypt them. Problems arise when the technology necessary for any of these functions becomes obsolete or otherwise inoperable. For example, EHR being formatted and encrypted using a proprietary file format are vulnerable to its creators being unable or unwilling to provide updates to keep the files up-to-date. The company could move away from the service or go out of business, leaving institutions vulnerable to data loss. Furthermore, flaws in the software or hardware can lead to a loss in the integrity of the data, or exposed security risks leading to the loss of records. The question of ownership and content control should be further explored, as this has major implications for privacy.Finally, the ethics of secondary uses of EHR data deserves greater attention. EHR has excellent possible applications in medical history and epidemiological research. However, given that laws vary between countries and in their protections for patients, there exists a temptation to use personal health data for commercial purposes. An example of this is a 2019 story by the Toronto-based newspaper, The Toronto Star. The article describes the sale of patient medical records to an American health data company. This resulted in an investigation by The Office of Information and Privacy Commissioner of Ontario . The secThere are limitations to this review. This review relied entirely on the two databases LISA and LISTA, and used a limited set of search terms that may have unintentionally left out relevant and meaningful research that has been conducted in this field. Additionally, all articles selected were written in English, thus excluding a variety of insightful works in other languages. In addition, despite the international focus of the review, there is no direct representation of EHR in Latin America.EHR is and will continue to be used in healthcare, and has the ability to advance the health field in a multitude of positive ways. However, its status, use and limitations, especially regarding privacy, are far from certain. Healthcare and information professionals are grappling with complex questions regarding the benefits and risks of EHR. It is clear that for EHR to be most effective, it comes at the cost of patient privacy rights and exposes patients to the consequences of security breaches. In this paper, we identified how EHR and privacy link to complex issues of communication, technology, ownership, and the future of healthcare information. We hope that this literature review will provide insight into how EHR and privacy have been studied in the LIS field, and impart an appreciation for the complexity of these issues. Although these themes are multi-layered and ethically deep, they are fundamentally of interest not only to health and information professionals, but also to interested patients, the general public, and for policy makers grappling with this issue.


OSAHS is an important disease in current medical settings because of its association with chronic cardiovascular diseases and socioeconomic impacts.to establish the correlation between the Friedman Classification and the OSAHS severity through the Apnea-Hypopnea Index) in patients with OSAHS for assessment and surgery purposes.Cross-sectional study. We evaluated and classified 143 patients, using the Epworth's and Friedman's scale and OSAHS severity according to the AHI.112 patients were submitted to polysomnography. We compared the Friedman Score and the IAH. The variables were associated with p<0.05. We found that patients with light OSAHS, tended to have a lower Friedman classification . By the same token, patients with moderate to severe OSAHS had a greater prevalence of Friedman's score of III and IV; p< 0.05 .We conclude that the Friedman's classification correlates with OSAHS severity - the higher the Friedman's score, the more severe is the OSAHS. SOAS (Sleep Obstructive Apnea Syndrome), described in 1973 by Cristian GuilleminaultThe physiopathology of OSAS is still unclear. During apnea events there is a drop in oxygen saturation, causing the activation of pressure-reflexes, triggering a widespread activation of the sympathetic autonomous nervous system. There is an adrenergic flow causing peaks of tachycardia and hypertension. This process repeats many times during sleep in apneic patients and, in the long run, it causes high sensitivity of the peripheral chemoreflex, with an exaggerated response, even during normoxia, pressurereflex dysfunction, increase in adrenergic burden, long term cardiovascular dysfunction, systemic inflammation and metabolic deregulation with insulin resistance and type II diabetes mellitusSOAS involve the obstruction of the upper airways (UAW) during sleep, causing apnea events with respiratory distress, being extremely important to establish the point of UAW obstruction in the assessment of patients with SOAS. In 1981, Fujita et al. created a classification for the UAW obstruction pointMore recently, the Friedman classification has been used to assess oropharynx obstruction, assessing tonsil size, the Modified Mallampati Classification and the BMI varying between 1 and 4. This classification has been broadly used in most of the snoring and sleep apnea wards. It has a well-defined prognostic value in the literature: the higher the Friedman classification, the lower the success of uvulopalatopharyngoplastyTo establish the correlation between the Friedman Classification and SOAS severity by means of the HAI (hypopnea and apnea index) in order to assess and treat patients with sleep apnea.This study was approved by the Ethics in Research Committee, under protocol # 113/08 and it was duly registered in the Clinical Trials Registry under ID NCT00883025. 143 patients with complaints of snoring and clinical history suggesting sleep apnea and symptoms of daily sleepiness, non-resting sleep and snoring were assessed in the SOAS Otorhinolaryngology Ward. All the patients were submitted to an assessment protocol, including interview, Epworth's scale, snoring subjective scale, Friedman's classification and complete otolaryngological exam .Table 1DThe Friedman's classification is used to assess: palatine tonsils; modified Mallampati score and BMI (body mass index). This way, they are classified in four stages . Patients with the lower Friedman's stage have a greater chance of success after uvulopalatopharyngoplasty in the treatment of SOASThe patients were submitted to nasofibroscopy with a 2.8mm Mashida scope. The test was done with the patient awake in the ward. We did not use vasoconstricting agents to assess the nasal cavity. After nasal cavity analysis, we did pharyngoscopy and a dynamic laryngoscopy.All the patients were referred to polysomnography in the sleep lab. The participants were submitted to nocturnal polysomnography and full monitoring of the following channels: eye movements, leg movements, nasal airflow, chest movement, EEG, EKG, heart rate and oxygen saturation. The patients were broken down according to disease severity, following the criteria agreed upon by the American Sleep Association Task Force1. We took off the study those patients with craniofacial changes.Of the 143 patients in the protocol, 112 were selected for the study and 31 were taken off the study for matching the exclusion criteria: not having a polysomnography study or for having an incomplete protocol. Distribution as to disease severity, in accordance to the criteria established by the American Sleep Academy Task Force1 is depicted on All the patients in the initial evaluation were assessed and classified according to the Friedman classification, which results are shown on SOAS classification and the Friedman classification were assessed in graphic cross-plotting and chi-squared statistical tests, with significant statistical correlation with the chi-square test by means of the linear association with p < 0.05. Result acquired by the analysis of the SSPS version 12.0 statistical software.The literature shows numerous surgical treatments for SOAS. Most of the literature studies show that the rate of improvements of HAI is between 45 and 90% with uvulopalatoplasty or pharyngoplasty as described by Hicklin et al.It is important to notice that there are only a few studies in the literature using only one type of surgery. In the study carried out by Jones et al. there are 151 cases reported, however with three types of surgical procedures, without mentioning a specific protocol to screen patients for surgerySOAS is a disease of airway obstruction with neuromuscular alterations, and a surgical approach must be indicated in order to correct the specific obstruction point and then obtain better results. For this reason, we carried out an association study between Friedman's classification and HAI. We considered important parameters in the evaluation of patients with SAOS. Video-nasofibroscopy is very important in the evaluation of the obstructive sites in the upper airwaysWe found a relationship in which patients with mild SOAS tend to have a lower Friedman score and, therefore, better surgical resultsThe best results are obtained through a prior study, and patients must be always informed of their chances for improvement and the side-effects of uvulopalatopharyngoplasty - soft palate failure and dry mouthPrior patient study is of easy clinical applicability. Friedman recently published a study showing that the Friedman classification has a high inter-examiner correlation, being useful to assess patients in research and teaching settingsThese results point to the importance of a proper UAW investigation in the pre-op evaluation of all patients with SOAS. Patients must be assessed considering a series of variables. Friedman et al. showed that the Friedman classification is better than HAI in the prediction of uvulopalatopharyngoplasty successSOAS is a disease which mainly affects the upper airways with numerous intrinsic and extrinsic factors associated to its appearance. We then conclude that the Friedman's classification is correlated with HAI. The higher the Friedman score, the greater tends to be the apnea severity. This correlation is extremely useful in the preoperative evaluation of patients with SOAS concerning surgical indication criteria, and long term follow up is necessary.


Introduction: Recently, we developed a home-based, minimal-equipment exercise training program HOMEX for people with chronic obstructive pulmonary disease (COPD) and tested its effectiveness over 1 year in a randomized controlled trial. The aims of the current study were to evaluate the implementation of HOMEX from the perspectives of all involved persons and to optimize the program to ensure its long-term sustainability.Methods: In this mixed-methods study, we used qualitative and quantitative approaches to evaluate the implementation of the intervention on the level of patients with COPD and coaches who provided the intervention and relevant stakeholders. To assess the implementation outcomes dose, reach, fidelity, and adherence, we summarized information recorded in the notes of the coaches and the diaries of patients, complemented with results from qualitative assessments. To assess acceptability and appropriateness, we conducted surveys with patients and coaches, and semistructured interviews with selected patients, coaches, and stakeholders.Results: The coaches delivered the three home visits with one exception according to the protocol (fidelity). Of the 53 intervention group participants, 37 (70%) conducted HOMEX training until the end of the study and 43 (79%) trained for at least 10 months. The exercise behaviors of the participants could be separated into the phases “Starting the training and stabilizing into regular training routine” and “Managing training disruptions” (adherence). Overall, patients, coaches, and stakeholders conveyed a very high “acceptability” of HOMEX, noting the home-based aspect as a particular strength and interaction with other patients as future need. All involved groups perceived the strength-training exercises as appropriate, efficient for people with COPD, and relevant to maintain improvements after pulmonary rehabilitation. The most important facilitators of the patients for long-term motivation were self-perceived improvement in strength, supervision by a coach, and integration of the training in daily routine. Based on these insights, we redesigned and reworded the exercise cards, introduced three new exercises, and refined the training book.Discussion: The results of this study provided insights of the involved persons in the frame of the HOMEX intervention implementation with a particular focus on the long-term training behavior of the participants and their perception and experience with the exercise program. These findings enabled us to optimize the training material and adapt the structure of the program for sustainable further use in clinical and other settings. Exercise training is a central component of pulmonary rehabilitation (PR) , 2. It iAgainst this background, we developed the HOMEX (HOMe-EXercise) strength training program for patients with COPD . We deliIt is a great challenge in healthcare research that innovations and interventions often do not find their way into clinical practice or the daily lives of patients after they were developed and initially tested in trials. With this study, we addressed exactly this gap. We aimed to thoroughly evaluate the implementation of the HOMEX exercise program in the frame of the HOMEX-1 RCT over the course of the study year and subsequent months, considering the perspectives and experiences of the involved persons, and potential future providers. Specifically, we aimed to capture and describe how the intervention was delivered, accepted, and perceived. A particular focus was to gain insights into the motivation of participants to maintain long-term training and into the relevance of different intervention elements. The results provided guidance to optimize the program materials and to ensure their further use and long-term sustainability.In this mixed-methods study, we used qualitative and quantitative approaches to evaluate the implementation of the HOMEX intervention from the perspectives of intervention group participants, the coaches who provided the intervention, and other relevant stakeholders, such as healthcare professionals from the involved rehabilitation clinics and potential future providers. The design was guided by the Medical Research Council (MRC) guidance on the process evaluation of complex interventions  as overaThe HOMEX exercise training program was developed by our interdisciplinary team  tailored to persons with COPD. It includes whole body exercises, i.e., trunk, upper limb, and lower limb exercises, modified in three different intensity levels as well as general warm-up and specific stretching exercises. The program is home-based, requires only minimal equipment (a chair and elastic bands), and can be conducted in either seated or upright positions. It was designed to be easily integrated into daily routines over the long term by developing habits to trigger daily completion. It is performed 6 days a week for about 20 min daily . Thirty-eight thoughtfully designed, high-quality illustrated training cards  or control group . Assessments took place in the clinics before randomization and after 1 year. The HOMEX coaches who delivered the program were healthcare professionals from the clinics specifically trained by the master coach (KDL) during a basic training and an update session a few months later . The master coach accompanied all coaches once at a home visit to ensure the intervention was conducted according to the protocol. During the time of the intervention, the HOMEX coaches were provided with “HOMEX-magic,” an email exchange system moderated by the master coach, to connect and exchange experience and to get support. More detailed information is provided elsewhere .The current study addressed three groups of persons who were involved in the program. On the part of the patients, we addressed persons who participated in the intervention group of the HOMEX-1 trial. Out of those, we additionally selected participants who did not prematurely stop the intervention for in-depth interviews. Second, we addressed the HOMEX coaches who delivered the intervention. Finally, we addressed relevant stakeholders. These stakeholders represent persons who would be responsible for implementing HOMEX in rehabilitation clinics and other settings.To review how the intervention was delivered in practice, we assessed “dose” (the quantity of intervention implemented) through the reports of the coaches regarding the number and duration of home visits and telephone calls and the materials delivered to each participant. “Reach” (the extent the target group came into contact with the intervention and how) was summarized by results from the qualitative assessments with patients. We assessed “fidelity” (whether the intervention was delivered as intended) by comparing the planned and implemented intervention elements . The “adherence” of patients to the intervention was assessed through daily training records, training breaks, and set and reached goals and rewards. We classified a week to be “adherent” if the participants conducted at least two exercises on 3 days of the given week. We crosschecked the entries of the patients with the protocols of the coaches and reported (serious) adverse events which prevented the participants from training.At the 12-months follow-up visit of the HOMEX-1 trial, the intervention group participants filled-in a satisfaction questionnaire and we conducted a short interview with them (most of these results presented in the HOMEX-1 RCT manuscript on effectiveness). Based on these insights, we developed an interview guide and conducted semistructured in-depth interviews with selected participants to investigate “acceptability”  and “appropriateness” . Many COPD patients suffer from comorbidities and usually experience limitations due to COPD and other health problems, which make training challenging. Our main aim of the in-depth interviews was to get insights on the long-term motivation and on how the participants succeeded in coping with difficult times and maintaining the training. Therefore, we included persons who did not prematurely stop the intervention before the end of the study and consecutively asked participants from the clinics whether they agreed to the interview. In addition to their long-term motivation, we also explored participants' reasons for participation, expectations, and feedback on the overall structure of HOMEX and specific program elements . We supplemented the feedback on the program elements with results from the satisfaction questionnaire filled-in by all participants at RCT end regarding the assessment of the specific features of the program and the most helpful elements for training support (results not presented yet).All the 12 involved coaches completed a written questionnaire regarding their experiences and satisfaction with the program, their assessment of specific elements , and their opinions on further delivery of the HOMEX-program. We then conducted semistructured interviews with the seven most involved coaches to gain deeper insights and to optimize the program elements and materials. For the interview, we selected those coaches either who coached at least five patients or who had additional coordination and supervising roles in their clinics and for the HOMEX-1trial. Finally, we conducted semistructured interviews with six stakeholders who represent current and potential future providers of the program. We selected, on the one hand, the responsible healthcare specialists from the participating rehabilitation clinics and on the other hand persons from other Swiss healthcare settings who could be the future provider of the HOMEX intervention. We aimed to learn about contextual factors and to plan concrete sustainable maintenance and further implementation of the program in different settings. Coaching protocols and questionnaire data were descriptively analyzed and responses to open-ended questions were categorized by conventional content analysis . ResultsThe adherence patterns of participants were identified through an adapted “grounded visualization” approach proposed by Knigge and Cope . This apThe in-depth interviews with the participants were recorded, transcribed by a professional transcriber verbatim, and deidentified. We analyzed the material through qualitative content analysis using mixed deductive and inductive approaches . We firsThe semistructured interviews with the coaches and stakeholders were recorded and analyzed by conventional content analysis  and then1) in percent predicted was 41.8 (SD 15.3). All participants suffered from comorbidities. On an average, they reported 4.0 (SD 2.1) comorbidities, most frequently cardiovascular and musculoskeletal diseases. Participants were recruited from the inpatient setting after completion of PR, with one exception (outpatient setting). Overall, 37 (70%) participants performed the HOMEX training until the end of the study (12 months), and 42 (79%) trained for at least 10 months. Sixteen participants stopped the training on average after 28 weeks (SD 14.6), 11 due to health reasons . Four stopped for other reasons , and one person did not start the training at all.Fifty-three out of the 61 intervention group participants who were included in the HOMEX-1 trial completed the 12-month follow-up assessments. Of these, 49% were women. The average age was 66.2 (SD 8.2) years and the average Forced Expiratory Volume in 1 second  out of the 37 persons who did not prematurely stop the intervention. Except for one interviewed person, all experienced weeks with bad health conditions when they could not train during the year.n = 9), sports scientist (n = 2), and study nurse (n = 1). All the 12 coaches filled in the written questionnaire. We conducted interviews with seven coaches; two coached at least five patients and five had additional supervising roles in their clinics and for the trial. We interviewed six stakeholders, three from the participating rehabilitation clinics  and three from other settings . Due to his function in the clinic, one person was interviewed as a coach and as a stakeholder.Twelve healthcare professionals coached between 2 and 17 patients with COPD in the HOMEX-1 RCT. Their age range was between 25 and 53 years. Ten coaches were women (84%), and five coaches also held the function of the study nurse within the trial. Their professional backgrounds were physiotherapist  phone calls. Their average workload for the whole intervention was 833 min/participant , divided as follows: Home visits: 277 min (92.3 min/visit), calls: 208 min , travel to home visits: 265.5 min (88.5 min/visit), and administration work: 82.2 mi. All the 53 participants received three elastic bands with varying resistance levels, exercise cards, and the training book. Upon request, six participants received an additional elastic band with a higher resistance level, and one participant received an electronic file to report the training in addition to the training book.The qualitative analyses of the interviews with the nine patients revealed that their main reasons for participation were to improve their health, particularly their strength, and that experienced changes and improvements during PR triggered their decision. The majority of the persons had expectations regarding the specific HOMEX exercises and assumed them to be similar to the ones learned during PR. Others had no expectations. The opportunity to continue training with additional supervision by a professional was an important motivation to take part in the study. Usually, patients are discharged from inpatient or outpatient PR with an exercise plan but without supervision  were provided according to protocol.From the side of the patients, adherence to the intervention was generally high. We excluded the person who did not receive any home visit and did not start with the training from the adherence analyses. On average, the 52 intervention group participants who completed the T4 assessment were adherent for 37.8 weeks  and experienced health-related training disruptions during 6.6 weeks . In weeks the participants trained, they completed on an average of 16 exercises in total, which sums up to ~80 min of exercise training per week, excluding the warm-up, and stretching exercises.n = 20), or take a few weeks to “find their rhythm” (n = 31), exhibiting increased variability in training practices during the first 2 months of the program. Most participants reached the point of “stabilization,” in which exercise behaviors leveled off and became consistent for months at a time. If training of the participants did not stabilize within the first 2 months of the program, they were more likely to quit the program prematurely (OR [95% CI]: 11.46 [1.88–91.48]). Participants who stabilized generally either maintained a training routine until the end of the program or exhibited a sudden, complete discontinuation of their training for health or personal reasons.The grounded visualization analysis suggested that the exercise behaviors of participants could be separated into phases: “Starting (and restarting)” training, “stabilizing” into a regular training routine, and “managing disruptions” to training . When stn = 6). Participants who were able to restabilize their training either did so at their “original training level” (58 observations) or at a “reduced or adapted training level” (18 observations). Reduced or adapted levels typically followed serious illnesses or medical procedures, especially those that limited the function of one part of the body and precluded certain types of exercise. Detailed visualizations of the contextualized annual training of the participants are provided in the Participants regularly experienced potential disruptions to their training, including illnesses, COPD exacerbations, medical procedures, and vacations. Participants either “maintained” their training level despite the disruption (13 observations), “experienced a dip” in their weekly number of exercises (51 observations), or “stopped their exercises” altogether (36 observations). Restarting exercise following a disruption followed similar patterns to those exhibited at the onset of the program. Occasionally, disruptions resulted in complete, abrupt discontinuation of exercise (n = 53) showed that they rated as most crucial feature of the program  that the exercises were presented on cards and not electronically by DVD or video . This was followed by the issues that the training was home-based , that the exercises were adaptable to their current health state , and that only minimal equipment was required . The participants rated the home visits , the phone calls by the coach  and the exercise cards  as most helpful elements to support them to train, and as less important setting monthly  and weekly  goals and contacts with the sparring partner .The results of the satisfaction questionnaire filled-in by all intervention group participants at the end of the RCT  facilitated training since it was not perceived as too time-consuming. The missing group component was a perceived barrier of HOMEX. Facilitating factors regarding the exercises were that they were easy to learn and adaptable; the majority of the interviewed patients found it very helpful that they could modify the exercises according to their current health status. On the other hand, the perception that the exercises were too easy was also a barrier. Less frequently, exercises were perceived to be as too strenuous.As suggestions to adapt the structure and exercises of the HOMEX program for future implementation, the vast majority of the participants proposed to start the training in the clinic during PR. Some suggested having group sessions or at least to start the training together with other participants to encourage exchange. Others would have liked to receive new exercises and regular updates on HOMEX. Those participants who assessed the exercises as too easy would have found it helpful to get more difficult options. A few participants specifically asked for endurance and breathing exercises .The participants had only positive experiences with the coach's support. For most of them, their coach was important to modify the conduct of the exercises, to instruct them how to correctly execute the exercises when they were unsure, and to answer questions. They perceived the three home visits as appropriate. For most, the phone calls were motivating and informative but the 17 pre-arranged calls were too many or not always needed. For the future, they suggested not offering pre-arranged calls but instead the possibility to contact the coach from their initiative.Regarding the training material, they highly appreciated the training cards and judged the description and the illustration as most important which allowed them to compare themselves with the picture and to check whether they were executing the exercises correctly. They had no suggestions or ideas for changes. The training book was perceived more ambiguously. Many participants found the reports of the daily training and weekly goals and rewards bothersome over the course of the year and more useful for the study than for themselves. However, for many patients, the training book was helpful to organize and structure the training week. For future changes, most participants suggested simplifying the training book and dropping the weekly goals and rewards .The questionnaire results  revealed that the coaches' overall impression of the program was very positive  and that they assessed HOMEX to be an efficient strength training program for patients with COPD . As most relevant elements for the effectiveness of the program, they rated the personal coach , the exercise cards , and the home visits , followed by the calls , the training book  and the monthly and annual goals . The relevance of the sparring partner was very differently perceived among the coaches . The setting of weekly goals was regarded as less important or even annoying or disruptive . Almost all coaches liked to work as a coach , the more patients they supported the better they liked the work overall.The interviews with coaches showed that they perceived HOMEX to be suitable as a follow-up program to PR in order to maintain or build upon training gains. As major advantages, they described that the program is individually adaptable, that it bridges the end of the rehabilitation with daily life at home, that the exercises are simple and embedded in a coaching program, and that the program has a long-term character. Overall coaches faced a need to provide patients with home-based and individually adaptable exercises after PR completion. They specifically highlighted the importance of the first home visit and the necessity to invest enough time and effort, in order to build up the personal relationship with the patients and to learn about the concrete environment, which were both essential for the further course of the coaching. As limitations, they experienced the missing endurance and breathing parts. Summarized, the coaches perceived that HOMEX closes a gap in the Swiss health system.We gathered further profound results regarding the coaches' general role, facilitators, and barriers of their everyday work, insight into how to cope with training disruption, their training and coach materials as well as the specific program elements and target population, not described here. However, based on all the coaches' experiences, we redesigned and reworded the exercise cards, introduced three new exercises, and refined the training book. In addition, this input informed the adaptation of the coaches' education and training manual and program.www.myhomex.ch, was developed after the onset of the Corona pandemic in spring 2020 when people were advised to stay at home whenever possible). In summary, the relevant persons from the PR clinics perceived HOMEX as an optimal supplement of their current offers, meeting the needs of a part of the patients. Suggestions to improve sustainability in the long-term were to reduce the number of home visits and calls, to introduce the web-based myhomex version during the inpatient time in the clinic, to start negotiations with health insurances for reimbursement, and to learn more about which patients adhered to and benefitted from the program. The results of the interviews with three additional health professionals who work in institution, which are potential new providers of HOMEX, were used to further develop the implementation of the program in their setting, and the detailed results are not described here.All three stakeholders from the rehabilitation clinics valued HOMEX very highly, particularly because it is adaptable in terms of volume and intensity, offers a unique way for training at home for patients who cannot leave the house, which was accentuated in times of the Covid-19 pandemic, and because the patients liked it. They rated the home visits as an important part of the program to support patients in implementing the concrete exercise in their usual environment. They perceived opportunities to supplement the HOMEX exercise program with PR elements such as self-management strategies to cope with symptoms, self-medication, breathing techniques, or exacerbation education. At the same time, the personnel cost and time required for the home visits, the fact that these costs are currently not refunded in a standardized way in the PR setting by health insurances, and that the inpatient clinics do not have a mandate to treat patients at home were reasons why HOMEX could not be offered as a complete program in the clinics after the RCT completion. Currently, the physiotherapists involved in the trial instruct single HOMEX exercises and offer the video-based my HOMEX program to patients for their home training after discharge  in the community setting, where it will be provided to persons with COPD by a half-day-exercise training course and subsequent home visits by a trained nurse. Finally, the web-based myhomex version is promoted in collaboration with Senior Citizen's University of Zurich and the Prevention and Health Promotion Canton of Zurich to their members and senior citizens in general, respectively. The Covid-19 pandemic increased the demand for home-based programs.The strengths of this study are that we took the perspective of all involved persons into account, which provided an overall picture of the program from different angles. Of particular value is the assessment and visualization of the daily training behavior of participants during 1 year, considering also several context factors that allowed a unique insight into long-term training patterns and disruptions. Furthermore, the study allowed insights into the long-term motivation of the participants. Finally, the study team comprised persons with different professional and scientific backgrounds who integrated several methodological approaches.One limitation of our study is the generalizability of the results. Our patient population included, with one exception, persons who were recruited during inpatient PR. It remains unclear whether persons who completed outpatient PR who are usually less severely ill would have behaved and perceived specific elements differently. Moreover, we do not know whether and how the intervention works in people who did not follow PR at all. The results of the HOMEX-2 RCT will presumably answer some of these uncertainties. In addition, we focused on the in-depth interviews of persons who did not prematurely stop the intervention, since our focus was to get insights on their long-term motivation. We consecutively asked participants from the clinics whether they agreed to the interview. This might have introduced selection bias of including more healthy people because some participants already died in the meantime, and of persons who were motivated to conduct the interview. Moreover, targeting participants who did not succeed in training in the long-term would have allowed going more deeply into the underlying mechanisms of training disruptions.With this study, we went beyond the effectiveness analyses of the HOMEX exercise program. The results provided unique insights of the involved persons, with a particular focus on the long-term training behavior of the participants and their perception and experience with the exercise program. These findings enabled us to optimize the training material, rethink the structure of program, and adapt the program for sustainable further use in clinical and other settings.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Kantonale Ethikkommission Zürich Stampfenbachstrasse 121 8090 Zürich, Switzerland. The patients/participants provided their written informed consent to participate in this study.AF, RK, and TC developed the concept and overall design of the study. TC developed and conducted the in-depth interviews with the patients and the qualitative analyses, supported by AF as second coder. AF designed and analyzed the survey and interviews with the participants at RCT end. RK designed, conducted and analyzed the survey, and interviews with the coaches in exchange with AF and analyzed the RCT documentation. AP developed the analysis plan for the annual training data, conducted the analyses, and developed the visualization of the data. KD was the master coach and piloted together with TR the feasibility of the intervention. AF, MP, TR, and KD designed the conception of the RCT. AF, TC, and RK drafted the manuscript. All authors read, revised, provided input, and approved the final version of the manuscript.This study was supported by Spark of the Swiss National Science Foundation (CRSK-3_190329) and by the Velux Stiftung . The HOMEX-1 RCT was supported by the Research Fund of the Swiss Lung Association, Berne (2017-19), and by the Research Fund of Klinik Barmelweid, Switzerland. The funding bodies had no role in the design of the study, data collection, analysis and interpretation of data, and in writing the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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. 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