Globally, low birthweight (LBW) infants  have the highest risk of mortality during the first year of life. Those who survive often have adverse health outcomes. Post-discharge outcomes of LBW infants in impoverished communities in Africa are largely unknown. This paper describes the design and implementation of a mother-to-mother peer training and mentoring programme for the follow-up of LBW infants in rural Kenya.Key informant interviews were conducted with 10 mothers of neonates (infants <28 days) from two rural communities in western Kenya. These data informed the identification of key characteristics required for mother-to-mother peer supporters (peer mothers) following up LBW infants post discharge. Forty potential peer mothers were invited to attend a 5-day training programme that focused on three main themes: supportive care using appropriate communication, identification of severe illness, and recommended care strategies for LBW infants. Sixteen peer mothers were mentored to conduct seven community follow-up visits to each mother-LBW infant pair with fifteen completing all the visits over a 6-month period. A mixed methods approach was used to evaluate the implementation of the programme. Quantitative data of peer mother socio-demographic characteristics, recruitment, and retention was collected. Two post-training focus group discussions were conducted with the peer mothers to explore their experiences of the programme. Descriptive statistics were generated from the quantitative data and the qualitative data was analysed using a thematic framework.The median age of the peer mothers was 26 years (range 21–43). From March-August 2019, each peer mother conducted a median of 28 visits (range 7–77) with fourteen (88%) completing all their assigned follow-up visits. Post training, our interviews suggest that peer mothers felt empowered to promote appropriate infant feeding practices. They gave multiple examples of improved health seeking behaviours as a result of the peer mother training programme.Our peer mother training programme equipped peer mothers with the knowledge and skills for the post-discharge follow-up of LBW infants in this rural community in Kenya. Community-based interventions for LBW infants, delivered by appropriately trained peer mothers, have the potential to address the current gaps in post-discharge care for these infants. Globally, 2.3 million neonates  died in 2020, and over a third of these were in sub-Saharan Africa (SSA) . AlthougThe World Health Organisation (WHO) and United Nations International Children's Emergency Fund (UNICEF) both recommend home visits for newborns as a strategy to improve the survival of all newborns in the first week of life . HoweverA recent study in Kenya found that accessing healthcare for LBW infants in a rural community in western Kenya was fraught with challenges at the individual, community and health system levels . In UganAn international systematic review has found that community-based peer support for mothers is effective in increasing the duration of exclusive breastfeeding among term infants, encourages mothers to initiate breastfeeding early, and reduces the risk of newborn prelacteal feeding in low resource settings . The useThe aim of this paper is to describe the design and implementation of a mother-to-mother peer support training and mentoring programme in rural Western Kenya. The focus of the training was to strengthen the community-based support available for LBW infants, empowering the local community with newborn care strategies to improve the health outcomes of vulnerable LBW infants.A mixed methods approach was employed to design and evaluate the implementation of this peer mother support training and mentoring programme for LBW infants . The quaThe initial study population included mothers of newborns in the rural communities of Rabuor and Ahero in Kisumu County of western Kenya. Then peer mothers from communities in the neighbouring Homa Bay County, who were recommended by the community health worker teams, were trained and recruited to follow-up LBW infants. For logistical reasons, this work was embedded within an existing maternal and child health research platform in the area meaning that the mapping of mother's experiences was conducted in Kisumu County and the peer mother support programme was implemented in Homa Bay County. All the peer mothers had cared for an LBW infant in the preceding 24 months.The study was conducted in the neighbouring counties of Kisumu and Homa Bay in western Kenya. Each county has a predominantly rural population of approximately 1 million . Nearly information-rich”  met the threshold for competency-based assessments and were recruited to deliver the community-based package of interventions .A)To enable the peer mothers to understand the challenges faced by LBW infants, for example difficulties feeding and increased risk of severe illness.B)To enable the peer mothers to understand the importance of adequate nutrition and safe newborn care practices, and to enable peer mothers to conduct practical tasks  on home visits in their role as peer mothers.The training programme was developed based on existing international and Kenyan national guidelines for infant feeding, essential newborn care (with particular attention to the extra requirements of an LBW infant), and postnatal care , senior nutritionists from UNICEF-Kenya and Action Against Hunger, Kenya , and a consultant paediatrician with expertise of working in rural communities in Africa (HMN). Collectively, this group had extensive experience of working among rural communities in Africa, including previous experience of training of healthcare providers about communication skills and emotional competency, basic life support skills and emergency care in children, and infant feeding and caring strategies. The learning outcomes of the training programme were:tal care , 26–29. tal care . At the tal care . SixteenThe KIIs were conducted by a trained research assistant (FA), who originated from this region of Kenya, was a mother herself, and had over 10 years' experience in conducting qualitative interviews in this community. These interviews were conducted in the local languages  or English depending on the language that a mother was fluent in. The KII guide was divided into the following four areas of inquiry: infant feeding; parenting skills; healthcare seeking behaviour; and support structures for mothers with newborn infants in the community. Each section had a combination of structured and open-ended questions. The interviews were audio-recorded and were complemented by field notes taken by the research assistant simultaneously.At the end of the feasibility study, two concurrent FGDs were conducted with the peer mothers. Sixteen peer mothers achieved the required competencies of the training programme, but one peer mother was absent on the day and the other one had dropped out of the study. Therefore, 14 peer mothers joined one of the two FGDs so each group had seven peer mothers present. The first FGD was convened by the research assistant, and the second one by the male field supervisor, who also had been trained in qualitative research methods. The FGD and KII guides can be found in the Demographic details of all the peer mothers were collected as they registered for the training programme. The field supervisor (DJ) kept a record of their activities, including home visits and meeting attendance. He maintained weekly contact with them and the community health visiting teams via mobile phone communication on the days with no scheduled study visits. He also reviewed their diaries for completeness.From March to August 2019, peer mothers had fortnightly debriefing meetings with members of the research team as well as maternal and newborn senior nurses at Homa Bay County Referral Hospital. During these meetings, they gave updates on the mother-infant pairs who had been assigned to them. These meetings also focused on the challenges and successes of facilitating shared learning, problem solving, team building, and enhancing peer support.The interviews in Dholuo or Kiswahili were translated and transcribed concurrently by the research assistant. The interviews in English were transcribed verbatim by the same transcriber. The transcripts were reviewed for translation accuracy by the research assistant and discussed with the principal investigator (HMN) during debriefing sessions. Any problematic translations in the transcripts were compared to the original audio recordings and revised accordingly. NVivo 12 software  was used to manage and support the analysis of the data. A thematic framework approach was used to analyse the data . This inAnonymized data were manually recorded onto the data collection forms and then entered onto an Excel spreadsheet that was stored on the secure LSTM server. Data was imported from Excel to Stata 15  for analysis. Descriptive statistics, including mean (standard deviation), median (interquartile range), and number (percentage), were used to describe the recruitment, training, characteristics, activity, and retention of peer mothers.The project was approved by the Research and Ethics Committee at the Liverpool School of Tropical Medicine (protocol number: 18–076) and the Kenya Medical Research Institute Scientific and Ethics Review Unit (KEMRI-SERU)) (protocol number: 3760). Written informed consent was obtained from all participants including the peer mothers prior to recruitment. Participants were given the option of consenting on the same day or after 24 h following consultation with other decisions-makers in their household. It was emphasised that consent was voluntary, and all participants were informed that they could withdraw from the study at any point without providing a reason. Anonymity was maintained by the study team and any identifiable details were removed from the recordings during the transcription process.The pre-training qualitative data informed the focus areas for the peer mother training, including communication skills, breastfeeding, thermal care, hygiene, and early identification of danger signs . The baseline mapping interviews were conducted with 10 mothers of newborn infants in the rural communities of Rabuor and Ahero in western Kenya. Their mean age was 27 years (range 20–34 years). Educational level varied with one mother having college education whilst the rest had secondary school education. Seven of the mothers were married, two were widowed, and one was single. The mean number of children was 2 (range 1–4 children).There were 4 key themes that emerged from the interviews about their experiences of community-based support for newborn care.There was a variable knowledge amongst the mothers when they were interviewed about infant feeding and hygiene practices. The majority of mothers reported that exclusive breastfeeding and appropriate hygiene practices were best for their infants as this was the advice that they had received at the hospital. However, they were often not clear about the details of this received advice : Quote 1Most of the advice about infant feeding and care practices was given to the mothers by healthcare providers during their pregnancy or at the time of birth. The mothers felt that this was a trusted source of advice : Quote 2Most of the mothers followed the advice to exclusively breastfeed their infant for six months, however some highlighted that this advice was not in line with the feeding practices followed by other mothers in their community. Mixed feeding of newborn infants was common with some mothers starting their newborn babies on solids from 2 weeks onwards due to the perception of having insufficient breast milk . Eighty percent of the peer mothers were married. All peer mothers had a basic level of education with 60% having primary level education and 40% having post-secondary level education. The majority (53%) of the peer mothers stated that their primary source of income was farming with 27% employed in a small-scale business and 20% employed as a casual labourer or stating that they were a housewife .The peer mothers were allocated a median of 5  LBW infants during the 6 months period, resulting in each peer mother conducting a median of 28  home visits. The activities of the peer mothers were monitored using their diaries, which showed a high level of completeness (93%) during the first three months. The completeness of the diaries dropped at 3 months to 79%, which suggests their activity lessened as time progressed .At the end of the study, fourteen peer mothers were retained and completed a minimum of seven post-discharge home visits per mother-infant pair. More details of these visits are in a related manuscript that is due to be submitted  Figure . Over thThe post-intervention FGDs aimed to explore the perspectives of the peer mothers at the end of the training/mentoring programme. The 3 key themes from the post intervention discussions are described below.The peer mothers reported that the training improved their understanding of appropriate infant feeding practices (Peer mothers reported improved knowledge and confidence in supporting mothers of LBW infants in the community, including specific care strategies such as Kangaroo Mother Care and cleanliness (The stigma of having an LBW infant was highlighted by many of the peer mothers (Our findings showed that the 5-day training programme for peer mothers, complemented with mentoring and debriefing sessions, equipped them with the knowledge and skills required to support the post-discharge care of LBW infants in western Kenya. The peer mothers were well accepted by their community and reported specific examples of improvements in the infant care practice and health seeking behaviour of other local mothers. Our results therefore suggest that the training of peer mothers was beneficial for the wider community. A recently published systematic review that evaluated interventions to improve the survival of preterm infants in LMICs found that low-cost interventions, including feeding support and thermal regulation, were key factors in the improved survival of these infants . FurtherOur baseline data from mothers of newborn infants showed that, although healthcare providers were a trusted source of advice for infant feeding and care practices, they were not easily accessible to mothers when they were back in the community post-discharge. Mothers therefore sought advice from multiple sources due to uncertainty about the advice that they had received. Interestingly, even the advice from community health workers was not always trusted. Our study also showed that home visits to LBW infants by skilled peer mothers with links with trusted healthcare providers led to positive interactions and better uptake of recommended infant feeding and care practices. A recent meta-analysis of postnatal care in sub-Saharan Africa showed that women living in rural areas with low literacy levels were less likely to utilise postnatal care services . This isThe attrition of peer mothers was minimal showing that the training and mentoring programme, coupled with their lived experiences, enhanced their motivation. This helped to mitigate the psychological distress of providing community-based support for infants at high risk of adverse outcomes. A systematic review exploring the motivating factors among community health workers for maternal, newborn, and child health service delivery in LMICs found that individual motivating factors at the outset improved retention although the health system challenges in these settings demotivated them . Indeed,A key strength of this training programme was the use of adult learning approaches . The proThe main limitation of this training programme was that, although the skills and knowledge evaluation strategies incorporated have been used in training healthcare providers in Kenya and The Gambia, they have not been validated for use among peer mothers. Further refinement of these strategies is work in progress. To enhance the skills and knowledge of the peer mothers, they were provided with ongoing mentoring and regular debriefing sessions. This meant the peer mothers were able to ask questions about any challenges they faced with their instructors in order to identify appropriate solutions. This also provided the opportunity for the peer mother's competencies to be reviewed by their instructors at least every 2 weeks depending on the needs of the peer mother. We plan to make the training resources widely accessible so that other researchers/educators in other LMICs can access them and evaluate their use in different contexts. Finally, the travel costs and childcare costs that the peer mothers incurred during these home visits were reimbursed, which may have contributed to the low attrition rate that may not be replicated in the “real life setting” where these costs are not reimbursed consistently or in a timely manner.Our peer mother training and mentoring programme appeared effective in enabling peer mothers to attain the competencies required to enhance the post-discharge follow-up of LBW infants in this rural community of western Kenya. In contexts where community health workers are overwhelmed with multiple priorities for maternal and child health, and therefore are unable to provide adequate post-discharge care to these vulnerable infants and their mothers, this peer mother programme has the potential to address this gap. Further refinement and evaluation of this programme in different contexts in sub-Saharan Africa is required to facilitate scale-up.


Heart failure with reduced ejection fraction (HFrEF) is considered a major health care problem with frequent decompensations, high hospitalization and mortality rates. In severe heart failure (HF), the symptoms are refractory to medical treatment and require advanced therapeutic strategies. Early recognition of HF sub- and decompensation is the cornerstone of the timely treatment intensification and, therefore, improvement in the prognosis. Echocardiography is the gold standard for the assessment of systolic and diastolic functions. It allows one to obtain accurate and non-invasive measurements of the ventricular function in HF. In severely compromised HF patients, advanced cardiovascular ultrasound modalities may provide a better assessment of intracardiac hemodynamic changes and subclinical congestion. Particularly, cardiovascular and lung ultrasound allow us to make a more accurate diagnosis of subclinical congestion in HFrEF. The aim of this review was to summarize the advantages and limitations of the currently available ultrasound modalities in the ambulatory monitoring of patients with HFrEF. Heart failure (HF) is considered a major health care problem with more than a million new cases every year . Over thHF decompensation may be provoked by trigger factors such as infection, myocardial ischemia, acute renal injury, or anemia. In the case of disease deterioration due to increasing fluid retention, subclinical congestion precedes the clinical manifestation of HF symptoms and hospitalizations for an acute HF decompensation by several days or weeks. Therefore, the identification of a vulnerable period before the symptomatic HF decompensation allows for a prompt increase in diuretic doses and treatment modification, which may prevent the upcoming hospital admission . PhysicaHospitalization negatively affects the prognosis and quality of life . MoreoveThe aim of this review was to summarize the current knowledge regarding echocardiographic and ultrasound features of subclinical congestion among a broad range of HFrEF patients.It is evident that hemodynamic deterioration precedes the development of clinical signs and symptoms by days or weeks, thus symptomatic clinical congestion may be seen as the “tip of an iceberg” of hemodynamic compromise . Due to It is well-established that an increased venous pressure can be detected by cardiovascular ultrasound, particularly by the assessment of inferior vena cava (IVC) characteristics and the detection of interstitial pulmonary edema through B-line identification. On the other hand, intracardiac hemodynamic changes and LV filling pressure increase precede the manifestation of HF symptoms and can be diagnosed by echocardiography ,17. CompOver the last decade, it has become apparent that natriuretic peptide-guided management of ambulatory chronic HF patients may optimize the treatment. Natriuretic peptides are important components of HF diagnostic work-up due to their high negative predictive value. However, the data on the utility of natriuretic peptides in the prevention of HF decompensations are relatively scarce. In the PARADIGM-HF trial, low levels of natriuretic peptides were associated with lower risks of cardiovascular events . In the Another concern regarding the diagnostic role of natriuretic peptides is related to morbidly obese patients, who have consistently lower natriuretic peptide levels ,22,23. OBasic echocardiographic assessment is an important tool for the diagnosis, classification, and treatment of HF. Some authors recommend using LV ejection fraction (EF) for the assessment of prognosis in ambulatory HFrEF patients, based on the role of EF dynamic increase as a predictor marker of an improved survival and hospitalization risk in this patient population . However2 . LU. LU55]. LUS has a high prognostic value for the prediction of hospitalization. Among the patients hospitalized for acute HF, the presence of residual B-lines at discharge is associated with a higher risk of rehospitalization ,58. LUS The use of LUS for the detection of residual congestion at discharge among the patients admitted for acute decompensated HF allows for the identification of undertreated patients who require more intensive diuretic regimens for the prevention of early rehospitalizations. Additionally, the detection of asymptomatic pulmonary congestion before the symptom onset allows for an early diagnosis of subclinical HF decompensation in outpatients. Thus, it may enable the making of timely treatment modifications, particularly loop diuretic dose up-titration, for the prevention of HF decompensation in ambulatory settings.In summary, the detection of B-lines by LUS plays an important role in the differential diagnosis of congestion and acute decompensated HF. Moreover, implementation of LUS in the ambulatory follow-up may enable HF specialists to identify the patients at high risk of an upcoming decompensation and may provide guidance in determining the optimal treatment strategy for the prevention of hospitalization among patients with chronic HF.Both patients and health care providers can be involved in the clinical follow-up-based approach for the prevention of hospitalization in ambulatory patients. Self-assessment of congestion by the patient requires daily weight checking and self-administration of an additional diuretic dose in the case of body weight increase for ≥2 kg in 2 days or the exacerbation of edema ,62. DespIn patients with HF, echocardiographic measurements of right ventricular (RV) pump function and right atrial (RA) pressure provide important information about RV dysfunction, overload, pulmonary artery, and central venous pressures. For the evaluation of RV systolic function, EF and tricuspid annular plane systolic excursion (TAPSE) are used in clinical practice. However, both parameters have important limitations. Particularly, the assessment of RV EF is difficult due to RV geometry and suboptimal visualization of the endocardial borders. Limitations of TAPSE include angle and load dependence, and extrapolation of single segment displacement amplitude to the overall RV ventricular function . TherefoNew parameters for the quantitative measurement of RV function have been widely investigated. Based on the available data, they are reliable, have a good correlation with the cardiac MRI findings, and can be used for the prediction of RV remodeling and clinical deterioration of the patients ,67. TAPSThe prognostic value of RA enlargement was analyzed in the study conducted by Almodares Q. et al. . MeanwhiStudies have demonstrated that patients with an IVC diameter >2.5 cm and collapse of <50% on inspiration have an RA pressure of more than 10 mmHg  71,72].,72.71,72A summary of the previous studies on the role of cardiovascular and lung ultrasound parameters in the assessment of congestion and prognosis of HFrEF patients is presented in In this review, we outlined the gaps in the LV EF evaluation by basic echocardiography and emphasized the importance of implementing other parameters beyond EF for the evaluation of HF patients in everyday clinical practice. This paper focused on the heterogeneous group of HFrEF patients with high or normal LV filling pressure and RV congestion. We suggest performing a risk stratification of HFrEF patients based on the echocardiographic evidence of LA hypertension for the prediction of decompensation and treatment optimization.Cardiovascular and lung ultrasound with hemodynamic assessment is a low cost comprehensive tool, which should be more widely used in heart failure clinics for the early detection of congestion signs before the development of clinical deterioration. The evidence suggests that subclinical congestion may be present in most of the clinical scenarios in both the outpatient period and after hospital discharge. The review of the currently accepted prognostic markers shows a limited significance of each of these parameters in clinical and predictive assessment.The assessment of congestion by several radiation-free, not time-consuming ultrasound methods may guide the intensification of diuretic treatment and decisions regarding the frequency of follow-up visits.Several important echocardiographic parameters beyond EF can be routinely used as part of an algorithm for the prediction of decompensation in chronic HF patients.Integration of multiple parameters, which can be easily determined by lung ultrasound and cardiovascular ultrasound including LV filling pressure, central venous pressure, left and right atrial remodeling enables moving beyond considering only LV systolic function.Complex cardiovascular ultrasound assessment allows one to obtain more precise parameters of HF deterioration and enables the identification of patients who require a personalized treatment approach.


During the COVID-19 pandemic and compared to other population groups, older people were at a heightened risk of developing lethal disease symptoms. Thus, many countries put in place protective measures to protect this “at-risk” population, especially in nursing homes, to limit the number of infections. These measures consisted mostly in the absence of social gatherings, the impossibility for relatives to enter the nursing homes, limitations in group activities, and the ban of group-eating. Although these measures were helpful to mitigate the spread of the disease, they also induced long periods of social isolation for the residents of nursing homes. This could have impacted the wellbeing and quality of life of residents and their relatives, with a possible impact on the overall health of residents. We designed this rapid review to investigate the literature on the impact of COVID-19 protective measures in nursing homes on the quality of life, wellbeing and physical health of residents and their relatives. Our results showed that most of the articles included in the review, either using qualitative or quantitative methods, evidenced a detrimental impact of protective measures on resident’s and their relatives’ wellbeing. We argue that, in the event of a new pandemic similar to the COVID-19, protective measures should also take into account their psychological impact, and not only their physical impact.The online version contains supplementary material available at 10.1186/s12877-023-04300-7. First identified in December 2019, the COVID-19 disease outbreak was declared a pandemic by the World Health Organization in March 2020. In face of the health risk imposed by this disease, many countries put protective measures in place for at-risk populations. Older people were especially at risk of developing fatal symptoms, compared to other population groups . Thus, mWhat has been the impact of the measures to protect against COVID-19 on the physical and psychological health, quality of life and end of life support for nursing homes residents?Which interventions prevented/reduced the impact of the COVID-19 protective measures on the physical and psychological health, quality of life and end of life support of nursing homes residents?What has been the impact of the protective measures against COVID-19 in nursing homes on the physical and psychological health and quality of life for close relatives of nursing homes residents?Which interventions prevented/reduced the impact of the protective measures against COVID-19 on the physical and psychological health, and quality of life for close relatives of nursing homes residents?reg.no. CRD42022321398). Report of the rapid review follow the PRISMA statement for reporting systematic review  founBeside these two studies, the other papers presented in this section all found a detrimental impact of protective measures on levels of depression and anxiety of residents. Arpacioğlu and colleagues 2021) [021 [2] fOne study compared overall levels of depression pre-pandemic found in the literature with levels of depression measured just after the first lockdown . They foTwo longitudinal studies were able to compare directly levels of depression and anxiety before and after the first lockdown. Pereiro and colleagues (2021)  showed tTwo other longitudinal studies investigated levels of depression and anxiety during the months following the first lockdown (May-September 2020). Sizoo and colleagues (2022)  found thOne last study was able to compare levels of depression during the first lockdown with the same measure from previous years . The autStudies presented above investigated older people without cognitive impairment. Now we will present three studies that were directly aimed at investigating anxiety and depression in nursing home resident diagnosed with cognitive impairment. El haj and colleagues (2020)  investigThree studies investigated whether the first lockdown had an impact on loneliness and overall quality of life. Savci and colleagues (2021)  used retFours studies used a quantitative approach to evaluate the impact of the first lockdown on physical functions, cognitive decline and nutrition. Perez-Rodriguez and colleagues (2021)  evaluateFinally, Curran and colleagues (2022)  investigOur search found eight qualitative studies investigating the experience of nursing home residents during the lockdown induced by the first wave of COVID-19. Ayalon and colleagues (2021)  intervieThe impact of the loss of autonomy on wellbeing due to the protective measures was also reported in the study from Kaelen and colleagues (2021) . This stBackhaus et al. (2021)  investigMurphy and colleagues (2022)  aimed atPaananen and colleagues (2021)  intervieThe last two studies included in our search investigated qualitatively the reopening following the first lockdown. First, Verbeek and colleagues (2020)  investigThere were four intervention studies aimed at reducing the impact of protective measures on physical functions and mental health. The Pinazo-Hernandis and colleagues’ study (2022)  examinedThe intervention study from Van Dyck and colleagues (2020)  investigThe Chen and colleagues’ study (2021)  investigFinally, Fogelson and colleagues (2021)  investigOur search found eleven studies that investigated the psychological impact of the protective measures against COVID-19 in nursing home on the relatives of residents. Four studies used a quantitative approach, whereas seven investigated the experience of relatives with the protective measures via qualitative designs. First, we will present the four quantitative studies, then, in another section, the qualitative studies.Borg and colleagues (2021)  investigPrins and colleagues (2021)  wanted tFinally, Monin and colleagues (2021)  investigSix qualitative studies investigated how relatives experienced the protectives measures. Chirico and colleagues 2022)  explored  exploreNash and colleagues (2021)  also expWammes and colleagues (2020)  exploredThe final studies selected by our search methodology interviewed relatives about their perception of the protective measures in Canada and the problems they elicited . RelativThe aim of this rapid review was to investigate what has been published on the impact of protective measures against COVID-19 in nursing homes on the wellbeing, quality of life, psychological health and physical health of residents and their relatives. Our systematic search found 42 papers that related to our questions of interest. Regarding residents, most of the papers reviewed here corroborated the hypothesis that mental health as well as physical health of nursing homes residents deteriorated during the first lockdown. First, several studies showed that residents had higher levels of depression and anxiety after the first lockdown than before it , 42, 45.However, these studies do not inform whether the impact of the lockdown was specific to nursing home residents or extends to the general population. Therefore, some studies compared nursing home residents with older people living in autonomy , 16. In The detrimental impact of the lockdown period on nursing homes residents was likely due to the COVID-19 protective measures. In several qualitative studies residents reported the direct link between their perceived decrease in wellbeing and protectives measures . For example, residents reported feelings of loneliness, heightened levels of depression, and anxiety , 26 and Although it is assumed that residents suffered the most from the protective measures, because measures were more restrictive in nursing homes, relatives of residents also suffered from these measures. People that lived with their older relatives had less anxiety, depressive symptoms, and sleep troubles than relatives of nursing homes residents of the same age . OverallWe saw in the preceding section that protective measures in nursing homes negatively impacted the wellbeing and quality of life of residents and their relatives. However, the studies found in our rapid review also presented several avenues to alleviate this detrimental impact. The main preventive factor against the psychological impact of protective measure was social contact. Indeed, two studies showed a negative correlation between social contact and levels of depression and anxiety , 33. AnoTo counteract the detrimental impact of the lack of social contact on residents, several authors proposed to use videoconference tools . This allows residents and their relatives to keep contact and minimize social isolation. Although residents and relatives welcomed the use of videoconference tools, it had several intrinsic problems. First, not every resident is able to use these technologies. For example, residents with hearing impairment or cognitive impairment struggled with videoconference tools. In addition, residents and relatives preferred in-person visits to videoconference, although videoconference tools were considered a good temporary solution , 4, 23.Several authors argued that totally isolating residents from the outside was not a good solution , 36. TheRegarding interventions that could help alleviate the detrimental impact of the protective measures, doing weekly physical exercise  and engaSeveral papers that were found in the literature search proposed recommendations on how to balance psychological health with the physical protection of nursing home residents from infections. Some of these studies were not included in our final set of included studies, because they did not follow our inclusion criteria. We nonetheless found useful to list recommendations made by these papers here, as they could help develop protective measures that balance mental and physical health in case of a future pandemic.Dichter and colleagues (2020)  proposedRapid reviews have inherent drawbacks, like the absence of formal quality evaluation of the included studies . In addiOur review of studies investigating the impact of the COVID-19 protective measures in nursing homes showed that these measures had detrimental impact on the wellbeing and quality of life of residents and their relatives. Although the measures helped protecting residents against infections, they also imposed psychological stress on people which had to live with these measures. Furthermore, recent studies linked more stringent protective measures to a heightened number of non-COVID-19 related deaths during the first lockdown. Since the role of nursing homes is to preserve the quality of life of their residents, it asks the question as to how they can fulfill this role while protecting residents from infections. We saw that the detrimental impact of the measures was mostly due to residents’ lack of social contact and loss of self-determination. Thus, measures that minimize social isolation and preserve self-determination should be preferred. Another aspect is that relatives of residents were also impacted negatively by the protective measures. Since relatives of nursing homes residents also have an important role in the caregiving of residents, they should not be considered as mere visitors, but as an integral part of the caregiving structure. Thus, in the case of a new pandemic similar to COVID-19, relatives should be considered as partner with the nursing homes and not be completely left-out. This would have the double effect of minimizing residents’ social isolation and relatives’ worries.Below is the link to the electronic supplementary material.Supplementary Material 1


Additive Manufacturing is noted for ease of product customization and short production run cost-effectiveness. As our global population approaches 8 billion, additive manufacturing has a future in maintaining and improving average human life expectancy for the same reasons that it has advantaged general manufacturing. In recent years, additive manufacturing has been applied to tissue engineering, regenerative medicine, and drug delivery. Additive Manufacturing combined with tissue engineering and biocompatibility studies offers future opportunities for various complex cardiovascular implants and surgeries. This paper is a comprehensive overview of current technological advancements in additive manufacturing with potential for cardiovascular application. The current limitations and prospects of the technology for cardiovascular applications are explored and evaluated. Industry 4.0—dubbed the fourth industrial revolution redefines the industrial and manufacturing world and also the healthcare, pharmaceutical, biotechnology, and medical device industries . The comIt is likely that nine different technologies will define the future of industry and manufacturing: Simulation, Augmented Reality, Autonomous Robots, industrial “Internet of Things” Cloud, Cybersecurity, Additive Manufacturing, horizontal and vertical system integration, and Big Data Analytics . IndustrThe second part is the physical environment in which Additive Manufacturing (AM) plays a significant role in the transformation by means of its capability to produce customizable products with sophisticated attributes  . The earAM is three-dimensional printing; the process converts the information contained in digital solid models piece by piece, surface by surface, and layer by layer into tool paths that allow the deposition of physical objects . AM has Additive manufacturing has been gaining momentum and is emerging as a crucial adjunctive tool in medicine . AdditivCardiovascular diseases (CVD) are the leading global cause of death. CVD claimed 17.9 million lives in 2016 which accounts for 31% of deaths that year according to the World Health Organization . The AmeThere is a demonstrable need for concurrent evolution of cardiovascular science and medical device manufacturing to advance these emergent technologies from the conventional manufacturing age to industry 4.0 at a faster pace to meet the rising rate of the global need for cardiovascular medical interventions and related solutions for patient care. This literature review demonstrates that additive manufacturing is currently in the development phase in cardiovascular applications but is gaining rapid popularity among clinicians and researchers because it has the potential to offer economical, feasible, and most importantly patient-specific applications. This review article explores the use of additive manufacturing in the advancement of cardiovascular treatments and evaluates its current limitations and prospects.Initially, a detailed study of the applications of additive manufacturing, 3D modeling, and 3D printing in cardiovascular procedures is performed. This was achieved by probing into scientific literature accessible on Google Scholar and PubMed databases, focusing on the technologies as applied to cardiovascular methodologies.Keywords related to Manufacturing Technology ,Terminology for Anatomical Structures, Organs, and Tissues ,Application terminology .The search criteria were divided into three sections:To maintain a contemporary perspective, we restricted our research to English-language articles published in the 21st century. Our intention is to scrutinize and showcase how additive manufacturing and 3D modeling have emerged as game-changers in the cardiovascular field in the medical domain. In our review, we endeavor to include all the latest technological breakthroughs that have happened in the cardiovascular realm, primarily attributable to advancements in additive manufacturing and 3D modeling. We examine various treatments, procedures, and applications adopted in the cardiovascular field by clinical teams leveraging these cutting-edge technologies.Based on insights gleaned from the articles reviewed, we further broadened and fine-tuned our search criteria. We incorporated new keywords, as stated in the three sections, to compile additional evidence and delve deeper into the subject matter.Creating a 3D model involves sequential steps of diagnostic image acquisition, digital modeling, and 3D printing . The firStereolithography (SLA) and powder layer casting technologies use lasers to fuse multiple layers of printed material. In stereolithography, an ultraviolet laser is used to harden the surface layer of liquid photopolymer resin, while in powder layer casting, the laser heats and melts each layer of the powder printing material without the need for a supporting structure. While there is a growing selection of photoreactive materials that can be used in stereolithography (SLA), it is important to note that the technology is still constrained by significant limitations, specifically, SLA is currently limited to the use of a single resin at a time when creating the final model . In addiMaterial extrusion and material jet technologies use a nozzle or jet to apply a liquefied printing material, which then solidifies to form a new layer . Materia3D printed models have proven useful for the pre-operative rendering of target anatomy for various congenital heart diseases and structural heart interventions. Such models have also been used to demonstrate suitable valve repairs, to evaluate internal cardiac defects, vascular anatomy, selection of cardiac procedures for cardiac tumors, and other complex heart interventions. Figure Certain heart conditions, especially congenital heart disease in both adults and children, require a detailed preprocedural study of the procedure and an in-depth understanding of the depth and spatial information of the heart . CurrentCongenital heart disease is one of the most common cardiac problems found in children and fortunately, technological advancement in the medical field means that most such children survive to adulthood, but the surgery and procedures can be extremely complex. Precise knowledge of cardiac anatomy is the starting point for initial assessment, follow-up diagnosis, and further therapy . 2-DimenCurrent advancements in medicine and additive manufacturing have led to the development of highly accurate 3D printed models that replicate the cardiac anatomy and defects to assist in both presurgical planning and the simulation of congenital heart disease. One of the studies led by Lee et al. developed 3D models with strong correlation and excellent reliability compared with the original CT images that are shown in Fig. A common access point for endovascular treatment is the femoral artery, often catheters and medical treatment devices are directed via the aorta via the cervical arteries to the cerebral arteries and the site of the treatments. Typically, the training for these kinds of catheter-based endovascular treatments for vascular diseases uses animals , but theEarly developments of physical Aortic model fabrication were recorded by Markl et al.  using MRSeveral recent studies have described developing the complex anatomy of aortic aneurysms and aortic pathology for surgical procedural facilitation and device selection to improve the accuracy and quality of treatment. As shown in Fig. Cardiovascular additive manufacturing has assisted in finding alternative solutions to aortic root replacement for patients with Marfan syndrome, Loeys–Dietz syndrome, and aortic root aneurysms . 3D modeIn the modeling aortic aneurysm pathology, most studies mention the need for accurate replication of internal complex aortic details. The high-resolution 3D modeling of internal components of the aorta will assist in making in-depth studies of the biomechanical and fluid dynamics properties of the cardiac tissues which should have a significant impact on future clinical treatments for patients with complex cardiac cases Fig. .Fig. 43DThe Society for Cardiovascular Angiography and Interventions (SCAI) recognizes that medical simulators will take a greater role in cardiovascular training and retaining cardiovascular certifications . SeveralCritical care training for clinical staff, residents, and nurses, on patient-specific 3D models before complex congenital heart surgeries, has not only improved the outcomes of the surgery but also enhanced communication between the cardiologists and patients . A studyThe current method of teaching congenital heart diseases to students is instructor-based using tools and limited practical techniques. Additive manufacturing and 3D printing can improve education by creating high-fidelity synthetic heart models with complex heart issues and applying these models to a novel, stimulation-based education program for premedical and medical students . Figure (i)Objectives and procedural for any complications were well defined.(ii)Assisted in identifying the potential challenges for device implantation.(iii)Mimicking the procedure on a 3D model assisted in better imaging techniques during the actual surgery for visualization of the anatomic target for device deployment in a quasi-3D environment.One of the first 3D image fusion-guided transcatheter repairs of a sinus venous atrial septal defect was carried out on a patient by Thakkar et al. 2018 with the assistance of 3D modeling. A 3D model was developed using a tissue-mimicking rubber-like material from post-CT angiography image segmentation. The stent graft was positioned and then implanted into the model using fluoroscopy and post-simulation demonstrated successful nature of the exclusion. The model was demonstrated to the patient to obtain well-informed consent for the surgery . The papAnother study showed simulation using a 3D model-assisted cardiac catheterization allowed preprocedural pre-operative trials of the complex navigational maneuvers needed to advance catheters from the aorta to the left ventricle and to position the catheter tip between the two papillary muscles, close to the mitral annulus .One critical study in pulmonary valve replacement was carried out by Phillips et al 2016. The majority of Fallot patients, a defect caused by a combination of four heart defects at birth, are not candidates for Transcatheter Pulmonary Valve Replacement (tPVR) due to the large irregularity of Dysfunctional Right Ventricular Outflow Tract (RVOT). A hybrid approach was used to remodel the RVOT in transannular patch patients using preprocedural 3D model simulations, to evaluate different strategies, and so to design individualized solutions for patients with different cardiac anatomies . A similA case report was reported by Dakowski et al. where a clinically applicable heart modeling technology was used for the preparation of a percutaneous mitral annuloplasty using the Mitralign percutaneous annuloplasty system . This teThis was not the first time that 3D printing has assisted in better planning of innovative heart interventions. Another intervention was reported by Forte et al 2018 where patient-specific 3D modeling was created to accurately access the anatomy of Sinus Venous Atrial Septal Defect (SVASD) and Partial Anomalous Pulmonary Venous Drainage (PAPVD) to develop a safe and clinically effective interventional catheterization treatment for 3 patients . A similThe procedural planning of appropriate surgical cases typically now uses 3D modeling as assistive technology in the diagnosis of several cardiac-related issues. 3D modeling has assisted in defining the aortic anatomy in aortic stenosis cases including those affecting the aortic valve area, root morphology, calcium distribution, and distance to coronary arteries , 80.3D printed models have evolved from the first-generation modeling used for initial training of the Transcatheter Aortic Valve Replacement (TAVR) procedure to multi-material printed models to mimic tissue properties for ex-vivo visualization of valve implementation . RecentlOne of the first patient-specific heart 3D models was made to aid in the planning of a percutaneous Mitral Valve repair where the 3D model demonstrated morphological details that assisted the team in the planning of catheter manipulation and device implantation . In vitrOf all the heart valves, the tricuspid valves have the least reports in the literature related to 3D modeling. One limitation is concomitant renal failure, which precludes the administration of intravenous contrast in many patients . A recen(i)the Valve is printed in only one phase of the cardiac cycle, typically mid-systole.(ii)the number of parameters that impact aortic flow and gradient  were not considered .One advance in cardiac diagnosis is the development of functional 3D models for hemodynamics studies across aortic valves which has great potential for diagnostic and preprocedural applications. Harb et al. 2018 developed a patient-specific 3D model of severe aortic stenosis with matching anatomical and hemodynamic properties including stroke volume. Models of this type can assist in the characterization of challenging cases where there is a discrepancy between aortic valve morphology, calculated aortic valve area, and estimated transaortic gradient. However, the study had limitations:Certain functional 3D printing studies have been successfully carried out on the mitral valve for catheter-based structural interventions for hemodynamics studies and evaluation . One stuBioresorbable stents (BRS) or Bio-absorbable vascular stents (BVS) are the most recent advance in stent technology having properties of biosorption, mechanical flexibility , and theThe additive manufacturing approach for BRS manufacturing has gained popularity in the last few years because of the resulting properties , economiRevascularization is a process of restoration of tissue perfusion to remediate cardiovascular disease and to restore vascular tissues to reduce the risk of heart failure . Thick, Our systematic literature search showed that various studies have analyzed and developed materials for BRS giving the required properties and made using additive manufacturing techniques , 98, 102A Polymeric drug delivery system is a device that facilitates the introduction of a therapeutic substance into the body and is a technology that has significantly developed in the last two decades . HoweverOne of the limitations mentioned in most of the studies was the imprecision of 3D models due to the poor initial resolution of the 3D images. Medical images need to be isotropic with a high spatial resolution to provide rich detail and high contrast to distinguish the adjacent structures. Low resolution and the presence of artifacts can produce false diagnoses . There hThe second major limitation discussed is the re-creation of soft tissues and vascular structures which consists of complex multicellular arrangement, involving a controlled combination of vascularization, and mechanical, biological, and electrical properties. Additional techniques such as biomechanical stimulation and electrical stimulation are used to improve 2-Dimensional cultures, but they lack the crucial anatomical and physiological properties of cardiovascular micro-environments and thereby fail to provide an effective strategy to generate viable cardiac tissue and are thus not suitable for developing disease and drug screening platforms , 108.In addition, the combined development of printing technologies and biomaterials are giving faster, more efficient, and more cost-effective results. If accompanied by better resolution of 3D images from imaging modalities such as CT and MRI this will enable the development of high-definition 3D modeling for not just cardiovascular applications but also for other healthcare and pharmaceutic applications.Clinical requests for a 3D printed model before imaging acquisition can result in the use of separate CT and MRI protocols to improve spatial resolution, spatial fidelity signal-to-noise ratio, and the contrast-to-noise ratio resulting in a better printed model . TechnolPersonalized cardiovascular 3D printed prostheses are not currently available but are imminent . ProgresHeart-on-a-chip technology and engineering innovations to re-create physiological conditions of organs are emerging as popular tools in drug delivery because of their potential for automated control of culture conditions , application for heart stimulations , and continuous monitoring and measurements of physiological responses—all of which are enabled by the application of built-in readouts, sensors, and electrodes . The con(i)Obtaining sufficient human-derived cardiovascular cells to achieve physiological distribution of associated cells.(ii)Development and optimization of bio-inks for cell viability, phenotypes, and functionality.(iii)Development of better bioprinters to improve speed and resolution.(iv)Creation of perusable vascular networks in thick constructs for improving the functional and biomechanical integration with the host cardiovascular system.(v)Balance of structural stability, degradation rates, flexibility, and proliferation space of printed myocardial cells .One of the studies on 3D bioprinting for cardiovascular regeneration mentions the following challenges which need to be addressed to assist in the development of a whole functional cardiovascular system:(i)Personalized patient care with precise preprocedural planning.(ii)Reduction in intraprocedural guesswork regarding catheter and device selection, thus improving patient safety.(iii)Improved operator confidence as 3D modeling assists in viewing models in all angles and views.(iv)Simulation and maneuvering of 3D modeling assists in gathering additional information along with traditional imaging.(v)Assisting operators to foresee intraoperative complications and plan better .Several significant advantages resulting from the use of additive manufacturing have been reported:3D models are currently derived from CT and MRI images; it is desirable that 3D modeling should overcome the current limitations of CT and MRI imaging to better define the functional morphology of Ebstein’s anomaly, atrioventricular septal defects, and for the evaluation of mitral regurgitation , 118. SeThe insight provided by additive manufacturing has the potential to increase the efficiency of cardiac procedures by improving conventional and surgical planning as well as reducing radiation exposure . FurtherFor in vitro device testing and procedural stimulation, 3D printed cardiovascular models mimic the appearance, mechanical behavior, as well as the dynamic behavior of the target organ through the cardiac cycle. Challenges still exist in finding the perfect match for the biologic tissues due to the inability of currently available processable materials to precisely mimic the non-linear and anisotropic behaviors of biologic tissues . In the Additive manufacturing is an evolving field concurrent with industry 4.0 but significant application and advancement in medical device and cardiovascular applications has only begun in the last decade. For this reason, more technological research and studies need to be carried out in the field of additive manufacturing to develop a high-resolution printing technology and to develop 3D printable biomaterials which are non-thrombogenic. A comprehensive assessment of materials and their mechanical and physical properties along with process optimization and blood compatibility studies can assist in the rapid and beneficial commercialization of additive manufacturing technology for medical implants and general medical science. The technology meets the various requirements in the cardiovascular field due to its flexibility and suitability for a number of patient-specific applications. For these same reasons, this technology has the capability of tackling various challenges that cannot be achieved with current conventional manufacturing technologies. In the future, additive manufacturing may have the capability to print a working smart material 3D heart model. This type of working model includes an effective time dimension and so is known as a 4-Dimensional model. Developing this technology to grow inside a patient’s body and to respond to patient-specific conditions  would open a whole another dimension of patient care and cardiac surgeries with the potential to revolutionize the fields of cardiology and general medicine.


This special issue discusses current progress in the utilization of defect centres in diamond as spin–photon interfaces for quantum applications. This issue is based on the discussions of the Theo Murphy meeting ‘Diamond for quantum applications' which covered the recent progress of diamond growth and engineering for the creation and optimization of colour centres, toward the integration of diamond-based qubits in quantum systems.This article is part of the Theo Murphy meeting issue 'Diamond for quantum applications'. The discovery of these effects led to a first quantum revolution, which brought advances such as transistors and LEDs, changing our world immeasurably. Our ability to control quantum mechanical phenomena in customized systems is now starting to be realized in a second quantum revolution, where the technological capabilities of quantum mechanics are fully implemented in devices with fundamentally superior performance in computing, sensing, imaging, simulation and communication. Diamond, as a solid-state host material for optically active defects, has the potential to accelerate this second revolution, with far-reaching social implications. These include safer encryption of data and an acceleration of biological research due to both advances in quantum sensing and quantum computing simulations of biological systems like protein folding. More efficient calculation of problems like minimizing travel routes and quantum-aided search algorithms could also have an enormous impact in terms of energy conservation. This special issue is based on a Royal Society Theo Murphy Meeting, which took place 10–11 October 2022, with the goal of accelerating the development of diamond as a quantum material by promoting the interaction of the key research fields in this area at a critical time in its development.Ongoing rapid research progress using optically active colour centres such as the nitrogen vacancy (NV) centre has shown diamond's significant potential for quantum applications. The recent demonstration of electronic readout of an electronic spin state of a single NV centre  shows th5 qubits estimated needed for useful quantum computing. The lively discussion at this meeting and summary of the outstanding issues in achieving ambitious quantum devices (such as 100 000 qubit diamond-based quantum computers) was therefore extremely timely. One issue is the low collection efficiency of indistinguishable photons from the NV centre. Device solutions such as optically coupled open microcavities were presented, as well as nanofabrication techniques for accurately positioning NV centres in such structures, such as multiphoton laser writing [Diamond, as a solid-state qubit host, offers major advantages over more technologically mature platforms, like superconducting qubits and ion traps. These include less restrictive temperature requirements and scalable two-dimensional arrays of qubits which can be extended to the approximately 10 writing , were al writing ,8 and ni writing , also il. 2− centre in diamond has been the most widely studied of the crystalline defects in diamond for quantum applications. This special issue also reflects this focus, with half of the papers looking at the optimization, use and deeper understanding of the NV defect. Two papers looked specifically at the properties of NV centres in diamond related to the nitrogen concentration of diamond grown by chemical vapour deposition (CVD) toward the optimization of the NV performance. Luo et al. [et al. [− centre, with the aim of maximizing the T2 coherence times. They describe a method for highly controlled nitrogen incorporation for the optimization of the magnetic field sensitivity of devices based on the grown NV diamond material.The NVo et al.  study di [et al.  summarizet al. [The use of highly sensitive NV diamond for magnetometry in real world environments is also an area of current research interest. Hatano et al.  describeet al. [− centre and the self-interstitial in diamond. They propose that the formation of a hybridization between the NV's electronic structure manifold and the π-bonds of the interstitial may form non-radiative channels allowing the excited electron to return to the ground state, which explains the fluctuating fluorescence signal observed during annealing by femto-second laser processing.A greater understanding of the physics underlying the creation of NV defects in diamond is also needed, to enable the full optimization of bulk NV diamond material as well as the properties of single centres formed with high spatial precision. The creation of NVs necessitates the creation of vacancies in the diamond, in the form of Frenkel defects , both components of which can interact with the formed NV centres, affecting their properties. Kirkpatrick et al.  use denset al. [229Pa, as well as defects containing stable analogues. These defects may be used in conjunction with quantum control methods to perform experimental tests of fundamental symmetry violations.Two of the other papers also used DFT methods, however moving away from the issue's initial focus on NV material, they have investigated the properties of crystal defects beyond the NV centre in diamond. Thiering & Gali  look speet al.  study cret al. [2 particles as the source of the tin impurity. They studied the optical properties of the grown material by photoluminescence, and attributed changes in the shape of and position of the zero-phonon line of the SnV to the effect of strain in the grown microcrystals. Boldyrev et al. [0 centres. Their findings included that for potential quantum applications of the SiV0, using isotopically pure carbon is more important than pure silicon for achieving a narrow spectral line.The experimental investigation of novel defects in diamond beyond the NV centre was a central focus of the Theo Murphy meeting and is represented in this special issue in two papers. Sedov et al.  producedv et al.  use spec


Dengue, a vector-borne disease, is a major public health problem in many tropical and subtropical countries including Bangladesh. The objective of this study is to estimate the societal cost of illness of dengue infections among the urban population in Dhaka, Bangladesh.A cost-of-illness study was conducted using a prevalence-based approach from a societal perspective. Costs attributable to dengue were estimated from a bottom-up strategy using the guideline proposed by the World Health Organization for estimating the economic burden of infectious diseases.A total of 302 hospitalized confirmed dengue patients were enrolled in this study. The average cost to society for a person with a dengue episode was US$ 479.02. This amount was ranged between US$ 341.67 and US$ 567.12 for those patients who were treated at public and private hospitals, respectively. The households out-of-pocket cost contributed to a larger portion of the total costs of illness (66%) while the cost burden was significantly higher for the poorest households than the richest quintile.Dengue disease imposes a substantial financial burden on households and society. Therefore, decision-makers should consider the treatment cost of dengue infections, particularly among the poor in the population while balancing the benefits of introducing potentially effective dengue preventive programs in Bangladesh. Dengue is a vector-borne viral disease affecting over 40 million people in Bangladesh. Dengue is endemic in urban Dhaka, Bangladesh, but the economic cost of illness is still limited. A growing literature shows that dengue imposes an enormous socio-economic burden on households, health systems, and societies. As there is no specific study estimating the economic costs of dengue infections in the Bangladesh context, the current study will serve as a benchmark to support evidence-based decision-making processes that guide the dengue prevention and control policies and allocation of health resources efficiently in Bangladesh. This study indicated, there is a substantial economic burden of dengue among the Dhaka city dwellers. We found that prevention of dengue hospitalization incidence, irrespective of the methods of prevention can save about US$ 479 per dengue case. Therefore, decision-makers should consider the treatment cost of dengue infections, particularly among the poor in the population while balancing the benefits of introducing potentially effective dengue preventive programs including vaccination strategies in Bangladesh. Aedes aegypti which was responsible for dengue [Dengue, a vector-borne disease caused by the dengue virus, is a major public health problem in many tropical and subtropical countries . The burr dengue . A recenr dengue .Dengue, a mosquito-borne viral disease, poses a significant threat to public health and imposes a substantial economic burden in Bangladesh. A growing literature shows that dengue imposes an enormous socio-economic burden on households, health systems, and societies ,9. A recEstimating the costs of dengue disease for Bangladesh is also important because it helps policymakers and public health officials allocate resources and design interventions to control and prevent the disease. Additionally, cost estimates can be used to identify cost-effective interventions and to measure the economic impact of dengue control efforts over time. Hence, the overall objective of this study is to estimate the cost of illness of dengue infections among the urban population in Dhaka from a societal point of view. As there is no specific study estimating the economic costs of dengue infections in the Bangladesh context, the current study will serve as a benchmark to support evidence-based decision-making processes that will guide the dengue prevention and control policies and allocation of health resources efficiently in Bangladesh.This study has been approved by the ethical review board of the Bangladesh Institute of Development Studies (BIDS), under the protocol number PSD/EEBDB/07.10/20. This study was performed in line with the principles of the Declaration of Helsinki. Written informed consent was obtained from all respondents before data collection.This is a hospital-based cost-of-illness study conducted in two private and two public hospitals in urban Dhaka, Bangladesh. The hospitals were randomly selected based on a list of hospitals provided by the office of the Director General Health Service Division under the Ministry of Health and Family Welfare, Bangladesh. Public hospitals play a significant role in providing treatment for a relatively large population as the treatment cost is less than private for-profit hospitals. However, people frequently visit both public and private hospitals in Bangladesh, irrespective of socio-economic class. The hospitalized patients who suffered from dengue fever between January to December 2019 and were confirmed as ’dengue cases’ by a registered physician consist of our study subject. According to the central limit theorem, at least 30 positive cases should be required to estimate the mean cost with an assumption of normal distribution . Thus, wThe study was performed from the societal perspective, which means all types of costs were identified, measured, and valued no matter who incurred them. The societal perspective is the aggregation of the provider and household perspective recommended in the current standards for cost-effectiveness analysis methods .Cost analysis was performed following the World Health Organization (WHO) guideline for estimating the economic burden of infectious disease . A bottoWe used age-specific and occupation-specific wage rates for capturing the productivity losses for non-market activities –20. FollThe patient-specific treatment cost approach was taken to estimate the average treatment cost borne by the hospital according to WHO guidelines . The cosBefore the data analysis, missing answers and outliers were systematically verified. The patient-specific cost of illness borne by the households and provider costs were reported separately. Proportion, frequencies, rates, and ratio were presented with a standard deviation in the local currency, i.e., Bangladeshi Taka (BDT) and US dollars (US$) applying the exchange rate during the time of the survey (US$1 = 83.28 BDT during the end-point of the data collection year 2020). A sensitivity analysis was conducted to examine the effect of potential outlier on the total cost of illness to test the robustness of the assumptions . One-wayA total of 302 hospitalized confirmed dengue patients were enrolled in this study , of whicThe average cost for treating the dengue patient was US$ 406.06 . The aveWe observed that the most influencing parameters were the cost of the diagnostic test, bed charge/fee, medicine, food cost and income loss of patients or caregivers during the treatment care .demonstrates the coping strategies during dengue treatment. The most common coping strategies were regular income (62.3%), borrowing from others (47.7%), savings (41.7%), a family donation (18.9%), and even selling permanent assets (1%).Dengue is an emerging public health problem in Bangladesh. In recent years, outbreaks of dengue have grown to be more frequent, larger, and with a greater proportion of severe cases and deaths in Bangladesh. The economic aspect of dengue infections has not been studied adequately in Bangladesh. This study provides the first estimate for the economic cost of dengue disease in urban Bangladesh from the perspective of the society. Therefore, this study could be used to gain a better understanding of how dengue prevention would bring about health and economic benefits to urban society in Bangladesh.This study found that the average societal cost of dengue was US$ 479, whereas the average societal cost of illness was US$ 342 and US$ 567 if the patients were treated in public and private facilities respectively in Bangladesh. The high share of out-of-pocket payments in the healthcare facilities demonstrates the economic hardship of the urban people in Bangladesh. A recent study conducted in a tertiary hospital in Bangladesh showed that the average cost of a hospitalized dengue patient was US$ 102 while 67% came from out-of-pocket cost . HoweverVarious studies on the economic burden of dengue infection were conducted in different regions of the world, and the average costs of illness per episode vary by the settings of the studies. A recent study mentioned that the annual economic burden of dengue fever was almost U$ 1,384 million in Southeast Asia with a per capita cost up to $ 2.41 . If we cThe findings highlighted the substantial economic burden of dengue among Dhaka city dwellers, which stresses on the urgent need for an effective national prevention strategy to perform considerable cost-savings besides reducing morbidity. Therefore, policy-makers should consider the treatment cost of dengue infections, particularly among the poor in the population while balancing the benefits of introducing potentially effective dengue preventive programs such as vaccine introduction. Indeed, vaccination is often considered to be the ‘best buy’ as it reduces the incidence of diseases and case fatalities, saves out-of-pocket expenditure, avoids productivity losses, mitigates the excessive pressure on the health system, and ensures equity . While tSeveral limitations might affect the interpretation of the outcomes. First, there may be recall bias and incorrect reporting primarily due to inaccurate memory during illnesses which could be under or over represent the real situation. Second, the inclusion of patients in a hospital setting indicates that they experienced relatively moderate to severe symptoms and, therefore, a proportion of mildly symptomatic patients may have remained undiagnosed and escaped inclusion. This study was limited among hospitalized dengue patients, but many episodes occurred at the community level which was not captured in this study. Thus, there is limited generalizability of using data from selected public and private health facilities informing the national policy and practices. Despite these limitations, our study has the most comprehensive list of costs for hospitalized dengue cases and identified the cost-driver during treatment in urban Dhaka to date. Further, the methods and analysis of results were presented in a straightforward manner so that anyone can compare similar study findings in other settings. Therefore, it is expected that the current study will be useful for informing the policymakers with the necessary knowledge for rational investment choice in preventing dengue infections from Bangladesh.There is a substantial economic burden of dengue among the Dhaka city dwellers. We found that prevention of dengue hospitalization incidence, irrespective of the methods of prevention can save US$ 479.02 per dengue case. Therefore, decision-makers should consider the treatment cost of dengue infections, particularly among the poor in the population while balancing the benefits of introducing potentially effective dengue preventive programs in Bangladesh. Further, this study allowed us to connect the economic impact of any public health interventions (either preventive or promotive) that can reduce the prevalence of dengue, which can be estimated from the data generated from this study. Further, dengue is a multifactorial disease requiring comprehensive approaches to address its spread effectively. Investing in sanitation can be a crucial aspect of reducing the vector breeding sites and the burden of dengue.S1 Fig(TIF)Click here for additional data file.


Multicellular organisms are very complex systems. This complexity is further increased by their interaction(s) with microbes. Recent technological advances have allowed us to study the interactions inside these complex systems at the single-cell level. This has revealed remarkable heterogeneity of both host and microbial cells, as well as heterogeneity in their interactions. The heterogeneity of interactions between host cells and isogenic bacteria has a large impact on the outcome of host-bacteria interactions.Our Research Topic focused on the heterogeneity of bacteria-host interaction and consists of six published articles by 32 co-authors with an acceptance rate of approximately 50%.Li et al. who examined the influence of saliva on the composition of the oral microbiota. First, the authors compared the composition of oral microbiota in mice with excised submandibular or sublingual glands with control animals. The treatment led to a significant increase in Lactobacilli in the operated mice, with a stronger effect noticed following submandibular gland removal. The authors further examined the protein composition of individual glands and identified that submandibular glands produce more immune-related proteins than sublingual glands. Single-cell RNA-seq analysis of cells from individual glands identified specific cell types responsible for the production of proteins identified by the proteomic approach. This study shed some light on the influence of individual host cells on the composition of the oral microbiota.The interaction between individual host cells and the local microbiome was studied by Gu et al. focused on the influence of a bacterial toxin on individual host cells. The authors used flow cytometry and microscopy techniques to study the influence of Campylobacter jejuni Cytolethal Distending Toxin (CDT) on the induction of apoptosis in human colon cells. The authors showed high variability in host DNA damage between individual host cells exposed to CDT-containing bacterial lysate. After confirming the cytotoxicity of CDT in their experimental model, the authors identified the Caspase-9/caspase-3/gasdermin E as the executive axis in CDT-induced pyroptosis. Finally, the authors indicated the role of reactive oxygen species in the CDT mechanism of action.Schulte et al. used TEM in combination with other microscopy techniques to examine morphotypes of individual viable pathogenic bacteria Salmonella enterica serovar Typhimurium. Using sample post-contrasting with uranyl acetate and lead citrate, the authors described two morphotypes of bacteria differing in cytoplasmic protein density, which they argued was caused by oxidative stress. Both morphotypes of bacteria were also found inside host cells and showed marks of proliferation. Similarly, the same proportion of both morphotypes was found to be metabolically active. Eventually, a third morphotype was discovered with a dense layer surrounding loose materials in the center. The authors correlated the appearance of bacteria with this “halo-shaped” morphotype with critical environmental conditions in which “the DNA needs to be shielded and protected”. Thus, using single-cell approaches, Schulte et al. provide experimental evidence of a heterogeneous morphological response of individual bacteria to environmental conditions.Transmission electron microscopy (TEM) has been used before to study bacteria in great detail. Luk et al. reviewed the differences and similarities of Salmonella intracellular lifestyles in epithelial cells, fibroblasts, and macrophages. The authors also concentrated on differences between particular cell lines used as models for each category of cells permissive for Salmonella intracellular survival. Special interest was given to the escape of Salmonella from Salmonella-containing vacuoles, the detection of escaped bacteria and their targeting for autophagy, and the hyper-replication of bacteria in the cytosol of epithelial cells. In contrast, cytosolic Salmonella does not hyper-proliferate in the cytosol of fibroblasts or immune cells. In addition, the authors described how the activation of caspase pathways by cytosolic Salmonella, which leads to host cell death, also differs between epithelial cells, fibroblasts, and immune cells. Another important topic discussed by the authors was the induction of persisters inside different types of host cells.Personnic et al. who chose Staphylococcus aureus, Salmonella enterica, Mycobacterium tuberculosis, and Legionella pneumophila as model organisms to describe the mechanisms that induce the formation of persisters in the host. The authors further described how persisters modulate their metabolic and defensive processes to be able to survive prolonged host attacks and how the persisters fight back to inhibit host bactericidal activities. The illustration of different bacterial persister states and host cell functional states underscore the complexity of the covered topic.Persisters were reviewed in more detail by Fernández-Fernández et al. reviewed the use of state-of-the-art cell sorting approaches to study Salmonella heterogeneity. The authors first introduced the concept of cell sorting and the different types of cell separation methods, including immunomagnetic cell sorting (MACS) and fluorescence-activated cell sorting (FACS). Then, the authors described how these cell separation methods can be applied to investigate bacterial heterogeneity during different types of bacteria-host interactions. The authors also described how cell separation methods can be applied to study the exposure to biocides, the purification of bacterial cell envelopes, and the study of bacterial susceptibility to antibiotics and gene expression. From this review article, it becomes clear that the use of cell sorting has lots of potential to explore key aspects of bacterial physiology that classic microbiology methods (that work at the whole population level) cannot address.In summary, the articles on this Research Topic brought together interesting observations on interactions between individual host cells and individual bacteria and summarized current knowledge on current technological development as well as on the heterogeneity of bacterial lifestyles upon interaction with the host.OC and DL-M conceived and wrote the editorial. CG reviewed and approved the final version.


Underwater autonomous driving devices, such as autonomous underwater vehicles (AUVs), rely on visual sensors, but visual images tend to produce color aberrations and a high turbidity due to the scattering and absorption of underwater light. To address these issues, we propose the Dense Residual Generative Adversarial Network (DRGAN) for underwater image enhancement. Firstly, we adopt a multi-scale feature extraction module to obtain a range of information and increase the receptive field. Secondly, a dense residual block is proposed, to realize the interaction of image features and ensure stable connections in the feature information. Multiple dense residual modules are connected from beginning to end to form a cyclic dense residual network, producing a clear image. Finally, the stability of the network is improved via adjustment to the training with multiple loss functions. Experiments were conducted using the RUIE and Underwater ImageNet datasets. The experimental results show that our proposed DRGAN can remove high turbidity from underwater images and achieve color equalization better than other methods. With developments in science and technology, Internet of Things (IoT) technology has been introduced into advanced underwater vision tasks, such as autonomous underwater driving, ocean scene analysis, and fisheries. Underwater data, such as the marine environment, marine density, and seafloor pathways, are monitored to understand the state of the underwater environment and the growth and health of underwater life through the intelligent analysis of real-time photographs taken underwater. However, the accuracy of the intelligent analysis results is greatly influenced by the underwater images’ quality; a complex imaging environment results in color casts and a loss of detail in the images obtained ,2. As a Underwater image enhancement is developing rapidly via both traditional and deep learning. In traditional methods, Drews et al. , influenIn recent years, the application of deep learning methods in underwater image processing has become more and more prominent, especially deep learning methods based on genetic algorithms. For example, Li et al.  proposedThe above methods focus on enhancing underwater images, as shown in (1)A multi-scale feature extraction module is proposed to extract image detail information and expand the receptive field.(2)A dense residual block is proposed to fuse feature maps into clear images, not only fully utilizing all layers with local dense connections but also adding residual connections to reuse information.(3)We combine multiple loss functions to facilitate the learning of the generator regarding the generation of clear images. The experimental results show that DRGAN outperforms the state-of-the-art methods in terms of qualitative and quantitative indicators.To solve the problems above, we propose the implementation of the Dense Residual Generative Adversarial Network (DRGAN). Here are the primary contributions:The remainder of this work is structured as follows. Generative adversarial networks are composed of two distinct neural networks: a generator and a discriminator . In thisHe et al.  suggesteAs shown in The distinction between densely connected convolutional networks (DenseNets)  and resiThe dense connections in Our generator includes a multi-scale feature extraction module (MSFEM) and dense residual block (DRB), facilitating the generation of crystal-clear underwater images. Using the yellow convolution unit in the MSFEM as a case in point, as demonstrated in As shown in As illustrated in By combining residual and dense connections, the DRB ensures the correct transmission of feature information and reduces the computational complexity of the module. More importantly, compared with other networks, the network efficiency is improved without additional logistical costs, making feature information fusion more efficient. The result of the residual can be expressed as:Derived from the SSIM test results shown in The proposed discriminating network, as illustrated in In the last layer, the sigmoid function is used to map the output pixel range to the undistorted image, which can clearly distinguish the authenticity of the created image and the undistorted image in a certain area. The function expression is as follows:(1)GAN LossThe adjustment of the network is facilitated by the linear combination of GAN loss and SSIM loss, as outlined below.(2)SSIM LossGAN loss functions are used to make the generated sample distribution as close to the true sample distribution as possible. The following is the definition of countermeasure loss:(3)Perceptual LossThe structural similarity of the two images is measured using SSIM loss. SSIM loss functions similarly to the human visual system. It is sensitive to the perception of local structural changes and is conducive to enhancing the image’s texture details. SSIM loss is defined as:(4)Overall LossThe parameters of the feature map in the trained convolutional neural network define the perceptual loss. The image details obtained after the function participates in the training are more realistic. The perceptual loss is defined as:The function of the overall loss obtained via the linear combination of the three loss functions can effectively improve the robustness of the network and is defined as:After many experiments, To verify the effectiveness of DRGAN, in this study, we firstly set the experimental details. Then, we compared DRGAN with different representative methods. These methods included Fusion , ICCB 2, L^2UWE We conducted experiments on the Underwater ImageNet  dataset The color of the undistorted swatch image would be degraded because of the complex underwater imaging environment. Therefore, the color restoration impact of DRGAN could be efficiently tested through color recovery experiments on the color card .As can be seen in Next, the method was applied to images from a complex underwater environment. The input image was affected by different degrees of color distortion, low brightness, and turbidity, resulting in various degradation phenomena. As can be seen in (1)The underwater color image quality evaluation index  (UCIQE) (2)The underwater image quality measurement  (UIQM) i(3)The structural similarity index measurement  (SSIM) i(4)The peak signal-to-noise ratio (PSNR) is an index to measure image quality. The calculation formula for the mean square error (MSE) is:(5)The CIEDE2000 evaluation index , which hThe image quality when applying our method was further evaluated through five objective evaluation indexes: UCIQE, UIQM, SSIM, PSNR, and CIEDE2000.Comparing the data in We used UCIQE to evaluate the images in The UIQM results from As the RUIE dataset has no ground truth, we chose the UIQE and UIQM metrics when comparing with other algorithms, and we used the UCIQE, UIQM, SSIM, and PSNR metrics on the Underwater ImageNet dataset. The test results using the Underwater ImageNet dataset and RUIE dataset are shown in We verified the effectiveness of DRGAN on the Underwater ImageNet dataset and applied the model trained on the Underwater ImageNet dataset to the RUIE dataset. In the Underwater ImageNet dataset, DRGAN’s PSRN, UIQM, and UCIQE outperformed the other algorithms, indicating that the DRGAN enhancement results are closer to the real images. On the RUIE dataset, on average, DRGAN also achieved better results. While FUnIE also adds residual connections, it is only in the Green and Atomization environments in the RUIE dataset that the SSIM indicators for the Underwater ImageNet dataset are better than those of DRGAN. From the above, it can be concluded that the addition of dense and residual connections in DRGAN has a better performance-enhancing effect and leads to a better generalization ability.We conducted module ablation experiments using the Underwater ImageNet dataset. Firstly, we evaluated the images processed via different modules using PSNR, SSIM, UCIQE, and UIQM. Then, we randomly selected an image for subjective comparison. Less image feature information makes underwater image detection more challenging. As shown in In this paper, we propose DRGAN as a means of enhancing underwater images, drawing inspiration from ResNet and DenseNet. Through the utilization of a multi-scale feature extraction module and a dense residual block in the generator, multi-scale feature information is integrated. The incorporation of these multi-stage features broadens the receptive field and safeguards against any decline in network performance due to gradient disappearance. Additionally, DRGAN optimizes network utilization by leveraging the benefits of both residual and dense connections. It is worth mentioning that the generator’s computational efficiency has been enhanced in comparison to networks that solely rely on dense blocks. We employ a discriminator akin to PatchGAN for adversarial training, and this augments the generator’s ability to sharpen images. The findings from the experiments conducted on intricate underwater scenes indicate that DRGAN greatly enhances the quality of images in comparison to various renowned techniques. In the future, we plan to use the proposed method in other areas of marine engineering, such as object recognition and detection within wider underwater scenes.


Teaching Point: Osteoid osteoma is one of the most frequent benign bone tumors; however, when found in the toes it usually presents atypical clinical and radiological features including soft tissue swelling that can lead to misdiagnosis. A 20-year-old male presented with complaints of progressing swelling and mild disturbance on the tip of the second left toe, without a preceding history of trauma. No involvement of other joints or systemic manifestations were reported. A foot magnetic resonance imaging (MRI) was requested under the suspicion of soft tissue abnormality.Magnetic resonance imaging showed a pseudonodular soft tissue subungual lesion with high signal on FS-PD images and contrast uptake .Associated findings included erosive changes on the terminal tuft and surrounding soft tissue edema . A presuDermatologists performed surgical exploration of the subungual tissue, but no tumoral lesion was identified. Soft tissue samples were obtained without relevant findings.Given the absence of a definitive diagnosis and the progressive development of morphological changes in the toe, it was decided to carry on with an excisional biopsy of the distal phalanx.The patient was treated surgically, and histopathology study of the specimen showed anastomosing trabeculae of woven bone rimmed by plumb osteoblasts consistent with osteoid osteoma .Osteoid osteoma (OO) constitutes 10–12% of all benign bone tumors. It has a male predilection and usually occurs in young subjects. Patients typically present with a distinctive nocturnal pain relieved by non-steroidal anti-inflammatory medication. Radiologically, a particular feature is the presence of a cortical lucent nidus surrounded by sclerotic bony reaction [OO of the toe has a low prevalence, being more frequent on the hallux and distal phalanges. Furthermore, when this lesion is found in the phalanges it is more likely to have an endosteal or periosteal location, which determines the uncommon clinical and radiological findings.MRI studies of similar cases from literature only reported a characteristic nidus in half of them, probably because in small lesions the nidus and surrounding cortex show an indistinguishable signal intensity.Less frequent pain of the lesion can be explained by the periosteal origin and the absence of weight-bearing stress. In addition, cutaneous and vasomotor alterations are directly related to the increased release of prostaglandins from the nidus.All these clinical and radiological aspects derived from the OO in the toe phalanx must be differentiated from a wide range of conditions including infective, rheumatic, traumatic, and neoplastic circumstances . Glomus The main treatment of OO is the removal of the nidus, either with surgical resection or by percutaneous procedures such as radiofrequency ablation.


Congenital gastrointestinal (GI) malformations like anorectal malformations (ARM), Hirschsprung's disease (HD), and intestinal atresias are conditions that are commonly presented. Though there is the possibility of some of them being detected antenatally in scans, they are usually missed or may even go undetected. Atresia is a congenital defect of a hollow viscus that results in complete obstruction of the lumen. Intestinal atresia is one of the most frequent causes of bowel obstruction in newborns and can occur at any point in the gastrointestinal tract. Cases of intestinal obstruction in neonates can be either congenital or acquired. Congenital causes involving obstruction of the digestive tract can be divided into high obstruction occurring above the level of the ileum and low-lying obstructions occurring in the ileum and the colon. Approximately one-half of the cases presenting with GI obstruction involve the duodenum. Amongst other congenital malformations of the GI tract, in the order of incidence, intestinal atresias are the most commonly presenting followed by anal atresia or anorectal malformations and lastly esophageal atresia as a part of the tracheo-esophageal fistula (TEF). Intestinal atresias contribute to nearly 50% of intestinal obstruction cases presenting in the neonatal period. About 20 percent of these are associated with chromosomal anomalies. Among the acquired causes of intestinal obstruction presenting in the neonatal period, midgut malrotation or midgut volvulus are seen, mostly in the first week of life. Here, we present a neonate brought to us on day 2 of life in view of feed intolerance at birth with bilious vomiting and abdominal distension. X-ray erect abdomen showed a classical triple bubble sign suggestive of jejunal atresia (A). The patient was taken up for explorative laparotomy and was found to have type high jejunal atresia with multiple, distal atretic segments, which falls into the type 4 category, the rarest form. Resection of 12 cm of the atretic jejunum and end-to-end anastomosis were done . All cases of obstruction, whether congenital or acquired, require radiological diagnosis as soon as one is suspected and surgical management in the neonatal period to avoid deleterious complications of gut ischaemia, perforation, and peritonitis. Most cases of neonatal GI obstruction have a good prognosis post-operatively, especially after the advent of parenteral nutrition with cautious its use and improved neonatal care facilities.