Colonoscopy is a valuable tool for preventing and reducing the incidence and mortality of colorectal cancer. Although several computer-aided colorectal polyp detection and diagnosis systems have been proposed for clinical application, many remain susceptible to interference problems, including low image clarity, unevenness, and low accuracy for the analysis of dynamic images; these drawbacks affect the robustness and practicality of these systems. This study proposed an intraprocedure alert system for colonoscopy examination developed on the basis of deep learning. The proposed system features blurred image detection, foreign body detection, and polyp detection modules facilitated by convolutional neural networks. The training and validation datasets included high-quality images and low-quality images, including blurred images and those containing folds, fecal matter, and opaque water. For the detection of blurred images and images containing folds, fecal matter, and opaque water, the accuracy rate was 96.2%. Furthermore, the study results indicated a per-polyp detection accuracy of 100% when the system was applied to video images. The recall rates for high-quality image frames and polyp image frames were 95.7% and 92%, respectively. The overall alert accuracy rate and the false-positive rate of low quality for video images obtained through per-frame analysis were 95.3% and 0.18%, respectively. The proposed system can be used to alert colonoscopists to the need to slow their procedural speed or to perform flush or lumen inflation in cases where the colonoscope is being moved too rapidly, where fecal residue is present in the intestinal tract, or where the colon has been inadequately distended. Colonoscopy is a valuable tool for detecting colorectal diseases. Chromoendoscopy is often used in the diagnosis of polyps through the enhancement of the color, vascular structure, and surface morphology of polyp lesions . GeneralPatients undergoing colonoscopy are required to maintain a low-residue diet and take laxatives to empty their bowels of excrement to allow the colonoscopists to have a clear view of the intestinal mucosa. While performing a colonoscopy, a colonoscopist inserts a colonoscope into the patient’s anus and further guides it into their bowel lumen, passing through the rectum, sigmoid colon, descending colon, transverse colon, and ascending colon before finally reaching the cecum. The colonoscopist then slowly pulls back the colonoscope from the cecum and may push it forward or pull it farther back as necessary to examine the mucosa in detail. Polypectomy or biopsy may be performed if a polyp or lesion is detected. Among the quality indicators of colonoscopy , the adeSeveral deep learning–based systems have been formulated for the diagnosis and detection of colorectal polyps ,12,13,14The clarity of images of the colorectal mucosa strongly affects the quality of colonoscopy. The factors behind low colonoscopic image quality include inadequate bowel preparation, insufficient air or carbon dioxide insufflation, lens fogging or a colonoscopic lens stained with fecal matter, and blurred images . In addiBlurred images refer to images rendered out of focus because of motion resulting from the rapid withdrawal of the colonoscope or from withdrawal with an unsteady hand, either of which can prevent the accurate observation and identification of lesions. Colonoscopists may miss lesions because of low image quality, and machine vision systems, whose accuracy is particularly dependent on image quality, may perform much worse if the problem of poor image quality is not addressed. Hassan et al.  reportedSharp and clear images are necessary for the computer-aided detection and identification of colorectal polyps and lesions. The technique of searching for and identifying the shape, texture, and morphology of protrusions in the intestinal tract is akin to the identification of foreign object damage (FOD) on an airport runway, which severely hinders flight and passenger safety ,27. SomeThis study proposed an alert system for colonoscopic examinations that uses deep learning to alert the colonoscopist with a message when the image is blurred because of rapid movement or when fecal matter or water in the lumen, insufficient air inflation, or polyps are detected. Colonoscopists should pay attention to any abnormalities during examination to avoid missing lesions and to improve the quality of colonoscopy. A CNN model was used to determine when an alert message ought to be sent. The experimental results revealed that the number of polyps of each case identified by the proposed system is the same as the number of polyps detected by endoscopists through per-polyp analysis. In addition, the sensitivity rates for the detection of high-quality images and the detection of polyps were 92% and 95.74%, respectively, and the false alarm rate of low-quality images was 0.18%. The proposed system can be employed by clinicians to improve the quality of colonoscopies.The remainder of this paper is organized as follows: The training and validation datasets used for the proposed system were obtained from the PolypsSet dataset  and ChanThe size of each input image was measured in terms of the width (W) × Height (H) × filter number (N). All of the images were adjusted to fit the specification of the CNN deep learning model. We employed convolution, batch normalization, a rectified linear unit, and maximum pooling operations to conduct feature extraction . Table 5Nearly 70% of colorectal adenocarcinomas develop from conventional adenomas, with the remaining 30% develop from sessile serrated polyps . The proColorectal lesion detection is markedly affected by the quality of the colonoscopic image obtained, which is evaluated in terms of colon cleanliness, the clarity of mucosal images, and the degree of bowel distension . Colon cIn addition to poor bowel preparation, another factor that may affect the clarity of mucosal images is the rapid withdrawal of the colonoscope, which can result in blurred images. According to multiple studies, physicians whose colonoscope withdrawal duration during a normal inspection is 6 min or longer have a considerably higher ADR than physicians whose withdrawal duration is less than 6 min . In addiOptimal colon distension is a prerequisite for colonoscopists to examine every part of the mucosa in detail. Several studies have confirmed that physicians who can adequately distend the lumen have a lower miss rate for colorectal adenomas . A studyThe results of our study revealed that the proposed system could effectively alert endoscopists to low-quality images or poor colon preparation, prompting them to focus the image, clean the bowel, or inflate the lumen for detailed examination. This system reduces the likelihood of clinicians failing to spot colon polyps. The main limitation of this study was that only retrospectively recorded videos from a single medical center were used. Therefore, a large-scale prospective multicenter clinical trial is needed to validate the efficacy of the proposed system in increasing the colon polyp detection rate.This study proposed an intraprocedure AI alert system for colonoscopy examination. Using feature extraction and classification alongside a CNN model, this system can identify blurred images, instances of inadequate bowel cleansing, and instances of insufficient air insufflation during colonoscopies. The system then alerts the clinician to the need to correct or pay greater attention to specific elements during examination in order to reduce the loss of crucial information and improve the reliability of the examination. The main novel feature of our study was the detection of low-quality images and foreign bodies in intestinal lumen to alert endoscopists and, thus, achieve higher-quality colonoscopy examination. Our experimental results indicated that blurred image and foreign body detection can prevent misjudgments and yield accurate polyp detection. In addition, our dynamic image sampling method indicated that the use of just three or four images from each second of footage for detection can yield accurate results; this means that our method is computationally lightweight.Several polyp detection and classification systems can reduce the false-positive rate by enlarging training datasets. However, these systems still encounter challenges in the presence of colon folds, fecal matter, or water during examination. Our experimental results indicated that blurred image and foreign body detection can prevent misjudgments and be used to accurately detect polyps. Furthermore, thanks to our dynamic image sampling method, the use of just three or four images from each second of footage for detection can reduce the information processing load and thus lower the hardware requirements for image processing.


The patient was a 69-year-old recreational golfer who injured his right . While walking between the 9th and 18th holes, he slipped on pine straw. Ultrasound images of the quadriceps tendon post-injury revealed a full-thickness tear of the Quadriceps tendon, Rectus Femoris and Vastus intermedius. The diagnosis was confirmed through MRI arthrogram imaging. The hypoechoic finding in the ultrasound exam demonstrated the imaging to be as precise in diagnosing a full thickness tear as the MRI. The patient underwent surgical repair of the Quadriceps Tendon and is currently progressing in rehabilitation.  Based upon these clinical findings, ultrasound imaging was performed at point-of-care showing full thickness mid-tendon tear of the rectus femoris .The patient was referred to an orthopedic surgeon, who performed MRI imaging , confirming an avulsion of the superficial aspect of the rectus femoris from its patellar attachment and retracted proximally 1.9 cm and a complete tear. Subsequently, the patient underwent immediate open repair of the quadriceps tendon and began rehabilitation after 6 weeks. The patient was a 69-year-old recreational golfer who injured his right knee by slipping on pine straw, forcefully flexing his right knee under full weight-bearing. He indicated immediate sharp anterior knee pain and the inability to move his right leg. Upon examination, he presented with a palpable deformity proximal to the apex of the patella and moderate swelling at the lateral knee. The patient was unable to produce a quadriceps contraction and Passive Range of Motion (PROM) was limited due to pain. At time of injury, the patient had been prescribed three rounds of steroidal anti-inflammatory drugs for sinus infections, and had a prior history of a 3This case illustrates the effectiveness of point of care ultrasound imaging identifying rectus femoris tendon tear. Prior researchhas indicated a high degree of clinical accuracy of ultrasound imaging for identifying partial and full thickness quadriceps tendon tears, comparable to MRI This study was approved by the Institutional Review Board of Florida Gulf Coast UniversityThe authors affirm they have no financial affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript, except as disclosed in an attachment and cited in the manuscript.


As patient-reported outcome measures (PROMs) have become of significant importance in patient evaluation, adequately selecting the appropriate instrument is an integral part of pediatric orthopedic research and clinical practice. This systematic review provides a comprehensive overview of PROMs targeted at children with impairment of the upper limb, and critically appraises and summarizes the quality of their measurement properties by applying the COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) methodology.A systematic search of the MEDLINE and EMBASE databases was performed to identify relevant publications reporting on the development and/or validation of PROMs used for evaluating children with impairment of the upper extremity. Data extraction and quality assessment  of the included studies was undertaken by two reviewers independently and in accordance with COSMIN guidelines.Out of 6423 screened publications, 32 original articles were eligible for inclusion in this review, reporting evidence on the measurement properties of 22 self- and/or proxy-reported questionnaires  for various pediatric orthopedic conditions, including cerebral palsy (CP) and obstetric brachial plexus palsy (OBPP). The measurement property most frequently evaluated was construct validity. No studies evaluating content validity and only four PROM development studies were included. The methodological quality of these development studies was either ‘doubtful’ or ‘inadequate’. The quantity and quality of the evidence on the other measurement properties of the included questionnaires varied substantially with insufficient sample sizes and/or poor methodological quality resulting in significant downgrading of evidence quality.This review provides a comprehensive overview of currently available PROMs for evaluation of the pediatric upper limb. Based on our findings, none of the PROMs demonstrated sufficient evidence on their measurement properties to justify recommending the use of these instruments. These findings provide room for validation studies on existing pediatric orthopedic upper limb PROMs , and/or the development of new instruments.The online version contains supplementary material available at 10.1186/s41687-022-00469-4. Over the last decades, the focus of clinical research has shifted from conventional survival and disease outcomes, to patient experience and patient-reported outcomes (PROs) . A PRO iOrthopedic injuries of the upper extremities are amongst the most common injuries in the pediatric population , 5. As tSystematic reviews of PROMs play an important role in guiding PROM selection . By provAs a result, the inadequate application and selection of PROMs is still common practice in pediatric orthopedics. In a recent publication, Arguelles et al.  demonstrThus, we conducted a systematic review of pediatric orthopedic PROMs validated for children with impairment of the upper extremity. The primary goal of this review was to provide a comprehensive overview of self- and/or proxy-completed questionnaires targeted at children with impairment of the upper limb, and to critically appraise and summarize the quality of their measurement properties. The secondary goal of this review was to provide evidence-based recommendations for PROM selection in pediatric orthopedic research and clinical practice.In conducting this systematic review, the updated COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) methodology for systematic reviews of PROMs was used –17. ThisThis study was pre-registered in PROSPERO (PROSPERO registration number: CRD42021254791).To identify relevant studies, MEDLINE was systematically searched using PubMed, and EMBASE was systematically searched through the Embase search engine. The timeframe was defined as 1st of January 2000 to 8th of February 2021. The search was restricted to English and/or Dutch articles only by using language filters.A comprehensive search strategy was constructed in collaboration with a clinical librarian to guarantee a thorough approach. The search strings for each database can be found in full detail in Additional file Articles were considered eligible for inclusion if a full-text original version of the article was available and if the article reported on studies describing the development and/or the evaluation of one or more measurement properties of a generic and/or disease-specific patient-reported and/or proxy-reported questionnaire of any language, in a population consisting of children (0–18 years old) with an orthopedic diagnosis in the upper extremity region. Exclusion criteria consisted of any study design in which the patient-reported and/or parent-proxy-reported questionnaire was only used as an outcome measurement instrument  and/or in which one or more questionnaires were evaluated that aimed to assess the use of prostheses by children (0–18 years old).First, all eligible studies were selected by screening the title and abstract. Thereafter, all selected papers were screened based on full text. During both phases two reviewers (JPR and TFF) independently identified eligible studies according to the predefined eligibility criteria and afterwards discussed the results. Disagreements were resolved by a third reviewer (IN or CJA). The references of the articles selected for full-text review were thoroughly screened to identify additional citations.The studies on measurement properties included in this review were assessed in accordance with the extensive and recently improved COSMIN methodology for qualitatively evaluating studies on PROMs . DetaileThe COSMIN Risk of Bias checklist  was usedStudies on content validity  were evaluated using the separate COSMIN methodology for evaluating content validity . The quaFollowing the methodological quality assessment, data on the characteristics of the included study populations , characteristics of the studied PROMs and results of each study on a measurement property were extracted using tables provided by the COSMIN initiative .The result of each study on a measurement property was rated against the updated criteria for good measurement properties . The indFinally, a qualitative synthesis of the evidence per measurement property, per PROM was constructed to come to an overall conclusion of PROM quality. If consistent , the results of the individual studies on measurement properties were qualitatively summarized and again rated against the criteria for good measurement properties. If inconsistent, an explanation for this inconsistency was sought. When the inconsistency remained unexplained, the overall result was rated as ‘inconsistent’ (±). An ‘indeterminate’ (?) rating was given when the individual results were all rated as ‘indeterminate’ .After qualitatively synthesizing and rating the overall results per measurement property, per PROM, the quality of this evidence was graded. In accordance with COSMIN guidelines, a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used for grading the evidence . The sumThe above-mentioned subsequent steps of the COSMIN evaluation were performed by two reviewers (JPR and TFF) independently. If consensus could not be reached during any of the evaluation procedures, an additional reviewer (IN and/or CJA) was consulted. For evaluating inter-rater agreement, a percentage agreement was calculated by dividing the number of ratings which the reviewers agreed on, by the total number of ratings given by the two reviewers. In accordance with the criterium for assessing inter-rater agreement proposed by Mokkink et al. , the intThe literature search initially identified 8179 articles. After duplicates were removed, 6423 articles remained. Of these 6423 references, 113 were deemed eligible for inclusion after screening the titles and abstracts. As a result of hand-searching the bibliographies of these eligible articles, 27 potentially relevant citations were identified. The full-text assessment of the remaining 140 articles resulted in the inclusion of 32 original reports. The PRISMA flow diagram describing the selection process is shown in Fig. The inter-rater agreement (percentage agreement) was calculated to be 94% and therefore considered appropriate.Table In agreement with COSMIN methodology, each version of a questionnaire was considered a separate PROM  . The chaThe results of the methodological quality assessment and criteria for good measurement properties ratings of the individual studies are presented in Table No studies evaluating the content validity of a PROM were considered eligible for inclusion in this review. Therefore, only the methodological quality of the included PROM development studies was determined. As each of the included development studies did not report on a pilot study assessing the comprehensibility and comprehensiveness of the instrument, the overall methodological quality of the four PROM development studies was rated as ‘inadequate’ or ‘doubtful’ –36.Structural validity was evaluated for eleven of the included PROMs –39. FiveFor internal consistency analyses to be interpreted correctly, an instrument should at least show low-quality evidence for sufficient structural validity . TherefoThirteen of the included PROMs demonstrated evidence for sufficient test–retest reliability , 39–44. The results of analyses on measurement error were all rated as ‘indeterminate’, since information on minimal important change (MIC) had not yet been published for the PROMs included in this review.This study is the first systematic review to provide a comprehensive overview of evidence on the psychometric properties of PROMs used for evaluating children with impairment of the upper extremity. Twenty-two PROMs, measuring various constructs, were included and evaluated using the updated version of the extensive COSMIN methodology to ensure a high-quality assessment. Additionally, this study provides an opportunity to formulate evidence-based recommendations for PROM-selection and increase awareness on proper PROM utilization in clinical practice and research.When basing recommendations for PROM-selection exclusively on the quality of their measurement properties, the current lack of evidence on PROM-quality has the consequence that the 22 pediatric orthopedic PROMs included in this review have the potential to be recommended for use, but further research is required to assess their quality. Evidence on content validity and internal consistency of a PROM is fundamental to formulating a transparent, evidence-based recommendation . HoweverWhen exploring additional means to provide clinicians and researchers with a basis to guide their PROM-selection, formulating recommendations based on feasibility aspects of PROMs constitutes a valuable alternative approach. The term ‘feasibility’ refers to the ease with which the instrument is applied in its intended context of use and includes PROM characteristics such as completion time and length of the questionnaire . AlthougThe overall methodological quality of the four PROM development studies included in this review was rated as ‘inadequate’ or ‘doubtful’ –36. For Whilst conducting this systematic review, we followed the extensive and newly updated COSMIN methodology for systematic reviews of PROMs, which can be considered one of the strengths of this study. Using the COSMIN checklists sometimes requires a subjective judgement by the reviewer . This potential source of bias was addressed by two reviewers independently extracting and evaluating data and by building consensus, further strengthening the approach utilized in this review.This review has some limitations. Even though using the COSMIN methodology guarantees a standardized and thorough approach for evaluating the included studies on measurement properties, “the worst score counts” principle applied in rating these studies can be considered reductive. As the worst rating in a COSMIN box will determine the overall result of the quality assessment, the absence of reporting on a particular evaluation step or statistical method can result in the study being rated as ‘doubtful’ or even ‘inadequate’. Consequently, a cogent argument can be made that using this principle results in the undervaluation of the already small amount of evidence available on pediatric orthopedic PROMs.In an effort to provide a comprehensive overview of the pediatric orthopedic PROMs available to clinicians and researchers, we purposefully used broad inclusion criteria with respect to study population  and type of instrument . Subdividing the population of interest based on affected limb, body region or disease type, was limited by the paucity of evidence available on pediatric orthopedic PROMs. In addressing the challenges these broad inclusion criteria posed to the feasibility of our review, some concessions had to be made regarding the scope of our search. Consequently, only MEDLINE and EMBASE were searched omitting potentially relevant databases like CINAHL, and the timeframe was condensed, possibly preventing the inclusion of additional relevant articles.In conclusion, a comprehensive overview was given of PROMs used in pediatric orthopedic research of the upper extremity. None of the PROMs included in this review demonstrated sufficient evidence on their measurement properties to strongly recommend the use of any of these instruments in children with impairment of the upper extremity. The absence of studies on content validity for any of the included PROMs is especially worrisome, as this implies it is currently unknown if the questionnaires used in pediatric orthopedic research and clinical practice adequately reflect the construct they intend to measure. When an alternative, feasibility-driven approach to guiding PROM-selection is adopted, the PROMIS – Upper Extremity CAT can cautiously be considered the most appropriate PROM for measuring upper extremity function in children with impairment of the upper limb. The lack of evidence on PROM-quality uncovers a need for high-quality development and validation studies, and especially studies on content validity, for PROMs utilized in pediatric orthopedics.Additional file 1.Appendix 1: search strings MEDLINE (PubMed) and EMBASE; Appendix 2: Results and ratings of measurement properties of the included PROMs.


The Maxilla and mandible provide skeletal support for of the middle and lower third of our faces, allowing for the normal functioning of breathing, chewing, swallowing, and speech. The ablative surgery of jaws in the past often led to serious disfigurement and disruption in form and function. However, with recent strides made in computer-assisted surgery and patient-specific implants, the individual functional reconstruction of the jaw is evolving rapidly and the prompt rehabilitation of both the masticatory function and aesthetics after jaw resection has been made possible. In the present review, the recent advancements in jaw reconstruction technology and future perspectives will be discussed. The reconstruction and rehabilitation of jaws following ablative surgery have been transformed in recent years by the development of computer-assisted surgery and virtual surgical planning. In this narrative literature review, we aim to discuss the current state-of-the-art jaw reconstruction, and to preview the potential future developments. The application of patient-specific implants and the “jaw-in-a-day technique” have made the fast restoration of jaws’ function and aesthetics possible. The improved efficiency of primary reconstructive surgery allows for the rehabilitation of neurosensory function following ablative surgery. Currently, a great deal of research has been conducted on augmented/mixed reality, artificial intelligence, virtual surgical planning for soft tissue reconstruction, and the rehabilitation of the stomatognathic system. This will lead to an even more exciting future for the functional reconstruction and rehabilitation of the jaw following ablative surgery. The maxilla and mandible play a crucial role in maintaining the facial contour and the upper airways and ensure masticatory function and the lip seal for swallowing and speech articulation. Ablative surgery of the jaw, for various reasons, often leads to a significant compromise of the jaw’s function and aesthetics, requiring reconstructions that are technique-sensitive and often time-consuming.In recent years, the development of computer-assisted surgery and patient-specific implants have revolutionized jaw reconstructive surgery. With their high efficiency, accuracy, and predictability, these techniques have pushed the boundaries of functional jaw reconstruction further . The devRecently, a great deal of research has been undertaken on augmented/mixed reality surgery, artificial intelligence, virtual surgical planning for soft tissue reconstruction, and muscular and stomatognathic system rehabilitation.In this narrative literature review, we aim to discuss the current state-of-the-art of the reconstruction and rehabilitation of the jaw and preview the potential future developments. These ground-breaking publications were summarized with the supplementation of papers yielded from keyword searches of each field in Google Scholar, PubMed, and ScienceDirect.Computer-assisted surgery has revolutionized jaw reconstructive surgeries. Through virtual surgical planning, more predictable and accurate jaw reconstructions can be achieved. In addition, a significant amount of operative time can be saved, thus enabling complex functional jaw reconstruction.Computer-assisted surgery normally starts from the clinical history-taking and physical examination. The history of previous surgeries and radiation therapy to the head and neck is crucial for the selection of suitable recipient vessels. A clinical examination is performed to determine the nature and extent of the lesion and formulate a tentative surgical plan. An intraoral scan is obtained to register the occlusion and the intraoral extension of the lesion. A CT scan of the head & neck and a CT angiogram of the donor site are crucial for assessing the vessel’s condition and the suitability of the free flap donor site.Three-dimensional models of the donor and recipient sites are built based on the CT and intraoral scans. Virtual resections and reconstructions may be performed for a better understanding of the intraoperative condition. Based on the virtual planning, surgical positioning, cutting guides, and/or patient-specific implants are designed. .A post-operative evaluation that compares the virtual surgical plan and the final surgical outcome is crucial for the assessment of the accuracy of the computer-assisted surgery and potential future improvements .Since the surgical procedure is well planned before the operation, the efficiency of surgery significantly improves with CAS. The systematic review and meta-analysis by Powchareon et al. demonstrated a reduced ischemic time to free flaps, reconstruction time, total operative time, and postoperative hospital stay . The appAnother advantage of CAS lies in its value for medical education and surgical training. Compared to free hand surgery, junior and less experienced surgeons can achieve more consistently favorable tumor resections and reconstruction outcomes, which is important for teaching hospitals .While providing a high predictability and reproducibility, CAS is also challenged for its rigidity and difficult improvisation during the surgery as most of the planning is performed before the operation.The first and the most significant concern is for the oncological safety of the predetermination of the surgical margins, especially in malignant jaw pathologies where positive and close margins can lead to compromised local-regional control of disease and patient survival . In CAS,Another concern is the low adherence to the CAS planning when the unexpected change of surgical plans arises intraoperatively. Wilde et al.  and Ma eThe steep learning curve of CAS has also been regarded as a challenge when popularizing the technique. A cumulative sum analysis revealed a three-stage learning curve of CAS, including initial learning, plateau, and overlearning, and surgical proficiency was obtained after 23 cases . This caCurrently, CAS is used mostly for bony reconstruction. The computer-assisted reconstruction of soft tissue defects after the resection of malignant tumors is still under investigation and will be discussed in A significant improvement in bone fixation plates has been observed in the past decades. The traditional mass-produced fixation plates come with universal shapes. Bending and adaptation to the specific defect may be technique sensitive and time-consuming, especially for complex cases . The repDifferent types of patient specific implants have been fabricated so far, the most common being the patient-specific fixation plates. Other applications include various types of prostheses used for the reconstruction of the midface, mandible, and temporomandibular joint . HoweverThere are two main technologies for the fabrication of PSI: subtractive manufacturing (CAD/CAM) and additive manufacturing (3D printing) .The development of PSIs started with the popularization of the technology of computer-assisted design and computer-assisted manufacturing (CAD-CAM).The traditional CAD-CAM technique was developed in the 1960s and started to be used in medical care in the 2000s, which led to a paradigm shift in head and neck reconstruction . It led However, traditional CAD-CAM fabrication by subtractive milling from a block of material by computer numerical control (CNC) causes material waste. Certain complicated shapes cannot possibly be manufactured by subtractive milling, which led to the introduction and development of additive manufacturing, i.e., 3D printing .The three-dimensional (3D) printing technique, also known as additive manufacturing, experienced its significant development phase in the 2010s. Compared to CAD-CAM, 3D printing is a form of additive manufacturing that produces solid objects by adding materials layer by layer from base to top . It offeDifferent types of 3D printing technologies have been developed. Each has its own advantages and disadvantages. The commonly used ones in the medical field include stereolithography (SLA) with liquid resin and selective laser melting (SLM) with powder materials . In jaw Compared to commercial stock plates, surgeons can avoid the time-consuming procedure of bending plates intraoperatively and avoid the risk of fatigue-induced plate fracture from repeated reverse bending. In combination with patient-specific osteotomy guides, PSIs can save a significant amount of intraoperative time which was previously used to segmentalize and adjust the bone segments of a bone graft  to produce an appropriate jaw contour. Yang et al. and Rana et al. reported increased accuracy with the use of PSIs in computer-assisted surgery ,24. WithHowever, at the moment, an implantable PSI is still relatively expensive, and the printing technology may not be available in some parts of the world. Careful post-printing treatments are needed to reduce the chance of infection due to the inborn rough surface and plate fracture under stress due to possible microcracks inside the PSI . With the popularization of 3D-printing technology, more 3D-printed medical devices are being adopted at the point of care (PoC). The recent systematic review by Murtezani et al. showed that 35% of studies were based on POC production methods while 12% were outsourced . This haTraditionally, dental rehabilitation was performed as a secondary procedure after the primary reconstruction of the jaw was completed, at least 3 to 6 months after the primary surgery. Besides the long waiting time until the patient can have a functional occlusion, this technique has several other disadvantages. If dental rehabilitation was not taken into consideration when designing the osseous flaps, the bony segments could be placed at an unfavorable position and angle, making further dental rehabilitation difficult, if not impossible. Moreover, when patients have undergone radiation therapy after the resection and reconstruction of the jaw, the placement of osseointegrated dental implants always carries the risk of osteonecrosis of the jaw and a loss of bone flap in the long term.With the development of CAS and PSI, the accuracy and efficiency of jaw reconstruction have been significantly increased . On top Schepers et al. described a technique comprising the secondary reconstruction of the jaw using prefabricated fibula grafts with pre-placed dental implants . In the Levine et al. proposed the concept of “Jaw-in-a-day”, where dental implants and dental prostheses were placed at the same stage of the primary reconstruction of the jaw . As the When the immediate delivery of a dental prosthesis is planned, a higher accuracy for the jaw reconstruction and implant placement is required. Multiple attempts have been made to improve the accuracy of simultaneous dental implants. A tooth-borne or plate-borne implant position verification guide was developed by Zweifel et al.  However,In most cases of mandibulectomy, the inferior alveolar nerve (IAN) is sacrificed due to oncological safety concerns or technical difficulties. Without proper reconstruction, the spontaneous recovery of the IAN has been shown to be minimal and rarely functionally meaningful . The losAutograft has been considered the “gold standard” for its well-proven clinical performance . The greBesides the selection of the nerve grafting material, there have been advances in techniques for autograft repair of the IAN after mandibulectomy. In the earlier studies, autografts have been anastomosed between the proximal and the distal ends of the IAN at the recipient site. However, for extensive oncological resections, the proximal end of the nerve may need to be sacrificed. The large gap also poses an additional risk for nerve grafts in terms of the recovery of sensation, as the clinical results of long-span nerve grafts are still under validation . MoreoveAttempts have been made to restore the oral sensation at the same stage of jaw reconstruction. Boyd et al. investigated the neurosomal anatomy of the fibula free flap skin paddle and discovered the dual innervation of the lateral sural cutaneous nerve (LSCN) and recurrent superficial peroneal nerve (RSPN). The same group also explored the possibility of anastomosing these nerves into the recipient site for jaw reconstruction using a sensate osteocutaneous flap ,53. In the case report by Tanaka et al., both sensate skin paddle and the reinnervation of the bilateral mental nerve were achieved at the same stage by end-to-end anastomosing the sural nerve graft included in the free fibular flap skin paddle to bilateral proximal ends of the IAN and end-to-side anastomosing the remaining mental nerves to the sural nerve . AlthougThe technology of augmented reality, also called mixed reality, has been used in jaw reconstruction surgery in recent years to overcome the shortcomings of conventional surgical navigation. When applying the conventional navigation system, the surgeons need to repeatedly switch attention from the surgical field to the 2-dimensional screen of the navigation system. This system provides only limited 3D information and relies entirely on the hand-eye coordination of the surgeon to correlate the real situation in the surgical field and the feedback from the navigation system on the screen. AR can overlap the 3D image pre-registered from the patients’ imaging  onto the intraoperative surgical field.There are currently two main streams of intraoperative AR, one with a monitor presenting the patient’s data with the 3D model overlaid, and the other with a see-through head-mounted display where the real world and the 3D projected image are overlaid and viewed by the surgeon through the glasses, e.g., HoloLens . The different levels of clinical acceptance for these techniques were investigated through surgeons’ perspectives . Compared to conventional surgical navigation, AR provides a more intuitive guidance system with better depth perception and hand-eye coordination, which is especially helpful for inexperienced surgeons . It faciWhile AR has been applied for various purposes, including resections of tumors positioned at jaws, dental implant placement and root canals, cranial vault surgery, etc.,  the applThe technology of AR has also been used to verify the location of dental implants inserted into the reconstructed jaw by augmenting the planned implant location and final prosthesis to the surgical field using a smartphone and a specially designed program. The alignment was still relying on the registration of a coded block attached to the surgical guide mounted onto the existing dentition . The maiComputer-assisted jaw reconstruction offers the advantages of high accuracy and intraoperative efficiency. However, the process of pre-operative computer planning is time-consuming and technique sensitive.Recent years have witnessed the great development of artificial intelligence and machine learning. However, in the medical field, the majority of the research has been focused on disease diagnosis and prognosis ,67. In tSoft tissue reconstruction for maxillofacial defects plays a major role in facial aesthetics. With the dental implantation in the reconstructed jaw becoming a new norm, soft tissue condition around the dental implants is crucial for the management of peri-implantitis and maintaining the quality of life of patients in the long run.Although current VSP techniques are relatively mature for the hard tissue reconstruction of the jaw, soft tissue reconstruction with the skin paddle is largely arbitrary. On the one hand, this is due to the unpredictable soft tissue defect after the tumor resection, which is more difficult to delineate in the preoperative imaging compared to the bony defect. On the other hand, soft tissue’s shape and size change significantly over time, especially in patients with postoperative adjuvant radiation therapy. Attempts have been made to design the fibula skin paddle preoperatively based on the perforators shown in the CT angiogram. A skin paddle-outlining guide was used to assist in harvesting the fibula skin paddle . HoweverFor a reliable soft tissue VSP, more data is required on the aspects of a predictable virtual surgical planning for the soft-tissue defect, postoperative volumetric change of reconstructed soft tissue, and long-term performance of the skin paddle around dental implants in the reconstructed jaw.While the autogenous bony tissue remains the mainstream of jaw reconstruction after ablative surgeries, donor site morbidity, prolonged operation times, and hospital stay cannot be ignored. Moreover, autogenous tissue is limited by its shape and may not exactly mimic the existing jaw.Efforts have been made in recent years to apply tissue engineering to jaw reconstruction. In the case series reported by Melville et al., mandible defects were successfully reconstructed by bone tissue engineering with a mixture of bone marrow aspirate concentrate (BMAC), bone morphogenic protein (BMP), and particulate allogeneic bone grafts, contained in a Ti mesh or resorbable membrane . Figure With a sThe technology of bioprinting has also been under investigation in multiple animal studies to serve as a scaffold for bone engineering with or without bioactive molecules . The mosThe success of a tissue-engineered bone graft relies significantly on the condition of the neighboring soft tissue for satisfactory blood supply and the strict separation from the oral cavity to avoid contamination. Currently, bone tissue engineering has mostly been applied to benign mandibular defects with no significant soft tissue defect from the ablative surgery . AlthougRegardless of the exciting potential of tissue engineering for replacing the traditional autogenous bone grafts and free flaps, several questions remain unanswered. Significant resorption was reported by Ismail in 2021 when the tissue-engineered bone block was transferred to the latissimus dorsi flap site. The rate of degradation and long-term stability remains unknown. With the relatively short history of clinical application, the possible immunologic reactions are still yet to be reported. Although the combination of BMA, BMP, and allogenic bone grafts have proven to be effective in bone tissue engineering, the optimal proportion and form of the components still remain to be investigated before this technique can be popularized in the future.With the ever-rising standard of functional reconstruction, masticatory rehabilitation has become one of its main aims. However, the imbalance of masticatory muscles after jaw resection and reconstruction could lead to a TMJ dislocation, a low chewing efficiency, and a compromised quality of life . The accBai et al. investigated 30 patients who underwent mandibulectomies involving the condyle for benign tumors and reconstruction with free fibular flaps. A significant decrease in the total volume of the masticatory muscles was observed on the affected side. Different muscles showed different reattachment patterns. Most of the cases achieved a lateral pterygoid muscle reattachment within 6 months, and an ectopic attachment of medial pterygoid muscles occurred in all cases. However, masseter reattachment on the affected side was only achieved in 10% of cases . No dataThe deviation in the static location of the temporomandibular joints after unilateral jaw reconstruction was investigated by Yang et al. Patients with condyles removed had higher deviations in the condyle and joint space, and 3D printed patient-specific plates increased the spatial accuracy of TMJ reconstruction . More reBased on more sound knowledge of masticatory muscle and TMJ function after jaw reconstruction, a more comprehensive and evidence-based stomatognathic system training and rehabilitation can be proposed in the future.The reconstruction and rehabilitation of jaw defects have been revolutionized in recent years by the development of computer-assisted surgery and virtual surgical planning. The surgeons can restore the function and aesthetics at the same stage of ablative surgery with the application of patient-specific implants and the jaw-in-a-day technique. Currently, a great deal of research is being conducted on augmented/mixed reality, artificial intelligence, virtual surgical planning for soft tissue reconstruction, and the rehabilitation of the stomatognathic system. This will lead to an even more exciting future for the functional reconstruction and rehabilitation of jaw defects following ablative surgery.


The report of the American Association of Physicists in Medicine (AAPM) Task Group No. 132 published in 2017 reviewed rigid image registration and deformable image registration (DIR) approaches and solutions to provide recommendations for quality assurance and quality control of clinical image registration and fusion techniques in radiotherapy. However, that report did not include the use of DIR for advanced applications such as dose warping or warping of other matrices of interest. Considering that DIR warping tools are now readily available, discussions were hosted by the Medical Image Registration Special Interest Group (MIRSIG) of the Australasian College of Physical Scientists & Engineers in Medicine in 2018 to form a consensus on best practice guidelines. This position statement authored by MIRSIG endorses the recommendations of the report of AAPM task group 132 and expands on the best practice advice from the ‘Deforming to Best Practice’ MIRSIG publication to provide guidelines on the use of DIR for advanced applications.The online version contains supplementary material available at 10.1007/s13246-022-01125-3. Registration and fusion of medical images , 2 has bThe report of the American Association of Physicists in Medicine (AAPM) Radiation Therapy Committee Task Group No. 132  publisheThis position statement authored by MIRSIG and consulted experts endorses the recommendations of the report of AAPM task group 132  and expaMoving dataset: The dataset that is being transformed or deformed to match another image.Stationary dataset: The dataset that another image is being registered to.Image registration (IR): The process of determining the geometric transformation that relates identical points in two image series: a moving dataset and a stationary dataset.Image fusion: The combined display of the mapped data from the moving dataset with the stationary dataset.Rigid image registration (RIR): A registration where the transformation preserves the distance between all points in the image. A rigid registration can include translation in all directions as well as rotations in all directions.Deformable image registration (DIR): A registration transformation that does not preserve the distance between all points in the image. The number of degrees of freedom can be as large as three times the number of voxels in the source dataset .Deformation vector field (DVF): A transform describing the vector needed for each voxel to generate a warped image.Target registration error (TRE): Point-based accuracy metric using implanted or naturally occurring landmarks visualised on a pair of images .Mean distance to agreement (MDA): Mean surface distance between two contours on registered images .Dice similarity coefficient (DSC): Volumetric overlap of two contours on registered images .Jacobian determinant: Volume expansion or contraction resulting from a DIR .Consistency: Independence of the transformation result to the direction of the registration (image A to image B or image B to image A) .Transitivity: Independence of the transformation result to the registration scheme with more than two images (image A to image C or image A to image B to image C) .Validation: The evaluation of the overall process and toolset to ensure that accurate image registration can be performed on a consistent basis for the intended use.Verification: The process of confirming that the accuracy of a specific image registration is acceptable for the intended use.Quality Assurance (QA): The procedures and process followed to ensure maintenance of quality in each image registration.Commissioning: The process of validating the IR system, verifying example patient cases, generating appropriate documentation and providing training to users of the IR system.Radiation oncology professional trained in DIR: A radiation oncology medical physicist (ROMP) , 18, radMIRSIG acknowledges the need to clearly identify and consistently use terminology in the context of IR and fusion evaluation, as was highlighted in the report of TG-132 . This poSplit screenCheckerboardImage overlayDifference imageContour/structure mapping displaysCine images (assessment of 4D deformation)The majority of commercially available IR and fusion software packages tailored for radiotherapy provide some quantitative and qualitative evaluation tools which can be used for validation, verification and QA. These tools should be used specifically for QA at treatment planning and re-planning, when commissioning an IR system and for verification at treatment delivery. MIRSIG endorses the use of the following tools either described in the report of TG-132  or used Assessing the registration of a pre-treatment cone beam computed tomography (CBCT) image to the planning CT image with the image overlay tool is a classic example of qualitative IR evaluation. An example use of the contour/structure mapping display tool is the visual evaluation of accuracy of a structure (e.g. the gross tumour volume) contoured on an MRI image but displayed on the registered planning CT image.MIRSIG endorses the use of the quantitative tools and associated tolerances listed in Table in addition to those listed in Table DVF histogramsJacobian mapsTransitivity error (TE)Harmonic energy (HE)Not all evaluation tools are suited for the more advanced applications of DIR where the result of the registration is used to deform a dose or other matrix . For example, accurate DIR-facilitated warped doses require accurate tissue-to-tissue mapping and not all tools evaluate all voxels within structures. In contrast for contour propagation, DVF errors occurring in a structure’s sub-volume are inconsequential if the structure’s boundaries are accurately mapped. For the evaluation of DIR-facilitated dose and other matrix warping, MIRSIG encourages the use of the following quantitative evaluation tools Descriptions and examples of these tools evaluating DIR in the context of radiotherapy can be found in the literature –24.Low image contrast, image distortion, noise, artefacts, algorithm restrictions/limitations and large anatomical changes are examples of factors that can cause DVF errors . SpecifiIt is the MIRSIG position that radiotherapy IR and fusion software packages should facilitate import and export of the registration transformation matrices or DVFs to allow independent validation. MIRSIG also endorses the goals of the Integrating the Healthcare Enterprise (IHE) Radiation Oncology Technical Framework Supplement—Deformable Registration in Radiation Oncology (DRRO)  of havinPhysical phantom end-to-end tests, digital phantom tests and clinical data tests are recommended in the report of TG-132  to commihttps://www.aapm.org/pubs/reports/report132.asp) and additional open-source datasets for DIR validation, which can be found in Supplementary Material A. Please note that the majority of the linked open-source datasets contain images only and have limited ability for ground-truth evaluation . However, efforts are on-going for their inclusion.Digital phantoms can be generated in house or purchased from vendors and either can be used to perform the evaluation tests outlined in Table IV  that reqPhysical and digital phantoms as well as real patient data have been utilised in attempts to validate DIR-facilitated dose warping , 43–49. MIRSIG advocates the evaluations outlined in Table While current tools and workflows for DIR-facilitated dose and other matrix warping are still in their infancy with regards to clinical use , suggestClear guidelines, rules and training are provided to the personnel performing the IR and/or fusion on what results to accept or not, and when to escalate if necessary.An efficient, patient-specific verification is performed for each IR prior to its use, as appropriate. For example, a qualitative assessment of the registration of a pre-treatment CBCT image to the planning CT image using only the image overlay tool is likely sufficient. In comparison, the majority of the quantitative tools listed in section ‘Registration accuracy is assessed at a frequency to minimise the effect of errors without prohibiting clinical flow.Clear identification of the accuracy of the registration is provided to the consumer (e.g. an RO who receives a resultant IR prior to contouring) of the image fusion so they are fully aware of and can account for any uncertainties.Policies and procedures are in place for data management. This is useful for tracking data, performing tasks in the correct order and deciding which workspace each task will be performed in.Sufficient resources are provided for IR processes, including its commissioning and QA.Workflows implementing IR should be assessed to prove net clinical gain .Clear rules regarding algorithm limitations or restrictions are provided to performers and consumers of IR and/or fusion systems.MIRSIG advocates the following recommendations which are combined from the report of TG-132 , the MIRAll users should understand the basic IR techniques and methods of visualising image fusion.All users should understand the basic components of the registration algorithm used clinically to ensure its proper use.If the IR is performed on a stand-alone system, end-to-end tests should be performed with a physical phantom for validation. Note that the stand-alone IR system must support exportation of intermediate results.Perform comprehensive commissioning of IR using the linked digital phantom data (or similar data) as well as clinical data from the user’s institutionEstimation of registration error should be assessed using a combination of the quantitative and qualitative evaluation tools described in section ‘Develop a request and report system to ensure clear communication and documentation between all users of IR.Establish a patient-specific QA practice for efficient evaluation of IR results.Appropriate training and education is given to staff performing the IR and staff integrating the results of the IR in patients’ clinical management.Understand the benefits and risks of IR using a risk-based framework  for eachMIRSIG endorses the clinical recommendations for IR and fusion systems which were summarised in the report of TG-132  and detaSupplementary file1 (PDF 839 kb)Supplementary file2 (XLSX 472 kb)Below is the link to the electronic supplementary material.


Cancer is one of the major diseases that seriously threaten the human health. Radiotherapy is a common treatment for cancer. It is noninvasive and retains the functions of the organ where the tumor is located. Radiotherapy includes photon beam radiotherapy, which uses X-rays or gamma rays, and particle beam radiotherapy, using beams of protons and heavy ions. Compared with photon beam radiotherapy, particle beam radiotherapy has excellent dose distribution, which enables it to kill the primary tumor cells more effectively and simultaneously minimize the radiation-induced damage to normal tissues and organs surrounding the tumor. Despite the excellent therapeutic effect of particle beam radiotherapy on the irradiated tumors, it is not an effective treatment for metastatic cancers. Therefore, developing novel and effective treatment strategies for cancer is urgently needed to save patients with distant cancer metastasis. Immunotherapy enhances the body's own immune system to fight cancer by activating the immune cells, and consequently, to achieve the systemic anticancer effects, and it is considered to be an adjuvant therapy that can enhance the efficacy of particle beam radiotherapy. This review highlights the research progress of the antimetastasis effect and the mechanism of the photon beam or particle beam radiotherapy combined with immunotherapy and predicts the development prospects of this research area. Cancer is one of the leading causes of death worldwide . About 1Considerable progress has been achieved in cancer treatment research in recent years . With thThe probability of the induction of the abscopal effect during radiotherapy in clinical practice is negligible. Usually, it can bring survival benefit to patients who have already developed distant metastatic cancer. The abscopal effect was first proposed by Mole in 1953 . This phImmunotherapy is considered as an auxiliary mean to enhance the efficacy of radiotherapy. The most representative types of immunotherapy include the “dendritic cell (DC)-based vaccine therapy”, advocated by Nobel Prize winner Ralph M. Steinman , and theThis review discusses the research progress of the antimetastasis effect and its mechanism of photon beam or particle beam radiotherapy combined with immunotherapy, and predicts the future developmental trend.New England Journal of Medicine reported a successful case of combining conventional radiotherapy with CTLA-4 immune checkpoint inhibitor for the treatment of pleural-based paraspinal metastatic melanoma, wherein the regression of hilar lymphadenopathy and splenic metastatic lesions was observed  cells might not be involved in the primary mechanism of the antimetastasis effect of the combination therapy . In 2010, this team reported that combining particle beam radiotherapy with α-galactosylceramide  pulsed DC-based immunotherapy could effectively inhibit the formation of metastatic cancer . Later o therapy . This st therapy . The resMoreover, preclinical studies of particle beam radiotherapy combined with immune checkpoint inhibitors have been conducted. For instance, a preclinical study performed by the team of Osaka University (Japan) reported that particle beam radiotherapy combined with dual immune checkpoint inhibitors (anti-CTLA-4 and anti-PD-L1) effectively suppressed both the proliferation of primary tumors and unirradiated distant tumors . AccordiThe abovementioned studies have suggested that particle beam radiotherapy combined with immunotherapy is a novel and effective treatment strategy for patients with cancer metastasis, but its universality and safety data are limited and need to be further investigated in preclinical studies and clinical settings in the future.Immunotherapy is a new method of cancer treatment that has been developing in recent years. Local radiotherapy combined with immunotherapy has been performed to induce the abscopal effect in an increasing number of clinical cases. For instance, several clinical cases have reported that the abscopal effect is induced by combining radiotherapy with immune checkpoint inhibitors , 31. Furin vivo to activate CD8+ and CD4+ T cells and natural killer (NK) cells, which are then involved in inducing the abscopal effect  on mice bearing 67NR breast cancer induces the abscopal effect . Anotherl effect –48. Recel effect . In addil effect . Furtherl effect  and an el effect . Some stl effect , 50, resl effect . TherefoIn summary, the radiation-induced activation of antitumor immunity may be a key factor in inducing the abscopal effect and immunotherapy further amplifies this immune response and enhances the systemic anticancer effect . The staOptimizing the radiation parameters of radiotherapy combined with immunotherapy is expected to engender better treatment outcomes. A recent study of radiotherapy combined with anti-CTLA-4 antibody immunotherapy showed that the relatively large total radiation dose that can almost eradicate the primary tumor not only significantly improved the treatment outcomes of the irradiated primary tumor but also inhibited the proliferation of the unirradiated distant tumor . AnotherIn both photon beam radiotherapy and particle beam radiotherapy, a significant shrinkage or even regression of unirradiated distant metastatic tumor has been observed in some individual patients after local irradiation of the tumor, and this phenomenon is called the abscopal effect , 19, 30.LM drafted the manuscript, contributed to the literature search and analysis, and reviewed and approved the final manuscript.This research was supported by the CIAE President's Strategic Grant (No. YZ212404000801).The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Sustainable supply chain management (SSCM) in sharing economy platforms supports resource management and achieves environmental sustainability. Corporate social responsibility (CSR) is an essential pillar of sustainability, but the link between CSR and SSCM has been missing in the literature. Therefore, the current study intends to examine the connection between CSR and SSCM practices in sharing economy-based platforms. This study has applied the means-end theory to understand customer intention in the sharing economy. The data of 379 respondents from five main cities of Pakistan have been collected through convenience sampling. Partial least square structural equation modeling (PLS-SEM) has been used to test the proposed conceptual model. The study results show that the corporate social responsibility approach adopted by the sharing economy platforms improves internal supply chain management that drives customers’ intention to use sharing economy platforms. Green concern has a significant moderating effect on customers’ tendency toward environmental issues and solutions. However, findings revealed that eco-design in the sustainable supply chain does not affect customer purchase intention in sharing economy platforms. The study findings provide practical implications to organizations focusing on sustainable supply chain management practices in the sharing economy. The influx of digital technologies has changed the ways of conventional businesses and opened avenues for new and sustainable businesses . One of The business model of sharing economy has evolved significantly since 2010 with the advancement of key players in many sectors such as LendingClub (finance sector), Uber (automobile sector), Thredup (retail sector), Airbnb , and Spotify (entertainment sector) through structural changes, technological developments and product developments . The shaThe sharing economy idea is practiced in many of Pakistan’s business sectors, significantly benefiting businesses and consumers. Like other traditional businesses in Pakistan, sharing economy-based products and services do not acquire inputs, produce, or sell physical products. Instead, they invite participants (seller and service providers) and match them in different groups to access the other groups of participants (buyers and end-consumers). The sharing economy decreases inefficiency by making it easier to share resources on-demand. Previous studies mainly focused on sharing economy in the context of tourism , customeApplying SSCM practices in the sharing economy fulfills customer demand in a cost-effective and timely manner that finally satisfies the customers . SSCM inFew studies in the domain of sharing economy have paid attention to the environment as a pillar of sustainability and produced narrow findings. For example, some studies  indicateThe present study aims to understand customers’ intention to use sharing economy platforms based on SSCM practices. SSCM practices help the organization manage resources and improve environmental sustainability. Furthermore, the study analyzes the moderating effect of green concerns on the acceptance of sharing economy platforms.The organization of the study is as follows: the first section is the introduction of the study that explains the importance of sharing economy and SSCM. The second section is the literature review and theoretical development. The third section of the article explains the methodology. The fourth section is the analysis. The last section is the discussions, implications, conclusion, and future research scope. The means-end chain theory (MECT) suggests that consumers make a rational decision  and consThe existing research on sharing economy is classified into two broad categories: organizational-level and individual-level. At the organizational level, research on sharing economy focused on model development and its application to industrial sectors . At the Corporate social responsibility encompasses business units’ philanthropic, moral, legal, and economic performances that extend to all stakeholders . Zhang eH1: Corporate social responsibility has a positive influence on internal green management of the sharing economy-based products and services.H2: Corporate social responsibility has a positive influence on green product quality of the sharing economy-based products and services.H3: Corporate social responsibility has a positive influence on the eco-designs of products of the sharing economy-based products and services.An organization’s green management practices denote the set of symbols, values , and intH4: Internal green management practices have a positive influence on customers’ intention to use sharing economy-based products and services.Quality of the products refers to consumers’ overall appraisal of the net benefit of a product . AsghariH5: Green perceived quality obtained in the SSCM positively influences customers’ intention to use sharing economy-based products and services.Eco-design incorporates environmental attributes into product development, thereby making it available to the designer to develop the product . In the H6: Eco-design practices have a positive influence on customers’ intention to use sharing economy-based products and services.Individual awareness regarding environmental issues and willingness to solve them represent green concerns . ResearcH7: Green concern has a positive impact on customer intention to use sharing economy-based products and services.H8: The influence of green perceived quality of customer intention to use sharing economy-based products and services is moderated by green concern. The higher the green concern of the customer, the more positive impact green perceived quality will exert on customer intention to use sharing economy-based products and services.The current study employed a convenience sampling technique for data collection. It is used to generate samples as per ease of access and readiness to be a part of the sample from the respondents. By using this technique, we observed the opinions of the customers of sharing economy regarding green practices performed by sharing economy platforms. The advantage of this type of sampling is that it is easy to access the data. The face-to-face self-administered data collection technique was used to understand customer intention. The data were mainly gathered from customers of sharing economy-based services in the cities of Karachi, Lahore, Sukkur, Faisalabad, and Islamabad. The reason for selecting these cities is that sharing services are available . The adequate sample size to conduct this research was 270, as suggested by A survey questionnaire was adapted from different sources and redesigned for data collection. The adapted items were modified by five marketing and supply chain experts. The questionnaire contains six variables and a total of 27 items. All the items were scaled on a five-point Likert scale, ranging from strongly disagree to strongly agree. The questionnaire was pre-tested to evaluate its reliability and validity. For the pilot study, 35 random respondents were selected to fill the questionnaire. The reliability of data collected from these respondents was checked. The respondents reported some ambiguities regarding the items of customers’ intention: “sharing economy-based products/services” that were later modified after consultation with the area experts. The modified questionnaire included “sharing economy-based services” only. For example, item 1: “I am willing to use sharing economy-based services in future.” The modified questionnaire was again presented to another 30 respondents. After achieving positive comments regarding the appropriateness of the questionnaire, it was then formally distributed to the target respondents. The sources of the measuring items are presented in Statistical Package for Social Sciences (SPSS) and partial least square structural equation modeling (PLS-SEM) have been used to analyze the collected data. SPSS has been used for data purification and assessing common method bias. However, PLS-SEM has been used to analyze measurement and structural models.Common method bias (CMB) may occur when a single source represents more than half of the variance caused by all factors . The chaHence, according to the recommendation of The data were collected from varying cities of Pakistan covering nearly all segments. Data quality was assessed by measuring internal consistency, which was first measured through Cronbach’s alpha values. All of the values adhered to the threshold value (≥0.70). Further following the recommendation of According to The inner model fitness has been assessed using the coefficient of determination (R2) and predictive relevance through the value of cross-validated redundancy (Q2). The R2 value is the percentage of the effect of predicting variables on the outcome variables. The R2 value of 39.7% represents moderate to high predictive accuracy. The cross-validated redundancy (Q2) was checked using the blindfolding method. The predictive relevance in the model is confirmed when the value of Q2 is greater than 0. The Q2 value of 29.1% of the proposed model is considered as substantial predictive relevance .p < 0.000). Then we introduced the interaction term of standardized independent and moderating variables. p < 0.000). To indicate the moderating effect of green concern, the relationships were replotted at the two levels (high level and low level)  . The modThis study is based on the means-end chain theory in the sharing economy economy-based services to predict customer intention to use sharing economy products and services. The role of CSR is essential in improving the local community and contributes to the betterment of society. For example, sharing economy progress will generate millions of job opportunities that improve the living standard of the communities. Previous studies extensively observed consumer intention in the sharing economy-based products and services . HoweverThe results signify that internal green management is an essential factor of the sustainable supply chain that affects customer intention to use sharing economy-based services. The study findings reveal that green perceived quality has a significant and positive influence on customer intention, which matches the results of previous studies . HoweverThe empirical findings of this study offer several theoretical implications. First, the study applied the SSCM concept and used novel constructs to predict customer intention to share economy-based products and services. It is among the first customer-centric studies that comprehensively focused on CSR and factors of SSCM in the sharing economy-based products and services. Second, the study provides valuable empirical insights that foster an understanding of SSCM factors and their effect on customer intention to use sharing economy-based products and services. Empirical evidence also helps understand the role of organization CSR activities on the elements of SSCM, which remains an issue of major concern for the organizations . Third, This study provides practical implications from the sharing economy perspective and environmental sustainability. The sharing economy concept is gaining momentum, and it would be among business models due to resource constraints and environmental benefits. The model of SSCM depicts that customers are willing to use sharing economy-based products and services for resource conservation and environmental sustainability. The current study considered CSR activity a significant driver of organization business functions that help drive customer purchases. The effectiveness of CSR activities offers new insights to the business to adopt the model for sustainable business operations. Therefore, sharing economy platforms should focus on CSR activities to provide unique products and services that meet customers’ expectations. In addition, sharing economy platforms can work with local communities for the promotion of their culture and job creation to increase customer loyalty and financial performance. Moreover, CSR can enhance sharing economy’s internal performance by focusing on internal green management, green perceived quality, and eco-design of the products. Businesses in the sharing economy-based products and services should enhance internal green management practices, ensure green perceived quality, and design products that meet environmental standards. Researchers argued that the green perceived quality of the products increases the probability of the products’ purchase . CustomeAlthough this study covers a broader perspective of sharing economy, certain limitations can be addressed in future studies. First, the study has only focused on the customers’ perspective, while in sharing economy, other stakeholders also play an essential role, such as employees, suppliers, and investors. Therefore, it is recommended to include different stakeholders contributing to sustainability through sharing economy platforms. Furthermore, this study focuses on the service sector in sharing economy platforms in the country, and samples have been included from ride-sharing users only. Future studies may explore additional areas of sharing economy-based products and services and assess the customer behavioral intention. The discussion on the integration of CRS in the supply chain of sharing economy is limited compared with related sustainable supply chain management themes. Therefore, CSR should be emphasized in the sustainable supply chain management of sharing economy, including ethical working conditions and human rights. Most of the previous studies were conducted qualitatively and used conceptual models. There is a lack of quantitative study research. At present, only one study has systematically proposed the SSCM model under the sharing economy platform . TherefoThe original contributions presented in the study are included in the article/This study has been reviewed and approved by the Directorate of Academics, University of Turbat, Pakistan. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.WL, IW, and CS conceptualized the topic, designed the methodology, and performed the data analysis. CS and IH helped in writing the first draft of the manuscript. WL, IW, CS, and MB worked on conclusion and implications. IW, IH, MB, and RA worked on the final draft of the manuscript. IW and RA edited the whole manuscript. All authors contributed to the article and approved the submitted version.


Pneumonia is the most frequent cause of hospitalization, resulting in a high risk of mortality. Diabetic patients are at high risk of aquatinting pneumococcal infections with their consequent complications. Despite the fact that glycemic control of the patients reduces the risk of diabetic complications and enhances their immunity, pneumococcal vaccination should still be given irrespective of the patients’ glycemic control. The purpose of this review is to address the present situation of pneumococcal disease prevention in diabetic patients in the Kingdom of Saudi Arabia (KSA) and to gather professional recommendations to overcome the vaccination-related barriers. Onsite insights of scientific leaders in family medicine, endocrinology, and internal medicine in Riyadh and Jeddah were gathered and linked with the available literature to tackle the current practice of pneumococcal disease prevention in diabetic patients in the Kingdom of Saudi Arabia. Pneumococcal vaccination importance is still not well recognized among endocrinologists across the Kingdom of Saudi Arabia, despite the availability of established local recommendations and the National Immunization Program. The prevention of serious and fatal pneumococcal diseases should be one of the treatment pillars for diabetic patients, and it is not less important than controlling other risk factors. Diabetes is a complex, progressive, and heterogeneous disease associated with a significant burden in terms of treatment cost, management of disease complications, disability, and loss of productivity -3. The bDiabetes represents a global public health emergency. The prevalence of diabetes in the Middle East and North African (MENA) region is high . The preDiabetes increases mortality rates and healthcare expenditures. As per the International Diabetes Federation (IDF), in 2019, diabetes and its complications were responsible for an estimated 418,900 deaths in adults aged 20-79 years in the MENA region. Moreover, health expenditure due to diabetes reached $24.9 billion . DiabeteAlthough adequate resources and facilities are established and provided by the Saudi government to offer the optimum management of diabetes, the disease burden and the other barriers related to the unorganized healthcare system are considered the primary significant reasons behind uncontrolled diabetes.In this review, we reported the proceedings of two scientific advisory boards that took place in Riyadh and Jeddah in 2017 and reviewed the available literature tackling the current practice of pneumococcal disease prevention in diabetic patients. A total of 13 scientific experts specializing in family medicine, endocrinology, and internal medicine were invited to discuss the local guidelines for pneumococcal disease immunization and their implementation in the Saudi health sector. The experts shared their insights regarding the local epidemiology of diabetes and the impact of pneumonia on diabetic patients. They also specified the specialties responsible for diabetic patients’ vaccination and elaborated on diabetic patients’ vaccination journey.The burden of T2DM in KSABased on the advisors’ discussion, in KSA, the mean age of patients with type 2 diabetes mellitus (T2DM) is 59.3 years. The majority of diabetic patients suffering from pneumonia are referred to public institutions instead of the private sector. The percentage of overall T2DM patients hospitalized due to pneumonia is estimated to be 16-25% in Jeddah and 6-15% in Riyadh. It is roughly estimated that <5% of immunized T2DM patients are hospitalized due to pneumonia, and <5% of hospitalized T2DM patients’ deaths are related to pneumonia.Hyperglycemia and infectionsT2DM is the most common type of diabetes in the GCC region, specifically KSA . DiabeteHyperglycemia affects both humoral and cellular immunity as it provokes oxidative stress, causing the immune system's exhaustion and inflammatory cytokines release, exposes the internal organs to an extra amount of glucose, and provides nutrients to foreign organisms (such as bacteria or viruses). These factors render patients more vulnerable to infections ,9,10. SaDiabetes negatively affects the micro-and macro-vasculature of various organs, rendering them exposed to very poor blood supply and increasing their vulnerability to infections. Hyperglycemia results in immune suppression, which in its turn increases the risk of infections .Pneumococcal disease in diabetic patientsDiabetes is sought to be an independent risk factor for increased susceptibility to acquiring bacterial infections, such as pneumonia ,11. DiabDue to the chronic nature of diabetes, diabetic patients are at high risk of contracting pneumococcal diseases in all seasons - not only in winter - unlike seasonal influenza . The outThe risk of pneumonia in diabetic patients increases with the number of comorbidities. Comorbidities include asthma, chronic kidney disease (CKD), cardiovascular diseases (CVD), cataracts, retinopathy, and neuropathy .The risk of mortality in diabetic patients increases after hospitalization due to pneumonia . It was Many pneumonia infections are resistant to antibiotics, and accordingly, they could be fatal . PneumonImmunization in KSAAs per the experts, immunization is not a common practice among some local clinics. Healthcare professionals (HCPs) recommend pneumococcal immunizations, while a minority of diabetic patients seek immunizations without guidance. In Jeddah, endocrinologists are the principal physicians responsible for prescribing the pneumococcal vaccine for T2DM patients since they have full access to prescribe the pneumococcal vaccine for T2DM patients. Whereas in Riyadh, family physicians are primarily responsible for the pneumococcal vaccine prescription for T2DM patients. Referral to nephrologists is possible according to the results of renal function tests.According to the panel, the pneumococcal vaccine can be administered in a timely manner with either diagnosis, treatment initiation, or one of the follow-up visits (20-30% of diabetic patients). However, it is argued that it might be unwise to discuss the importance of vaccination with patients who are still in the diagnosis or treatment initiation phases. All the advisors agreed that the most appropriate time to discuss the importance of immunization with patients is before Hajj/Umrah. In KSA, the pneumococcal vaccine is not mandatory prior to Hajj, unlike the meningococcal vaccine.The ideal time to seek pneumococcal immunization was believed to be zero to six months from diagnosis, based on the presence of the associated comorbidities and risk factors. The vaccination step could be considered after six months of diagnosis to allow for time to adjust the medications and the glycemic state of the patient.Although the glycemic control of the patients reduces the risk of diabetic complications and enhances the immunity of the patients, pneumococcal vaccination should be given irrespective of the patients’ glycemic control. It is important to encourage diabetic patients to receive three main vaccinations against influenza, hepatitis, and pneumococcal infections.As per the experts’ risk stratification, diabetic patients could be classified into three categories: low-risk, intermediate-risk, and high-risk patients. Diabetic patients with high-risk comorbidities such as heart failure, pulmonary diseases, hypertension, renal impairment, and old age are categorized as high-risk patients and should receive immediate pneumococcal vaccination.Many years ago, it was very difficult to convince people about the significance of vaccinations in general and for adults specifically. In the meantime, it is much easier to administer pneumococcal vaccines to diabetic patients. Raising public awareness about adult pneumococcal vaccination and optimizing the healthcare system for diabetic patients is crucial. Different domains, including the concept of adult vaccination, smoking cessation, and the awareness of risk factors, should be comprehensively addressed by the healthcare authorities and pharmaceutical companies in order to achieve state-of-the-art management of diabetes.The leading barriers to refusing pneumococcal immunization in T2DM patientsAwareness among patients plays an essential role in deciding whether to receive the vaccination or not. The role of the media in raising awareness of public health issues, including the diabetic population, to protect them against pneumonia, has a strong impact.The most common barriers to vaccination are accessibility, availability, and the fear of potential side effects of vaccines; lack of established recommendations from the Ministry of Health (MOH); lack of knowledge about the vaccine; fear of injection site pain; and lack of time for the physicians to recommend vaccination. Many strategies could be adopted to overcome such barriers Table .Optimization of pneumococcal vaccination in T2DM patientsStrategies that could be adopted to optimize vaccination include raising awareness through establishing educational flyers and guidelines and cascading the knowledge from endocrinologists to GPs and patient educators.Raising the awareness of insurance companies about the risk of pneumococcal disease in diabetic patients is highly impactful. Adopting preventive medicine, different screening tools, and vaccination have an important role in reducing the economic burden. The easier and smoother flow of institutional procedures, the availability of the vaccines at reasonable prices, and convincing insurance companies about the protective effects of the pneumococcal vaccines, along with the burden on patients if they are left unvaccinated, are the main points of concern to raise awareness about pneumococcal vaccination. The key performance indicators (KPIs) of pneumococcal vaccination should be considered to the same extent as those exhibited in target glycated hemoglobin and blood pressure in diabetes. Raising the awareness of endocrinologists about pneumococcal vaccination is critically important.It is difficult to identify the vaccination status of diabetic patients who were hospitalized due to the development of pneumococcal infections. Accordingly, the mortality rate for this category is not known.Pneumococcal vaccination's importance is not well recognized yet among endocrinologists across KSA. Accordingly, pneumococcal vaccination urgency could be considered a risk given the fact that most patients are not fully convinced of the necessity of receiving the influenza vaccine in the first place. The four leading accessibility barriers are institutions' infrastructure, inclusion procedures, medical facility regulations, and insurance policies Table .Pneumococcal disease immunization for T2DM patientsAlthough the American Diabetes Association (ADA) recommends pneumococcal immunization for diabetic patients, especially the elderly population , the conA well-structured patient pathway starts at the clinics of general practitioners (GPs) or endocrinologists in collaboration with patient educators, followed by a referral to other specialties (nephrologists) as needed. Such a pathway would be highly beneficial in facilitating the introduction of the vaccine to patients.In KSA, the Saudi Thoracic Society recommends pneumococcal vaccination for all pilgrims to Hajj . The SauMerging pneumococcal vaccination awareness campaigns with influenza vaccine campaigns could lead to a higher percentage of vaccinated patients. Convincing patients to follow the preventive vaccination approach could be easily endorsed by the long-term mutual trust between patients and their physicians.Local vaccination guidelinesInternational guidelines recommend the administration of influenza and pneumococcal vaccinations for diabetic patients. Recommendations for pneumococcal vaccination in diabetic patients might vary across guidelines depending on the vaccine type, the patient's age at the time of vaccination, and the dosing schedule . PneumocThe local adult National Immunization Program (NIP) recommended that the dose of PCV be one dose for adults with comorbid/immunocompromised conditions and adults aged 65 years or older ,27. The In 2016, the Saudi Thoracic Society Pneumococcal Vaccination Guidelines announced their pneumococcal vaccination recommendations Table  20,21]..21].Diabetic patients are vulnerable to unusual types of pathogenic infections. Therefore, implementing an immunization program for diabetics should be an obligation. A well-structured patient pathway starts at the clinics of GPs or endocrinologists in collaboration with patient educators, followed by a referral to other specialties (nephrologists) as needed. Such a pathway would be highly beneficial in facilitating the introduction of vaccination to patients. It is recommended to formulate local guidelines in KSA to raise awareness about pneumococcal vaccinations for diabetic patients. Pneumococcal vaccination should be given regardless of the patient's glycemic control. Convincing patients to follow the preventive vaccination approach could be easily endorsed by the long-term mutual trust between patients and their physicians. Similar to glycated hemoglobin and blood pressure targets in diabetes, the key performance indicators of pneumococcal vaccination should be considered. Further studies could be conducted to investigate the effects of education and awareness among the population on the vaccination rate.