With the miniaturization of ultrasound and the development of artificial intelligence, its application in disaster scenes and pre-hospital emergency care has become more and more common. This study summarizes the literature on portable ultrasound in pre-hospital emergency and disaster scene treatment in the past decade and reviews the development and application of portable ultrasound. Portable ultrasound diagnostic equipment can be used to diagnose abdominal bleeding, limb fracture, hemopneumothorax, pericardial effusion, etc., based on which trauma can be diagnosed pre-hospital and provide guiding suggestions for the next triage and rescue; in early rescue, portable ultrasound can guide emergency operations, such as tracheal intubation, pericardial cavity puncture, and thoracic and abdominal puncture as well as improve the accuracy and timeliness of operation techniques. In addition, with the development of artificial intelligence (AI), AI-assisted diagnosis can improve the diagnosis level of ultrasound at disaster sites. The portable ultrasound diagnosis system equipped with an AI robotic arm can maximize the pre-screening classification and fast and concise diagnosis and treatment of batch casualties, thus providing a reliable basis for batch casualty classification and evacuation at disaster accident sites. At present, under the background that medical equipment, medicine and biology technologies, 5G network and artificial intelligence have entered into deeply integrated development, the demand for AI enhanced medical technology is growing stronger in the development of the emergency trauma medicine field so as to protect the lives of the injured using the optimal resources. The development of AI has gone through three stages  which imitates human intellectual behavior . Deep leIn the field of emergency medicine and pre-hospital examinations, the AI robotic arm of portable ultrasound diagnostic system uses wireless network as a transmission link to display instant images on cell phones or iPad, and with the help of 5G technology, the detected information is recognized in time and provided to doctors as a diagnostic reference . As a kiThe scene of future wars and major emergencies, large numbers of casualties will be produced in a short period of time, the complex types of injuries include multiple injuries, compound injuries, and special injuries see , all kinPortable ultrasound diagnostic systems can be used in the field of trauma emergency chest emergency examination to determine the cause of the patient’s dyspnea, such as the presence of pulmonary edema, pneumonia, pleural effusion, etc.; have similar diagnostic effects to chest CT; and are better than chest X-rays ,38. The In the evaluation of thoracic trauma, the examination includes subcostal views and the cardiac region, and if a pericardial effusion is found, pericardial tamponade treatment along with puncture decompression is required. Ultrasound examination on the anterior aspect of the chest is useful in identifying hemothorax and pneumothorax with higher specificity and sensitivity compared to X-ray examination . In addiAI also can use the modular software system to automatically assist the analysis of cardiovascular ultrasound images, simplify the vascular ultrasound examination process, reduce the dependence on the operator, and shorten the examination time .Focused assessment sonograph for trauma (FAST) is a medically proven method for the initial evaluation of closed intra-abdominal injuries. The portable ultrasound diagnostic system takes less time than traditional ultrasound and CT and is more mobile than CT and conventional ultrasound in terms of accuracy and sensitivity in exploring the abdominal cavity, with no significant differences . It can In addition, portable ultrasound diagnostic system has the advantages of small size, light weight, and ease of transport . Pre-hosThe use of ultrasound in the diagnosis of ectopic pregnancy in pre-hospital emergency can accurately determine the staging of ectopic pregnancy, and the accuracy of Transvagin Scan (TVS) and Transabdominal ultrasound (TAS) diagnosis is higher, which can provide reliable guidance for emergency medical care . In thisTraumatic pneumoperitoneum is usually caused by a perforated gastrointestinal tract, so prompt examination can assist in the early diagnosis of the patient. Gastrointestinal perforation is usually diagnosed using X-ray or CT. Some investigations have shown that the sensitivity and specificity of abdominal ultrasound for pneumoperitoneum examination are 85–90% and 100%, respectively, and experienced physicians can even detect 1 mL of gas, which is comparable to CT examination . A studyIn terms of artificial intelligence, Pavlopoulos et al. analyzed liver ultrasound images using a fuzzy neural network. The results show fractal dimension texture analysis (FDTA), spatial gray-level dependence matrix (SGLDM), gray-level co-occurrence matrix (GLCM), gray-level run length statistics (RUNL), and first-order gray-level parameters (FOP). The five feature parameters are trained to the network through the geometric blur device, which can be used to intelligently identify disseminated liver lesions .In earthquakes, typhoons, tsunamis, and other disaster sites that rescuers cannot swiftly reach in great numbers—and to which large X-rays, CTs, and other equipment is inconvenient to move—the application of portable ultrasound diagnostic system examination can be more convenient to diagnose the patient. Musculoskeletal ultrasound (MSUS) is a new ultrasound examination technology for diagnosing musculoskeletal system diseases through high-frequency ultrasound (3–22 Hz) scans to provide excellent clinical images to clearly show the hierarchical relationship of muscle and other soft tissue and its internal institutions. For example, the application of portable ultrasound with a robotic arm to examine the direct signs of fracture sonograms can determine whether the part is a fracture or a continuity fracture, providing more direct evidence for further treatment. More common after earthquakes is crush syndrome, which is also one of the main causes of death of the injured after earthquakes. Crush syndrome refers to severe damage to the soft tissues of human muscles under the action of blunt external forces, such as crushing and blows, and the main manifestations include swelling, bleeding, local sensory impairment, and even acute renal failure at the damaged area. Portable intelligent ultrasound diagnosis can obtain accurate diagnostic information on suspected lesion sites and at the same time can assist in the diagnosis of crush syndrome by observing the activity level of muscles, tendons, etc. This is the preferred screening method for soft tissue injuries after earthquakes .The portable ultrasonic diagnostic system can detect the degree of soft tissue and bone damage at the trauma site and make timely and accurate injury judgments for patients while preventing the emergence of crush syndrome to a certain extent. It can also judge fluid accumulation in joint cavities and abnormal muscle echogenicity. Through the examination and diagnosis of portable ultrasound, people affected by the earthquake can have an understanding of their own physical condition and also relieve post-earthquake psychological pressure and improve their confidence in their own physical recovery, which also has a positive effect on post-disaster reconstruction.In addition, with the wide application of high-resolution ultrasound in the skeletal muscle system, sonographers expect to use AI technology to improve the consistency and accuracy of the clinical interpretation of ultrasound imaging of skeletal muscle injury .Real-time guidance by ultrasound can significantly improve the success rate of puncture, especially in facet joint manipulation. For the special complex effusion with separation, ultrasound guidance can avoid the phenomenon of “dry pumping”, which can easily occur in blind wear.Craniocerebral injuries account for the second largest proportion of casualties in a disaster setting. Increased intracranial pressure indicates the presence of intracranial hematoma or even the risk of cerebral herniation, which endangers life. Thus, rapid diagnosis and management are critical to patient survival. Portable ultrasound diagnostic systems equipped with AI robotic arms to measure the diameter of optic nerve sheath for intracranial pressure assessment can detect plateau cerebral edema in time. The results recorded using color ultrasound for trauma-induced cerebral edema casualties are quickly conveyed to the rear expert pool through the AI’s memory system, applying the current 5G network, and through feedback from rear expert opinions. Treatment is implemented at the rescue site immediately, providing strong support for the recovery of the function of craniocerebral injury casualties.At present, artificial intelligence ultrasound combined with 3D technology has been successfully applied in the monitoring of fetal thalamus, choroid plexus, transparent lumen, lateral, fissure and other brain structures and combined with neural network information analysis to make accurate judgments .In addition to the above applications, portable ultrasound combined with AI can also assist doctors in emergency invasive operations, such as tracheal intubation, cricothyroidocentesis, assisted arterial placement, and nerve block anesthesia, which can effectively improve the efficiency and success rate of emergency care.The application of modern technology combined with artificial intelligence can transform the management of trauma, respiratory distress and cardiac arrest patients, and the images obtained can be comparable to those obtained with conventional ultrasound equipment and save human resources. Ultra-portable handheld ultrasound with augmented reality (AR) technology and remote guidance allows physicians with extensive POCUS experience to remotely guide pre-hospital emergency for personnel in making treatment decisions and ensuring examination qualities. With the continuous improvement of ultrasound technology, diagnosis, and treatment methods and procedures, portable ultrasound diagnostic systems are more advantageous for the diagnosis and management of emergency cases as well as for ultrasound-guided treatment. With the continuous development of technology, Artificial intelligence -assisted portable ultrasound diagnosis systems are showing good prospects for application and are gaining popularity among physicians.Portable ultrasound intelligent system examination is suitable for patients with unstable or potentially unstable vital signs; can rapidly identify life-threatening trauma, including pneumothorax, hemothorax, and pericardial effusion; can assist clinicians in choosing whether to perform other examinations to help patients receive timely treatment; and can repeatedly and dynamically evaluate trauma patients without radiological damage. In addition, remote operation through 5G technology is also a future development trend . MoreoveCurrently, an artificial intelligence portable ultrasound inspection system combined with a 5G communication platform helps in battlefield or disaster scene rescue work. Ultrasound robots can perform examination, diagnosis, operation, etc., autonomously—which can be detached from the reliance on manual operation during battlefield rescue—and carry out ultrasound remote examination, image transmission, rapid remote consultation, etc., thus saving human and material resources. Intelligent ultrasound can not only be applied to the diagnosis of organs such as those in the chest and abdomen but also has better diagnostic efficacy for the degree of benign and malignant clinical thyroid, which can effectively improve the clinical specificity and positive value . AdditioWith this technology, 5G communication can transmit images and other related data to the rear hospital in real time, and the rear hospital personnel can make a diagnosis, which improves the accuracy of diagnosis to a certain extent. In addition, intelligent robots equipped with ultrasound systems have more advantages—such as resistance to fatigue, ability to adapt to harsh environments, ability to work continuously in low- or zero-oxygen environments, automatic driving and positioning, identification of obstacles, etc.—that are practically significant. However, there are still many problems to be solved in other aspects of artificial-intelligence-equipped portable ultrasound systems, such as its weight and it generally being equipped with only an abdominal probe, which leads to a narrow inspection range. Additionally, robotic-arm-carrying ultrasound systems require professional training. In particular, the probe is prone to instrument failure when touching or falling; otherwise, there are few physicians with relevant expertise in the treatment of injuries at the scene of disaster accidents, and physicians who have not been trained in ultrasound operations have not fully mastered portable ultrasound examination techniques. In addition, machine-stylized diagnosis may create a gap between doctors and patients and weaken the multidisciplinary joint diagnosis and treatment of diseases. Therefore, in order to give full play to the advantages of ultrasound AI in diagnosis, we must properly coordinate between machines and humans.Currently, the portable ultrasound system equipped with artificial intelligence has characteristics of low power consumption, low latency, high speed, and wide coverage, meanwhile breaking the technical barriers to the development of remote ultrasound robots. Data management and sharing, remote consultation, background analysis, reverse control, and pre-hospital emergency are realized through remote data retrieval ,66, whilThe limitations: Although some progress has been made in AI-assisted technology, there is still a lack of systematic multi-center clinical trials and effective validation, and there is still a gap between the requirements of clinical standardization. Ultrasound recognition artificial intelligence algorithm has a certain range of cognitive limitations in the application field of practical ultrasound technology. Although ultrasound artificial intelligence technology effectively helps to improve the recognition and resolution ability of medical ultrasound images, there is still some distance from the requirements of clinical standardization when it is really introduced into clinical practice. Implementation of machine learning and tele-ultrasound applications is likely to alter the point-of-care ultrasound (POCUS) landscape, and physicians should continue to study and embrace these technologies for the improvement of patient care.In summary, AI is expected to become an effective auxiliary tool for imaging doctors in the diagnostic process in the future. The portable ultrasound system has, to some extent, improved the speed and efficiency of pre-hospital diagnosis and fought for time and human resources for pre-hospital emergency and disaster bulk casualty detection and classification treatment despite carrying intelligent 5G system allowing it to realize remote diagnosis and detection, further improving the accuracy and level of diagnosis and safeguarding the life and health of patients. AI-integrated ultrasound technology has significant advantages in the pre-examination and triage of disaster sites and pre-hospital emergency treatment. Therefore, we forecast that in the future, multi-ultrasound technology and AI development can help greatly in the initial assessment of the sick’s conditions.


Ectopic teeth in the maxillary sinus are a rare finding and pose a diagnostic challenge due to their unusual location and clinical management. A 28-year-old man presented with complaints of discomfort and pressure in the maxillary sinus region. A CT scan and cinematic rendering revealed the presence of ectopic teeth in the maxillary sinus bilaterally. The use of cinematic rendering provided a more detailed and accurate visualization of the ectopic teeth and surrounding anatomical structures. A CT scan is the primary imaging modality used for the diagnosis and visualization of ectopic teeth in the maxillary sinus. In addition, the use of cinematic rendering can improve diagnostic accuracy and reduce the need for further imaging studies. The use of CT and cinematic rendering can help in the diagnosis and visualization of ectopic teeth in the maxillary sinus, aiding in the planning of surgical interventions. Ectopic eruption of teeth is a rare but important condition in dentistry. It is a developmental disorder that can cause teeth to emerge from locations outside of their normal arch or bone boundaries. Indeed, the development of teeth begins early in life with the formation of the dental lamina. Abnormal interactions between the oral epithelium and the underlying mesenchymal tissue can lead to ectopic tooth development and eruption .Although ectopic teeth can emerge from various parts of the body, including the palate, mandibular condyle, coronoid process, orbits, nasal cavity, or even through the skin, the maxillary sinus is one of the rarest and most clinically significant sites for this finding. Due to the rarity of this condition, its incidence deserves to be added to the literature and discussed. Teeth ectopically erupted in the maxillary sinus can cause sinusitis, ocular symptoms, and other complications, and the condition may go undiagnosed for years until the patient undergoes radiography for another reason .In some cases, ectopic teeth in the maxillary sinus may be associated with dentigerous cysts, which are benign odontogenic cysts that develop from the crown of impacted or unerupted teeth. Dentigerous cysts are thought to originate from the follicle of the unerupted tooth and are caused by the expansion of the dental follicle due to the accumulation of fluid between the tooth crown and epithelial components. The presence of cysts and ectopic teeth can cause a range of complications, from sinus obstruction to blindness.The identification of ectopic teeth in the maxillary sinus may have implications for preoperative planning in cases of maxillary sinus pathology, particularly if surgery is required. Advanced imaging techniques such as computed tomography (CT) and magnetic resonance imaging (MRI) can provide improved characterization of different bone/soft tissues and their relationships. In addition, post-processing techniques, such as cinematic rendering (CR), represent an advanced 3D visualization technique, particularly useful to detail complex anatomical regions and also for presurgical planning [We present a case of a 28-year-old man who was referred to our institution with a complaint of hypertrophy of the lymphoid tissue in the nasopharynx and turbinates. The patient reported symptoms of nasal obstruction, rhinorrhea, and occasional epistaxis. There was no significant medical history or previous surgical interventions. The patient gave written informed consent for this study.The patient underwent a CT scan using a Siemens Somatom Force DSCT scanner . The maxillo-facial CT scan was performed without contrast agent injection using the following parameters: 120 kVp, 100 mAs, a slice thickness of 0.625 mm, and a 0.3 mm gap. The images were reconstructed using a soft tissue algorithm (head regular (HR) 64; Advanced Modeled Iterative Reconstruction (ADMIRE) strength level: 3).The CT images were reviewed and reported by a radiologist with expertise in interpreting head and neck CT scans. In addition, a specialized radiologic technologist in 3D imaging performed CR of the entire data set using Cinematic Playground , a specialized software (software version vb60a hf04) that generates CR from CT and MR acquisitions. The radiologist evaluated the presence of any anatomical variations or abnormalities in the paranasal sinuses and nasal cavity .An impacted tooth can get stuck in gum tissue or bone for a number of reasons. The area may be overcrowded, leaving no room for the tooth to emerge. For example, the jaw may be too small to hold the wisdom teeth. Teeth can also become twisted, tilted, or displaced as they try to come out.The tooth, which fails to erupt in the oral cavity in its functional position, has lost its further potential for eruption according to Archer’s classification (1975) for the imposition of maxillary third molars .The maxillary third molar is not impacted as frequently as the mandibular third molar, but the frequency of impaction is high. Impaction of the maxillary third molar is considerably more difficult due to many factors that are favorable compared to the mandibular third molar, such as the visibility factor, reach, tuberosity, and its proximity to the maxillary sinus. These are the many factors that make maxillary impaction a challenge for dentists.The different types of maxillary third molar impingement are similar to mandibular third molar impingement based on the angulation, prevalence, and prediction of extraction difficulty of the tooth in relation to the second molar. Archer qualitatively classified them into seven types: mesioangular , distoangular, vertical, horizontal , buccoangular, linguoangular, and inverted [Several theories have been proposed to explain the occurrence of ectopic teeth in the maxillary sinus, including migration of tooth buds, developmental abnormalities, trauma, and infection. Diagnosis can be challenging, considering that most ectopic teeth have no symptoms. In spite of this, impacted teeth can cause orofacial pain due to their location, mimic temporomandibular joint pain, be a source of focal infection, or develop an odontogenic cyst or odontogenic tumor in conjunction with follicle dysplasia due to the pathology. Imaging techniques such as maxillo-facial CT and panoramic radiographs are often used to aid diagnosis.Maxillary third molars rank second in terms of teeth most commonly impacted, while mandibular molars top the list. Since the third molar is the final tooth to emerge in the maxilla, it is more prone to displacement due to limited space, potentially explaining the increased occurrence of ectopic third molars in the maxilla. The genesis of teeth, or odontogenesis, starts during the sixth week of fetal development, coinciding with the formation of the dental lamina in both the maxilla and mandible . The forThe first report of an ectopic maxillary third molar was published in 1952 by Isasi Garcia et al. . EctopicDaimi et al. (2020) presented a case study involving a dry human skull with a bilateral ectopic third maxillary tooth. The estimated age range of the skull was between 30 and 35 years. The tooth was found to be partially erupted on both sides from the infratemporal surface of the maxilla, displaying a downward and lateral direction of eruption. Morphometric measurements were conducted to assess the relationship between the tooth and surrounding anatomical landmarks, including the midsagittal plane, alveolar canal, pterygomaxillary fissure, and superior alveolar margin. These measurements provided valuable insights into the position and orientation of the ectopic tooth within the skull .In a separate case reported by Arici et al. (2022), a 32-year-old female patient presented with bilateral ectopic maxillary third molars situated within the maxillary sinuses. The patient experienced symptoms such as facial swelling, pus discharge from the nostril, and nasal airway obstruction. A surgical intervention was performed, involving the removal of the impacted third molars and the enucleation of the associated dentigerous cyst. The procedure successfully alleviated the patient’s symptoms, and a one-year follow-up confirmed the positive outcome .Similarly, Sharma et al. (2019) presented a case of a 27-year-old female patient with recurrent facial swelling and purulent nasal discharge. Clinical examination revealed mild facial swelling and tenderness, along with missing maxillary third molars. Radiographic evaluations, including a panoramic radiograph and cone-beam computed tomography (CBCT), confirmed the presence of ectopic maxillary third molars within the maxillary sinuses. To address the condition, surgical removal of all impacted third molars and enucleation of the associated dentigerous cyst were performed under general anesthesia. The patient experienced complete resolution of symptoms, and histopathological examination confirmed the absence of malignancy .In a different context, Berberi et al. (2023) presented a case involving a 24-year-old female patient referred for the assessment of her third molars prior to orthodontic treatment. A clinical examination revealed minor pain in the anterior and posterior maxillas, prompting a radiographic evaluation. Both 2D panoramic radiography and CBCT confirmed the presence of bilateral ectopic maxillary third molars located within the maxillary sinus cavities. The findings were crucial in determining the treatment approach before proceeding with orthodontic intervention .Lastly, Al Khudair et al. (2019) documented the case of a 19-year-old male patient with complaints of facial pain over the upper jaw and post-nasal discharge. The patient reported recurring sinusitis episodes but lacked any other noteworthy medical history. A CT scan of the paranasal sinuses uncovered bilateral cystic formations and ectopic teeth in both maxillary sinuses. The patient then received an endonasal endoscopic procedure to remove the cysts and extract the impacted teeth. Subsequent post-operative assessments verified the alleviation of symptoms .These cases highlight various presentations of ectopic maxillary teeth within the maxillary sinuses and emphasize the importance of appropriate diagnostic imaging and surgical intervention to address associated symptoms and prevent complications.None of the reported works and cases have ever used volume rendering (VR) or CR for three-dimensional visualization of the molar in the maxillary cavity.Ectopic teeth are relatively common, although they are usually asymptomatic. However, when an ectopic tooth is associated with a dentigerous cyst and invades the maxillary sinus, symptoms may present late, including facial pain, swelling, headaches, purulent discharge, and nasolacrimal obstruction. In our patient’s case, his main complaint was pain when blinking his right eye, as well as headache and maxillary pain, often accompanied by postnasal discharge and recurrent sinusitis.The effects of an ectopic tooth in the maxillary sinus can include facial fullness, headaches, recurrent chronic sinusitis, local sinonasal symptoms, and elevation of the orbital floor. If the lesion extends along the floor of the orbit, it can cause diplopia and even blindness.In such cases, a thorough clinical examination and diagnostic imaging, such as maxillo-facial CT, are essential to accurately diagnose and monitor the condition.CT provides detailed information about the location and morphology of the ectopic tooth, as well as the evaluation of surrounding anatomical structures, facilitating treatment planning.In the present case, CT was used to visualize the ectopic teeth in the maxillary sinus. CT has been widely used to diagnose ectopic teeth in the maxillary sinus because it can provide detailed information about the location and morphology of the ectopic tooth. In addition, CT allows evaluation of the surrounding anatomical structures, such as the sinus walls and adjacent teeth, in light of a possible surgical treatment, facilitating its planning .We also used cinematic rendering to visualize the ectopic teeth in the maxillary sinus. By simulating the propagation and interaction of light beams as they move through the volumetric data, cinematic rendering creates a representation of 3D pictures that is more lifelike than that produced by ordinary volume rendering . In geneIn contrast to traditional VR, which treats each reconstructed voxel independently, CR presents neighboring voxels interactively. This adaptability allows for the manipulation of lighting and shadow conditions in a panoramic view. Furthermore, in addition to shadowing, CR’s global lighting model excels at revealing intricate anatomical details, making it particularly useful for visualizing small structures . The useOverall, the use of CT and film rendering in our case allowed us to accurately diagnose and localize the ectopic teeth in the maxillary sinus. These imaging modalities are valuable tools in the diagnosis and management of ectopic teeth in the maxillary sinus and may aid in the planning of surgical interventions .Surgical removal of ectopic teeth in the maxillary sinus is required in symptomatic cases and typically involves extraction of the cyst-associated impacted or unerupted tooth. In some cases, initial marsupialization may be performed to reduce the size of the bony defect prior to enucleation and tooth extraction. The Caldwell–Luc procedure is a common surgical approach for the removal of dentigerous cysts and ectopic teeth in the maxillary sinus. In this procedure, a window is created in the lateral wall of the maxillary sinus, allowing direct visualization and access to the cyst and ectopic tooth. In some cases, endoscopic sinus surgery may be used alone or combined to remove the ectopic tooth, considering that the lateral, anterior, and inferior walls of the maxillary sinus might be challenging to access with the endoscopic technique . In our In conclusion, this case report emphasizes the crucial role of advanced imaging techniques such as CT and cinematic rendering in the bilateral maxillary sinus ectopia teeth. Our findings support the potential of CR, using software such as Cinematic Playground, to provide improved visualization of complex anatomical structures and their relationships. This study highlights a rare but clinically significant condition, which can have implications for preoperative planning in cases of maxillary sinus pathology. The literature on this topic is limited, and further studies are required to determine the prevalence of ectopic teeth in the maxillary sinus and their potential impact on surgical outcomes.


Background: This review focuses on multimodality imaging of cardiotoxicity in cancer patients, with the aim of evaluating the effectiveness of different techniques in detecting and monitoring cardiac changes associated with cancer therapy. Methods: Eight studies were included in the review, covering various imaging modalities such as cardiac magnetic resonance imaging, echocardiography, and multigated acquisition scanning. Results: Cardiac magnetic resonance imaging emerged as the most definitive modality, offering real-time detection, comprehensive assessment of cardiac function, the ability to detect early myocardial changes, and superior detection of cardiotoxicity when compared to the other imaging modalities. The studies also emphasize the importance of parameters such as left ventricular ejection fraction and global longitudinal strain in assessing cardiac function and predicting cardiotoxicity. Conclusion: Due to the common use of HER2 agents and anthracyclines within the breast cancer population, the LVEF as a critical prognostic measurement for assessing heart health and estimating the severity of left-sided cardiac malfunction is a commonly used endpoint. CTRCD rates differed between imaging modalities, with cardiac MRI the most sensitive. The use of multimodal cardiac imaging remains a nuanced area, influenced by local availability, the clinical question at hand, body habits, and medical comorbidities. All of the imaging modalities listed have a role to play in current care; however, focus should be given to increasing the provision of cardiac MRI for breast cancer patients in the future to optimize the detection of CTRCD and patient outcomes thereafter. We present a state-of-the-art review of multimodal imaging use within the breast cancer population. The scope of this systematic review is to comprehensively evaluate the existing literature on the use of different cardiovascular imaging modalities and imaging markers in the detection of cardiotoxicity induced by anti-cancer treatments. The primary objective is to determine which imaging modality is most effective in identifying cardiotoxicity. The review will also address secondary objectives such as assessing the accuracy, reliability, sensitivity, and specificity of different imaging modalities and markers, as well as the advantages and limitations of each method, particularly when subgroups of patients are involved.Cardiotoxicity is a significant side effect of many cancer treatments, including chemotherapy and radiotherapy. It can lead to damage to cardiomyocytes, causing various cardiac dysfunctions, such as left ventricular dysfunction, myocardial infarction, arrhythmias, and heart failure . ChemothTrastuzumab is a monoclonal antibody used in the treatment of HER2-positive breast cancer, with its relationship to cardiotoxicity previously documented . The mecTyrosine kinase inhibitors (TKIs) are a class of targeted cancer therapies that work by inhibiting the signals that encourage cancer development. They have a recognized relationship with adverse cardiac events ,13, withOne of the most common causes of cardiotoxicity is the use of anthracycline chemotherapy drugs. These drugs have been shown to induce oxidative stress and DNA damage in cardiac cells, leading to cell death and impaired cardiac function ,19. AddiAlkylating agents are used in the treatment of various cancers  and can induce cardiotoxicity through multiple mechanisms, including myocardial depression and vasospasm . The repIn addition to chemotherapy drugs, radiation therapy can also cause cardiotoxicity. Various factors have been associated with the mechanism of cardiotoxicity, including oxidative stress, deoxyribonucleic acid degradation, and inflammatory cytokine release with subsequent fibrotic changes of the myocardium, pericardium, and valvular structures, as well as the vasculature . The incMultimodality imaging is effective in the early detection and monitoring of cardiotoxicity in cancer patients. Previous publications  demonstrEchocardiography is a widely used imaging modality for the assessment of cardiac function. It is non-invasive, portable, relatively inexpensive, and does not use ionizing radiation. Echocardiography via the use of global longitudinal strain (GLS) can provide information on left ventricular ejection fraction (LVEF), regional wall motion abnormalities (RWMA), and valvular function . It is pMagnetic resonance imaging (MRI) is a versatile imaging modality that can provide information on both cardiac function and structure. It can detect RWMA, changes in LVEF, and myocardial fibrosis. Myocardial fibrosis is a common finding in patients with cardiotoxicity. It is a marker of irreversible damage to the heart muscle and can be detected by late gadolinium enhancement on MRI , with anIn recent years, cardiac computed tomography angiography (CCTA) has emerged as a valuable tool in the diagnosis and management of various cardiovascular diseases, including coronary artery disease and coronary anomalies , where aNuclear cardiac scanning is a non-invasive imaging technique that utilizes radiotracers to evaluate myocardial perfusion and function. It is an alternative imaging modality in patients who cannot undergo other imaging modalities , with multigated radionuclide angiography (MUGA) and single-photon emission computed tomography (SPECT) further acquisition methods that, via a range of radioisotopes, can assess LVEF and for perfusion defects . Prior eCardiac biomarkers have some relevance in the screening of the cardiotoxicity of anti-cancer treatments, including HER2 therapies . To thisFor published articles, the following electronic databases were utilized: PubMed/MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science. The search strategy combined keywords associated with the following ideas with medical subject headings (MeSH) terms: echocardiogram, single-photon emission computed tomography (SPECT), MRI, CT, strain imaging, contrast agents, perfusion imaging, and cancer treatment-related cardiotoxicity. The search strategy included relevant synonyms and related terms and used Boolean operators  to combine the different search concepts.ClinicalTrials.gov. To find additional studies, the reference lists of the included studies and pertinent systematic reviews were also hand-searched.In addition to the electronic database search, the following sources of unpublished or gray literature were also searched: the World Health Organization, the International Clinical Trials Registry Platform (WHO ICTRP), the conference proceedings of relevant cardiology and radiology conferences, and Duplicate results were eliminated after importing all search results into a reference management program. The surviving studies’ titles and abstracts were reviewed by two impartial reviewers to determine their eligibility based on the requirements for inclusion and exclusion criteria. Studies that satisfied the eligibility requirements had their full-text papers retrieved, and two independent reviewers decided whether to include those studies in the systematic review. A third reviewer or a majority vote was used to settle any disputes.The inclusion and exclusion criteria were consistently applied to all studies. The inclusion criteria were as follows: Randomized controlled studies, prospective and observational studies, studies presented in English, patient populations who had a history of breast cancer treatment and underwent at least two of the following cardiovascular imaging modalities: echocardiography, CT, MRI, multigated acquisition (MUGA) scanning, and were 18 years or older. In the participant selection domain of the PROBAST model, the signaling questions addressed issues such as the representativeness of the study sample and the handling of missing data. In the predictor domain, the signaling questions focused on issues such as the measurement of predictors and the handling of missing data. In the outcome domain, the signaling questions assessed the quality and completeness of outcome data. Finally, in the analysis domain, the signaling questions addressed issues such as model overfitting and handling of missing data.In addition to the PROBAST tool, reporting transparency was also assessed using the Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis (TRIPOD) statement . The TRIOverall, the risk of bias and reporting transparency of the included studies were found to be variable. Some studies were found to have a high risk of bias in one or more domains, while others had a low risk of bias. Similarly, some studies were found to have incomplete or unclear reporting, while others had more transparent reporting. These findings highlight the need for standardized reporting and better adherence to reporting guidelines in prediction model studies.The literature highlighted in this review demonstrates the use of different cardiovascular imaging modalities predominantly within the realm of HER2 therapies, anthracyclines, and alkylating agents. The investigation of HER2 patients for cardiotoxicity is relevant to their prognosis, and although HER2 status in invasive cancer is established in a patient’s prognosis, its presence in ductal carcinoma in situ (DCIS) is less so, with current guidance suggesting against HER2 testing in these patients . As the The selected studies report several advantages for cardiac MRI in the assessment of cardiotoxicity, suggesting it provides high spatial resolution and excellent tissue characterization, allowing for the detection of early myocardial changes that may not be picked up by TTE and MUGA imaging . HouboisDepending on the clinical question at hand, each of the named imaging modalities has a use in different situations and is highly dependent on availability and local expertise. The use of strain imaging techniques, such as tissue velocity and strain imaging, showed promise in predicting early left ventricular dysfunction. Fallah-Rad et al.  reportedA common measure of cardiotoxicity using the LVEF parameter  is a decrease in absolute value to below 50% without a decrease from the baseline of >10% . HoweverOur study provides a state-of-the-art review of studies focused on multimodality imaging of cardiotoxicity, showing that choice of imaging is dependent on the anti-cancer therapy agent, clinical question, and local availability/expertise. Ultimately, this literature is of most relevance to breast cancer patients receiving HER2 agents, anthracyclines, and alkylating agents, where the CTRCD of note is cardiomyopathy, witnessed as a depressed LVEF/GLS. By including a diverse range of studies from a number of countries, the review offers a comprehensive analysis of the topic, enhancing the reliability and validity of the findings. Furthermore, given that this review focuses on studies conducted on patients in the real world undergoing cancer treatment, we feel this makes the findings directly applicable to clinical practice. By considering the implications of the imaging modalities in real-world scenarios, the study enhances its practical significance and relevance to healthcare professionals.Each of TTE, MUGA, and cardiac MRI have a role in these patients care. Systems of healthcare, equipment availability, private/public funding, and the availability of local expertise all determine imaging choice. The breast cancer population, by virtue of this background, has a multimodal approach, with a predominance of different modalities used across different jurisdictions. Indeed, cardiac CT is not included in our review but is well-established in the detection of coronary artery disease that may have been accelerated by radiotherapy . The useOur review was limited by the heterogeneity of the studies. The included studies varied in terms of sample size, study design, patient population, and imaging protocols. This heterogeneity could introduce potential sources of bias and limit the ability to draw definitive conclusions. There was a lack of standardized protocols and criteria for defining and assessing cardiotoxicity across different imaging modalities, which could potentially lead to inconsistencies and challenges in comparing results across studies. Longitudinal studies with extended follow-up periods would provide more robust evidence regarding the long-term outcomes of cardiotoxicity detection. We felt the studies included in the review may have inherent selection biases due to their specific inclusion and exclusion criteria. This could affect the generalizability of the findings to broader patient populations. Many of the included studies may have relatively short follow-up periods, and only one study  providedOne of the major gaps in the current literature regarding multimodality imaging is the lack of standardization in the use of established protocols for cardiotoxicity assessment and interpretation of imaging findings. However, international societies are making progress in this regard , and theThe use of multiple imaging modalities can be expensive, and there is a need to evaluate the cost-effectiveness of these modalities in different patient populations. Comparative studies that evaluate the costs and benefits of different imaging modalities could help guide clinical decision-making and resource allocation. While many studies have evaluated the utility of imaging modalities in detecting early cardiac dysfunction, there is a need for studies that evaluate the long-term prognostic value of these modalities in predicting adverse cardiovascular outcomes. Predictive models would enable clinicians to identify patients who are at high risk of developing cardiotoxicity, allowing for the implementation of preventive strategies. Individual imaging modalities are effective in detecting cardiotoxicity, but there is a need to evaluate the added value of combining different imaging modalities. Multimodality imaging approaches could provide a more comprehensive assessment of cardiac function and facilitate the early detection of cardiac dysfunction. A summary of the above can be found in The influence of breast cancer therapy on the heart, known as cardiotoxicity, is the topic of substantial investigation. Studies previously employed imaging modalities such as TTE, cardiac MRI, and MUGA to assess cardiotoxicity. Of particular relevance within the breast cancer population is the LVEF, a critical prognostic measurement for assessing heart health and estimating the severity of left-sided cardiac malfunction. CTRCD rates differed between imaging modalities, with cardiac MRI the most sensitive. The use of multimodal cardiac imaging is a nuanced area, influenced by local availability, the clinical question at hand, body habits, and medical comorbidities. All of the imaging modalities listed have a role to play in current care; however, focus should be given to increasing the provision of cardiac MRI for breast cancer patients in the future to optimize the detection of CTRCD and patient outcomes thereafter.


Neurodevelopmental disorders (NDD) are a group of conditions that originate in the early stages of life but often persist through adulthood. Among them, the most prevalent in Europe and the USA are autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD), learning disabilities, and other impairments affecting language and communication. Diagnosing, treating, and monitoring such conditions are usually a complex and costly process especially since these often evolve into chronic conditions. Difficulty and delay in diagnosis and intervention due to the recent COVID-19 pandemic, lack of access to expert therapists and medical staff, or high-cost burden all contribute to poorer therapeutic conditions and outcomes.In response to the pandemic, there has been a notable surge of telehealth and assistive technology and delivery that include artificial intelligence and machine learning-based applications. The growth and subsequent widespread adoption of such technologies, especially in the field of mental health, has the benefit of providing instant automated access to interventions, improving therapeutical conditions, and reducing the distance gaps between the patient and the clinician. Additionally, it allows patients to receive personalized clinical consultations without the burden of face-to-face interactions.The scope of this Research Topic is to investigate the impact of telehealth, assistive technologies, and Artificial Intelligence-based applications in the diagnosis, treatment, and monitoring of NDDs. In particular, the Research Topic focuses on the benefits that the adoption of these technologies can bring to the management of mental health, to the outcome of therapeutic interventions, and patients' health in general.The present Research Topic covers original research articles and case studies on novel technological solutions targeted at patients with neurodevelopmental disorders at early or late developmental stages.García et al., the behavioral intention and attitude of mental health practitioners in the potential adoption of virtual humans to provide affect recognition training was explored. Affect recognition, especially in social contexts, is a crucial cognitive skill that allows us to interpret social situations. This skill is impaired in various psychiatric disorders, including schizophrenia. The study stems from the need to provide standardized technology-based therapies for such patients and to evaluate the interest in these techniques from the professionals involved in the field. After viewing a video presentation of the therapist-controlled software, practitioners all showed a positive intention to adopt virtual reality tools for their training, with younger professionals expressing less concern about the knowledge required to use the VR tool and older professionals reporting more potential enjoyment.In the work by Minissi et al. administered three virtual reality tasks to both ASD and typically developed (TD) children. These tasks required them to execute precise and goal-directed movements. The authors found that, in the context of the flower task that required participants to move accurately one of their upper arms horizontally, ASD children showed evident motor abnormalities. Specifically, these children displayed notable displacements in the head, body, and upper limbs, along with variations in velocity, acceleration, and deceleration in the limbs or hand. Their execution time was also longer in comparison with TD children.Social recognition impairment is not the only NDD symptom lacking standardized therapies or evaluation methods. Atypical motor skills, in fact, are by consensus one of the core and earliest markers in autism spectrum disorder (ASD), regardless of its severity. Milano et al. investigated finer movements of the fingers using motion detection software connected to a tablet. The technology-enhanced setting reproduced the structure of a traditional cognitive battery (the Leiter-3 test) in which children were asked to drag on the screen a series of moving cards near designed placeholders. Hypothesizing the presence of latent features in the movement patterns, the authors analyzed the trajectories using a specific type of Artificial neural network, the variational autoencoder, finding distinctive clusters. The motor features that contributed the most in discriminating the movement pattern of ASD children from TD children were the standard deviation of the speed, the maximum and minimum acceleration, and the standard deviation of the acceleration.In another study on the topic of motor abnormalities in ASD children, Shiozu report a case study of applied therapy using Cognitive Orientation to daily Occupational Performance (CO-OP) for tele-occupational therapy. The intervention was delivered to the patient, an 8-year-old child, fully remote and online, with the use of video conferences and e-mails. The authors showed that all predefined goals for the child were achieved and that the child's measured satisfaction was positive, with a marked improvement in performance in comparison with that reported before the intervention.Developmental coordination disorder is a form of motor disability that greatly affects patients' daily lives. Occupational therapy, defined as an intervention aimed at facilitating children in performing daily activities including educational and leisure activities, can greatly improve patients' quality of life. In this context, Bertacchini et al. summarize the AI-enhanced and technology-assisted devices currently in use in the assessment, treatment, and monitoring of NDDs and identify the limitations of such systems along with the open challenges posed by the potential adoption of each of the different tools and techniques available. In the context of social robotics and human-robot interaction, the authors propose an experimental setup for children with ASD based on the humanoid robot Pepper and the more recent large language model ChatGPT. The integrated system, equipped with face-detection, emotion-recognition software, and speech-recognition software, is developed to convey both informal and structured interactions to promote social interactions and deliver cognitive training.In conclusion, the purpose of the Research Topic is to provide a significant contribution to the comprehension of how these innovative approaches affect the management and treatment of NDDs. Specifically, it aims to outline the ongoing progression through which technological and AI applications, encompassed by pioneering theoretical perspectives, can potentially establish new benchmarks that either supplant or complement conventional medical and psychological interventions.DP: Conceptualization, Data curation, Methodology, Software, Writing—original draft. BL-P: Writing—review & editing. DM: Conceptualization, Supervision, Writing—review & editing.


Itsgreater precision in detecting metastatic lesions has increased the accuracy of thediagnosis and guided therapeutic decisions, opening new possibilities for thecustomization of practice in view of the latest therapeutic advances.In the relentless quest to improve the management of prostate cancer, great advances havebeen made and improved upon in the diagnostic and therapeutic fields, especially in thelast decade. After the role of magnetic resonance imaging (MRI) in locoregionalevaluation had been consolidated, the advent of prostate-specific membrane antigenpositron emission tomography (PSMA-PET) brought transformations that provided a newperspective on the disease and its management. This advanced imaging method hasdistinguished itself as a revolutionary tool, redefining the scenario of biochemicalrecurrence, advanced metastatic disease, and, more recently, the initial staging ofpatients with prostate cancer,3. This increase in accuracy comes from the combinationof the molecular component of PET and the structural component of CT/MRI, given thatPSMA is overexpressed in neoplastic cells within the prostate. That added accuracy isessential to avoid understaging and to allow the therapeutic intervention to beimplemented early, thus increasing the likelihood of treatment success and potentiallyreducing morbidity by averting unnecessary treatments.Compared with conventional imaging methods, such as computed tomography (CT), MRI, andbone scintigraphy, PSMA-PET has greater sensitivity and specificity for detectingmetastatic diseaseIn the clinical scenario of the initial staging of prostate cancer, the value of PSMA-PETis more significant in the evaluation of nonprostatic disease such as pelvic lymph nodeinvolvement (N), as well as distant, bone and visceral metastases , for which conventional methods have major limitations. This assumedadvantage of PSMA-PET has become an ally in the therapeutic decision-making process.However, the use of PSMA-PET in the preoperative evaluation of the prostate is a topicthat is still under exploration, especially in comparison with the currently availablemethod with higher spatial resolution (MRI) and with histopathological correlation.Therefore, this is a highly relevant, current topic that deserves to be investigated ingreater depth in order to improve the diagnostic approach and perhaps to be replicatedin scenarios of earlier disease detection., authors of the article “Preoperative evaluation ofprostate cancer by 68Ga-PSMA positron emission tomography/computedtomography: comparison with magnetic resonance imaging and with histopathologicalfindings”, published in this issue of Radiologia Brasileira. Their article confirms somepremises put forth in the literature. The ability of PSMA-PET to detect a lesion within the prostate appearsto be similar to that of MRI in the context of the initial staging. I find that to bethe most interesting piece of data in the article, because the vast majority of patientswere at low or intermediate risk according to the histological grade , which could reduce the detectionability of PET compared with MRI, because the expression of PSMA correlates with thepercent Gleason grade pattern 4 in the tumor. That confirms the ability of PSMA-PET todetect cancer and supports the potential extrapolation of its use to an earlierscenario: prostate cancer detection. In addition, it demonstrates the superiority of MRIin detecting extraprostatic extension of a tumor (T3), which is expected given thesuperior spatial resolution of MRI in comparison with that of CT and PET, because suchextension is minimal in the vast majority of cases.This editorial congratulates the initiative of Stasiak et al. study has somelimitations related to its retrospective design. In comparison with conventionalmethods, PSMA-PET has higher sensitivity and specificity for the initial staging ofprostate cancer. Despite thelimitations, half of the patients did not undergo extended lymphadenectomy (the goldstandard for intraoperative confirmation) and there was a low prevalence of positivelymph nodes in the patient sample, which reduces the statistical impact of thecomparison. That is evidenced by the fact that the sensitivity of PET was found to betwo times greater than that of MRI (44% vs. 22%), although the difference was notstatistically significant. Nodal staging is particularly relevant in this clinicalscenario, because it has a prognostic value that has been validated in the literaturefor patients staged as N1 by PSMA-PET and their worse treatment outcomes. Therefore, how to use this informationin order to reduce morbidity and intensify treatment is a topic currently under debatein the uro-oncology community.The Stasiak et al. demonstrated that combining PSMA-PET with MRI increased thesensitivity and the negative predictive value for the detection of clinicallysignificant tumors. That opens the possibility of further exploration of whetherPSMA-PET can be used in a variety of potential scenarios, such as in the detection oreven active surveillance of clinically non-significant (ISUP grade 1-2) tumors, as wellas in guiding biopsies of such tumors, questions to which we should soon have cleareranswers.The incorporation of PSMA-PET into the evaluation of the prostate, together with MRI, hasprogressed to an earlier context: in the detection of prostate cancer in patients withclinical suspicion of the disease. Emmet et al.


The convergence of China’s digital economy and green finance holds great significance for fostering a sustainable and high-quality developmental path. However, existing studies have not explored the coupling coordination development between these two crucial subsystems. To bridge this gap, this paper employs a modified coupling coordination degree (CCD) model to assess and affirm the coupling coordination degree between the digital economy and green finance across 30 provinces in China from 2015–2021. Based on degree results, provinces are classified into three clusters by using K-means and hierarchical clustering algorithm. Our findings unveil that the current level of coupling coordination development in China is at a primary coordination stage. Although regional disparities significantly exist, the overall level of coordination remains steadily increasing, with the eastern region outperforming the western region. Additionally, we determine that the COVID-19 pandemic’s disruption on the coupling coordination development of these systems has been limited. This research sheds light on the evolution of coupling systems and offers practical recommendations for strengthening the coordinated development of the digital economy and green finance. In recent times, the development of the digital economy has significantly contributed to promoting economic growth and optimizing and upgrading the economic structure . For insWith the growing integration of the digital economy and green finance, they are progressively coupling to foster high-quality economic growth. The digital economy’s digital platforms and technological tools find widespread application in the realm of green finance, primarily focusing on green technology innovation, decision-making in green finance, and management of green supply chain. For instance, digital technology enables financial institutions to provide innovative services rooted in big data and artificial intelligence, including risk assessment, green bond issuance, and carbon emission trading, which serves as the groundwork for the innovation of green finance . In addiThe relationship between the digital economy and green finance has emerged as a prominent area of research, with scholars exploring two key aspects. Some scholars considered that the digital economy played a significant role in enhancing the efficiency of green finance. Tian et al. 2022)  and Han 22  and HThe phrase coupling usually refers to the interconnectedness between two entities that exhibit mutual influence and interaction . The theWith the gradual infusion of digital elements into the green industry, digital technology and digital platforms of the digital economy have emerged as the core elements of the development of green finance. By enhancing the digital foundation of green finance development, digital technology makes up for its technological limitations. However, current researches have mainly examined the significance and influence of the relationship between the digital economy and green finance. There are few studies discerning their logical nexus and regional disparities from a coupling perspective. Therefore, elucidating the coupling and coordination relationship between the digital economy and green finance has become a significant topic. Specifically, this study aims to answer the following questions:Based on theoretical analysis, how does the coupled system comprising the digital economy subsystem and the green finance subsystem operate?By establishing a modified CCD model, whether it can be validated that digital economy subsystem and green finance subsystem have a coupling and coordination relationship?Has the evolution of the coupled system reached a definitive conclusion? If not, are there different stages of coupling coordination and, if so, what types of variation are present?In order to answer these questions, this study establishes evaluation metrics and constructs a modified CCD model to evaluate the CD and CCD. On one hand, by utilizing coupling theory as the analytical framework, a novel coupled system is constructed, elucidating the main logical relationships and mechanism. On the other hand, based on the analysis results of CD and CCD, examinations are conducted regarding the trends of change and regional disparities. Furthermore, a clustering analysis of the 30 provinces is conducted based on the CCD over the past few years. Ultimately, recommendations are proposed concerning the coupling and coordination development of the digital economy and green finance.The structure of this paper is as follows: Section 2 provides a review of the existing research on the relationship between the digital economy and green finance, examining it from two perspectives. Section 3 presents a theoretical analysis of the coupling mechanism, focusing on the digital economy subsystem and the green finance subsystem. Section 4 establishes a comprehensive evaluation index system to assess the CD and the CCD. It also introduces the main models utilized in this study. Section 5 discusses and analyzes the empirical results derived from the evaluation index system. Section 6 proposes countermeasures and suggestions for promoting the coupling coordination development between the digital economy and green finance. Section 7 summarizes the key findings and draws three main conclusions. Additionally, it discusses the innovation and limitations of this paper.The integration of the digital economy and green finance contributes to promoting sustainable and high-quality economic development. Digital technology innovation enables the interaction and connection between green finance and digital technology, leading to a transformation from a traditional risk management approach into a value enhancer that fosters sustainable development. Digital technology enhances data analysis and evaluation methods for green finance, thereby promoting the development of green industries. Consequently, the coordinated development of the digital economy and green finance has become a hot research topic within the academic community.The existing literature has studied the relationship between digital economy and green finance from various perspectives, which can be organized into two major themes through sorting and summarizing, as follows.Regarding the significance of digital economy to the development of green finance, some scholars suggested that the efficiency, transparency, and feasibility of green finance can be improved through the application of digital technology of digital economy, which can further promote sustainable development and the rational utilization of resources. The advancement of digital technology has substantially improved the efficiency and transparency of green finance. Wang et al. (2022)  claimed Scholars have extensively examined the influence of digital finance on green finance. As a pivotal component of the digital economy, digital finance has redefined the conventional financial framework by means of tools such as online payment, mobile payment, electronic banking, and digital currencies . This trIn summary, scholars have predominantly examined the significance and relationship of the digital economy and green finance. However, research is limited on the coordinated relationship between them and regional development variations. In addition, limited research exists on the pathways of their coordinated development and the related quantitative assessments. What’s more, there is no study that have conducted in-depth research on the logical relationship and regional variations surrounding the coupled coordination development of the digital economy and green finance.Therefore, this study has established an evaluation index system and constructed relevant models to assess the coupling and coordination relationship between the digital economy and green finance, as well as to further examine the provincial development disparities in China. To achieve this, we first constructed an analytical framework based on system theory and coupling theory to clarify the logical relationship and mechanism of the coupled system. Subsequently, by utilizing the analysis results of the coupling degree (CD) and coupling coordination degree (CCD), our study has examined trend changes and regional variability, providing valuable recommendations for the coupled development of the digital economy and green finance.The relationship between the development of the digital economy and green finance is not entirely independent, parallel, contradictory, or incompatible. Instead, it represents a fusion and mutually reinforcing connection. This study builds upon system theory  and coupTo unveil the coupling relationship between the digital economy and green finance, it is essential to elucidate their interactions and the pathways that connect them. The digital economy represents a novel economic form, with data resources at its core, which are primarily disseminated and applied through modern information networks; Information and communication technologies (ICTs) play a crucial role in driving the development of the digital economy . ExistinThe similarities in the developmental processes of the digital economy and green finance signify the possibility for synergistic development between the digital industry and the green industry . FirstlyThe digital economy, through digital industrialization, brings new technologies, business models, and dynamics to traditional industries . On the Through the process of industrial digitalization, digital technology has the potential to enhance the efficiency of traditional industries, reduce product costs, and address the problem of information asymmetry. Simultaneously, the adoption of green technology has played a vital role in industrial transformation by boosting energy efficiency, curbing pollution emissions, and facilitating resource allocation through sustainable practices , 48. TheThe coupling of the digital mindset and the green mindset is beneficial for achieving high-quality and sustainable economic development. As these mindsets intertwine, they place higher demands on economic progress. The green mindset acknowledges the interdependence between humans and nature, perceiving the environment and humans as integral parts of a symbiotic system. Within this system, growth and development hold distinct meanings; Growth implies a quantitative increase, while development emphasizes the enhancement of quality . SecondlTo explore the coupling and coordination relationship between the digital economy subsystem and the green finance subsystem, it is essential to establish an evaluation index system. Taking into account the research conducted by Su et al. (2022)  and WangCurrently, there is no unified standard in the academic community to measure the level of digital economic development. However, several studies have proposed evaluation indicator systems. For example, Liu et al. (2020)  decomposCurrently, there is no unified standard for evaluating indicators in the field of green finance. Jiang et al. (2020)  construcTherefore, this study draws on the research of previous scholars and considers data availability. This paper selects five indicators from three dimensions: green securities, green investment market, and carbon market for constructing the evaluation indicators, as shown Various methods exist for constructing indices, including AutoML , TOPSISSDigital economy index and green finance index serve as the basis for assessing the coupling coordination degree between the digital economy and green finance, employing a modified CCD model. Furthermore, the K-means clustering analysis algorithm is applied to classify and analyze the development level of coupling coordination among 30 provinces in China, based on the results of the coupling coordination degree analysis. The analytical process is shown in U1). Factor analysis is a statistical technique employed to streamline and scrutinize datasets characterized by high dimensionality. By effectively transforming numerous observed variables, also known as indicators, into a reduced set of latent factors, this method facilitates a more concise representation of the data. Such dimensionality reduction serves to simplify the subsequent analysis and interpretation processes, while also mitigating the computational complexity associated with subsequent analytical procedures [Considering the large number of evaluation indicators in the field of digital economy and taking into account the advantages of factor analysis models, this paper selects the factor analysis model to calculate the digital economic index T. The elementary loading matrix is represented by Compute the eigenvalues Extract common factorsw) of each common factor based on the elementary loading matrix and extract m principal factors. This paper employs probabilistic principal component analysis (PPCA) as a method to extract common factors. In comparison to traditional principal component analysis (PCA), PPCA presents several advantages, including enhanced flexibility, interpretability, and robustness [We need to calculate the contribution rate . EWM is an objective way to give weights based on the entropy value provided by the standardized values, specifically by measuring the degree of differentiation to assess the indicator’s value [Due to the limited number of evaluation indicators for green finance, this paper utilizes the EWM to calculate the green finance index   introducK distinct clusters, optimizing the similarity within each cluster while minimizing the similarity between different clusters [K) to meet specific requirements. By increasing or decreasing the value of K, the granularity of clustering results can be controlled, thus catering to practical needs [This paper aims to perform a clustering analysis on the level of coupling coordination development across 30 provinces in China, based on the outcomes of CCD. The clustering analysis in this study falls under the realm of traditional numerical data clustering problems. Therefore, two algorithms, namely the K-means algorithm and hierarchical clustering algorithm, are adopted. The K-means clustering algorithm is specifically designed to partition data into clusters . It is pal needs . On the In order to ensure statistical consistency and data availability, this study focuses on 30 provinces in China  as the research subjects. The analysis primarily relies on various data sources, including the “China Statistical Yearbook”, “China Third Industry Statistical Yearbook”, “China Electronic Information Industry Yearbook”, “China Industrial Statistical Yearbook”, “China Science and Technology Statistical Yearbook”, provincial statistical yearbooks and bulletins, EPS Global Statistical Database, CSMAR Database, among others. To address any missing data for specific years, trend extrapolation or interpolation methods are employed to supplement the gaps and maintain data continuity.Based on the calculation process outlined in section 4.2.1 on factor analysis, Python is utilized in this study to calculate the digital economy index for each province spanning the years 2015 to 2021, as shown in In Additionally, our analysis of According to section 4.2.2 on entropy weight method, the results of green finance index and its descriptive statistics are shown as in Regions with high levels of green finance development are primarily situated in the northeastern coastal areas, such as Shanghai, Beijing, Guangdong, and Zhejiang provinces. These regions boast higher levels of economic development, abundant economic resources, and stronger technological capabilities, which provide them with a significant advantage in green industries and sustainable development. They actively promote the advancement of environmentally friendly industries, facilitate the transition towards a low-carbon economy, and proactively introduce and nurture green financial institutions and projects. To contextualize our findings, we conducted a comparative analysis with the research conducted by He et al. (2020)  and Lin According to the section 4.2.3 on modified CCD model, the calculation results of CCD and its descriptive statistics are shown in Tables From the In addition, based on the results, it seems that the COVID-19 has had a modest influence on the coupling coordination development between China’s digital economy and green finance. The analysis reveals a slight decline in CCD across each region, indicating that the COVID-19 has impacted the level of coordination between these two sectors. The reasons behind this decline in CCD are likely multifaceted. The pandemic has disrupted economic activities, presenting challenges for the digital economy and green finance sectors. Factors such as reduced investments, shifts in consumer behavior, and disruptions in supply chains may have affected the coordinated development between these sectors.It is important to note that although the impact of COVID-19 on CCD is evident in the results, the decline appears to be relatively minor. This suggests that the digital economy and green finance sectors have demonstrated resilience and adaptability in the face of the challenges posed by COVID-19. Government efforts to mitigate the impact and facilitate recovery from the disruptions caused by COVID-19 may have contributed to the overall stability and gradual improvement observed in the coupling coordination development between the digital economy and green finance.In summary, the descriptive statistical results indicate an increasing trend in the coordinated development between the digital economy and green finance in China’s provinces. Provinces in the eastern region, such as Beijing, Shanghai, Zhejiang, and Guangdong, lead the way with notable progress. The central region shows a mixed performance, while the northeastern and western regions demonstrate varying levels of coordination.According to the information provided in section 4.2.4, this paper employs a combination of the K-means algorithm and hierarchical clustering algorithm for the classification analysis of the coordinated development between China’s digital economy and green finance. To evaluate the quality of the clustering results, the paper conducts silhouette analysis. Silhouette analysis calculates the silhouette coefficient for each sample, which quantifies the closeness of a sample to its own cluster compared to other clusters . A silhoThe provinces included in the second cluster, namely Tianjin, Hebei, Liaoning, Anhui, Fujian, Shandong, Henan, Hubei, Hunan, Sichuan, and Shaanxi, exhibit a CCD between their digital economy and green finance at approximately 0.4, indicating that they are in the primary stage of coordination. Despite the relatively low coupling degree, these provinces have demonstrated a positive trend of stable growth over the past seven years. To facilitate the development of the digital economy, these provinces prioritize the creation of favorable conditions. They actively promote digital innovation capabilities and accelerate the digital transformation of their respective industries. By embracing digital technologies and fostering innovation, these regions aim to enhance productivity, competitiveness, and overall economic growth. Moreover, these provinces make investments in green finance and closely monitor its development and challenges. Recognizing the importance of sustainable finance, they establish multi-level green finance policies and service platforms. These initiatives facilitate the coordinated development of green finance across regions, based on unified industry standards. By aligning their efforts, these provinces foster a synergistic approach to green finance, contributing to sustainable economic growth and environmental protection. Overall, while these provinces may have a relatively lower level of coordination between the digital economy and green finance, they have shown positive progress and stability in their development. Their focus on creating favorable conditions, promoting digital innovation, and investing in green finance demonstrates their commitment to achieving a more coordinated and sustainable approach to economic development.The third cluster includes Shanxi, Inner Mongolia, Jilin, Heilongjiang, Jiangxi, Guangxi, Hainan, Chongqing, Guizhou, Yunnan, Gansu, Qinghai, and Xinjiang provinces. These provinces exhibit a low degree of CCD between the digital economy and green finance, nearly in the lowest level of coordination. Most of these regions have relatively lower levels of economic development and lack a foundation for nurturing the digital economy. They face challenges such as insufficient innovation capacity in key areas, relatively slow digitization of traditional industries, and the need to overcome the digital divide. Moreover, the governance system for the digital economy requires improvement. Additionally, the development level of green finance in these regions is relatively low, with inadequate product innovation capacity and limited market depth and breadth. The intermediary services for green finance development in these regions are also relatively weak.To rectify the disparity in the coordinated development of the digital economy and green finance across different regions in China, the policymaker should implement macro-level measures aimed at regulating and optimizing fiscal intervention. These measures seek to distribute policy resources more equitably and efficiently.One specific measure involves strategically allocating policy resources to the central and western regions, which are comparatively less developed. The policymaker should increase investments in green technology innovation and digital infrastructure construction within these regions. By directing resources and support towards these areas, the objective is to stimulate their rapid development in the digital economy and green finance sectors. This approach aims to promote sustainable development and bridge the regional development gap within the country.Through fostering the expansion of the digital economy and green finance in the central and western regions, the policymaker intends to ensure that all areas can benefit from the opportunities presented by these sectors. This approach fosters economic inclusivity by enabling regions with traditionally fewer advantages to participate and contribute to the overall development of the country. Additionally, it seeks to establish a more balanced and harmonized economic landscape, where the benefits and opportunities of the digital economy and green finance are distributed more evenly nationwide.In summary, the government’s macro-level measures prioritize leveraging fiscal intervention to address regional disparities in the coordinated development of the digital economy and green finance in China. By allocating policy resources towards the less developed central and western regions, increasing investments in green technology innovation and digital infrastructure, and promoting sustainable development, the policymaker aims to bridge the regional development gap, foster economic inclusivity, and ensure that all regions can benefit from the opportunities presented by the digital economy and green finance.In the realm of production and consumption, businesses are increasingly recognizing the significance of utilizing digital technology to expand their range of green consumer products. This enables them to offer a broader selection of high-quality digital intelligent products that not only cater to but also guide the preferences of environmentally conscious consumers. Governments play a crucial role in facilitating this shift towards green consumption.Governments should actively promote industrial digitization by leading efforts to enhance the integration of front-end and back-end industries. This involves collaborating with upstream and downstream enterprises to reduce resource consumption during production and minimize pollution emissions throughout the consumption process. Through active engagement with stakeholders and the implementation of effective policies, governments can drive economic development towards technological advancement and encourage the adoption of environmentally friendly products.However, it is important to acknowledge that while the digital economy brings notable penetrability and significant economies of scale, it also carries environmental implications of its own. The substantial energy consumption and carbon dioxide emissions associated with the digital economy must not be overlooked. Therefore, it becomes imperative for us to establish a green consensus and mitigate redundant consumption resulting from the digital transformation process in order to ensure sustainable development.By embracing sustainable practices and striving for resource efficiency, both businesses and governments can effectively address the environmental impact of the digital economy. This necessitates a comprehensive approach that encompasses the development and promotion of green consumer products, as well as the implementation of policies and measures to minimize the ecological footprint of digital technologies.In conclusion, the integration of digital technology with green production and consumption is vital for driving economic growth and achieving sustainability goals. Through digital innovation, businesses can diversify their product offerings to meet the needs of environmentally conscious consumers. Simultaneously, governments must actively promote industrial digitization and collaborate with industry stakeholders to reduce resource consumption and pollution emissions. By establishing a green consensus and adopting sustainable practices, we can ensure that the process of digital transformation aligns with the principles of green development and contributes to a more environmentally friendly future.In this study, both factor analysis modeling and the entropy weight method were employed to calculate and analyze the digital economy index and the green finance index of various provinces. Based on the index outcomes, a modified coupling coordination degree model was formulated to assess and validate the disparities in coupling relationships and coordination levels between the two subsystems. Furthermore, to illuminate spatial and temporal variations in coupling coordination development across different regions, this study employed two clustering algorithms: K-means and hierarchical clustering. According to the findings presented in this research, 30 provinces were categorized into three clusters based on their coupling coordination degree. On a broader perspective, China’s digital economy and green finance are presently undergoing coupling coordination development at a relatively modest level, positioned at the primary coordination stage. The coupling coordination development of the two subsystems, in general, demonstrated steady growth; however, there were pronounced regional disparities among provinces. Specifically, the level of coupling coordination development in the eastern regions was comparatively higher than that in the western regions. Likewise, coastal areas exhibited higher level of coupling coordination development compared to inland regions. Remarkably, despite the impact of COVID-19, the coupling coordination development of the two subsystems displayed resilience, showcasing an overall upward trend.This study makes significant contributions in both theoretical and practical aspects. Theoretical expansion is achieved by extending the research scope of coupling theory to encompass the digital economy and green finance. In terms of practical implications, the study enriches the application of the digital economy and green finance through the use of the modified coupling coordination model to analyze the degree, evolutionary stages, and trends of their coupling coordination. Additionally, based on the research findings, we can put forth several policy recommendations to facilitate the coupling coordination development between digital economy and green finance in China, such as formulate region-specific development policies, support green technology innovation and digital infrastructure, promote industrial digitization and collaboration and establish a consensus on green practices.While this study demonstrates innovation, there are limitations attributed to factors such as time constraints and data availability. The evaluation index system may also have limitations, despite employing a rigorous selection process and a substantial number of evaluation indicators. Further consideration is necessary to address the issue of indicator deviation, which may require calibration and improvement in different environments or provinces. Moreover, the study only analyzes 30 provinces in China due to data availability, posing limitations in terms of representativeness. Future research could expand the sample range to include a broader range of regions, such as urban and rural areas, in order to obtain more comprehensive and accurate research results.S1 Raw data(ZIP)Click here for additional data file.


Several perioperative factors are responsible for the dysregulation or suppression of the immune system with a possible impact on cancer cell growth and the development of new metastasis. These factors have the potential to directly suppress the immune system and activate hypothalamic-pituitary-adrenal axis and the sympathetic nervous system with a consequent further immunosuppressive effect.Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system, inflammatory system, and angiogenesis, with a possible impact on cancer recurrence and long-term outcome. Even if the current data are controversial and contrasting, it is crucial to increase awareness about this topic among healthcare professionals for a future better and conscious choice of anesthetic techniques.In this article, we aimed to provide an overview regarding the relationship between anesthesia and cancer recurrence. We reviewed the effects of surgery, perioperative factors, and anesthetic agents on tumor cell survival and tumor recurrence. Surgery represents one of the leading treatments for the therapeutic management of several kinds of tumors. However, at the same time, surgery can have a direct and an indirect effect on tumor cell survival leading to tumor recurrence. Surgery can lead to the release of cancer cells into the bloodstream during tumor manipulation with consequent metastatic spread to distant organs . FurtherLikewise, anesthesia techniques may affect metastatic progression of tumor cells . In factAccordingly, it is crucial for healthcare personnel to consider the possible relation and implication between anesthesia, perioperative stress factors and cancer for a future better and conscious choice of anesthetic technique with the goal of improving cancer outcome. In this article, we aimed to provide an overview regarding the relationship between anesthesia and cancer recurrence. We reviewed the effects of surgery, perioperative factor, and anesthetic agents on tumor cell survival and tumor recurrence.Perioperative stress factors trigger physiological responses that in turn can create an appropriate microenvironment for the growth of pre-existing micro-metastatic, for the formation of new ones and for their spread . SeveralIncrease shedding of cancer cells due to mechanical manipulations of the tumor during surgery ;Activation of inflammatory response ;Modulation of immune function ;Triggering the neuroendocrine and paracrine stress responses ;Activation of pro-angiogenic signaling pathways ;Expression of specific genes and/or molecular pathways .Perioperative metastasis survival and growth are mediated through various mechanisms :IncreaseMetastasis can occur through transcoelomic, lymphatic, and/or hematogenous routes. Transcoelomic spread refers to the diffusion of cancer cells to the peritoneal cavity, due to the migration of a primary cancer of the abdomen/pelvis or due to the systemic spread of another kind of primary cancer . During The activation of inflammatory system due to surgical stress lead to the migration of macrophages, neutrophils, fibroblasts and mesenchymal stem cells on the site of the surgery . These cThe activation of neural signaling is induced not only by surgical tissue trauma but also by other stress factors . The activation of neural signaling  led to the release of stress hormones  with important consequences on cancer cell invasiveness . The conFinally, another important aspect is represented by the possible correlation between stress response and expression of specific genes or molecular pathways with the consequent changes in the cell signaling , 55, 56.The increasing interest in the impact of anesthetics and cancer progression has stimulated several in vivo and in vitro studies on the relation between different kinds of anesthetics used during surgery and cancer development and progression , 62. EveOn the other hand, propofol presents anti-inflammatory and immunosuppression properties –72. SeveInhibition of HIF-1α protein synthesis induced by hypoxia ;Inhibition of the mRNA expression of MMP-2 and MMP-9 and p38 MAPK signaling  ;Inhibition of the NF-κB pathway ;Downregulation of S100A4 in endothelial cells and suppression of VEGF expression from cancer cells with consequent anti-angiogenic effects , 84;Upregulating miRNA expression (tumor suppressors and by inhibiting the expression of miRNAs that works as oncogenes) ;Inhibiting histone acetylation .Propofol may also modulate genetic signaling pathways with important consequences on carcinogenesis:Noteworthy, signaling pathways are not usually independent and participate in a crosstalk to create a regulatory network. Consequently, propofol may affect several pathways with important regulation on genes expression. Propofol with its anti-inflammatory and pro-immunity effects has been suggested to have a positive impact on long-term survival and cancer outcome –90. HoweIn 2021, Ramirez et al. performed a review describing how drugs may regulate important function on immune and cancer cells . The autFinally, ketamine and thiopental present immune effects. Thiopental inhibits the function of neutrophils and NK . KetaminIncreasing evidence suggests that, beyond their primary analgesic function, opioids present several physiological effects. Opioids modulate wound healing and cancer progression through their endothelial action and through their influence on angiogenesis . FurtherThe interplay between opioids and cancer, however, is complex and far to be understood deeply. It was also observed that neutrophils, macrophages and T cells also release endogenous opioid peptides with consequent reduction of inflammation and pain through the binding of peripheral opioid receptors , 104. NoMorphine: suppresses the activity of NK cells, promotes lymphocyte apoptosis, reduces the differentiation of T cells, and stimulates angiogenesis ;Fentanyl: decrease the activity of NK cells and increase the number of regulatory T cells ;Sufentanil: decrease the activity of NK cells, increase the number of regulatory T cells, inhibits leukocyte migration ;Alfentanil: decreases the activity of NK cells ;Remifentanil: suppress the activity of NK cells and lymphocytic proliferation .In brief, different kinds of opioids seemed to act different effects in in vitro/in vivo model:Interestingly, methyl-naltrexone, an opioid antagonist, seemed to inhibit tumor cell invasion and implantation, while continuous infusion of MNTX decreases primary tumor growth and development of lung metastasis .Reduces the stress response to surgery (via pain control or sympathetic block) and reduces the levels of cortisol, β-endorphin, and epinephrine , 113;Reduces the need for opioids or volatile agents (indirect effect);Activates apoptotic pathway ;Inhibits tumor cell growth and migration ;Increases the activity of NK ;Increases the number of T-helper (Th) cells, preserved the ratio of Th1 to Th2 cells ;Preserves IFN-gamma concentrations ;Modulates gene expression, DNA demethylation ;Increases IL-4 and decreasing IL-10, IL-8, TNF-alfa .The implementation of regional anesthesia/analgesia techniques seemed to have a positive impact on reducing cancer recurrence via several mechanisms :Reduces . The authors compared two groups: general anesthesia versus general anesthesia and regional anesthesia groups [Besides the possible beneficial mechanism triggered by regional anesthesia, there is no strong evidence regarding the effect of regional anesthesia on cancer recurrence. Xu et al. evaluated the effects of epidural anesthesia-analgesia on recurrence-free survival after lung cancer surgerya groups . The auta groups . Even moa groups . On the a groups . Severala groups , 124–126NSAIDs and COX-2 inhibitors: represented the most widely painkiller used for the management of perioperative analgesia. NSAIDs inhibit the cyclooxygenase 1 (COX-1) and the cyclooxygenase 2 (COX-2) enzymes with consequent anti-inflammatory, analgesic and antipyretic effects. Several trials have already shown the potential benefits of NSAIDs in the prevention of human cancer [2) and promote immune responses [2 plays a crucial role in promoting cancer progression; enhancement of cellular proliferation, promotion of angiogenesis, inhibition of apoptosis, stimulation of invasion/motility, and suppression of immune response [n cancer . Above an cancer , 128. COn cancer , 129–131n cancer , 133. NSesponses . In partresponse . Neverthresponse . Consequresponse .Paracetamol: inhibits prostaglandin endoperoxide H2 synthase and cyclooxygenase activity with pain-relieving and antipyretic properties. However, paracetamol has no anti-inflammatory effects. Paracetamol can be administered in combination with opioids or NSAIDs to increases the analgesic efficacy and reduce daily morphine consumption [sumption . Analyzisumption , 139. HoAlpha-2 adrenoceptor agonists: dexmedetomidine and clonidine are alpha-2 adrenoceptor agonists mainly used for sedation and as part of multimodal opioid-sparing analgesia. Alfa-adrenoceptors are found to be expressed in breast cancer, both epithelial and stromal cells [al cells . Consequal cells –143.Other drugs commonly used in the perioperative period:Overview articles represent a useful aid for addressing bias and concerns or to put light on the insufficiency of the current literature and to stimulate further research in a particular field. We decided to provide an overview only on the impact of anesthetic techniques and surgery on cancer recurrence because the current data are controversial and contrasting. Our aim was to summarize content from several articles and provide the reader with a general understanding of the possible relation between anesthetics and cancer.It is also important to highlight that, up to now, the heterogeneity of the factors implied in cancer recurrence during surgery are high and the heterogeneity of the current literature on cancer and anesthesia would make impractical, or at least hard, to summarize and to come to any kind of conclusion. Not only the anesthetic technique but also several perioperative factors can influence immune surveillance and inflammatory responses and they may favor proliferation of metastasis. Furthermore, the impact of anesthetics technique depending on the type of cancer could make the discussion confusing considering the vast and divergent literature available on this topic. This would made even more difficult to come to any kind of conclusion.Another important limitation is represented by the fact that it is impossible to evaluate the effect of each single drug on cancer recurrence, since anesthesia requires a combination of different classes of drugs . The difference in baseline characteristics between groups , the different concentration of volatile anesthetics used in the clinical studies, the different duration of the surgery and the extension of surgical incision  represented important confounding factors. Even more, the majority of the data looking at the relationship of these techniques and cancer outcome in different kind of tumor originates from retrospective studies.Surely, evidence is arising about the possible impact of anesthesia technique, perioperative period, cancer recurrence and long-term outcome. Even if the current data are controversial and contrasting, it is crucial to increase awareness about this topic among healthcare professionals for a future better and conscious choice of anesthetic techniques. Consequently, further trials are needed for a deeper understanding of the aforementioned mechanisms and on the actual impact of anesthetic techniques on the long-term survival. At this stage of the clinical research, we think that share awareness represents the major goal in an informative way.