A novel two-dimensional matrix taxonomy, or atlas, of personality, emotion and behaviour is presented. The two dimensions of the atlas, affiliation and dominance, are demonstrated to have theoretical foundations in neurobiology and social psychology. Both dimensions are divided into five ordinal categories, creating a square matrix of 25 cells. A new catalogue of 20,669 English words descriptive of personality, emotion, behaviour, and power is also presented. The catalogue is more comprehensive than previous catalogues, and is novel in its inclusion of intrapersonal, group, and societal behaviours. All words in the catalogue were scored according to the atlas, facilitating visualisation in two dimensions. This enabled a contiguous and novel comparison of existing psychological taxonomies, as well as broader societal concepts such as leadership, ethics, and crime. Using the atlas, a novel psychological test is developed with improved sensitivity and specificity. Since antiquity, humans have sought to identify a framework for understanding the whole person, encompassing personality, emotion and behaviour–3. RaymoThe lexical hypothesis states that, ‘All aspects of human personality, which are or have been of importance, interest or utility, have already become recorded in the substance of language’ and, ‘WhPrevious taxonomies of personality derived from lexical analysis, such as 16PF, HEXACO and fiveFor thousands of years, circles have been used in various ways to map the breadth of the human experience. For insInterpersonal Circumplex taxonomies,29,30 arCriticisms of the circumplex approach have included the apparent subjectivity of item placement, difficuThe Abridged Big Five-Dimensional Circumplex (AB5C),53 advanThe characteristics of a parsimonious taxonomy of personality have previously been described,8,9, fouComprehensive: Encompassing all of what psychologists mean by ‘personality’. The. The62].To avoid ambiguity of trait placement and achieve the requisite level of specificity required for parsimony, two structural modifications to the Interpersonal Circumplex are proposed. Firstly, to overcome the imposed correlation between dimensions, it was proposed to remove the concentric circles. Therefore, behaviours and personality traits may be measured independently by reference to each orthogonal axis. Secondly, to allow for the categorisation of behaviours and traits of neutral dominance and affiliation, one of the ordinal categories for each dimension must be created to specifically allow for neutral behaviours. In keeping with the concept of neutrality, this category will be assigned the value of 0.In order to categorise phenomena according to the taxonomy with specificity, each dimension must be divided into non-overlapping categories. OrdinalAn actor may attempt to assert, proffer, evoke or induce states of affiliation and/or dominance with respect to an observer; however, the response of the observer is inherently influenced by their perception of the actor’s behaviour/emotion. These perceptions may be dependent upon many factors, such as individual neurobiological variation in personality, cognitive states including attentional networks, power status, context, and the cultural milieu. For these reasons, the proposed classification scale does not specify or infer causal relations, rather, it identifies correlations rated typical of general cases.Representative examples of the application of this table include:Behaviours that are maximally disaffiliative and maximally dominant  include ‘maim’, ‘attack’, as well as the absolute behaviour, ‘kill’. Observers of these behaviours may label the actor as ‘cruel’, ‘violent’ or ‘criminal’. Antecedent emotions to such behaviours and traits include ‘rage’, ‘anger’ or ‘wrath’.Behaviours that are maximally disaffiliative and maximally submissive  include ‘self-harm’ and the absolute behaviour, ‘suicide’. Observers of these behaviours may label the actor as ‘dejected’, ‘morose’ or ‘melancholic’. Antecedent emotions to such behaviours and traits include ‘despair’, ‘emptiness’ or ‘futility’.Behaviours that are maximally affiliative and maximally submissive  include ‘worship’, ‘honour’ and ‘adore’, and the absolute behaviour, ‘martyrdom’. Observers of these behaviours may label the actor as ‘reverent’ or ‘devoted’. Antecedent emotions to such behaviours and traits include ‘love’, ‘veneration’ and ‘devotion’.Behaviours that are maximally affiliative and maximally dominant  include ‘charm’, ‘excite’ and ‘inspire’. Observers of these behaviours may label the actor as ‘exuberant’, ‘dynamic’ or ‘charismatic’, and the absolute behaviour, ‘perfection’. Antecedent emotions to such behaviours and traits include ‘ecstasy’, ‘passion’ or ‘triumph’.Behaviours that are of neutral dominance and affiliation  will be rarely noticed by either the actor or observer(s). These neutral emotions and behaviours include the awareness of our basic senses and involuntary behaviours such as ‘digestion’ and ‘respiration’.The atlas taxonomy addresses the deficiencies of the Interpersonal Circumplex, thus forming a parsimonious taxonomy of human personality. By removing the radial and concentric constraints and dividing each axis into ordinal divisions, a matrix structure is created, see Studies 1 to 4 in the present research seek to confirm that the proposed atlas taxonomy is both comprehensive and synthetic. If so confirmed, the atlas taxonomy will be demonstrated to be comprehensive, synthetic, mechanistic and specific, and will therefore satisfy the criterion for being a parsimonious taxonomy of personality. Study 5 in the present research develops a pilot psychological test founded upon the atlas that may be used as the basis for future research using the atlas.The objective of this Study was to catalogue all English language words descriptive of human interaction and emotion.WordNet was idenTo achieve consistent categorisation, the four concepts were defined as follows: behaviour is an observable action , emotion is the perception of a neurological impulse that initiates behaviour , persona20,669 words were identified as being descriptive of personality, emotion, behaviour and power. A summary of the words is shown in Examples of the 1,970 words descriptive of power, included ‘rich’, ‘poor’, ‘skilled’, ‘unskilled’, ‘employed’, ‘unemployed’, ‘king’ and ‘servant’.Previous catalogues of adjectives are in the range of 1,710 to 4,500 words,79–81. TDespite the comprehensiveness of the catalogue, without replication, it is possible that important descriptors of personality, emotion or behaviour may have been overlooked.The objective of this study was: firstly, to confirm that the words in the catalogue can be classified according to the atlas matrix taxonomy, and secondly, to score a subset of up to 20% of the catalogued words.A Delphi approach was utilised to obtain a reliable consensus of opinions of a small group of health professionals. The DelPhase one: To ensure the Delphi process covered all of the 25 cells of the atlas, the author performed an initial scoring of the entire catalogue. From this initial scoring, 10 nouns, 10 verbs and 10 adjectives were selected from each of the 25 cells of the atlas .Phase two: Without being informed of the scoring performed in Phase one, the judges were asked to independently score each word. The judges then discussed their scores, during which, the judges were encouraged to revise their individual scoring until consensus was achieved.Phase three: Synonyms of words scored in Phase two were identified from which were selected 35 nouns, 35 verbs and 35 adjectives from each cell . These word lists were collectively discussed by the judges. The scoring of each word was reviewed by exception until consensus was achieved. It was observed in this phase that the judges referred to synonyms and antonyms of other words selected to achieve a level of consistency in their scoring. Subsequent to the group process, the author and neurologist rescored the remainder of the catalogue.Phase four: The author selected 1,620 antonymic word pairs. The word pairs consisted of words made opposite by prefix or suffix, such as ‘observant/unobservant’, ‘engaged/unengaged’ and ‘merciless/merciful’, and word pairs identified as antonyms in either or both of the reference thesauri. If both words had previously been scored as diametrically opposite in earlier phases, the scoring was retained. If both words had not been previously scored as diametrically opposite, a manual revision of their scoring was performed to achieve exact opposite scoring. These word pairs were then independently reviewed by three judges. In cases where at least two of the three judges had assigned identical scoring to word pairs, these word pairs were considered to be archetypal. The remaining words scored by the judges in Phase three were also deemed to be archetypal.Phase five: The author reviewed the scored archetypal words and made minor amendments to ensure that synonyms, conjugates and inflections were proximately located where appropriate. The judges then performed an overarching review of a summary of 1,800 archetypal words until consensus was achieved by all judges  or personality trait (adjective). In these instances, the words were categorised by the judging panel in the same cell irrespective of the context. An example of a word that can be used in different contexts but would be categorised in different cells is ‘humble’. ‘Humble’ used as an adjective was scored by the reviewers as having affiliation of 1 and dominance of -2. When used as a verb, ‘humble’ was scored as having affiliation of -2 and dominance of 1. When such instances were detected, the word was excluded as being candidate archetypal words. However, due to there being relatively few words in the cell  and the word ‘humble’ was retained as an archetypal word for this cell.Of the 1,620 antonymically opposite word pairs, 27 were rejected by two or more judges leaving 1,593 word pairs remaining. Of the remaining 1,593 word pairs, 150 were opposite due to a prefix or suffix, 711 were identified as antonyms in both reference thesauri and 731 were identified as antonyms in one of the reference thesauri. Consensus amongst the four judges was achieved for 96% of word pairs, with a single dissenting judge on 4% of word pairs. The near complete consensus was viewed as confirming that the catalogued words can be successfully classified using the atlas. Colouration applied to assist interpretation. See The thesauri did not frequently identify synonymic associations between the words descriptive of personality, emotion and behaviour; for example, the words ‘kill’ (behaviour) and ‘murderer’  were not synonymously related. The reference thesauri did however nominate ‘killer’  and ‘murderer’  as synonyms. ‘Kill’ and ‘killer’ can be linked by virtue of having the same linguistic stem. The linking of stem words was performed manually in the present research; however, it could be automated in future. By supplementing the thesauri derived synonyms with manually linked stem words, a robust association between personality, emotions and behaviours was achieved.Some emotions are known to give rise to physiological changes, such asHistorically, it has been acknowledged that relationships exist between personality, emotions and behaviour, although the nature of these relationships is yet unclear. The present research has illustrated the linguistic associations between the catalogued words. Building upon this, future research may use the atlas as a tool to clarify the nature of the causal relationships between personality, emotion and behaviour.Extensive research has been conducted on the human and non-human ability to recognise emotion through facial expression,19,86–88A limitation of this study is that a large number of words were categorised by a small number of judges and that only 20% of the catalogue was manually scored. These limitations give rise to the possibility of bias. These limitations may be overcome by independent replication with additional judges and greater sample sizes.The objective of this Study was to automate the scoring of words in the catalogue using a spring-based network Network theory has been used to visualise and analyse related concepts, including affiliation and dominance. Network theory has previously been applied to both psychological ,94 and lThe equilibrium position of the nodes is determined when the combined attracting and repelling forces are minimised. When equilibrium is achieved, nodes connected by an attracting force are often proximate and nodes joined by a repelling force are normally distant from each other. A hybrid visualisation of networks is one in which some nodes are fixed and other nodes move freely. The attracting and repelling forces of each edge are typically modelled using the physical forces of Maxwell's equations of electromagnetic fields or Hooke's Law of springs. NetworkIn this Study, a network approach was used to categorise the affiliation and dominance for words not previously scored in Study 2, totalling approximately 80% of catalogue (nodes). Edges representing synonymic links were modelled as an attracting force and antonymic links modelled as repelling forces. The use of Hooke’s Law to model the attracting and repelling forces ensured that synonyms were closely proximate and antonyms were disparate when visualised using the atlas.A Python computer program was developed to implement the following steps:The synonyms and antonyms for all catalogued words were obtained from the Oxford and Merriam-Webster thesauri,72.For unscored words in the catalogue with 100% (threshold) of their synonyms previously unscored, the equilibrium position was calculated such that the forces of attraction between synonymic words and repulsion between antonymic words were minimised. Hooke’s Law was used to calculate the forces of attraction and repulsion. Hooke’s Law states that the force needed to extend or compress a spring is proportional to the extension or compression from the resting position. Synonyms that are distant from each other will experience a strong force of attraction whereas synonyms that are close together will experience no force. Conversely, antonyms that are close together will experience a strong repulsive force and antonyms that are distant from each other will experience no repulsive force.Step a. was repeated by successively reducing the threshold  by 1% until all words in the catalogue were scored.First iterationThe equilibrium position for each word in the catalogue was re-calculated in alphabetical order using the location of previously modified word scoring. This process allowed each word to freely move in the atlas, until equilibrium was reached and the words ceased to move.This process was repeated until all words achieved their equilibrium position and no further word movements occurred.Subsequent iterationsA total of 543,830 synonymic pairs and 97,394 antonymic pairs were identified between words in the catalogue. Eight iterations of Step 3. were required until equilibrium was achieved. A qualitative review of the word placement by the spring-based network method confirmed that the method accurately placed the majority of words.The spring-based network approach was able to efficiently score all words in the catalogue not previously scored in Study 2. A review of the scored words suggested that the process was accurate and satisfactory for the purpose of analysing existing psychological and social constructs.The objective of this Study was to visualise in two dimensions a wide range of existing psychological, psychiatric and social constructs using the atlas.A benefit of the atlas is that it is two-dimensional, consequently, a wide range of existing visualisation tools are readily available. One such method of visualisation is based on kernel density estimates,100. KerThe DSM-5 and ICD-11 were selected as the foremost texts on psychiatric disorders. The five-factor model and Dark Triad were selected as representative personality scales. Leadership, ethics and criminality were selected as important social constructs.A Python library was developed that processes a list of words. The words were then mapped to their affiliation and dominance scores obtained in Studies 2 and 3. For example, the word ‘ordinary’ was scored with affiliation of 1 and dominance of 0, or , similarly ‘kill’ is translated to  and ‘love’ . Points on the atlas were then visualised in two-dimensions using the matplotlib Python library.For each personality construct, a clinical psychologist assigned the most representative single word adjective to each question constituting the construct. For example, the clinical psychologist assigned the word ‘extroverted’ as being the most appropriate single word adjective to the question ‘I am the life of the party’. The DSM-5 and ICD-11 constructs were defined in terms of single word personality traits, emotions and behaviour, and were subsequently compiled into a list for each construct. For good and bad leadership behaviours, leading texts–104 wereThe results of this Study are visualised in It was demonstrated that the atlas can be used to visualise a range of important psychological and social taxonomies . The DarThe atlas was able to visually demonstrate and differentiate the poles of multi-pole concepts, such as concepts defined by poles of positive and negative valence. For example, the subsidiary concepts constituting the Dark Triad , Autism The observed correlations between the five factors of five-factor models has hitherto evaded theoretical explanation,115,116.The proposed atlas introduces a novel approach to visualising psychological and social concepts. There are, however, several hundred existing psychological constructs in existence and one limitation of this study is that only a small number have been visualised. The atlas could be further validated by visualising additional psychological constructs.The purpose of this Study was to develop a pilot psychological test that may form the basis of future research based on the atlas.To be comprehensive, it was determined that the psychological test must ask questions from all cells of the atlas. However, the centre cell of the taxonomy  identifies basic functions of living, such as occult emotions and involuntary and reflexive behaviours. Measuring involuntary and reflexive behaviours is unlikely to be of interest to individuals or personality researchers, and therefore the  cell was excluded from the test. After excluding the centre cell, 24 cells remained. It was determined that a single question could compare two cells simultaneously by asking dipole questions, where each option is sourced from a different cell, for example ‘Are you more often happy or unhappy?’. From this it was inferred that the minimum number of questions required for the proposed psychological test was 12.Sensitivity and specificity are statistical measures often used to assess the performance of binary classification tests, and were presently used to determine the optimal configuration of the 12 dipole questions. The concept of sensitivity measures the proportion of correctly identified positives, and specificity measures the proportion of correctly identified negatives. To achieve high levels of sensitivity and specificity, a parsimonious test must ask questions that maximally distinguish the concepts under consideration. Greater distinction was hypothesised for antonymic binary choice questions as opposed to near synonymic binary choice questions. For example, antonymic binary choice questions such as ‘Are you usually friendly or unfriendly?’ are likely to have greater sensitivity and specificity when compared with near synonymic binary choice questions such as, ‘Are you usually friendly or polite?’. Therefore, the 12 dipole questions were restricted to antonymic binary choices.24P24 ≈ 1023 permutations of binary questions that could be asked of the respondent. It is not possible with modern computational techniques to test all 1023 permutations in order to identify the combinations that maximise the overall contrast, therefore, a simulation and alpha-beta pruning[In a matrix of 24 cells, there are a pruning approachThree measures were developed to compare the efficacy of various psychological tests and constructs. The first measure was termed ‘Completeness’ and defined as the proportion of cells in the atlas at which one side of a dipole was located. Tests with higher levels of completeness are likely to be efficacious for a diverse range of diagnostic applications. The second measure was termed ‘Diffusion’ and defined as the proportion of questions in the test that are represented by the atlas outside of the modal cell containing one side of the dipole. Tests with lower levels of diffusion are likely to have higher levels of sensitivity and specificity. The third measure was termed ‘Discrimination’ and defined as the average distance between the poles of a dipole as represented by the atlas. Tests with higher levels of discrimination are likely to have higher levels of sensitivity and specificity. A limitation of these measures is that they are only relevant if the research approach is predicated on the use of the atlas.23 permutations maximised the average distance between the possible antonymic binary pairs Click here for additional data file.S2 TableTwo 48 Question tests. The first test uses antonymic adjectival descriptors of personality traits. The second using antonymic abstract noun descriptors of emotion.(PDF)Click here for additional data file.S1 FilePool of antonymic word pairs. Groups of 12 may be selected to form a questionnaire based on the atlas.(XLSX)Click here for additional data file.


The treatment success rate of pulmonary tuberculosis (PTB) patients aged 64 years and below in Japan, a tuberculosis (TB) middle-burden country with a notification of 13.9 per 100,000 populations in 2016, has been fluctuating around 70% for some years. In order to improve treatment outcome, it is critical to address those lost to follow-up (LTFU). The objective of the study therefore was to describe the characteristics of, and analyze the risk factors for those LTFU among pulmonary TB patients aged between 15 and 64, and discuss policy implications.The study used a mixed method of quantitative and qualitative approach, and was conducted in two phases. The first involved analysis of cohort data from the national TB surveillance of PTB patients newly notified between 1 January 2006 and 31 December 2015. The second phase involved focus group (FGD) discussions with public health nurses, who are responsible for supporting TB patients’ adherence to medication, on the possible reasons why some patients become lost to follow-up.Analysis of the surveillance data suggested that among all patients, positive sputum smear  and cavitary lesion on chest x-ray  decreased the risk, while not requiring hospitalization increased the risk of LTFU . Among females, being a physician (aOR 2.07 95%CI 1.23–3.48) and nurse  were identified as additional risk factors for LTFU. The analysis of focus group discussions revealed three possible themes which may be useful in understanding why nurses and physicians were at a higher risk of becoming LTFU–firstly, the possibility that physicians and nurses were finding it difficult to make medication taking a routine, secondly, their low risk perception towards TB is affecting their adherence behavior, and thirdly, their unwillingness to accept DOTS was increasing their risk of becoming LTFU.The analysis of surveillance data and FGD transcripts indicated that patient education for those starting their treatment as an outpatient, and establishing DOTS that is both acceptable and realistic to physicians and nurses, may be two issues which need to be addressed urgently. Japan is a tuberculosis (TB) mid-burden country, with a notification of 13.9 per 100,000 population in 2016 [1, as well as among specific populations such as foreign-born patients [However, even among the PTB patients notified in 2015 who were aged 64 and below, the proportion of treatment success was 69.3% [The study was conducted in two phases. The first phase was conducted between February and April 2017, and consisted of a cross-sectional study whereby aggregated cohort data from the Japan TB Surveillance (JTBS) of pulmonary TB patients aged between 15 and 64 and newly notified between 1 January 2006 and 31 December 2015 was analyzed. Under the JTBS, treatment outcome of pulmonary TB patients is evaluated at the end of 12 months. The outcome categories include “cured”, “treatment completed”, “died”, “treatment failure”, “lost to follow-up”, “transferred out”, “still on treatment”, and “unevaluated”. The outcome categories are automatically calculated by the internal algorithm of the JTBS, which in principle follow the WHO guideline [1. Analyses were conducted for all patients, then further sub analyses by sex. R version 3.1.3  was used for all statistical analyses.Those LTFU were extracted and analyzed in terms of sex and age groups. Those who did not receive treatment, and whose treatment status was unknown, were excluded from the study population. Multiple-regression analysis was conducted with LTFU as independent variable, and the following as dependent variables–sex, country of birth (Japan- or foreign-born), job category and status, history of homelessness in the previous one year, cavitary lesions on chest x-ray (CXR), sputum smear examination results, being on welfare scheme, not being under any health insurance and initial hospitalization. The variables were chosen based on previous literatures ,8,9, 10.The second phase involved focus group discussions (FGD) with public health nurses working at public health centers, who are responsible for overseeing adherence support for TB patients, including organizing and conducting DOTS, in Japan. Under the so-called “Japan DOTS” strategy, sputum smear positive patients are hospitalized for at least two months, until they are considered no longer infectious, and during which they receive intensive hospital DOTS. Upon discharge, they, as well as non-infectious patients, are assessed of their risk of interrupting the treatment by local public health nurse using a risk assessment form, and are categorized as requiring any one of the three types of adherence support–type A, consisting of directly observed therapy every day, type B, consisting of adherence support once to twice a week, and type C, once to twice a month.The FGDs were conducted with the purpose of further exploring one particular aspect of the results from the analysis conducted in the first phase, which indicated that physicians and nurses were at a risk from becoming LTFU. The FGDs were organized in September 2017, with public health nurses who were attending a training course on TB at the Research Institute of Tuberculosis, Tokyo, Japan. Upon orientation to the course, all participants were introduced to the study, and invited to take part in a FGD. 13 participants gave written consent to participate, and were divided in two groups. The participants were first asked to discuss on their general experience of patients who were, and whom they felt were at a high risk of becoming LTFU. In the latter part of the discussion, the participants were shown the results of the analysis of the TB surveillance data on treatment outcomes, and were asked to exchange their thoughts, with a particular focus on assisting physicians and nurses in treatment adherence. Each discussion lasted approximately 60 minutes, and both discussions were voice recorded, upon consent of all participants, using an integrated circuit recorder and were transcribed verbatim.The FGD data were analyzed by performing interpretive content analysis, which firstly involved familiarization of the text through review of all transcripts. A thematic framework was then designed using an iterative process, and segments describing the perceived risk factors for LTFU were retained for further analysis. These segments were then organized by means of open coding and abstraction, to see if any new discourses arose, which could help us further understand why physicians and nurses were at a higher risk of becoming LTFU.The study protocol was approved by the Ethical Committee of the Research Institute of Tuberculosis, Japan Anti-tuberculosis Association (reference number: RIT/IRB 29–1).Between 2006 and 2015, a cumulative total of 175,222 PTB patients were notified to the JTBS, out of which 73,591 were aged 15 to 64. Treatment outcome of PTB patients aged 15 to 64 years notified between 2006 and 2015 is summarized in Over the study period, of the cumulative total of 73,591 patients, 5,760 (7.8%) had been lost to follow-up. The general characteristics of those LTFU are summarized in The majority was Japan-born and with no history of previous TB treatment. 61.7%  of the LTFU patients were males, with the largest number in those aged 55 to 64 years old. However, among the females, the largest number was found in those aged 25 to 34 years old . FurtherLooking at those LTFU by their job status and categories, the largest number of LTFU patients were diagnosed among those with full-time and part-time workers among both males and females, followed unemployed and/or temporary or self-employed workers for males, and nurses among females . HoweverIn exploring the possible reasons why physicians and nurses were at a higher risk of becoming LTFU, three broad themes were identified. These were termed as “difficulty in making medication taking a routine”, “low risk perception”, and “unwillingness to accept adherence support”. Each is elaborated in detail below.A number of participants agreed that they felt that it was difficult for nurses and physicians to make medication taking a routine practice, simply because of the nature of the work;“…because they (physicians and nurses) have nightshifts… it seems difficult for them to set a particular time of the day to take medicines.”“Their work is irregular and really tough. Sometimes they’re too tired to take the medication and forget. Of course, they forget once, then it’s easy to forget the next time, and next time…”The above two comments were regarding a physician and a nurse on TB treatment, however, a similar opinion was voiced regarding a physician on LTBI treatment.“My current patient…she is a young female physician, and she’s only just started (her treatment) but already, she’s told me she’s not sure whether she can complete it. Like, she decides to take the medication in the morning, but then she has nightshift, then there is no morning for her…”Although not all physician and nurse patients whom the participants had assisted had become LTFU, several experienced treatment interruptions and occasions whereby their patients admitted forgetting to take their medication “because they were busy”.Low risk perception arising from familiarity, especially on behalf of the physicians, was voiced out by several participants. The participants had felt that this in turn affected the motivation and attitude of the physicians towards TB medication. The following excerpt illustrates this concern;“I think the physicians are too used to seeing diseases… like, it’s not a special event for them.”“I agree…I don’t think they’re too worried (about them getting TB). So they…may not be so serious about the treatment.”“Or …because they take (other) medications quite casually…TB medicine is no different…”The last quote expresses the participant’s concern that because physicians may regard TB medication no different from other medications, they may be less serious about the consequences of interrupting TB treatment. Another participant commented that the way physicians make estimates about the dangerousness of health risks appear to be totally different from “ordinary” people.“Like needle-stick injury…if we  ever get ourselves involved in a needle-stick injury, it’s a big matter, right? But for physicians, it’s nothing! I once assisted a physician…can’t remember exactly, but it involved administering an anesthetic to a patient, and the physician was…pricking himself all over his fingers, as if it were nothing…so may be, I thought, if he ever gets TB, he will probably think, or not think, about the various consequences the same way he did with needle pricks.”Finally, a number of participants elaborated their experience with physicians and nurses who were not willing to accept adherence support, and of struggling to build a relationship of trust.“I had one nurse patient…who started off by saying ‘you don’t have to tell me about DOTS , I know all about it’. But the next thing she said was, she didn’t want it . So we came to a compromise, I call up her once a month…but she doesn’t pick up her phone. It becomes once every one and a-half month… then every two months…it’s no more DOTS.”“I am currently supposed to be assisting one physician. But every time I call him up to check if he’s taking medications alright, he is like ‘yes, yes, everything’s fine’ and hangs up the phone. Then I can’t help but think, even if he has forgotten to take his medication, he will never tell me the truth”“Oh it’s so difficult to get them (physicians) on DOTS…they’re professionals. Why should they be checked up by us, the public health nurses? I think that’s what they think.”“I really find it hard to build a relationship with physicians…they have the knowledge, so they think they don’t need us giving them advices …rather than asking us questions, they would much rather consult their colleagues”.In fact, the difficulty in communicating with physicians and nurses were experienced not only in the TB patient-public health nurse relationship, but also in other moments, such as public health nurses attending a DOTS meeting at a hospital, or calling the hospital to confirm patient information, or to ask for results of certain examinations.Gender difference, in other words the possible reasons why the risk was particularly high among female physicians and nurses, could not be explained by the participants.To our knowledge, ours is the first study to have examined specifically the risk factors for LTFU, using national TB surveillance data, in Japan. Social and demographic factors such as male gender ,8, foreiIn our study, positive sputum smear and cavitary lesions were even identified as protective factors –these may be considered as a proxy of perceived severity of disease. Indeed, several studies from abroad have reported that lack of symptoms and patients feeling better were associated with poorer compliance ,16. On tAnother interesting, and potentially a worrying finding was that being a physician or a nurse was identified as a risk factor among females. Reports on the effect of occupation to LTFU are in fact very limited–one study from Malaysia has similarly examined the effect of occupation to LTFU, however, the authors did not find any statistically significant results . On the One possible solution, which was also identified by several of the participants of the FGDs, may be the use of infection control nurses in the hospitals to ensure adherence to TB treatment among nurses and physicians. By doing so, the public health nurses were able to achieve two objectives; firstly, they could avoid contacting the patients directly, an action which was apparently unwelcomed by physicians and nurses. Secondly, by involving infection control nurses, DOTS became a part of an infection control measurement, and not a mechanism to “check-up” the individual act of taking medication (which was again unwelcomed by physicians and nurses). Compliance with an infection control measurement may be more easily acceptable as a professional and official duty, and the consequences of non-compliance recognized as being more far-reaching, than with one’s TB treatment.Lastly, though the level of significance varied across males and females, the odds ratios were in the same direction to point that unknown job category, sputum smear status unknown and sputum smear not done were a risk factor for LTFU. This may be due to the job category and sputum smear status “unknown” resulting from public health nurse not being able to contact the patient to conduct adequate epidemiological investigation. As explained in the Methods, although initial defaulters (those who did not start treatment) were excluded from the analysis, it is possible that patients whose job category is unknown are similar to initial defaulters in nature, and are therefore at a higher risk of interrupting the treatment. Sputum smear status “not done” may be an indication of a slightly more serious issue–the proportion of “examination not done” among the females was twice that of males (2.3% vs 1.2%). Exploration of the reasons as to why females have higher proportion of sputum examination “not done” is beyond the scope of this study–however, it has been previously indicated that females face greater cultural and social inhibitions about producing deep sputum compared with males .Our study had several limitations. Firstly, as we analyzed the data from surveillance, factors not included in the JTBS, such as smoking and alcohol which are occasionally indicated as risk factors to LTFU, could not be examined. On the other hand, as mentioned above, these factors are already included in the risk assessment form used by public health nurses in Japan. Policy implications would therefore have been minimal, even if these factors had been included in the analysis. Secondly, timing of LTFU was not considered in our study. Interventions to prevent LTFU may need to be tailor-made according to the different timings at which LTFU occur. Thirdly, examination of the possible gender aspect of LTFU remained minimal, due to limited data available from the JTBS. Lastly, the FGDs were conducted with public health nurses, and not the patients themselves. The possible reasons for LTFU were thus identified from the perspective of health service provider, which may differ from patient perspective. A similar qualitative study with patients may provide additional insight to understanding LTFU.A combined methodology of analysis of surveillance data and FGD transcripts revealed several potential risk factors for LTFU. The results indicated that patient education for those starting their treatment as an outpatient, and establishing DOTS that is both acceptable and realistic to physicians and nurses, may be two issues which need to be addressed urgently.S1 File(DOCX)Click here for additional data file.S1 Table(XLSX)Click here for additional data file.S2 Table(XLSX)Click here for additional data file.S3 Table(XLSX)Click here for additional data file.S4 Table(XLSX)Click here for additional data file.


Inflammatory bowel disease (IBD), comprising Crohn disease and ulcerative colitis, affects 1 to 3 million people in the United States. Telemedicine has shown promise in IBD. The objective of this study, telemedicine for patients with IBD (TELE-IBD), was to compare disease activity and quality of life (QoL) in a 1-year randomized clinical trial of IBD patients receiving telemedicine versus standard care. Treatment groups experienced improvements in disease activity and QoL, but there were no significant differences between groups. Study adherence to the text-based intervention was less than 80%, the targeted goal.To understand adherence to remote monitoring, the goal of this qualitative assessment was to obtain TELE-IBD trial participants’ perceptions, including their recommendations for future monitoring.a priori concepts and emergent themes with the aid of ATLAS.ti, version.7 qualitative data analysis software.In this study, patients attending 3 tertiary referral centers with worsening IBD symptoms in the previous 2 years were eligible for randomization to remote monitoring via SMS text messages  every other week, weekly, or standard care. Participants (n=348) were evenly enrolled in the treatment groups, and 259 (74.4%) completed the study. For this study, a purposive sample of adherent (N=15) and nonadherent (N=14) patients was drawn from the TELE-IBD trial population. Adherence was defined as the completion of 80% (278/348) or more of the weekly or every other week self-assessments. Semistructured interviews conducted by phone surveyed (1) the strengths and benefits of TELE-IBD, (2) challenges associated with using TELE-IBD, and (3) how to improve the TELE-IBD intervention. Interviews were recorded, professionally transcribed, and coded based on Participants' discussions centered on 3 elements of the intervention: (1) self-assessment questions, (2) action plans, and (3) educational messages. Participants also commented on text-based platform, depression and adherence, TELE-IBD system in place of office visit, and their recommendations for future TELE-IBD systems. Adherent and nonadherent participants prefer a flexible system that is personalized, including targeted education messages, and they perceive the intervention as effective in facilitating IBD self-management.Participants identified clear benefits to the TELE-IBD system, including obtaining a better understanding of the disease process, monitoring their symptoms, and feeling connected to their health care provider. Participants’ perceptions obtained in this qualitative study will assist in improving the TELE-IBD system to be more responsive to patients with IBD. Inflammatory bowel disease (IBD), comprising Crohn disease (CD) and ulcerative colitis (UC) affects nearly 1 to 3 million people in the United States . IBD areThe objective of this study, telemedicine for patients with IBD (TELE-IBD), was to compare disease activity and QoL in a 1-year randomized clinical trial of IBD patients receiving telemedicine versus standard care. Treatment groups experienced improvements in disease activity and QoL, but there were no significant differences between groups. Study adherence to the text-based intervention was less than 80%, the targeted goal . To undeStudy trial protocol and results of the parent randomized clinical study have been previously published ,15. BrieParticipants randomized to the control group received standard care. TELE-IBD was designed using a mobile phone for participants and a decision support server with website for staff and providers. The website provided an interface for staff and providers for participant profiles and collected data from each self-testing session. The provider could individualize alerts and action plans for each participant, if needed. A standard set of baseline action plans based on the criteria were available to providers. If predetermined criteria were met after testing, simultaneous action plans and email alerts were sent to the participant and study team, respectively. The study team reviewed the information and if necessary, consulted the prescribing provider for management changes. Medication changes were updated in the participant profile and communicated to the participant.Participants in the 2 intervention groups were prompted to respond to a series of SMS text messages  grading their IBD symptoms. To assess bowel symptoms and extraintestinal manifestations, abbreviated disease activity forms were used. CD participants completed a modified Harvey Bradshaw Index ,17. OverAfter answering SMS text message questions about their symptoms, participants received a list of medication(s), dose(s), and direction(s). Participants were asked if they experienced any drug side effects. Participants were asked to describe and grade the severity  of side effect; moderate to severe side effects generated an alert.Alerts and action plans were customized for participants and generated based on responses to the core questions in the activity indices for CD, UC, and IC. Depending on the response, participants were assigned to a disease activity zone: the green zone represented patient remission or mild disease activity, the yellow zone represented moderate disease activity, and the red zone represented severe disease activity. Depending on the severity zone, the provider could select an action for the participant to begin.TELE-IBD intervention participants received an educational tip twice weekly (W group) or every week (EOW group) and at the discretion of the provider. For example, the provider could send an SMS text message during flu season asking participants to obtain a flu vaccination.For the descriptive qualitative assessment reported here, the purposive sample of adherent (N=15) and nonadherent (N=14) patients was drawn from the TELE-IBD trial population. To achieve this sample, 50 patients were contacted from each group of adherent and nonadherent patient participants. No patients refused out of disinterest; 1 patient was out of the country, and the remaining patients could not be contacted after multiple attempts. The final sample was not different from those who participated in this qualitative study. Adherence was defined as the completion of 80% or more of the weekly or every other week self-assessments; 3 core questions described above for each IBD condition had to be answered for the self-assessment to be considered adherent. Participants were contacted via telephone; interviewers described the qualitative study and determined participant willingness to participate in this follow-up study. Phone interviews were scheduled at the convenience of participants; the study was described again, and verbal informed consent was obtained. The study Interview Guide is included in the supplementary file as a a priori concepts of interest, including symptoms, TELE-IBD core questions, action plans, education messages, and medications and themes that emerged from the SMS text message. Braun and Clarke’s 6 phases of thematic analysis was applied to organize and identify core themes and subthemes  It’s not going to help all. Some of them, it’s not going to matter, but I believe it will help some of them. It will push some of them along, you know, to go and get the proper treatment and not delay, and to be honest with your doctor about your symptoms and everything.Adherent participantParticipants had difficulty recollecting the action plans, often needing reminders from interviewers that the system provided a green, yellow, or red zone indicator at the end of the assessment. Although appreciative of the reminder to take their medication or to continue with their routines, participants who were mainly in the green zone did not remember receiving an action plan.Those who did recollect receiving yellow or red indicators when they were not feeling well, which resulted in a call-back from the providers’ nurse staff, were often appreciative of the ease and immediacy of the contact with the provider’s office. As 1 adherent participant described, knowing symptoms would produce a TELE-IBD action plan was helpful:I knew, OK if it was Wednesday, I know I’m getting the call Thursday so I would just wait and do that instead of calling the nurse and saying, “Hey this is what’s going on.” If I knew it was something that would put me in the yellow zone, I would just wait...Adherent participantI really liked it believe it or not because I was able to provide feedback on a weekly basis and I was often, depending on my answers, getting calls immediately practically from the doctor or nurse. She’s like, “what’s going on?”...OK, I’ll talk to the doctor and we’ll do whatever if need be. I thought that was awesome.Nonadherent participantThe primary critique of the action plans was that the zone ratings were not perceived as accurate, and participants felt they had no means to provide explanatory information. Participants indicated, for example, that at times their assessments and subsequent zone ratings reflected other illnesses, life events, or even data entry errors. Rather than receiving the call from the provider’s office, participants would have liked to have been able to indicate why no follow-up was needed.Participants described mixed perceptions of the educational messages. Enthusiasm for the educational messages did not vary by adherence status or whether the participant was in remission at baseline.Participants who liked the educational messages appreciated learning more about the disease, the intestinal system, diet strategies, and terminology that could then be used when talking with their health care provider. Participants who liked the messages described them as “enlightening,” “kinda fun,” and helpful “trivia.” To these participants, the educational messages reinforced their health literacy; as one described:I got all these things in the back of my mind that hey, this could be something, you know, it just makes it easier to, you know, catch that in the future.Adherent participantAnother indicated the messages served as important refreshers, or “a ha” moments that helped her more quickly identify symptoms:I was getting a lot of little snippets of information, parts of information I already knew but maybe forgot about so when I got the information it was like oh yeah, oh that’s right. So it was helpful in that sense and it helped me, I feel like I’m in more control of my body. I know when I’m getting the symptoms. I know when something starts to irritate me a lot quicker than I did in the past.Adherent participantDisease information then traveled along participants’ social networks, as participants indicated they would share messages with spouses or other family members with similar conditions.The most common negative comment on educational messages was that over time the messages became repetitive. Participants recommended reducing the repetition and adding more information on vitamins, probiotics, or diet. Others commented that the messages were not relevant to their disease. For participants who had a long history with their illness or a strong understanding of its triggers, the education messages did not provide new insights, such as this nonadherent participant:I felt that they were kind of generic, but I also had been diagnosed and had been dealing with the UC for, you know, probably over five years at that point.Participants who worked in an allied health field also felt the messages were not informative. It is important to note that participants who critiqued the educational messages commonly indicated that they believed the messages could be of great value to others. As a nonadherent participant with a clinical background suggested, “I can understand how it would be helpful for someone who was coming at it from a different perspective.”Participants generally approved of the mobile phone platform for the text-based telemedicine system. Among the participants for whom texting is a part of daily life, the system was a “short” and “convenient” way to monitor their symptoms and stay connected to their provider. Participants who did not like the mobile system objected to specific design features or noted problems attributed to their carrier.Regarding design features, the chief design criticism was that data entry errors could not be corrected, and there was no means to communicate errors to prevent a call-back from their provider. Participants also perceived that the numerical response system did not fully capture their health status and were frustrated that there was not space in the system to elaborate on their current situation. Participants further noted that the timing of the SMS text messages became inconvenient over the course of the study if their work or family responsibilities changed.Technical issues such as delayed responses from the TELE-IBD system were described as “extremely irritating,” significantly extending the amount of time required to complete the assessment. Participants perceived the response window as too short to accommodate the vagaries of life and issues caused by their cell phone providers. As 1 adherent participant described:It wasn’t necessarily inconvenient, but there were times that I would see that I got the messages and it was like a time sensitive, if you didn’t respond, you know, it wouldn’t prompt the next questions. So there were times that I missed like that particular like set of questions just because it, you know, it like timed out or I wasn’t able to finish answering because I was in class or busy or doing whatever.Participants who were not satisfied with the delivery mechanism noted that having an option for email delivery or some other type of survey delivery would be helpful. However, this should not be interpreted as a recommendation to switch entirely to an email system as others felt strongly that current delivery method was effective.The UM-SOM TELE-IBD team  found that depression correlates with adherence, especially among younger participants . One 20-When I would get these messages, it made me feel better because it made me realize that I’m not actually the only one that had these kinds of problems. So, when I would get them, I would get a bit excited, a good bit excited and I would feel relieved. Like a ten-pound weight had been lifted off my shoulders or off my chest.In this study, emotions were tied closely to one’s health status. When in a flare, participants reported feeling stressed, depressed, or anxious. These participants were more likely than those who were not in a flare to be adherent to the TELE-IBD system core self-assessment questions. An adherent participant described what it was like to be in a flare, addressing indirectly how responding to the TELE-IBD system may have been part of the internal focus on one’s disease:Well when I was in the flare-up, it was, I’m more, what’s the word, introverted, you don’t talk as much, you’re very concerned about what’s going on in your body, so you don’t focus on much more than that.A nonadherent participant likewise eventually reasoned that feeling ill might lead one toward being more responsive:I do suppose if, if someone were really feeling down about it, it could feel like one more burden of oh goodness why am I doing this. But on the other hand, if they’re having issues like that then that’s all the more reason to be in communication with their physician.We also asked participants to reflect on the finding regarding depression. Several expressed surprise that being depressed is associated with adherence. A nonadherent participant responded by saying, “Ah!” and then, “Yeah, well it’s, it does feel like, you know, someone’s asking you how you’re doing and it’s a way to engage you for this from afar so I can definitely see that.” Another nonadherent participant could see how this might be: “I think when people feel poorly, they’re probably happy to answer as many questions as it’s going to take for them to get helpful information.” At the same time, an adherent participant cautioned that receiving TELE-IBD SMS text messages while being depressed might make someone more depressed:If somebody was more depressed, I definitely think it would have affected them differently but I’m not sure if would be positive or negative. Maybe more negative because it’s a constant reminder that you kind of have the disease.Finally, participants also indicated that the emotional impact of the disease was not well-incorporated into the system, for example, the core self-assessment questions. One participant explained:I would say, and this isn’t just for the study but in general, I think a bigger focus on emotional impact of the disease and also the fatigue. I think a lot times you focus on, you know, weight and, and pain levels and other things but a lot of it is just, it’s very fatiguing and, you know, there’s a lot of malnutrition, malabsorption that goes on. So I think fatigue is just one, is, you know, it’s one of the more debilitating aspects and it’s surprisingly so, I think people focus on, it must have hurt, you know, stomach pain all the time but you kind of build a tolerance to that but it’s hard to build a tolerance to being tired all the time.Adherent participantParticipants had mixed perceptions on how participating in a TELE-IBD system would impact their routine health care. Some indicated that if they were not having any IBD-related issues, checking in through the TELE-IBD system could substitute for a face-to-face visit. This was an especially attractive concept for participants who travel a long distance for provider office visits. However, others expressed concern that they would still want to meet with their provider twice a year or in the event of a flare. For example, 1 adherent participant who lived an hour from her provider expressed the system could help monitor, but:I would still want to go in and make sure my medication is OK...Over the six months a lot of times I might develop like a question that I might want to ask and through that, you know, the text message you’re not able to necessarily do that. So, it’s nice to be able to go in and have that dialogue about certain things that I might be experiencing.A few patterns emerged regarding adherence, participants’ perceptions of the relevance of the system, and experiences with design and technical glitches.First, regarding the relevance of the system, nonadherent participants were much more assertive in indicating they actively managed their disease and/or had a strong understanding of the disease , such that the system was less helpful to them than it may be to others.Second, although both adherent and nonadherent participants experienced technical difficulties, discussions of the technical problems were much more salient among the nonadherent participants. The system became “extremely irritating” when the SMS text message questions timed out too quickly, extending the time required to complete the questions to 15 min or more.Regarding the role of health status, both the adherent and nonadherent participants noted the value of the TELE-IBD system during a flare or when changing medications. The TELE-IBD system was clearly recognized as allowing for a more immediate and effortless way to communicate with the doctor’s office. It also is very reassuring to receive the doctor’s call back when experiencing symptoms. Although both groups reported the system was “repetitive,” the nonadherent tended to voice more strongly that the regular pings from the system were “annoying” when they were feeling well.To our knowledge, this is the first telemedicine for IBD post-RCT qualitative study of adherent and nonadherent intervention participants. The main finding was that patients prefer a flexible follow-up system that is personalized, including education messages that can be targeted to individual patients and decreased repetition. A telemedicine system that is 2-way communication, easily connecting patients with providers and provides “actionable” responses to patient self-assessment is preferred. Telemedicine implemented as an adjunct to patient-initiated consultations and self-management and regular office visits was identified as optimal approaches to meet the patients’ needs. The TELE-IBD system was reported by participants as effective in facilitating IBD self-management. Participants also considered the TELE-IBD useful in treatment decisions made with providers in-between office visits. New models of IBD telemedicine care could improve the patients’ experience of care and reduce or delay unnecessary health care utilization.The TELE-IBD intervention in this study followed a participatory care framework by testing pilot feasibility ,23 and aWe recognize the reported study has limitations. The qualitative assessments were from patients willing to be interviewed and may not be representative of all patients in the TELE-IBD clinical trial or other IBD patients considering a telemedicine system of care. We attempted to address this by recruiting adherent and nonadherent persons to be interviewed. Interviews occurred after use of the system. Memory or recall may have affected participants’ responses. Finally, it’s important to note that although clinicians and scientists have expectations for adherence, not all patients want to be “engaged” all the time. Patient engagement is a continuous behavior, and our assessment of adherence may have captured patient perceptions at a single point in time.Participants, both adherent and nonadherent, identified clear benefits to the TELE-IBD system, including obtaining a better understanding of the disease process, monitoring their symptoms, and feeling connected to their health care provider. In this sense, TELE-IBD facilitates access to care, particularly for those who live a long distance from the provider and/or are reluctant to or have difficulty contacting the provider between scheduled office visits. Both educational messages and core assessment questions contribute to these perceptions of the TELE-IBD system. Such a connection is particularly welcome during an IBD flare and not as necessary when asymptomatic.Participants experienced considerable recall issues around the action plans, although could remember the color zones once prompted and appreciated knowing that they would receive a provider call if experiencing critical symptoms. Reminders regarding medication were appreciated by some, but others said the reminders were not necessary. The study reported here demonstrates the importance of qualitative assessment of participants’ views in technology-based interventions. On the basis of our results, future studies of revised remote monitoring systems in patients with IBD are needed. To promote patient engagement, future systems should include flexible options for testing (mode of testing and frequency of testing), reduce “irritant” factors such as timed lock outs and set testing schedules, and allow for corrections in responses. Furthermore, assessment of symptoms and receipt of action plans and educational messages should be as personalized as possible. Finally, remote monitoring should remain an adjunct to in-person monitoring.


Augmented reality (AR) comprises special hardware and software, which is used in order to offer computer-processed imaging data to the surgeon in real time, so that real-life objects are combined with computer-generated images. AR technology has recently gained increasing interest in the surgical practice. Preclinical research has provided substantial evidence that AR might be a useful tool for intra-operative guidance and decision-making. AR has been applied to a wide spectrum of orthopedic procedures, such as tumor resection, fracture fixation, arthroscopy, and component's alignment in total joint arthroplasty. The present study aimed to summarize the current state of the application of AR in orthopedics, in preclinical and clinical level, providing future directions and perspectives concerning potential further benefits from this technology. Computer-assisted orthopedic surgery has gained increasing interest, especially in the last two decades , being eAR has been described as “the concept of digitally superimposing virtual objects onto physical objects in real space so individuals can interact with both at the same time” . In contThe basic structure of an AR system used in orthopedic surgery, as it was described by Nikou et al. , comprisThere is a wide variety of AR systems which have been implemented in preclinical and clinical level. An example of a camera-augmented C-arm was described by Navab et al. . A videoBased on preclinical data, Blackwell et al.  remarkedWe aimed to investigate the current state of the implementation of AR in orthopedic surgery. We searched in PubMed and Cochrane Database of Systematic Reviews, using the key words: “AUGMENTED REALITY” AND (“ORTHOPAEDIC” OR “ORTHOPAEDICS” OR “ORTHOPEDIC” OR “ORTHOPEDICS” OR “ARTHROPLASTY” OR “REPLACEMENT” OR “ARTHROSCOPY” OR “FRACTURE” OR “SPINE”). Our inclusion criteria were: studies published after January 2010 and until September 2018 (end of our search), written in English language, with a purpose to investigate the outcomes of the implementation of AR in a specific orthopedic surgical intervention, either in preclinical or in clinical level. We excluded conference papers, expert opinions and review articles. In total, 91 studies were found after the initial search. Finally, 22 preclinical and nine clinical studies met our inclusion and exclusion criteria.Several preclinical studies have been conducted during the last two decades, which have demonstrated that AR could improve the accuracy of interventional procedures. Firstly, there has been substantial evidence published to support the use of AR in fracture surgery. Van Duren et al.  describeLondei et al.  illustraFallavollita et al.  assessedUtilization of AR in spine surgery has been investigated by various researchers. Gibby et al. , who useVarious clinical studies assessing the usefulness of AR in orthopedic surgery have documented satisfactory outcomes . In the Ogawa et al.  evaluateSeveral clinical studies were conducted regarding spine surgery. According to Elmi-Terander et al. , AR surgAs it has been showed, the implementation of AR could possibly lead to improved accuracy in positioning and decreased radiation in a wide spectrum of orthopedic procedures, concerning either trauma or elective orthopedic surgery. However, the cost-effectiveness of AR in orthopedics is a factor which should be critically estimated  before tAlso, concerns have been raised about the extent to which display of information via AR could be misleading or disturbing during surgery . AdequatAlthough it has been shown that AR might have a beneficial impact to orthopedic residents' training, it would be interesting to investigate to what extent AR could play a significant role in providing orthopedic trainees with a valuable learning experience. Moreover, verifying the learning curve would be an interesting aim , which sIn addition, under conditions of real-time surgery, there are factors which might be critical and there are absent in preclinical studies. For example, the effect of patient's respiratory movement has to be taken into account during thoracic spine surgery . MoreoveWe should note that the papers which were found after our search and met our inclusion and exclusion criteria might not cover the whole spectrum of the implementation of AR in orthopedic surgery and, also, could be soon outdated by the ongoing research. In summary, further clinical studies are required to confirm the favorable preclinical outcomes of the use of AR in orthopedics.DC did the literature search and wrote the first draft of the manuscript. M-AM proofread the manuscript and made corrections. VN had the initial idea of writing the manuscript, proofread, and edited the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Residents of rural and remote Australia have poorer health outcomes than their metropolitan counterparts. A major contributor to these health disparities is chronic and severe health workforce shortages outside of metropolitan areas—a global phenomenon. Despite emerging recognition of the important influence of place-based social processes on retention, much of the political attention and research is directed elsewhere. A structured scoping review was undertaken to describe the range of research addressing the influence of place-based social processes on turnover or retention of rural health professionals, to identify current gaps in the literature, and to formulate a guide for future rural health workforce retention research. A systematic search of the literature was performed. In total, 21 articles were included, and a thematic analysis was undertaken. The themes identified were (1) rural familiarity and/or interest, (2) social connection and place integration, (3) community participation and satisfaction, and (4) fulfillment of life aspirations. Findings suggest place-based social processes affect and influence the retention of rural health workforces. However, these processes are not well understood. Thus, research is urgently needed to build robust understandings of the social determinants of rural workforce retention. It is contended that future research needs to identify which place-based social processes are amenable to change. Residents of rural and remote Australia have poorer health outcomes than their metropolitan counterparts . CompareIn Australia, the federal government invested in policies and strategies aimed at addressing rural health workforce shortages since early 2000 . These pResearch focused on the recruitment and retention of the rural health workforce in advanced economies identified the decisions of health professionals to stay or leave rural practice to be informed by a range of issues including job satisfaction, professional development, and career advancement opportunities, which intersect in unique ways ,21. SomeA better understanding is required of the ways in which place-based social processes manifest or are relevant for health professionals living and working in their towns of origin compared to those relocating from elsewhere. The main aim of this paper was, thus, threefold. Firstly, this paper aims to give readers a clear understanding of current knowledge on this topic by providing a comprehensive synthesis and analysis of existing rural allied health, nursing, and medical workforce literature that addresses the influence of place-based social processes on retention. Secondly, as part of the analysis, this paper aims to identify current research gaps in this field. Thirdly, in considering both existing knowledge and gaps in the literature, the paper aims to provide an outline of how research in this field could be developed to build the evidence base needed to effect change in the retention of a rural health workforce.A structured scoping review was undertaken to describe the range of research addressing the influence of place-based social processes on turnover or retention of rural health professionals, to identify current gaps in the literature, and to formulate a potential guide for future research in this area. Undertaking a scoping review was considered appropriate for this research topic because it was not previously comprehensively reviewed . In a scRetention refers to the length of time between commencement and cessation of employment with a particular employer ,39. TurnThe search was conducted in June 2018 using database-specific search strings in MEDLINE (Ovid), Web of Science, Embase Classic, CINAHL, PsycINFO, and Informit Health Collection. The terms searched were “community attach*” OR “community satisfaction” OR “social network*” OR “social bond*” OR “sense of belonging” OR “sense of community” OR “place attach*” AND “retention” OR “turnover” OR “leave” OR “remain” OR “retain” AND “rural*” OR “remote*” OR “regional*” AND “allied health*” OR “dentist*” OR “dietetic*” OR “dietician*” OR “exercise physiologis*” OR “medic*” OR “medical laboratory technician*” OR “medical technolog*” OR “nurs*” OR “occupational therap*” OR “patholog*” OR “pharmac*” OR “physiologis*” OR “physiotherap*” OR “podiatr*” OR “psycholog*” OR “radiograph*”. Citation snowballing from the reference lists of the included articles was also undertaken .Articles included concerned rural health workforce turnover or retention studies  that identified place-based social processes as significant determinants and offered an explanation as to how they influence turnover or retention. Studies included empirical research and evaluations, including systematic reviews. During the initial search, two authors (C.C. and C.M.) reviewed the identified articles and independently screened titles and abstracts against pre-determined exclusion criteria: (i) language other than English, (ii) publication prior to 1995, and (iii) not based on findings from Australia, Canada, New Zealand, or the United States of America (USA).In total, 21 peer-reviewed journal articles meeting the inclusion criteria were identified. The results in each stage of the search and screening processes are illustrated in Health professionals from rural backgrounds identify the existence of strong social bonds, familiarity with the physical environment, and enjoyment of a rural lifestyle as all having strong “pull effects” on their decision to take up or stay in rural positions ,47,48,49Opportunities to meet people and develop social networks in the place they moved to was found to be important for retention for non-local health professionals across a number of studies ,43,49. IAlmost all the non-locals in Cosgrave et al.’s study of factors affecting turnover intention of nursing and allied health professionals working in rural public sector community mental health services in NSW, Australia, reported feelings of alienation and social disconnection, especially in the first year of moving to a rural town . The extIntegration among non-locals was observed in several studies to be a gradual, stepped process ,46,54. TIn many of the reviewed studies, satisfaction with community was linked to job satisfaction ,57,58,59Gillham and Ristevski’s study found that the non-locals most likely to leave were those whose main social connections continued to be based outside of the local area following relocation. This study also found that non-locals whose spouses had moved with them were more likely to stay than those whose spouses lived elsewhere . RelatedAuer and Carson’s study of physicians working in the Northern Territory  found that most physicians were non-locals and nearly all expressed that their time living and working in the NT was a “temporary adventure” . ParticiPierce identified retention of non-locals as processes encompassing “coming here”, “being here”, and “staying here”, and argued that the transition for non-locals from “being here” to “staying here” involves a merging of personal identity with rural place. She found that among participants who were long-term stayers all expressed a deep satisfaction with their “identity-in-place” . ManahanIncreasingly over the last decade, the importance of place-based social processes for rural health workforce retention was identified in the literature. However, many retention research studies to date lacked analytical depth; only two published studies ,46 propoIdentifying and implementing effective solutions that can respond to needs at an individual and workforce level is a much more challenging endeavor. To date, there was little progress in responding to the place-based social processes affecting retention of a rural health workforce, despite emerging recognition of their importance. In fact, the research reviewed in this paper suggests that place-based social processes are the most central to retention, yet remain the least explored and addressed dimension. More research on the place-based social dimensions influencing retention is, thus, urgently needed. However, future research must go beyond the identification of contributing factors and offer robust understandings of the social determinants of rural retention, so that responsive policy initiatives can be developed and trialed. In short, the social determinants of retention need to be conceptualized in ways that reflect the complexities of and variances involved in the processes and contexts at play.To progress the rural workforce retention research agenda, more clarity and agreement is needed concerning the common language used in rural health retention research , so that stakeholders can be clear about the specific issues or phenomena under interrogation. The research so far undertaken also suggests an urgent need for more nuanced conceptualizations of retention that reflect, in particular, a life-stage perspective on likely duration of stay. Such conceptualizations need to be effectively disseminated to and taken up by managers and executive staff in rural health services so that internal retention goals and strategies can be appropriately developed. From this point, stronger conceptual frameworks that take into account, deconstruct, and respond to the social determinants of rural health workforce retention can be built and applied in the field.This scoping review focused on the social determinants of retention, and established that place-based social processes are an important influence on rural health workforce retention, both positively and negatively. However, it is important to acknowledge that rural health workforce retention is a complex phenomenon and is influenced by a broad range of issues. These include the funding and policy setting for both rural health services and the various health professions, work roles, team and organizational culture, and access to professional development and career-building opportunities. Undertaking further research to better understand place-based social processes will provide a more complex and complete understanding of rural health workforce retention. Other more minor limitations of this study were previously noted in this section.This review described the range of literature that addresses the influences of place-based social processes on the retention of allied health, nursing, and/or medical professionals in rural communities. There is sufficient evidence across the existing literature to consider place-based social processes to be important influencers affecting the retention of rural health workforces. Thus, further research focused on the social dimensions of retention is needed, and comprehensive conceptual frameworks that consider and enable thorough exploration of these determinants should be developed. The authors suggest that, in the future development of research in this area, critical and focused attention should be given to identifying those place-based social processes that are amenable to change (and those that are not). This will enable the generation of responsive, evidence-informed change initiatives for application in the field. Such future research will generate new insight into how rural health professionals can be recruited and, importantly, retained. This research will have particular resonance in the fields of rural allied health and nursing, where there are currently the most severe shortages, by allowing for retention to be conceptualized and approached holistically at a workforce level. It is hoped that, with the translation of this research into practice, more stable and adequate health workforces can be secured for rural communities, and a reduction can be achieved in current health disparities between those living in rural and metropolitan areas.