People living with obesity are at elevated risk of hospitalisation, serious illness and mortality due to COVID-19. Little is known about their experience of living with obesity during the pandemic and its associated stay-at-home orders. This study sought to understand the experiences of people living with obesity during the COVID-19 pandemic.n = 15) living with obesity engaged in open, phenomenological, interviews and a participatory photovoice methodology to capture both verbal and visual accounts of their experiences during the COVID-19 pandemic. Interviews, conducted throughout 2021, were transcribed verbatim and analysed thematically.A stratified sample of Irish adults (Two overarching themes were identified. A) The pandemic and associated stay-at-home orders had a positive impact on the health and well-being of some participants; a negative impact on others; and this impact changed over time as the pandemic progressed. B) People living with obesity reported feeling stigmatised and ‘othered’ by their ‘at risk’ categorisation. Public health messaging and public discourse relating to obesity resulted in some people feeling segregated and punished by society.Changes in lifestyle initiated by the pandemic's stay-at-home orders had a varied impact on the health behaviours and outcomes of people with obesity. This variance offers helpful insight into the psychosocial aspects of obesity. Furthermore, the ‘othering’ effect of public health messaging during the pandemic warrants caution in light of the already stigmatised nature of this disease.This study is part of the SOPHIA project which received funding from the Innovative Medicines Initiative 2 Joint Undertaking under grant agreement No 875534. Large-scale studies have highlighted the negative impact of COVID-19 and its associated stay-at-home orders on the health behaviours and outcomes of people living with obesity. Concerns too have been raised at the increased presence of weight stigma in the media, healthcare settings and public campaigns during the pandemic.To the best of our knowledge, this study is the first to provide insight into the experiences of Irish adults living with obesity during the COVID-19 pandemic. It employed a range of novel qualitative methodologies and followed participants through ten months of the COVID-19 pandemic - capturing changes in their experiences as the country went into, out of, and back into periods of ‘lockdown’.This study highlighted how the impact of COVID-19 and its stay-at-home orders changed over time for people living with obesity. Furthermore, it highlighted how many living with obesity felt stigmatised and ‘othered’ by public health and media representations of obesity during the pandemic.Alt-text: Unlabelled box,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and its resulting novel corona virus disease 2019 (COVID-19) has resulted in more than five million recorded deaths globally since it was first identified in late 2019.Beyond the impact of the SARS-CoV-2 virus itself, the negative impact of the pandemic and its resulting stay-at-home orders on people living with obesity has also been charted. Globally, as the incidence of COVID-19 cases began to rise, national governments responded with measures such as stay-at-home orders; school and workplace closures; cancellation of public events and gatherings; policies on the use of face coverings outside of the home; restrictions on international and internal movement; and testing and contract tracing policies.This study aimed to examine the impact of the COVID-19 pandemic, and it's associated stay-at-home orders, on Irish adults living with obesity.Two complementary qualitative approaches were adopted to explore participants’ experience of living with obesity during the COVID-19 pandemic. The first approach was hermeneutic phenomenological in design with an open-interview method applied to understand participants’ experiences of the pandemic and its associated stay-at-home orders or ‘lockdowns’. Phenomenology is, as Merleau-Ponty2. Researchers then generated a random list of participants under these five headings and contacted each participant by telephone, inviting them to participate. The aim was to achieve a sample size of 15, a sample size that is considered suitable for studies of this nature that focus on depth rather than breadth.,A non-probability, convenience, sample of participants was drawn from two Irish hospital-based weight management and diabetes management clinics. Convenience sampling, in contrast to probability sampling, does not aim to generate a sample representative of the entire population but rather “implies that a researcher is choosing informants because those informants might have something to say about an experience”.Data were generated over a ten-month period from February to November 2021 – during which time Ireland was subject to varying ‘levels’ of restrictions according to the National Framework for living with COVID-19.The first methodology involved a series of in-depth one-to-one hermeneutic phenomenological interviews with 15 adults living with obesity. These interviews were open-ended, beginning with a single question: ‘can you tell me about your experience of living with obesity’. The interviewers  did not interrupt the participant except to clarify a point or detail (e.g. “that took place before you attended the clinic?”); describe what they had heard ; or to invite participants to elaborate on the experience (“what was that like?”). Such an open approach offered participants the opportunity to share their experiences in their own words and in their own way without the curtailment of researcher-designed interview schedules or questions. A total of fifteen interviews were carried out, ranging in duration from 45 to 105 minutes. The average interview length was over one hour.Following their phenomenological interview, participants were invited to participate in the second, photovoice, methodology. Thirteen of the fifteen participants chose to progress to this second stage and disposable cameras were posted to their home address along with guidance notes. This guidance asked them to take images that represented three areas – the first related to their fears associated with living with obesity; the second the hopes for obesity treatment and; the third related to their experience of living with obesity during the COVID-19 pandemic. Participants used the return envelope to send back their cameras for photo developing and an interview was arranged where participants discussed the nature and meaning of each photo with researchers . These interviews lasted up to two hours with any interview extending beyond that time being rescheduled for a second session to avoid participant and researcher fatigue. Following each individual interview, participants identified five photos which best represented their experiences and were invited to discuss these at an online group ‘audiencing’ session. Five participants agreed to participate in two group audiencing sessions – four females and one male. Facilitated by the lead researcher, these group audiencing sessions offered participants the opportunity to share their experiences of living with obesity and enabled a deeper layer of discussion and understanding as the researcher took a ‘step back’ from the process and participants proactively shared and discussed their experiences together.This study focused on data relating to participants experiences of COVID-19 generated in the phenomenological interviews, photovoice interviews and photovoice group audiencing sessions. Following verbatim transcription, researchers removed all identifying information from the written data and participants were assigned a pseudonym to protect their anonymity. All data were initially analysed by two researchers  to identify high-level themes and all data relating to the COVID-19 theme were analysed by an individual researcher (E.F.) using Braun and Clarke'sThe study's funding source had no role in study design, data collection, data analysis, data interpretation, or writing of the report. All authors had access to the dataset and supported the decision to submit for publication.Two overarching themes were identified (a) the impact of COVID-19 on health and well-being and (b) the experience of being categorised as ‘at risk’.COVID-19 and its associated restrictions or ‘lockdowns’ had a marked impact on the health and well-being of many participants in this study. For some, this impact was negative, charted by participants in terms of weight gain, reduced activity, boredom and the effects of loneliness and isolation. For others the change in lifestyle precipitated by Government restrictions offered more time to exercise, cook, spend with loved ones and connect with their creative interests and community. As this study spanned a total period of ten months, it offered the opportunity to capture changes over time as vaccines were introduced, new variants emerged, and the COVID-19 pandemic, and successive periods of restriction, wore on. Outlined below are three sub-themes associated with the impact of COVID-19 restrictions on health and well-being: negative impact, positive impact and varied impact reflecting how, for many, the experience was both positive and negative depending on the time, life or living circumstance.“The experience of living with obesity during COVID-19?… Weight gain. And I know it's not just obese people, I think the majority of people gained weight” – Ada“I I put up the COVID stone in the last year” [laughs] – Miriam“When lockdown came, everything changed and then the weight it started going back on” – Cora“The food intake went up, the number of take-aways went up, the amount of wine went up” – PeadarFor many participants COVID-19 restrictions were associated with weight gain:“We couldn't go out, we couldn't go anywhere, and I got fed up of cooking. Then there were all these [takeaway] menus in the house and so […] because we couldn't go out we had those” – ÁineA reduction in the availability of healthy food options was identified by several participants:“I was kind of living from one treat to the next treat. My focus had gone off life and had gone on to when is the next treat? When am I having the next take-away, the next meal, the next bottle of wine?” – PeadarFor many, getting a takeaway represented one of the few available treats at a time, when, as Steve put it, “there's very little natural rewards in life at the moment”:“I found that I was eating more sweets and comfort food during COVID, during the pandemic. So, yeah, I definitely, I have gained weight during that time. […] That's kind of pandemic thing, you don't have much to do so you probably eat a bit more” – AdaFor Ada, eating was related to boredom and “not having much to do”:“In many ways it's boredom, you know, it's to get a break from the room and break from the computer […] whereas if you're in work, you just have a chat with somebody” – KeithFor Keith his increased “fridge visits” were also related to boredom:“I love to walk the beach [but] it came in under the category of COVID restrictions [as] it's 7km away from the house. […] That was just one of the things I really missed” – Áine“I found that hard I have to say, the gym being closed. […] The weight resistance was really good and it was working, and I was really enjoying it and feeling really good, and then the lockdown came, and I hadn't had my knee surgery, so walking wasn't really an option, you know? And I found that very difficult then” – Catherine“That [picture] is the new office chair that I bought during lockdown, because I was confined to barracks, and I suppose the word that comes to mind is sedentary. I tended to live a very sedentary life.” – PeadarWorking from home also had an impact on participant's activity levels. Many were affected by gym closures and the geographical limits associated with the earlier lockdowns while others who, as Rory put it, “sit down for a living”, found that they were increasingly sedentary:While the quotes above point to the negative impact COVID-19 restrictions had on the health and well-being of many participants, for others they represented a more positive experience.“I was never a baker or a cook or anything like that but I'd make dinner for the four of us every Saturday […] I'd make a desert as well, I'd make it all from scratch. […] That was actually a nice memory from COVID because I never did that before and it was nice” – AprilThe closure of cafés, bars and restaurants meant that April started bringing a lunchbox to work in place of her daily visit to a local café. She also described how, in the absence of dining and social activities, she developed the habit of visiting her parents every weekend and cooking dinner:“I was using the time I would normally spend in a car out getting exercise. I got back cycling, I'm probably fitter than I have been for a few years.” – KeithKeith described how he lost weight over the first six months of the pandemic when his usual long daily commute to work was replaced by working from home:Time emerged as a key theme for many participants – time to reflect, to pursue creative interests, to connect with others and to spend with family and loved ones.“It [lockdown] gave me time to tease out what I wanted in life and, where I was going, not just the weight, but every other aspect of my life, […] Covid gave us time to ourselves and with our family and the important things started to show.” – AngelaAngela described how the lockdowns “gave me time to reflect”:Having time to herself and her family had a very positive impact on Angela's well-being. She says “there were huge positives” associated with the period of restrictions and “I wouldn't say I'm alone with the goodness of the pandemic, you know, that lockdown period was really good”.“We had a really lovely time. Okay, so we couldn't go anywhere, but the fact that we couldn't go anywhere was really great, and we kind of did things we'd never done before and we had a great old time at one level, you know?” – PeadarPeadar too described how he had “a great lockdown”, particularly during the first ten-week lockdown in Spring 2020.“Living a life in a car to and from work or living a life to and from airports, I don't necessarily think it suits a lot of people. We just do it because we have to do it. If I had a choice, I certainly would, certainly now, prefer to work at home or closer to home. I have never been able to just walk into work. […] I think the world we have ended up with in terms of work, it's just not good for the human spirit” – Keith“I have to say it's been a good pandemic” – KeithKeith described how the lockdown has forced him to reflect on his pre-pandemic lifestyle:“The first lockdown was great because the weather was so beautiful. But the most recent one I think has been difficult. Certainly, I found it difficult.” – KeithKeith was one of the participants who distinguished between his experience of the first major lockdown (March – May 2020) and the second (October 2020 – April 2021). This variance was associated with variables such as the weather, work and home conditions, and fatigue associated long periods under Government ‘stay-at-home’ orders.“I just felt I was going in a downward spiral with my mental health. [In the city] you're surrounded by people, but you just feel so lonely. And the whole pandemic for people living on their own, this is the worst you know?” – AdaAda was one participant whose job was impacted by the pandemic. She was made redundant during the first lockdown and described how she “definitely fell into a depressive hole”:“I'm lucky I'm six weeks in this wonderful place, and I'm calling [it] my six weeks of physical and mental health” – AdaAda made the decision to move out of the city and to rent a house from a friend in the countryside. This move, precipitated by the pandemic and its effects, had a positive impact on her health and well-being:“So, the first lockdown from March to whenever last summer, they [children] were all here and we had great support, great times, great barbeques, getting back to nature and all that kind of stuff. This time the lockdown at Christmas we were on our own, they all went back and decided not to come home every weekend because of the COVID they stayed in [city] for a lot of the weekends“ – PeadarPeadar too described the ways in which his experience of the first lockdown, when his grown-up children returned home to spend the period with their parents, was very different to his experience of the second:From the early stages of the pandemic, the Irish Health Service Executive (HSE), in line with many other national health agencies, declared individuals with obesity as ‘high risk’ for complications of COVID-19. The government advised that those over the age of 70, and those in this high-risk group, to ‘’stay at home as much as possible and to limit physical contact with other people”Being identified as high risk was significant for those who participated in this study.“It kind of scares me, you know? [I] realise that if I got COVID that I would probably end up being very sick, that's scary, you know?” – SteveSteve described how realising he was in a high-risk category was “definitely a wake-up call”:“It's the language around COVID; obesity is named constantly as at-risk […]. I know I'd have a better chance of survival if the weight was off”Angela too spoke about the “fear” of being “at-risk because of being overweight” – “its always hanging over you”:Sharing a photograph of her Health Service Executive “I got my COVID-19 vaccine” badge , Angela “The policies at the moment are segregating, it's not your choice of isolation, it's systemic isolation. […] There is a ‘them and us’ sort of scenario with the segregation. It's not a nice place to be on either side of the fence in society. You're being punished for not being vaccinated but in many ways you're being punished for being overweight as well. Isolated from participation in society in subtle ways” – Angela“At the beginning of COVID when people were talking about the obesity and you know, it just sounded as if it was all obese people that were blocking the beds in the hospital and basically they should be eradicated, you know? It was just horrible, I was afraid to nearly go out at all at that time” – FreidaFreida also spoke about the damning narrative around obesity during the pandemic:“The conversation […] was, oh you know, ‘these are all overweight people and because of that they are high-risk’. There was even a comedy show on RTÉ  and the comedian was on Grafton Street saying ‘Oh, fattie, don't come near me because you're high risk’” – Ada“It's not nice when you're portrayed in that way in the media […] that makes you feel like an outsider, you know […]. It's almost like a zoo sometimes, how people look at you, and you're just ugly. And now on top of that you're also sick so you're high-risk. No, it doesn't make you feel good at all” – AdaAda also spoke about how the public discourse and portrayal of people with obesity made her “feel like an outsider”:This study and its findings highlight two important points regarding the experiences of people living with obesity during the COVID-19 pandemic. The first is that this experience is not homogenous. Just as the pandemic experience of wider society is influenced by a range of variables such as work, living, personal and financial situation, so too is the experience of those living with obesity. While the experience may be a ‘mixed bag’, its contents warrant unpacking and examination as these social, personal, and environmental factors offer helpful insights into what can have a positive and negative impact on the health and well-being of people living with obesity. Participants in this study pointed to the poor availability of healthy and affordable take-away food options as well as the closure of gyms as having a negative impact on their health. This, combined with the curtailment of exercise to within 5km of home, made exercise and activity a challenge for many participants. Working from home and limited travel compounded this reduced activity and a number of participants “tended to live a very sedentary life” as Peadar described it. These findings support larger, quantitative, studies that highlight the negative impact of the pandemic on health-related behaviours.The change in lifestyle and working conditions precipitated by the pandemic and national measures, also presented an opportunity for many. Working from home meant that participants no longer had to spend long hours commuting to and from the office which, in Keith's case, meant that he could use “the time I would normally spend in a car out getting exercise”. In the wake of pandemic-related redundancy, Ada had the opportunity to move to the countryside which had a positive impact on her health and well-being while April described how she appreciated the time to cook meals for her family “from scratch”. Time emerged as a key theme for participants – time to reflect on what is important in life, time to spend with family and completing creative pursuits. Participants almost apologised for admitting “we had a really lovely time” (Peadar) but the changes brought about by restrictions afforded opportunity to re-evaluate life and working conditions and connect more with others.,The longitudinal nature of this study, albeit just ten months, allowed for reflection on the changing nature of experiences during COVID-19. Just as the experiences within the sample were not homogenous, the experiences at an individual level changed over time. These changes were shaped by factors such as the weather; change in living circumstances; and the wane in energy from the “in this together”,The second major point of discussion relates to participants experience of being identified as ‘at-risk’ of complications due to COVID-19. They described the fear and sense of segregation that resulted from this categorisation. Several participants felt “like an outsider” (Ada) amongst the general population – particularly as a result of the portrayal of people with obesity in the media: “it just sounded as if it was all obese people that were blocking the beds in the hospital and basically, they should be eradicated” (Freida). Extensive research points to the manner in which people with obesity are stigmatised by the media,While being identified as ‘at-risk’ meant that participants could take critical extra measures and were prioritised for vaccination, it also had an impact on their identity and sense of belonging: “you're being punished for being overweight […]. Isolated from participation in society in subtle ways” (Angela). Little is known about the impact of the ‘at-risk’ categorisation on those living with obesity and this study points to the potentially ‘othering’ effect of this categorisation. Othering, according to Powell and Menendian,In conclusion, the COVID-19 pandemic has had wide ranging impacts on people living with obesity. Many of these were negative, including weight gain and isolation, while others were positive with time for reflection and health gain. The categorisation of, and narrative surrounding, people with obesity as “at-risk” of COVID-19 complications has resulted in many feeling stigmatised, segregated and ‘othered’. Understanding the legacy of this stigmatisation and the impact of COVID-19 restrictions on the health outcomes of people living with obesity is essential in providing an effective response to the disease as we move from pandemic to endemic.Conceptualisation: D.McG., E.F.Data curation: E.F., E.H., D.McG.Formal analysis: E.F., E.H.Funding acquisition: Cl.R., J.N., D.McG.Investigation: E.F., E.H., D.McG.Methodology: D.McG., E.F.Project administration: D.McG., J.N., E.F.Resources: Cl.R.Software: NASupervision: D.McG., Cl.R.Validation: AllVisualisation: E.F.Writing – original draft: E.F.Writing – review & editing: All.Approved final manuscript: All authors had full access to all the data in the study and had final responsibility for the decision to submit for publicationThe data associated with this study will be made available in anonymised format from the corresponding author upon reasonable request.Cl.R. reports grants from the Irish Research Council, Science Foundation Ireland, Anabio, and the Health Research Board. He serves on advisory boards of Novo Nordisk, Herbalife, GI Dynamics, Eli Lilly, Johnson & Johnson, Glia, and Boehringer Ingelheim. Cl.R. is a member of the Irish Society for Nutrition and Metabolism. He was the chief medical officer and director of the Medical Device Division of Keyron in 2011. Both of these were unremunerated positions. Cl.R. was a previous investor in Keyron and was gifted stock holdings in September 2021 and divested all stock holdings in Keyron in September, 2021. He continues to provide scientific advice to Keyron for no remuneration. J.N. is the President/CEO of the Obesity Action Coalition and serves as volunteer co-chair of the Obesity Care Advocacy Network. E.F., E.H. and D.McG. have no conflicts of interest to declare.


We read the recent study by Niemann et al. (2022) . This stMcNally et al. did not count local problems, such as prolonged wound leakage or dehiscences, as complications”. This is not correct and may hide the real reason for their high reoperation rate. In our paper, we listed each wound leak with its site, time of onset, duration, treatment and outcome in a section entitled “Complications”. We also summarized these data in a table entitled “Secondary Complications” [The study offers a report on a small retrospective series of 20 patients treated over 5 years (mean 4 patients/year). The authors reported a 50% reoperation rate, mainly due to wound leakage or dehiscence. They compared their results to our better results (6% wound leaks and no wound dehiscence in a prospective series of 100 patients) […the outcome data presented in the present paper appears to be more realistic as real-world data for most centers”. This is hard to understand, as they are reporting on a highly selected, non-consecutive, retrospective series of just 20 cases, chosen from the several hundred patients treated in their center over 5 years. There is no information on how these cases were selected for this treatment or why other cases were treated differently. We would contend that our two large, unselected, prospective, consecutive series of 100 and 163 patients represent the real-world of cases seen in many centers [Niemann et al. believe that “the frequency of revision surgeries…”. However, it should be noted that the decision to reoperate is in the hands of the surgeons. Niemann et al. stated that “10 (of their 20 patients) needed at least one revision surgery during the study period due to OM persistence or local wound complications”. They decided to operate on six (30%) of their cases due to a wound leak. These operations occurred between day 4 and day 39 after surgery. It is not possible that wound problems in the first few days are due to the implanted antibiotic material, as it has not started to dissolve to any extent by day 4. It is much more likely that these early reoperations are due to poor wound closure after initial surgery.The primary outcome measure of this study was “It has been widely published that the early leakage of antibiotic materials can be managed conservatively, with excellent results ,5,6,7,8.preferably with primary wound closure’ but, unlike our studies, they gave no details on the soft tissue management. This is important because 55% (11/20) of their cases affected the tibia. In our series, over one-fifth of these cases required plastic surgical reconstruction to enable closure. Failure to do this, or choosing to leave the wound open, will undoubtedly increase the need for early revision surgery to achieve wound healing. This condemns the patient to an unplanned two-stage approach.Careful management of the soft tissues is essential in osteomyelitis surgery ,4,9,10. The authors claimed that they were the first to provide functional scores and PROMS for chronic OM patients. They presented a 50% follow-up rate (10/20) for this, and some of their scores were reported for just 2 or 3 patients. The claim is surprising, as they quote our paper , which iTherefore, standardized antibiotic concepts and surgical treatment strategies have been elaborated, which comprise single-stage and two-stage treatment protocols” is referenced with an editorial [Throughout the paper, references are added to imply support for the text, but often the quoted reference has nothing to do with the text. For example, the statement “ditorial  which isIt is important, when presenting new research, to use references and report data from published papers accurately. It is equally important to understand lessons learnt from the new research. It is not reasonable to misquote other papers or misrepresent the content of those papers. In this study, Niemann et al. have ignored the evidence included in previous work, failed to appreciate or report the effect of their management of the soft tissues and exposed their patients to unnecessary secondary surgery.


Parent–child relationships, the rearing attitudes of parents toward their children as well as the interactive relationships, such as play and cultural activities that parents and children enjoy together, serve as important factors in predicting a child’s growth and development. These experiences of annual events celebrated with the family may be related to the school-age child’s development. However, this relationship has not been investigated sufficiently. Therefore, this study aimed to identify the relationship between the experience of annual events observed in the family and a child’s social adjustment.Setsubun or the day before the start of spring, Mother’s Day, Father’s Day, the Tanabata or Weaver Festival, Respect for the Aged Day, Winter solstice, etc.), and the child’s social adjustment (Strengths and Difficulties Questionnaire). A total of 653 children who met the criteria of not having any developmental disorders were included as participants for the analysis.In 2019, a self-administered questionnaire survey targeting fifth graders (ages 10–11) in Japan was conducted with children’s parents. Major survey items included participants’ characteristics , annual events observed in the family (The participants had celebrated an average of 15.47 (± 5.52) annual events with their families that year. The number of annual events celebrated was significantly related to family composition and the parents’ educational backgrounds. We found that children who came from families with numerous experiences of annual events were more likely to have higher prosocial behavior and were less likely to have externalizing or internalizing problems. The same pattern was found even after adjusting for the family’s socioeconomic background and other factors; that is, children who came from families having diverse experiences of annual events were more likely to show prosocial tendencies.Our findings suggest that the experience of annual events observed with family potentially enhances a child’s prosocial behavior. Thus, celebrating and preserving cultural and personal events in the amily context may be an important developmental experience in terms of children’s social adjustment.The online version contains supplementary material available at 10.1186/s13034-022-00475-w. Researchers have shown that diverse experiences in daily life affect a child’s socio-emotional development . Family Educational guidelines for kindergartens, nursery school childcare, elementary schools, and in other documents [Countries worldwide have traditional family rituals as annual events that have been transmitted across generations for a long time and continue to be passed on as events unique to that particular country. Japan has a variety of traditional annual events that are held for each season throughout the year; there are also many annual events that, over time, have been adopted from other countries. Cultural experiences play an important role in fostering a child’s identity and building self-esteem . Researcocuments –15. The This study was part of a research effort to examine the effects of parenting environment on children’s social development and adjustment, and was conducted in affiliation with Kyoto University. In 2014, parents of 5–6-year-old preschoolers were recruited as participants from 52 kindergartens and 78 nursery schools in Aichi Prefecture, a major metropolitan area in Japan. We followed up with these participants annually. Data for the current study was collected in 2019, from the same cohort of participants from 2014, during one of our annual follow-ups. In 2019, this cohort of children was aged 10–11-years and were in the fifth grade of elementary school. The parents (N = 1414) responded to self-reported paper-based questionnaires. The survey items included participants’ characteristics , description of the experience of annual events celebrated with the family during one year, and the child’s level of social adjustment. The questionnaires were distributed by mail to 1414 respondents and were returned by 720 of them. The total number of valid responses obtained was 709, after excluding 11 respondents with missing answers on items concerning child’s social adjustment, annual events, etc., which were necessary for this study. From the 709 valid responses, we excluded children with developmental disorders (n = 56) and used data for the remaining 653 children for our target analysis. We excluded data of children with developmental disabilities from this analysis because of their potential impact on annual family events performed in the family. For example, in the case of severe developmental disabilities, families may be reluctant to engage in certain annual family events. Thus, the addition of this cohort may have led to a high variance in responses as well as a misrepresentation of the impact of annual family events. Determination of developmental disability was based on parental report.In this study, the children’s parents completed the Strengths and Difficulties Questionnaire (SDQ) , which is a screening scale that is formulated to assess a child’s social adjustment using a paper-based questionnaire –18. The Nanakusa—the seventh day of the New Year for eating the seven spring plants and vegetables, Kagami-biraki—cutting the New Year rice cake and eating it with a clear soup or as a sweet red bean soup, etc., Setsubun—throwing dry beans to expel demons, eating Ehomaki rolled sushi, etc. on the day before the start of spring, Doll’s Festival—displaying Hina dolls, eating special rice crackers and tossed sushi, etc., Children’s Day—displaying carp streamers, Boys’ Festival dolls, eating the event’s special sweets, etc., Tanabata—Weaver Festival, Bon Festival for remembering the dead, Respect for the Aged Day, Winter solstice, and New Year’s Eve. In terms of internationally popular annual events, they were asked about Valentine’s Day, Mother’s Day, Father’s Day, Halloween, Christmas, etc. They were also asked them about their family’s anniversaries, and children’s, parents’, and grandparent’s’ birthdays. In total, 28 kinds of annual events were included.The children’s parents also answered questions about the annual events observed in their family throughout the year, in a questionnaire-based survey ; the answers were close ended (yes/no). Specifically, they were asked about Japan’s major traditional annual events, such as New Year’s Day, In addition, the children’s parents provided data regarding the child’s sex, family composition, siblings, annual household income, and the parents’ educational backgrounds using a paper-based questionnaire. In this analysis, we established the child’s sex as boy or girl; the family’s composition as single-parent household or two-parent household; the family’s annual household income as less than three million yen, 3–6 million yen, 6–9 million yen, or more than nine million yen ; and the parents’ educational backgrounds  as middle school or high school, junior college or vocational school, or university and graduate school.t-test and one-way analysis of variance.To investigate the relationships between the participants’ characteristics  and the number of annual events, as well as the relationship between the participants’ characteristics and social adjustment, we conducted analyses using the Next, to investigate the relationship between the experience of annual events and the child’s social adjustment, we considered social adjustment  as the objective variable and the number of annual events as the explanatory variable. We then conducted a multiple regression analysis. In Model l, analysis was performed without including moderator variables, and in Model 2, it was performed by establishing the following as the moderator variables: child’s sex, family composition, siblings, annual household income, and parents’ educational backgrounds.Table Table Table Table In this study, the number of annual events experienced was significantly related to family composition and the parents’ educational backgrounds. Single-parent households experienced fewer events than two-parent households. The lower the mother’s educational background, the fewer the events experienced by the child. Studies have found that families with a low socio-economic status (SES) tended to have a low-quality family environment , 22. The2 was not high, it was meaningful as it indicated a significant association between family experiences and behavior in children. Annual events represented by family rituals are special events such as celebrations, traditions, and patterned family interactions that have symbolic meanings shared by the entire family [In this study, we investigated the relationship between the experience of annual events and the child’s social adjustment. We found that children from families with numerous annual events were more likely to show higher prosocial behavior and that their externalizing/internalizing problems were likely to be less acute. Even after adjusting for families’ socioeconomic background and other factors, the trend was similar. Although the Adjusted Re family . Family e family . Previoue family . In addie family , 27. Thee family . This maThis study has several limitations. First, because this was a cross-sectional study, it was not possible to examine causal relationships. Second, although we investigated annual family events that are popular in Japan, several events were not included in the list. Third, we looked at limited aspects of children’s social adjustment using the SDQ. Fourth, out of a distribution of 1414 participants, this study had 709 valid responses, of which 653 were used for analysis, which may indicate bias in the selection of respondents. Finally, this study was conducted in a limited region in Japan, which may affect generalizability. We hope that future studies take these points into consideration for further research related to our findings.This study used a sample of school-age children to identify the relationship between children’s experiences of cultural and personal events celebrated with their families and their social adjustment. Our findings suggest that the experience of annual events is likely to enhance a child’s prosocial behavior. Previously, it has been observed that the diversity of a child’s experiences, both inside and outside the home, is affected by the family’s SES. Even after adjusting for background factors such as household income and parents’ educational backgrounds, the number of experiences was shown to relate positively to prosocial behavior. Thus, celebrating and preserving annual events with the entire family plays an important role in a child’s social adjustment across a variety of family environments. The results of this study will contribute to the literature on environmental factors in child-rearing that promote the development of children’s social abilities and social adjustment.Additional file 1: Appendix 1. Strengths and Difficulties Questionnaire.Additional file 2: Appendix 2. List of annual events.


Focusing on the putative inflectional zero morpheme, we discuss the theoretical origins and pitfalls of this approach and advocate the important role for neurobiological research that could try to elucidate the neurocognitive reality of such constructs in linguistic communication.Knowledge of language, its structure and grammar are an essential part of our education and daily activities. Despite the importance of language in our lives, linguistic theories that explain how the language system operates are often disconnected from our knowledge of the brain’s neurocognitive mechanisms underpinning the linguistic function. This is reflected, for example, in the inclusion of abstract and often controversial elements into theories of language. Here, we discuss the case of the so-called  The phenomenon of a defunct object was addressed in classical philosophy, where it was seen as contradicting itself . The prozero morpheme. It is posited that zero morpheme is a morphosyntactic unit without overt graphemic and phonological counterparts: e.g., compare “cat-Ø” (singular) vs. “cat-s”  where the singular inflectional form is allegedly represented only implicitly while the plural form receives the explicit -s marker. This “invisible” member of the corresponding category  is purported to be necessary for efficient linguistic processing, and is assumed to be a part of most languages’ grammars. Since its representation is not accompanied by any physical referent, there is a widespread controversy surrounding the nature and the neurocognitive reality of zero morphology – in relation to both individual languages and the universalist approaches to grammar.Language is one of the most sophisticated products of human evolution that supports communication and thus enables all our individual, social, economic, cultural, and intellectual activities. However, conventional linguistic theories do not always take into account the knowledge of the neurobiological foundations of the language function in the human brain. As a result, they often rely upon highly abstract and derived models that include categories and notions not necessarily represented overtly in linguistic behavior and enjoy little-to-no support from experimental research. One such example is the so-called This problem is inherently paradoxical – even from the viewpoint of its accessibility for empirical investigation as it makes experimental hypothesis falsification somewhat problematic . As mentOne of the founding fathers of the 20th-century linguistics, Ferdinand de Saussure, defined language as a system where the absence of overt features is as important as their presence . This chstol” (table) in Russian nominative and dative cases: “stol-ØNom” – “stol-aDat”] for the purposes of saving the structural system in universal templates. Thus, we have an element without the phonological level of representation, which is, however, attributed with a morphological representation and an abstract internal syntactic function. According to the UG, which postulates a relatively universal structure of all language systems that can be expressed in a specific set of rules, the human brain contains a limited set of constructs for organizing the language system, thus necessitating zero morphemes where overt “classical” ones are not obviously present. By contrast, the Lexical Morphology hypothesis (LMH), derived from Being placed within single words, zero morphemes stand out among other null constituents and are understood as covert markers – inflectional or derivational. For example, the Universal Grammar UG;  proposedAt the same time, Finally, Distributed Morphology approach , combine., “I walk-Ø” – “she walk-s”) and derivation . Until now, several questions were raised regarding derivational zeroes (table-Ø” – “table-s”). Thus, arguably the optimal way to investigate the cognitive reality of zeroes is to start from their easiest and less controversial cases – inflectional zeroes, such as those in case, gender, or number marking. While we will not consider in detail the special cases where zero inflection entails phonological changes in the root, such as in irregular verbs and noun plurals  due to the more complicated/multiple processes involved, we will briefly discuss some other pitfalls that beset empirical studies in this field.Cases of putative zero morphology can be found in both inflection  is to assume the presence of zero affixes in one language but not in another. Developmental data indeed offer some support to this view: For instance, English-speaking children produce more single stem (without overt affixes) forms in contrast to their German or Russian-speaking peers who rarely produce forms lacking overt affixation  for young children, decreasing with age d,” a parsing attempt later discarded; While this discussion can adequately address decomposition processes where we divide wordforms into stems and affixes marking potential features, it also raises a further question regarding words’ whole-form storage vs. morphological decomposition as well as their encoding and retrieval from memory with or without morphological features . A potenbuy” in “PL”they buy-Ø (as opposed to “he buy+SG”s) or a similar Swedish noun-number marking contrast [“PL” (parentsEltern-Ø) vs. “Eltern+teilSG” (parent)], the final stage of processing needs to be disambiguated between that of the zero morpheme (number marker) per se simply and the detection of a “missing something” at that point . As a result, experimental research has not yet succeeded in detecting traces of zero morpheme retrieval that could help elucidate its neurobiological and cognitive reality with any certainty. In the next section, we will suggest some possible ways for tackling this problem.Indeed, despite the abundance of words with no overt affixation across languages and an extended theoretical use of zero affixes in linguistics, there is little experimental psycholinguistic or neurolinguistic evidence documenting the neurocognitive reality of zero morphemes. In the absence of an optimal neurocognitive theoretical framework, one has to proceed with the assumption that it is not possible to ensure the presence of a null element unless one could mechanistically separate syntactic (or morphosyntactic) processing traces from the semantic ones . That isDespite the problems associated with investigating the neurocognitive mechanisms of zero morphemes, there have been already some attempts to trace zero morpheme access in linguistic behavior. For example, At the brain level, the available evidence is even more scarce. we walk-s” vs. “he walk-s” and “we walk-Ø” vs. “*he walk-Ø”, where physically the same zero and overt surface forms are rendered as correct or incorrect (*) by the context of the preceding pronoun. Thus, even though event-related potentials (ERPs) in response to both overt (-s) and zero (-Ø) affixes are elicited by the same acoustic events in each contrast, the linguistic events diverge, affecting language-specific brain activation. Using such an approach, the main research question could be addressed by implicating a morphosyntactic priming theory , its presence  could lend support to zero-morpheme brain activation, demonstrating an overt ERP response to the elusive covert zero affix, thus supporting neurophysiological reality of zero’s representation in the brain.Following the dual-system approach and considering the recent findings regarding a very early timing of zero-inflected form processing, one could try addressing the question of the neurocognitive reality of zero morpheme representations by focusing on the time-course of their putative access in the brain. This would require neuroimaging methods allowing high temporal resolution, such as magnetoencephalography (MEG) or electroencephalography (EEG) that can track neuronal activity with a millisecond precision – an essential feature for highly dynamic linguistic processes . Importag theory  that canTo address this issue in a more comprehensive way, different types of verbal, adjectival, and noun inflections can be used in this type of designs. Furthermore, this approach can be extended by an additional contrast–unprimed single verb with zero inflectional marker – where we can limit the impact of the contextual effects on the selection of a particular affix (zero or overt), thus introducing an additional control condition. Moreover, such unprimed condition manipulation could be used to address the question of the default zero-forms in different parts of speech. Such an approach could be used in the future to tackle different zero-inflection morphemes  in different word classes. Furthermore, it could be applied cross-linguistically to address the question of the universality of zero constituents predicted by the UG framework and the availability/absence of zero inflections in typologically diverse languages. In addition to recording ERPs, such a design could also be used to track oscillatory activity of the brain’s networks across different bands, known to underpin morphosyntactic processing, as well as delineate their cortical spatio-temporal patterns and neuroanatomical substrates .Furthermore, this approach could be adapted to psycholinguistic experiments, implementing different paradigms based on the morphosyntactic priming theory (see In this paper, we briefly discussed the existing evidence regarding the neurocognitive reality of one of the smallest and most evasive concepts of the language grammar, the zero morpheme, and suggested potential research avenues that will foster better understanding of the neurophysiological foundations of this phenomenon. Future research will be able to verify the existence of neurobiological and behavioral signatures of accessing such non-overt, abstract morphemes. It will also shed light on the bases of morphosyntactic processing in general. In addition, this line of research will offer an “experimental hand” to the linguistic theories of zero morphology and improve our understanding of more complex null constituents as well as other abstract theoretical constructs. This, in turn, will lead to a better dialogue between linguistic and neuroimaging research fields and advance our understanding of the nature of language faculty.All further inquiries can be directed to the corresponding author.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


Pediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers.a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution.We conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use.PEWS improved the quality of attention for patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes.In resource-limited hospitals, PEWS use results in multi-level positive impacts on  Hospitalized pediatric oncology patients are at high risk for clinical deterioration, particularly in resource-limited settings , 2. PediThe impacts of PEWS have been demonstrated across multiple levels of hospital care. PEWS decrease clinical deterioration events and pediatric intensive care unit (PICU) utilization , and impWhile many positive impacts of PEWS have been identified in resource-limited settings, little is known about how these effects are achieved or interrelated. This study explores hospital staff perceptions of the multilevel impacts of PEWS, how they are achieved, and the process by which they facilitate and augment one another.This is a secondary analysis of a study designed to identify barriers and enablers to PEWS implementation, and study methods have been previously described in detail . The stuEscala de Valoraciόn de Alerta Temprana (EVAT) is a Spanish-language PEWS validated in pediatric oncology patients . ProyectFive Proyecto EVAT centers which completed PEWS implementation prior to March 2020 were selected to participate in the study with representation from Mexico, Central America, and South America. Center characteristics are described in via a video conferencing platform (WebEx) from June to August of 2020. The interviewers were previously unknown to participants, not affiliated with their hospital, and not involved in PEWS implementation. Audio recordings of the interviews were professionally transcribed, translated to English, and de-identified  prior to analysis.An interview guide . The guia priori , and center characteristics .Three “outcomes” codes were identified to describe perceived impacts of PEWS at the level of the patients, clinicians, team dynamics, and institutions. Seventy-one interviews were conducted at 5 pediatric oncology centers in Latin America . Staff explained that, prior to PEWS, deteriorating patients would go undetected for hours as their bed was the last discussed on rounds or because vital signs were checked only once or twice a shift: “before when a child got critical in the [ward] no one was aware of him” . With the PEWS algorithm, patients were monitored at appropriate intervals based on their clinical status ; “now, the detection of the child is done on time” .Using PEWS required frequent and focused patient assessments leading to increased situational staff awareness and more individualized attention: ““if you see a patient who doesn’t look that bad but he has a yellow [PEWS], it makes you act before; you prevent a bigger complication and it doesn’t depend on what you see but it’s something more objective” . As a result, deteriorating patients were identified and treated earlier, leading to fewer unplanned PICU transfers. Patients who did need PICU care were transferred earlier and required fewer interventions: “The patient doesn’t need to go to intensive therapy to get better. In case the patient goes to intensive therapy … he won’t stay too long or need a tube,” .Greater situational awareness facilitated early detection of clinical deterioration and increased opportunities for prevention of critical illness: the mortality was highly reduced,” . Additionally, with early detection, a patient transfer to the PICU was no longer synonymous with death: “Before [PEWS], children with cancer would go to the ICU and it was considered a child with no opportunity, that child should die. Once [PEWS] came, our children began to get out and we started saying a child with cancer doesn’t die, we just transfer him too late” .These improvements led to a perceived reduction in the morbidity and mortality of hospitalized patients: “clinicians, including reduced nursing workload, improved job satisfaction, increased knowledge, and empowerment . Additionally, some centers leveraged the initial increase in nursing workload to advocate for a reduction in the nurse-to-patient ratio: “Without [PEWS] we couldn’t justify the need of a nurse to take care of 6 children, they used to take care of 10 or 12 before,” .While nurses initially perceived PEWS use as increasing their workload, with continued use, it became part of their workflow, and ultimately, the reduction in deterioration events and earlier PICU transfers due to PEWS was felt to decrease nursing workload as they were caring for fewer critical patients: you can intervene your patients early and avoid ICU or even death; that gives you great satisfaction,” . Staff members across all disciplines found this to be motivating: “they see that their work is represented in a patient who is discharged in very good conditions, that makes their effort worthy,” .As a result of using PEWS to positively impact the care of their patients, clinicians experienced greater job satisfaction: “we used to take signs without knowing what was normal … now with [PEWS], we know how different it is to have a bradycardia or an asymptomatic bradycardia, it changes a lot,” . As a result, they were better able to monitor their patients and felt more confident speaking up when necessary to raise an alarm.Additionally, many staff members, especially nurses, found that PEWS and the accompanied trainings expanded their knowledge-base: “little by little the nurses found out they could go beyond with their work in the service, more than just give medicine, prepare chemotherapies, the fact that they could evaluate a patient … makes them feel more educated, with more power for decision,” . PEWS empowered nurses to take a more active role in patient assessment and management, and physicians felt empowered to contribute to ongoing improvements in patient care: “there is motivation from the resident part knowing the supervision is higher in the entire service” .As staff gained knowledge and confidence, they reported increasing feelings of empowerment: “team including better communication between healthcare providers and improved interprofessional  and interdisciplinary  team dynamics . PEWS use provided teams a common language, improving interprofessional and interdisciplinary communication: “with the [PEWS] score, it was so easy with everyone talking about the same thing to detect a patient when he needed to be transferred to the ICU or when they could treat him in the [ward] … now we all speak the same language” .Participants explained that prior to the introduction of PEWS, nurses and physicians did not have common terminology to discuss patient status, resulting in ineffective communication: “relationship between them improved a lot” , “not only professionally, but friendly” . PEWS diminished hierarchies between physicians and nurses, and as a result, nurses felt their input was welcome and valued in ways that it was not previously: “that we would all talk the same language and that the nurse would have voice and vote in the evaluation of the patient, it’s been one of the biggest and most successful projects,” . Similarly, the use of PEWS facilitated better relationships between the ward and PICU teams: “before it was like we must transfer him to the ICU, I’m scared they won’t accept him, but not anymore … they are more sensitized, more accessible,” . Following PEWS implementation, PICU transfers were less chaotic as PICU clinicians were more willing to evaluate and admit patients earlier in the course of illness.Improvements in team dynamics not only enhanced communication but also improved interprofessional and interdisciplinary relationships. Prior to implementation of PEWS, collaboration between professions was minimal; after implementation, nurses and doctors interacted more frequently and the institutional impacts of PEWS included cost reduction, a change in hospital culture emphasizing high-quality patient care, receipt of institutional awards, and opportunities for collaboration with other hospitals .PEWS use reduced hospital costs by decreasing inpatient days and resource utilization: “the culture changed, the culture for the whole medical staff to see the patient in a comprehensive way,” . Staff experience using PEWS demonstrated that clinical deterioration was largely preventable, leading to a hospital-wide focus on patient safety: “[Clinicians] see that his life is in danger or that he could get critical … they visualize that it is very important to be on alert with that patient so he won’t have risks, and applying [PEWS] on all our patients has influenced a lot as part of their safety” . Quality improvement projects became more common as staff were inspired to explore other strategies to improve patient care: “A lot of us have started to get involved in other quality improvement projects that maybe didn’t exist before [PEWS], but it has helped us and pushed us to work … to motivate ourselves as professionals to keep looking for alternatives for our patients,” .Additionally, participants at all sites noted that PEWS implementation altered hospital culture to increase emphasis on patient-centered care: “all we wanted was to implement [PEWS] and try to give quality to our patients, but it has been recognized by the Ministry, so that’s an achievement bigger than we expected,” . Additionally, participation in Proyecto EVAT provided new opportunities to collaborate with other hospitals: “We’re able to visit other countries, know the realities of other people, share experiences, share situations,” .Centers were further motivated by receiving awards honoring their PEWS program from entities such as the Ministry of Health: “It was the motivation of seeing the children who could have had a fatal ending return to the [ward] in a better condition” . Greater job satisfaction and empowerment among staff led to improved interdisciplinary and interprofessional relationships and communication. Hierarchical barriers were reduced and the interprofessional team functioned more cohesively: “we gained friendship and fellowship, which reinforced our work” . As relations improved, so did the work environment, facilitating a change in hospital culture with implications for staff’s wellbeing and patient safety. Additionally, observed reduction in resource utilization and mortality galvanized support for PEWS among hospital leadership: “Even in the administration field, we can see that if there’s a better response to the patient’s need before he gets critical, this reduces spending and reduces the probability to go to the ICU or get critical or even die” . This encouraged leadership support for ongoing staff training and expansion of PEWS within the hospital. Over time, PEWS became embedded in the hospital’s culture and workflow, further reinforcing its continued use: “The hospital has accepted [PEWS] as part of the staff’s work, so they give us the sheets, they open the doors for the training” .PEWS implementation led to benefits for patients, clinicians, teams, and institutions initiating a feedback loop that reinforced ongoing PEWS use Figure 1Our study demonstrates multiple benefits of PEWS implementation for patients, clinicians, healthcare teams, and institutions and the ways in which these benefits modulate and reinforce one another. Similar to prior studies, we found that staff perceived PEWS to reduce adverse events , improveImplementation and improvement research is important in resource-limited settings where contextual and infrastructural challenges make implementing evidence-based practices more difficult . CorrectThe cycle of reinforcement identified in our study provides a model to promote the sustainability and expansion  of effective quality improvement interventions. Prior work suggests that an institution’s capacity to sustain an evidence-based practice such as PEWS increases with time , and theOur study has several limitations. Key stakeholder interviews have a risk of social desirability bias ; howeverThis study uniquely describes the interplay between the multilevel impacts of PEWS implementation in resource-limited settings. Benefits at the level of the patient, clinician, team, and institution create a cycle of reinforcement that amplifies impact and supports ongoing PEWS use. These findings can guide advocacy for PEWS to different stakeholders, improve PEWS implementation and efficacy, and inform the implementation and evaluation of other quality improvement initiatives to reduce disparities in childhood cancer outcomes globally.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by St. Jude Children’s Research Hospital Institutional Review Board. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.AA and DG developed the idea. MP-T, SG, PE, HM-T, AGR, MA, CB, RDC, CH, SJ, JJL, AM, EMo, EPe, and EPi collected the data. AA and DG provided supervision. EMi, GF, and AA conducted the data analyses. EMi, AA, and DG drafted manuscript and prepared the tables and figures. EMi, GF, and AA had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the analysis. All authors contributed to the interpretation of the findings, the editing of the article, and the approval of the final submitted version.This study was funded by the American Lebanese-Syrian Associated Charities (ALSAC). EMi was supported by grant R25CA23944 from the National Cancer Institute. These funders were not involved in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.We thank the PEWS implementation teams at all Proyecto EVAT centers, including those who participated in this study, as well as the Proyecto EVAT Steering Committee for oversight of this work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To prevent needlestick injury and leftover instruments, and to perform efficient dental treatment, it is important to know the instruments required during dental treatment. Therefore, we will obtain a dataset for image recognition of dental treatment instruments, develop a system for detecting dental treatment instruments during treatment by image recognition, and evaluate the performance of the system to establish a method for detecting instruments during treatment. We created an image recognition dataset using 23 types of instruments commonly used in the Department of Restorative Dentistry and Endodontology at Osaka University Dental Hospital and a surgeon’s hands as detection targets. Two types of datasets were created: one annotated with only the characteristic parts of the instruments, and the other annotated with the entire parts of instruments. YOLOv4 and YOLOv7 were used as the image recognition system. The performance of the system was evaluated in terms of two metrics: detection accuracy (DA), which indicates the probability of correctly detecting the number of target instruments in an image, and the average precision (AP). When using YOLOv4, the mean DA and AP were 89.3% and 70.9%, respectively, when the characteristic parts of the instruments were annotated and 85.3% and 59.9%, respectively, when the entire parts of the instruments were annotated. When using YOLOv7, the mean DA and AP were 89.7% and 80.8%, respectively, when the characteristic parts of the instruments were annotated and 84.4% and 63.5%, respectively, when the entire parts of the instruments were annotated. The detection of dental instruments can be performed efficiently by targeting the parts characterizing them. A needlestick injury (NSI) is one of the most frequent medical incidents in dental treatment, and an NSI can occur not only during treatment but also during cleaning procedures. NSIs tend to occur intraoperatively in oral and periodontal surgery, whereas, in general dentistry, NSIs tend to occur during cleanup due to various treatment methods and frequent changes during instrument preparation2. Thus, to prevent NSIs, not only the surgeon or assistant, but also the cleaner, must be aware of all available instruments. In dentistry, a variety of instruments are used according to the nature of the treatment. For example, in caries treatment, an excavator is used to remove caries, and a composite instrument is used to fill composite resin; in root canal treatment, an excavator is used to remove temporary seals, and a reamer is used to form root canals; in periodontal treatment, a probe is used to measure periodontal pockets, and a scaler is used to remove calculus. It is critical that these instruments are well prepared and that their presence is known before treatment for smooth and safe treatment. In other words, to prevent medical accidents and improve the efficiency of dental treatment, it is necessary to monitor changes in the number of instruments present during treatment in detail and in real time and to implement operations that use this information.As several instruments and devices are used in medical care, they should be operated correctly and safely. However, due to staff shortages and fluctuations in the number of patients, it is extremely difficult to ensure thorough management of instruments and equipment. Therefore, incidents affecting the lives of patients and the quality of medical care are likely to occur in the general operations of healthcare workers. A specific example of a life-threatening incident is leaving instruments or gauze inside a patient’s body after a surgical operation3 have been used in various fields. One of such technologies is object detection via image recognition7 and semantic segmentation9. Object detection is the estimation of an area in an image, where the target object exists, and semantic segmentation is the estimation of the object type for each pixel in an image. Both technologies use a computational method called convolutional neural networks (CNNs)10. DL-based image recognition has been used for human safety. For example, object detection is used in automobiles for collision prevention and automatic driving12 based on detection of vehicles, people, and road signs and used in trains for detection of passengers falling from platforms13. Object detection is also used in the medical field, for instance, to detect lesions using endoscope images14 and to detect abnormal areas in X-ray images15. Semantic segmentation is also used to extract instruments in endoscopic images16.In recent years, various technologies based on deep learning (DL)18, but their introduction cost and maintenance burden have become an issue20. In addition, many dental instruments are small, and it is often difficult to affix color codes or attach RFIDs. Shape recognition based on edge detection using the Canny filter that do not require these methods, for instruments used in otolaryngology surgery was 84.9%21. Simple shape recognition via contour extraction has a limitation of being unable to detect instruments because their contours change when they overlap. Therefore, although instrument recognition via contour extraction is effective in operating rooms and other environments, where operating room nurses can arrange instruments, it is unsuitable in a general dental practice, where a surgeon inserts in and removes instruments as instruments tend to overlap. In addition, training data for image recognition systems are annotated with rectangles to detect targets; however, since instruments overlap in dental treatment, there is a high possibility that another instrument may exist within a rectangle when annotating instruments with rectangles, making efficient training difficult.According to a study on medical instrument detection during a procedure, color codes and RFIDs have already been used to detect the presence of instrumentsTherefore, in this study, to realize real-time monitoring of instrument selection during dental treatment, we constructed a system that detects instruments placed on a tray during dental treatment using a CNN and compared the detecting accuracy of the instruments for different annotation methods.6 and YOLOv77 were used as the object detection method.In this study, to clarify the difference in the detection accuracy (DA) of instruments due to different annotation methods, we annotated images taken in a laboratory and clinic through two different approaches to create two training datasets for image recognition. The two datasets were created by annotating only parts characterizing the target instruments and by annotating the entire target instruments, respectively. The image recognition system was trained using each dataset, the weights obtained were used to detect instruments in a clinic, and the results were compared and evaluated. The DL-based object detection software YOLOv4In DL-based object detection, the labels and coordinates of the bounding boxes (BBs) of a target object in an image are estimated and used to train the detector. Therefore, to obtain images used for training and estimating the detector, a device was developed to capture images of a paper tray (size: 16 cm × 25 cm) on which instruments are placed during an actual dental procedure.The device was equipped with a Raspberry Pi 3 Model B  and a Raspberry Pi 3 Model B  to capture images of the tray and its surroundings in H.264 format, 1920 pixels wide by 1080 pixels high, 25-fps frame rate, and 16.67 million color resolutions. This device can be fixed to a dental treatment table with a digital camera stand . In this study, images of 23 types of instruments/objects commonly used in the Department of Restorative Dentistry and Endodontology, Osaka University Dental Hospital, and a surgeon’s hands were used for image recognition  annotates an instrument-specific part Fig. . The “inSimilarly, to create the evaluation dataset, 200 images without duplication were selected by eye examination from images taken during 98 examinations of consenting patients between September 26, 2018, and January 22, 2020, and these images were annotated , , , , , , , , } for AA, {, , , , , , , , } for AB.For the parameters of the YOLOv4 neural network, the input size was changed to (832 × 832). For AA, the number of outputs was changed to 24, and for AB, the number of outputs was changed to 22. YOLOv4 performs object detection using a predetermined size anchor box. The appropriate size of the anchor box for training and inference differs between annotating a specific part of an instrument and annotating the entire instrument because the size of the target object differs between the two cases. Therefore, we used the k-means method to calculate the appropriate anchor box size based on the size of the BB in each imageFor the parameters of the YOLOv7 neural nerwork, we used YOLOv7-E6 model and the input size was changed to (1280 × 1280), and other parameters were left at default.23.To evaluate the accuracy of the detection of the number of instruments present in a clinic using the trained image recognition system, the number of each instrument detected via image recognition was set as true if it was correct and false if otherwise, and the percentage of true recognition for each instrument was calculated as the DA. In addition, as a performance evaluation metric of the image recognition system, average precision (AP) at the intersection over union (IoU) = 50% was obtained for each instrument using the same method as the PASCAL VOC ChallengeFor “condenser,” “condenser_disk,” and “condenser_round” in AA, the results were averaged and summarized as “condenser.”A desktop PC with Intel Xeon Gold 6226R CPU, 96 GB RAM, NVIDIA Quadro RTX6000 GPU, and Ubuntu 18.04 OS was used for training and evaluating YOLOv4 and YOLOv7.This study was conducted following the Ethics Review Committee approval (H29-E23) of the Osaka University Graduate School of Dentistry and Dental Hospital, and was conducted in accordance with the “Ethical Guidelines for Medical and Biological Research Involving Human Subjects”. Although the data obtained in this study do not contain identifying information, the conditions of the instruments during the examination were photographed only after explaining the study to the patients and obtaining their informed consent in advance.Table Table Table Table 21. The CNN used in this study extracts feature maps using a kernel for local regions to be explored from images and evaluates the similarity of feature vectors24. Therefore, it is more suitable for detecting deformable objects such as “clamp_forceps” and “syringes” than shape recognition because CNN-based image recognition is robust to deformation and size changes. Although the evaluation method used in this study is different from that used in previous studies and thus cannot be uniformly evaluated, the number of instruments present was detected with a certain degree of accuracy, even when the instrumentation nurse did not align those instruments and when they overlapped. This indicates that the proposed CNN-based instrument detection method is effective in detecting dental treatment instruments placed on top of each other on a narrow tray during dental treatment.The accuracy of detecting instruments during otolaryngology surgery via shape recognition based on contour extraction is 84.9%In addition, to improve the DA of dental instruments by image recognition using a dataset containing a few images, it was shown that DA and AP were improved by explicitly annotating images of the target part of an instrument, instead of annotating images of the entire instrument for both YOLOv4 and YOLOv7. This annotation method is considered reasonable and efficient because dentists also discriminate instruments by identifying the tips where the instruments perform their function. However, since it is possible to narrow down the candidates of instrument types from the grasping part that is common to multiple instruments, it cannot be assured that excluding the common parts of each instrument from the annotation will necessarily improve DA when learning instrument types from a significant number of images.Although AP is used as a general image recognition performance indicator, it has the problem that it cannot evaluate omissions of detection  because its evaluation is based on the reliability and correctness of the results obtained via image recognition. Since the focus of this study was to correctly detect the number of instruments present during dental treatment, we defined a DA index to evaluate the correctness of the number of instruments detected.This evaluation index tends to be suitable for instruments with a reasonably high frequency of occurrence: . However, there is a problem that the number of true negatives for infrequently occurring instruments is high, resulting in high apparent values, even if there are many false negatives. For example, instruments that appeared less than 20 times in the evaluation dataset  all had above-average DA of more than 90%. However, the AP of all other instruments except “clamp” in YOLOv4, “clamp” and “clamp_forceps” in YOLOv7 were below average for each annotation method. Conversely, for instruments placed in large quantities at a time, even one false positive or negative results in false detection, reducing the DA. For example, instruments with a frequency of 600 or more occurrences (“reamer” and “cotton”) in the evaluation dataset both had AP above 90%, but their DA was below average.25. Among the instruments in the basic dental set, the recognition accuracy of “explorers,” “tweezers,” and “probes” was lower. This may be because the parts characterizing the instruments were sharper and smaller, and the parts discriminating the instruments were relatively smaller when the entire body of the instrument was annotated.Instruments included in the basic set of dental practice in the Department of Restorative Dentistry and Endodontology are “dental_mirror,” “explorer,” “tweezer,” and “probe.” The DA for most of these instruments was below the average of the results for each annotation method. However, for AP, “dental_mirror” showed a high value of 95.4% in YOLOv4 and 97.7% in YOLOv7 when annotating instrument-specific parts. This result may be due to the larger mirror surface area of “dental_mirror” and its relative area in the BB. The one-stage detector has a tradeoff with its high detection speed, which reduces the recognition accuracy of small objectsOn the other hand, a common trend among all types of instruments with high AP was that they had a monotonous shape and a large size in the BB. “Hand,” “dish,” “reamer,” “reamer_guard,” and “cotton” are typical examples, as there are no sharp edges as the shape of the instruments and the area of the instruments occupying the BB is large. However, when the entire part of an instrument is annotated, the shape of the BB becomes more complex, including the gripping part, and AP is considered to have decreased.A common tendency of instruments with low AP was the small number of annotations required and shape complexity. For example, “excavator_spoon,” “composite_instrument,” “clamp_forceps” and “excavator” all had less than 300 annotations in the training data, and their shapes were also complex. Since augmenting the training dataset generally improves the training effect on image recognition systems, it is important to increase the number of training images for instruments with complex shapes.For instruments where their entire parts were targeted for detection using both annotation methods (instruments with * appended to the instrument name), there were differences in results for both DA and AP. This may be due not only to differences in the initial anchor box size in YOLOv4 but also to differences in the number of output layers and the annotations of other instruments used as negative examples during training.Instruments for which annotating their entire parts improved DA were “excavator_spoon,” “tweezers” and “spreader” in YOLOv4, and “composite_instrument” and “excavator_spoon” in YOLOv7. Howeger, the change was smaller than that of “dish*” in YOLOv4, and “reamer_guard*” in YOLOv7 which was not changed annotation method. Therefore, changing the method from annotating the entire part of instrument to annotating instrument-specific part improved DA. Conversely, annotating an entire instrument  resulted in a larger than average decrease in DA, probably because annotating the entire body of an instrument made it difficult to detect parts that identify the instrument, as described above.The AP of “clamp_forceps” and “tweezers” was more improved than that of “dish*” in YOLOv4. For these instruments, annotating their entire parts, rather than characteristic parts, may improve DA and allow for more efficient learning. On the other hand, for “probe,” “dental_mirror,” and “explorer,” DA decreased by more than 10%. This is a larger change than 4.5% for “finger_ruler*” in YOLOv4, 13.0% for “dish*” in YOLOv7 which did not change its annotation method. AP of all instruments was improved, except for instruments for which the annotation method was not changed, namely, “clamp_forceps,” “tweezers” and “syringe” in YOLOv4, and “clamp” in YOLOv7. Therefore, annotating an entire instrument decreases DA, which may reduce the learning efficiency.1. However, a problem exists in that patients are exposed to radiation, which is essentially unnecessary. By introducing our image recognition-based method for identifying the number of instruments present in the surgical field, the risk of leaving instruments behind in a patient’s body can be mitigated and minimally invasive medical care can be provided to patients during surgery.In the medical field, instruments and gauze are frequently left behind in patients’ bodies during laparotomies. When an instrument or gauze is left behind, not only reoperation is required, but in the worst-case scenario, the patient may die. To avoid such risks, it is considered reasonable that all patients should be radiographed after surgeryIn addition, by analyzing the history of instrument use and procedures automatically generated from object detection results, operational efficiency can be improved, for instance, by suggesting combinations of instruments when preparing instruments necessary for a procedure, or by suggesting when to replace instruments based on their frequency of use, thereby preventing accidents involving instrument damage. This will reduce the workload of medical personnel, which in turn will improve medical safety.In this study, we developed a real-time dental instrument detection system using CNNs. When creating the dataset used to train the CNN, it was found that by annotating only those parts of the dataset that characterize medical instruments rather than annotating the entire body of the instruments, the mean DA, the percentage of the number of instruments correctly detected, was improved by 4.0–5.3%, and the mean AP was improved by 11.0–17.3%.