Female sexual dysfunction is commonly neglected, under-investigated, and under-treated in Ethiopia. Therefore, this study aimed to determine the prevalence and its associated factors of female sexual dysfunction among reproductive-aged women at Gurage zone hospitals, in southern Ethiopia.p-value of < 0.05.An institutional-based cross-sectional study was conducted among 424 reproductive-age group women. A systematic random sampling method was employed and structured questionnaires were used to collect the data through a face-to-face interview. Data were entered into EpiData version 4.6 and analyzed by SPSS version 25.0. Descriptive statistics, and bivariable, and multivariable logistic regression were conducted. Statistical significance was declared at a Four hundred two participants completed the interview with a response rate of 94.8%. Arousal dysfunction 91.0% and pain during sexual intercourse 39.3% were the most and the least prevalent domains of female sexual dysfunction respectively. Overall 32.1% of the respondents had female sexual dysfunction. Body mass index , history of pelvic surgery , marriage satisfaction , a satisfaction of spouses’ sex ability , breastfeeding , and mode of delivery , were statistically associated with female sexual dysfunction. All-encompassing professional counseling addressing psychological and interpersonal acts and weight management interventions are needed for couples to maintain sexual functioning. Four hundred two participants completed the interview making the response rate 94.8%. About 247 (61.4%) respondents were under the age of 30 with a mean age of 28.14 ± 6.33 years. Arousal dysfunction was the most prevalent 366 (91.0%) domain of female sexual dysfunction while pain during sexual intercourse 158 (39.3%) was the least reported domain of female sexual dysfunction. Overall, in this study about 129 (32.1%) of the respondents had female sexual dysfunction. Body mass index, history of pelvic surgery, marriage satisfaction, satisfaction of spouses’ sex ability, breastfeeding7, and mode of delivery were statistically associated factors with female sexual dysfunction in multivariable analysis. All-encompassing professional counseling that addresses psychological and interpersonal acts and the importance of weight management interventions is needed for couples to maintain sexual functioning. Sexual life is a natural and complex element of human behavior, which is determined by numerous physiological, psychological, and social factors –3. WorldThe prevalence of FSD varies by community, with the global prevalence ranging from 35.4 to 62.1% , 15. A sAlthough sexual dysfunction is more common, only a small number of women seek counseling or therapy for it , 19, 20.Sexual dysfunction is typically multifaceted with socioeconomic, biological, medical, and psychological factors all playing a role , 22, 23.Age, religion, and working hours of more than 8 per day were found to be significant related factors for FSD , 24–27. Female sexual dysfunction has a detrimental impact on public health because it impairs the quality of life and physical well-being of women , 30, 31.Women’s sexual dysfunction is frequently neglected, under-identified, and undertreated by healthcare professionals, despite its high prevalence and considerable impact on life , 26, 33.This study was conducted at governmental public hospitals in the Gurage zone, southern Ethiopia. Gurage Zone is one of the administrative zones of SNNPR in Ethiopia. It is divided into 16 districts and 5 town administrations where Wolkite town is the zone’s capital. Gurage Zone has a total population of 1,635,311 people, with 842,065 women and 793,246 men, according to the Ethiopian Central Statistical Agency’s 2017 population forecast . The zonAn institution-based cross-sectional study was conducted at hospitals in the Gurage zone, southern Ethiopia. All reproductive-age women who visited hospitals in the Gurage zone during data collection time were the source population in this study.All married reproductive-aged women who visited Gurge zone hospitals during data collection were included in this study.Women currently not living with the spouse, pregnant women, and women within 6 weeks of postpartum were excluded. Women who had undergone major pelvic surgery within the last 4 weeks or planned to undergo major pelvic surgery and women with a known mental disorder were also excluded from this study.The sample size was determined by using a single population proportion formula with the assumption of a 95% confidence interval, 5% precision, and taking the prevalence of sexual dysfunction 50% due to the lack of previous local studies among this group of population Where,➢ ➝ n= sample size➢ ➝ Z = critical value for normal distribution at 95% confidence level which equals 1.96 .➢ ➝ P = .❖ ➝ To compensate for non-response 10% was added making a total sample size of 424 reproductive-age women.The sample size for the second objective was determined by Epi info software version 7.2 using significant factors from the study conducted in Cameroon and Saudi by considering the following assumptions: 95% confidence interval, 80% power, 1 ratio of unexposed to exposed  was used to assess sexual function, and it is a valid questionnaire with a high level of reliability ranging from 0.76 to 0.93 , 37–40. Questions 1, 2, 15, and 16 were assessed with a Likert scale from 1 to 5, while the others were scored on a six-point Likert scale ranging from 0 to 5. Then, each of the six domains of sexual function was calculated by summing each domain’s score and multiplying the result by the domain factors , which ranges from 1.010 to 1.199. Model fitness was checked using the Hosmer-Lemeshow test. Association was described using an adjusted odds ratio along with 95% CI and A total of 402 participants completed the interview with a response rate of 94.8%. The majority, 247 (61.4%) of the respondents were below age 30 with a mean age of 28.14 ± 6.33 years. About 232 (57.7%) and 146 (36.3%) of the participants were Islamic and Orthodox Tewahido Christianity religion followers respectively. Regarding their ethnic group, 293 (72.9%) of the respondents belonged to the Gurage ethnic group followed by Mareqo 40 (10%) ethnic groups. About 243 (60.4%) participants were urban residents, 145 (36.1%) completed their primary education, 205 (51%) participants had shared one bed with their babies, and about 291 (72.4%) were housewives. The mean age difference between couples was 7.8 ± 3.9 years. The length of marriage for the majority was below 5 years with the mean length of marriage 8.98 ± 7.49 years. The daily workload for 152 (37.8%) of the respondents was more than 8 h while only 23 (5.7%) had practiced regular physical exercise. The average monthly family income was 4864.9 ± 2510.3 Ethiopian birrs and the majority’s 261 (64.9%) monthly family income was below 5250 Ethiopian birrs (Table The majority of 310 (77.1%) of the respondents had a history of female genital mutilation. The mean age of the respondents at Coitarche was 19.3 ± 3.1 years and 11(2.7%) of the respondents had a history of sexual assault. About 30 (7.5%) and 41 (10.2%) of the respondents had a history of genital tract infection and pelvic surgery within the previous 24 months respectively. One hundred thirty-two (32.8%) had utilized modern family planning methods within the last 12 months. The great majority 348 (86.6%) of the respondents had given birth before and 48 (11.9%) of the respondents had more than five children. Of those who delivered 199 (57.2%) delivered their last baby vaginally without tear/episiotomy and 247 (71%) were feed breast for their baby during data collection time. Twenty-eight (7.0%) of the participants had a history of chronic medical diseases within the previous 12 months and of these hypertension accounts for 15 (53.6%) followed by DM 11 (39.3%) and TB 2 (7.1%). Regarding participants’ body mass index about 73 (18.2%) and 77 (19.2%) of the respondents were underweighted and overweighed respectively (Table About 62 (15.4%) of the respondents were dissatisfied with their marriage. Of those who delivered 305 (87.6%) participants resumed their sexual practice within 5–8 weeks. About 30 (7.5%) of the respondents were reported that their partners had diagnosed with sexual dysfunction and 55 (13.7%) were dissatisfied with their spouses’ sexual ability  domain of FSD while pain during sexual intercourse 158 (39.3%) was the least reported type of FSD. Overall, in this study about 129 (32.1%) of the respondents had FSD . Body mass index, length of the marriage, history of pelvic surgery, marriage satisfaction, the satisfaction of spouses’ sex ability, breastfeeding, and mode of delivery were continued statistically associated with FSD (P < 0.05) in multivariable analysis.On bivariable logistic regression analysis body mass index, length of the marriage, couple’s age difference, history of genital tract infection, history of pelvic surgery, the feature of the menstrual cycle, daily workload, marriage satisfaction, a satisfaction of spouses’ sex ability, breastfeeding, housing situation, and mode of delivery were significantly associated with FSD  higher among those overweighed respondents as compared to those who had normal body mass index. This is due to that increased BMI can result in lower body image, which can affect sexual functioning in significant ways. However, some studies argued this finding by concluding that there is no difference in mean FSFI scores between subjects with normal BMI and overweight ones .Participants who had a history of pelvic surgery were 3.5 times  more likely to develop FSD as compared to their counterparts. This can due to surgery through the vagina can leave scar tissue that could modify the sexual function of patients. On the other hand, dissection near the hypogastric plexus in the abdominal approach can also have an impact on sexual function .Participants who had chronic medical diseases were 10.6 times  more likely to develop FSD as compared to their counterparts. Chronic medical diseases can affect sexual life directly by disrupting normal functioning including body hormones and indirectly by bringing a reduction of self-image, depression, and body impairment. Those participants who were dissatisfied with their marriage were 3.9 times  more likely to develop FSD as compared to those who were satisfied with their marriage. Those participants who were dissatisfied with their spouses’ sexual ability were 3.1 times  more likely to develop FSD as compared to those who were satisfied with their spouses’ sexual ability. Those participants who fed breasts to their children were 3.3 times  more likely to develop FSD as compared to those who did not breastfeed. Those participants who delivered their last child with tears/episiotomy and instrument were 3.7  and 7.0  times more likely to develop FSD as compared to those who delivered vaginally without tears/episiotomy respectively  was the most prevalent domain of FSD. A cross-sectional study conducted in Nigerian and Iranian supports this finding , 23, 44.This study showed that the odds of FSD were 3.6 times  higher among those overweighed respondents as compared to those who had normal body mass index. Similarly, several studies reported the existence of an association between obesity and sexual inactivity. A case-control study conducted in Iran observed particularly that there was a strong and inverse correlation between BMI and arousal, lubrication, and orgasm –48. IncoFour hundred-two participants completed the interview with a response rate of 94.8%. The majority, 247 (61.4%) of the respondents were below age 30 with a mean age of 28.14 ± 6.33 years. Arousal dysfunction was the most prevalent 366 (91.0%) domain of FSD while pain during sexual intercourse 158 (39.3%) was the least reported type of FSD. Overall, about 129 (32.1%) of the respondents had FSD. Body mass index, history of pelvic surgery, marriage satisfaction, satisfaction of spouses’ sex ability, breastfeeding, and mode of delivery were factors statistically associated with FSD in multivariable analysis.Therefore, all-encompassing professional counseling is needed for couples about postpartum sexuality and the importance of weight management interventions as a strategy for maintaining sexual functioning. Additionally, professional support and education about psychological and interpersonal acts are needed for those who face a problem with their marriage and spouses’ sexual ability. These can be attained by creating a smooth and private environment for such in clinical practice. It is also recommended that responsible professionals and government bodies develop uniform guidelines to decrease technical/practical errors that might lead to sexual dysfunction after pelvic surgery.Being one of a few studies that address neglected and under-investigated topics in Ethiopia is the strength of this study.Although their confidentiality was reassured since sexuality is a sensitive issue, respondents may feel that their privacy was violated. As a result, the tendency to hold back or give false information could be a limitation of this study.


The study of prevalence, risk factors, and vaccine effectiveness (VE) in children, adolescents, and young adults during the Omicron era has been limited, making this the objectives of the study.A prospective, test-negative case-control study was conducted on patients aged 0–24 years old classified as patients under investigation (PUI) from January to May 2022. PUI with positive RT-PCR within 14 days were classified as cases, whilst PUI with negative RT-PCR in 14 days were controls. Univariate and multivariate analyses determined risk factors; VE was calculated using [1-adjusted odds ratio (OR)] × 100.The final analyses included 3,490 patients with a PUI infection rate of 45.6%. Heterologous vaccination regimens, including inactivated vaccines, viral vectors, and mRNA were utilized during the study period. A total of 2,563 patients (73.5%) had received at least 2 vaccine doses, regardless of regimen. Male gender and household infections were independent risk factors for the development of infection, with an adjusted OR of 1.55 and 1.45, respectively. Underlying comorbidities and obesity were not significantly associated with the development of infection. Patients with underlying comorbidities were more likely to have at least moderate severity of infection with the adjusted OR of 3.07. Age older than 11 years was associated with lower infection risk and development of at least moderate infection with adjusted OR of 0.4 and 0.34, respectively. Vaccinated participants also had a lower risk of developing at least moderate infection: adjusted OR of 0.40. The adjusted VE of any vaccination regimen for infection prevention for one, two, three, or more than four doses was 21.8%, 30.6%, 53.5%, and 81.2%, respectively. The adjusted VE of any vaccination regimen for prevention of at least moderate severity of the disease for one, two, three, or more than four doses was 5.7%, 24.3% 62.9%, and 90.6%, respectively.Disease prevalence among PUI was substantially high during the Omicron wave. A two-dose vaccination regimen does not appear sufficient to ensure protection against infection. From the end of 2019, Coronavirus disease (COVID-19), as caused by SARS-CoV2, has become a global scourge, leading to a severe economic and health burden. According to the World Health Organization (WHO), to date, more than 578 million people have been infected, and approximately 6.4 million people have lost their lives  as any variant with evidence of increased transmissibility, higher severity, reduction of neutralizing antibodies after vaccination, and lesser treatment modality effectiveness . In ThaiDuring these previous studies, the COVID-19 vaccination rollout in Thailand was rather limited; however, vaccinations were eventually approved for adolescents (12–18 years old) in September 2021 and for children (5–11 years old) in December 2021. Thailand has approved both inactivated COVID-19 vaccines (CoronaVac and BBIBP Sinopharm) as well as mRNA ones  for those 5–18 years of age. For young adults (18–24 years old), ChAdOx1 nCoV-19  was also authorized. First and subsequent boosters  have been endorsed for adults over 18 years of age who never received an mRNA vaccine. One booster (third dose) was approved for children 5–18 years old.Nevertheless, concerns were raised when a new variant, Omicron, came into play. According to the US CDC, Omicron possesses numerous mutations rendering increased transmissibility and the ability to escape infection or vaccine-induced immunity . OmicronThe primary objective of this study was to describe the prevalence of COVID-19 infection in people at risk, in a tertiary care center in Thailand during the Omicron era. The secondary objectives were to identify the risk factors for the development of infection and the risk factors for the development of at least moderate severity of the disease. The VE for preventing infection and preventing at least moderate severity of the disease were also to be identified.A prospective, test-negative case-control study was conducted on all patients aged 0–24 years old who were classified as a patient under investigation (PUI) at Thammasat University Hospital (TUH), Thailand from January to May of 2022 (Omicron era) to determine the prevalence and risk factors of COVID-19 infection in this group. TUH is a large, tertiary care, university hospital with a total of 700 beds, 100 pediatric beds, and a 6-bed mixed medical and surgical pediatric intensive care unit. In accordance with Thai government policy during the study, all COVID-19-positive patients were admitted into the national healthcare system. TUH also offered a home isolation healthcare system for patients with milder diseases. Children with perinatal COVID-19 infection, patients with positive antigen test kits (ATK) for COVID-19 without reverse-transcriptase polymerase chain reaction (RT-PCR) tests, or people with positive RT-PCR from other hospitals were excluded. The study was approved by the Ethics Committee of the Faculty of Medicine, Thammasat University: MTU-EC-PE-2-020/65. Informed consent was obtained from all participants verbally at the time of admission to prevent the transmission of the disease.2  criteria. These criteria include fever, respiratory symptoms, gastrointestinal symptoms, unknown cause of pneumonia or respiratory failure, or history of contact with a confirmed case of COVID-19 infection. All PUI underwent an initial nasopharyngeal swab for RT-PCR for COVID-19 within 5 days of developing symptoms or initial contact and were followed up to monitor disease development for 14 days. Subsequent RT-PCR tests were obtained in patients with initially negative RT-PCR tests but developed new symptoms within 14 days. PUI with positive RT-PCR within 14 days were classified as cases and admitted to the healthcare system of TUH, whilst PUI with initially negative RT-PCR tests and subsequent negative RT-PCR within 14 days were classified as controls. Obesity was based on WHO criteria: For children <5 years of age, obesity was defined as weight-for-height >3 standard deviations (SD) above the WHO Child Growth Standard median. Children and adolescents aged between 5 and 18 years were defined as obese if BMI-for-age was >2 SD above the WHO Growth Reference median. Adolescents aged over 19 years were defined as obese if BMI is ≥30 kilogram/meter2 –13.Demographic data, vaccination status, and clinical information were collected using manual chart review and telephone interviews. Telephone interviews were done to obtain demographic data, vaccination status, and baseline clinical information on day 1 in both cases and controls. Another telephone interview was conducted on day 14 in controls to confirm the absence of clinical symptoms and subsequent negative RT-PCR. In the case group, disease severity categorization was based on the National Institutes of Health (NIH)  for at least 21, 14, and 7 days, respectively at the time of the study. These durations were derived from a previous study of two-dose vaccine regimens and a study of the third dose/booster regimen , 16.Data were analyzed using STATA for Windows v14.0 . Prevalence of infection was reported as frequency and percentage. Continuous data were reported as mean and standard deviation or median with interquartile range (IQR); other categorical data were reported as frequency with percentages. Comparison of continuous data was analyzed using the Student t-test. Categorical data analysis was conducted with Chi-square. Risk factors for COVID-19 infection development were analyzed using univariate and multivariate logistic regression. Due to a lack of vaccination coverage in children younger than 5 years of age during the study period, children under 5 years old were excluded from the final multivariate logistic regression model in the determination of risk factors for developing an infection and developing at least moderate severity of infection in order to identify the true relationship between age and vaccination. The logistic regression was then used to identify the odds ratios and 95% confidence interval (CI) of COVID-19 infection among all unvaccinated and vaccinated individuals. VE (%) was calculated using (1—adjusted odds ratio) × 100 .A total of 3,600 participants met the initial inclusion criteria, with 110 patients excluded due to having only positive ATKs without RT-PCR results. No perinatal infection was found. The follow-up rate was 100% at 14 days for control cases. Thus, the final population for analysis was 3,490 patients.p < 0.001). Proportions among different age groups were significantly different between cases and controls (p < 0.001), especially in children under 5 years old (20.6% VS 6.6%). There were significantly more male patients in the infected group when compared to the non-infected group . Mean BMI was 21.1 ± 6.6 kilogram/meter2 with 479 patients (13.7%) defined as obese; the proportion of obese patients did not differ significantly among groups. Underlying comorbidities were present in 123 patients (3.5%), the most common being chronic lung or airway diseases ; proportions did not significantly differ among groups. Household infections were documented in 973 patients (28.6%), having a significantly higher amount of household contacts in the case group vs. the control .Demographic data for all PUI is given in p < 0.001). The vaccination regimen data are outlined in The majority of patients were classified as having mild disease , whilst only 21 patients (1.3%) had severe and critical infections. A total of 2,563 patients (73.5%) received at least two doses of COVID-19 vaccination. The percentages of patients receiving vaccination were significantly different among groups: the non-infected group had a higher percentage of patients receiving at least two doses  of 1.66 (95% CI: 1.45–1.90), and 1.95 (95% CI: 1.63–2.33), respectively. Older children (> 11 years old) were less likely to have an infection when compared with their younger counterparts with crude odds of 0.22 (95% CI: 0.19–0.27). After adjusting for statistically significant risk factors, male gender and household infections remained independent risk factors for infection with adjusted ORs of 1.55 (95% CI: 1.33–1.80) and 1.45 (95% CI: 1.18–1.78), respectively. Children over 11 years of age still served as a protective factor for developing infection with the adjusted OR of 0.40 (95% CI: 0.29–0.57).There were fewer vaccinated individuals in the infected group compared to the non-infected group (64.1% VS 87.8%) with a crude OR of 0.26 (95% CI: 0.22–0.31). After adjusting for statistically significant risk factors, vaccinated children showed a non-statistically significant trend in preventing the development of infection with the adjusted OR of 0.71 (95% CI: 0.50–1.00). The univariate and multivariate analyses are outlined in A total of 116 patients were found to have at least moderate COVID-19 infection in this cohort. Univariate analyses demonstrated that male gender, underlying comorbidities, and household infections were statistically significant risk factors for the development of at least moderate severity. Vaccinated patients and children older than 11 years old were less likely to develop a moderate or worse infection with a crude OR of 0.10 (95% CI: 0.07–0.15) and 0.34 (95% CI: 0.24–0.51), respectively. After adjustment, only underlying comorbidities remained as an independent risk factor, with an adjusted OR of 3.07 (95% CI: 1.53–6.18). The adjusted OR for those receiving vaccination and those older than 11 years of age were 0.41 (95% CI: 0.18–0.95) and 0.34 (95% CI: 0.14–0.77), respectively .In p < 0.001).Young adult patients (19–24 years old) were more likely to be asymptomatic or have a mild infection vs. children under 5 years of age , 30.6% (95% CI: −7.8–55.2), 53.5% (95% CI: 26.7–70.5), and 81.2% (95% CI: 68.1–88.9), respectively . The adjThe infection development prevalence rate in patients at risk for COVID-19 in this cohort was substantially high: 46.5%. Prevalence during this Omicron wave was significantly higher as compared to the low positivity rate of 6.1% in a previous study by Maciel et al. (2020), the latter being during a time of predominantly wild-type COVID-19 . OmicronHousehold infection was the most significant independent risk factor for the development of infection. This was similar to a previous paper studying adults by Bruminhent et al. which revealed that close contact with an index case poses a higher risk of getting infected: adjusted OR of 3.49 (95% CI: 1.49–8.15) . UnderlyThe adjusted VE after receiving one and two doses of vaccination were as low as −21.8% (95% CI: −49.6–25.2) and 30.6% (95% CI: −7.8–55.2), respectively. The adjusted VE for preventing moderate infections were 5.7% (95% CI: −66.8–70.5) and 24.3% (95% CI: −56.9–75.3) for those receiving one and two doses, respectively. VE has been variable in different studies. A large study by Tan et al. revealed that the VE of BNT162b2 for preventing RT-PCR-confirmed infections in partially vaccinated (one dose) and fully vaccinated (two doses) children aged 5–11 years old were at 24.3% (95% CI: 19.5–28.9) and 65.3% (95% CI: 62.0–68.3). The VE for preventing hospitalization was 42.3% (95% CI: 24.9–55.7) after one dose and 82.7% (95% CI: 74.8–88.2) after two doses . AnotherOur apparent differences in VE vs. other studies may have four explanations. First, in our study, VE was calculated as cumulative among all age groups. Due to the low vaccination coverage in children 5–11 years of age, as well as variable coverage in other age groups, sample sizes were not adequately powered to perform an overall post-hoc analysis. Second, other studies were mostly conducted using mRNA vaccines rather than inactivated vaccines. Thailand, like Brazil and Chile, used inactivated vaccines in all age groups along with several heterologous vaccination regimens. A Brazilian study demonstrated that the VE of CoronaVac during the Omicron era in children 6–11 years old for preventing symptomatic infection and hospitalization was 39.8% (95% CI: 33.7–45.4) and 59.2% (95% CI: 11.3–84.5) at more than 14 days after the second doses . A largeSeveral major strengths of this study should be outlined. This study was the first in Thailand aiming to elucidate the prevalence, risk factors, and VE in children, adolescents, and young adults for the development of COVID-19 infection during the Omicron era. Our large and robust clinical dataset, with a 100% follow-up rate in the control group, and the ability to independently reaffirm the vaccination schedule of each participant from the MoPH database allowed us to realize the possibility of determining risk factors and VE in these participants. In addition, the approval of the booster vaccine doses helped confirm a dose-related relationship with increased VE.Aside from the previously mentioned concern regarding the limited population to perform a post-hoc VE analysis in each subgroup, some other limitations should also be noted. As the control group was a convenience sample of PCR-negative PUI in a prospective study of a single center during the study period, the age and disease severity matching was not feasible at the time of enrollment. Furthermore, due to the low number of severe patients, VE determination in preventing severe infection was difficult. Furthermore, since all COVID-19-positive patients in Thailand were admitted into the national healthcare system, VE for hospitalization prevention may not be an appropriate marker. Thus, patients with at least moderate severity of infection were used as a surrogate for severe disease and hospitalization. Nevertheless, caution should be used in interpreting our VE results, so that we can continue to prevent more severe clinical courses. Another large, multicenter study is warranted for determining VE among different vaccination regimens and age groups.COVID-19 infection prevalence during the Omicron era was substantially high, with male gender and household infection as independent risk factors. Vaccinated individuals were less likely to develop infections when compared to those unvaccinated. Two-dose vaccination regimens do not appear to ensure sufficient protection against infection.


To explore the boost effect on ameliorating functional constipation in elderly patients through empowerment-based, healthy dietary behavioral intervention.In this randomized parallel group study, elderly patients with functional constipation were recruited and assigned to the experimental and control groups at a ratio of 1:1. The control group received routine intervention. The experimental group received 3-month empowerment-based intervention. The results were evaluated based on the Healthy Lifestyle and Personal Control Questionnaire (HLPCQ) and Cleveland Clinic Constipation Score (CCS). GraphPad Prism (Version 9) software was used for the statistical analysis.As the world's population ages, functional constipation in the elderly has attracted widespread attention. The practical behavioral intervention to ameliorate constipation are worth exploring.Sixty elderly patients with functional constipation.P > 0.05). After the intervention, the scores of HLPCQ (77.90 ± 14.57 vs. 61.11 ± 13.64) and CCS (7.48 ± 3.73 vs. 9.70 ± 3.07) in the experimental group were significantly higher than those in the control group (P < 0.05).The study results showed no significant difference in the baseline data between the two groups (The results showed that empowerment-based intervention can effectively strengthen the healthy dietary behavior of elderly patients. Through patient empowerment, the subjective initiative and willingness to communicate were boosted in the experimental group. Their symptoms of functional constipation improved considerably better than in the control group. Constipation, as one of the geriatric syndromes, affects up to 11.7% of older citizens every year, and its prevalence is still rising . ComplicTherefore, a concept of empowerment is introduced here. In the medical field, empowerment means that people have the ability to control their own lives and improve their health by enhancing their ability to solve important problems . RespondThis randomized parallel group study was conducted at a tertiary hospital in Wuxi, China from 2020 to 2021. The study was single-blinded for the participants but not for the researchers, and a randomized list was generated by a statistician who used a computer to determine the group assignment of every participant. The main outcome indicator was healthy behavior, and the secondary outcome indicators were constipation symptoms. See Sixty participants with functional constipation were recruited from July to October 2020. A total of 30 participants were allocated to the experimental group, which received empowerment-based behavioral intervention for 3 months and 30 participants in the control group were given routine care.The inclusion criteria were as follows: (1) older adults (more than 65 years of age), (2) the Rome IV criteria for functional constipation including dyssynergic defecation and slow colonic transit, officially published by the American Gastroenterology Association in 2016 , (3) avaThe exclusion criteria were patients (1) with evolving cancer, serious cognitive problems, a psychiatric disease, or a serious medical or health condition that would hinder their ability for defecation, (2) having received abdominal and intestinal surgery, (3) with intestinal obstruction by electronic enteroscopy, (4) with rectal prolapse and internal hemorrhoids rated as grade 3–4 and (5) taking drugs affecting the intestinal motility.n1 = n2 = [(Z1 – Zα/2 + Z1−β)2*  and based on the following formula: (1) Internal factors: improve patients' internal beliefs and attitudesThe intervention was mainly based on empowerment theory and was conducted around three elements of empowerment. Patients in the experimental group diagnosed with functional constipation were managed by a constipation treatment panel, which consisted of 6 nurses, 4 doctors and 3 nutritionists who had qualification certificates and rich work experience. In addition, 4 graduate students provided assistance. The research contents to meet the three elements of empowerment were as follows:Patients are encouraged to express their feelings and dietary preferences. Through explanation and goal setting, patients can obtain a clear understanding of functional constipation and establish confidence in overcoming constipation.(2) Interaction elements: enhances the interaction between patients and the environment and promotes the acquisition of patients' knowledge, skills and resourcesMedical staffs and patients worked together to analyse the causes and mainly sorted out the following factors of functional constipation: (1) Medical staff: lack of cooperation of specialized nurses, doctors and nutritionists; (2) patient: the general diet regulation failed, the large adjustment cannot be adhered to and the healthy dietary behavior was poor; (3) methods: lack of individualized home assessment and professional guidance; (4) resources: lack of health education materials for constipation; lack of resources and skills to effectively ameliorate constipation.The corresponding intervention to promote patient empowerment were as follows: (1) medical staff: establishment of a constipation treatment panel; (2) patient: establishment of a plan based on empowerment theory, interaction with patients by high-fiber food models and cards during health education and testing of patients' knowledge and familiarity diet matching skills; (3) methods: the patients were required to record their 24 h fluid intake, dietary intake, defecation and exercise contents in the healthy dietary behavior log. In addition, health lectures were carried out and a WeChat official account pushed relevant knowledge on the phone; (4) resources: provided patients with paper and electronic education materials and prebiotic food.(3) Behavior elements: promote patients to adopt healthy dietary behaviorThe nutritionist designed the patient's recipe based on the recommended nutrient intake in the P < 0.001, and the KMO value was 0.797 by Kaiser-Meyer-Olkin measurement, suggesting a good reliability and validity in applying HLPCQ  was developed by Darviri in 2014, and it focuses on the evaluation of the healthy behavior of patients . The totng HLPCQ . In adding HLPCQ . The totying CCS . The tooThe distribution and collection of questionnaires were the responsibility of five designated researchers. In order to reduce the bias in the research process, the researchers were able to unify the guidance language and accurately master the knowledge related to functional constipation, scale content and data collection methods. General information about patients can also be obtained through medical care records and archives of the community. Besides, all subjects included in the study completed the 3-month trial, and all data collection was completed.t-test was performed. The enumeration data were statistically described by frequency and percentage and analyzed using the Chi-square test, and P < 0.05 was defined as statistically significant.The statistical analysis of the data obtained from the study was performed using GraphPad Prism(Version 9) software. The measurement data with normal distribution were expressed as mean (M) and standard deviation (SD) and a Student's P > 0.05) (The  > 0.05) .P > 0.05). The overall average in the experimental group (77.90 ± 14.57) was significantly greater than that in the control group (61.11 ± 13.64) after the intervention (P < 0.05). The scores in four out of five dimensions, including healthy dietary choices (21.48 ± 3.15 vs. 12.55 ± 2.71), dietary harm avoidance (12.68 ± 2.94 vs. 8.53 ± 1.50), daily routine (23.37 ± 4.72 vs. 14.11 ± 3.89) and social and mental balance (14.72 ± 2.27 vs. 11.01 ± 1.64), showed that the empowerment results of the experimental group were significantly better than those of the control group (P < 0.05). Among these, 14/26 questions received higher scores in the experimental group than in the control group (P < 0.05).P > 0.05). After intervention, the overall mean score of the experimental group decreased to 7.48 ± 3.73, which was less than that of the control group (9.70 ± 3.07) (P > 0.05). Significantly, 5/8 clinical problems, including defecation frequency (0.20 ± 0.41 vs. 1.61 ± 0.62), difficult defecation (1.10 ± 1.08 vs. 1.99 ± 1.08), incomplete evacuation (1.17 ± 1.03 vs. 1.99 ± 1.15), straining period of defecation (0.86 ± 0.74 vs. 2.33 ± 1.10) and defecation failure (0.58 ± 0.73 vs. 0.96 ± 0.58), in the experimental group received lower scores than those in the control group (P < 0.05).In this study, the majority of patients with functional constipation were women, which is consistent with the domestic and international epidemiological data . The reaThe overall average scores of healthy behavior of 60 patients with functional constipation were lower than Darviri's survey results on the healthy population , indicatOn the basis of the 24-h review, the patient adhered to our recommendations. After the intervention of empowerment-based behavioral intervention, improvements were observed in the patients' healthy dietary behaviors, such as being careful about the amount of food put on their plate, calculating meal calories, consuming organic foods and whole-wheat products and avoiding packaged or fast food. Individuals who do not eat whole grains, fresh fruits and vegetables every day have a high prevalence of constipation . In the The main purpose of patient empowerment is to encourage patients to adopt healthy dietary behavior and the final outcome is the improved symptoms of constipation. Compared with the control group, the constipation symptoms of patients in the experimental group, including defecation frequency, difficult defecation, incomplete evacuation, straining period of defecation and defecation failure, significantly improved. Rasmussen reported that the defecation frequency during daytime is the most prominently associated with health-related quality of life . TherefoThis study showed that empowerment-based intervention plays a considerable role in improving the healthy dietary behavior of elderly patients with functional constipation. The intervention yielded a significant positive performance in the experimental group, addressed the problems experienced by elderly patients due to functional constipation, resulted in a decreased constipation severity and improved the quality of life. Besides, strengthening the subjective initiative of elderly patients through patient empowerment can reduce patients' over-dependence on medical resources. Therefore, this study provides a non-pharmacological treatment reference for elderly patients suffering from functional constipation.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Ethics Committee of Wuxi Third People's Hospital  (No. IEC201803001). The patients/participants provided their written informed consent to participate in this study.XZ, FZ, DL, and JC designed the trial. YX and XZ conducted the study. YX, XZ, DL, and QW analyzed and interpreted the data. XW, FZ, DL, and HC were responsible for project administration and supervision. XW, XZ, FZ, and DL wrote the first draft of the manuscript and had primary responsibility for the manuscript's final content. All authors critically revised the manuscript. All authors contributed to the article and approved the submitted version.


Hypertension guidelines recommend that absolute cardiovascular disease (CVD) risk guide the management of hypertensive patients. This study aimed to assess the proportion of patients with diagnosed hypertension with sufficient data to calculate absolute CVD risk and determine whether CVD risk is associated with prescribing of antihypertensive therapies. This was a cross-sectional study using a large national database of electronic medical records of patients attending general practice in 2018 (MedicineInsight). Of 571,492 patients aged 45–74 years without a history of CVD, 251,733 [40.6% (95% CI: 39.8–41.2)] had a recorded hypertension diagnosis. The proportion of patients with sufficient recorded data available to calculate CVD risk was higher for patients diagnosed with hypertension [51.0% (95% CI: 48.0–53.9)] than for patients without a diagnosis of hypertension [38.7% (95% CI: 36.5–41.0)]. Of those patients with sufficient data to calculate CVD risk, 29.3% (95% CI: 28.1–30.6) were at high risk clinically, 6.0% (95% CI: 5.8–6.3) were at high risk based on their CVD risk score, 12.8% (95% CI: 12.5–13.2) at moderate risk and 51.8% (95% CI: 50.8–52.9) at low risk. The overall prevalence of antihypertensive therapy was 60.9% (95% CI: 59.3–62.5). Prescribing was slightly lower in patients at high risk based on their CVD risk score [57.4% (95% CI: 55.4–59.4)] compared with those at low [63.3% (95% CI: 61.9–64.8)] or moderate risk [61.8% (95% CI: 60.2–63.4)] or at high risk clinically [64.1% (95% CI: 61.9–66.3)]. Guideline adherence is suboptimal, and many patients miss out on treatments that may prevent future CVD events. Traditionally, hypertension guidelines have relied exclusively on blood pressure (BP) levels to guide treatment initiation and intensity . HoweverIn Australia, the Heart Foundation recommends calculating the absolute risk of a primary CVD event over the next 5 years by applying the Australian National Vascular Disease Prevention Alliance (NVDPA) risk assessment and risk management algorithm , which iExisting evidence suggests that between 41 and 96% of physicians use a CVD risk calculator to assess absolute CVD risk . These sStudies evaluating the CVD risk profile of patients with hypertension in primary care are limited –15. A stEvidence from real-world primary care settings where GPs are not prompted to collect data as part of a study is lacking. However, electronic health records (EHRs) provide an opportunity to evaluate real-world practice of CVD risk assessment in patients diagnosed with hypertension and subsequent prescribing patterns . TherefoThis study is a cross-sectional analysis of MedicineInsight, a large Australian general practice database of EHR. This study was reported according to REporting of studies Conducted using Observational Routinely-collected health Data Statement reporting guidelines .As at October 2018, MedicineInsight included data from patients attending over 2700 GPs and 660 general practices across all states and territories  –21. PatiThis study includes all patients aged between 45 and 74 years, or between 35 and 74 years for Aboriginal and Torres Strait Islander people, without CVD recorded in their EHR  who regularly attended one of these practices (i.e. at least three visits between 2016 and 2018) . The metFirst, we estimated whether patients had available recorded information on the different risk factors to enable CVD risk calculation, irrespective of whether they had hypertension or not. We used the most recent measures recorded . As guidelines recommend CVD risk be reviewed at least every 2 years , measure2 or persistent proteinuria ], (4) systolic BP above 180 mmHg, (5) diastolic BP above 110 mmHg, (6) familial hypercholesterolaemia or (7) total cholesterol level exceeding 7.5 mmol/l ,  systolicNext, for those patients with diagnosed hypertension who were not at high risk clinically and with sufficient variables available, we calculated the absolute risk of a primary CVD event over the next 5 years by applying the Australian NVDPA risk assessment and risk management algorithm , 8. The Therefore, except for those with insufficient data for CVD risk score calculation, patients were classified in one of four groups: (1) low CVD risk, (2) moderate CVD risk, (3) high CVD risk , or (4) clinically at high risk of CVD.According to current guidelines, patients at low or moderate CVD risk should be prescribed lifestyle therapy and, depending on BP levels (e.g. BP persistently ≥160/90 mmHg), an antihypertensive agent. In contrast, patients at high CVD risk should be treated with an antihypertensive agent irrespective of their BP levels . To assePatient sociodemographic characteristics included sex , 5-year age groups, remoteness  and socioeconomic status in quintiles, as measured by the Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD). Age in 2018 was calculated using the patient’s year of birth. IRSAD is a macroeconomic indicator of relative advantage and disadvantage developed by the Australian Bureau of Statistics that summarises information about households’ social and economic conditions within an area  and is based on residential postcodes .All analyses were performed in STATA 16.0 , using practices as clusters and conditioned on the number of consultations to minimise selection bias  .The sociodemographic and cardiovascular risk characteristics were presented by sex and age group and expressed as proportions (%), with their corresponding 95% confidence intervals (95% CIs). We present crude results unless otherwise stated.The proportions of patients prescribed antihypertensives according to CVD risk status  or those with insufficient data to calculate CVD risk was assessed using logistic regression adjusted for age, IRSAD and remoteness, and was presented separately for males and females.The Human Research Ethics Committee of the University of Adelaide exempted this study for ethical review, as it used existing and non-identifiable data. Access to the data for this study was approved by the MedicineInsight Data Governance Committee (project 2016-007).The sample included 571,492 regular patients without a history of CVD and aged 45–74 years , including 12,129 Aboriginal and Torres Strait Islander people aged 35–74 years. Of these, 251,733 [40.6% (95% CI: 39.8–41.2)] had a recorded diagnosis of hypertension . Figure The proportion of patients with sufficient recorded data available to calculate CVD risk was higher for patients diagnosed with hypertension [51.0% (95% CI: 48.0–53.9)] than for patients without a diagnosis of hypertension [38.7% (95% CI: 36.5–41.0)]. This finding was consistent for males and females across all age groups Fig. .Fig. 2Dan = 128,836) or insufficient  data to calculate their CVD risk  or had diabetes  than females. The mean systolic and diastolic BP for males and females were similar . The mean total cholesterol for males and females was 4.9 (SD 1.1) mmol/l and 5.3 (SD 1.1) mmol/l, respectively and the mean HDL cholesterol was 1.3 (SD 0.4) mmol/l for males and 1.6 (SD 0.4) mmol/l for females.Supplementary Table n = 128,836), another 17,819 patients with hypertension were identified as clinically at high risk of CVD [n = 146,655), 29.3% (95% CI: 28.1–30.6) were at high risk clinically, 6.0% (95% CI: 5.8–6.3) were at high risk based on their CVD risk score, 12.8% (95% CI: 12.5–13.2) at moderate risk and 51.8% (95% CI: 50.8–52.9) at low risk. Figure p < 0.001) or moderate risk . This difference was larger in older age groups  and 60.5% (95% CI: 58.9–62.1), respectively. Figure When the prescribing investigation periods were extended to 12 and 24 months  , 31, but2–96% , 3In Australia, patients aged 45–49 years with at least one identifiable risk factor  are eligible for a Medicare-funded health check. This programme aims to prevent or delay the onset of chronic disease and includes undertaking examinations and investigations as clinically required . FurtherOur study found that GP prescribing of antihypertensive therapy was not guided solely by absolute CVD risk. Approximately the same proportion (~61%) of patients diagnosed with hypertension in all risk groups, including patients with insufficient data available for CVD risk assessment, had been prescribed an antihypertensive drug in the last 6 months of the study. This pattern was similar for males and females. We are only aware of one other study investigating the prescribing patterns by CVD risk in a population with diagnosed hypertension . This KoThe prescribing of antihypertensive medications in our study did not vary by absolute CVD risk, even when we investigated longer prescribing periods. These results reflect undertreatment of high-risk patients and potential overtreatment of low-risk patients for CVD risk reduction. According to the Australian guidelines , all patOur study is the first in Australia to evaluate the cardiovascular risk profile of patients diagnosed with hypertension and included a large sample of patients across Australian general practice. A limitation of MedicineInsight is the inability to track patients across different practices. This limitation may have resulted in underestimating the proportion of patients with available data to calculate CVD risk. However, the median number of annual visits between 2016 and 2018 ranged from six for those with insufficient data to eight for those clinically at high risk. Therefore, most patients visited the same practice every 2 months on average, enabling enough opportunities to have their CVD risk assessed. Another limitation of MedicineInsight is that progress notes are not extracted, and these may contain information related to CVD risk factors. However, it is unlikely that this limitation would change our results. A recent validation study found accuracy close to 90% between algorithms for chronic conditions using the same fields as our study compared to the original EHR, which included the progress notes . The FraPatients with hypertension are at increased risk of CVD. Despite guidelines recommending the use of absolute CVD risk in the management of hypertension, only half of patients have sufficient data to calculate CVD risk. For hypertensive patients aged 45–74 who regularly visit their GP, with a calculated high or moderate CVD risk, 40% were not prescribed antihypertensive therapies, despite three-quarters of them having BP levels above the threshold. Therefore, many patients miss out on guideline-promoted treatments that minimise BP complications and reduce the risk of future CVD events.Cardiovascular disease (CVD) risk factors tend to cluster together, particularly in patients with hypertension.Guidelines therefore recommend that the management of hypertension should be guided by absolute CVD risk, rather than blood pressure alone.Electronic health records provide an opportunity to evaluate real-world practice of CVD risk assessment and subsequent prescribing patterns.CVD risk calculation was only possible in half of patients with a diagnosis of hypertension.GP prescribing of antihypertensive therapy was not solely guided by absolute CVD risk.Many patients miss out on guideline-promoted treatments that minimise BP complications and reduce the risk of future CVD events.Supplementary FileSupplementary Table


Antimicrobial resistance has always been an important issue as antimicrobial therapies are becoming less effective due to incorrect use and overuse. Our objective was to evaluate the impact of social media education on spreading antimicrobial stewardship awareness among healthcare students and residents.A prospective interventional study was conducted over 5 months, from November 2021 until March 2022. Weekly educational posts on infectious diseases were posted along with pre- and post- quizzes on a designated Facebook page. The primary endpoint of change in knowledge score was assessed using the independent t-test. Expected average pre-training is 2.5 over 5, and the expected average post-training is a minimum of 3.5 over 5 (common standard deviation of 1) for a minimum of 20% improvement that produces an effect size d = 1. Expecting a larger number of respondents on the pre-test than post-test, the ratio N1/N2 was set to 1.5. With the desired power set to 80% and alpha at 5%, sample size was determined as a minimum of 22 (N1) and 14 (N2). All analyses were carried at the 0.05 significance level.In the entry questionnaire, 85.6% (107/125) of participants believed that antibiotics are overused, 26.4% (33/125) confirmed that they overuse antibiotics, and 88.8% (111/125) confirmed the importance of having an antimicrobial stewardship program. 76.8% (96/125) of the participants regularly use social media for educational purposes and only 2.4% sometimes refer to social media as an educational tool. Improvement in knowledge was noted in all pre and post – quizzes except for two quizzes (prostatitis and acute cystitis – 18.4% and 13.2% improvement respectively). In total, there was a significant 36.2% improvement between all pre and post quizzes [min 13.2% and max 52.8% across all quizzes].This intervention demonstrated the importance of social media as a valuable tool to enhance antimicrobial stewardship knowledge among pharmacy, medical and nursing students and residents. Future studies are needed to examine the impact of social media education on behaviors in practice. Clostridioides difficile infection (CDI) . Participants attended different universities in Beirut, Lebanon including Lebanese American University (LAU) 75.2% (94/125), American University of Beirut (AUB) 7.2% (9/125), Holy Spirit University Kaslik (USEK) 4.8% (6/125), Lebanese International University (LIU) 2.4% (3/125), Notre Dame University (NDU) 2.4% (3/125), Beirut Arab University (BAU) 2.4% (3/125), University Saint Joseph (USJ) 1.6% (2/125), Balamand University 0.8% (1/125), Makassed University of Beirut 0.8% (1/125), Lebanese University (LU) 0.8% (1/125). Two participants were from foreign universities: Bahauddin Zakariya University Multan Pakistan 0.8% (1/125) and Tishreen University 0.8% (1/125). Participants were divided as follows: 3.2% (4/125) professional year-2 pharmacy students, 24.8% (31/125) professional year-3 pharmacy students, 30.4% (38/125) professional year-4 pharmacy students, 1.6% (2/125) masters, 0.8% (1/125) community pharmacist, 12% (15/125) medical year-3 students, 8.8% (11/125) medical year-4 students, 11.2% (14/125) nursing students and 7.2% (9/125) residents (of whom 33.33% (3/9) were pharmacy residents and 66.66% (6/9) were medical residents). 40.8% (51/125) participants have an infectious diseases or antimicrobial stewardship rotation before the end of the study in March. In the entry questionnaire, 85.6% (107/125) believed that antibiotics are overused, 26.4% (33/125) confirmed that they overuse antibiotics, and 88.8% (111/125) confirmed the importance of having an antimicrobial stewardship program. Table 76.8% 96/125) regularly use social media for educational purposes and 2.4% sometimes refer to social media as an educational tool. The most common social media platform used was Instagram 63.2% (79/125) followed by Facebook 56% (70/125), LinkedIn 43.2% (54/125), YouTube 40.8% (51/125), Twitter 29.6% (37/125) and finally Medscape 2.4% (3/125). Table 5 regularImprovement in knowledge (> 20% improvement) was noted in all pre and post – quizzes except for two quizzes prostatitis and acute cystitis – 18.4% and 13.2% improvement respectively. In total, there was a 36.2% improvement between all pre and post quizzes [min 13.2% and max 52.8% across all quizzes]. However, not all quizzes showed significant improvement results. Non-significant improvement results were respectively for cellulitis, community acquired pneumonia, prostatitis, acute cystitis and acute cystitis treatment; 30.8% (p = 0.073), 21.6% (p = 0.231), 18.4% (p = 0.057), 13% (p = 0.125) and 20.8% (p = 0.098). Table Improvement in knowledge was significantly seen across all questions types . Table Antimicrobial resistance (AMR) is one of the most serious global public health issues today. Antibitoic-resistant infections, longer hospital stays, higher medication costs, an overburdened public health system, service delays, and higher mortality rates have all been linked to AMR. The discovery of new antibiotics has slowed dramatically in recent decades. Furthermore, AMR reduces the efficacy of current antibiotics. The World Health Organization (WHO) recently released a study titled “Global Antimicrobial Resistance and Use Surveillance System (GLASS) Report: Early Deployment 2020,“ which revealed troubling AMR rates in 78 countries. The focus now is on the correct antibiotic, for the correct indication, the correct condition, at the correct time, with the correct dosage, path, and length of therapy, with the least amount of risk to the patient and potential patients. Through incorporating evidence-based approaches, an ASP has consistently shown an increase in the safe and effective use of antimicrobials .Most students and residents acknowledged that antibiotic resistance was a challenge and recognized the value of good-antibiotic-use knowledge. However, only 26.4% of the participants confirmed that they overuse antibiotics. The exit questionnaire confirmed the importance of antimicrobial stewardship programs and highlighted the increase in confidence and usefulness of the educational posts. A small number of participants still referred to other references such as Medscape; however, this referral didn’t influence the impact of the educational posts on the gained knowledge.Instagram and Facebook were the most commonly used social media platforms by the participants in this study. The use of Instagram might have exceeded that of Facebook due to the more user-friendly features offered by Instagram. This might be because Instagram has the poll feature which makes learning easier compared to accessing the quizzes via the link on the Facebook page.Pisano et al. (2019) conducted an interventional study where internal medicine residents at their academic center were offered iPads to access available ASP tools and enter trivia contests on Facebook and Twitter for better dissemination of information. In addition, the authors tested if social media reinforcement would also increase the use of the hospital’s order sets. Confidence in choice did not significantly change pre and post intervention; however, confidence in choosing the appropriate duration of antibiotics increased significantly. Residents also gained wide knowledge about ASP and drug dosing recommendations. All knowledge-based test scores significantly improved and those who had an ID rotation did not have better scores than the others. These results are consistent with our study; nevertheless, it is important to note that our study was anonymous, had a wider range of participants  and did not include the use of hospital order sets. Our main objective was to use social media to disseminate antimicrobial stewardship knowledge.Our research study had some limitations. First, we had a relatively small sample size in few of the quizzes which subsequently were not powered to detect a difference. However, effect size was achieved as the under-powered quizzes showed at least 20% improvement in quiz scores even if the p-value was not statistically significant . Therefore, clinical significance in these topics was achieved even if statistical significance was not reached. Second, the participants in the pre-intervention phase may not have been exactly the same as that in the post-intervention phase since the quizzes shared on the Facebook page were filled anonymously. The participants demographic information was independently collected from the quizzes and cannot be tracked by using the Facebook social media platform due to privacy/anonymity of answers Third, some students / residents had completed an infectious disease or antimicrobial stewardship rotation during the post-intervention phase. This might have interfered with the study results where participants might have scored higher in the post intervention quizzes. Fourth, we had two participants that were not from Lebanese universities and we could not trace their results due to anonymous reasons so excluding them was not possible. In addition, many students/residents are not using the Facebook platform anymore and reaching them can be challenging.This interventional study allowed the investigators to interact with many healthcare professionals and students/residents including community pharmacists, healthcare students from different majors, masters’ students and residents from outside Lebanon. Many professionals followed the Facebook page and interacted on the educational posts without filling out the quizzes due to inclusion criteria restrictions. The educational posts are always available for referral and can be saved as pictures to ensure maximal benefit for the interested audience.Social media education might be more effective than expected especially during these times where technology is being integrated more in the medical field . This isSocial media plays a major role as an educational tool for the new healthcare generation. This interventional study demonstrated the involvement of healthcare students/residents in online education and the importance of social media platforms as a venue for antimicrobial stewardship learning. Further studies need to be conducted in different disciplines to evaluate the effectiveness of social media education and its’ impact on healthcare practice.


The duration of forensic psychiatric care is in Sweden not determined at the time of sentencing; instead, offenders are regularly evaluated, often with regard to risk of criminal recidivism. The length and justifiability of such a sanction have been greatly debated; however, previous estimates of treatment duration based on datasets delimited to discharged patients—have provided an uncertain groundwork for these deliberations. The aim of this study was to use a more suitable approach to calculate average duration of forensic psychiatric care and to examine the relationship between length of treatment and subsequent recidivism after discharge.n = 2064), with a follow-up period until May 2020. We used Kaplan–Meier estimator to calculate and visualize treatment duration including analyses comparing levels of relevant variables, and then evaluated criminal recidivism in patients discharged from treatment between 2009 and 2019 (n = 640), after stratification for the same variables and dichotomization by treatment duration.This retrospective cohort study focused on offenders sentenced to forensic psychiatric care in Sweden between 2009 and 2019 and registered in the Swedish National Forensic Psychiatric Register (The median duration of forensic psychiatric care was estimated to 89.7 months (95% CI 83.2–95.8). Treatment was longer in offenders who committed violent crimes, suffered from psychosis, or had a history of substance use disorder, and in offenders whose sentences included special court supervision. The cumulative incidence of recidivism in patients discharged from treatment was estimated to 13.5% at 12 months (95% CI 10.6–16.2) and 19.5% at 24 months (95% CI 16.0–22.8). Corresponding cumulative incidence of violent crime post discharge was 6.3% at 12 months (95% CI 4.3–8.3) and 9.9% at 24 months (95% CI 7.3–12.4). Among other findings, in patients without a history of substance use disorder and patients whose sentences did not include special court supervision, recidivism was significantly higher in those with a shorter treatment duration.Using the entirety of a suitable, contemporary, prospectively enrolled cohort of mentally ill offenders, we were able to estimate—with greater accuracy than previous studies—the average duration of Swedish forensic psychiatric care and rate of subsequent criminal recidivism. The STwo recent studies performed using a Swedish dataset have investigated time estimates for and rates of reconviction after termination of forensic psychiatric treatment, as well as risk factors associated with reconviction, including length of stay, age, and substance misuse , 14. HowA common aim for the treatment of mentally ill offenders in most countries is prevention of relapse into crime, but the particular framework for forensic psychiatric care, such as the duration of treatment, can differ quite considerably; the same is true for the subsequent recidivism rate –23. It i2.2.1.We conducted a retrospective cohort study of patients registered in the Swedish National Forensic Psychiatric Register (SNFPR) who, according to the Swedish National Council for Crime Prevention’s crime registry, were sentenced to forensic psychiatric care between January 1, 2009, and December 31, 2019.The SNFPR was established in 2008 and in 2019 covered 96% of forensic psychiatric units and 86% of all patients under forensic psychiatric care in Sweden . The enrWe used patients’ unique Swedish personal identity numbers to link the SNFPR with the Swedish National Council for Crime Prevention’s crime registry  to link and obtain individual data on convictions, including the type of offense and dates of crime and sentencing. Then, the linked datasets were supplemented with information on patients who died during the study period according to the Swedish Cause of Death Register. Patients without Swedish personal identity numbers were excluded, as such numbers were necessary for the linkage of registries.2.2.The SNFPR provided information on 2,444 individuals receiving forensic psychiatric care at any point between January 1, 2009, and May 31, 2020. A total of 380 of these individuals were excluded from the analysis, because a corresponding sentence after January 1, 2009, was not present in the crime registry .a priori were hypothesized to potentially influence treatment duration were sex, type of offense, and type of sanction , as extracted from the crime registry; as well as diagnosis and history of substance use disorder according to data from the SNFPR. The type of offense was divided into lethal violence , non-lethal violence  and non-violent crime . Attempted lethal violence was included in the non-lethal violence group, as it did not in fact result in death. Involuntary manslaughter was included in the same group, based on the absence of intent of harm, a factor that, in the penal system, is associated with a considerably more lenient sentence. The diagnosis was coded as “psychosis” if an ICD-10 code . All data were pseudonymized and as such could no longer be attributed to a specific person.3.3.1.3.1.1.In the SNFPR were registered 2064 individuals who were sentenced to forensic psychiatric care between January 2009 and December 2019 according to the crime registry. Twenty-one patients were discharged and then sentenced again to forensic psychiatric treatment during the follow-up period; as such observations cannot be considered independent, for each patient, only the first treatment period was included in our analysis.Of the 2064 individuals in total, 1,697 (82.2%) were men. Sentences of forensic psychiatric care were most commonly based on non-lethal violent crimes , followed by non-violent crimes  and lethal violent crimes . In 1581 cases (76.6%), the sentence of forensic psychiatric care included a provision requiring special court supervision, while 1,530 individuals (74.1%) were diagnosed with psychosis during the treatment period, and 1,267 (62.9%) had a history of substance use disorder .3.1.2.There were 657 patients registered as discharged from forensic psychiatric treatment between January 2009 and May 2020. The median duration of treatment, calculated using the Kaplan–Meier estimator, was 89.7 months , compared to 92.7 months (95% CI 84.0–99.4) for non-lethal violent crime and 55.3 months (95% CI 46.7–78.5) for non-violent crime . The med3.2.3.2.1.Between January 1, 2009, and December 31, 2019, 640 patients were discharged from forensic psychiatric care, 508 (79.4%) of whom were men. Sentences of forensic psychiatric care were most commonly based on non-lethal violent crimes , followed by non-violent crimes  and lethal violent crimes . For 396 individuals (61.9%), the sentence of forensic psychiatric care included a provision requiring special court supervision. In total, 438 individuals (68.4%) were diagnosed with psychosis during the treatment period, and 325 (52.5%) had a history of substance use disorder. The median duration of forensic psychiatric care was 37.8 months , and the mean age at the time of discharge was 42.3 years SD 13.8; .3.2.2.In total, 132 individuals (20.6%) relapsed in crime after discharge from forensic psychiatric care. The first offense after discharge involved non-lethal violence in 45 individuals (34.1%), whereas the remaining 87 individuals (65.9%) relapsed in a non-violent crime; no lethal violence was observed. In total, 107 (81.1%) of the reoffenders were men. Median follow-up time for all discharged patients was 26.3 months , and the recidivism rate was 7,132 instances of reoffending per 100,000 person-years . The cumulative incidence of recidivism was estimated to 13.5% at 12 months (95% CI 10.6–16.2), 19.5% at 24 months (95% CI 16.0–22.8) and 24.9% at 60 months  for men, and 41.6 months  for women. The difference in recidivism in relation to duration of care  was statistically significant for men but not for women . When st3.2.3.Of the 640 discharged individuals, 69 (10.8%) committed at least one violent crime after discharge from forensic psychiatric care, 55 (79.7%) of whom were men . Median When the cohort was alternately stratified according to sex, original crime, type of sentence, presence of psychosis, and history of substance use disorder, and then dichotomized according to treatment duration, no significant differences in violent offending were observed, with one exception: among patients whose sentence did not include special court supervision, treatment duration shorter than or equal to the median (25.1 months) was associated with a higher probability of committing a violent crime . PD + NP = developmental and personality disorders.Click here for additional data file.SUPPLEMENTARY FIGURE 14Estimated time to reoffending after discharge from forensic psychiatric care after stratification by diagnosis  and dichotomization according to treatment duration. PD + NP = developmental and personality disorders.Click here for additional data file.SUPPLEMENTARY FIGURE 15Estimated time to violent offending after discharge from forensic psychiatric care after stratification by diagnosis  and dichotomization according to treatment duration. PD + NP = developmental and personality disorders.Click here for additional data file.


One hundred and nine respondents, to a survey on medical and preventive management of working dogs, reported a relatively low percentage of dogs submitted to a specific sports medical examination (36.4%) or to a generic orthopaedic examination (55.5%) before starting their professional activity (conditioning and competition). Injury incidence was relatively high (45.5%), even if mostly represented by mild muscular trauma; and preventive exercise or pre- and post-activity exercises (warm-up and cool-down phases) were performed sporadically.A survey with 100 multiple choice and open-ended questions was proposed by free access to working dogs’ handlers. One hundred and nine respondents were recorded and their dates processed. The most represented breeds were: Belgian Malinois, Labrador, Border Collie and German Shepherds. Of these, 71.6% were intact dogs and 28.4% were spayed or neutered, with a median age range of 3–4 years. Furthermore, 55.5% had undergone early radiographic examinations for hip or elbow dysplasia diagnosis. The dogs performed the following activities: search and rescue on surface (59%), search and rescue on rubble (37%), Internationale Gebrauchshund Pruefung (IGP) (9%), man trailing (5%), sled dog (5%), search on avalanche (4%), dog towing (3%), canine shows (3%), hunting (2%), water rescue (1%), pet therapy (1%), wildlife conservation dog (1%), Mondioring (1%). Only 36.4% of respondents submitted their dogs to a specific sports medical examination and 55.5% to an orthopaedic examination. An injury incidence of 45.5% was recorded, generally related to mild musculoskeletal trauma. A limited number of handlers routinely performed warm-up and/or cool-down activities. A positive assessment emerged of the need for many respondents to attend and request education courses and updates on the proper health management of their dogs. Presently, working dogs are actively involved in specific and professional tasks aimed to improve civil security and disaster risk management. The role of the dog is essential to allow a greater degree of safety for human health, especially when natural disasters or missing persons occur.The relationship established between the dog and the handler is incredibly symbiotic and the handler experience represents a good indicator and an essential source of information regarding the possibility of receiving useful data to improve the therapeutic approach and in the prevention of common musculoskeletal pathologies ,2,3,4,5.In sports medicine, injury incidence seems to be relatively higher in dogs performing high-impact sports, such as agility and flyball. The literature on agility dogs has reported that 32–41.7% had experienced at least one injury, most commonly located at the shoulder region, iliopsoas muscle, back region, and digits . UnfortuInjuries in dogs performing flyball activity reported a similar rate 34–39%) compared with agility ,9,10.% compareCurrently, the specialist literature does not report a high number of musculoskeletal injuries in working dogs engaged in humanitarian missions or in environmental disasters . PatholoGenerally, when injuries occur and veterinary personnel are not available, it has been reported that 40–50% of healthcare providers (HCPs) were enrolled in the Joint Forces Combat Trauma Management Course for managing emergently injured military working dogs. Care provided by HCPs is limited to circumstances in which the dog is too unstable to be transported to veterinary facilities or medical evacuation is not possible; immediate care is necessary to preserve life, limb or eyesight .The aim of this study was to describe the frequency and types of injuries experienced by working dogs, also investigate their healthcare management, nutrition and training activities. This investigation was conducted through an internet survey of working dogs’ handlers.On the basis of the author’s clinical experience and caseload, we hypothesised that the prevalence of injuries would be lesser than high-impact sports dogs .An online survey (anonymous self-administered form) was advertised through clinical newsletters, social media (Messenger), farm groups and working dog associations. Owners could address the survey only once for each owned dog and only questionaries that received the consent for publication by owners were included in this study. The questionnaire consisted of 100 questions (multiple choice and open-ended questions) and was subdivided into 11 main sections according to the following complaints: 1. signalment and current health status; 2. dog diet; 3. dietary supplements or medication; 4. dogs’ housing; 5. transport; 6. training tools; 7. work the dogs were trained to perform; 8. training protocol; 9. injury prevention; 10. location, diagnosis and treatment of injuries; 11. owner training and education . Some quThe questionnaire was also associated with informed consent  to data Data collection was carried out in a five-month period, from January to May 2022: a total of 109 respondents participated in the study by completing the survey .SECTION 1—Signalment and current health status—The breeds included in the study were Belgian Malinois (n = 17), Labrador Retriever (n = 17), Border Collie (n = 17), German Shepherd (n = 12), Golden Retriever (n = 9), mixed breed (n = 7), Australian Shepherd Kelpie (n = 5), Siberian Husky (n = 5), Dutch Shepherd (n = 2), Czechoslovakian Wolfdog (n = 2), Dog Beauceron Shepherd (n = 2), Langhaar (n = 1), Dobermann (n = 1), Red Irish Setter (n = 1), Giant Schnauzer (n = 1), Weimaraner (n = 1), German Pinscher (n = 1), American Akita (n = 1), Lakeland Terrier (n = 1), Cane Corso (n = 1), German Longhaired Pointer (n = 1), Hovawart (n = 1), Italian Hound (n = 1), Giant Poodle (n = 1), Pointer (n = 1). Out of 109 dogs considered, 71.6% were breeding dogs and 28.4% were spayed/neutered. The age of the dogs was: <1 year (n = 7), 1–2 years (n = 21), 3–4 years (n = 29), 5–6 years (n = 21), 7–8 (n = 20), 9–11 years (n = 11). In questions 4–10, the prophylaxis against the main pathologies carried by vectors and external parasites was taken into consideration. In particular, the deworming treatment rate was 25.4% as a puppy, sporadically in 16.4%, once a month in 20%, once a year in 38.2%. Heartworm prevention was as follows: 10% never, 3.6% sporadically, 41.7% once a month, 43.6% once a year and 2% unspecified. Tablets (62.4%), vaccination (28.7%), spot on (4.45%) or other unspecified methods (4.45%) were used for prophylaxis. Leishmaniasis prevention was carried out as follows: never (14.5%), sporadically (7.7%), once a month (28.2%), once a year (50%); and collar (33.7%), vaccination (38%), spot on (28.3%) were used for prophylaxis. Control of external parasites was carried out as follows: 3.7% never, 7.3% sporadically, 64.5% once a month, 24.5% once a year; collar (30.5%), spot on (33.3%), tablets (30.5%) and other unspecified forms (5.7%) were used for prophylaxis.Next, the interviewees were asked if their dogs had undergone early and/or ultimate diagnostic radiographic examination (for example for hip or elbow dysplasia) and which anatomical districts were investigated. Of these, 55.5% of the dogs underwent early radiographic examinations whereas 44.5% did not.Early radiographic examinations were carried out on hips (n = 45), elbows (n = 36), knees (n = 1), shoulders (n = 2); confirmatory radiographic tests were performed on elbows (n = 44), hips (n = 52), shoulders (n = 5), spine (n = 2).Overall, 55.5% of the dogs were submitted to an orthopaedic examination, 43.6% were not and 0.9% had an orthopaedic evaluation during standard radiographic assessment. The age at which the orthopaedic examination was performed was three months (n = 2), four months (n = 1), five months (n = 5), six months (n = 8), seven months (n = 2), eight months (n = 1), one year (n = 14), two years (n = 12), three years (n = 4), four years (n = 4), five years (n = 2), six years (n = 5), seven years (n = 1). The reasons for visiting were routine clinical examination (n = 35) and suspected muscular-skeletal diseases (n = 9).As working dogs generally require high performance, we assessed whether the dog had ever undergone a specific sports medical examination. One hundred and nine responses were divided as follows: 63.6% never, 36.4% yes. Fifteen dogs had routinely undergone a sports medical exam (every year).Overall, 39.1% of dogs had undergone general blood tests once a year; 9.1% only as a puppy; 31.8% sporadically and 20% never.It was also asked whether and why the dog had ever undergone to a cardiological examination. To this, 62.7% answered that they had never undergone a cardiological examination, 19.1% once a year, 11.8% sporadically, and 6.4% only as a puppy.Thirty-two owners did not know the physiological parameters of their dogs, 20 owners relied on their veterinarian to evaluate these parameters and 28 owners knew both the parameters and the range of values.SECTION 2—Dog diet—Of the interviewees, 79.1% administered dry commercial food, 10.9% BARF, 3% cooked meat, 2% commercial wet food, 5% other; 83.5% give two meals a day, 10.1% three meals, 6.4% one meal a day. Responses to fasting times before work were highly variable, ranging from 2 to 12 h. Furthermore, 53.2% of the interviewees did not make any food changes during the year while 46.8% changed feeding.SECTION 3—Dietary supplements or medication—Of the interviewees, 50.9% did not administer any type of supplement, 49.1% administered supplements, above all multivitamin complexes (25.9%) and omega-3 supplements (22.2%), two–three cycles of treatment per year. When asked about the administration of chondroprotectors, 50.1% gave them quarterly. Overall, 94.5% of the dogs were not on medication, while 5.5% of owners gave an affirmative answer, but then when asked what kind of drug the dog took, they referred to the medication, not the specific problem and the medications were highly variable.SECTION 4—Dogs’ housing—Questions were asked about the domestic environment where the dog usually lived in order to examine the daily habits and whether the domestic environment could influence the activity carried out by the dog, injury occurrence and the relationship with the handler. Overall, 57.3% of dogs lived between the owner’s home and garden, 36.4% exclusively in the home, 4.3% exclusively in the garden and 2% in a place other than the handler’s home. For dogs living in the garden, 60% lived free, while 40% were fenced. The surface on which the dogs spent most of their time was grass (60%) house tiles (30%), gravel and soil (10%). Additionally, 53.6% of dogs slept on a ‘dog bed’, 12.7% slept in kennels, 10.9% on the floor, 22.8% on other types of unspecified materials.SECTION 5—Transport—Overall, 90% of dogs are transported by car: 89.1% in a cage, 8.2% unrestrained and 2.7% restrained, while 10% of dogs are transported in van, always in special kennels. The environment in which the dog travelled was usually air-conditioned (86.4%), but not in 13.6% of cases. The journey had a variable duration, ranging from a minimum of 10 min to a maximum of six hours, with an average value of about 1.5 h. Furthermore, 20.9% of the dogs, due to their specific work, required other types of transport to reach the search field; 14.3% are ferried, 80% are transported by helicopter and 5.7% by cable car.SECTION 6—Training tools—When the dog was not working, in 83.6% of cases it usually wore a collar or harness. Dogs were restrained with a leash whose length varied from 1 to 3 metres (52.7%), 39.1% of the dogs were unrestrained and 8.2% were restrained with other techniques. During work, 51.8% of dogs wore a specific harness: a rescue harness (80%), a helicopter harness, a sledding harness, a utility and tactical harness, a climbing and tracking harness. Additionally, 48.2% of dogs wore nothing while working. Eighty percent of handlers who used a specific harness took them off after work, while the remaining 20% did not remove them. Evaluating the reaching of inaccessible search places via helicopter rescue, it was asked if the handlers noticed a difference in the dog working after removing the harness: 100% of them did not show any discrepancy.SECTION 7—Work the dogs were trained to perform—The dogs performed the following work/activities: search on surface (59%), search on rubble (37%), Internationale Gebrauchshund Pruefung (9%), man trailing (5%), sled dog (5%), search on avalanche (4%), dog towing (3%), canine shows (3%), hunting (2%), water rescue (1%), pet therapy (1%), wildlife conservation dog (1%), Mondioring (1%). The dogs’ work was part-time (78.2%) or full-time (21.8%): dogs started working at ages ranging from 2 to 15 months. Dogs worked three times a week (32%), twice a week (28.5%), four days a week (12%), every day (15%) and only 8% one day a week; 4.5% of owners did not provide a clear answer. Forty-eight percent were in activity, i.e., they had passed exams so in the event of natural disasters or missing people they could be activated by civil protection and work in the field. Overall, 34.6% of dogs were still in training, whereas 7.4% had passed aptitude exams, i.e., they have passed the training phase and were preparing for the operational phase; the remaining 10% worked sporadically. The dogs worked on different ground surfaces: 80% woodland and the rest consisting of rubble, snow, the aquatic environment and grass.SECTION 8—Training protocol—Only 5% of the owners answered correctly to the question ‘In your opinion, what is a training program’, identifying as the purpose of the training program the physical fitness, that included cardiorespiratory  and neuromuscular  components [SECTION 9—Injury prevention—Overall, 42.7% of handlers carried out prevention techniques, i.e., massage (17%), warm-up (22%), stretching (9%), cool-down (11%) and proprioception exercises (2%). When asked about the type of warm-up carried out before a work session, 80% did not warm-up properly, describing only a run with ball throwing, whereas 20% described a walk of about five minutes. With regard to the cool-down, after working, the dogs rested directly in the kennel (80%), took a walk (15%), and did stretching exercises and massages (5%). The prevention protocol was drafted by the owners autonomously (45.5%), by the physiatrist vet (17.5%), by the coach (12.5%), by the vet (4.5%), by other unspecified figures (20%). Twenty-eight owners answered that they did nothing to prevent limb injuries, two repliers performed massage, three maintained a healthy weight, five performed muscle strengthening exercises, four handlers practiced proprioception exercises on their dogs, eight avoided jumping when they realised that the dog was not fit, ten owners performed warm-up; 90% did nothing to prevent spine injuries, the remaining 10% massaged and warmed up and avoided jumping. Regarding time dedicated to prevention, 90% of 109 respondents answered negatively , 10% dedicated just a few minutes a week, with activities mainly represented by walks or massages (37.7%).SECTION 10—Location, diagnosis and treatment of injuries—Of the owners, 80% identified pain with lameness, 20% with both behavioural changes and inappetence. Overall, 54.5% of dogs have never suffered an injury, whereas 45.5% had reported an injury, i.e., muscle injuries (22%), phalangeal or carpal fractures (20%), fingertip lesions (10%), cruciate ligament rupture (3%) and shoulder injuries (3%). In 40% of cases, the symptoms occurred in the days following the trauma, in 60% on the same day. In 91.8% of cases, the injury was temporary and never recurred, in 8.2% it was permanent. The time range of rest for the dog varied between seven days and three months depending on the type of injury found. The diagnosis was made in 79.1% of cases by a veterinary surgeon, and in 20.9% independently by the owner. Post-traumatic treatment was decided by the veterinary surgeon (70%), autonomously by the owner (28.2%) or by the coach (1.8%). Only 20.9% of dogs required physiotherapy. Out of 37 responses from those who used physiotherapy, 90% of the dogs were treated with laser therapy and underwater treadmill, and 10% with anti-inflammatories. About 10% of the dogs required surgical treatment, but not all respondents stated which specific surgery was performed.SECTION 11—Owner training and education—Of the owners, 42.7% followed courses on the well-being of their dog, above all courses held by veterinary surgeons or pharmaceutical companies. Of these, 83.6% agreed to submit their dogs to a specific sports medical visit; 16.4% do not consider it necessary.The aim of this survey was to obtain information on injuries experienced by working dogs, and also investigate their healthcare management, nutrition and training activities. We hypothesised that the prevalence of injuries would be lesser than high-impact sports dogs, but on the basis of our sample, the hypothesis was not confirmed, as handlers reported a 45.5% injury incidence. Moreover, the outcomes of our survey highlighted some rather questionable aspects in relation to canine health management, the early radiological screening of congenital articular pathologies that could be a source of pain and limitation for work activity (hip or elbow dysplasia) and finally, for injury prevention.The first section of our survey was dedicated to canine signalment and clinical management. Belgian Malinois, Labradors and German Shepherds were the breeds more expressed, in line with previous scientific studies on working dogs; with similar results also for the age of dogs routinely involved in activities of search and rescue and other civil security and disaster risk management ,11,14. AVaccination for disease prevention is mandatory for all working and athlete dogs, especially for working dogs that act in contact with several other teams of dogs and are often transported in extremely varied environments or foreign countries .The final part of the first section was dedicated to the clinical examination of dogs specifically selected for working activities, with particular attention to early radiological screening in order to verify the initial joint conditions and exclude dogs potentially affected by hip or elbow dysplasia, both pathologies that could provide structural instability generating pain during work . In our Furthermore, 49.1% of respondents administered diet supplements to their dogs, generally represented by chondroprotective components in order to prevent articular disease in such active dogs. However, no certain preventive effect has been proven in scientific literature in healthy dogs . These ‘Transportation is another crucial issue for working dogs’ management, because it has been proven to be stressful and its familiarisation needs a positive early exposure in life . LuckilyThe final sections of this survey highlighted interesting aspects of the management of the working dog: the incidence of trauma (relatively high) and prevention (extremely limited).Injuries generally occurred in very active dogs, above all when they were employed in high-impact sports, i.e., agility or flyball. As previously described, these disciplines have reported an injury rate varying from 22% to 41% . Our resCanicross is a sport in which dogs generally run attached to the handler on a distance varying from 1 to 45 km or more, in a rural or wooded environment, with uneven terrain in terms of texture and slope. These conditions could hypothetically lead to an increase in injuries to handlers and dogs, but correct conditioning is probably the reason for the quite low trauma incidence in this discipline . For thiWarm-up/cool-down exercises and their real effect on injury prevention have been largely discussed in the literature, but prospective studies have still not been conducted in veterinary medicine; however, it is widely accepted that execution of specific conditioning exercises  may improve physical fitness . In our The last part of our survey was dedicated to the handler’s perception of further updating training courses to improve dog management, in order to reduce the incidence of trauma. It was positive that the open final comments by respondents were generally concentrated on a request to increase the opportunities for frequent educational courses.A first limitation of this report could be related to the online questionnaire itself with intrinsic disadvantages such as recall bias, lack of veterinary records/verification, and selection bias. Additionally, the owners are reporting in a single time-point, thus cause/effect cannot be determined: for example, the question in the survey related to warm-up did not specify if this activity was planned from the beginning of the conditioning period of puppies or only after a trauma, therefore care should be taken to interpret the potential impact of the warm-up or cooldown.Moreover, another limitation of this study could be also related to the moderate number of respondents : however, the percentage of trauma was high and could be due to the fact that handlers with injured dogs could be more sensitive to the topic of the study and more motivated in attending to the survey, hoping to stimulate answers on the correct management of their dogs.This study, despite the limited number of cases, has highlighted the need to further promote the training of handlers and owners of working dogs to make them aware of the risks that their dogs run during their professional activity. The injury incidence was particularly high, even though the injuries reported by handlers were mostly mild with a rapid recovery. In the future, it would be useful to carry out studies aimed at the individual categories of working dogs, to better understand the impact that each specific discipline  has on dogs that practice that working activity.