Recent literature has revealed a long discussion about the importance and necessity of nerve conduction studies in carpal tunnel syndrome management. The purpose of this study was to investigate the possibility of automatic detection, based on electrodiagnostic features, for the median nerve mononeuropathy and decision making about carpal tunnel syndrome. The study included 38 volunteers, examined prospectively. The purpose was to investigate the possibility of automatically detecting the median nerve mononeuropathy based on common electrodiagnostic criteria, used in everyday clinical practice, as well as new features selected based on physiology and mathematics. Machine learning techniques were used to combine the examined characteristics for a stable and accurate diagnosis. Automatic electrodiagnosis reached an accuracy of 95% compared to the standard neurophysiological diagnosis of the physicians with nerve conduction studies and 89% compared to the clinical diagnosis. The results show that the automatic detection of carpal tunnel syndrome is possible and can be employed in decision making, excluding human error. It is also shown that the novel features investigated can be used for the detection of the syndrome, complementary to the commonly used ones, increasing the accuracy of the method. Carpal Tunnel Syndrome (CTS) is caused by compression of the median nerve as it travels through the carpal tunnel, formed by flexor retinaculum, while the other nerves of the hand  are not affected by the syndrome  . Final dNerve Conduction Studies (NCSs) have long been considered the most useful tool for the confirmation of the median nerve mononeuropathy and the decision of therapeutic strategy in CTS [On the other hand, electrophysiological y in CTS . Analysiy in CTS . Differey in CTS . The comy in CTS .Nevertheless, many controversies have arisen regarding the necessity of NCSs as confirmatory tests or tools contributing to patient management ,20,21,22Recently, machine learning based methods have found widespread use in healthcare, revolutionizing the area of medical diagnosis ,26,27. TThe main target of this study is to evaluate the sensitivity of different NCSs’ parameters for the diagnosis of median nerve mononeuropathy and the ability of different classifiers to automatically discriminate normal and pathological values. Machine learning techniques were employed to examine signal characteristics and compute the accuracy of automatic classification.This study included 38 volunteers that were examined prospectively, over a period of two months, at the Laboratory of Clinical Neurophysiology, Neurological Department of the University Hospital of Ioannina. Among them, 28 participants were patients with symptoms and signs suggestive of CTS, who were referred to the laboratory by hospital physicians not affiliated to the study . Patients diagnosed with other neurological disorders apart from CTS , as well as patients with other systemic diseases, were excluded from the study. Ten age-matched healthy individuals were also included in the study .All participants signed an informed consent form and underwent an initial clinical evaluation from two neurologists of the study for both hands, before neurophysiological testing. From the total number of hands examined (76), 65 were included in the study (46 with CTS and 19 control) and 11 hands were excluded because there was either a history of prior surgical intervention for CTS or a mismatch between clinical and neurophysiological diagnosis ,35. ClinA (no MM). Group B (mild MM) included ten hands with sensory conduction velocity from index finger to wrist smaller than 40 m/s and motor terminal latency from wrist to Abductor Pollicis Brevis (C (moderate MM) included 17 hands with motor terminal latency for SNAP . Group D (severe MM) included 19 hands with motor terminal latency for B, C and D. The participants of the study were carefully selected and each hand was finally included in the dataset only in the case of a perfect match between clinical diagnosis and NCSs, enabling a robust grouping of the hands and facilitating further accurate signal analysis and classification.A detailed neurophysiological examination of both hands was carried out on all participants using the same equipment , as previously described . The temNext, machine learning techniques were used to analyze those data and investigate the sensitivity of the signal characteristics and the ability to automatically discriminate controls and patients. Experiments were performed with two sets of features. The first one consisted of those features which are considered common and are widely used today by medical doctors and medical devices for the diagnosis of median nerve mononeuropathy. The purpose was to test whether it is possible to achieve a high level of accuracy in automatic diagnosis using machine learning classifiers and the widely used features. In order to decouple the classification capability from the selected classifiers, experiments were performed with five different classifiers, selected based on their popularity and the expected ability to achieve increased accuracy.The second set of features consisted of novel features. The purpose this time was to identify new features which could carry useful diagnostic information and do not belong to the set of the common features; features which, if used in addition to the common ones, could possibly increase the classification capability of the machine learning classifiers. Features with physical or mathematical meanings were selected.Finally, feature selection techniques were employed in order (a) to evaluate the level of significance of each feature in the automatic diagnostic procedure and (b) to help the classifiers present a better performance, a common practice in machine learning.common features and one for the novel.Features were separated into two subsections; one for the The following common features were tested: Sensory Amplitude or Height Hs, , SensoryArea As, , Motor DTo investigate characteristics which have some inherent diagnostic information, not exploited by common features;To explore features, which may reveal new diagnostic information, not easily predicted or explained by current knowledge. Such features should be further investigated with other studies and examined by a larger number of researchers, before reaching a conclusion about possible physical meaning;To suggest features that do not heavily depend on the detection of critical points of the signal. This detection is now performed manually by the medical doctor, who indicates them with the aid of a pointing device. In this way, the extraction process is independent from the manual detection and excludes the human error.Next, some features are presented, tested for the first time in this study for the diagnosis of CTS. The main goals and motivation to test these features were:(a) Expanded Absolute Sensory Area  Duration (A descriptive name for this feature is (c) Areas and their ratios:In (d) Slopes:Areas are of special interest. They not only describe single features as the duration or the height, but they also consider relations between figures, since their values depend on the duration, height and the shape of the curve. Even though sub areas cannot be directly connected to physiology, it cannot be ignored that valuable information can be hidden there. This information is very difficult to explain, since, as noted above, it depends on more than one factor. The rations between areas, especially, could hide information that is even more complicated and difficult connect to physiological reasons.Two kinds of slopes have been examined for both left and right sides of the curve. k points :(1)tanθlA similar definition comes from the right side of each curve:Fitting slope is the line that best fits all the data points of the left  and the sequential backward feature selection (SFS) algorithms [Using the selected parameters, each classifier was trained again. A custom gorithms . In eachK-fold cross validation is called the technique of partitioning the dataset into k subsets of equal size. One of these subsets is used as test data and the other k times, since each subset must play the role of the test data exactly once. In the special case where N: number of instances), the k-fold cross validation is induced to leave-one-out cross validation.For training and testing leave-one-out cross validation was selected, a technique appropriate when the amount of available data is not large. LR, SVM, kNN, DT, NB) in order to decouple the classification capability of each classifier from the results. The dataset was segregated into several subsets and different problems were studied based on this segregation. Their names were given based on the number of the classes that were attempted to be discriminated: 4-class, 3-class and 2-class. In the 4-class problem, the categorization between the groups A (no MM), B (mild MM), C (moderate MM) and D (severe MM) was studied. Please also see 3-class problem, the groups B and C were merged and the categorization between groups A, D (severe) was studied. Finally, in the 2-class problem, all groups with symptoms  were merged into one A) and patients  were employed in the NCS signal analysis and the results were compared to the neurophysiological and clinical diagnosis. Automated discrimination between patients and controls, with the most accurate classifier (SVM), reached an accuracy of 0.9513 compared to NCS and 0.8906 compared to clinical diagnosis. Further analysis with SVM and classification into three groups  reached an accuracy of 0.9415 compared to NCS and 0.7144 compared to clinical diagnosis. Finally, SVM performed equally well in the classification of the study population into four groups , with an accuracy of 0.9117 compared to NCS. Comparing the maximum accuracy of the present study with other studies in the literature ,32,43, iCurrently, NCS is considered the gold standard for the confirmation of median nerve mononeuropathy in the CTS. The aim of the present study is to find a methodology to enable automatic diagnosis through the analysis of conventional electrodiagnosis signals with machine learning techniques. This would facilitate and accelerate the electrodiagnosis, excluding the human error. The results show that the inclusion of the novel features described here can increase the accuracy of the automatic electrodiagnosis, when they are used together with the common features. So, the inclusion of the novel features does not aim to replace the common features but to enhance their performance.The findings of this study show that an accurate automatic electrodiagnosis for median nerve mononeuropathy is possible. Apart from testing the accuracy of the common NCSs’ features, several geometric features with indicated physiological meaning for median nerve compression were extracted and presented. These features are employed for the first time in the workup of CTS. The classification model proposed is unbiased and indicates that these features can play an important role in supporting the diagnosis of the syndrome and grading its severity. However, the evaluation of the results through a larger database of CTS patients would be useful, in order to establish an accurate grading scale and produce more robust generalizations. Such a grading scale could serve as a basis for an automatic electrodiagnosis, excluding the human error, implemented in costume electrophysiological testing or hand-held devices.


RNA vaccines represent a milestone in the history of vaccinology. They provide several advantages over more traditional approaches to vaccine development, showing strong immunogenicity and an overall favorable safety profile. While preclinical testing has provided some key insights on how RNA vaccines interact with the innate immune system, their mechanism of action appears to be fragmented amid the literature, making it difficult to formulate new hypotheses to be tested in clinical settings and ultimately improve this technology platform. Here, we propose a systems biology approach, based on the combination of literature mining and mechanistic graphical modeling, to consolidate existing knowledge around mRNA vaccines mode of action and enhance the translatability of preclinical hypotheses into clinical evidence. A Natural Language Processing (NLP) pipeline for automated knowledge extraction retrieved key biological evidences that were joined into an interactive mechanistic graphical model representing the chain of immune events induced by mRNA vaccines administration. The achieved mechanistic graphical model will help the design of future experiments, foster the generation of new hypotheses and set the basis for the development of mathematical models capable of simulating and predicting the immune response to mRNA vaccines. Becauseimmunity , howeverin vitro evidence, animal models, clinical trials, etc.) requires an additional effort to integrate the retrieved information into an interactive platform that can be queried by the users. Databases are usually the preferred solution to store parameters and other numerical information, but as per RNA vaccines some processes may particularly benefit from a mechanistic graphical model that would help identify and fill in the knowledge gaps. Indeed, literature derived data could be complemented with proprietary knowledge and used to draft a mathematical model of the underlying biology. Accordingly, progressive and iterative refinement of the mechanistic process through targeted wet-lab experiments in animal models contributes to the model evaluation. The finalized model is eventually applied to specific scenarios of interest to predict, investigate and support drug development.The strategy depicted in https://www.cosbi.eu/fx/9839203 dynamic figure) tracing the stages of the immune response to mRNA vaccines, from the innate immune activation at the site of injection up to the adaptive response, measurable in the peripheral blood system several days after vaccination. The proposed mechanistic graphical model facilitates the interpretation of what has been discovered so far and fosters interactions among investigators with very different backgrounds, such as immunologists and data scientists.Although mRNA vaccines have been the focus of several studies in the last decade, they are usually employed with different components  and investigations focused on different arms of the immune response or different biological sites. Consequently, the generated knowledge tends to be rather specific to each individual platform, not always generalizable and sometimes even fragmented. This is what motivated our effort to collect and consolidate all publicly available scientific evidences, related to mRNA vaccine mode of action, into an interactive mechanistic graphical model , induced by mRNA vaccines through an NLP-guided literature mining process . The iniScientific literature mining is foundational for the generation of new hypotheses as well as for driving future research and designing new studies. At this point, data and facts of different type and format are gathered and need to be integrated, pressuring data-integration methods to be efficient, in order to explicitly represent the deeply connected big picture the scientist is looking for .https://www.cosbi.eu/fx/9839203. Given the known similarities and discrepancies between the mouse and NHP models, we represented separately mouse and NHP data, each of them accessible by clicking on the respective black animal shape in the left upper corner of the model, overlapping the shared information when possible. The immunization process reported in de facto a self-adjuvanticity property in the SAM platform that should, at least in principle, be beneficial for the generation of potent immune responses. However, the activation of PPRs is typically associated with the production of type I interferons (IFNs) by plasmacytoid DCs (pDCs) , which showed a more persistent protein expression than systemic intravenous delivery . RNA-LNPs (pDCs)  and the s (pDCs) , 30–32.The mRNA-based vaccines have shown to most likely leave the injection site through vaccine loaded myeloid DCs (mDCs) making their way to the draining lymph node (dLN) , where tSubsequently, circulating CD4+ and CD8+ T cells may undergo through two possible fates: apoptosis and survival into memory. Indeed, Th1 cells and CTLs may give rise to central memory (CM) CD4+ and CD8+ T cells, respectively. Moreover, depending on the mRNA vaccine doses, both Th1 cells and CTLs have been observed to produce IFNg , which iomics technologies, has resulted in the accumulation of a vast amount of data and information. With this work, we built from this unique opportunity and applied text-mining algorithms to screen and analyze scientific literature, with the aim of collecting all available experimentally validated evidence related to the mechanisms of action of mRNA vaccines. We processed and used this information to collect, in a centralized and structured fashion, the various stages of the immune response to mRNA vaccines across different organs and tissues. This knowledge base collection comes in the form of an interactive mechanistic graphical model, which allows to explore the different arms of the immune response to this kind of vaccines.mRNA vaccines are emerging as one of the most promising technologies in vaccinology. Several pharmaceutical companies and research institutes are working at the development of new platforms for mRNA-based antigen delivery, trying to identify and characterize those parameters that are required for a safe and protective vaccine response. This, combined with the recent advancements in To maximize the simplicity and interpretability, the model was built using the minimal set of graphical elements, consisting of arrows  and symbols representing relevant cells and immunoactive peptides. Ideally, a mechanistic graphical model should be readily available to the different stakeholders, should provide some level of interactivity for exploration of the underlying data and be readily upgradable to incorporate new evidences and information. Indeed, an interactive version of the model was made accessible, even remotely, using a web browser, by a proprietary javascript framework. Hosting a copy of the mechanistic graphical model on a remote server ensures future updates to be readily available, avoiding the need of sharing files and risk of misalignments among different versions. Furthermore, all the elements of the mechanistic graphical model can be clicked upon to access the original reference describing that specific evidence. The knowledge gathered during the development of the mechanistic graphical model provides an updated description of the biological phenomena underlying the immune response to mRNA vaccines. The graphical modelling platform can also facilitate the interaction among scientists from different areas, highlight potential gaps in data availability and knowledge and guide the design of new experiments. The natural evolution of this work would be to leverage on the quantitative information acquired during the process  to develop a mathematical model describing the immune response, across different biological compartments (e.g. injection site and lymph node) over time (manuscript in preparation). Ideally, this will help highlighting the key elements of an immune response to mRNA vaccines that are responsible for a protective response or, conversely, elements that may lead to suboptimal responses or undesirable effects. Provided an accurate mathematical model is achieved, this could be used to support the experimental design, by allowing to simulate multiple scenarios and predict their outcome. An example could be that of predicting a presumably safe dose range in a dose finding, first time in human clinical study.As mentioned before, modelling, and prospectively predicting, the behavior of the immune system is a highly challenging task. Consequently, the presented mechanistic graphical model should not be regarded as an endpoint but rather as a milestone within a broader modelling roadmap that we propose as a promising strategy to achieve a better understanding of the human immune system and how it responds to vaccination. The design of future studies for unraveling mRNA mechanism of action will have new pace through the use of literature mining and mathematical modelling, brought together by the power of modern technology.LL, GL, GS and SP computed the results presented in the paper. DT and SG provided technical support in implementing the interactive version of the graphical model. DM, ES and LM conceived the study. ES, GL, LL and LM wrote the manuscript. LL and GL share first authorship. ES and LM share last authorship. All authors contributed to the article and approved the submitted version.This research project was funded by GlaxoSmithKline Biologicals SA.GL, HS, DM, and ES were all employees of the GSK group of companies at the time of the study. The “Fondazione The Microsoft Research – University of Trento Centre for Computational and Systems Biology (COSBI)” institute received financial remuneration for conducting the activates described in this study.The authors declare that this study received funding from GlaxoSmithKline Biologicals SA. The funder had the following involvement in the study: study design, interpretation of data, the writing of this article and the decision to submit it for publication.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Although national licensing examinations (NLEs) may be a costly process, they can predict performance of medical practitioners for many years following graduation. The current licensing requirements do not fulfill this function as there are no clear performance criteria for them. Therefore, new requirements should be developed and announced.Objective: The study aims to develop a framework for the Egyptian Medical Licensing Exam (EMLE) by exploring the opinions and perceptions of Egyptian health practitioners and medical educators.Methods: This study is a two-phase exploratory mixed-method study. An online discussion forum was conducted with medical practitioners and educators concerning the development of the EMLE. Then, an online survey was distributed to explore the opinions of medical practitioners and educators about the EMLE.Results: Fifty medical practitioners and educators participated in the discussion forum about the development of the EMLE, while 266 participants responded to the online survey. The responses of the participants contributed to the development of a framework for the EMLE that is divided into two main sections, the exam logistics and the exam set up. The exam logistics included the exam committee, prerequisites for the exam, the admission criteria and fees, and validity of the license. The exam set up included exam setting, structure, pass marks, and exam retake policy.Conclusion: The study concluded that medical practitioners and educators could contribute greatly to the planning for the EMLE. Their opinions are based on their experiences and include the timing of the exam, blueprinting, assessment methods, psychometrics and retake. In response to the increased demand for social accountability over the last 20 years, many countries have shown a greater tendency towards improving medical regulations. This in turn created the need for extensive examinations to assure that minimum standards for competent medical graduates are being met . FurtherMany economic, political, and socio-demographic factors affect the regulation and licensing of novice doctors, causing variation from one country to another . The avaM.B.B.Ch). This allows the graduates to register, obtain their license, and become general practitioners [In Egypt, the Egyptian Medical Syndicate (EMS) and the Ministry of Health and Population (MOHP) regulate the registration and licensing of physicians . Until ritioners . There iitioners .There are many challenges that impact the quality of medical education in Egypt. For instance, there is an increasing need to improve infrastructure capacities and financial resources allocated for medical schools -10. In aA proposal for the Egyptian Medical Licensing Exam (EMLE) came to light in 2019. It was to be implemented in 2020 as a pilot for all graduates of medical schools across Egypt, but implementation was delayed due to the COVID-19 pandemic. The application of the Egyptian licensing exam is now supposed to be issued by the year 2023, with the graduation of the first batch of the new medical education curriculum (5+2). It would be helpful to learn about how the Egyptian medical practitioners and educators could contribute to the planning of this exam in terms of structure, logistics, pre-requisites, timings, etc. Therefore, this study aims to assist in the development and implementation of this important exam and help other international health systems that are willing to implement a medical licensing exam, especially those of a similar educational strategy. Accordingly, the current study presents a framework for the EMLE based on a deep investigation of Egyptian medical practitioners' and educators’ vision regarding the exam format and criteria.Study designA two-phase exploratory mixed-method study was conducted and included both medical practitioners and educators as shown in Figure Phase oneContext (Design)The first phase of the program was an online discussion forum held with Egyptian medical practitioners and medical educators. The forum was part of an online master’s program in medical education that includes students from different medical specialties, clinical and academic. The purpose of the discussions was twofold: (i), exploring the opinions of health professionals with respect to the purpose, context, preparation, and implementation of EMLE, in addition to (ii) designing a survey tool to explore the perceptions and opinions of medical practitioners and medical educators towards the EMLE.SamplingA voluntary response sample of 50 participants shared in the discussion forum. They were heterogeneous participants as they varied in gender, specialty, academic rank, working place and residence.Tools and Data CollectionAn online discussion (LISTSERV) was moderated by the researchers (Appendix 1). It was an asynchronous activity through email threads. The researchers prepared the discussion guide including the objectives, questions, case scenarios, and facilitators. The objectives of the discussion included exploring and critiquing participants’ opinions towards the EMLE regarding the criteria for development and admission, assessment methods, implementation, and certification/licensing requirements. The discussion was carried out over two weeks during February 2020. The discussion threads had reached 196 unique individual responses. The participants' responses were analyzed and summarized.AnalysisThe participants’ responses to the discussion were analyzed thematically, and in part, contributed to the design of the survey and its sections as this appears in their description in the second phase.Phase twoDesignBased on the results of the analyzed responses of the online discussion, an online survey was developed. It aimed to explore the opinions on a wider scale of medical educators, academics, and practitioners regarding the EMLE. The survey was composed of 17 items within four sections: participants’ characteristics, EMLE admission criteria, the exam structure, and the medical license renewal process.The survey was validated by 10 medical education experts from the Medical Education Department, Suez Canal University. The final version of the online survey was prepared and distributed, using Google forms (Appendix 2).Data CollectionThe survey was disseminated through various social media platforms to reach wide sectors of the medical community. The online mode was the most convenient method during the COVID-19 pandemic. These platforms included WhatsApp groups, Facebook groups and Facebook pages that gathered members from different medical practitioners’ and medical educators’ communities. Participants joined the study on a rolling basis over a month duration, March 2020. The survey was distributed on a wide scale among medical practitioners and medical educators in Egypt. A voluntary response sampling was applied in this study. It included 266 Egyptian medical educators and practitioners who responded to the online survey. The use of various social media platforms contributed to an equal chance for different Egyptian medical educators and practitioners to be included in the sample.Statistical AnalysisThe collected data were coded and analyzed using Statistical Package for Social Sciences (SPSS) version 27 . The results of the descriptive analysis were presented by calculating frequencies and percentages. Furthermore, bivariate analysis using a Pearson Chi-Square correlation test was used to compare differences in certain selected outcomes among groups of participants according to their affiliation and specialties. The results were considered statistically significant when p ≤ 0.05.Ethical considerationsEthical approval for the study was obtained from the Faculty of Medicine-Suez Canal University Research and Ethics Committee (FOMSCU 4317/2020). Data collection was done in accordance with the Helsinki Declaration . All theDemographic dataTwo hundred and sixty-six medical practitioners and educators responded to the survey. The study participants varied according to their professional rank as shown in Table What is the framework?The aim of the study was to develop a framework for the development of the EMLE exam through exploring the medical community’s opinions regarding the exam format and criteria. The input from the online discussion and the survey contributed to the development of the following framework that is divided into two main themes: A) The Exam Logistics and B) The Exam Set Up, as shown in Figure In the discussion forum, participants have highlighted the need for establishment of licensing exams for Egyptian medical graduates. A clinical educator stated, “from my point of view, establishment of EMLE is an urgent need, and it is applied on a wide scale in different countries worldwide”. An academic educator added “Application of this system serves different dimensions such as internationalization of the medical education, better opportunities for accreditation, and preparation of the medical graduates for the global world”.Another clinical educator mentioned, “I think there are two important driving forces for the establishment of licensing exams; the increased number of medical schools in Egypt and the need for a standardized exam that ensures the achievement of common standards of medical knowledge and clinical skills among Egyptian graduates”. Another academic educator added “EMLE will ensure that standards are met and will maintain the high reputation of Egyptian physicians’.A. The exam logisticsThe EMLE Committee (A Multidisciplinary Team)Participants in the discussion forum highlighted that EMLE should be conducted and maintained by several parties: representatives from staff members of medical schools and consulting experienced organizations in exam conduction. Also, they recommended the recruitment of medical education experts to assist in the development, administration and psychometric measures of these examinations in order to attain high test standards.Also, the participants of the discussion provided suggestions regarding the committee for EMLE. They all agreed that the team should be multi-disciplinary and responsible about the planning, implementation, and evaluation of the exam. A clinical educator mentioned “The personnel in the multidisciplinary team should be clinical and basic science professors from different universities and ministry of health. Also, I recommended the presence of medical educationists, infection control, medical ethics and quality control specialists in the team”. While another academic educator added “I recommended that an independent subcommittee must revise and validate the difficulty of the questions included in the question bank prepared by the multidisciplinary team, and I suggested an intensive training should be provided for this team prior to the preparation of the question bank”.Prerequisites For the EMLE Regarding the prerequisites of admission, all the participants agreed that the students should be holders of a bachelor degree and graduated from an accredited Egyptian - or international - medical school listed in the Egyptian Supreme Council of Universities. In addition, credit hours in social, behavioral and clinical competencies, were suggested. An English language certificate (TOFEL or IELTS) and computer skills courses were proposed as a must in the prerequisites. On the other hand, other respondents cited that a proof of attendance of Continuous Medical Education (CME) activities is also suggested.According to the survey results, most of the participants selected the Basic Life Support (BLS) certificate (80.8%), an English language certificate 72.6%), a basic computer skills certificate (i.e. ICDL) (63.2%), and an accepted house officer’s portfolio/logbook (60.2%) as obligatory admission criteria for the EMLE  encouraged allowing the house officers to apply for the EMLE immediately after the end of the two years pre-registration house officers period (internship). The rest of the participants recommended later admission that ranges from two to six months after the completion of the undergraduate studies as shown in Table Fees and Validity of the LicenseMost of the participants in the survey (65.8%) proposed that the first-time application for EMLE should be free of charge and that payment should be only in case of the exam retake. Regarding the License validity, 42.1% of participants recommended a 5 years validity period for the license, in addition to completion of Continuous Medical Education (CME) hours during this duration. Another 39.1 % recommend an open validity duration till applying for a new position or promoting, with CME hours during this period. Finally, few participants have recommended 10 years as a validity period or a single life-long licensing as shown in Table The current study revealed a statistically significant difference between participants’ affiliations and their preferences for EMLE fees, where the majority of participants (72.8%) who work at academic institutes preferred the exams to be paid for, in comparison to participants affiliated to the Ministry of Health who preferred that fees be paid only when exams are related to their promotion, rather than at each setting, even if the first one was waived (p = 0.019).B. The exam set upThe Exam Settings (the EMLE Test Centers)Many participants in the online discussion have highlighted the importance of convenient infrastructure, logistics, and human resources. A summary of the participants’ opinions regarding the EMLE test center’s criteria is as follows:Infrastructure: Responses included the need to have large, equipped, and air-conditioned exam halls, with seating arrangements allowing for distancing, as well as enough measures for exam security. In the case of electronic exams, the responses showed the need for upgraded functioning computers, with high internet connection that is fast and secure. Besides, IT support teams could also include medical educators or e-learning specialists. If OSCE Exams are to be implemented, exam centers should have skill labs, highly simulated mannequins and equipment.Human resources: Some responses stressed on the importance of having invigilators, in addition to a medical support team to attend to urgent matters, if needed.Availability and accessibility: Exam centers should be available in terms of number or geographical distribution with the capacity to accommodate a large number of students.Comfort, safety and ease: This was highlighted in terms of providing elements that allow students to perform without being exposed to internal or external factors, including environmental factors, in terms of seat comfort, adjusted temperatures, proper lighting, aeration and ventilation and noise levels.Exam instructions: Instructions are to be stated clearly. Instructional notes and posters could be available to aid and remind examinees about exam process, and regulations. Exam support team should be ready and available to respond to inquiries.The Exam Structure  The online discussion participants have reached a consensus regarding the proportional weights of disciplines to be included in EMLE blueprint. They suggested: Internal Medicine (25-30%), Surgery (20-30%), Obstetrics and Gynecology (15-25%) and Pediatrics (15-25%). A considerable number of participants added Primary health care, ICU and Basic Sciences.The survey participants have added the type of assessment methods and the appropriate number of test items in the exam as shown in Table Moreover, all the study participants agreed that the exam shall focus on interpretation and case-based scenarios. As mentioned by a clinical educator “The MCQs should be constructed to assess higher cognitive levels and should be based on clinical vignettes to increase clinical reasoning ability for reaching diagnosis, investigation and management options.”The results also showed that 51.5% of participants recommended the exam to be carried out in two sessions separated by a break on the same day, with every session lasting for 1.5 hours, while 32% recommended to carry out the exam on two sessions also, but on two separate days, each is for two hours for theoretical and another two hours for the clinical assessment sessions as shown in Table As shown in Table Post-test analysis and psychometrics of the exam were discussed by the participants of the online discussion which favored the selection of MCQs and emphasized on applying the utility formula of assessment, as well as analyzing exam psychometrics.The Exam Standard-Setting and Pass MarkRegarding the pass mark of EMLE, most of the participants of the survey 177 participants (66.5%) recommended a score of ≥60% to pass the exam. Forty-five participants (16.9%) recommended the passing score to be ≥70%, while 34 participants (12.8%) suggested the passing score to ≥50% as shown in Table The Exam Retake Policy and RequirementsThe survey respondents recommended a time interval for applying for the retake exam and additional prerequisites to be attached as evidence of competencies enhancement. The time interval ranged from immediate retake to a maximum nine months. Most of the participants 155; 58.3%) suggested no added prerequisites before the retake exam, while some participants  requested additional prerequisites as interviews and CME hours as shown in Table 5; 58.3% The current study is important as it suggests a framework for the development of licensing exams that can provide evidence about potential healthcare providers’ competency and determine those who are able to satisfy licensing requirements to practice according to regulatory standards. This would reassure the public that healthcare would be maintained with high-performance providers across the different delivery indicators.The suggested time for EMLE administration in this study ranged between immediately after, to six months interval after the completion of the two years internship training. In some European countries, like Belgium and Hungary, medical graduates are allowed for registering for licensing exams immediately after obtaining a medical degree, while other countries like Malta require proof of professional practice . RegionaThe current situation of licensing in Egypt is based on two obligatory criteria, completion of a bachelor degree in medicine and surgery from an Egyptian university or from an international university that is accredited by the Egyptian Supreme Council of Universities, and completion of the medical pre-registration house officer year(s). The current study suggested other prerequisites for licensing, such as Basic Life Support (BLS) courses, basic computer skills certificate, and an English language certificate. The main purpose of collecting more evidence on skills acquisition is to improve the professional life of the graduates through gaining skills that are essential for their career. The English language plays an important role in medical studies to help graduates to be eligible for international mobility. In line with this concept, Kovacs et al. raised a concern about the effect of language incompetency on patient safety and requested to balance freedom of movement between countries/workplace with language competence. Moreover, basic computer skills are beneficial for reporting and documentation, communication, research, and learning of graduates . After tThe study highlighted the importance of using a portfolio as a prerequisite for EMLE. Portfolios are beneficial for monitoring and documenting progress in a longitudinal and continuous manner, as well as helping in the development of the physician through reflection and self-assessment . PortfolEMLE is a high-stakes exam; it may shape and control the physician's career. Therefore, it is important for the exam to fulfill all the criteria of objectivity and fairness. The framework suggested in this study included several parameters to ensure these points. First, a test blueprint is an important starting step to be planned in accordance with the National Academic Reference Standards (NARS) and the national competencies of the Egyptian medical graduates. The purpose of the blueprint is to ensure that both content and face validity of the test are determined . Second,It is important to bear in mind that the exam is multidisciplinary and should be testing different levels and domains. Therefore, The MCQ format may be more applicable as it can be used in large numbers. These advantages guided the recommendation of the test item number in our study that ranged from 100-200 items to 150-300 MCQs. It is also important for MCQs to be constructed to assess higher cognitive levels, such as analysis, synthesis, and evaluation, and be based on clinical vignettes to increase the likelihood of integrating the clinical sciences . In the United States, the first part of USMLE consists of a 322 MCQ to measure the basic science knowledge, divided into seven blocks with 46 items per block, and each block for one hour with a maximum of seven hours testing .Furthermore, other types of summative assessments were suggested; clinically related Short Answer Questions (SAQs), and Modified Essay Questions (MEQs) to assess theoretical knowledge and OSCE and simulated clinical exams were the best choices for the clinical skills assessment. This is the current situation in many countries all over the world like Canada, Ireland, Korea, Switzerland, the United States, and the United Kingdom . In SaudAdding another important point to the fairness and objectivity of the exam, most participants recommended a standard set of ≥60% to pass each part of the exam separately. Additionally, the post-exam psychometrics analysis is of high importance as it considers the quality check of the exam items after its implementation. For instance, the Difficulty Index could gauge how 'hard' or 'easy' the question is . In addiIt is important to consider that the NLE is an obligatory exam. Therefore, flexibility and practicality are essential. This can be reflected in the retake policy, fees, and license validity period. The retake policy is recommended to be flexible in terms of time and requirements. In Saudi Arabia, all eligible candidates have the chance for three exam sittings since their first attempt if they failed to achieve a passing score .Regarding the fees, the current study defends the support of the medical graduates by waving them from the exam fees for the first time. It is an essential issue to be considered that the country provides the exam for the first attempt with free or even at low cost in relevance to the salary provided to the candidate during their internship training year. Exam costs should be considered, as they differ among different countries due to the nature of the implemented exams, available resources, and number of applicants. In the United States, licensing exam total fees would amount to 3200 USD, comparable to 800 USD paid by international medical graduates . TherefoFinally, the validity of the license was a point of difference and debate between the participants. The validity period may vary but the fact that the NLE is a discriminating exam should be considered. Accordingly, it may be better to give the applicants the time for learning and maturity before re-taking the exam. Moreover, taking the exam several times may create wise students who can beat the system and pass the exam easily. Adding to this, the burden that will be added on the test developers’ team for continuous development, revision and adding new test items to safeguard the test from losing its main purpose. The current study revealed no differences between clinicians and academics in respect to their responses towards the validity of the license. More in both categories chose open validity until promotion. Promotion is a valued merit where progress in the field, acknowledgement by peers and salaries may depend upon, yet it was the least option that required renewal. Regular intervals of certification and providing CME proof are universally recognized as means of ensuring quality of profession and updating knowledge and competencies .Overall, the study showed the perceptions and aspirations of the medical education community towards the EMLE and enabled the development of a framework of EMLE that could guide its planning, implementation and evaluation.The current study has developed a framework for the Egyptian National Medical Exam. The framework focused on two main themes: the exam logistics and the exam setting. A multidisciplinary team was suggested for the exam committee together with convenient infrastructure, logistics, and human resources for the exam setting. Fairness and objectivity were highlighted through several factors: development of exam blueprint, types of the assessment methods and post-exam analysis. Finally, the retake policy, fees and validity of the license was recommended with a student-centered perspective. We tried to suggest a roadmap through a critical reflection for the best of the Egyptian health care system. We want to stress that this exam is not "the Magic Solution" for all our medical education system’s challenges in Egypt. But it is considered as a good starting point towards standardization and globalization of the Egyptian medical education. Additionally, it is a recommendation for further study to explore the views of the students about the EMLE after its real implementation by the year 2023.Although the current study used the suggestions of medical practitioners and educators regarding the suggested framework of the EMLE development, the results might have related to the experiences of the presented sample and therefore not be generalizable to a larger population. Despite this, we have tried to use all the available platforms, multiple mixed methods and reach diverse participants.


Catheter-associated urinary tract infection (CAUTI) is the most common complication in patients with indwelling catheterization. The incidence of CAUTI in my country is still at a relatively high level compared with foreign countries, especially for the ICU, which has a high usage rate of urinary catheters, to focus on prevention and control. This article focuses on studying the risk factors of CAUTI in critically ill patients and discusses targeted preventive care measures. This article investigates and examines the clinical data of CAUTI in critically ill patients. After statistical analysis, the risk factors that affect CAUTI are summarized, so as to derive the cause of CAUTI in order to strengthen clinical care and to further study the prevention, control, and nursing of CAUTI to provide reference. Clinical data shows that the CAUTI infection rate of patients with catheter indwelling ≥7 days is greater than that of patients with catheter indwelling days less than 7 days. The CAUTI infection rate of the patients who change the urine collection bag every day or ≥7 days is greater than that of the patients who change the urine collection bag within 2 to 4 days. CAUTI refers to the urinary tract infection that occurs in patients after the catheter is indwelled or within 48 hours after the catheter is removed , 2. ResiRegarding the research of CAUTI, many scholars at home and abroad have conducted in-depth discussions. For example, Roy et al. found through research that if the recommended preventive measures are taken, the occurrence of CAUTI can be reduced ; MuramatThis article focuses on studying the risk factors of CAUTI in critically ill patients and discusses targeted preventive care measures. This article investigates and examines the clinical data of CAUTI in critically ill patients. After statistical analysis, the risk factors that affect CAUTI are summarized, so as to derive the cause of CAUTI in order to strengthen clinical care and to further study the prevention, control, and nursing of CAUTI to provide reference.With the extension of permanent catheters in ICU patients, the incidence of CAUTI also increases. This is because the permanent urinary catheter destroys the normal environment of the urethra, and the immune system weakens the phagocytosis of neutrophils, which affects the physiological role of the bladder on bacteria, making it easier for bacteria to enter the bladder and ureter, and the development of organs in the system and reproduction can cause infection , 12. At In other words, for patients with long-term indwelling catheters, frequent replacement of catheters may be more likely to cause urinary tract infections, so the most appropriate replacement method is generally to replace the patient when the patient has an infection or the catheter is blocked.x2 = 7.21, P < 0.05).After processing the survey data, the impact of patient age distribution on CAUTI is shown in It can be seen from With age, the body's physiological defense function gradually decreases, and the functions of important organs in the elderly ≥60 years old gradually deteriorate, making them susceptible to CAUTI. At the same time, most elderly people are accompanied by serious chronic diseases. Once invasive operations such as catheterization are performed, the immune defense function of the whole body will be damaged, the resistance will be greatly reduced, and the susceptibility to diseases will be greatly increased.CAUTI can severely affect the quality of life of elderly patients and increase the time of hospital stay and medical expenses. Therefore, the principle of aseptic surgery should be strictly adopted in the treatment and care of elderly patients to reduce unnecessary invasive surgery. Multiple methods can be used to improve the immune function in elderly patients and reduce the morbidity.x2 = 5.24, P < 0.05).The comparison of CAUTI infection rates with different urine collection bag replacement time is shown in It can be concluded from Changing the urine collection bag every day will artificially destroy the closed drainage system and easily contaminate the connection between the urine collection bag and the urinary catheter, resulting in a significant increase in the infection rate of CAUIT. The urine collection bag replacement time is ≥7 days. The urine is prone to turbidity and crystallinity, which increases the probability of urethral obstruction. It is easy to cause bacterial viruses and other pathogenic microorganisms to multiply, which directly leads to an increase in the CAUIT infection rate. Therefore, the best time to replace the urine collection bag is 2 to 4 days.Patient's catheter replacement time should best be replaced every 2 weeks. By extending the mounting time of the catheter, a bacterial biofilm will be formed on the surface of the catheter to facilitate the adhesion and reproduction of bacteria and viruses. Bacterial biofilms can protect bacteria and viruses from host immune responses and eliminate bacteria. Therefore, it would be difficult to remove the source of infection without pulling out or replacing the catheter.Medical institutions need to set up full-time management personnel to formulate and update the detailed rules for the application of cluster management to prevent CAUTI in critically ill patients and regularly conduct publicity and education, skill training, implementation inspections, and effect evaluations for medical staff. At the same time, the necessary medical conditions are provided for cluster management. At least each ward should have a handwashing basin, and each bedside should be equipped with disinfectant.The implantation of the catheter should be performed by a qualified physician. The hands should be cleaned with soap or hand sanitizer before the operation, and sterile gloves should be worn during the operation; hands should be cleaned before and after the catheter is used and before and after changing the dressing of the puncture site, if possible. It is best to wear clean or sterile gloves; when the catheter is pulled out, it is recommended to wear sterile gloves to avoid infection caused by bacteria passing through the puncture point due to contact.Surgeons should wear masks, hats, sterile gloves, sterile surgical suits, and use sterile masks covering patient's whole body to reduce the number of observers. The optimal catheter location and type of catheter were selected based on patient's own condition. For patients with high risk of infection, a catheter coated with heparin or antibiotics can be used. It is recommended to cover the puncture site with a transparent dressing or sterile gauze after surgery. Transparent dressing is more convenient to observe the puncture point than sterile gauze and contributes to the timely detection of infection signs.The choice of catheter type and material depends on the size of patient's urethra and clinical judgment. Generally, hydrophilic materials are selected. Urinary catheters should be thoroughly disinfected before and after use to avoid multiple uses of one tube. After dialysis, the residual urine in the catheter should be flushed with normal saline. Patients with high risk of infection or suspected CAUTI patients should be given antibiotics and sealed with sterile gauze. Evaluate whether the catheter continues to be retained every day, and pull out the catheter that is no longer in use in time. At the same time, patient's body temperature should be monitored every day to facilitate timely detection and treatment of CAUTI.v/E) under a unit electric field is called mobility or electric mobility (μep), and the mobility measured in an infinitely diluted solution is called absolute mobility μ0ep. Under the action of the electric field, the electric field force received by the dotted particle Fe is equal to the product of its static charge q and the electric field strength E, namely. L is the length of the capillary.Capillary electrophoresis, as a new high-efficiency separation technology, is developed on the basis of traditional electrophoresis. The basic theory lies in the transfer of solutes in the capillary zone electrophoresis process. Electrophoresis is the directional movement of charged particles under the action of an electric field. The electrophoresis rate  Patient's urinary tract infection information: according to patient's state of consciousness, the CAUTI infection rate was divided into four levels: lethargy, confusion, lethargy, and coma for comparative analysisThe number of days hospitalized by case inquiry is the time of stay from the date of stay to the date of investigation. The mean length of hospitalization between the two groups was calculated based on whether they had CAUTI, to classify patients into infected and uninfected groups. Previous medical history mainly discussed whether the relationship between patients have diabetes and benign prostate hyperplasia and the CAUTI infection rate. According to patient's urine collection bag replacement time (days), it is stratified into four levels: 1, 2~4, 4-6, and ≥7; according to the urinary catheter replacement time (weeks), the stratification is 1, 2, and ≥4 three levels.Before collecting data, conduct intensive training for investigators. The investigators included 4 postgraduates from the nosocomial infection research group and 3 postgraduate nurses in neurosurgery of the hospital. The training content includes investigation methods, data collection, knowledge about CAUTI infection, treatment, and nursing knowledge and skills.The investigator himself screened patients with indwelling catheters, explained the purpose, methods, and rights of the study to eligible patients, and obtained their patients' informed consent before they were included in the study. In this study, general patient information was collected by consulting medical records and bedside inquiries.The investigator kept a urine specimen on the day the catheter was removed. The method is before removing the urinary catheter, disinfect the sampling point with a cotton swab soaked in the urinary tube , draw 510 ml of urine from the catheter with a sterile syringe, and inject it into the sterile specimen cup. After collecting the urine sample, immediately send it to the laboratory for culture test. For patients with repeated catheterization, the catheter needs to be kept before removal each time.Before data entry of the questionnaire, the data of all the questionnaires shall be initially screened, and the questionnaires with serious missing data shall be excluded. The duo entered the data into the Excel database and repeatedly verified the proofreading data information.Most patients in the ward who require surgical treatment require indwelling urinary catheters, except for patients who have undergone intramedullary nail removal and plate removal. On the day of the operation, before being sent to the operating room, the doctor in charge issued a medical order, and the responsible nurse performed indwelling catheterization. The indwelling guide tube is then brought into the operating room by the patient. For some male patients with enlarged prostate or elderly women with hypertrophic labia, indwelling urinary catheterization is performed by nurses in the operating room.After completion of the operation, the patient can be transferred to ICU observation according on patient's condition or directly returned to ward's treatment. Patients transferred to ICU usually return on day 23 after surgery and after a stable condition. Following doctor's order to remove the catheter, the nurse removed the catheter 27 days after surgery. Individual patients can be hospitalized for up to 1 month.When the patient is lying in bed, fix the urine collection bag of the urinary catheter to the bed unit with a pin to avoid discounting or bending. The height of the urine collection bag is lower than the level of the bladder to avoid contact with the ground and prevent retrograde infectionDuring the indwelling catheter, use a broken solution to clean the urethral opening, once a day in the morning and afternoon. Patients with fecal incontinence should also be disinfected after cleaningAccording to the type of urinary catheter, short-term urinary catheters should be replaced every 7 days, and long-term urinary catheters should be replaced every 30 daysChange the urine collection bag every 3 daysIrrigation is not routinely performed, and antibiotics are not routinely used for bladder washingBefore removing the urinary catheter, perform clamping to train the bladder function. The method is to remove the bladder when the patient is willing to urinate after the clamping. There are also patients who are intermittently clamped according to doctor's request, open every 4 hours, and remove the catheter after 12 days of exerciseNursing and management requirements after intubation:When nurses find suspected signs of infection such as fever, lower abdomen pain, and percussion pain in the kidney area in patients with indwelling catheterization, they should take physical measures such as cooling down and report patient's condition to the doctor in charge to assist the doctor in taking corresponding treatment and collecting urine specimens.x2 = 5.06, P < 0.05, the difference is statistically significant.The effect of catheter replacement time on CAUTI is shown in It can be concluded from x2 test, x2 = 6.91, P < 0.05, which is statistically significant.The comparison of the CAUTI infection rate of different underlying diseases is shown in From CAUTI is one of the common complications of critically ill patients with indwelling catheter. This article focuses on studying the risk factors of CAUTI in critically ill patients, and discusses targeted preventive care measures. This article investigates and examines the clinical data of urinary CAUTI in critically ill patients. After statistical analysis, the risk factors that affect CAUTI are summarized, and the causes of CAUTI are obtained in order to strengthen clinical care, to further study the prevention, control, and nursing of CAUTI to provide reference.


To determine the instructional programs required by volunteers based on the studies carried out worldwide.A systematic search was carried out by PubMed, Cochran Library, Scopus, EMBASE, Science Direct, Web of Science and ProQuest databases between January 1970 and the end of June 2019. The articles were selected based on the keywords chosen by the author. In the end, the volunteer’s instructional titles were extracted from the articles in disasters.Eleven articles were chosen for final analysis after studying the titles, abstracts, and complete articles texts which 45 instructional titles were extracted. The most frequent scales in terms of repetition were ethics, kinds of exercises, personal protection instruments, general hygiene, awareness of certain disasters, accident command system, disaster triage and emergency planning. Governments should offer programs that can best serve the improvement of their performance by considering the daily increasing growth in the number of volunteers and in natural and manmade disasters. Universities and schools play determinant roles in this regard. It is hoped that the present study findings can be effective in codify an efficient instructional program for elevating the performance of the volunteers by taking part in disasters response. People who lives in developing countries are usually more influenced by natural disasters. In fact, the majority of mortalities and casualties occur in these countries . Human bst century [Volunteer refers to an individual who tends to spend time for a good deed without expecting any money in exchange . Volunte century . Volunte century . Digital century , 10. Vol century . Volunte century .Volunteers are recommended to be trained; therefore, their capacities can be put into practical use at the time of disasters when there are few or no professionals . The relOverall, the majority of countries around the globe are disaster-prone. Volunteers pervasively and comprehensively attend various disaster scenes but they usually have relatively low knowledge and awareness. The present study aims to determine the instructional programs required by volunteers based on the studies that have been carried out worldwide.Eligibility Criteria and Search StrategyThe study protocol was first registered in PROSPERO database with the identification number CRD42020187680. In this systematic review, the search method was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). A systematic search was conducted in peer-reviewed and English texts from January 1970 to June 2019 which were related to the study question; i.e., “what instructional programs are required to enhance the volunteers’ knowledge and awareness in disasters?”. At first, a general and swift search was carried out in Cochrane Library Database to ensure that no systematic reviews were carried out in this regard. No similar articles were found. Then, searches were conducted in electronic databases like PubMed, Cochran Library, Scopus, EMBASE, Science Direct, Web of Science, and ProQuest. Moreover, additional searches were made in grey literature includes books, internet websites, conference articles and dissertations. The group of using words was made the operator “and”, and it was considered as separate concepts. Furthermore, operator “or” was applied between the synonymous words. Searches were conducted in the titles, abstracts, and keyword of the articles. In PubMed database, MESH term was utilized for finding the articles. The employed search strategy has been shown in Inclusion CriteriaFirstly, the keywords related to instructional programs required by the volunteers in disasters had to exist in the titles, abstracts and keywords of the searched articles. The related works’ abstracts were studied and finally the whole articles were analyzed by using assessment tools. The searches in the present systematic review were carried out for the articles published from 1970 to the end of June 2019. Unpublished articles (grey literature), protocols, conference articles, guidelines, instruction manuals, and credible organizations’ reports were explored, as well. The review, qualitative and quantitative articles were selected. Peer-reviewed articles were also selected.Exclusion CriteriaThe articles of irrelevant variables to the study question were omitted.ScreeningAt first, all articles title were investigated by the author from the databases. The articles that met the inclusion criteria and were related to the study question were chosen. In the next stage, the selected articles’ abstracts were read by the author. Next, the parallel articles of the study goal and inclusion criteria were selected and the articles perfect texts were read and evaluated by the author. In the end, the instructional titles’ articles required by the disaster’s volunteers were selected. PRISMA guidelines were employed to evaluate the articles. Documentation and publication biases were also taken into consideration and the articles with a high rate of documentation were carefully evaluated. Quantitative articles were evaluated with strengthening the reporting of observational studies in epidemiology (STROBE) checklist, qualitative articles with consolidated criteria for reporting qualitative research (COREQ) checklist, mixed methods articles with consensus-based Standards for the selection of health status Measurement Instruments (COSMIN) checklist and review articles with PRISMA checklist. The entire aforementioned stages were repeated twice.Data ExtractionThe required information was extracted based on a summarization and data gathering form after carefully reading the articles. The information includes the corresponding author, study population, study sample size, study period, study design, data gathering instrument, study method, results, limitations, conclusion and instructional titles required by the volunteers. The summarization forms were completed for each of the selected articles. Two researchers completed all the forms and exhibited their tabular form following the investigation of all the articles. Finally, other study’s researchers offered their ideas regarding the conflict issues in the articles. The forms were composed in Microsoft Word, version 2016.After searching the databases, 12712 articles were selected. Of these, 4026 were omitted because they were found repeated in various databases. After investigating 8686 article titles, 8601 were excluded because they were found not to be consistent with the study goal. The 85 remained articles’ abstracts from the previous stage were studied and 71 articles were excluded due to not being relevant to the study goal. Eventually, 14 complete article texts were selected for this study. In the end, 11 complete articles’ texts were found to be perfectly matched with the study goal. The articles selection process has been depicted in A summary type of the extracted articles has showed in The results analysis obtained from the selected articles has showed in After reading the perfect texts of the 11 articles, the results were summarized in The present study aimed to extract the instructional titles required by volunteers in disasters of various countries around the globe. According to the results, six cross-sectional studies were dealt with the investigation of knowledge, awareness and instruction of the volunteers through questionnaires. Indeed, two combined articles were dealt with the issue through interviews, modeling methods, questionnaires and focus group sessions. Three review studies were carried out, as well. Out of the extracted studies, six were conducted in the US. After that, the highest studies’ frequency was related to Indonesia, Thailand, Japan, China and Australia since devastative natural disasters had occurred in these countries and volunteers played more accentuated roles in the rescue and relief operations. st century. In Australia, five strategies have been taken into account for emergency conditions management includes the strategies development of flexible volunteers, corroboration of the active and always ready volunteers, surge capacity, digitalization of the volunteers, and growth in the volunteers’ skills and society-oriented interventions to reduce disasters [Considering the fact that the society’s resilience is enhanced in the course of disasters, more accentuated roles are expected to be exhibited by the volunteers in disasters. However, the roles of the volunteers have undergone more considerable changes in the 21isasters . CertainVermont’s Department of Healthcare (VDH) in the US has codified an instructional program with three goals including background information about general hygiene, preparation under emergency conditions and practical instructions to the volunteers. The main components of the instructional programs are goals and capacities of general hygiene, an introduction to preparation under emergency conditions, exercises, personal and familial preparation exercises and guidelines. In order to increase the volunteers’ potentials, multivariate instructional programs were implemented online, by email, and in person . In thisInitial precaution, disaster triage, search and rescue, logistics and communications, and organizational team are amongst the most important titles that should be taught to the volunteers. However, few studies have been conducted on the knowledge and skill of emergency care in disasters. It has been suggested that the volunteers should be trained in the same way that their capacities can be utilized when there are few or no professionals present on the disasters scene . Start tMoreover, the volunteers who get present for rescue and relief in disasters should be able to restore themselves psychologically and physically. Furthermore, governmental organizations should provide the damages’ information to predict the disasters course as well as the prevention instruction of disaster occurrence for the local residents. Residents should also prepare the incident map and disaster prevention with the assistance of other habitants. In the end, enhancement of the local associations’ activities might increase the residents’ cooperation .The volunteers’ needs for psychological health in response to disasters are of great importance and should have be taken into account by policymakers. The volunteer’s disaster-responding might have special psychological health needs. Thus, certain measures should be taken into account for psychologically supporting the volunteers who have stress and worries and are not mentally prepared . In thisThe volunteers attending disasters should have a good deal of knowledge and awareness; therefore, they can provide proper response to this kind of incidents. Universities are important environments for performing voluntary interventions. A private organization volunteers who are willing to help in the course of natural disasters and have certain skills can also be useful in damages reduction. As for the settlement of the volunteers in the course of disasters, things should be learnt and instructed. The disasters instructing preparation is a rational step for the volunteers in universities . The volIn response to natural and manmade disasters, the governments should offer instructions to improve their performance by considering the daily increasing growth in the number of individuals who taking part. Universities and schools also play determinant roles in this respect. It is hoping that the findings of this study can be effective in codification of an efficient instructional program for enhancing the volunteers’ performance in respond to disasters. Considering an effective and decisive presence of volunteers in natural and man-made disasters and their awareness of vital issues such as self-protection with personal protective equipment (PPE), incident command system (ICS) and first aid measures can help save the lives of the injured or sick as was observed in the COVID-19 crisis.Planners and policy makers of relief organizations includes the Red Crescent, the Red Cross, and the Ministry of Health should formulate a training program to help the integrate maximize training, performance and effectiveness for volunteers. It has reached the ultimate goal of disaster management which is reducing deaths and injuries.Study LimitationOne of the limitations of this study was using only English made articles. The search was also very extensive and covered a wide spectrum which led to the selection of a large array of articles.


It becomes a difficult and time-consuming process for radiologists to do the manual identification and categorization of the tumour. It is a complex and time-consuming procedure conducted by radiologists or clinical professionals to remove the contaminated tumour region from magnetic resonance (MR) pictures. It is the goal of this study to improve the performance and reduce the complexity of the image segmentation process by investigating FCM predicted image segmentation procedures in order to reduce the intricacy of the process. Furthermore, relevant characteristics are collected from each segmented tissue and aligned as input to the classifiers for autonomous identification and relegation of encephalon cancers in order to increase the accuracy and quality rate of the neural network classifier. An evaluation, validation, and presentation of the experimental performance of the suggested approach have been completed. A unique APSO (accelerated particle swarm optimization) based artificial neural network model (ANNM) for the relegation of benign and malignant tumours is presented in this study effort, which allows for the automated identification and categorization of brain tumours. Using APSO training to improve the suggested ANNM model parameters would give a unique method to alleviate the stressful work of radiologists performing manual identification of encephalon cancers from MR images. The use of an APSO-based ANNM  model for automated brain tumour classification has been presented in order to demonstrate the resilience of the classification model. It has been suggested to utilise the improved enhanced fuzzy  In the current medical sciences and clinical research developments, many models have been developed for earlier tumor detection for saving a patient's life. Perhaps, detecting tumor from MRI scans is a very time-consuming and complicated process. It takes several times for segmenting the tumor cells from brain tissues . ConsequThe supratentorial cortex is a term used to describe the cortex in specific cases. Located in the frontal lobe of the brain, it is responsible for decision-making. Hemispheres are found on each side of the brain, with one on each side of the brain. It is the cerebrum's responsibility to perform the following activities, among others: movement initiation and coordination, temperature, touch, vision, hearing, judgement, thinking, problem solving, emotions, and learning. The cerebrum, also known as the cortex, is the most important region of the human brain. It is responsible for the majority of cognitive functions. It has been shown to be associated with higher order brain activity such as thinking and action, among other things. The cerebral cortex is divided into four areas, known as lobes, which are as follows: the frontal lobe, the parietal lobe, the occipital lobe, and the temporal lobe. The frontal lobe is the largest of the four lobes. In terms of prominence, the frontal lobe is the most prominent of them. The frontal lobe is engaged in problem solving and critical thinking, among its many other activities. It also regulates a variety of aspects of the voice, movement, and emotions. Parietal lobe regulates the functions of movement, direction, recognition, and perception of inputs in addition to other activities. The occipital lobe is a part of the brain that is involved in the processing of visual information. Aspects of the temporal lobe's function include the detection and identification of auditory events, as well as the storage and creation of words.Tumor is a standout amongst the most well known and deadly of the regular brain disorders, and it is notably harmful in children. Worldwide, according to estimates, more than four lakh individuals suffer from tumours each year, and early identification and treatment are crucial for more than four lakh people who suffer from tumours each year in the United States. Therapies using imaging technologies have progressed to the point that they may be employed in a variety sectors of medicine, including computer-aided pathology diagnosis, surgical planning, and directing, as well as longitudinal investigation, among others. In neuro-science and neurosurgery, magnetic resonance imaging (MRI) and computed tomography (CT) are the two therapeutic imaging modalities that are most often employed, out of all the therapeutic imaging modalities available. The segmentation of objects from magnetic resonance imaging, especially anatomical structures and disorders, is an important endeavour since the results are extensively utilised as the basis for a range of applications. Segmentation techniques differ significantly based on the specific application and image modality that is being utilised in the segmentation procedure. Additionally, medical image segmentation is a difficult procedure since medical pictures often include a large amount of data as well as a few artefacts as a result of the patient's short collecting period and sensitive tissue boundaries that are not always clearly defined. When dealing with brain tumours, a range of complications arise, making it difficult to categorise them into discrete categories. Various tumour types exist, with each having a distinct mix of forms and sizes. Cancer is classified into several categories. Depending on the scenario, it may emerge in any area and with varied image intensities, or it may occur at all. Some of them induce deformation of the surrounding structures, while others may be connected with oedema, which causes the intensities of pictures around the tumour to change. Oedema is a condition in which the intensity of images around the cancer changes. Additional to this, the existence of a few distinct magnetic resonance imaging collecting methodologies gives various information on the brain's structure and function. With each shot, a different aspect of the tumour is brought to light in some manner. Automatic segmentation based on past models and the utilisation of prior knowledge are both difficult tasks to complete. The exact segmentation of the inner architecture of the brain is a source of considerable interest in both cancer research and the treatment of malignancies, and it is becoming more important. The mortality rate for thyroid cancer is being lowered, and the surgical and radiotherapeutic treatment of thyroid tumours is being improved. An evocative human brain model is also desirable because it enables researchers to coordinate tumour information extracted from magnetic resonance imaging (MRI) and computed tomography (CT) images, such as tumour localization and shape, function, and the tumor's impact on surrounding neural tissue and brain structures, with information extracted from other sources. While the medical imaging industry has made multiple efforts and witnessed some hopeful results in recent years, reliable and repeatable segmentation and abnormalities characterisation continue to be very difficult tasks. Automation, applicability, and accuracy are all areas where existing approaches have significant space for improvement. Because it can image at any angle without the use of potentially harmful radiation, magnetic resonance imaging (MRI) is excellent for diagnosing diseases of large vessels as well as structural changes of the heart and heart lining. It also provides more accurate information than conventional echocardiogram regarding the structure and function of the heart, as well as excellent tissue differentiation regardless of whether contrast material is used. The MRI system may cause tissues in the body to appear in a number of different ways depending on the examination settings that are used during the procedure. This is quite beneficial in judging if anything seen is normal or abnormal. The disadvantages of magnetic resonance imaging (MRI) are the lengthy study time necessary, the loud noises generated, and the restricted setting in which it must be performed. Additional limitations include the presence of some metallic biomedical equipment or foreign objects that prevent MRI from being conducted.There different kinds of brain tumor diagnosis methodologies are developed in the recent decade. In general, the automatic tumor segmentation issues are complicated, and new inventions are still required to solve problems. Moreover, the processing functions include typical operations such as image preprocessing, tissue segmentation, feature extraction, and image classifications. An automated and efficient model is required for handling the complexities and time consumption in tumor image diagnosis from MRI scans . It is oIt is necessary to change the brain tumour feature extraction for easier classification. It is also necessary to categorise the tumour pictures using neural network algorithms and neuro-fuzzy algorithms. It is also necessary to segment and identify the brain tumour by combining CT and MRI images. The remaining part of the paper is organized as follows: In , segmentThe work provided by the authors of  used theK-nearest neighbor-based brain tumor detection has been described in [In , a hybriribed in . The claribed in  for succribed in , the autFurther, feature extraction has been performed using principal component analysis (PCA) to minimize computational complexities. The work used the Olivetti Research Lab (ORL) database data set for evaluations. The training and testing have been carried out using neural network techniques.In work , a hybriStatistical Association Rule Mining technology has been applied in  for effeFurther, in the works of , 21, assFor reducing the death rate of cancer patients, the proposed model utilised soft computing techniques for detecting the brain tumor in earlier stages. Moreover, brain tumor detection is carried out using ANN classification from the segmentation of MRI scan images. As in the general tumor detection process, the proposed soft computing-based brain tumor detection and classification (APSO (accelerated particle swarm optimization) based artificial neural network model (ANNM) contains four phases, namely, MRI image preprocessing, segmentation, feature extraction, and classification .C-means clustering, and the feature extraction process [The initial preprocessing phase is carried out using a median filter and edge detection to reduce the noise in from the obtained image and clearly define the vision for further process. Following, the images used for segmentation, which is done with fuzzy  process  are perfThe human brain images are complex and composite in structure, which make the processing complicated. It is required to remove the unwanted noises from the obtained MRI image . Here, tNoise elimination from the input MRI images performed with the median filter that uses a non-linear filtering process. This kind of filter is used to remove salt and pepper noise, specifically based on the average pixel rates .  FigureEdge detection is utilised here to detect and identify the sharp discontinuities in the MRI image. Here, the Canny edge detection approach is applied for suitable localization of edge points . And, thc-means clustering model is used. Here, the FCM method is used for enhancing the precision in image segmentation with an appropriate definition of the object function [Segmentation is a significant process in the tumor detection process that segregates the input image into several regions overlapping each other . It is ufunction . FurtherP={p1,  p2,   … pn}. And, based on the member rate of each pixel, it as belonging to one or more clusters. Several iterations are carried out for reducing the objective function with the member set “F” called fuzzy membership, and “U” is considered to be the cluster center.Fijm” denotes the pixel member table, “m” is the fuzzy parameter of the cluster, and (pi − Uj) is the Euclidean distance between the pixel member and the cluster center. It is evaluated that point closer to “U” has the highest rate of membership than the other points towards the boundaries. In FCM, the cluster centers are initially assigned and rate for each cluster. Then, the center points are shifted to the exact place by increasing the number of iterations based on the data set [Fij and cluster center “U” are updated based on the defined objective function, which is given as follows:The image of the MRI scan is divided into several pixels , which adata set .The datamaxiij{|Fijk+1).Initialization with cluster center kth step, the cluster center is calculated as given in (At given in .maxiij{|Fijk+1) in defining GLCM is considered by the number of occurrences of the pixel with “a” presented in the described spatial similarity to another pixel with the value “b” in the obtained MRI. Moreover, the process is very much helpful in pointing the exact tumor location [Extracting proper features from the images is a significant process for defining effective classification patterns for précised result categorizations. In this work, the feature extraction process is computed with GLCM, which is an effective arithmetic process that uses the spatial pixel similarities for computations . Based olocation  and its (i)Shape:As a general definition, shape denotes the geometrical features of an object or its clear edges concerning their composition, color, and image texture.(ii)Color and Image Intensity:Here, color is also considered as an important feature, which can be noted by the image coordinates, and the strength of color is denoted as intensity.(iii)Texture:The visual quality of the image is noted as texture, which is also derived here.(iv)Contrast:Contrast is evaluated by analyzing the separation of lighter and the darker areas in the image as(v)Homogeneity:It denotes the closeness of element or object distribution on to the matrix diagonals, which points to the homogeneous quality.(vi)Correlation:The correlation coefficients are generally ranged between -1 and +1 and computed as(vii)Energy:Here, energy is defined as the sum of squared pixels rates of the defined gray-level co-occurrence matrix, which is computed asIn this model, the main features considered for evaluation are shape, color, image intensity, texture, contrast, homogeneity, correlation, and energy.In the proposed work, artificial neural network (ANN) is used for performing the classification operation. This classification technique is incorporated here for its adaptive learning abilities, self- organization pattern, and well suitable nature of real-time implementations. The network pattern contains three layers, input layer, hidden layer, and output layer, which are given in There are two kinds of operations are performed in ANN, namely, training and testing. In training operation, the neural network is trained with the obtained features that are extracted from the previous section, and testing is performed effectively for validation of results. The parameters that are used for ANN designing are presented in The activation function used here is “purelin” and “tansig” that represent the hyperbolic tangent sigmoid function and linear transfer function. And the learning model used here is Levenberg–Marquardt backpropagation, which is the speed training method. The mean square rate is the computation of the number of errors that occurred in the classification process. Here, the artificial neural network is trained with input MRI images that contain 5 nodes in hidden layer nodes and 1 node at the output layer. The activation functions are applied at the hidden and output layer. After recovering features from the feature extraction procedure, training samples and testing samples are segregated and supplied for testing in ANN and backpropagation technique, respectively. The obtained results are evaluated using the evaluation parameters such as sensitivity, specificity, precision, and accuracy.The proposed model is analyzed using the MATLAB tool for implementation with the benchmark data set known as DICOM databases containing MRI brain images . ClinicaFor providing evidence for the proposed model, the obtained results are compared with the existing models such as PNN and FCM-based cancer detection. Support vector machine (SVM) and perceptron found neural network model (PNN). Each training and testing phase is processed with 18 brain samples divided into 9 each for training and testing, respectively. The trained representatives are provided as input to the ANN for training, and the validation is carried out with the testing samples. After performing simulations, the value computed for models without tumor is almost similar to 0, and cancer presented images to obtain about 1 and classified based on that. The sample brain images obtained from the Dicom library are shown in (i)True-positive rate is to evaluate brain images with tumor that are correctly detected as abnormal.(ii)True negative is defined as the normal samples are mentioned as normal.(iii)A false positive is the tumorless sample that is falsely identified as containing a tumor.(iv)False negative in the abnormal samples is incorrectly defined as normal.(v)Here, sensitivity, specificity, and accuracy rates are computed asThe performance of the proposed model is measured using metrics such as specificity, sensitivity, and accuracy rates using true-positive, true-negative, false-positive, and false-negative rates. Moreover,Based on the above factors and computations, the performances of the proposed work in classifying brain tumor images are evaluated.−5. At the 19th iteration, the best value is achieved with a minimal error rate of 0.0000041.When applying the ANN computing for tumor image classifications, the performance is evaluated with the training, testing, and validation results. The performance graph is given in The results obtained on accurate classification results are evaluated and portrayed in As mentioned in They are presented in The graph on the right illustrates the results of a performance study of brain scans. Listed in Generalizations aside, it is possible to classify data sets into two categories: training data sets and testing data sets. The correctness of the categorization is essentially determined by the two basic procedures, namely the training and testing processes, which are carried out. It is necessary to evaluate a brain tumour classification system when it has been appropriately trained on the largest available database of tumours. Testing the classification system's accuracy in categorising various forms of brain tumours during this phase provides for the verification of the system's correctness. The technique that has been described may be used to more than 70 distinct photographs at the same time. The various MRI brain scans are collected from a local medical facility. In the proposed technique, there has been a significant improvement in the efficacy of its classification.In the present scenario of medical image processing, an efficient methodology is required for accurate tumor diagnosis. This paper presents a new model using a soft computing technique based on brain tumor detection and classification for assisting the radiologists in providing efficient treatments to the affected persons. Moreover, the median filter is used here for noise removal, and edge detection is used to accurately define the MRI brain image. For segmenting the tumor image effectively, Fuzzy c-means clustering is incorporated. Further, the feature extraction for performing efficient classification is performed with GLCM. The derived features of obtained brain images are given for ANN-based sort, which results in an appropriate type with an accuracy rate of 96.6%. The simulation results show that the proposed work produces better classification results compared to the existing models in terms of metrics such as classification accuracy, error, model efficiency, and processing time.In the future, the work can be enhanced in such a manner to categorise the stages of the tumor for improving the decision pattern to provide treatments.