Malaria was endemic in Sri Lanka for centuries and was eliminated in 2012. It is widely assumed that the costs of elimination are generally greater than that of control. The costs of malaria elimination in Sri Lanka with that of malaria control in the past using periods in which starting transmission dynamics were similar were compared.The expenditure of the Anti-Malaria Campaign (AMC), total and by budget category, during 2002–2010 is compared with that of malaria control during the period 1980–1989, using regression analyses and the Mann Whitney U statistic.The expenditure on malaria control and malaria elimination was similar ranging from 21 to 45 million USD per year when adjusted for inflation. In both periods, external funding for the malaria progamme constituted around 24% of the total budget; during the control phase in the 1980s, external funds came from bilateral agencies and were disbursed in accordance with government budget guidelines. In the elimination phase in the 2000s, most of external funding was from the Global Fund and had flexibility of disbursement. In the 1980s, most funds were expended on commodities—insecticides, diagnostics and medicines and their delivery; in the elimination phase, they were spent on programme management, human resources, technical assistance and monitoring and evaluation; monitoring and evaluation was not a budget line in the 1980s. Although the cost per case of malaria was considerably higher during the elimination phase than in the control phase, expenditure was not on individual cases but on general systems strengthening.Malaria elimination in Southeast Asia may not require more funding than malaria control. But sustained funding for an agile programme with flexibility in fund utilization and improved efficiencies in programme management with stringent monitoring and evaluation appears to be critically important. In 2012, malaria was eliminated from Sri Lanka, a tropical island with a population of 21 million, which was endemic for malaria for centuries. It received World Health Organization (WHO) certification as a malaria-free country in 2016 .There is currently, a heightened global interest in eliminating malaria from countries , keepingSeveral published reports on the costs incurred by malaria control and elimination programmes including several during the Global Malaria Elimination Programme have been subjected to a systematic review . The revThe malaria incidence in Sri Lanka, as in the Southeast Asian region in general fluctuates seasonally as well as cyclically over periods of about 15–20 years    and early 2000s (elimination phase) the component of foreign funding which supplemented national government funding of the malaria programme was proportionately similar p = 0.548), and constituted, on average, 24% (range 13–38%) of the total budget of the AMC. However, the source of external funding was quite different in the two periods. In the 1980s (control phase), most of the external funds were from bilateral sources . In the 2000s (elimination phase), nearly all of external funding came as grants from the Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). The expenditure categories, i.e. commodities and services for which total funds of the AMC were expended also differed markedly in the two periods. Years 1989 and 2010 were taken at the end of the two periods as examples for comparison , and there was an explicit budget line for programme monitoring and evaluation, which in themselves reflect a major change in strategy on which operations were based.Importantly, during the elimination phase spending on malaria was maintained despite the case numbers decreasing leading to a major increase in the cost per case. The cost per case during elimination being incredibly high can potentially undermine a malaria programme’s ability to secure consistent domestic funding when there are competing priorities, and if there is insufficient understanding of, or support for, a malaria elimination goal at higher levels of government. However, as this case illustrates, the funds were expended not on individual malaria cases unlike in the 1980s, but on programme management and human resources, which supported a state-of-the-art surveillance system, and on monitoring and evaluation of the programme. These are capacities that benefit the entire health system well beyond malaria, which further increases efficiencies. These are noteworthy aspects of a successful elimination programme.Apart from flexibility in the use of funds, particularly for staff recruitment through the use of external funding, and increased programme efficiency impelled by the GFATM grant management system, the other most significant change in 2000s was probably the motivation for malaria elimination created by the heightened global interest in malaria. The enthusiasm created by WHO’s Roll Back Malaria Initiative in 1998 which aimed to reduce the burden of malaria, permeated down to country malaria control programmes. In contrast, the 1980s was a grim period globally for malaria control-countries had not recovered from the aftermath of the failed Global Malaria Eradication Programme (GMEP), and were also riddled with technical challenges of drug and insecticide resistance. A sense of helplessness had set-in in countries and the will to combat malaria, leave alone eliminate it, had dwindled.Plasmodium falciparum malaria to chloroquine was widespread globally in the 1980s and it was so in Sri Lanka as well, and this could have accounted for the increase in cases in the 1980s. However, P. falciparum accounted for less than 30% of malaria cases in Sri Lanka then, and the country was quick to switch to the alternative medicine sulfadoxine-pyrimethamine and so, it is unlikely to have been a major cause for the epidemic. Globally, highly effective artemisinin-based combination therapy (ACT) began to be deployed for malaria treatment in the early 2000s and it was as late as 2008 that Sri Lanka adopted an ACT, and then was only for the treatment of P. falciparum which accounted for a minority of infections [Several other factors that may have accounted for the striking difference in outcomes from the efforts of the AMC-elimination versus epidemic, were considered. Improved technologies and products were available in the 2000s, which were not in the 1980s. Rapid diagnostic tests which enabled a malaria diagnosis to be made at the point-of-care were used in Sri Lanka from 2002 onwards, but microscopy-based diagnostic services were the most widely used method in the country’s robust health system and all malaria diagnoses were eventually confirmed by microscopy. Long-lasting insecticidal nets (LLINs) were used in Sri Lanka from 2004 onwards, although here again, there was as much use of Indoor Residual Spraying (IRS) which was the mainstay of vector control in the 1980s as there was dependency on LLINs, and coverage by both, were relatively low during the 2000s [fections . It is sThe stark implication of these findings is that, at least in the context of Southeast Asia and other regions with similar transmission dynamics, malaria elimination does not have to cost more, financially, than does malaria control. This finding provides a compelling case for eliminating malaria, over and above the considerable returns in terms of both economic and health benefits on an investment in eliminating malaria .Most malaria endemic countries in Asia are targeting elimination in the near or mid-term future. The Sri Lankan experience shows, that provided there is adequate and sustained funding, what is critical to achieve malaria elimination under these transmission conditions may be a responsive and agile programme which is ready and able to change course and technical strategy in response to a changing malaria situation, for which the financial support, or at least a component of it, needs to be flexible in its disbursement. Malaria elimination will also require vast improvements in programme management and efficiency. Mechanisms to support these changes were inherent in the Global Fund’s funding model. In the 1980s malaria control in Sri Lanka, apart from having as its goal, reducing malaria to a low level rather than elimination, had neither flexibility to be responsive to the malaria situation, nor the strategic approach required to bend the malaria curve, and malaria rose again subjected to environmental forces, despite the investment of an equivalent amount of funds.It is well known that poor programme management resulting in inefficiencies are rife within public sector disease control programmes, particularly in developing countries. Improved management of disease control progammes with monitoring and evaluation, and flexibility of fund utilization are solely needed to get more returns from financial investments in public health. Unfortunately, these softer attributes of public health programmes are too often ignored in favour of tools, technical strategies and financial investments, which are more tangible and easier to count, measure and report on. The findings of this study also suggest that donor funds for health programmes may yield better outcomes if they are channeled through well-managed multilateral global health funding agencies such as the GFATM, than through bilateral avenues.Malaria elimination in Southeast Asia may not require more funding than malaria control. However, an agile programme with flexibility in fund utilization and improved efficiencies in programme management with stringent monitoring and evaluation are critical requirements.


The findings also aided in the development of productive packaging design, in which these design elements were beneficial to reduce environmental impact. These findings had a significant impact on the manufacturing industry in terms of the economics and time of the molded expanded polystyrene packaging development.A molded expanded polystyrene (EPS) cushion is a flexible, closed-cell foam that can be molded to fit any packing application and is effective at absorbing shock. However, the packaging waste of EPS cushions causes pollution to landfills and the environment. Despite being known to cause pollution, this sustainable packaging actually has the potential to reduce this environmental pollution because of its reusability. Therefore, the objective of this study is to identify the accurate design parameter that can be emphasized in producing a sustainable design of EPS cushion packaging. An experimental method of drop testing and design simulation analysis was conducted. The effectiveness of the design parameters was also verified. Based on the results, there are four main elements that necessitate careful consideration: rib positioning, EPS cushion thickness, package layout, and packing size. These parameter findings make a significant contribution to sustainable design, where these elements were integrated directly to reduce and reuse packaging material. Thus, it has been concluded that 48 percent of the development cost of the cushion was decreased, 25 percent of mold modification time was significantly saved, and 27 percent of carbon dioxide (CO Therefore, finite element analysis is performed to compare the design parameters in detail, and the most critical design parameters are identified from the critical area in research findings see .Expanded polystyrene foam is the best rigid substance to use as protective packaging for household appliances, but its sustainability is in doubt. Therefore, its reuse and reducing waste were the biggest contributions from packaging-design engineers . AdditioExplicit dynamic analysis was used in this finite element analysis. It is set that the product’s packaging is dropped with a gravity parameter of 9806.6 mm/s and the floor is in a fixed rigid setting. Product damage is predicted. Improvements in sustainable design were implemented at an early stage of the product development cycle. The maximum stress and deformation direction are used as a reference in the analysis result to predict the critical area that would have design failure. The FEA analysis was compared to the results of the drop tests.The comparison of packaging design model analysis results in numerical maximum stress values. The maximum stress area was also compared, as shown in The numerical value of the maximum stress was discovered to be marginally different for each model of packaging that has been studied. The highest value for model A was found on the bottom side of the packaging, while models B and D were found on the rear side of the cushion packaging, as stated in Differences in analysis results are caused by the cushion packaging’s productive design. The high strain was close to the most critical component: the screen. This outcome demonstrates that it is likely to damage the screen and clip internal product components. Due to the lack of support on the front and back cushions, as shown in In general, the results of all analysis models are influenced by the EPS cushion design parameters as outstanding protective packaging. However, the primary important factors need to be ensured to produce sustainable cushion packaging. The analysis results show that the packaging design of models C and E are seen to be similar, but the cushion layout and length of bottom inner cushion are different. This difference in cushion layout has produced the same analysis results, where the possibility of damage is shown on the critical component, which is the screen panel, as illustrated in On the other hand, the design considerations of molded packaging for models D and B are the same in terms of cushion layout design, dimensions, and thickness, even though the product size is different. Both models show the same analysis result, which is the emphasis on the position and dimension of ribs, predominantly on the top of the cushion packaging. However, because the installation of pre-existing accessory components must be taken into account, the cushion packaging model A that has been made differs greatly from all four models. Cushion thickness and rib positioning, moreover, have been identified as the main design factors to emphasize. The comparison results of destructive testing and finite element analysis are discussed below.A damaged or cracked screen panel is a major problem that has been identified. This indirectly causes product deformation defects, as shown in The analysis of design failure concludes that there is a lack of cushion packaging toughness to resist shock loads or impact. The design reliability is lower than expected due to several factors. First, the position of rib was placed on a sensitive area, such as on the middle chassis or on the clip of the panel board. This clip is placed in the front of the screen panel, which is used as a holder for each layer of the screen projector. This clip must avoid being exposed to any pressure or impact. Secondly, there is insufficient rib strength in order to absorb the impact, and the wall thickness of cushion is less than 10 mm (minimum thickness). In fact, the strength of cushion is influenced by the position, height, and thickness of ribs. In addition, the packaging weight also affects cushion stiffness. Therefore, the cushion weight must be reduced, and the design needs to be improvised if necessary. Minor consideration, such as tolerance between packages and goods, must be checked by considering the material types of protection bags. Commonly, the thickness of protection bags ranges from 0.02 mm to 0.4 mm.In shear modulus (G), the shear stress (Ʈ) is directly proportional to shear strain (ɣ) as expressed in Equation (1) :G = Ʈ/Ɣ ,21,25. IPractically, the rigidity modulus (G) value can also be defined through the experimental drop test. The machine used in the drop test was connected to a PC. All parameters were controlled and monitored by the PC. The value was discovered from sensor detector that are attached together inside appliances and packaging, as shown in However, the comparison result shows that the maximum modulus of rigidity that is obtained through the destructive test is in the range of 8 G’s to 30 G’s per surface of each following model, as illustrated in The string of this study has assumed that sustainable EPS cushion design should consider the weight and shape of the cushion (design optimization). Logically, the effectiveness of cushion packaging reliability is based on the complexity of the design or the tendency to reduce overall packaging material usage, which is in line with previous studies ,10,16,172 reduction that will be employed in the manufacturing sector is disclosed [Generally, waste from EPS cushions can be recycled in many ways once it comes to the end of its life. The choice of recycling methods is based on technology, environmental, or economic factors. The authors’ views are similar to that of the study by Muralikrishna and Manickam (2017), where the interpreted life-cycle assessment is a cradle-to-grave analysis technique to assess environmental impacts associated with all the stages of a product’s life: from raw material extraction through to material processing, manufacture, distribution, and use . Accordiisclosed , and theisclosed .Knowledge of specific sustainable product design principles, such as designing for repair/reuse/remanufacture/recycling, is widely recognized as a vital skill and is supported by an earlier study ,55. The A combination of the life-cycle assessment (LCA) and life-cycle cost (LCC) analysis was significant , allowinThe ISO 14,040 rules state that an LCA study consists of four stages: defining goal and scope; inventory analysis; impact assessment; and interpretation. This guideline framework defines how much of a product’s life cycle is engaged in sustainable design . On the 2) reduction. The summary of the findings has been summed up into the below accomplishments:Costs were saved by 48% of the total cost of the cushion packaging development see . These aSignificant cost differences are found in the development of sustainable EPS cushion packaging. Modification costs are higher when improving the design if it is based on conventional practices. However, by incorporating these discoveries into a sustainable design (using the design parameters and reducing the use of EPS cushion), the massive amount of modification costs can be well organized.In the meantime, the average mold modification time was also saved by 43.5%, as shown in 2) released from sustainable design method. It is estimated that improvements in packaging design, material, and multiple functional uses have cut CO2 emissions by as much as 27%. The value of CO2 emission per one set model (kg) was calculated. The comparison of the reduction is shown in The most significant finding is the reduction of carbon dioxide (COAdditionally, it was discovered that the grafting method, which entails using a dovetail technique in rib cushion design, is used in optimization design to input a new parameter refer . This deFinally, this paper was found to be beneficial in saving 48% of the development cost; had a 25% modification time reduction; and estimated a 27% carbon dioxide (COThe rib dimensions determined by the dovetailed technique are 40 mm × 20 mm × 20 mm, with a 25-degree slant. However, the detailed rib design consideration for new molded cushion packaging is depicted in The significant parameters of EPS cushion design increase the packaging reliability.The sustainable design can be implemented, and packaging design can be optimized through the manufacturing process and cost.Finite element analysis of the cushion design was a great idea for analyzing possible defects caused by design failure before the molding tool development begins.Optimization design through the reuse and reduction of EPS cushion usage contributed to increased design sustainability.The challenge in this finding is that every packaging engineer must change their current design practice and analyze the packaging design prior to the development phase.The intention of this study is to emphasize the design parameters that should be applied in cushion-packaging testing using destructive testing, finite element analysis, or risk analysis. The findings have a great potential to minimize the pollution impact on the environment and save development costs and materials, as well as realize an EPS cushion design sustainably. It would also be beneficial to the manufacturing industry in managing the EPS cushion waste. Therefore, the tendency for simulation analysis usage in industry is accepted to enhance designing process efficiency and improve skills in bringing forth sustainable protective packaging for electrical and electronic appliances. Hence, it can be concluded that:More research is needed to identify the biodegradable raw material or mixed composite based on these discovery parameters, especially for the molded expanded polystyrene cushion packaging of electrical and electronic appliances.


Nasal septoplasty is one of the most common surgical procedures in otorhinolaryngology and optimising both patient selection and the surgery is a challenge. The Nordic countries have similar public healthcare systems and comparable populations in terms of size.This is a review of studies of outcome and predictors related to septoplasty from Denmark, Finland, Norway and Sweden, published during the last decade. The aim of this review was to identify areas in need of further research to meet the challenges of septoplasty in the Nordic countries with reference to international data.Postoperative patient satisfaction at 6–12 months was reported in around 2/3 of the patients and well in line with international data. Patients with more severe symptoms had a higher chance of improvement. Lack of standardisation in patient selection, surgical methods and skills, and follow up procedures, still makes it difficult to explain the 25% failure rate in septoplasty surgery.This review of the Nordic studies from the last decade shows that septoplasty in general is effective in relieving nasal obstruction. There is a need for studies addressing the standardisation of diagnostic tools and algorithms and the systematic and continuous implementation of follow-up of the surgical results at both departmental and personal level. This includes an awareness of how surgical skills in septoplasty are obtained and maintained. Septoplasty is a common surgical procedure in the field of Otorhinolaryngology—Head and Neck Surgery (ORL-HNS). The main indications address functional deficits caused by a deviated nasal septum, which can usually be corrected satisfactorily. Septoplasty has been part of the ORL-HNS practice for more than 100 years and most of the basic principles were developed long before evidenced medicine was introduced. Numerous non-randomised studies support the clinical benefits of septoplasty, but, only recently, the first randomised study by van Egmond et al. supported that septoplasty was more effective than conservative measures in managing a deviated septum . In a coAreas of concern contributing to successful septoplasty service include surgical indications and patient selection, preoperative measurements ), PROMs, surgical technique and skills, perioperative considerations , postoperative care  and evaluations of surgical management . It remains a challenge to study these factors separately and systematically and to compare the results between healthcare systems and surgical centres.The Nordic countries, Denmark, Norway, Finland and Sweden, are all affluent countries with a governmental tax-financed public healthcare system for all citizens. Most patients undergoing septoplasty are diagnosed and operated on at ORL-HNS departments and by publicly employed surgeons without any personal reimbursement related to the number or type of surgeries performed. The indications for septoplasty are regulated to manage functional upper airway obstruction and, to a minor extent, to facilitate FESS surgery, the use of nasal CPAP masks, in tumour surgery or to treat nasal trauma. The private sector is comparatively small except in Denmark and regulated by public healthcare contracts and clinical guidelines and the indications are thus similar to those in the public system. In Denmark, around one third of simple rhinology is treated in the private sector, including septoplasty, turbinate reduction and other types of surgery which do not require postoperative hospitalisation. However, during the last two years, i.e., during the current Covid pandemic, more than 90% of the septoplasties have been performed in the private sector. Specific differences regarding the use of local anaesthesia, preoperative antibiotics, diagnostic rhinomanometry or other diagnostic objective measurements and surgical techniques still exist between the Nordic countries, as well as between individual centres. In Sweden, the annual number of septoplasties is around 20/100,000, Denmark 48/100,000 and Finland 27/100,000.https://sep.registercentrum.se/omregistret/septumplastikregistret/p/Sk0aanMH).During the past decade, several studies from the Nordic countries have addressed the aforementioned factors related to the successful outcome of septoplasty. The data in the Nordic studies are derived either from conventional clinical cohorts or from the unique Swedish national septoplasty registry (SNSR). The SNSR holds limited yet important data regarding indication, surgical procedure and pre- and post-op symptoms of septoplasties from an entire country since 1997 . This also relates well to the Nordic situation, apart from snoring and sleep apnea not being primarily treated by septoplasty alone. In 2019, 2,138 septoplasties with or without turbinoplasty were performed in Sweden, according to the National Patient Register , where all surgical procedures in Sweden are registered. Sixty per cent  of these were also reported to the SNSR, which includes only septoplasty with and without turbinoplasty. In 2019, 52% of the procedures in the SNSR were septoplasties alone and 48% were septoplasties combined with a turbinoplasty.The main indication for septoplasty according to the American Academy of Otorhinolaryngology, Head & Neck Surgery, is “Nasal airway obstruction  causing any of the following: mouth breathing, snoring, nasal congestion, sleep apnea, unresponsive to medical management”  and septoplasty with turbinoplasty (n = 68) ) to evaluate the results of septoplasty alone ((n = 68) . PNIF in(n = 68) .www.orluems.com). In the Nordic countries, the ability to perform uncomplicated septoplasty and turbinate reduction is a requirement to acquire specialist training certification, though the level of autonomy vary between the countries.Surgical skills remain fundamental to a successful septoplasty outcome. Surgical training programmes on how to perform septoplasty follow a similar track in the Nordic countries. Specialist training mainly takes place in hospital ENT clinics where surgical skills are gradually transferred from senior to junior doctors in training, primarily through four-handed procedures. Doctors in training first perform surgery assisted or observed by an experienced colleague until they are considered autonomous. The UEMS logbook is used by residents in training . This is almost identical to the results from an earlier Finnish study, where 75% of 117 septoplasty patients reported no or mild nasal obstruction one year after surgery  . In the Studies of septoplasty results exceeding a follow-up of 12 months are scarce . In thisThe age of the patients at surgery has been studied in two Nordic studies. In the study from the SNSR comprising 5,865 patients (mean age 39 years), higher patient age was associated with a significantly better result measured as self-reported patient satisfaction, six months after surgery . On the In the SNSR, postoperative unplanned visits due to infection, bleeding or pain were related to a significantly poorer outcome regarding both patient satisfaction and improvement in nasal obstruction , 16. BleIn recent years an increasing interest has been directed towards the significance of trigeminal function and the ability to lateralize the perception of menthol exposure to either of the two nasal sides –25. It hThe aim of this review, targeting the outcome of septoplasty surgery in the Nordic countries over the past decade, was to define scientific questions that remain unanswered and to compare the Nordic setting with global surgical data. It is obvious that septoplasty is a relevant surgical procedure relieving chronic nasal obstruction in at least 2/3 of the patients and improving their health-related quality of life.We have focused on septoplasty with and without turbinoplasty with the indication nasal obstruction, leaving out septoplasty to facilitate FESS or as an emergency procedure in trauma. In all the reviewed studies, the indication for septoplasty was established by nasal surgeons examining the patients and taking a patient history, sometimes with the aid of rhinomanometry. The lack of standardisation in these procedures is a problem when it comes to monitoring indications and outcome in septoplasty, but it can also be seen as an expression of the substantial difficulties associated with objective and subjective assessments of nasal airflow and resistance. Clinical decision-making and patient selection for septoplasty surgery clearly warrant uniform guidelines in order to enable an evaluation of postoperative results in a multicentre setting.Septoplasty used on a broader scale as a one “fits all” type of surgery for any structural nasal obstruction in accordance with tonsillectomy for tonsillitis is inadequate. Issues related to the nasal valve, columella, or nasal deformities may be totally overlooked. We found no Nordic studies evaluating the technique of a nasal examination using anterior rhinoscopy and nasal endoscopy in the diagnostics of patients undergoing septoplasty or its impact on the result. Nasal endoscopy with a flexible or rigid endoscope is typically performed in the evaluation of a symptomatic septal deviation to assess the full length of the nasal cavity and to exclude concha bullosa, nasal polyps or tumours as the cause of nasal obstruction. Imaging of the nasal cavities such as computer tomography (CT) or Cone Beam CT (CBCT) are not in regular use to evaluate symptomatic septal deviations in the Nordic countries due to radiation exposure and availability. When performing an anterior rhinoscopy, the columella with the most anterior part of the septum is easily pushed aside and therefore ignored. The sensors of nasal openness are in the most anterior part of the nose, in the vestibular area . DiffereIn fact, it is more likely that the ORL profession as such has inadequate tools and algorithms to properly diagnose and differentiate the different aspects of impaired nasal airflow. For instance, in the diagnosis of heart failure, using echocardiography, the blood flow in the heart can be studied in real time. If a similar non-invasive technique were available for nasal airflow, it would probably increase our diagnostic accuracy and potentially the surgical results. Computional fluid dynamics (CFD) is an emerging and promising technique to study nasal airflow that may change this situation in the future .One obvious and important factor for the success of septoplasty is surgical skill and experience, although data from studies are less conclusive on this issue , 29. TheThe surgical technique naturally has an important effect on the surgical result. Modifications of transfixation incision and unilateral or bilateral submucosal surgery are used in the Nordic countries and endoscopic surgery is used to a minor degree, as well as different postoperative packaging from stents, staples, tubing and gauze to septal sutures and no packaging at all. Nasal packaging from one day to one week after septoplasty has been the dominant postoperative tradition in the Nordic countries, however, recently the use of septal sutures or staples instead of nasal packaging has gradually increased. Removal of nasal packaging including nasal stents is perceived by many patients as traumatic and painful which suggest it should be avoided. The rationale for using nasal packaging despite this fact has been to stabilize the septum during the immediate postoperative period and to avoid the formation of septal hematoma that could jeopardize the final result. The use of various nasal packaging was, however, inadequately described in detail in most of the Nordic studies and different techniques were not compared. For this reason, we have chosen not to discuss this further in this article.Apart from indications for septoplasty based on clinical findings and a patient history of nasal obstruction as such, an assessment of the severity of the disease is important. In at least two Nordic studies, the improvement in nasal patency was greater in patients experiencing severe nasal obstruction before surgery compared with patients with moderate or mild nasal obstruction, which was previously reported by Stewart et al. . In the In accordance with previous international studies, this Nordic review confirms that objective measurements such as rhinomanometry, acoustic rhinometry and peak nasal flow reveal increased nasal geometry and airflow after septoplasty. Objective methods have previously been compared and appear to correlate well with one another . A signiPROMS are important tools when studying medical interventions over time. In the studies reviewed here, symptom evaluation, satisfaction rate and HR-QoL instruments were used. Although SNOT-20 and -22 were originally developed for the evaluation of chronic rhinosinusitis (CRS), they have also been used to assess septoplasties . As in CExpectations of outcome by both patients and surgeons and how this is communicated is a potentially important factor for the surgical outcome. The Nordic healthcare system is based on “informed consent”, meaning that the patient should be provided with the best available information regarding diagnosis and treatment options, as well as expected outcomes and complications. It is not customary, however, to sign a preoperative agreement, as in some healthcare systems. How the surgical problem is communicated to the patient and how the patient perceives the message from the surgeon has not been well studied, but it could be a potentially important factor for success. In particular, the issue of possible complications of septoplasty appears to have been left out of the patient information . This di. Preventing foreseeable complications and reducing their risk could potentially increase patient satisfaction and improve the quality of surgery. While these complications may indicate insufficient surgical management and could lead to longstanding complications such as synechiae and septal perforation, it is likely that their occurrence also undermines the trust of the patient in the surgery.All types of surgery including septoplasty are associated with potential side-effects and complications. In the SNSR studies, unexpected visits to healthcare due to pain, bleeding or infection within the first postoperative period were associated with a poorer self-reported result 6–12 months after surgery , 16. In Nasal septoplasty is a common and logical/relevant surgical intervention in patients with a deviated septum and nasal obstruction, with a success rate of around 2/3 in the Nordic countries 6–12 months after surgery. Studies from the Nordic countries during the past decade show that patient selection and the degree of nasal obstruction are correlated to surgical outcome. Using the best available surgical technique and postoperative care aimed at achieving the best result, involving PROMS and avoiding postoperative complications also affect the final result. There is, however, a need for further studies addressing the standardisation of diagnostic tools and algorithms and the systematic and continuous implementation of follow-up of the surgical results at both departmental and personal level. This also includes an awareness of the way surgical skills in septoplasty are obtained and maintained.


Artificial Intelligence (AI) systems are gaining momentum in complementing and/or replacing performing tasks typically done with the aid of human ability. AI systems, inherently human creations, are, however, beset by, wittingly or unwittingly, so-called male chauvinism, despite all the advancements made in the progress of civilization to make inroads for women's equitable participation in the labor force, particularly in relation to the digital economy, and more importantly, AI. In regards to the Canadian context, this perspective has examined the evidence to find research highlighting gender representation in the Canadian AI ecosystem. We found a lack of studies on women and their contribution to AI-related activities. Canadian women's participation in their country's AI sector therefore should go beyond mere instruments such as the Montreal Declaration for a Responsible Development of AI, and disjointed interests. On a more general level, the paucity in a paradigm shift toward AI-female friendly policies from design phase to implementation omits the female voice for adequate representation for action. Advocating for Canadian women in the AI sector requires a voice of unison best achieved through parliamentary action. This perspective is thus issuing a clarion call to attaining gender fairness and equity, global principles under the United Nations (UN) Sustainable Development Goals, to which the Government of Canada is committed. Artificial Intelligence (AI) is rapidly becoming the new skill-set of today's Fourth Industrial Revolution, blurring the lines between the physical and virtual workforce. However, achieving gender parity in such a labor market is cause for concern with the World Economic Forum (WEF) finding that females represent just 22% and males, 78%   which is “a set of practices and behaviors that help an organization use data and digital technologies in ways that are perceived as socially, economically, and environmentally responsible” (Corporate Digital Responsibility, The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.LD conceptualized and co-wrote the manuscript with BC and SB. BC helped revise the revised manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The capital market economy had created a good environment for the development of enterprises, and innovation had brought great impetus to the sustainable development of enterprises. However, the research on the relationship between stock market and enterprise innovation was not deep enough. Therefore, this paper proposed an empirical study on the relationship between stock price information and enterprise innovation management based on information learning mechanism, in order to provide reference for enterprise innovation and development. Firstly, taking the A-share listed enterprises from 2005 to 2020 as the research sample, this paper analyzed the factors that may affect the innovation behavior of enterprises, such as enterprise stock price information, peer stock price information, and IPO, and put forward relevant assumptions. Secondly, according to various factors that restrict the innovation behavior of enterprises, this paper defined relevant indicators to reflect the change law of enterprise stock price information, peer stock price information, and IPO and described the restrictive relationship between exploratory innovation and developmental innovation with different influencing factors by constructing a correlation regression model. Finally, through empirical analysis, the results show that exploratory innovation and developmental innovation are not affected by the enterprise's own stock price information, but with the increase of peer stock price information, enterprise exploratory innovation becomes more sensitive to peer stock price information. Although the share price information of peers has no significant impact on enterprise development and innovation, after IPO, enterprises are more sensitive to the share price information of peers in exploratory innovation and developmental innovation. However, with the passage of time, the impact of peer stock price information on enterprise developmental innovation is gradually weakened. The enterprise development strategy driven by innovation is an important way for countries to realize economic transformation. Innovation can provide power for sustainable development for enterprises. With the rapid development of capital market economy, IPO has become an important way of financing for most enterprises . The stoUsually, enterprises are faced with huge investment costs and uncertain risks in the process of technological innovation. Capital market can provide services for enterprise innovation by effectively easing financing constraints and risk dispersion. Capital market is very important for the generation and aggregation of information. Information transmission is the internal mechanism of capital market promoting enterprise innovation and development. Effective information transmission can not only reduce information asymmetry, reduce capital cost, and promote enterprise innovation, but also help managers improve the efficiency of technological innovation decision-making and promote enterprises to obtain competitive advantage in the product market . InvestoAs an important way of information transmission, stock price information has attracted extensive attention of scholars. Relevant research shows that enterprises pay more attention to the share price information of their peers, and learning information from the share price of their peers can help enterprises improve the efficiency of innovation activities . HoweverEnterprise innovation can not only bring vitality to the survival and development of enterprises, but also an important driving force to promote economic growth. Researchers have proposed two different organizational learning behaviors in their early years: utilization and exploration . On the Stock price information mainly refers to the private information contained in the stock price, which may be new information for managers and can provide decision-making reference for enterprise production management and investment management. People generally use price asynchrony to measure the private information in stock price. The asynchrony of stock prices reflects the changes in the company's stock return, which cannot be explained by market and industry activities. At the same time, stock price information has been proved to be the best index to reflect the dynamic changes of stock price information. Stock price information may contain bull and bear market news related to enterprise innovation strategy. In order to study the sensitivity of enterprise technological innovation to stock price information, enterprise innovation activities can be divided into exploratory innovation and developmental innovation. Compared with development innovation, exploratory innovation requires greater investment, longer cycle, and higher prospect uncertainty risk. Exploratory innovation can promote enterprises to obtain more lasting competitive advantage. In order to explore the importance of management learning in enterprise innovation activities, we can study the impact of future stock price asynchrony on enterprise innovation results and then compare the role of enterprise stock price information and peer stock price information in enterprise innovation.From the existing empirical research results, it is found that the impact of enterprise's own stock price information on exploratory innovation and developmental innovation is not significant. Relevant studies show that the sensitivity of investment to stock price depends on the amount of incremental information related to management contained in stock price . The motRelevant studies mainly analyze the factors driving enterprise innovation from multiple perspectives. Among them, the impact of stock price information on managers' investment decisions has been confirmed by scholars. However, the research on the impact of stock price information on enterprise innovation is still not deep enough. For example, there are few studies on the relationship between stock price information and two-way innovation strategy, and the impact mechanism of stock price information on enterprise two-way innovation is not clear enough. Therefore, based on the development of China's capital market, this paper mainly takes Shanghai and Shenzhen A-share listed enterprises as samples to study the impact of stock price information on enterprise innovation activities, so as to provide reference for further exploring the factors affecting enterprise innovation. Due to the heterogeneity of stock price information sources, listed companies can learn information not only from their own stock price, but also from the stock price information of their peers. This provides a basis for further exploring the different impact mechanisms of enterprise stock price information and peer stock price information on innovation activities. Due to the changing regulatory environment and market competition faced by enterprises after IPO, IPO decision not only affects the innovation strategy of enterprises, but also has a positive impact on the source of enterprise information acquisition. It is of great significance for enriching relevant theoretical and empirical research to carry out in-depth changes in the sensitivity of enterprise innovation to peer stock price information after IPO.The service of capital market for enterprise innovation and development largely depends on the effectiveness of information transmission. Stock price information can reflect not only the comprehensive effect of factors such as the degree of information asymmetry and the level of internal and external governance of the company, but also an important index to measure the efficiency of market information transmission. In the research on the influencing factors of stock price information, some scholars found that when facing the uncertainty of economic policy, enterprises have the motivation to spread more information, which may lead to the decline of stock price . High quSome scholars have also studied the relationship between investment and stock price information and its influencing factors. For example, cross listing enables enterprises to obtain accurate information about enterprise investment returns from the stock market, and the investment of cross listed companies is more sensitive to stock prices. The implementation of insider trading law not only has a great impact on stock price information, but also can increase the sensitivity of investment return . Some scConsidering the heterogeneity of stock price information sources, enterprise managers can learn information not only from their own stock prices, but also from the stock prices of their peers. The content and value of peer stock price information will also affect the innovation activities of enterprises. When peer enterprises have a larger market share, informed traders are more willing to trade peer stocks . When thAlthough IPO can effectively alleviate the financing constraints faced by enterprises in the process of innovation, it also exposes a series of problems such as short-sighted incentives and disclosure requirements that restrict innovation. This trade-off is expected to form a unique innovation strategy model in listed enterprises. These enterprises may have experienced the loss of technology inventors and the decline in the productivity of the remaining inventors after IPO. Listing has changed the strategy of enterprises pursuing technological innovation. The equity dispersion, agency problems, and short-term pressure brought by IPO lead to the reduction of R&D investment. Compared with development innovation, exploratory innovation has a longer cycle and greater risk, and the level of exploratory innovation of listed enterprises is lower . Listed IPO decision not only affects the innovation behavior of enterprises, but also provides a platform for enterprise information sources. Private enterprises can learn more valuable things from the stock price information of listed peer enterprises. After listing, enterprises have more information resources. Listed companies can not only learn information from their peers' share prices, but also rely on their own share prices as a source of information. Therefore, IPO will affect the relationship between two-way innovation and peer share price information. In addition, due to the different intensity of industry competition, the efficiency of stock market price information may have different effects on innovation activities. After the initial public offering, with the intensification of competition, enterprises pay more and more attention to the share price information of their peers. Therefore, the learning mechanism of IPO can have a great impact on the stock price innovation of enterprises.According to the current research progress on enterprise stock price information, peers' stock price information, and IPO, as well as the research results on the relationship between them and enterprise innovation, this paper puts forward the following research hypotheses.As the enterprise stock price information increases, the enterprise exploratory innovation becomes more sensitive to its own stock price information.As the enterprise stock price information increases, the enterprise exploitative innovation is not affected by its own stock price information.As the peers' stock price information increases, the enterprise exploratory innovation becomes more sensitive to the peers' stock price information.As the peers' stock price information increases, the enterprise exploitative innovation is not affected by the peers' stock price information.After the IPO, the enterprise exploratory innovation becomes more sensitive to the peers' stock price information.After the IPO, the enterprise exploitative innovation becomes more sensitive to the peers' stock price information.In order to make a scientific evaluation of the above research proposition, this paper proposes to use the following scheme to conduct empirical analysis and test the relevant assumptions, as shown in In China, patents are classified into three types: invention, utility, and design. Patents that describe the degree and level of innovation of an enterprise are divided into two categories: invention patents and noninvention patents. Invention patents refer to new technical solutions for products and methods, emphasizing originality and novelty and having outstanding substantive features and significant progress compared with existing technologies. Therefore, invention patents largely reflect the ability and performance of an enterprise to engage in exploratory innovation. The more invention patents, the more new products or new technologies the company has that is different from its competitors. Noninvention patents include utility patents and design patents. A utility patent refers to a new technical solution suitable for practical use proposed for the shape, structure, or combination of the product. A design patent refers to a new design of the shape, pattern, color, or combination of the product that is rich in aesthetics and suitable for industrial application. Design and utility both involve the shape of a product. The shape involved in the utility is considered from the perspective of the technical effect and function of the product. However, the shape involved in the design is considered from the aesthetic point of view of the product. A noninvention patent requires progress in existing technology, and the creativity is significantly lower than that of an invention patent. To a large extent, noninvention patents describe the degree and level of an enterprise's exploitative innovation, that is, to what extent the enterprise has improved existing products or technologies.Explore) of enterprises is measured by 1 plus the logarithm of the number of invention patents. In order to reflect the exploitative innovation (Exploit) of enterprises, this paper selects 1 plus the logarithm of design and utility patent counts.Based on the existing research , this paIPO to measure whether an enterprise is listed or not. In the observation year, if the enterprise has been listed, IPO = 1; otherwise it is 0.For ease of description, this paper uses a dummy variable INF [INFi,t represents the weekly rate of return of enterprise i in period t, INFm,t is the market return in period t, and INFj,t is the return of industry j in which firm i is located. β0, βm, and βj represent the weight coefficient, and εi,t denotes the adjustment coefficient.Firstly, we need to calculate the price asynchrony, that is, the change of stock return that cannot be explained by market and industry factors, and take it as the main index to measure the stock price information. If the stock return of the enterprise is closely related to the market and industry return, the stock price of the enterprise is unlikely to convey the specific information of the enterprise, which plays an important reference role in the investment decision-making of the management. Because the data required for the calculation of this index is easy to collect and widely used, this paper adopts the existing methods to calculate the stock price information, which is denoted as INF . The speINF1i,t represents peer stock price information, and its calculation model reflects the weighted stock price information of circulation market value of all peer enterprises except i enterprise. If Ri,t2 denotes the square of the regression coefficient, 1 − Ri,t2 can be used to represent the asynchronous index of stock price, which is composed of two aspects: enterprise specific information and noise trading information.Studies have found that price asynchrony can reflect more private information than noise . Based o2), return on assets (Roa), enterprise scale (Size), enterprise capital structure(Lev), enterprise age(Age), etc. The selection and definition of control variables are shown in In order to facilitate regression analysis, this paper uses relevant control variables to describe different characteristics that may affect enterprise innovation behavior, including relevant stock price information and its influencing factors. These control variables mainly include industrial competition (CO), industrial competition square –(6) represent the impact of peer stock price information on developmental innovation. However, compared with the stock price information of the enterprise itself, the stock price information of peers has no significant impact on the development and innovation of the enterprise. This result shows that there are some differences between exploratory innovation and developmental innovation under the influence of stock price information.Through the regression simulation of the relationship between peer stock price information and innovation, the regression results of the impact of peer stock price information on enterprise innovation behavior can be obtained, as shown in ∗ IPO on enterprise exploratory innovation. This can be seen from the information coefficient of the IPO model (P + 0.053) that is 119.5 on the stock price of enterprises. When IPO = 0, P = -0.053; when IPO = 1, the influence coefficient is p = 0.066. In other words, enterprises after listing are more sensitive to the share price information of their peers in terms of exploratory innovation. Models (4)–(6) in ∗ IPO on enterprise developmental innovation. In model (4) in p = −0.086 + 0.124 ∗ IPO. The results show that, after IPO, the sensitivity of enterprise utilization innovation to peer stock price information is enhanced. With the passage of time, the impact of peer stock price information on enterprise development innovation is gradually weakened. This shows that the regression results are consistent with the hypothesis.Private enterprises can rely on the share price of their peers as a source of information, especially when these enterprises are listed, and they can start to learn information from their own share price. Therefore, this will affect the relationship between the two-way innovation of enterprises and the share price information of their peers. Through the regression simulation of the relationship between stock price information, IPO, and enterprise innovation, the regression results of the impact of stock price information and IPO on enterprise innovation behavior can be obtained, as shown in In order to show the accuracy of the conclusion, the text tests the robustness of the above empirical results. Different industry classification standards may have a certain impact on the relevant variables of the industry index. For example, peer stock price information and industry competition indicators are closely related to the industry classification standards. In the robustness test, this paper uses wind secondary industry classification standards to remeasure the industry competition, peer stock price information, and other relevant indicators. In addition, considering the heterogeneity of demand for technological innovation in different industries, this paper selects high-tech industrial enterprises as the research sample to test the robustness of this research hypothesis. According to the classification of high-tech industries (manufacturing industry) (2017) implemented by the National Bureau of Statistics, this paper uses eight industries in the primary industry classification of ShenyinWanguo Securities Research Institute to represent high-tech industries, including electrical equipment, electronics, national defense and military industry, chemistry, mechanical equipment, computer, communication, pharmaceutical, and biological industry. Through the robustness test, the test results are highly consistent.Because technological innovation can provide competitive advantages in the product market for the sustainable development of enterprises, this paper analyzed the important impact of stock price information on the two-way innovation behavior of enterprises. Firstly, by analyzing the development status of China's capital market, this paper explored the impact of enterprises' own stock price information on two-way innovation activities. The empirical results showed that enterprises' exploratory innovation and developmental innovation were not affected by their own stock price information. Secondly, the impact of stock price information on enterprise innovation behavior depended on the source of information. With the increase of peer stock price information, enterprise exploratory innovation became more sensitive to peer stock price information. However, the development innovation of enterprises was not affected by the stock price information of peers. The results showed that enterprises pay more attention to the stock price information of their peers when making exploratory innovation decisions. In addition, it explored the impact of IPO on the relationship between two-way innovation and stock price information. After IPO, enterprises had a wider range of information sources, but also faced changes in the product market competition environment. Enterprises' exploratory innovation and development innovation were more sensitive to the stock price information of their peers. With the passage of time, the impact of peer stock price information on enterprise development innovation was gradually weakened.This study fully showed that enterprises should strengthen managers' awareness of learning stock price information and improve the efficiency of innovation investment. Since the function of optimizing the allocation of resources in the stock market depended on the effectiveness of information transmission, relevant departments should further improve the construction of information transmission mechanism in the capital market and improve the efficiency of capital market serving enterprise innovation. This study had certain reference significance for promoting enterprises to obtain innovative competitive advantage for sustainable development.


To explore the hazard factors affecting the quality of life for patients with lung cancer after chemotherapy, so as to provide evidence-based clinical proof to improve their quality of life. quality of life questionnaire for Chinese cancer patients receiving chemobiotherapy (QLQ-CCC) was used to evaluate the patients' quality of life.  The clinic data of lung cancer patients treated with chemotherapy from November 2020 to November 2021 in our hospital were selected for retrospective analysis. A questionnaire survey was administered to 74 patients who met the inclusion criteria. The general condition questionnaire made by the department was used to analyzed the patients' demographic characteristics and disease status. The P < 0.001).  The research objects selected for this study scored an average of (94.53 ± 22.65) points in the quality of life. It was found by logistic regression analysis that age, education level, marital status, pathological types, monthly family income, and metastasis were the independent influencing factors that lowered the quality of life of lung cancer patients after chemotherapy ( Chemotherapy can lead to a decline in the quality of life of lung cancer patients, and there are many factors at play. Therefore, medical and nursing staff should focus on the overall condition of patients when carrying out clinical treatment. Lung cancer is currently the leading cause of death from malignancies worldwide , with a Chinese Medical Association guidelines for clinical diagnosis and treatment of lung cancer [(edition 2018) and were confirmed by MRI, CT, and histopathological examination, with symptom manifestations of cough, hemoptysis, pleural effusion, and dysphagia; (2) the patients were eligible for chemotherapy , and their performance status scores (KPS) were no less than 60; and (3) the patients had no other comorbidities that obviously threatened their quality of life except for the primary disease, lung cancer.The research objects selected for this study were the lung cancer patients who received chemotherapy treatment from November 2020 to November 2021 in our hospital. The study was in line with the Declaration of Helsinki (2013) . The incg cancer  (editionThe exclusion criteria were as follows: (1) patients with major diseases such as liver, kidney, brain, and heart dysfunctions; (2) patients with communication or comprehension disturbance that make it difficult to cooperate with the scale assessment; (3) patients who switched to other treatment regimens during chemotherapy; and (4) patients with psychiatric symptoms and previous oral medications of sedative and antidepressant drugs.In this study, the questionnaires included general condition and quality of life questionnaires.The questionnaire was designed by the department, mostly including gender, age, pathological types, family income, and residence of the patients.quality of life questionnaire for Chinese cancer patients with chemobiotherapy (QLQ-CCC) [P < 0.001.The QLQ-CCC)  was adopThe questionnaires were issued by the researcher who specified how to fill in the scale to the respondents with uniform instructions. The respondents were required to complete the questionnaires independently within 45 min, and the questionnaires were retrieved as soon as they were finished.P < 0.05 indicated that the differences were statistically significant.Professional statistical software SPSS 26.0 was used to process the data of this study. The patients' quality of life was evaluated by total scores, mean scores, and standard deviations. Logistic regression was used to analyze the effects of demographic factors and disease factors on the quality of life for lung cancer patients after chemotherapy, and The results are shown in The results are detailed in Taking the QLQ-CCC scores as the dependent variables, the univariates with statistical significance were included in the multivariate logistic regression analysis which concluded that age, education levels, marital status, pathological types, monthly family income, and metastasis were independent influencing factors lowering the lung cancer patients' quality of life after chemotherapy, as shown in Lung cancer is a malignant tumor with high morbidity and mortality in China, which not only threatens the physical and mental health of patients, but also is a menace to their lives . In receQuality of life refers to the overall feeling of people thinking about their individual health and state of life, which is mostly evaluated from the physical, psychological, and social aspects of patients in medicine . There aIt has been found that after chemotherapy, the older the patients are, the poorer their physical functions are, which is due to the fact that the physiological functions of vital organs such as the liver and kidney, as well as the generation and reserve capacity of bone marrow decline gradually along with age. Therefore, the tolerance to chemotherapy will diminish, resulting in a poor quality of life after chemotherapy . As a reThe limitations of this study are as follows: due to the single sample source, small sample size, and deficient or inadequate considerations about the factors affecting patients' quality of life after chemotherapy, the study results lacked universality and systematicness. In addition, the influences from chemotherapy regimens on patients' quality of life were not considered. The investigations into nutritional status, chemotherapy regimens, and beliefs should be added in future research studies to observe their impacts on patients' quality of life. Thus, researchers can fully understand the factors affecting lung cancer patients' quality of life after chemotherapy and explore methods for improving their quality of life.


COVID-19 has posed a significantly severe impact on both people’s lives and the global economic development. Increasing the community epidemic resilience will considerably improve the national public health emergency response capacity from bottom to top. This study identifies the influencing factors of community epidemic resilience through systematic literature review under the 4R framework, then obtains the relationships of influencing factors through Interpretive structural model, and finally assesses the performance of epidemic resilience using PROMETHEE II method through empirical cases in Nanjing, China. The results show that: (1) Eight factors influencing the epidemic resilience of community are identified, and the economic level plays the root role; (2) Community epidemic resilience can be improved from robustness, rapidity, redundancy and resourcefulness aspects; (3) Through the empirical analysis, the epidemic resilience ranking of community can be displayed (Community D > T > S > F); (4) Additionally, the performance and sensitivity analysis of influencing factors in each community can be demonstrated. (5) Finally, four implications are proposed, namely, allocating public resources rationally, significantly increasing the economic level, ensuring the accuracy of information delivery and conducting disaster learning. The COVID-19 pandemic in the early 2020 has posed a serious threat to the whole world . SimultaTo respond to the COVID-19, most of the foreign governments have enforced border shutdowns, travel restrictions and quarantine . Given tCommunity resilience includes the prevention and response to natural disasters and major social emergencies, and the restoration and even leapfrogging of community functions after disasters ,11. A reIdentifying a systematic list of the influencing factors is the key to improving the resilience of urban community ,19,20. AThe aforementioned studies have contributed greatly on the assessment of epidemic resilience in urban communities, but a few gaps still remain to be bridged: (1) More technical measures should be implemented than management measures; (2) There is a lack of systematic framework among influencing factors of community resilience; (3) Few research has been conducted on the source factors that affect community resilience under the epidemic situation as well as the relationship among these factors.To fill these gaps, this study aims to discover the relationships between the factors affecting the community resilience through a systematic framework, which would be applied to the real community for experimental analysis to provide policy-makers with useful empirical evidence and reference regarding preparations for future incidents such as outbreaks of infectious diseases.(1)This paper uses systematic literature review (SLR) for factor screening and combines principal component analysis (PCA) for factor selection by dimensionality reduction. The integrative review is the broadest type of research review method, which allows a comprehensive understanding about the phenomenon of concern . Moreove(2)There are several ways to investigate the source sexuality factor. The interpretative structural model (ISM) is simpler to implement than other methods, which allows the demonstration of the internal structure of a system by processing known but intricate system–element relationships . Therefo(3)The PROMETHEE method uses a priority function to depict the priority of a finite number of alternatives in terms of attributes, and ranks the superiority of each alternative according to the gaps between the values of the attributes. Compared to other multicriteria decision making methods, the PROMETHEE method is simple and straightforward to implement and can thus be easily understood by decision makers. This makes it one of the predominantly used decision method for solving multi-attribute decision problems .(4)Graphical Analysis for Interactive Aid (GAIA) is a descriptive helper method for PROMETHEE. It is a three-dimensional visual representation of the similarity between decision criteria and decision objectives. Each indicator is made axis in a space, and the projection length of the community on each axis indicates the advantage (or deficiency) degree of the indicator represented by the community on the axis .Based on the above methods, A combined theoretical and practical approach is proposed as shown in Community resilience can be defined as: (1) the ability to maintain basic functions in the face of the uncertainty and perturbation of COVID-19; (2) the requirement for various resources, including human and material resources, as well as government policies to complement epidemic preparedness; (3) the governance in epidemic situations which emphasizes self-organization, self-adaptation and self-recovery, rather than reliance on external assistance.4R characteristics of resilience include robustness, redundancy, rapidity and resourcefulness, each of which indicates an aspect of the preparedness and mitigation capacity that communities demonstrate when responding to disasters . The morRobustness: The ability to considerably maintain normal functioning and stable operating conditions after exposing to epidemic. Increasing the system’s robustness will significantly reduce the recovery time and thus prevent or minimize severe disruptions to the community [ommunity . Rapidity: The response of community to disasters, and the speed and efficiency of reconstruction and recovery from the epidemic. As an essential element of the epidemic resilience, it is closely related to the severity of the disaster, the availability and amount of the resources provided and the ability of the community to manage and operate the system [e system . Redundancy: The ability to maintain the original functional state through backup or other alternative systems, despite of the damaged systems of the community during the epidemic. The redundancy allows a community to maintain an acceptable level of service by providing additional systems [ systems . Resourcefulness: The capacity that allocates resources and the ability to evaluate the performance of resilience of a community during the epidemic [epidemic . It alsoepidemic .“COVID-19” “community” “Resilience/resilient” are used as keywords to search in the two mainstream databases of ScienceDirect and Wiley Online Library, from which all retrieved English literature are screened and verified. In addition, all the studies are based on advanced search, limited to title, keywords and abstract. Only English language is accepted and the majority of the literature are journals. Moreover, the publication time is set from 2019 to 2022.This paper formulated the following strategies for multiple screening of existing articles  , includiBy using the above-mentioned index selection method, 45 articles related to evaluation indicators of resilience of urban communities during the outbreak of COVID-19 are finally determined in this paper. Based on the above research basis, word frequency statistics of the first and second level indicators in the above 45 articles are conducted. The indicators with occurrence frequency ≥ 3 are extracted and sorted out. The articles selected as well as the indicators are shown in The influencing factors listed in Based on the 30 valid online questionnaires collected, PCA method is adopted to screen the influencing factors. With exclusion of the secondary influencing factors of which the frequency is lower than 3, a total of 21 influencing factors are obtained, which correspond to Q1~Q21 in the questionnaire respectively. The questionnaire results are summarized, and the Pearson correlation coefficient is used to calculate the correlation coefficient between the influencing factors as shown in It can be noted from The above eight influencing factors are classified by 4R characteristics as follows.Economic level and social network are considered to belong to robustness. Firstly, economic level is closely related to people’s lives and thus can greatly influence the operation of the urban epidemic resilience . MeanwhiEmergency response and daily management are considered to belong to rapidity. First of all, rapid emergency response following disasters is indispensable. This function will allow the provision of assistance for satisfying basic needs such as food and shelter . In addiMedical resources and public service are considered to belong to redundancy. Adequate reserve supplies and well-organized emergency supply chain will guarantee a smooth operation of a city, thus enhance the redundancy of the community in the face of epidemic . RepreseExperience in disaster and information technology are considered to belong to resourcefulness. Whether a community implements early warning to respond to disasters or innovative measures to prevent disasters, can be used to assess its disaster experience gained previously . RegardlThe ISM method was first proposed by Warfield to construct the hierarchical model of influencing factors in complex systems. By using this structural model, vague ideas, relations and views can be transformed into an intuitive model structure with good structural relations, which also delivers good and intuitive readability and reference .Eight experts from higher education institutions in related fields are selected to weight and score the eight factors, of whom five are male and three are female, accounting for 62.5% and 37.5%, respectively. The interviewees include four professors, two associate professors and two lecturers. These experts conduct their own research in this field and their evaluations are fairly reliable. The matrix of relationships between the influencing factors is shown in Based on the results calculated with the MATLAB software, the ISM model is built, as shown in The PROMETHEE method depicts the priority of a limited number of alternatives  on attributes through a set of evaluation criteria, and lists the advantages and disadvantages of each scheme according to the gap between the attribute values of each scheme. The set of influencing factors and the target communities are identified first, and then the performance of different communities under various influencing factors is assessed with the expert scoring method to obtain a weight matrix. Finally, a suitable preference function is selected in Visual PROMETHEE software. Integrated with the weights of influencing factors, the weight matrix is imported to analyze the results.Taking Nanjing as an example, this paper selects four different communities under the jurisdiction of Meiyuan Street in Xuanwu District, including: Community F, S, T and D. The basic information of the communities is shown in Five staff of Meiyuan Street Office are invited to score the four communities with the Likert five-point scale method, on a scale from 1 to 5, as shown in The resilience of the four communities following COVID-19 is obtained as shown in As noticed from TPM communities are predominated by administrative departments, with fewer residents, armed forces, forming relatively single and fixed social network relationships, so they are less affected by this. Most of this community is covered by the Nanjing Military Region, the affiliated family buildings, and the Nanjing Military Region General hospital. Soldiers are trained with high execution ability, strong unified command and coordination skills, and can quickly respond to emergencies. Community F is relatively geographically remote, occupied by old buildings with mostly elderly residents, who are closely related to each other. Consequently, it is significantly affected by the social network. Furthermore, since the elderly are relatively vulnerable, this community can be considered more sensitive to daily management and medical resources.Community S is less densely populated with several small residential areas. It accommodates residents with relatively high level of education, such as college students and retired teachers. The overall civilization is considerably higher than the other three communities. Considering its community structure, it has high requirements for information quality and transmission, so information technology poses the greatest impact, whereas economic level, social network and emergency response would exert negligible influences. The strengths and weaknesses of each community are shown in The sensitivity analysis of influencing factors are as follows: (1) When the weight of economic level reaches 84% or public service resources reaches 94%, the desired resilience performance of Community F can be achieved. It demonstrates that the economic level and public service resources in Community F need to be developed urgently. (2) The social network is not a major influence to Communities F and S, however, increasing social network complexity in both communities without restriction will place a negative impact on community resilience once social network reaches 36%. (3) Community S is heavily influenced by emergency response and accordingly, a lack of prior emergency response will pose a major constraint on community resilience. (4) The information technology is not a major constraint on the epidemic resilience for Communities F and D. However, overemphasis on information technology does not increase the desired effect on community resilience. On the other hand, the Community T has a poor level of information technology, and only a fair increase in information technology will expectantly improve the resilience.Graphical Analysis for Interactive Aid (GAIA) is a descriptive helper method for PROMETHEE as shown in RobustnessIt is imperative for the neighborhood committee of Community T to effectively improve prevention and control measures, and strengthen the governance and function of urban management department for better coordination and greater efficiency.Considering that Community T is mostly a government department and military station, it is reasonably necessary to build a good relationship between the police and the people. Concurrently, these following measures will presumably enhance the community resilience, including, improve the cooperation between the sub-district office and the city management department, emphasize the mental health of residents, solve the conflicts among the residents in a timely and effective manner, and focus on specific groups of people.The Community F performs poorly under economic indicators. After collecting 650 valid questionnaires in China, Zhang et al. also pointed out that communities with a higher level of economic development tend to be more resilient during the outbreak of the COVID-19 [RapidityLinked to the ability to operate the system, rapidity is an essential element of the community resilience. Here, rapidity refers to emergency response and daily management. Community D performed well in emergency response, owing to its relatively solid economic foundation and rapid information transmission. The early warning department can use the neighborhood committee as the fundamental unit of disaster prevention and control, which can effectively improve the efficiency of information transmission. When data is questioned and inaccurate information is disseminated, community resilience will be largely challenged ,55. The Additionally, the community should necessarily strengthen the communication and connection with external volunteer groups and other social forces to enhance community resilience. All four communities are affected by daily management, which all perform satisfactorily. The reason for the investigation is that daily management is most closely related to people’s livelihood, and in the ISM analysis results, it is the primary source factor, which places a substantial impact on community resilience. All four communities highly value daily management, and the community governance is well-organized, which allows strong community resilience.RedundancyIn terms of medical resources, Community S and Community T exhibit excellent performance. Community S has a series of tertiary hospitals such as Zhongda Hospital, with advanced medical care and abundant medical resources, which have played a critical role in fighting the epidemic. Mainly based on military hospitals, Community T is highly unified, distributed with orderly and standardized medical resources. As the source indicator of community epidemic resilience, public service resources have an impact on all four communities, of which Community D performs the best, while T, Fand S communities perform the worst. Owing to its rapid development, numerous commercial streets, excellent economic conditions, and large flow of people, Community D has a large demand for, thus accordingly, a good reserve of public resources and excellent resilience in redundancy when dealing with major disasters. Community F contains numerous small old communities, where the facilities are aging and not updated timely. When dealing with sudden disasters, public service resources are not sufficient for it to respond well. From the study in Kerala India, Shine et al. similarly found that a rational redistribution of health care resources, endows Kerala with the highest recovery rate and lowest death rate among Indian states . In thisResourcefulnessThe disaster experience is at the root level, and all four communities which perform well are affected by it. It can be considered that the community has encountered disasters before and accumulated certain experience from them. Both the management and the residents of the community can learn from past disasters, which strengthens resilience for the community to fight against the epidemic. The community management department can regularly hold disaster-related knowledge sharing activities such as disaster drills, publicity and education, and general science lectures in the community, to improve residents’ skills against disasters. In terms of information technology indicators, Community F has the worst performance. Considering the aging of the community, the acceptance of new information is slow. Neighborhood committees can set up information display board in the community to update the latest news.Generally, Community D has performed best, with effective information communication and sufficient material reserves. Community T performed relatively well among the four communities, with numerous small groups, extensive contacts with the community police, and strong action skills. But the problem is that the power and authority within the community are relatively centralized, which leads to inefficient transmission of information, thus attention should be paid to strengthening association with external organizations. Regarding economic indicators, Community F lacks financial support, and the connection between various stakeholders in community liaison is sparse and not close, resulting in obstruction of information transmission.The improvement of community resilience is a major research topic in the context of COVID-19. By researching existing studies, it is found that there are many factors that can possibly influence community resilience. This paper finds through ISM analysis that community resilience is mainly influenced by eight factors, of which emergency response, daily management, public service resources and experience in disaster are the root factors. Finally, this study evaluates the performance of epidemic resilience using PROMETHEE II method through empirical cases in Nanjing, China.(1)Rational allocation of public resourcesThree main implications were identified from this study, which are critical for stakeholders and decision-makers in China to incorporate into their resilience planning:The level of health care is one of the most important influences in determining the resilience of a community during a new crown epidemic. Communities with more resourcefulness are able to provide sufficient material resources to cope with the epidemic; contrastingly, is it pressing to provide sufficient medical resources for those communities with poor location and aging residents. Therefore, it is necessary to redistribute health care resources for different communities. Ensuring the adequacy of public resources in the community is an effective initiative to improve community resilience.(2)Ensure the accuracy of information deliveryNoted from the case study, the resilience of Community can be strengthened by improving the stable transmission of effective information and interdepartmental synergies while preventing the spread of the virus during the COVID-19. This shows that ensuring the accuracy as well as the timeliness of information will greatly booster community resilience.(3)Conduct disaster learningFrom the case above, it is found that emergency response placed a significant impact on community resilience. Lack of prior emergency response can exert a major constraint on the level of community resilience. Significantly improving emergency response can effectively increase the level of community resilience. Communities need to ensure that lessons are learned from previous disasters and that associated changes are made immediately in the aftermath. Only then will it be possible to effectively implement changes in practice for post-disaster management and thus improve pandemic preparedness.Overall, community resilience is multi-dimensional and multi-factorial, and thus it requires an improved level of integration to essentially strengthen community resilience. The research framework and the several implications proposed in this paper provide a practical reference for other countries around the world to apply to improve community resilience during COVID-19. Nonetheless, there is still much relevant work to be done in the future. First, a limited number of influencing factors have been fully examined in this study, and other factors might be considered in the future to reveal additional insights. Second, the proposed improvement paths for community resilience can be evaluated through simulation techniques in future studies to test the validity.


Recent studies have suggested that it is important to incorporate LAA geometrical and hemodynamic features to evaluate the risk of thrombus formation in LAA, which may better delineate the AF patients for anticoagulant administration and prevent strokes. This review focuses on the LAA-related factors that may be associated with thrombus formation and cardioembolic events.Left atrial appendage (LAA) is believed to be a common site of thrombus formation in patients with atrial fibrillation (AF). However, the commonly-applied stroke risk stratification model (such as. CHA Atrial fibrillation (AF) is the most common sustained rhythm disorder worldwide –4, and tIn AF patients, irregular heart rhythm disturbs blood flow, which can lead to blood stagnation and clot formation, with subsequent dislodgment and embolization in the brain resulting in thromboembolic events –15. Therviz.: CHA2DS2 or CHA2DS2-VASc, shown in the following In AF patients with thromboembolic event, studies have revealed that more than 90% of thrombi originate in the left atrial appendage (LAA) –20, whicRecent studies have shown extensive evidence that it is necessary to include some important LAA features to better evaluate the thromboembolic risk and prevent stroke risk. This study serves to overview of current concepts and recent developments in the relationship between stroke risk and LAA risk-related characteristics.A number of studies have focused on the stroke-related LAA characteristics. These characteristics can be classified into three groups: shape, morphology and hemodynamics. In the following paragraphs we elucidate the relationship between these characteristic groups and stroke risk.Shape is an intuitive term for describing the external form, contours, or outline of the LAA, and various classification approaches have been proposed for describing LAA shape –29. In tDi Biase et al.  conductevia detection of spontaneous echo contrast (SEC) or thrombi using 3D transesophageal echocardiography (TOE) in 320 AF patients and found that the cauliflower LAA type was associated with a higher prevalence of SEC or thrombi. Adukauskaite et al. , body surface area (BSA)], so that these morphology characteristics could be compared between different patients.Apart from LAA orifice, LAA volume see  is anothDifferent from the focus on LAA volume for a specific cardiac phase, Al-Issa et al.  focused In addition to the above-mentioned characteristics, some other characteristics were also studied, such as the angle of LAA bend , the depTo better quantify this complexity, Kaminski et al.  used difAlthough the morphology parameters are considered to be an objective approach for characterizing the LAA, the morphology parameter features are inherently isolated from the complex LAA geometry, and it lacks a comprehensive and mechanistic prospective for stroke evaluation. Under this circumstance, the hemodynamic analysis attracted the attention, for that the hemodynamic description utilizes the entire 3D dataset and is more comprehensive compared to the single or several morphological parameters. Furthermore, the study of hemodynamics is aligned with Virchow's triad used to characterize the relationship between blood flow and thrombus formation. In this regard, evaluating the stroke risk from the aspect of hemodynamics in the LAA may be an optimal approach for evaluation of stroke risk.2DS2-VASc scores  have also been studied. For LAA flow pattern, Garciafernandez et al.  identifiAlthough evaluation of stroke risk by means of LAA hemodynamic parameters is particularly convincing, the availability of direct clinical measurements of these parameters is often limited. Alternatively, computational fluid dynamics (CFD) method has been used to obtain these parameters. CFD is a numerical analysis approach for predicting the behavior of fluid flows whereby the hemodynamic details of LA and LAA can be obtained and visualized. Utilizing the CFD method, Gracia-Isla et al.  not onlyBased on CFD, some other studies applied more intuitive and quantitative methods in evaluating thrombus formation. Bosi et al.  used conIn addition to studies assumed the boundary walls to be rigid to simulate the idealized AF conditions , 86–88. Although several hemodynamic parameters proposed by the CFD models rely on numerical simulations to evaluate thrombus formation risk. further research is required to validate their potential application in stroke risk evaluation in patients.As illustrated in the former section, shape, morphology and hemodynamic parameters of the LAA are all validated to be highly associated with the risk of stroke. Several studies have pointed out the subjectivity of the shape classifications and the advantages of morphology and hemodynamic descriptors as objective classifiers, which have led to studies of relationships among these parameters. A number of these studies have established that the non-chicken wing type LAA is usually associated with a larger LAA orifice , 33 and The relationships among the shape, morphology and hemodynamic parameters highlight the importance of LAA in stroke evaluation, which motivates further studies to find and evaluate the key LAA features.As shown in the Compared with other imaging modalities, echocardiography can obtain the image at low cost and with high efficiency, so it is a widely used method in clinics. During the imaging procedure, the probe of TEE is close to the heart with high frequency, and therefore TEE can be used not only to assess the LAA morphology, but also to screen out the thrombus and spontaneous echo contrast (SEC) in the LA/LAA , and it All in all, TEE is widely applied in the clinical practice related with LAA with its efficient, clear and low-cost imaging procedure. And this imaging modality with high time-resolution is applicable in the shape, morphology and especially the hemodynamic evaluations for the LAA.Compared with TEE, cardiac CT offers superior spatial resolution. Its high-quality multi-planar and 3D reconstruction would do much help in the characterization of the LAA anatomy and accurate sizing . TherefoIn general, cardiac CT is limited in the time resolution, but its high spatial resolution contributes to a wide application in the shape and morphology evaluation for LAA.Cardiac MRI is a noninvasive imaging modality for the structure and hemodynamic evaluation. It has excellent tissue characterization capacity but a lower spatial resolution when compared to the cardiac CT . MeanwhiGenerally speaking, though the MRI modality is noninvasive and can obtain the shape, morphology and hemodynamic parameters of the LAA, the present number of its application scenarios in LAA are small, most for the patients unsuitable for TEE and CT . Its pot2DS2-VASc score scheme. This scheme first became part of guideline medical therapy as part of the 2012 European Society of Cardiology updated guidelines  could be utilized for the LAA related studies:The pre-processing of image segmentation and reconstruction are the foundation for shape and morphology evaluation, while the manual segmentation and reconstruction for a patient-specific data is time-consuming. In this regard, some auto or semi-auto segmentation and reconstruction algorithms were put forward –124 to iBlood stasis is one of the three conditions in Virchow's triad, the study of blood stasis requires a comprehensive characterization of the local hemodynamics, and the clinical measurement of echocardiography is currently the main tool to explore the blood flow patterns and velocity profiles. While the echocardiography cannot fully characterize the complexity of 4D blood flow patterns, new imaging techniques like 4D flow MRI or blood speckle tracking are promising but their capability to capture the low flow velocities related to thrombus formation is still unclear. As an alternative, CFD poses a great potential to thoroughly assess the hemodynamics inside the LA/LAA, and several studies have been performed to analyze the hemodynamic parameters in the LAA in relation to thrombogenic risk –82, 84.in-vitro flow equipment to validate there CFD models. Finally, it is worth to mention the work performed by Morales et al.  and hemodynamic parameters on stratification of stroke risk, especially in patients with low CHAZL and LZ designed and supervised the study. RF and YL reviewed the literature and wrote the original manuscript. JW and ZW helped with the literature search. JA and CC modified the article. All authors contributed to the article and approved the submitted version.This work is partially supported by the National Natural Science Foundation of China , Postgraduate Research & Practice Innovation Program of Jiangsu Province (No.SJCX20_0012) and the Fundamental Research Funds for the Central Universities (3207032103D).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.