Telepractice facilitates services in exceptional settings and situations. The ongoing COVID-19 pandemic is certainly such a situation. Due to pandemic-related restrictions, speech-language pathologists (SLPs) needed to adopt new approaches to their professional functioning. The aim of the paper is to examine SLP professionals' perceptions and application of telepractice in SLP settings in Croatia during the COVID-19 pandemic. Two hundred and fifty-five SLPs completed an online survey. The results demonstrated that most SLPs had provided direct online therapy, mainly those employed in health care and private practice. The chief reasons for clients' refusal of therapy delivered via telepractice included the lack of equipment, insufficient independence, and doubts on the effectiveness of telepractice. Although only 3% of SLPs had acquired some formal knowledge of telepractice before the pandemic, over 70% expressed satisfaction with telepractice because it allowed them to provide undisturbed clinical services in an exceptional situation. According to the The term telepractice can be used interchangeably with telehealth and will be used throughout this article to describe speech and language services delivered through a telehealth service delivery model. Key considerations when using telepractice for speech and language pathology (SLP) include accessibility, environments, regulation, legislation , tele-ethics, competency, and preparation for service delivery .Environments include different situational settings  when using telepractice. Legislation policies, licensure and reimbursement coverage are country-specific and sometimes dependent on the system of employment. This is the case in Croatia, where codes of practice within different systems define the scope of SLP activities . Due to Tele-ethics is a concept which encompasses all components covered by ethics in general, with some additional specific issues. In a broad sense it refers to one's professional responsibility to uphold the client's well-being. In a more specific sense, tele-ethics includes a professional's duty of care towards the client ; equivalence of services ; privacy of information and place ; and the equity of access . Examples of best ethical practices for telepractice are outlined in Preparation for telepractice includes thorough consideration of the general needs for services, organisational and environmental assessment, practitioner readiness , selection of optimal technologies and tools, as well as client selection .This paper will mainly discuss the latter .Telepractice within speech and language therapy is still relatively new, which is why the efficacy research is limited, especially meta-analysis studies. A 2020 analysis of the PubMed database revealed that less than 1% of all papers on telepractice were published during the 1990s, and approximately 82% were published between 2010-2020. This significant rise in the number of published papers during the last 30 years is proof of changing practice trends, and the increasing importance of telepractice in recent years.setting , professional readiness (level of education and feelings of competence), and client selection (as the driving-force for adequate service to those who are most likely to benefit). These factors may impact the provision and effectiveness of telepractice  with a matched control group . These tA small amount of available data usually reports effectiveness and usefulness of telepractice in the adult population, mostly patients with post-stroke aphasia or Parkinson's disease , communiThose who perceive this relatively novel service delivery model for providing speech and language services point out several beneficial characteristics. It provides SLPs and their clients with the opportunity to work towards achieving clients' goals outside of strictly clinical settings, thus easing and speeding up the process of transferring to natural settings. Furthermore, it aids in overcoming distance and travel issues and the expenses that usually accompany them. Finally, it helps fill service gaps in educational and adult health care settings . DespiteIs the professional adequately educated and competent to use telepractice for the delivery of speech and language services?Who is telepractice intended for and under which circumstances should it be implemented?How can professionals ensure a proper setting for themselves and their clients?Which tools and equipment should be used?What are regulation requirements and ethical responsibilities?face-to-face in-person therapy. There are only two papers focused on SLP telepractice in Croatia, and both are written from a technological, and not a therapeutic point of view.Telepractice has not often been the interest of research in Croatia, and its use in clinical settings is still sporadic. Almost every SLP in Croatia uses various hardware and software  is the Standing liaison Committee of EU speech and language therapists and Logopedists. The CPLOL made recommendations for SLPs throughout Europe to carry out telepractice whenever appropriate so that clients might continue to benefit from therapy despite the pandemic . NeverthThe use of telepractice in response to the COVID-19 pandemic was more or less imposed, and the transition occurred extremely rapidly. The exact details of its implementation across various settings and amongst SLPs with different professional expertise; their years of clinical experience; and their work with clients of different ages, diagnoses, and social backgrounds, is not entirely clear. For most SLPs the implementation of completely new methods and tools for service provision occurred in the context of scarce knowledge of preferable settings and factors that should guide telepractice. Attaining a clearer insight into the present use of telepractice during the COVID-19-pandemic in largely understudied telepractice settings should be the first step toward informing more in-depth future analyses.The main aim of the current paper was to examine professionals' perceptions and their application of telepractice in SLP settings in Croatia during the COVID-19 pandemic. The specific aims were to analyse what drives professionals' and clients' choices in decision-making and to explore SLPs' attitudes and level of confidence towards adopting this novel approach to service delivery.Several questions were formulated to address these goals:Is there a difference in the application of direct SLP services through telepractice with respect to an SLP's age, years of working experience, and employment system?Why don't some SLPs offer telepractice to certain clients?Why do some clients not accept telepractice?Does an SLP's age, years of working experience, employment system, and whether or not they conduct online direct therapy influence their satisfaction with telepractice?Do SLPs consider themselves sufficiently competent to conduct telepractice after only one month of experience?n=65). The answers of these 65 SLPs were analysed with respect to the general demographic and employment data (questions 1-7). Other analyses included data provided by the remaining 190 participants who were conducting telepractice during COVID-19. Demographic details of all respondents are presented in A total of 255 speech and language pathologists (SLPs) in Croatia participated in the study. This number represents a quarter of all SLPs in the country. The SLPs came from various regions, belonged to different age groups and worked within different systems (both public and private). The Survey was pre-designed to automatically exclude participants who reported that they had provided no telepractice services . The other participants worked either with school-aged children , children under the age of 3 years , or with the adult population .Most participants' caseloads constituted preschool children in the age range from 3-7 years (Only 4.2% of the sample reported receiving education in telepractice via webinar or in-person training before the COVID-19 pandemic.Survey on the Implementation of Remote Speech and Language Therapy Services (or telepractice) During COVID-19 Related Restrictions, henceforth referred to as “the Survey,” was specifically designed for this study. It was structured to be both user-friendly  and informative . The Survey was constructed via the SurveyMonkey platform. The first version was piloted by one SLP. After her valuable comments on the structure and terminology, the Survey was revised. The final version contained 31 questions divided into three sections which corresponded to the study goals: (1) demographic data of the respondent (SLP) and his/her employment system (q. 1-7); (2) data on provision and features of telepractice, as well as on its beneficiaries (q. 8-21); and (3) data on the general opinion and level of satisfaction with this type of service provision (q. 22-31). Most questions were free-choice or yes-no questions, with some Likert-scale and open-ended type questions. In all, 27 questions were mandatory, while the remaining four were optional .The rd April 2020), a public e-mail invitation was sent to the members mailing list by CLA administrators. The email contained the purpose and the link to the Survey. Participation was optional, with anonymity of personal data and confidentiality guaranteed. A link to the Survey was available from the beginning of May 2020 until the middle of the same month as by that time the first relaxation of restrictive measures related to SLP service delivery was declared by the National Civil Protection Headquarters. During the period of data collection most of the respondents already had approximately one month of telepractice experience. Each respondent completed the Survey individually. Survey completion took approximately 10-15 minutes.Prior to the study, a request for permission to start data collection was sent to the Board of Directors of Croatian Logopaedic Association [CLA]. After the Ethics Approval  or not . From the sample of 190 respondents who implemented telepractice during the COVID-19 pandemic, 115 (60.5%) stated that they provide direct services, while 75 (39.5%) reported that they do not work directly with the client. Frequency distributions are outlined with respect to SLPs' age, years of working experience and employment system, all provided in To compare frequency distributions and to see whether there were differences with respect to age, years of working experience, and system of employment, a chi-square test was employed. Analyses were based on the reported frequencies . ResultsThe second question addressed in this study identified reasons behind each professional's decision to not offer telepractice to certain clients. The proportion of SLPs who decided to offer these services to all their clients, and those who did not offer it to all clients, was extracted. These proportions are presented in Most respondents offered telepractice to all their clients (71%) because their caseload was relatively homogenous with respect to age and diagnosis. The remaining 29% of the sample deliberately chose to not offer remote services to all clients; their client selection was based on pre-established criteria. While answering the Survey questions respondents were instructed to mark the most relevant factor that influenced their decision not to offer telepractice services to certain clients. The majority of the SLPs singled out complexity of the client's clinical picture and their chronological age as the main reasons; organisational, time- and technology-related factors were chosen to a lesser extent. The distribution of selected answers is presented in n=116) of the current SLP sample indicated that not all their clients agreed to this sudden and unexpected remodelling of the previous and well-known mode of service provision, whereas 38.9% (n=74) of SLPs marked that all of their clients decided to receive services via telepractice during the pandemic. From the SLPs' perspective, the reasons for clients to reject the proposal were few. They seemed mostly related to the lack of technical conditions (n=48) and the fact that this service delivery model would require additional engagement of the parents and/or other family members, as well as the clients themselves (n=118) who were burdened with the need to restructure their personal and professional lifestyles in less than a month. Interestingly, 12 SLPs marked that their clients decided not to engage in telepractice due to a lack of confidence in its effectiveness.The third question of the study addressed clients who chose not to receive speech and language services through telepractice during the COVID-19. The percentage of client declination of telepractice was relatively high. Up to 61.1%  a direct face-to-face online therapy. To address this question, professionals' satisfaction measured on a Likert-type scale was put in relation to each of these factors, and a series of simple analyses of variance were performed.Of the 190 of the sample who stated that they conducted telepractice during COVID-19 in May 2020, 178 responded to the question inspecting their level of satisfaction. As indicated in F(3.177)=9.084; p<0.001]. The post-hoc Scheffe test revealed that differences were significant between health care and education system, with SLPs working in health care being more satisfied with telehealth , as well as between education and private practice/NGO, with the latter again indicating a significantly higher level of satisfaction  , years of working experience (for the second) and system of employment (for the third). Significant differences were observed only when level of satisfaction was put in comparison relative to the system an SLP was employed in ; those who worked directly with the client via telepractice were much more satisfied  than those who did not .Next, the researchers investigated features of general satisfaction with telepractice, to observe whether there was a difference in the overall level of satisfaction with telepractice between those who decided to implement direct face-to-face online services with their clients and those who used an indirect (counselling) approach. An independent sample n=190), 73% felt competent enough to do so, while 27% did not. When these two groups (according to self-perceived competence) were compared also with respect to their above-mentioned satisfaction with telepractice, the differences were significant . SLPs who felt competent were generally more satisfied with telepractice  than those who did not feel competent .The fifth and final question investigated whether SLPs generally perceived themselves as competent to conduct telepractice after only a month of experience. From the current sample of participants who indicated they conducted telepractice (Despite that very few respondents (only 4.2%) received additional education in telepractice before the COVID-19 pandemic (see Participants section), they generally recognized its importance. More specifically, 68.5% of the sample considered additional education in telepractice absolutely necessary, and 6.7% reported that education is needed only if one wishes to implement it in work with certain types of disorders , ASD or with generally more complex clinical pictures or comorbid conditions). On the other hand, 24.7% found additional training for the conduction of remote therapy unnecessary.The COVID-19 pandemic brought new working conditions to which speech and language pathologists had to adapt quickly and efficiently, and telepractice was the only option for providing speech and language services during quarantine. The aim of the current study was therefore to gain an insight into how SLPs in Croatia coped with the implementation of telepractice during the COVID-19 crisis, in the phase of a sudden and complete lock-down.The results showed that 60% of SLPs continued to provide direct therapy, and did so via telepractice. Interestingly, age and years of working experience did not appear to be significantly related to this decision, but the system of employment did. SLPs working in health care systems and in private practice were the ones who implemented direct therapy the most. Reasons for this can be found in their job descriptions. SLPs employed in health care and private systems in Croatia primarily conduct so-called prototypical speech and language activities - assessment, diagnostics, therapy and counselling - whereas SLPs working in education have a broader scope of work, which at times exceeds their prototypical professional roles. Namely, the educational system treats SLPs as members of the school team responsible not only for provision of speech and language services, but for promoting examples of good inclusive practice supporting students, teachers and parents, or ensuring adequate social environments for children with speech, language and communication needs. It appears that individuals employed within this system were, due to their usual workload, more inclined to provide general counselling related to education or policies, and to consult and monitor parents or other family members.The study also aimed to understand SLPs' reasons for not implementing telepractice with certain individuals. This question partially contributes to the understanding of key components of telepractice, such as characteristics of the environment and client selection, i.e. the appropriate choice of individuals who will surely benefit from telepractice . There aThe percentage of clients that declined telepractice was relatively high. Only 38.9% of SLPs reported that all their clients decided to receive telepractice services during the lock-down. The main reasons for rejection were the lack of technical conditions and the need for additional engagement of parents and/or other family members. These results corroborate findings reported by setting  and client selection , and much less to the lack of certainty in effectiveness or confidence in true potentials of telepractice.Observing the broad motives for not offering and not agreeing to receive telepractice, it seems that both were associated with challenges related to Findings on SLPs' satisfaction suggest that the level of satisfaction was relatively diverse. This seemed to be dependent on the system a person worked in, and whether or not the professional provided direct therapy to the client. Both these notions can be linked to the first finding of the study. SLPs employed in health care and private practice are more satisfied with telepractice than those working in the education system, partially due to the fact that telepractice is a much more convenient tool for the application of direct therapy , while it is much less convenient for SLPs in education. As highlighted earlier, aside from providing speech and language services to the clients, SLPs in education systems implement interventions that support students in meeting the demands of the curriculum . TherefoThe practice landscape has rapidly changed and the usual way SLPs, as professionals, organize their work and engage socially with their clients has been seriously challenged as a result of the COVID-19 pandemic. Job descriptions and the entire scope of professional obligations will most likely experience substantial change, as well. The education system will need to follow these tendencies, which is something that SLPs, at least those included in the current study, became aware of very recently. Almost 70% (including those who conduct direct online work and those who provide counselling to advise family members) feel that competency with telepractice requires additional training.The current study presents insights into telepractice in Croatia during the COVID-19 pandemic. Since it offers a rather brief overview of practice during this period, certain limitations are evident. First, the Survey was designed specifically for SLPs, so there is no data on client perception. Even questions that inspect reasons for clients' refusal of telepractice were answered by the SLPs. It would be worthwhile to observe in more detail the exact client-related factors that contribute to acceptance , as well as the successful application of telepractice with respect to socio-economic and other individual and familial characteristics of the client. Also, analysis related to other aspects  was not included in the analysis. Rather, the focus was mainly on client selection and preparation for telepractice.Future studies should investigate other concepts, including ethical and environmental aspects related to the use of telepractice for delivery of speech and language services. This is indeed very important, especially if implementation of telepractice continues to increase as a result of recent events. Since countries worldwide still significantly differ in educational and legislative aspects regarding provision of telepractice, it would be interesting to observe changes in each of these areas in the months and years to come.Until recently, telepractice has been completely understudied in Croatian SLP settings. However, in the recent months it has received more attention due to its applicability in response to the COVID-19 pandemic. Times of crises do not allow for the usual approach to services and therefore all SLP services require additional adjustment.This study is the first to investigate telepractice in Croatia, and the results must be interpreted in the context of the extreme conditions in which the data was gathered. Nevertheless, this was the exact goal: to examine SLPs' reactions to the COVID-19 pandemic and to explore their perceptions, insights, and preparation for telepractice. This first step in the research process provides a foundation for forthcoming studies and clinical work, which will likely include increasing use of telepractice in the future.The results suggest that SLPs in Croatia, despite their relative lack of additional education and experience in telepractice, do approach it thoroughly. They contemplate and ponder over client selection, which they base largely on age and complexity of clinical picture, and they question and reflect on their own competence. Other factors that shape preparation for telepractice are relatively out of SLPs' control ; this may indirectly contribute to feelings of satisfaction and competence, or the lack thereof. Benefits of telepractice most often reported in studies are equity of services, mitigation of distance and travel issues, and transfer to natural settings. Nonetheless, key components of telepractice need to continuously be investigated in-depth, as all services, whether provided in-person or remotely, must rely upon a strong evidence base. Education and legislation should follow the prevailing trends, and ideally be one step ahead.


Nanotechnology refers to the science that manipulates matter at molecular and atomic levels, and studies matter at the nanoscale level to detect and exploit the useful properties that derive from these dimensions; materials with components less than 100 nm in at least one dimension are called nanomaterials. Nanotechnology is applied in many fields, such as medicine (nanomedicine) and dentistry (nano-dentistry). The purpose of these innovations and research in this field is to improve human life and health. This article aims to summarize and describe what the most recent and known innovations of nanotechnology in dentistry are, focusing on and paying particular attention to the branch that is orthodontics, and on the application of new nanomaterials in the realization, for example, of orthodontic elastomeric ligatures, orthodontic power chains, and orthodontic miniscrews. We also address a very important topic in orthodontics, which is how to reduce the friction force. Nanotechnology is the science that manipulates matter at molecular and atomic levels. Different fields of application have been considered by researchers to detect and exploit the useful properties that derive from components at the nanoscale level. The term was coined by N. Taniguchi in 1974 at the Tokyo Science University [Materials with components smaller than 100 nm in at least one dimension are called nanomaterials. These components may include grains, fibers, clusters, nanoholes or a combination of these forms. In one dimension are defined sheets; in two dimensions, nanowires and nanotubes; and in three dimensions, they are called quantum dots. A fundamental aspect of these new particles is that they increase the surface area per unit mass compared to bigger particles, significantly modifying the physical and chemical properties of the material ; the novNanotechnologies are applied in many fields, including medicine (nanomedicine) and dentistry (nano-dentistry). Nanomedicine is the science of preventing, diagnosing and treating disease and preserving and improving human health using nanosized particles . The purThe toxicity of nanomaterials and nanoparticles is a hotly debated topic: some studies that we have reviewed have not addressed it; others underline the fact that today, there is still little evidence about it, especially in the dental sector. Nanotechnology can make the clinic simpler and easier, but some authors point out that there are currently limitations relating to the topic of safety .Nanomaterials have particular characteristics: the surface area/volume ratio (volume-specific surface area) of nanoparticles is greatly increased, and therefore, they are much more reactive compared with larger particles with the same composition. They have a high absorption rate in the body, in particular, through the skin, digestive tract and lungs; after prolonged use, they can accumulate in various organs, such as the lungs and digestive tract. They have the potential to cause DNA mutations, cell damage and inflammation. The relevance of these findings in dentistry is unknown ,5. In deAll these factors make it clear that nanotechnology is a relatively new field and still unexplored in some aspects. Many ideas are still difficult to implement due to technological, biological and ethical challenges. To date, further research and studies are needed for the application of this field as regards dentistry .A new branch called nano-dentistry has become more famous in recent years, and it involves the effort of different researchers and clinicians for the development of new materials. Nano-dentistry can be described as the science that uses nanostructured materials and technologies to diagnose, treat and prevent oral and dental disease . A commoConservative, endodontic, anesthesiology, aesthetics and orthodontics are the branches mainly involved. In recent years, much attention has been paid to dentistry nanorobots and tissue engineering, but also to studies regarding stem cells for bone augmentation and cartilage regeneration ,8,9,10.However, some applications of nanotechnology in dentistry have already been tested and are now used in various sectors; others need further studies and scientific research .This article aims to summarize and describe what the most recent innovations of nanotechnology in dentistry are; the authors took care in reviewing the most recent literature, to evaluate and report, in this research, the most significant innovations in the orthodontic field, comparing different articles and literature reviews and focusing the attention on the application of new nanomaterials in the realization, for example, of orthodontic elastomeric ligatures, orthodontic power chains and orthodontic miniscrews. We also address a very important topic in orthodontics, which is how to reduce the friction force.To summarize, the following paragraphs are the different fields of application of nanotechnology in orthodontics on which clinicians and researchers are focusing their efforts .The authors reviewed the available literature and selected articles using the PubMed search engine. The following keywords were entered: nanotechnology; nano-dentistry; orthodontics; nanomedicine; nanomaterials in dentistry; nanobiomaterials; nanorobots in dentistry; silver nanoparticles; nanocomposite; dentifrobots; nanorobots; fullerene nanoparticles. The most complete and recent articles on this scientific topic were searched from the last 15 years. Thanks to the abstracts of the articles, those that focused their attention in particular on dentistry and orthodontics were then sought. The authors identified and selected the items to include; they researched the most investigated topics in the literature regarding nanomaterials and nanotechnology in orthodontics, and then organized the articles into macro-topics and subsequently evaluated them with the aim of collecting the most useful and scientific information from each. In this way, the materials that today have a significant role for dentists were selected. The authors’ aim was to pay particular attention to orthodontics, and they therefore divided this article into sections dedicated to the most used materials in this field.Orthodontic elastomeric ligatures (OEM) are synthetic elastic modules of polyurethane material, with advantages such as the quickness of application and patient’s comfort; they are often a wise solution in clinical practice because they are inexpensive.Streptococcus mutans, Staphylococcus aureus and Lactobacilli.During orthodontic therapy, there is an inevitable microbiological colonization of the material, firstly, due to the obvious increase in the retention surface: in fact, there is an increase in the accumulation of bacterial plaque, bacterial colonization and enamel decalcification, with a worsening of bleeding rates. The increase in bacterial plaque is also partially related to the irregular surfaces of the orthodontic auxiliaries. For these reasons, maintaining correct oral hygiene and self-cleansing are indeed more difficult. Bacterial counts increase approximately thirty times at six weeks with an increase in Several studies have tried to highlight the associations based on the chemical characteristics of different elastic ligatures and the requirements of modifications for hampering the microbiological biofilm’s effects on oral health. Some studies have evaluated ligatures that release fluoride, but the results are varied and controversial: some highlight how, in particular, there is long-term ineffectiveness linked to the inability of the ligatures to guarantee a prolonged release over time; they also seem to be ineffective even against the decalcification ,23,24.It has been proposed that elastomeric ligatures can act as a support for the transport of nanoparticles, which can be molecules with anticariogenic or anti-inflammatory characteristics and/or antibiotic drugs (such as benzocaine) incorporated into the elastomeric matrix. Additionally, medicated wax applied to orthodontic brackets that reduces the pain associated with mucosal irritation caused by the brackets by slowly and continuously releasing benzocaine was shown to be significantly more effective .The most recent studies seem to evaluate the potentiality of the association of ligatures with silver nanoparticles, a material that appears to have the ability to counter dental biofilm and decrease the enamel demineralization caused by the accumulation of bacterial plaque, without affecting the mechanical characteristics of the material itself and therefore the effectiveness of orthodontic therapy. Nanotechnology in dentistry applied to materials is innovative for the concept of leading to better anticariogenic characteristics; the silver particles have been incorporated into different materials and can be obtained with minimally invasive methods from elements such as flowers and mushrooms. It is known that silver has a superior antibacterial property compared with other metals; it has a strong cytotoxic effect on a wide range of microorganisms: the mechanism is not very clear; it probably acts by denaturing the enzymes of the respiratory cycle and DNA synthesis. Furthermore, silver is not very toxic and has good compatibility with human cells. Today, however, other studies are needed to determine their actual biocompatibility .Power chains have been used daily in every orthodontic practice since their development in the late nineteen sixties. They are generally composed of polymeric materials (polyesters or polyethers) formed through a process of polymerization. They present different clinical advantages: they are affordable, user-friendly and easy to adjust to every patient and provide light and continuous forces. They are characterized by high flexibility, and they enhance space closure in extraction cases. On the other hand, power chains also have unfavorable characteristics: it is amply demonstrated that their mechanical effectiveness is limited in time, and, for this reason, they must be replaced periodically. Both intrinsic and external factors affect the strength of orthodontic power chains and determine permanent deformation. The intrinsic factors are the material composition, production methods and external morphology. The external factors are the oral cavity temperature, pH and moisture absorption. They also have hydrophilic characteristics and undergo discoloration over time; they absorb fluids from the oral cavity and are therefore not very appropriate for maintaining oral health .In a study conducted in Taiwan by Cheng et al., the authors tried to improve the physical properties of power chains by performing a surface treatment called nanoimprinting. The treatment consists of creating nanostructures on the surface of the chains called nanopillars. The results seem encouraging, as this treatment converts the material from hydrophilic to hydrophobic and alleviates the shortcomings of these orthodontic auxiliaries .Streptococcus mutans and Lactobacilli, increasing the risk of enamel demineralization, white spot lesions and cavities [Fixed orthodontic treatment often requires the insertion of dental bands, which are often essential for orthodontic movements. However, these auxiliaries can cause the retention of bacterial plaque, especially in the posterior dental sectors, which are difficult to clean. Prolonged plaque accumulation around orthodontic brackets and bands has been demonstrated to determine a rapid shift in the bacterial flora, promoting acidogenic bacteria such as cavities . Differecavities .Technology made it possible to add antimicrobial agents to dental resins and to cement to reduce the incidence of white spot lesions and cavities and, at the same time, maintain unchanged the adhesion properties. Companies tried to incorporate zinc oxide, chlorhexidine and fluorides to reduce the acid oral environment and decrease bacterial metabolism.Additionally, in this case, it is hypothesized that the use of antibacterial release materials such as silver nanoparticles helps to maintain good oral hygiene during orthodontic treatment .Band cements with antimicrobial characteristics  have been developed to counteract the onset of white spots. These resins have mechanical properties potentially comparable to controls, and in most cases, they were found to be biocompatible. However, further studies are needed to validate the efficiency of these materials in the oral environment, considering the length of an entire orthodontic treatment .Managing the anchorage during tooth movement is a fundamental aspect of a successful orthodontic treatment. The principal aim of an orthodontic treatment is to control the anchorage and create a force system to provide the desired effect and avoid undesired movements.In different years, temporary anchorage devices (TADs) have been integrated for orthodontic purposes  includinTADs generally find their stability mechanically  and do not require biomechanical osseointegration ,30,31. CIt is therefore important to have a close intimacy between the bone and the surface of the miniscrew, as this allows better stability and greater resistance to orthodontic forces. Furthermore, inflammatory processes can affect the primary stability and determine a premature loss of the screw.2 (titanium dioxide) nanotube arrays [Two studies have evaluated the stability and osseointegration of miniscrews surface modified by nanotechnology: the studied surface was characterized by TiOe arrays ,17.2 nanotube arrays were loaded with RhBMP-2 (recombinant human bone morphogenetic protein-2) and ibuprofen and were compared with a control group of standard miniscrews. The effects of the drugs were evaluated in vivo: the study looked at how drug-modified miniscrews had a positive effect on tissue health.The TiOThese modified miniscrews can convey other drugs, such as antibiotic agents, aspirin and Vitamin C, to decrease inflammation at the insertion site and patient discomfort. This modification to the materials has also proved important in ensuring greater surface roughness of the aids and improving wettability compared to conventional products.One of the goals of modern dentistry is to improve prevention and reduce the need for more invasive treatments. Nanotechnology can improve the management of these aspects; in particular, it seems to address the control of bacterial biofilms and remineralization following tooth decay. In this way, it would be easier for patients to maintain good oral hygiene, especially in those young patients at high risk of dental decay .White spot lesions or enamel demineralization caused by acid biofilms are very common, particularly as a consequence of orthodontic treatments, because the various orthodontic devices inevitably lead to an increase in plaque presence and retention. These lesions develop mainly in areas adjacent to orthodontic brackets .2 (titanium dioxide), SiO2 (silicon dioxide) or SNPs (silver nanoparticles) have been tested and extensively discussed [2 nanoparticles into an orthodontic adhesive has been shown to enhance its antibacterial effects for 30 days without compromising its physical properties [2 nanoparticles doped with nitrogen [To overcome the problem of caries around orthodontic brackets, antibacterial adhesives with different nanoparticles such as TiOiscussed ,38. The operties . Furtheroperties ,38. Howenitrogen  or Ag–Zrnitrogen .The early lesions of enamel can be remineralized with dentifrices that contain nanosized calcium carbonate ,11. InorTo date, some studies have evaluated the power of remineralization of toothpastes and mouthwashes based on the concepts of nanotechnology.It was demonstrated that dentifrices containing nanosized calcium carbonate allowed early enamel remineralization ,19. CurrThere are, however, new studies concerning dental robots , kinds of nanorobot that are incorporated in mouthwash or toothpaste to clean the surfaces above and below the gingival margin, and that counteract the formation of calculus, metabolizing trapped organic matter into harmless and odorless vapors; they are safely inactivated when ingested ,17,18,20The perspective is that all these strategies may be an alternative to fluoride materials, especially for younger patients who are at higher risk of fluorosis ,42.However, some studies have shown that the presence of nanofillers in fluoride-releasing materials does not promote further benefits against carious lesion development . FurtherOrthodontic treatment consists, essentially, of sliding brackets along an archwire; however, this implies that a friction force inevitably develops between the surfaces of the two auxiliaries (the archwire and the bracket), which opposes the therapeutic movement of the teeth. To perform the dental movement, the force applied by the orthodontic appliance has to overcome this resistance. It has been measured that more than 60% of the orthodontic force applied to obtain dental movement is expected to be lost due to frictional forces .The factors that mostly affect the determination of friction forces are the design of the bracket (torque), the section of the slot, the types of ligation, the section of the archwire, the inter-bracket distance and the oral functions ,45,46.It is easy to understand that the reduction of friction force would be advantageous to reduce treatment times and the risk of root resorption, allowing greater control of the movements and the anchorage ,44,47.For many years, different strategies have been sought to find solutions to reduce friction. First of all, research focused on different designs for the brackets. Secondly, different archwire alloys and surface treatments were studied.2 (molybdenum disulfide) and W2 (tungsten disulfide) [Today, nanotechnology aims to reduce frictional forces, allowing the system to work more easily: it was suggested that the best solution is the coating of orthodontic archwires with a film incorporating nanoparticles. The best materials for achieving the goal of friction reduction are considered to be MoSsulfide) ,21  nanoparticles have been exploited for this purpose; it was shown that under certain reducing and sulfidizing conditions, at elevated temperatures, tungsten oxide (WO3) nanoparticles could form nested WS2 fullerene-like nanostructures, creating layers that resemble an onion or a nanotube. The layers were weakly connected through van der Waals forces only, and it is known that WS2 and MoS2 particles with layered structures (platelets) provide good lubricity [2 and W2: they have a layer structure, similar to graphite, which is characterized by the overlapping molecular planes. These nanoparticles were firstly described by Tenne in 1992. The van der Waals forces between the layers are relatively weak, and this determines the characteristics: these nanoparticles are allowed to roll rather than slide when they are interposed between a metal and solid lubricant [The inorganic fullerene-like tungsten disulfide (IF-WSubricity . The posubricant ,22. Amonubricant .Regarding the toxicity of these materials, some studies have demonstrated no toxic effects in rats and after dermal application . FurtherToday, nanotechnology has an important and more consistent role in the dental field since it has the potential to bring significant innovations and benefits. The recent positive results must be a stimulus for future research, in particular, regarding the field of orthodontics. We have explained how nanomaterials have introduced many advantages in this field, especially regarding their mechanical and antibacterial properties. The coordinated and safe management of orthodontic treatment is fundamental; the limitations of dental materials and technical procedures often refer to this goal, but science and nanotechnology have helped to partially solve some limitations, improving patient management in the clinical pathway. However, nanotechnology needs to evolve to express its maximum potential since production technical difficulties and engineering problems have not yet been completely overcome. Further studies are needed to develop fully safe and biocompatible materials ,11,49,50


Pervasive health technologies can increase the effectiveness of personal health monitoring and training, but more user studies are necessary to understand the interest for these technologies, and how they should be designed and implemented. In the present study, we evaluated eWALL, a user-centered pervasive health technology consisting of a platform that monitors users’ physical and cognitive behavior, providing feedback and motivation via an easy-to-use, touch-based user interface. The eWALL was placed for one month in the home of 48 subjects with a chronic condition (chronic obstructive pulmonary disease—COPD or mild cognitive impairment—MCI) or with an age-related impairment. User acceptance, platform use, and potential clinical effects were evaluated using surveys, data logs, and clinical scales. Although some features of the platform need to be improved before reaching technical maturity and making a difference in patients’ lives, the real-life evaluation of eWALL has shown how some features may influence patients’ intention to use this promising technology. Furthermore, this study made it clear how the free use of different health apps is modulated by the real needs of the patient and by their usefulness in the context of the patient’s clinical status. Pervasive health technology—ensuring a continuous flow of information from the comfort of the user’s home—allows persons to claim a more active role in the management of their health . Radio-fEnd-user populations that require constant health monitoring and/or are prone to use new technologies willing to improve their health are those that may especially benefit from pervasive technology. These populations offer the best conditions for viable business models and durable services. People with age-related impairments (ARI), chronic obstructive pulmonary disease (COPD), or mild cognitive impairment (MCI) are suitable examples of population groups fitting this description.Older persons with ARI start losing functional capacity in the physical, cognitive, or psychological domain, and have an increased risk of frailty . COPD isDespite the great potential that pervasive health technology offers for persons with progressive physical or cognitive disorders , there is still a lack of success stories. A limiting factor is surely the alleged limited interest of end-users in pervasive health technology services. A recent study which conducted focus group interviews with people having chronic conditions  indicateThe application of pervasive health technology in real life experienced some major pitfalls. After reviewing the literature, Orwat and colleagues  concludeIn this article, we report on the real-life experience with eWALL—a home care platform that monitors the end-user’s physical and cognitive behavior, and provides feedback and motivation via an easy-to-use, touch-based user interface  presenteAnswering these questions will allow us to fill the knowledge gaps discussed above with a result in practical design advice for future studies with pervasive health technology for patients with chronic diseases. The framework of the paper will be structured as follow: (i) after a detailed description of the eWALL platform technology and its installation at patients home, (ii) the measurements protocol adopted to evaluate the impact of tele-monitoring in the life of frail elderly will be exposed; (iii) results will be study in deep and accurately show supported by statistical algorithms aimed at (iv) verify their reliability, discuss what parameters influenced acceptance and utilization of such kind of services in the field of healthcare, pointing also on limitations and other issues; (v) finally conclusive statements will be drawn.The eWALL platform  is a tecThe user interface is mounted on a cabinet which hides away hardware responsible for running the interactive home software, and collecting and forwarding sensor data to the cloud. Behavioral , environmental , and biometric data  are collected wirelessly (Bluetooth protocols)from activity tracker, medical monitoring devices and domotic sensors.The touch-based user interface provides access to various health and wellbeing applications. The interface design visualizes a virtual living room , with eaThe photo frame shows pictures that family members or friends can upload through an online service. The window indicates the current and upcoming weather at the user’s location. The lava lamp shows the number of steps taken on a day and changes its color from red to yellow and green to indicate to users how close they are to reaching their daily step goal.The set of “book applications”  provides information about the user’s lifestyle, showing daily records of sleeping or activity behavior, or sensor-based information like blood pressure. A game board set in the bookcase gives access to a set of games  for cognitive rehabilitation, while a specially designed calendar can help users in structuring their daily life by facilitating the scheduling of everyday activities like having breakfast or taking a shower using drag-and-drop functions. The television shows “advertisements” for healthy behavior or can be used to access a personalized physical rehabilitation program with increasing difficulty level, giving the possibility to rate difficulties and pleasure for each exercise. A virtual embodied agent—Robin the Robot (on top of the television), assists the user in using the applications, and gives tailored advice on achieving daily physical activity goals.People with age related impairments were recruited in Denmark and Austria and were included if they were over 65 years of age and had a score below 65 on the physical functioning scale of the Short Form 36 (SF36-pfs). Exclusion criteria for these participants were physical and/or cognitive impairments that do not allow proper use of eWALL, lack of independence in functional abilities and an inability to read and speak the language in which eWALL is offered ;Patients with COPD were included in Denmark and in The Netherlands if they were clinically diagnosed with COPD  and when their disease was stable . Exclusion criteria for these participants were: having other diseases that influence bronchial symptoms or the need for oxygen therapy, impaired hand function or disorders causing an inability to use eWALL, and the inability to read and speak the language of the clinical site;Subjects with MCI were included in Italy if they were over 65 years of age, had a Mini Mental State Examination (MMSE) score adjusted for age and education above 23, had a Clinical Dementia Rating (CDR) score of 0.5, had a pathological score of 3 in one episodic memory test or in one of other function and had normal scores with all the other battery tests. These participants were excluded if they were over 80 years of age, had presence of a physical impairment that does not allow the proper use of the eWALL, experience lack of independence in functional abilities and were unable to read and speak the language of the clinical site.Participants were recruited in Austria, Denmark, Italy, and the Netherlands between April and October 2016.This study was conducted according to the principles of the Declaration of Helsinki  and in accordance with The Directive 95/46/EC of the European Parliament and of the Council of 24 October 1995 (amended with the regulation (EC) No 1882/2003) on the protection of individuals with regard to the processing of personal data and on the free movement of such data. Local Ethics Committees approved or received communications with the study protocol . All patients provided written informed consent.Before inclusion, interested participants received a clear explanation of the purpose of the study and all the technical aspects concerning eWALL and its installation. During the first week of the study, technicians installed the eWALL in the participant’s home and explained all the functionalities of the eWALL. Participants and informal caregivers received a training on how to navigate the main screen and various applications. Pre-test assessments were conducted at the participant’s home after installation. These assessments were performed by professionals with a clinical background. Participants had access to eWALL for a period of four weeks. Participants and their informal caregiver had the possibility to keep in touch with technical staff; moreover, a devoted telephone line was available, also out of office hours. Apart from this, the eWALL contained a Help application with information about the various applications and an overview of frequently asked questions. At the end of the four weeks home intervention period, the eWALL was uninstalled and participants completed the post-test assessment.During the early design and implementation phases of the platform, researchers applied different methods for understanding end-user acceptance of an eHealth technology . In the (1)Interaction with eWALL. We grouped all interactions that occur on a specific day for a specific user and analyzed the data over time.(2)Interaction with the eWALL applications. We calculated for the individual participants as well as for all participants together, how many interactions they had with each application.(3)Frequency of use of each of eWALL applications. We counted for every participant and for every day whether or not each application was used. For example, if a participant used the My Activity Application on 21 different days, while he had access to eWALL for 28 days, we define his application use for the My Activity Application as 21/28 = 75%.(4)Time of day of using eWALL. We calculated for each half-hour of the day, how many interactions with eWALL took place in total.To assess the use of the device and its individual applications, an interaction logging service was developed that keeps track of user’s interactions with the user interface. The analysis of data logs was focused on the following aspects:In order to triangulate the quantitative data in the data logs , we condThe potential clinical effect was defined by the Short Form (36) Health Survey (SF-36) . The SF-Statistical analyses were performed using SPSS, version 19.0 . All outcome measures were inspected for a normal distribution of data, using histogram plots with normality curves and normal probability plots. These determined our selection of appropriate statistical tests. Mean scores ± standard deviation (SD), or median with range were calculated for each of the outcome measures. For statistical analysis, the level for significance was set at α < 0.05.t tests. For the analysis of the interviews, we follow the method as defined in Patton [To determine the reliability of the psychometric measurement scales, Cronbach’s alpha was calculated for each factor, whereby we considered a score of ≥0.70 to be good reliability . As prern Patton  and applIn total, 50 participants were enrolled in the study: 17 participants with MCI , 24 participants with COPD (21 from The Netherlands and 3 from Denmark) and 10 participants with age-related impairments (5 from Austria and 5 from Denmark). Two MCI participants and one COPD participant decided to leave the study for personal reasons. After installation, two participants with COPD dropped-out due to an increase in stress levels, attributable to their involvement with the study. One participant with ARI decided to leave the study due to technical difficulties related to the immaturity of the prototype. Main characteristics of the participants are described in Not all the participants completed the whole intervention time. The evaluation of the acceptance was based on data from 15 MCI, 16 COPD, and 5 ARI participants. To determine the reliability of the Technology Acceptance measurement scales Cronbach’s alpha for the different rating scales was calculated. Based on a minimum threshold of 0.7, it can be stated that all scores were from good to excellent. In r’s from 0.53 to 0.86).The calculation of the linear correlation was a prerequisite for conducting regression analyses, Pearson’s correlation coefficient was computed among all technology acceptance factors. Results described in p < 0.01) and Controllability . For the dependent variable ‘Perceived usefulness’, we included the factors Enjoyment, Aesthetics, Controllability, Trust in technology, and Ease of use. The model resulted in an R² of 0.50, and included four not significant predictors: Enjoyment , Ease of use , Controllability , and Aesthetics . Trust in technology affected Perceived usefulness significantly . The model to explain ‘Intention to use’, included the Perceived usefulness and the Ease of use. The first run resulted in an R² of 0.58. Both predictors significantly affected the Intention to use .Three backward linear regression analyses were conducted on the following dependent variables, namely: ease of use, perceived usefulness, and intention to use.According to results from the correlation analyses, Enjoyment, Aesthetics, Controllability, and Trust in technology were included in the model explaining the ‘ease of use’. The first model resulted in an R² of 0.81, and included Aesthetics  and the application that showed a user’s physical activity .For the end-users with COPD and ARI, one other application stood out: The health application. For end-users with MCI, interest in this application was low, but replaced by a relatively high use of the cognitive games, which were specifically designed for this target population. In total, over 73% of all interactions with eWALL were centered on these four applications. The distribution of total interactions per application for ARI was much more evenly spread than for the other two sub-groups. Analyses of daily use of the platform showed that the activity, sleep, and health applications were used, on average, at least every other day by all users. The cognitive exercise and video exercise application were used at least every week. Finally, we examined how the interactions were distributed throughout the day see . The anaIn order to increase the extractable information and integrate it with the results from the data log analyses, we conducted semi-structured interviews at the end of the intervention period. To optimize the user experience of the platform and to evaluate and resolve technical problems, an interview was organized to record the technical problems encountered by the participants; the following issues were mentioned more than once: activity tracker did not measure physical parameters correctly ; Bluetooth medical devices (for assessing blood saturation and blood pressure) did not synchronize with eWALL; eWALL was very slow or froze; the platform could not synch or lost its connection; domotics measurements were incorrect or did not work.Most of the participants with ARI found the physical rehabilitation training too easy to do and quickly gave up, due to the lack of challenge. Some users decided not to use the physical training functionality of eWALL, as they already exercised in other ways. One participant suggested that the eWALL should provide the option of choosing exercises from a large repository, so that each user could assemble his/her own training program, geared towards individual goals. The participants with COPD would have preferred breathing exercises for pulmonary rehabilitation, alongside the exercises focusing on gaining strength, balance, and flexibility. One participant with ARI really liked the physical training videos and used them every day. In his opinion, the difficulty level was sufficient. And as he did not do any physical exercise before interacting with the eWALL, his activity level increased. All participants found the physical training application easy to use.All MCI participants found the cognitive exercises enjoyable. All participants that tried out the cognitive rehabilitation training (including participants with COPD and ARI) found the game application fun and easy to use.Thirteen participants with COPD found it very interesting to receive information about their sleep. As a result, one participant with COPD tried to improve his sleep, but did not succeed. The other twelve stated that eWALL could not influence their behavior (4 times) or that eWALL lacked actionable advice on this matter (two times). One participant with ARI was very enthusiastic about the application and proper recognition of his sleep. Most participants with MCI  found the information about sleep interesting or very interesting, as well as clear.Nine participants with COPD measured their blood pressure and eight assessed their oxygen saturation. They did so as they were interested (7 times), they used this information while exercising (1 time), they wanted to check their health (2 times), or because someone told them to (1 time). Six of them indicated that the associated overviews on eWALL are nice. Two participants were rather negative. They found the information nothing new (1 time) or dull (1 time). The experience of the My Health book by the Danish and Austrian participants was influenced by the instability of the transfer of data. The health data was not available at all for some users and only partly available for the remaining users.Three participants with COPD negatively perceived the messages and alarms they received via the robot avatar. They found their content quite meaningless and irritating. Eight participants with COPD were positive, mentioning that it was a fun way to interact with eWALL (2 times) and that the messages were correct and lead to concrete actions on their part (4 times). Five out of the 15 participants with MCI mentioned that they received notifications via the robot and found these notifications interesting. The Danish participants did not express a lot of interest in interacting with the robot. Most of the users did not actively start an interaction with the robot. Two users found it too difficult to interrupt the interaction with the robot. One participant with ARI was able to comment on this feature, stating that the messages were motivating to be more physically active.When we asked participants how they experienced the time with eWALL in their house, the majority was positive. The general experience with eWALL was found rewarding, stimulating, and interesting, by 27 participants. The most positive experiences with the platform were those linked with the monitoring and training of physical and cognitive capacity. The importance of cognitive training was confirmed by the interview results: eWALL was positively evaluated by 14 out of 15 MCI participants. The most negative experience was the instability of the platform  (29 out of 36).p > 0.087).The score on the various domains of the SF-36 are presented in In this study, we evaluated the acceptance, use, and potential impact on physical and mental health of eWALL, a platform for telemonitoring and telecontrol, based on pervasive health technologies. The developed framework provides healthcare services that enhance traditional medicine, exploiting the powerful applications of Internet and Technology.  eWALL waA key issue concerning pervasive mobile healthcare systems regards technology acceptance of different groups of users, given the different approach of single users with these devices and the variable perception about its utility. The need of further studies investigating this feature has been emphasized by Huzooree and colleagues, who reviewed and evaluated twenty recent studies monitoring patients affected by chronic diseases .As a matter of fact, the acceptance of eWALL differed over the different study populations, i.e., ARI, COPD, and MCI, while the intention to use eWALL was influenced by the perceived ease of use and usability of the platform. The use of eWALL was intense in the first week of intervention and decreased, remaining stable, in the following weeks. The participation was undermined by technical issues, but several features were appreciated. In particular, all patient groups enjoyed receiving feedback on their sleeping behavior and physical activity. Persons with COPD and ARI also liked the option to have an overview of their health parameters . Persons with MCI on the other hand, valued positively eWALL’s cognitive training. The different attitude of the three study groups with respect to the Acceptance of eWALL was clearly demonstrated by the Likert scale. Subjects with ARI and MCI showed a more positive approach towards the technology if the system , while those affected by COPD proved less confident to use the device, and were overly critical and mistrustful of the technology. This could be due to several reasons. Firstly, persons with COPD found the interaction with eWALL and the platform functionalities poorly fitting with their wishes. For example, they missed COPD-specific exercises within the physical training. Secondly, despite a standardized installation protocol was used by all researchers in the four countries, the different attitude may have been generated by cultural distances , or by the different approach used by the demonstrators during the installation phase. Furthermore, a possible interviewer bias in different groups may have determined groups discrepancies. However, different countries are likely to have different standards with respect to the use and quality of health technology, which influences people’s expectations and that should be considered when health technologies are proposed to study groups located in different geographic areas.2 lower than expected. However, results highlight the importance of the interface design when advanced healthcare platforms are proposed: The intention to use a technology depends on the perceived usefulness and ease of use of such technologies, and these factors can be modulated, facilitating trust in technologies by stimulating persons’ awareness, and improving interfaces and graphic elements. Furthermore, even if the aesthetics domain could seem a not important factor, the appearance influences the enjoyment that the user may receive from the interaction with the platform, but not the possible intention to use eWALL. Indeed, as reported by Ziefle and colleagues, when facing healthcare technology, fun and aesthetics may not be necessary conditions to reach the expected results [As regards the Intention to use the technology, backward linear regression analyses revealed three predictive factors: Trust in technology, Controllability, and Aesthetics. These variables drive the Intention to use the proposed technology, but a mediating role of the Perceived usefulness, and the Ease of use should be considered . It wort results .This is Analysis of data logs clearly showed that, after the first week of intense use, most likely due to the novelty effect, the volume of interactions lowered but remained stable. This observation shows that participants were generally inclined to a constant use of the platform, appreciating the support in managing their condition or improving their health. Most participants gave positive feedback about sleeping behavior and physical activity, demonstrating that technologies serving as the home ‘health-hub’ should always provide behavioral descriptions. Other functionalities were more disease specific. Participants were not instructed to use a specific application, but they were invited to use the platform freely, following their needs and preferences. Indeed, it is quite interesting to notice the different approach to the platform experienced by target groups. The analysis of use showed how MCI participants focused more on cognitive activities, on activity applications and sleep behavior. The most used applications for the COPD target group are the Activity Application (23%), Sleep Application (22%) and Health Application (21%). Interestingly, participants with specific impairment focused freely on applications specifically designed for them. As mentioned above, participants with MCI used cognitive training far more than participants with ARI or COPD, which more often checked their physiological parameters . This result gives additional support to the proposal of conducting a fine-disease oriented evaluation of eHealth . These tIt is not possible at this stage to draw conclusions about the impact of the platform on preserving functional capacity and improving quality of life, given the small sample size and the limited duration of the intervention. When considering the intervention period (from 2 to 6 weeks), it was clearly anticipated that the primary outcome of the study would be the acceptance of the system rather than stating improvements in cognitive or physical conditions. Indeed, it was quite unlikely that significant modulations of the cognitive, physical status or, perceived Quality of Life could be observed in such a short period. Obviously, we cannot rule out the possibility that eWALL does not have any positive effect on the health of end-users, having still in mind that facing progressive diseases such as those investigated in our experiment, the fundamental objective is to keep stable physical/cognitive conditions as long as possible, and the. However, the probability of a clinical effect of eWALL in persons with a chronic disease or age-related impairments is very high, given their use of the technology and comments during the interviews, and extending the study length is a priority goal.Convincing potential users of these types of pervasive health technology to place such a big device in their homes for four weeks was a significant achievement, especially since they were informed that these ubiquitous technologies require a longer period of use before sorting any clinical effect. This condition presents a difficult situation for evaluators of pervasive health technologies, since they need to keep a balance among study length, participant burden, and the power of the studies to assess the possible effect of this technology on health parameters. Furthermore, a long lasting study could help to understand other long-term use effects, like annoyance and fatigue, that however patients could experience after several months of use of the platform. These are the greatest challenges for the planning and organization of future studies.In our study, we included participants with different medical backgrounds, living in different countries. Since our sample was not big enough to simultaneously control for both factors, it is possible that differences among end-user groups were influenced by these parameters. Future studies focusing on the acceptance of pervasive health technology should take medical and cultural heterogeneity into account in their research models. The participants in our study regularly experienced technological problems while interacting with eWALL. This hindered their use of the platform or some of its features and may as well have affected their opinion and acceptance of the technology ,16. PervThe present study shows that persons with COPD, MCI and ARI are in general open to interaction with pervasive technology, and that they are available to use it on a regular basis. In addition, they are interested to get more insights about their condition and they specifically interact with those features that are beneficial for them due to their medical background. Pervasive technology has the potential to make a difference in the life of people with chronic diseases or age-related impairments, although its technological immaturity may affect the results, especially as regards the management and clinical impact of the use.In conclusion we suggest that a stable use of eWALL may stimulate participants with specific impairment to be more active with the applications designed, mainly for the purpose of the specific target group. This interaction can lead to beneficial effects including specific empowerment of users, promotion of cognitive and physical rehabilitation, self-management of health, sleep behavior monitoring and early detection of sleep disorders, physical activity reinforcement and cognitive stimulation.A more extensive clinical trial with a more mature version of the technology and a longer time of interaction between the end-user and technology should therefore be conducted. Nonetheless, this study provides us with important advice for designing pervasive health technologies that are accepted by end-users and for setting up an evaluation of these innovations.


Silvopasture is the deliberate integration of a woody component with grazed pastures as understorey. It is one of the most extended agroforestry practices all over the world. Silvopasture use is key to increase the sustainability of livestock farming systems as silvopasture reduces the use of concentrates since the woody component provides feed for animals. However, it is not an extensively used practice in Europe. This paper aims at evaluating, from Eurostat, LUCAS database and the 118 rural development programs, the current situation of permanent grasslands in the Mediterranean area of Europe as well as the rural development programmes fostering silvopasture to better understand how sustainable land use systems are promoted and provide insights to foster silvopasture across Europe. The results of this study show that most of the policy measures related to silvopasture are adapted to the local necessity. The already existing agroforestry managed land (dehesas/montado) are related to measures supporting regeneration and maintenance while in those areas where agroforestry does not exist the measures are related to forest fire prevention. Agriculture in Europe is strongly influenced by the Common Agricultural Policy (CAP) which establishes a set of rules for the 28 countries included in the European Union (EU). The CAP consists of two Pillars, the Pillar I (Regulation 1307/2013) where farmers receive direct payments based on the surface they have, and Pillar II (Regulation 1305/2013) which is more linked with the environment because promotes good practices, such as cooperation among producers and environment friendly, climate resilient farming methods. Up to now, the EU provides the general rules for the EU Member States to fund sustainable farming through direct payments across Europe. However, the rules of the Pillar II are usually provided by the Member States to foster sustainable practices according to the different EU biogeographic regions and locally adapt these practices to increase the ecosystem service delivery [Grasslands area is one of the most important types of land use in Europe, where, according to the European Statistical Office (EUROSTAT) represents the 50.5 and 18.8% of the whole and agricultural land in Europe (EU-28), respectively . PermaneResults will be presented taking into account the main indicators that affect the productivity of the system and may modify the implementation of policies according to social, geographic, biological and policy aspects. Within the social aspect, the land ownership will be taking into account as an indicator of evaluating long-term practices and as a restriction to receive CAP payment. In the geographic aspect, the altitude will be considered as an indicator of environment constraints. In the biological aspect, the vegetation and the agroforestry practices distribution will be studied. Finally, in the policy aspect, the rural development policies that are developed at the regional level by each member state will be evaluated. These indicators can be related to the promotion of farming systems to fulfil the main pillars of the CAP: social, economic and environmental aspects.The way to estimate the silvopasture extent is described in LUCAS is a two-stage sample survey. The first phase is a systematic sampling carried out in around 1.1 million points (spaced 2 km). In a second stage, a representative subset of 270,267 points was selected to be physically visited by inspectors.LUCAS uses a double classification system for land covers that also includes the land use with multiple layers, used only for specific landscapes, such as agroforestry and complex or heterogeneous area. For example, in silvopasture, a woody vegetation layer (LC1) is typically accompanied by the secondary layer (LC2) composed of grass. Another useful variable included in the LUCAS database is land management, which contains information if there are signs of grazing or not, which therefore identify silvopasture. By using LUCAS data we distinguish silvopasture in arable crops (temporary grassland) which are grazed, silvopasture with orchards, and silvopasture within forestland. To estimate the extent of agroforestry of silvopasture in hectares at RDP region level, we divided the number of points coded as silvopasture in each territory by the total number of LUCAS points in this territory and multiplied this by the surface of the territory .The policy analysis was conducted considering the measures activated by the Pillar II of the CAP  related The obtained geographical indicators from LUCAS (percentage and number of hectares), as well as the policy indicators (activated measures), were upscaled and mapped per region of Europe by using QGIS 2.18. Both forest ownership and altitude have been processed with QGIS 2.18.The type of ownership of forest lands in the Mediterranean Region of Europe is mostly private . RegionsOther regions placed in Spain have over 30% of public forest  as happens in Greece, and most of the Mediterranean Regions of Italy excluding Toscana, Umbria, and Sardegna. Only Andalucía has over 30% of the properties associated with “other forest property” being also present to some extent in Italy  and some other areas of Spain . The categorization of other forest ownership depends on each EU Member State, which makes difficult to have a clear comparison of their meaning, but they are usually areas that cannot be categorized either as public or as private.If the forestland use is considered , most ofSilvopasture is the most important agroforestry practice in Europe, reaching up to 37% of the land in some regions of Europe . SilvopaSilvopasture can be part of agricultural lands as well as forestlands mainly dominated by woodlands or shrublands as shown in Pasture under shrubland is mainly associated with La Rioja, the Spanish Dehesa (Extremadura), Sardegna , Corsica (France) and Greece followed by some regions of Italy , Spain . When silvopasture linked to woodlands is evaluated, Extremadura but also Andalucia and Portugal, the places with the largest share of the Iberian present the highest share, followed by Castilla León, Madrid, La Rioja and Castilla la Mancha in Spain, Corsica in France, Sardegna, Basilicata, Calabria and Lazio in Italy and also Greece.One of the most important aspects to foster agroforestry is the development of management plans  in generBoth no timber woodland production through the development of forestry technologies, processing, mobilizing, and marketing of forest products, as well as the development of the value chain, are key to increase diversification and income for farmers from forestlands . The forThe Mediterranean area of Europe is characterized by mild temperatures on winter but hot temperatures and lack of precipitation in summer, which may explain perennial crops as permanent grasslands or permanent crops (mostly olive groves and in some Spanish areas nut trees and/or vineyards) are the dominant vegetation in this area. Depending on the woody perennials, silvopasture could be related to forestlands  or agricultural lands (low tree density or permanent crops (e.g. fruit trees)). The dominant woody perennial vegetation delineates the first framework for the development of the silvopasture agroforestry systems. Silvopasture implementation is a type of seminatural system where management transforms the landscape. Anthropogenic pressure, linked to intense pastoral and arable activities in the Mediterranean forest, caused a reduction in pine-oak forests in the Mediterranean area for centuries, being this reduction more intense in the second half of the XXth century . AfterwaOpposite to the well designed and managed dehesa systems, adapted to the Mediterranean weather conditions, there are other areas with high anthropogenic pressure in the past reflecting a high degree of degradation ,18. ThesAragón, Malta, and La Rioja are the three regions with a land cover dominated by unmanaged shrublands, as the share of silvopasture is rather low but higher than in other areas of Europe not dominated by shrublands. Unmanaged shrublands are transformed into forests ,18 whileMediterranean islands acknowledge a different share of land use cover, from those with a high anthropogenic impact (Sicily) to those with lower impact (Sardegna or Corsica). Sicily is closer to the continent than the other Mediterranean islands and presents a long tradition of olive trees agroforestry, declining nowadays due to the land abandonment . HoweverThe presence of woody perennials in most of the Mediterranean area of Europe can be related to the fact that deep-rooted species are needed to overcome the long and dry summer that Mediterranean plants have to face while providing feed to animals in silvopasture systems . Both thSilvopasture is an important practice across the Mediterranean region, mostly associated with oaklands, but also present in permanent crops (olive) in some areas. The extent of silvopasture is high in the west part of the Iberian Peninsula where the share of public land is low as financial benefits are obtained from the land. However, most of the regions have a low extent of silvopasture and can be linked to a high (intensive agriculture) and low (abandonment) anthropogenic pressure. Most of the policy measures related to silvopasture are adapted to the local necessity. The already existing agroforestry managed land (dehesas/montado) are related to measures supporting regeneration and maintenance while in those areas where agroforestry does not exist the measures are related to forest fire prevention.


Dear Editor:Inaccuracy in the Article “Scrambler Therapy Treatment: The Importance of Examining Clinically Meaningful Improvements in Chronic Pain and Quality of Life”I read with great interest of the article “Scrambler Therapy Treatment: The Importance of Examining Clinically Meaningful Improvements in Chronic Pain and Quality of Life.” I share the intent of the article, and thank the authors for their work.Although the study is well conceived, and undoubtedly useful, it unfortunately does not appear to comply with the standard methods of use that registered in the procedure FDA 510(k) # K142666. These standards have also been the object of a recent scientific publication that provides the scientific and medical community with further clarification and documentation on how to avoid or reduce bias in clinical studies on Scrambler Therapy.I must also clarify that only the first generation of Scrambler Therapy devices marketed in the USA uses the commercial brand name “Calmare” (510 (k) # K081255).It was during this initial phase of distribution in the USA that information on the correct use of the device were not fully aligned with the original specifications. This depended on the fact that there were many independent attempts to deviate from the official standards , aimed at simplifying the placement and regulating procedures, the duration of the treatment period, and consequently, the cost and the usage difficulties. However, although these attempts were justified from a commercial point of view, the results produced have always been extremely disappointing.Objectively, these elements of deviance created by the spread of official and nonofficial information and methods, also present in many independent publications, have undoubtedly created a great deal of uncertainty and confusion in the medical and scientific community. I presume this is one of the reasons why the authors were unable to use adequate information to conduct the study correctly.More specifically, the proper use of Scrambler Therapy, being operator-dependent, allows only for a partial double-blind or single-blind trial design. Attempts to do a complete double-blind clinical trial automatically cause substantial changes in the standard treatment protocol, which requires substantial patient interaction to determine proper placements of electrodes and intensity of treatment. These changes prevent the operator to follow the normal procedures registered in the health care authorizations and can erase or significantly reduce the efficacy of the treatment, consequently invalidating the scientific data. In addition, the nonconformity of the placement and interactive regulation procedures, in some conditions makes an increase in pain highly likely, instead of completely suppressing it in each individual treatment.As regards the device used as sham, it should be noted that for correct regulation, the stimulation must be perceived by the patient under the electrodes only. Consequently, an “ineffective” perception threshold does not exist. For the same reason, the electrodes should be positioned well away from the pain area to avoid spurious interference.I would once again like to thank the authors for their important contribution, and I hope the clarification that I have provided is useful for future clinical studies.The author developed the Scrambler Therapy basic and applied research and is the patent owner of the ST technology.Giuseppe Marineo, researcher, ScDDelta Research and Development, University of Rome Tor Vergata, Via di Mezzocammino 85, Rome 00127, Italy


Reproducible science requires transparent reporting. The ARRIVE guidelines  were originally developed in 2010 to improve the reporting of animal research. They consist of a checklist of information to include in publications describing in vivo experiments to enable others to scrutinise the work adequately, evaluate its methodological rigour, and reproduce the methods and results. Despite considerable levels of endorsement by funders and journals over the years, adherence to the guidelines has been inconsistent, and the anticipated improvements in the quality of reporting in animal research publications have not been achieved. Here, we introduce ARRIVE 2.0. The guidelines have been updated and information reorganised to facilitate their use in practice. We used a Delphi exercise to prioritise and divide the items of the guidelines into 2 sets, the “ARRIVE Essential 10,” which constitutes the minimum requirement, and the “Recommended Set,” which describes the research context. This division facilitates improved reporting of animal research by supporting a stepwise approach to implementation. This helps journal editors and reviewers verify that the most important items are being reported in manuscripts. We have also developed the accompanying Explanation and Elaboration document, which serves (1) to explain the rationale behind each item in the guidelines, (2) to clarify key concepts, and (3) to provide illustrative examples. We aim, through these changes, to help ensure that researchers, reviewers, and journal editors are better equipped to improve the rigour and transparency of the scientific process and thus reproducibility. The bioscience community has introduced a range of initiatives to address the problem, from open access and open practices to enable the scrutiny of all aspects of the research5 through to study preregistration to shift the focus towards robust methods rather than the novelty of the results,7 as well as resources to improve experimental design and statistical analysis.810In recent years, concerns about the reproducibility of research findings have been raised by scientists, funders, research users, and policy makers.1118 Animal research is a good case in point, where poor reporting impacts on the development of therapeutics and irreproducible findings can spawn an entire field of research, or trigger clinical studies, subjecting patients to interventions unlikely to be effective.20Transparent reporting of research methods and findings is an essential component of reproducibility. Without this, the methodological rigour of the studies cannot be adequately scrutinised, the reliability of the findings cannot be assessed, and the work cannot be repeated or built upon by others. Despite the development of specific reporting guidelines for preclinical and clinical research, evidence suggests that scientific publications often lack key information and that there continues to be considerable scope for improvement.2130 They apply to any area of research using live animal species and are especially pertinent to describe comparative research in the laboratory or other formal test setting. The guidelines are also relevant in a wider context, for example, for observational research, studies conducted in the field, and where animal tissues are used. In the 10 years since publication, the ARRIVE guidelines have been endorsed by more than a thousand journals from across the life sciences. Endorsement typically includes advocating their use in guidance to authors and reviewers. However, despite this level of support, recent studies have shown that important information as set out in the ARRIVE guidelines is still missing from most publications sampled. This includes details on randomisation (reported in only 30%–40% of publications), blinding (reported in only approximately 20% of publications), sample size justification (reported in less than 10% of publications), and animal characteristics .32In an attempt to improve the reporting of animal research, the ARRIVE guidelines  were published in 2010. The guidelines consist of a checklist of the items that should be included in any manuscript that reports in vivo experiments, to ensure a comprehensive and transparent description.PLOS ONE, designed to test the effect of requesting a completed ARRIVE checklist in the manuscript submission process. This single editorial intervention, which did not include further verification from journal staff, failed to improve the disclosure of information in published papers.34 In contrast, other studies using shorter checklists  with more editorial follow-up have shown a marked improvement in the nature and detail of the information included in publications.3436 It is likely that the level of resource required from journals and editors currently prohibits the implementation of all the items of the ARRIVE guidelines.Evidence suggests that 2 main factors limit the impact of the ARRIVE guidelines. The first is the extent to which editorial and journal staff are actively involved in enforcing reporting standards. This is illustrated by a randomised controlled trial at 38 however, researchers are often unfamiliar with the much larger systemic bias in the publication of research and in the reliability of certain findings and even of entire fields.3840 This lack of understanding affects how experiments are designed and grant proposals prepared, how animals are used and data recorded in the laboratory, and how manuscripts are written by authors or assessed by journal staff, editors, and reviewers.The second issue is that researchers and other individuals and organisations responsible for the integrity of the research process are not sufficiently aware of the consequences of incomplete reporting. There is some evidence that awareness of ARRIVE is linked to the use of more rigorous experimental design standards;41 As a community, we must do better to ensure that, where animals are used, the research is both well designed and analysed as well as transparently reported. Here, we introduce the revised ARRIVE guidelines, referred to as ARRIVE 2.0. The information included has been updated, extended, and reorganised to facilitate the use of the guidelines, helping to ensure that researchers, editors, and reviewers—as well as other relevant journal staff—are better equipped to improve the rigour and reproducibility of animal research.Approval for experiments involving animals is generally based on a harm–benefit analysis, weighing the harms to the animals involved against the benefits of the research to society. If the research is not reported in enough detail, even when conducted rigorously, the benefits may not be realised, and the harm–benefit analysis and public trust in the research are undermined.42 . New additions comprise inclusion and exclusion criteria, which are a key aspect of data handling and prevent the ad hoc exclusion of data;43 protocol registration, a recently emerged approach that promotes scientific rigour and encourages researchers to carefully consider the experimental design and analysis plan before any data are collected;44 and data access, in line with the FAIR Data Principles .45S1 Table summarises the changes.In ARRIVE 2.0, we have improved the clarity of the guidelines, prioritised the items, added new information, and generated the accompanying Explanation and Elaboration (E&E) document to provide context and rationale for each itemThe most significant departure from the original guidelines is the classification of items into 2 prioritised groups, as shown in 46 with external stakeholders to maximise diversity in fields of expertise and geographical location, with experts from 19 countries providing feedback on each item, suggesting new items, and ranking items according to their relative importance for assessing the reliability of research findings. This ranking resulted in the prioritisation of the items of the guidelines into the 2 sets. Demographics of the Delphi panel and full methods and results are presented in Supporting Information S1 Delphi and S1 Data. Following their publication on BioRxiv, the revised guidelines and the E&E were also road tested with researchers preparing manuscripts describing in vivo studies, to ensure that these documents were well understood and useful to the intended users. This study is presented in Supporting Information S1 Road Testing and S2 Data.Revising the guidelines has been an extensive and collaborative effort, with input from the scientific community carefully built into the process. The revision of the ARRIVE guidelines has been undertaken by an international working group—the authors of this publication—with expertise from across the life sciences community, including funders, journal editors, statisticians, methodologists, and researchers from academia and industry. We used a Delphi exercise43 and the minimum standards framework and checklist .47 The revised guidelines are also in line with many journals’ policies and will assist authors in complying with information requirements on the ethical review of the research,49 data presentation and access,5052 statistical methods,52 and conflicts of interest.54While reporting animal research in adherence to all 21 items of ARRIVE 2.0 represents best practice, the classification of the items into 2 groups is intended to facilitate the improved reporting of animal research by allowing an initial focus on the most critical issues. This better allows journal staff, editors, and reviewers to verify that the items have been adequately reported in manuscripts. The first step should be to ensure compliance with the ARRIVE Essential 10 as a minimum requirement. Items from the Recommended Set can then be added over time and in line with specific editorial policies until all the items are routinely reported in all manuscripts. ARRIVE 2.0 are fully compatible with and complementary to other guidelines that have been published in recent years. By providing a comprehensive set of recommendations that are specifically tailored to the description of in vivo research, they help authors reporting animal experiments adhere to the National Institutes of Health (NIH) standards55Although the guidelines are written with researchers and journal editorial policies in mind, it is important to stress that researchers alone should not have to carry the responsibility for transparent reporting. Funders, institutions, and publishers’ endorsement of ARRIVE has been instrumental in raising awareness to date; they now have a key role to play in building capacity and championing the behavioural changes required to improve reporting practices. This includes embedding ARRIVE 2.0 in appropriate training, workflows, and processes to support researchers in their different roles. While the primary focus of the guidelines has been on the reporting of animal studies, ARRIVE also has other applications earlier in the research process, including in the planning and design of in vivo experiments. For example, requesting a description of the study design in line with the guidelines in funding or ethical review applications ensures that steps to minimise experimental bias are considered at the beginning of the research cycle.37 thus increasing the likelihood that the findings are reliable and, ultimately, reproducible.Transparent reporting is clearly essential if animal studies are to add to the knowledge base and inform future research, policy, and clinical practice. ARRIVE 2.0 prioritises the reporting of information related to study reliability. This enables research users to assess how much weight to ascribe to the findings and, in parallel, promotes the use of rigorous methodology in the planning and conduct of in vivo experiments,5658 Here, we propose an expert consensus on information to prioritise. This will provide clarity for authors, facilitate transfer of manuscripts between journals, and accelerate an improvement of reporting standards.The intention of ARRIVE 2.0 is not to supersede individual journal requirements but to promote a harmonised approach across journals to ensure that all manuscripts contain the essential information needed to appraise the research. Journals usually share a common objective of improving the methodological rigour and reproducibility of the research they publish, but different journals emphasise different pieces of information.59Concentrating the efforts of the research and publishing communities on the ARRIVE Essential 10 items provides a manageable approach to evaluate reporting quality efficiently and assess the effect of interventions and policies designed to improve the reporting of animal experiments. It provides a starting point for the development of operationalised checklists to assess reporting, ultimately leading to the build of automated or semi-automated artificial intelligence tools that can detect missing information rapidly.Improving reporting is a collaborative endeavour, and concerted effort from the biomedical research community is required to ensure maximum impact. We welcome collaboration with other groups operating in this area, as well as feedback on ARRIVE 2.0 and our implementation strategy.