Background: This paper presents the development of a multi-dimensional mobility divide index (MDI) for assessing the accessibility of public transport developed using a co-design approach, directly involving end-users in the index design process. The index measures the gap that persons with disabilities feel they need to over-come to use public transport in the same way non-disabled citizens do. The MDI covers six accessibility-related dimensions: 1) safety, 2) convenience, 3) comfort, 4) affordability, 5) travel time, and 6) autonomy.Methods: The method paper describes the step-by-step approach to create the MDI as a set of indicators to be rated by people with different access needs to 1) provide evidence of the main criticalities to be addressed through the design and implementation of new inclusive mobility solutions, 2) guide the design of new inclusive mobility solutions and measure their impacts, and 3) inform the transport sector encouraging positive changes in transport by providing recommendations for policy-making, new directions for service innovation, improvements and practical advice or highlighting investment priorities to pave the way for a more inclusive mobility.Results: We present our findings in ways that can inform universal design and provide actionable information to researchers, policymakers, transport and urban planners, operators, and stakeholders’ representatives to promote inclusive and equitable mobility solutions for all.Conclusions: Finally, we suggest follow up research and innovation, as well as recommendations for its uptake and utilisation in the pursuit of European accessibility standards and requirements for products and services in the mobility sector. The article presents an innovative method for the assessment of the level of the accessibility of the public transport services, from the disabled users perspective.The method has been developed from the concept of the ‘mobility divide’, that is the gap that person with reduced mobility have to overcome in order to have equal mobility opportunities. The adoption of these accessibility metrics is recommended for all kinds of urban transport services. The accuracy and transferability of the mobility divide index (MDI) has been assessed in the framework of the European Project ’TRIPS’ (TRansport Innovation for Persons with disabilities needs Satisfaction).Put simply, “Accessibility is about getting there...easily” , where aTheAs we can see from this list, inaccessibility can be caused by any barrier of using public transport that affects people’s motivation or capacity to travel. People’s motivation or capacity to travel has knock on effects on people’s choices in other facets of life, such as going to school or work, seeing the doctor, running errands, but also meeting friends, visiting a restaurant, a gym or cinema, or simply being outdoors; hence inaccessible transport is a basis of discrimination. Despite increasing awareness about the importance of equal access to public transport for all citizens, including persons with disabilities, there is still lack of metrics that can measure accessibility in ways that are meaningful to all users and reflect everyone’s struggles with transport inaccessibility in their everyday life . whether or not ‘an idealised average user’ can access a specific service, but nothow easy it is for users of various abilities to do so. As such, they bare little relevance to actual users, particularly people with disabilities who have quite different access needs from the norm. Hence, such metrics provide little actionable information as to which gaps to address to satisfy users and decrease their perceived and lived discrimination. A number of projects have already begun to address this concern.Attempts to measure accessibility by institutional actors strive for objective and quantifiable measures of accessibility, but they are mostly excluding users from the development of such metrics . Hence, For example, the10. Research was driven by experts, rather than users. Three national experts within each country were chosen for their public transport accessibility, disability and policy knowledge and experience. Interviews were carried out at the national level in 25 EU Member States with:Furthermore, the PTaccess project  also attan individual of a national organisation representing disabled people;a representative of a public transport operator; anda representative of the national government.The information derived from Interviews was complemented by intensive internet research and resulted in a good practice report covering more than 70 examples of mobility systems in various countries. Examples covered individual transport modes without taking into account multimodal aspects or the entire travel chain. Good practice has accounted for different types of disabilities , yet it did not involve users in their evaluation or selection.https://cordis.europa.eu/project/id/770115/) focused on understanding, assessing, and evaluating the accessibility and inclusiveness of transport solutions, identifying gaps and unmet needs to ensure accessible, inclusive, and equitable conditions for all, especially vulnerable user categories. The project team analysed 51 case studies from different locations with regards to accessibility and inclusion. A methodology consisting of four layers of requirements , while urban planners place more emphasis on land use metrics (such as distance to the next public facility).distance and traveltime from a place A to a place B, ignoring other dimensions equally or even more important to users as well as individual differences between them12. Other methodologies mostly identifywhether or not users can access a specific service, but nothow easy it is for them to do so.According to our users, however “accessibility is a door-to-door issue”. Hence current approaches ignore the importance of multimodality. In addition, objective measures of accessibility may captureThere is an increasing recognition that the measurement of accessibility should consider users’ travel disutility or impedance, individuals’ travel preferences and constraints, should we want metrics to inform transport planning, operations, and policy. In addition, differences in personal needs, abilities, and travel patterns are often responsible for disparities in accessibility which can lead to unreliable analysis of transport equity . SheddinThe literature review byIn a nutshell, previous projects, publications and approaches have focused on different individual aspects of accessibility, for example, travel planning and execution, including assistance and companions for disabled people, as well as the topic as a whole. In their research, policies and evaluation indicators for assessing accessibility for people with disabilities were also considered from various viewpoints.https://transport.ec.europa.eu/facts-fundings/calls-tenders/assessing-and-improving-accessibility-urban-areas_en).Our critical evaluation of prior work highlights the lack of comprehensive, user-centric accessibility metrics that captures the main criticalities that affect users’ daily travel experience and reflects their prioritization, but are also meaningful, and easy-to-understand. The majority of previous projects did not sufficiently involve people with disabilities neither in method design and development nor method validation to ensure that the new indices represent their specific needs. In our experience, this is a critical point for meaningfully reflecting users’ perspective. It was yet clear that there is a real operational and managerial need for data and information that can inform transport investments and priorities to meet EU’s strategic priorities on accessibility as reflected on the European Commission's Study on ‘Urban Mobility – Assessing and improving the accessibility of urban areas’ , it is usually users’ subjective experience of the use of the transport system that matters to them. The challenge of a comprehensive metric is to translate such personal experiences in manageable quantitative data that can drive priorities and operational decisions.3. accessibility depends (at least in part) from the user’s individual needs, attitudes and abilities. Moreover, it would be non-sensical and unhelpful operationally to average out their evaluations.USER-RELATED RELEVANCE: The impact of the various transport infrastructure and/or service on accessibility may differ greatly depending on their disability. For example, the nearest bus stop may be easily accessible to the blind but really hard to get to by people on wheelchairs. Hence,The goal is a new measurement system that reflects a definition of accessibility compatible with these three challenges to develop a synthetic metric that can still capture the complexity of the concept in a manageable way.mobility divide, defined as “the gap that a vulnerable user has to overcome in order to have pair access opportunities to transport services, in comparison with normally endowed users”  has been envisioned as the composite of a set of indicators that aims to provide an overall measure of accessibility, through the evaluation of the mobility divide. The MDI multilevel structure enables a synthetic overall rating of the audited service, but also it provides different views, since it can be sorted with different keys, such as the kind of impairment or the audited transport service, so several perspectives can be made available for analysis and for a better understanding of the plus and minus of the local mobility system.To this end, the index is designed to be:Holistic, offering an easy to interpret and valid instrument to support the decision-making without dropping the underlying information base. Hence, the structure of the index has been shaped as a multi-level framework  and clustering and re-clustering of such items in groups according to their impact (dimensions) through an iterative, co-design process of reflecting. Such participatory approach ensures that the resulting indicators system measures accessibility in ways meaningful to users, yet useful to transport professionals.End-to-end, addressing all the phases of the journey experience from planning to arriving in one’s destination as per the ‘journey cycle' defined by Lafratta  accessibility to services and facilities, 2) transport organization and operation, 3) travel conditions and interactions with staff and passengers  and as per Deliverable 9.1. H-POPD – Requirement No. 2 describing the way TRIPS aligns with the European Commission (EC) regulations on personal data protection, all of which have been approved during the project interim review. Written informed consent was obtained from participants prior to inclusion in the study.During the first brainstorming workshop, held on 30 September 2020, we asked participants to recount everyday barriers they face during a typical journey on the public transport services and to correlate the insights with the proposed dimensions . This work helped attendees to better understand and give personal definitions of such concepts.Out of the five dimensions participants agreed that travel time and autonomy can be more readily and objectively assessed through a discrete scale of levels, whereas the comfort, safety, and convenience dimensions where more open to subjective interpretation of personal experience and merited a deeper discussion. Consequently, participants were randomly assigned to different focus groups, each devoted to each of these ‘subjective dimension’.People were asked to reflect about their dimension  in relation to each of the phases in the journey cycle  seeFig. All facAs a take-home task, participants were asked to prioritize the comfort, safety, and convenience factors and provide comments, examples, and eventual changes about clustering and naming. A person within each participant group was selected as coordinator and tasked to integrate feedback into the master spreadsheet. Through this process, ‘affordability’ was proposed as the sixth dimension and included in the MDI.A second validation workshop took place on 4 November 2020 with the same participants to:1. share the outcomes of the take-home task with the other participants,2. agree on the clustering of factors associated with each dimension and3. approve the addition of ‘affordability’ as a key-dimension of the MDI.To ensure that MDI framework made sense to persons with disabilities beyond those directly involved in the development of the MDI and terms, concepts and descriptions are easily understandable in each of the languages of the pilot cities involved, we task the team leaders of the user groups to translate and engage their teams in validation of the MDI framework in their local language. Hence, the MDI was discussed offline by local user leads (LULs) with the core user teams (CUT) members, namely groups of 5–7 people with different types of disabilities who have been recruited by LULs themselves in each of the project cities. As LULs were invited to optionally present the MDI to their teams to collect their comments and opinions, results for this were available only for Brussels (French), Stockholm (Swedish), and Cagliari . Data were collected between November and December 2020 from the team leaders. Basically, people were asked to review the six dimensions and factors adding parameters and additional explanations in order to have a wider view of end-users perceptions and focus on the particularities of urban transport system that can prevent people with disabilities to not encounter difficulties during their travel experience.People involved in this final stage of the process approved the MDI factors previously proposed by their colleagues and prioritized them. They showed that not all the MDI components have the equal importance and some interesting discrepancies exist. For example, concerning ‘Comfort’ factors, people assigned a value of 10 (on average) to getting on and off the means of transport, while using facilities and supporting infrastructure did not seem to matter the participants, as the mean value of importance rounded to 4. While such data cannot be considered statistically significant, they nevertheless highlighted the need to rate the relative importance of MDI components instead of assuming an equal rating across factors and dimensions.Factor Weighting section. The participatory outcomes were mapped into the final MDI framework comprising a two-layer hierarchical structure of 22 factors identified by the users clustered into six dimensions . The existing literature offers quite a rich menu of alternative weighting methods, all having pros and cons  or the factor analysis (FA)- rely on large volume of quality statistical data. In such case, higher weights are assigned to statistically reliable data with broad coverage. Given that MDI is in a nascent state of development, such data does not exist. Finally, MDI aims to reflect the current users’ point of view, hence, we only examined methods based on public opinion which employ participatory methodologies in assigning weights. Researchers provide several examples of participatory methods, like the budget allocation process (BAP), the analytic hierarchy process (AHP), and the conjoint analysis (CA).We chose the budget allocation method (NAP) as the weighting technique for estimating the dimensions weights of the MDI. Compared to the other methodologies, BAP is easier to be applied through common participatory research, as it does not require a high computational cost and process integrations with additional focus groups or workshops. For these reasons, it was selected as the most proper method to rate the relative importance of each dimension.Based on such theory, we designed a multi-language online survey aiming to collect the importance given by European people with different access needs to the different MDI dimensions and factors. The survey was created by using Microsoft Forms and it was available in English, Italian, French, German, Greek, and Portuguese . An easyOverall by the 10th of March, 2021, 113 persons with disabilities  had participated in the survey expressing a rate of importance to each dimension and factor.Results analysed through the ANOVA test , indicated that prioritisation differs depending on the type of disability, phase of the journey, and mode of transport; hence reporting of data should maintain its sensitivity to reflect such differences to reflect user experiences and be useful to transport staff. This survey allowed use to derive a set of weight coefficients (w) for each factor per type of disability. A more detailed account of findings can be found at:In order to obtain each factor rating, the user  is asked to evaluate its own level of accessibility about each factor individuated, choosing within a discrete range of fixed answers.We have defined and agreed with the stakeholders that each answer must be expressed in natural language, where possible.This is because firstly we would not like to require disabled users to put in an effort to assign a numerical value, and secondly, we wanted to ensure the homogeneity of the data. In this way, we have a clear and comparable scale for everyone.In order to clarify the criteria adopted for the conversion,In order to obtain the overall index value, the MDI algorithm was calculated where each dimension value is calculated as the weighted average of its factors, and the overall MDI as the weighted average of the six dimensions see. This coTo make findings accessible and easy to understand for users and transport staff alike, a dashboard was created based on a colour coding, traffic like system.The green colour code represented values between 0 and -3,33 and indicates a low divide;the yellow colour code ranges between -3,34 and -6,66 indicates medium divide,the red colour code ranges between -6,67 and -10 – which indicates a high divide. This colour-coding system characterised both dimensions and factors and their subfactors as inThis ‘drilling down’ organisation of the presentation of findings was chosen to facilitate users and transport staff to understand an issue but also to filter data in useful to them ways .process of continuous improvement .4. MDI monitoring: continuous measurement, through the MDI, of the impact of the improvement actions, that should result in the gradual reduction of the initial gaps.5. Results assessment: the measurement of final MDI rating should show of the satisfaction of the users’ needs and the actual improvement of the transport accessibility.6. Re-visioning: a new improvement cycle can be launched, though the identification of further accessibility needs to be satisfied.We envision key institutional players to be involved in the implementation of the indicator system serving particular roles, such as:The city authority  who is in charge of the planning of mobility services and of the monitoring of the related service levels, in order to ensure the satisfaction of the citizens’ mobility needs. The MDI can represent the tool through which the city authority can check the actual accessibility of the planned transport services; therefore, they will have the role of process owner of the data collection, which will include the formal adoption of the MDI tools, the mobilization of the local disabled community in the MDI survey, and the evaluation of the audit results.The local transport operators, who shall commit to support the implementation of the MDI survey on the operated services. The transport operators collaborate with the city authority in the evaluation of the audit results, in the identification of the actions necessary to remove the reported barriers and in their implementationThe community of persons with disabilities: Disability non-governmental organisations (NGOs) and private citizens are encouraged to play a leading role in the improvement process: their direct experience will be the base of the data collection for the MDI evaluation, and they will also be asked to report specific malfunctions and proposals for improvement. They shall be involved in the identification of the solutions to be implemented, in collaboration with institutional and technical stakeholders, and in the final evaluation of their effectiveness.https://mdi.tbridge.it/login) which automatically analyses and visualizes results of users’ audits. The TRIPS MDI App is available both on the AppStore (https://apps.apple.com/lv/app/trips-mdi/id1630779990) and on Google Play (https://play.google.com/store/apps/details?id=com.tbridge.trips), and it is used by persons with disabilities for rating the accessibility and for reporting barriers during their travel. The data collected through the TRIPS MDI App are stored in a dedicated repository and processed through the MDI algorithm. The dashboard is a public page that visualises data to make analytics useful to and actionable by policy makers, transport and urban planners, operators, stakeholders' representatives, citizens, and researchers. For example, it allows the detailed examination of specific dimensions and factors. In addition, local city authority and transport operators, have access to tools that allows them to analyse specific issues reported by the users via photos and open text.While the MDI proof of concept was piloted via a web survey tool, its full-scale implementation is envisioned as 1) a mobile application (TRIPS MDI – Accessible Transport Gap) that enables users to send their feedback while travelling and 2) a web dashboard  and disability NGOs who participated in the weighting survey.We appreciate that this MDI effort should be put to further testing, validation, and evaluation with wider communities of users and institutional actors before it can be consolidated and established as an industry standard, but also that priorities will change as transport systems evolve and users’ abilities to navigate the transport transform due to adjacent factors, e.g., personal technologies. To enable our model to be piloted and replicated in and by other cities, both the TRIPS MDI app and the MDI dashboard can be set up for any city interested in the adoption of the MDI method. Currently, such tools are in BETA testing phase  in the TRIPS pilot cities, to finetune the applications and its adoption process. Subsequently, a new release of the applications will be launched for further piloting in European cities.https://www.uitp.org/) and other institutional and political actors to agree on the establishment of a European Accessibility Observatory that can act as a transparent, two-way communication platform between citizens and the transport ecosystem. The platform will collect MDI data and reported barriers logged as incidents from users in each European city to monitor the level of accessibility of their transport cities at real-time and provide detailed info on the issues to be addressed. In addition, it will publish each city’s MDI dashboard, as well as institutional responses and their status by the responsible institutions. Time series data analytics will demonstrate the impact of such institutional responses on accessibility and citizen satisfaction over time. Collecting such data across European cities will provide a database of context specific information on accessibility barriers to be mined for uncovering effective best practices to address them and their principles to guide policy and practice.At a systemic level, the TRIPS consortium works closely with its partner UITP  for auditing the accessibility of public transport as the perceived disparity in the ease of using transport between disabled and non-disabled citizens. The MDI was developed using a co-design approach, directly involving end-users. We argued to the superiority of such an approach in terms of being holistic due to multidimensionality, usefulness in terms of translating user data into useful and actionable quantitative data for institutional users to enact upon yet remaining representative of user viewpoints and relevance to the users and their issues enabling meaningful representation and enabling institutional responses to be relatable from users’ standpoint. Six dimensions transpired as most relevant and important for accessibility according to users: 1) safety, 2) convenience, 3) comfort, 4) affordability, 5) travel time, and 6) autonomy and measures. We present our findings and links to tools in development in the hope that they can be replicated and utilised by institutional stakeholders to promote inclusive and equitable mobility solutions for all and the pursuit of European accessibility standards and requirements for products and services in the mobility sector. The consortium will remain open to expressions of interest by institutional actors to enable their adoption in their urban environment throughout the duration of the TRIPS project until January 2023. Into the future, we offer the mobility divide index as a part of our contribution towards a better understanding of users’ need and requirements towards a assessable and inclusive transportation for all. The article Developing the multi-dimensional mobility divide index (MDI) as a Methodology to Assess the accessibility level of Public transport Systems provides an overview of the accessibility indicators, especially for people with reduced mobility. The state-of-the-art or literature review describes the projects and activities conducted in this field. The article is written in a sufficient scientific manner. The theme is actual, and the provided analysis method is good enough. The major research point is the provided methodology with the description of the method and analysis with results validation. Moreover was developed the co-design approach, which directly involves the end-users. For results validation, the mobility divided index framework was done, defined by the users and after the budget allocation method as the weighting technique was chosen for estimating the dimensions weights. A minor point could be formatting, such as citing the project's name (title) in the Introduction needing improvement. And to providing the reading more comfortable, the Headings numeration (2.1...) is required. The article is approved.Are sufficient details provided to allow replication of the method development and its use by others?YesIs the description of the method technically sound?YesAre the conclusions about the method and its performance adequately supported by the findings presented in the article?YesIs the rationale for developing the new method (or application) clearly explainedYesIf any results are presented, are all the source data underlying the results available to ensure full reproducibility?YesReviewer Expertise:Urban mobility, transport simulation, sustainable transport system development and analysisI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The article is of great interest because it summarizes all the general parts of TRIPS-funded research. Of good generosity are the cross-references to previous research and references that allow one to move around within the topic in order to explore it further and creating a good steering scheme of the research presented in the article. Obviously this scholarly article is the narrative of the funded research, and in its main body I think there is no point in asking for any changes or insights that would be outside the research itself that has already been accomplished, because perhaps the only weakness is the number of questionnaires produced, which are already a good sample, but perhaps do not allow for an appreciation of all the facets that the MDI could provide with respect to the authors' suggestions. Perhaps in the main body it could be explicated with more practical examples of how disabled users can interact through the mobile application and provide the correct (and subjective) data to populate the index data and whether and how the data user can, as I imagine, act site specific. The data present and attached are of great interest and complete, I also consider for reproducibility by other researchers, and for this reason I believe it is not necessary to upload other data  that would have necessary copyright coverage. Not only do I find the article in its structure very interesting, but especially the research presented and the presentation of MDI.Are sufficient details provided to allow replication of the method development and its use by others?YesIs the description of the method technically sound?YesAre the conclusions about the method and its performance adequately supported by the findings presented in the article?YesIs the rationale for developing the new method (or application) clearly explainedYesIf any results are presented, are all the source data underlying the results available to ensure full reproducibility?YesReviewer Expertise:Researcher in Urban Planning (UNIGE), my fields of research include new technologies for city management and urban transportation.I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


The aim of this systematic review is to analyze the role of occupational therapy in the school setting for children with additional support needs or disabilities. (2) Method: We conducted a systematic review using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. This systematic review was registered in PROSPERO (CDR42022314271). The search was performed in the following databases: ERIC, Dialnet Plus, PubMed, OTseeker, Cochrane, Scopus, CINAHL, and PsycINFO. (3) Results: In total, 1954 studies were identified, from which 18 articles were selected. These studies were heterogeneous and showed different types of intervention of the occupational therapist in school environments. (4) Conclusions: The main conclusions highlighted the effectiveness of the occupational therapist within the school environment, the importance of an interdisciplinary team to cover the special needs students within the school and the need for intrinsic motivation for an active and inclusive participation of the students with special needs. However, there is a need for more homogeneous studies with a larger sample size that specifically focus on the school context and include the involvement of occupational therapists in order to replicate the findings obtained. The primary objectives of occupational therapy are to enhance individuals’ capacity to engage in desired, necessary, or prescribed occupations across their lifespan . OccupatIn Europe, specifically Switzerland, the role of occupational therapists is included as a part of the school system even though it can originate from outside the school; however, there exists permanent communication with educators . In SoutAt present, Spanish education is regulated by the Organic Law 3/2020 of 29 December on Education (LOE)  and the Nonetheless, both in the Spanish legislation and the regional legislation of Andalusia, there is no law that covers the role of the occupational therapist. There are some professional associations in other regions, such as Castilla-La Mancha, Navarra, Galicia, the Balearic Islands, Aragón, and La Rioja that have prepared documents justifying the role of the occupational therapist. The Basque Country community stands out as a pioneer in introducing occupational therapists among the support staff for students with special educational needs . AccordiA systemic review was carried out following the guidelines of preferred reporting items for systematic reviews and meta-analyses (PRISMA), considering the studies published between 2015 and 2022 in the following databases: ERIC, Dialnet, PubMed, OTseeker, Cochrane, Scopus, CINAHL and APA PsycINFO. The search was carried out using the following keywords based on the health sciences descriptors (MESH/DECS): “occupational therapy”, “primary school”, “school”, and “learning disabilities”. This systematic review was registered in PROSPERO (CRD42022314271).The inclusion criteria were as follows: Studies published between 1 January 2015 and 7 November 2022; participants included children between the ages of 6 and 12; atopic about learning disorders or problems at school; studies that included the role of the occupational therapist in the school (primary); and the language of the study was Spanish or English.Exclusion criteria were as follows: review letters to the editor, conference abstracts, studies about special education in higher and lower primary education, and studies about interventions by other professionals that did not include the occupational therapist.Two independent reviewers conducted a thorough assessment of studies to determine their suitability for inclusion based on the predetermined eligibility criteria.Three scales were used to minimize the risk of bias according to the type of study analyzed. CONSORT guidelines 2010  were useAfter removing duplicate records, 154 were reviewed screening titles and abstracts, but only 39 were selected. These studies were analyzed by title and abstract, of which 39 were selected by full text . FinallyThree systematic reviews were identified. Firstly, Stauter et al.  employedOutside the framework of systematic analysis, we encountered narrative reviews that highlight the significance of education following the Montessori model, with Luborsky  emphasizConcerning pilot studies, Grajo et al.  first prSecondly, Siyam et al.  employedHandwriting Without Tears in children with Down Syndrome [In this systematic review, we also included randomized controlled trials, such as Esmaili et al.  and a prSyndrome  and emphSyndrome . AnotherSyndrome .Handwriting Without Tears [Keyboarding Without Tears®(KWT) [Another practical approach was ut Tears  through s®(KWT) . Donica s®(KWT)  proposedAccording to case–control studies, as was previously mentioned, a sensory-based approach is currently being researched as complementary to traditional methods. Wild et al.  proposedThe findings derived from the analysis of the research articles indicated a generally limited quality rating, primarily attributed to small sample sizes and the variability of the occupational therapist’s role within the school setting. Nonetheless, the research proved to be informative and valuable for practitioners, given the extensive range of intervention possibilities and diverse practice areas. Evidently, all children with learning difficulties benefited from the occupational therapist’s interventions within the school or, alternatively, as part of multidisciplinary teams. The synthesis of the studies revealed commonalities in successful educational strategies, participation outcomes, and emerging literacy achievements.This systematic review aimed to analyze the current status of occupational therapists’ role in the school environment and its impact on the education of children with disabilities. The 18 articles selected were subsequently analyzed and categorized based on their respective subject areas, according to our objectives. The obtained results were not homogeneous, possibly attributed to the diverse range of areas within schools where occupational therapists can provide interventions.Stauter et al.  focus onAuthors should discuss the results and how they can be interpreted from the perspective of previous studies and the working hypotheses. The findings and their implications should be discussed in the broadest context possible. Future research directions may also be stressed.Inclusive educational environments are one of the top priorities in every educational system, but, indeed, it is not a real functional option yet. It was analyzed by Anaby et al.  that varHandwriting Without Tears [The utilization of conventional learning methods can present challenges for children across the board, and adopting alternative approaches to learning has the potential to enhance their performance . There aut Tears ,44, whicut Tears ,32.Keyboarding Without Tears, developed from the original intervention Handwriting Without Tears, which can be used with general or special education students. It is also an adaptation for those with physical impairment [Another alternative is pairment . Menin epairment  indicatepairment .The contribution of occupational therapy to literacy is highly extensive, as it can intervene when there are organic or neurological challenges in the processing or execution of the activity .Beyond the confines of traditional and antiquated educational structures, Luborsky  underscoFinally, Virtual reality could promote engagement in intervention easily and, at the same time, changes in self-regulation in children with special educational needs, as indicated by recent studies .It is necessary to emphasize that the occupational therapist holds the exclusive professional qualification to address issues about sensory integration. Consequently, they are the only professional entitled to establish an intervention in any environment, including the school .One of the most relevant conclusions of this systematic review is the effectiveness of occupational therapists within the school setting. Primary objective achievements are the significant findings from all the analyzed studies that were considered, encompassing an evaluation of the favorable and unfavorable aspects of the therapist’s engagement in schools and their interaction with children with disabilities. The following conclusions can be drawn following the framework structure employed in the discussion. Although the selected studies had a reduced sample, most of them highlighted the occupational therapist’s relevance and the importance of an interdisciplinary team to cover the special needs within the school. It includes the intervention within the environment, in this case, the classrooms with the children. Additionally, it is necessary to provide a degree of intrinsic motivation for the active and inclusive participation of children with special needs. It should also be noted that the therapist could intervene with students without special needs, but they need to organize routines, habits, etc., to obtain a generally positive effect.The literature reveals the transformations in the educational approaches for children, particularly those with learning difficulties. Although the advantages of alternative teaching methods, such as those employed in literacy, are widely acknowledged, their widespread implementation may not be readily apparent. Nevertheless, the emergence of novel techniques and instructional approaches has expanded the scope of professionals involved in education beyond traditional teachers, notably occupational therapists.In general, one of the aspects that must be highlighted is the effect of the intervention on neurotypical children since some studies also analyzed this population. This data could lead to a reflection on the benefits of occupational therapy applied to all students, both those with unique needs and neurotypical students. Specifically, researchers have highlighted the deficits observed in typical developing children and the potential advantages of emerging technologies, which present therapeutic applications in the school setting. Consequently, studies have demonstrated the benefits of occupational therapy for children with learning difficulties, aiming to assess its effectiveness in improving outcomes for both groups of children.Finally, several limitations have been identified in this review. One limitation is the need for more homogeneity in the literature on the subject. Additionally, other limitations were observed regarding the scope of occupational therapy within the classroom and the types of studies that consider the occupational therapist’s role. These limitations may stem from the versatile nature of the occupational therapist’s role. It is essential to emphasize the lack of evidence specifically within Spain, primarily due to the absence of nationwide recognition of occupational therapists in primary schools according to Spanish legislation. However, some professional associations are actively working to address this issue and achieve recognition for occupational therapists comparable to that in the public health system.


Psychosis is one of the most disabling mental health conditions and causes significant personal, social, and economic burden. Accurate and timely symptom monitoring is critical to offering prompt and time-sensitive clinical services. Digital health is a promising solution for the barriers encountered by conventional symptom monitoring approaches, including accessibility, the ecological validity of assessments, and recall bias. However, to date, there has been no digital health technology developed to support self-management for people with psychosis in China.We report the study protocol to evaluate the validity, feasibility, acceptability, usability, and safety of a symptom self-monitoring smartphone app  for people with psychosis in China.This is a nonrandomized validity and feasibility study with a mixed methods design. The study was approved by the University of Manchester and Beijing Anding Hospital Research Ethics Committee. YouXin is a smartphone app designed to facilitate symptom self-monitoring for people with psychosis. YouXin has 2 core functions: active monitoring of symptoms  and passive monitoring of behavioral activity . The development process of YouXin utilized a systematic coproduction approach. A series of coproduction consultation meetings was conducted by the principal researcher with service users and clinicians to maximize the usability and acceptability of the app for end users. Participants with psychosis aged 16 years to 65 years were recruited from Beijing Anding Hospital, Beijing, China. All participants were invited to use the YouXin app to self-monitor symptoms for 4 weeks. At the end of the 4-week follow-up, we invited participants to take part in a qualitative interview to explore the acceptability of the app and trial procedures postintervention.Recruitment to the study was initiated in August 2022. Of the 47 participants who were approached for the study from August 2022 to October 2022, 41 participants agreed to take part in the study. We excluded 1 of the 41 participants for not meeting the inclusion criteria, leaving a total of 40 participants who began the study. As of December 2022, 40 participants had completed the study, and the recruitment was complete.This study is the first to develop and test a symptom self-monitoring app specifically designed for people with psychosis in China. If the study shows the feasibility of YouXin, a potential future direction is to integrate the app into clinical workflows to facilitate digital mental health care for people with psychosis in China. This study will inform improvements to the app, trial procedures, and implementation strategies with this population. Moreover, the findings of this trial could lead to optimization of digital health technologies designed for people with psychosis in China.DERR1-10.2196/45170 Psychosis is one of the most disabling mental health conditions and causes significant personal, social, and economic burden , which iAccurate and timely symptom monitoring is arguably one of the essential components of quality clinical services. Conventional symptom monitoring approaches in mental health services face several practical and methodological challenges. First, conventional methods rely on clinical interviews or comprehensive assessment batteries, which can be carried out only by trained professionals and require service users to attend an in-person meeting with their health provider. However, a lack of resources means that access to in-person services is limited; the wait times between referral and assessment can range from 4 weeks to 6 months or longer . MeanwhiSecond, the conventional approach to assessing symptoms lacks ecological validity; current methods for assessing service users’ difficulties, broadly speaking, capture cross-sectional information rather than continuous information over a certain period of time ,12. ClinThird, recall bias has long been identified as a limitation of conventional clinical assessment methods ,14. ServThe aforementioned barriers affect countries worldwide , even hiChina has invested substantial resources to reform its mental health system to improve the accessibility and quality of mental health services in the past 15 years; however, the effort has only been partially successful, and the mental health treatment gap remains significant ,20. The In China, mental health services are primarily delivered through psychiatric hospitals -28. CompDigital health is a promising solution to address both the barriers encountered by the conventional symptom monitoring approach  and ChinAmong different types of DHTs, smartphones are the most advantageous tool for symptom monitoring given their ability to generate a plethora of data through active and passive monitoring methods . Active Smartphone-based symptom monitoring for people with psychosis has proved to be feasible in the Western context ; howeverThe aims of this study are to evaluate the validity, feasibility, acceptability, and safety of a symptom self-monitoring smartphone app (YouXin) for people with psychosis in China.The study was approved by the University of Manchester (Ref: 2022-13262-24297) and Beijing Anding Hospital (Ref: [2021] Research No.58 ) Research Ethics Committee. The study was conducted in full conformance with all relevant legal requirements and the principles of the Declaration of Helsinki, Good Clinical Practice, and the UK Policy Framework for Health and Social Care Research 2017. Potential participants were given a participant information sheet to read. The detailed informed consent procedure is described in the Recruitment section. Participants were informed that they are free to withdraw from the study at any time and for any reason. Withdrawal from the study did not impact participants' access to standard care at Beijing Anding Hospital. The delivery of the intervention did not affect any form of clinical care participants received, and they continued to be actively supported by the hospital during their participation in the study. Study data are anonymous and were managed according to the data management plan described in the Data Management section. Participants were given a ¥100 (US $13.76) gift voucher for each completed assessment. For participants who took part in the interview, at the end, they were given a ¥100 (US $13.76) gift voucher as a thank you for their time and to cover any costs incurred as a result of their participation. This information was included in the participant information sheet and was provided to participants before they entered the study.The study took place at Beijing Anding Hospital of Capital Medical University, which is one of the largest tertiary psychiatric hospitals in the Beijing metropolitan area. The hospital has 800 beds, an average 5000 inpatient admissions per year, and over 1200 daily outpatient visits.The study uses a mixed methods design consisting of a nonrandomized feasibility study and a nested qualitative acceptability study. The study was designed according to the Consolidated Standards of Reporting Trials (CONSORT) statement extension for pilot and feasibility studies . We recrEligibility criteria were deliberately inclusive to fully assess feasibility and validity of the app and to reach generalizable conclusions for a wide range of service users with psychosis. Due to the limited resources, the research team could not provide devices to participants who did not own a smartphone. However, according to a recent survey study in China, 83.2% of service users and family members reported owning and frequent use of mobile devices . ParticiInclusion criteria:Diagnosed with schizophrenia spectrum according to DSM-5 (F20-F29) or met the criteria for being at clinically high risk for developing psychosis according to the Structured Interview for Prodromal Syndromes (SIPS)Aged 16 years to 65 yearsReceiving care from Beijing Anding Hospital and will continue to be actively supported by the hospital over the next 5 weeks Own and able to use a smartphoneExclusion criteria:Diagnosed with organic or substance-induced psychosisLack of capacity to provide informed consentUnsafe to participate in research as viewed by their treating clinician Participants were recruited from Beijing Anding Hospital, which is a major tertiary psychiatric hospital located in Beijing, China. Participants were initially approached by a clinician working at the hospital to introduce the project and assess the willingness and potential eligibility of the potential participant to participate in the study. If participants appeared to be eligible and willing to participate, they were referred to the principal researcher who confirmed their eligibility. When eligible, potential participants were given a participant information sheet to read, and their contact details were obtained by the researcher with their consent. The principal researcher followed up with a phone call to the potential participant after at least 48 hours to explain the details of the study and answer any questions that the potential participant had about the study. If the potential participant was still interested in taking part, a face-to-face meeting was arranged to obtain written consent to participate using a hard copy consent form prior to conducting the baseline assessment at the same meeting. Participants were recruited until the recruitment target was met (n=40).YouXin is a smartphone app designed to facilitate symptom self-monitoring for people with psychosis. The app is adapted from the ClinTouch app , a self-The YouXin development team consisted of experts from various disciplines, including academics, clinicians, software engineers, and experts by experience. The principal researcher led the development of the app and was supported by members of the research team who are academic clinicians at the University of Manchester . A psychiatrist at Beijing Anding Hospital assisted the development of the app to ensure the content reflected the Chinese context. A technology team led by a computer scientist at Beijing Jiaotong University supported software development.To maximize the usability and acceptability of the app for end users , the development process utilized a systematic coproduction approach. A series of coproduction consultation meetings was conducted by the principal researcher with service users and clinicians at Beijing Anding Hospital. We used an iterative approach to coproduction, which means the outputs of a previous meeting formed the content of subsequent consultation meetings. The framework for coproduction shown in  was inspAlpha:The alpha phase aims to understand the end users’ (clinicians and service users) needs for using digital tools to monitor symptoms and demonstrate the preliminary design with users (the ClinTouch app and the user interface prototypes of the YouXin app). The design, contents, and functions of the app were further developed based on the feedback from users.Beta:The principal researcher and software engineer integrated the feedback and delivered a functional prototype that users could install on their phones. During the meeting, users tested the app and provided feedback.Live:A fully developed digital platform was presented to users (3 clinicians and 3 people with psychosis) to try out for a week. This meeting focused on evaluating the usability and acceptability of the app and any major issues regarding implementation.YouXin has 2 core functions: active monitoring of symptoms  and passive monitoring of behavioral activity . The app is available for both Android and iOS platforms. The active monitoring uses a time-contingent design. To minimize participant assessment burden and increase compliance, in accordance with a previous similar study , promptsParticipants were given a training session by the principal researcher to help them navigate the app after they consented to take part. During the training, the principal researcher helped the participant download the app onto their smartphone and gave a demonstration of the app. Participants had the opportunity to practice using the app and ask questions during the process; they had access to the app from the training session until the 4-week timepoint. An opt-out approach was applied to give participants autonomy to switch on or off the passive sensing section during the study.The principal researcher provided technical support as needed during the study; no clinical care was provided by the research team . The participant was referred to their treating clinician for appropriate mental health care should any clinical issues be raised to the research team. Participants were informed at the training sessions that the app is not suitable for seeking urgent medical care while in any emergency circumstance.The timeline of outcome assessments is summarized in Sociodemographic characteristics including age, gender, education level, marriage status, average income, accommodation and living situation, employment status, and ethnicity were collected. We also collected data regarding digital literacy and mental health literacy.Number of hospitalizations, time at first onset, number of episodes, and medication(s) or therapy used before and during the study were collected from service users’ electronic health records (EHRs). At Anding Hospital, the EHR is used in both outpatient clinics and inpatient units and is shared within the hospital. All records are kept in the EHR system using computers, and no records are written by hand; service users receive a hard copy of their record following each appointment.The Chinese version of the Mini International Neuropsychiatric Interview ,51 was uThe Chinese version of the Structured Interview for Prodromal Syndromes ,53 was uPsychotic symptoms were rated using the Chinese version of the PANSS ,55, a 30Mood symptoms were assessed using the Chinese version of the CDSS ,57, a 9-Service user engagement was measured using the Chinese Version of the Patient Health Engagement Scale , a self-Social functioning was rated using the Chinese version of the Personal and Social Performance scale (PSP) ,60, a 10Quality of life was evaluated using the Chinese version of the EQ-5D-5L , a self-Active monitoring consisted of the following 3 sections: psychotic symptoms, mood symptoms, and contextual information. The psychotic and mood symptom items were translated into Chinese from the ClinTouch app and were compared against the Chinese version of the PANSS and CDSS. Contextual questions were added to understand the context of participant responses and to validate GPS data. Examples of the items are shown in Passive monitoring used collected GPS data to measure mobility and activity level of users. GPS mobility indicators measured on the smartphone, including home time, distance travelled, and location clusters, will be extracted following the procedures by Müller et al . BrieflyThe validity of active monitoring items will be assessed against relevant clinical assessments  using Spearman correlation. An exploratory analysis will also be conducted to understand the association between mobility indicators, corresponding contextual questions in active monitoring, and PANSS negative symptom scores. We define a moderate statistically significant correlation  as the validity threshold.To assess the feasibility of the study, we collected detailed recruitment and retention data accordant with the CONSORT statement for feasibility studies , includiThe quantitative feedback questionnaire (QFQ) was given to participants at the 4-week timepoint to collect quantitative information regarding acceptability. The QFQ is a 27-item questionnaire designed to assess the acceptability of utilizing smartphone app interventions for service users. It has been used in previous digital mental health studies for people with psychosis ,65.Qualitative interviews were conducted to explore their experiences using Youxin including (1) overall impressions of YouXin, (2) positive and negative aspects of the app in terms of content and usability, (3) how it helped or did not help, (4) what changes they would make, (5) barriers and facilitators to engagement, and (6) views on the training session.To evaluate the safety of the app, detailed adverse events and serious adverse events were collected and reported using standardized operating procedures in line with National Institute for Health and Care Research and Health Research Authority Safety Reporting procedures.We did not expect participating in the study would cause any significant risks. Although the study involves people with severe mental health problems, the eligibility criteria for the study require the participants to be stable and at low risk for self-harm or harm to others, as judged by a clinician. There is the potential for participants to report elevated levels of distress because of taking part in assessments and digital self-monitoring. This may include the potential for increasing awareness of one's own symptoms. Participants were informed during the recruitment process that they may encounter such situations, and they were encouraged to discuss this with the research team if they feel distressed during the study.All quantitative analyses will be performed using R (version 4.0.5) . FeasibiThe active monitoring will generate 3 levels of data, with the data entered for each “beep” as level 1, nested within the level 2 “day” level, which is nested within the level 3 subject level. Because the PANSS and CDSS measure participants’ symptoms for the past week, and to minimize the impact of missing data, the subject level mean score of the first week will be used to calculate the association between active monitoring items score and relevant symptom domain scores of the PANSS and CDSS at the week 1 follow-up assessment to evaluate validity. The significance level for the study will be set to .05. Cronbach alpha will be used to calculate the internal consistency reliability of the sets of the items of active monitoring. To account for the nested structure of the data, multilevel models will be used to explore the instability of the different constructs across time and patterns of missing data.The GPS mobility indicators will be extracted from passive monitoring data. The convergent validity of passive monitoring will be calculated by the correlation between GPS mobility indicators and the PANSS negative symptom score. Discriminant validity of passive monitoring will be demonstrated by low correlation between GPS mobility indicators and positive symptoms measured by PANSS.Qualitative data will be transcribed verbatim in Chinese and then translated to English by the principal researcher. A framework analysis approach will be used based on the protocol by Braun and Clarke , which cNames and contact information are password-protected and stored electronically and separately with anonymous questionnaire responses in a secure, password-protected folder on the principal researcher’s university drive and are kept for the purposes of contacting participants during the study. All quantitative data are stored as an anonymous electronic file and stored on the principal researcher's university drive for the purpose of analysis. Data generated from the smartphone app are stored on a secure server at Beijing Anding Hospital. The server is managed by the IT department of Beijing Anding Hospital according to the Chinese government’s data protection regulations. Only the IT staff can access the data stored on the server. The principal researcher applied to download the raw data at the end of the study data collection.Qualitative interview data recordings were anonymized as soon as practical after the interview, and anonymous transcripts were prepared by the principal researcher. Personal information was removed from the final transcripts or replaced with pseudonyms where appropriate. The file name was saved with the date of transcription and allocated a number to protect confidentiality and ensure no file names are the same . For the publication write-up, quotations may be used for which the participants will be given a pseudonym ; however, they will not be identifiable by the research team at this point.Recruitment for the study was initiated in August 2022. Of the 47 participants who were approached for the study from August 2022 to October 2022, 41 participants agreed to take part in the study. Reasons for not participating included concerns that answering app questions would be a burden (n=1) and family member concerns that answering app questions might be triggering for the participant (n=1). Another 4 participants declined to participate without giving any reason. We excluded 1 participant for not meeting the inclusion criteria, leaving a total of 40 participants taking part in the study. As of December 2022, 40 participants had completed the study. We expect to report the validity of the app-based monitoring and results for feasibility on the (1) number of eligible participants consenting, (2) completeness of outcome measures, (3) number of participants lost to follow-up, and (4) reasons for withdrawal. We also expect to report participants’ overall impressions of YouXin, positive and negative aspects of the app in terms of content and usability, perceived helpfulness of the app, barriers and facilitators to engagement, and views on the training session.This study aims to test the validity, feasibility, acceptability, usability, and safety of the YouXin smartphone app for people with psychosis in China to self-monitor symptoms. To the best of our knowledge, this study is the first to develop and test a symptom self-monitoring app specifically designed for people with psychosis in China. Therefore, a feasibility study is necessary to determine if a DHT like this will be appropriate to facilitate self-management for this population.We conducted a systematic review and series of surveys and qualitative interviews with people with severe mental health problems and mental health staff in China to facilitate the development of the app. Based on our previous findings, DHTs were generally feasible and acceptable among people with mental health problems in China , and menOne of the concerns of utilizing DHTs is the risks related to data security and privacy, which may hinder the implementation of DHTs -71. To tIf YouXin is feasible, acceptable, and safe and brings clinical benefit, a potential future direction is to integrate the app into clinicians’ workflows to facilitate a digitally enabled care pathway to support timely mental health care for people with psychosis in China. This could include a remote symptom monitoring system  or a morIn summary, this study will provide valuable insights for evaluating the feasibility, safety, acceptability, trial procedures, and implementation strategies of a DHI with this population in the Chinese context. Moreover, the findings of this trial have the potential to inform the development of digital solutions for China’s mental health services in general, and, more specifically, it could lead to optimization of DHTs designed for people with psychosis in China.


Stress urinary incontinence affects a large proportion of women in their lifetime. The objective of this review was to describe and compare the latest surgical trends in urinary incontinence and focus on the literature advantages, disadvantages, complications and efficacy of surgical procedures regarding this pathology. Using network meta-analysis, we have identified the most frequently used procedures , and we have described and characterized them in terms of effectiveness and safety. Midurethral procedures remain the gold standard for surgical treatment of stress urinary incontinence, although the potential of serious complications following this procedure should be taken into consideration always. There is a clear need for a much more unified evaluation of possible complications and postoperative evolution. This process will help practitioners to adapt and individualize their strategy for each patient.  Urinary incontinence is defined by the International Continence Association as any involuntary leakage of urine. Most of the time, it occurs due to physical activity that puts pressure on the bladder, such as exercise, sneezing, coughing, laughing or bending over ,2.All over the world, it is a worrying condition that can reduce the quality of life in women. Furthermore, the economic burden is considered to be high. The prevalence varies from 20% to 50% throughout life but is seen more often in women who have had children, and it becomes higher with age ,2. ThereIn Europe, the prevalence of SUI was estimated in 2022 at 14.5% according to a study carried out in 2022 in the population group of 30–60 years, and in Romania, it is evaluated to be 18%, maybe even higher due to the poor addressability of the patient regarding this pathology [Stress incontinence appears when the pressure inside the bladder, as it fills with urine, becomes greater than the strength of the urethra to stay closed . If the muscles that keep the urethra closed are damaged, the urethra may not be able to stay continent. Problems with the pelvic floor muscles may be caused by childbirth, increased pressure in the abdomen, surgery in the pelvic area, connective tissue disorders or neurological conditions .Although urinary incontinence is a non-life-threatening condition, it is known to have a significant health impact on the aging female population and leads to low quality of life in many ways. When conservative treatments have failed to control the condition, surgical treatment is necessary.Surgical treatment for stress urinary incontinence was described with a lot of procedures, each new procedure was developed to overcome the previous ones, but this situation led to a lot of ambiguities .In 1998, a prospective study was conducted on the comparison between the medium- and long-term effects of various surgical treatment procedures in female stress urinary incontinence. Basically, at that time, three types of surgical interventions were performed: the Kelly suburethral plication, transvaginal needle suspension (or its variants) and Burch colposuspension ,6,7.In the beginning, the indications for one of the procedures depended on the surgeon’s choice, the Kelly plication procedure being predominant due to its technical simplicity and simple postoperative evolution. This approach seemed to be easy and a little time-consuming from the technical perspective than the other two procedures and, for a long time, was the standard surgical procedure for stress urinary incontinence ,8.These interventions were surpassed by midurethral sling surgery developed in the 1990s, described as a minimaly invasive surgery that used a strip of synthetic mesh (sling) that was placed with no fixation (tension-free) on the structures that needed to be suspended ,8.Until the development of urodynamic investigation equipment 1998), the selection criteria for the procedures were exclusively clinical and limited to the recurrent form, especially after the Kelly operation, or to certain forms considered to be more complicated. The introduction of a urodynamic investigation managed, first of all, to objectify the type of incontinence preoperatively and objectively analyze a segment of the operated patients. Many patients did not find themselves in a subsequent segment because of the high subjectivity regarding self-evaluation. Moreover, a large number of recurrences were not found in the computerized statistics of the urodynamic apparatus [, the selAnterior vaginal repair colporrhaphy (anterior repair);Bladder neck needle suspensions;Open retropubic abdominal colposuspension;Retrosuspension made laparoscopic;Traditional sub-urethral retropubic sling;Midurethral retropubic sling (retro-MUS);Transobturator midurethral sling (transob-MUS);Single-incision slings small procedures;Peri-urethral injectable bulking agents.Currently, there are different types of surgical treatments for this condition, including the following:Each of these operations can be performed with different techniques, and each has its own advantages and disadvantages. Because of the lack of consensus and the different types and techniques used to perform this surgical operation, it is difficult to determine which procedure should be better used . ComparaIn this paper, we describe the latest trends in SUI with a focus on the literature advantages, disadvantages, complications and efficacy. Besides the description of the techniques, their analysis and comparison are extremely useful for refining the selection process of an individualized technique for each patient.The motivation for this review comes from the need to increase the addressability of this pathology with multiple personal, social and economic implications. At this moment, there is a multitude of surgical techniques described, each with its advantages and disadvantages, but there is a clear need for a much more unified and anatomically adapted approach to this problem. The multitude of techniques described leads to a non-unitary evaluation of possible complications and postoperative evolution. The purpose of the review was to draw attention to these ambiguities and to establish the clear need for collaboration in order to standardize procedures and declare complications.Standardization of interventions, as well as a more accurate declaration of existing postoperative complications, would help practitioners to adapt and individualize their strategy.We conducted a search of the literature limited to the last 10 years. We included systematic reviews and meta-analyses, retrospective cohort studies and large prospective cohort studies in our data synthesis. We hand-searched conference proceedings, journals and reference lists of relevant articles. Case series and case reports were not included in our data synthesis . The folA search of the literature was most commonly centered on the three most common surgical methods, including the midurethral sling, Burch colposuspension and autologous pubovaginal sling .This review was registered to PROSPERO with the ID NR. CRD42023409430/10.04.2023.Cochrane Incontinence published eight systematic reviews of randomized controlled trials that analyzed nine surgical interventions used for the treatment of stress urinary incontinence in women. These reviews represent an excellent literature base of evidence for surgical interventions in this domain, published in the last 5 years. The multitude of possible comparisons makes it difficult for both women and health professionals to interpret the current evidence because of the lack of consensus ,13. All data they collected are systemized into a meta-analysis comparing the clinical benefit of surgical procedures, and they also described adverse events and complications in this type of surgery ,12,13.They screened using inclusion criteria, such as randomized controlled trials or quasi-randomized controlled trials, women with urinary stress incontinence or mixed urinary incontinence with predominant symptoms of stress urinary incontinence and comparing two or more surgeries ,14,15,16They included eight surgical methods in the analysis ,17,18,19The results were impressive, which was the first extensive attempt to estimate the clinical effects and safety of surgical interventions for the treatment of stress urinary incontinence based on clinical trial evidence.The conclusions of the study are that, in the short- to medium-term (one year), retropubic MUS, transobturator MUS, traditional sling and open colposuspension seem to be more effective for the treatment of this type of incontinence. Evidence was insufficient to describe the long-term effectiveness and safety of surgical treatments ,16.Careful consideration of all surgical options and a better understanding of their associated risks is a must before choosing a different, potentially less effective, non-MUS procedure. Each case must be personalized and adapted to the need and desires of the patient.A search of the literature was centered on the three most common surgical methods, including the midurethral sling, Burch colposuspension and autologous pubovaginal sling. The reason why the literature is centered on these three techniques is due to the fact that although there is a multitude of complex techniques described, the research groups are very small and inconsistent, and the techniques are non-standardized. Each surgeon can imagine a personalized technique, but this leads to deficient anticipation of the postoperative evolution and to a low safety profile, so we can only take into consideration established and intensively studied techniques for which we have reported results, analyzed techniques and large study groups.A midurethral sling system is designed to provide a strip of support under the urethra to prevent it from falling during physical activity. It is considered that this procedure has a symptom cure rate of 80–95% and an objective cure rate of 57–92% . Midurethral sling, as a surgical procedure for SUI, was the most extensively studied regarding the efficacy and the safety profile, so most of the reviews have the highest evidence-based results on this procedure.Midurethral sling involves inserting a strip of synthetic mesh through the retropubic space or obturator foramen. Transobturator (TOT) was developed to minimize the potential risk for bladder injuries and is considered to be the safer of the two options because, unlike TVT, it avoids a surgical approach between the pubic bone and the bladder. TOT and TVT are both made of polypropylene mesh ,19.In 2009, Cochrane’s review of 12,113 women described the efficacy between the two procedures as similar, with a lower risk of vascular injuries and urinary retention in the transobturator approach. The most recent reviews update reconfirmed the data. Furthermore, they were also described to be more cost-effective. Fusco et al. performed an updated systematic review to compare the efficacy and safety of MUS compared to Burch colposuspension and pubovaginal slings and found that MUS was appreciably superior for overall cure rates. They had a comparable risk of further incontinence surgery and late complications [Morling et al. described a study performed on 16,660 women who had undergone a first single procedure with mesh compared with colposuspension, a mesh method that was found to be more effective regarding immediate complications and with low second interventions for relapse ,22.In 2017 in an updated systematic review, the advantage of TVT against retropubic urethropexy and autologous fascia sling was reconfirmed [In 2018 a multi-center study compared the tension-free vaginal tape and Burch colposuspension showed a higher rate of continence in the TVT Arm at 2 years .A 2013 Nordic multi-center cohort study demonstrated an objective cure over 90% at 17 years after TVT with only one mesh complication .Regarding mesh safety, concerns about complications such as erosion, pain, dyspareunia and infections were described. These complications can result in disabling symptoms requiring major surgery and can sometimes reduce the quality of life. Additional questions regarding polypropylene carcinogenic properties were raised, but a nationwide Swedish cohort study including over five million women showed no association with increased cancer risk following MUS surgery .In general, the complications after MUS surgery appear to be lower than alternative non-mesh-based SUI surgeries .A Scottish independent review was reported in March 2017 and deduced that a retropubic mesh tape is a good option with good safety and efficacy profile .It is important to know that some of the women will suffer serious complications that can affect their quality of life and are not easy to correct, but in most cases, they will describe an improvement in SUI after treatment by a surgeon with high experience.In 2022, a single-center prospective study that evaluated the functional outcome at 20 years after the vaginal sling procedure showed that the functional outcomes decline after 20 years post-correction, so the cure rate after 5 years of TOT implantation was 80%, and the follow-up showed that they dramatically decreased over the years. The limitation of this study is that it is a single-center study, and the strengths are that it is one of the few studies that evaluate the patient’s long-term satisfaction, but we all need to evaluate more carefully the long-term outcomes in our patients, not only in 5 years but longer .All of these studies have a general and common idea that, when used in appropriate patients by appropriately trained surgeons, mesh procedures have a good safety and efficacy profile . The autologous fascial pubovaginal sling was first described in 1978 and involves collecting a piece of rectus fascia or sometimes tensor fascia lata which is placed under the urethra after making a small vaginal incision. This procedure is described as taking longer operative time because of the dissection and harvesting operative time, higher blood loss involving dissection and postoperative morbidities such as seroma, so nowadays, it is reserved for women with recurrent SUI, severe SUI or previous complications of MUS surgery ,30.The pubovaginal sling is also indicated in the case of a urethral fistula or diverticulum repair because of its obstructive effect and concomitant urethral reinforcement ,31. The low risk of complications, such as erosion due to foreign bodies associated with synthetic mesh, is the principal advantage of this technique.A contemporary large systematic review from the UK that described comparative the pubovaginal sling with colpourethro suspensions and MUS showed similar success rates regarding efficacy profile .In 2007, a trial called the Stress Incontinence Surgical Efficacy trial made at 24 months from the procedure described that the rate of success was higher for autologous pubovaginal sling compared with colposuspension, although side effects and need for reintervention was higher in the autologous pubovaginal sling . Schimpf et al. found in their study that autologous pubovaginal sling was superior, comparing subjective cure rates, to Burch colposuspension; however, MUS was found to be superior to the pubovaginal sling regarding cure rates and had a lower incidence of overactive bladder symptoms .The pubovaginal sling is an effective procedure with high satisfaction rates but with additional morbidity of harvesting of fascia. Concerns regarding mesh-related complications increased interest in the pubovaginal sling technique because of the few pain-related complications and lack of mesh erosions reinterventions. However, the described surgical morbidity and low surgeon expertise may be obstacles to wider use of this procedure ,33.This procedure consists of a suspension of the anterior vaginal wall to the iliopectineal ligament and has been the main surgical procedure for many years and can be performed open or by laparoscopic approach. Complications of this intervention include bladder perforation, overactive bladder syndrome, prolapse and hemorrhagic incidents.Because of its use for more than 50 years, the Burch procedure has data on long-term outcomes, with cure rates up to 82% at 5- to 10-year follow-up. A large review found similar results, and the continence rates for open Burch procedures were noted to be 85% at 1 year postoperatively and approximately 70% after 5 years . Cohrane’s review from 2017, which included almost 5500 women, reviewed 55 trials and demonstrated Burch urethropexy’s continued efficacy, especially for long-term urinary management.The procedure can also be laparoscopically performed. A study conducted at 2 years postoperation was shown to be as effective as an open Burch procedure, however, with a significantly longer operative time but a shorter length of hospitalization ,31.EAU guidelines suggest that any type of approach, open or laparoscopic, has comparable cure rates, and it has to be offered as an alternative when a midurethral sling cannot be considered . NICE guidelines suggest that laparoscopic colposuspension should be made only by an experienced laparoscopic surgeon who is part of a multidisciplinary team .Burch and robotic Burch, which are minimally invasive options for treating this condition, have similar outcomes but lack comparison data .The robotic Burch urethropexy was first reported by Francis and colleagues in 2015. The cost of robotic surgery procedures is known to be significant, and the authors propose that a robotic approach in this pathology is particularly useful in patients that benefit from other concomitant robotic surgeries, especially in the pelvic area ,37.Another minimally invasive variant of the Burch colposuspension is the “Mini-Incisional Burch”. This procedure was proposed by Lind and colleagues in 2004, with the desire to allow through a smaller incision the same surgical correction. The authors of the study reported a complete cure in 97% of patients at short-term follow-up . Due to the intensive use of sling operation, the use of the Burch colposuspension has decreased nowadays but still has a significant role in the treatment of stress incontinence. Specifically, this strategy has to be considered when we have limited space access, intra-abdominal concurrent surgery or contraindications in the use of mesh.SUI generates a lower quality of life, having an effect on emotional well-being, depression and anxiety, alternating relationship activities, low self-esteem and sometimes associated comorbidities. Given the impact of the clinical manifestation, it also implies an economic impact for both the individual and society, especially in our country, where the patient is much less compliant with intermediate therapies and early investigation of the health problem .Milson and Coyne (2014), in a systematic review of economic costs, report that in multinational studies, the annual estimated cost of disease for UI was billion-wise in five European countries in 2010. In terms of cost efficacy, in recent years, health economics has been a very important area in decision-making because, with their studies, they make plans for the development of medical strategies by considering the costs involved in different medical approaches. Regarding SUI, there are involved high direct economic costs expressed in a decrease in labor productivity that leads to a second economic loss for society in all areas . In addition to the economic and social implications, the implications in the sexual sphere are not to be neglected. Due to the pelvic anatomy and the proximity of the urinary tract to the genital tract, sexual problems can occur. Women who suffer from this pathology may associate anxiety with the possibility of losing urine during sexual intercourse. Such a dysfunction involving low predictability of the event and poor control can determine the woman not wanting sexual intercourse or being anxious during it, something that leads to couple and trust problems. Studies on female sexual dysfunction estimate sexual disturbances in 39–45% of sexually active women. Several papers studied the relationship between urinary incontinence and sexuality, and they concluded that urgency symptoms or even urine loss were associated with anxiety, mood disturbances and low quality of life of SUI in the context of sexual life, sometimes leading to depression . The pathophysiology of stress urinary incontinence in complex and the unitary action of all pelvic anatomical structures, such as urethral support, vesical neck function and urethral muscles, is important in maintaining balance. Stress incontinence appears when the pressure inside the bladder, as it fills with urine, becomes higher than the strength of the urethra to stay closed . Slow-contractile muscle fibers from the urethra generate tension and maintain the closed urethra . The mecPerhaps one of the most important aspects of continence control concerns the balance between all of these systems. The anatomical pathogenesis of SUI facilitates a better understanding of the mechanism of SUI and provides new ideas for surgical treatment. There are several theories that explain the dysfunctions in SUI at the level of each system as well as imbalances in the whole system. There are various anatomical factors, but the majority of the studies pay much attention to the joint contraction of the levator ani muscle and the external urethral sphincter. Therefore, in the treatment of SUI, the solution is the repair and reconstruction of the levator ani muscle and external urethral sphincter. The surgical technique should be improved according to findings in anatomical pathogenesis of SUI, and by anatomical basis, we should develop and use more appropriate slings to reduce the impact of surgical operations on pelvic organs .There are many options for treating SUI in women, the most used are autologous fascial slings, midurethral tapes and colposuspension. Historically, colposuspension was the most used procedure, but now, after years of research, most patients are offered midurethral tape. The new guidelines  recommend offering first-choice MUS to women with SUI and no complications as the preferred surgical intervention.It is important for the surgeon to discuss with the patient the risks and benefits of each intervention, to evaluate their personal needs, social status and how incontinence affects their life. The choice of the technique and the operative moment must be adapted to the patient’s expectations. They must be realistic and as reproducible as possible postoperatively. The role of the surgeon is to mediate the patient’s needs with the surgical possibilities.MUS remains the most extensively studied treatment with the lowest complication rates, but women should be informed regarding the rare but serious erosions mesh-related complications. Perspectives in the development of new bio-synthetic mesh materials may lead to new surgical techniques with fewer complications.Careful contemplation of alternative surgical options and a better comprehension of their associated risks and benefits is a must requirement before opting for different, potentially less effective non-MUS procedures.Increasing concerns regarding mesh-related complications renewed interest in autologous fascial slings because of the lack of complications of mesh erosions, but the potential morbidity after harvesting of fascia makes it less used. By improving the fascia sampling technique and standardizing the insertion procedures, we can obtain better results with minimal complications.The newest guidelines (EAU guidelines) suggest providing a colposuspension procedure if a midurethral sling cannot be considered.A better evaluation and acknowledgment of complications after surgery for stress urinary incontinence is imperative. It is important to promote awareness of later complications, and it could be very useful to record them in national databases and registries to generate uniform data for each surgeon to access.Both at the scientific level and at the level of each patient, there is a clear need to identify personal needs as well as to evaluate the associated risks for good control of the risks and benefits of each intervention.


Liposomes have been known of for about 60 years, since they were discovered by A. Bangham in the mid-1960s in a serendipitously brilliant finding , as drugThis Special Issue had the purpose to gather a collection of articles that highlight some recent liposome applications, such as the development of stealth liposomes to aim for the placenta, the use of liposomes as vaccine adjuvants, the development of prodrugs to increase liposome encapsulation and specific targeting, the development of theranostic (therapeutics and diagnostics) liposomes, and the use of elastic and ultradeformable liposomes for topical use.One of the populations that can benefit from the use of drugs delivered in liposomes is pregnant women. However, to date, there are not enough studies on the pharmacokinetics and placental disposition of liposomes in this population. Fliedel et al.  presente® 09b. This system induces a type I interferon response and can be used as a pan-viral prophylaxis prior to the development and approval of specific vaccines. Intranasal administration of these liposomes to mice showed an improved immunological defense response to the Influenza virus if administered prior to infection.Zimmermann et al.  presenteKobanenko et al.  studied Analytical techniques for the characterization of liposomes are also highlighted in this issue. Skupin-Mrugalska et al.  used AF4Souto and co-workers  presente