The collaborative clinical simulation (CCS) model is a structured method for the development and assessment of clinical competencies through small groups working collaboratively in simulated environments. From 2016 onward, the CCS model has been applied successfully among undergraduate and graduate medical students from the Universidad de Talca, Chile; the Universität de Barcelona, Spain; and the Universidad de Vic-Manresa, Spain. All the templates for building the clinical cases and the assessment instruments with CCS were printed on paper. Considering the large number of CCS sessions and the number of participating students that are required throughout the medical degree curriculum, it is impossible to keep an organized record when the instruments are printed on paper. Moreover, with the COVID-19 pandemic, web platforms have become important as safe training environments for students and medical faculties; this new educational environment should include the consolidation and adaptation of didactic sessions that create and use available virtual cases and use different web platforms.The goal of this study is to describe the design and development of a web platform that was created to strengthen the CCS model.The design of the web platform aimed to support each phase of the CCS by incorporating functional requirements  and nonfunctional requirements  that are needed to run collaborative sessions. The software was developed under the Model-View-Controller architecture to separate the views from the data model and the business logic.MOSAICO is a web platform used to design, perform, and assess collaborative clinical scenarios for medical students. MOSAICO has four modules: educational design, students’ collaborative design, collaborative simulation, and collaborative debriefing. The web platform has three different user profiles: academic simulation unit, teacher, and student. These users interact under different roles in collaborative simulations. MOSAICO enables a collaborative environment, which is connected via the internet, to design clinical scenarios guided by the teacher and enables the use of all data generated to be discussed in the debriefing session with the teacher as a guide. The web platform is running at the Universidad de Talca in Chile and is supporting collaborative simulation activities via the internet for two medical courses: (1) Semiology for third-year students  and (2) Medical Genetics for fifth-year students .MOSAICO is applicable within the CCS model and is used frequently in different simulation sessions at the Universidad de Talca, where medical students can work collaboratively via the internet. MOSAICO simplifies the application and reuse of clinical simulation scenarios, allowing its use in multiple simulation centers. Moreover, its applications in different courses  support the automatic tracking of simulation activities and their assessment. Medical education has progressed toward student-centered learning approaches that allow students to have a more active role in their learning and the development of competencies compared with classic teacher-centered approaches -3. CliniThe CSCL environment empowers students to collaborate through technology, which positively influences their learning ,9. With The collaborative clinical simulation (CCS) model is a structured learning model for the acquisition and assessment of clinical competencies through small groups working collaboratively to design and perform in simulated environments supported by technology . CCS is An essential feature of the CCS model is its capability to support the collaborative design of CS cases, which applies to a large part of the medical curriculum. The cases are created for untrained medical students guided by a teacher. The process is based on what was learned in classroom sessions; it is an instance where students can learn collaboratively, integrating information in the construction of a clinical case while acquiring, reinforcing, and applying their knowledge and skills in a simulated clinical environment . The medFrom 2016 onward, the CCS model has been applied successfully among undergraduate and graduate medical students from the Universidad de Talca, Chile; the Universität de Barcelona, Spain, ; and theConsidering the large number of CCS sessions and the number of participating students that are required throughout the medical degree curriculum, it is impossible to keep a clean record when the instruments are printed on paper. Tracking simulation activity logs, scheduling simulation sessions, creating templates for assessment instruments, sharing patient data, monitoring the progress of students, and reusing clinical cases are impossible when the work is paper based. Moreover, managing all of the above information requires specialized software in order for a CS center to maintain systematized indicators, attendances, inventories, and simulation activity logs. A platform must support the management of a center with an emphasis on the teaching and learning processes with innovative tools for the collaboration between students and teachers.To give computer support to collaborative simulation activities with the CCS model, we developed MOSAICO, a web-based platform. This platform allows for the designing, performing, and assessing of collaborative CSs through small groups working collaboratively in simulated environments supported by technology. The web platform enables a collaborative technological environment where each group works independently, while connected by the internet, to design clinical scenarios guided by the teacher, perform in the simulated clinical scenarios, and use all data generated for discussing and closing their learning gaps in the debriefing session with the teacher as a guide. Considering the importance of tracking the progress of medical students adequately, the web platform was created to strengthen the CCS model , assist The benefits of using simulations and tracking the progress of students in health care, construction, engineering, aviation, natural resources, and the military are widely documented . The capThis paper aims to describe the MOSAICO web platform, which was created to facilitate and expand its application and track student progress across the curriculum.  To reach this goal, this paper reports on the requirements elicitation, design, and development process for implementing MOSAICO in the Faculty of Medicine of both the Universidad de Talca, Chile, and the Universität de Barcelona, Spain.The requirements elicitation was the first phase of the web platform development process. This phase is a critical aspect because it lays the foundation for all the subsequent project work, and it affects the success of the development project . The CCSIn order to complement the features and structure of the web platform, we interviewed the personnel involved in academic activities, such as medical professors, students, and support staff. The interviews were semistructured for each CCS phase, and each meeting was recorded and documented. For the requirements elicitation from academics, we used an ad hoc instrument to document and analyze all the requirements. Furthermore, we modeled each process workflow involved in the functional requirements by module  with the Business Process Model and Notation  standardThe documentation and analysis of the requirements to generate the web platform were divided into functional and nonfunctional. The functional requirements are the features that the web platform will be able to perform, such as schedule simulation, create a clinical guide, and design evaluation rubrics. Nonfunctional requirements describe how the web platform should behave, such as security, interoperability, and performance .The web platform was designed to support each phase of the CCS by incorporating the functional requirements needed to run collaborative sessions. In this way, the system comprised four modules: (1) educational design, (2) students’ collaborative design, (3) collaborative simulation, and (4) collaborative debriefing. Regarding the nonfunctional requirements, usability is essential to the design of functional interfaces  by consiOn the other hand, the platform needs to secure users’ authentication with different roles and permissions. Security and confidentiality are essential, since small groups of students need to generate clinical cases, which are monitored by an instructor, without the other students knowing the diagnosis. For the collaboration, all the interactions between students  can be achieved with the assistance of mobile devices . At the end of the simulation sessions , it is necessary to store the information on simulated clinical cases and the evaluations of both students and instructors as well as keeping records of collaborative debriefing sessions.After designing the web platform, we considered its development to include all the functional and nonfunctional requirements. The software was built under the Model-View-Controller architecture  to separA full-time bioinformatics engineer (JGD) and the lead of the biomedical informatics laboratory (SGM) designed and developed the web platform. They took 12 months to create the prototype and 6 months to make modifications during the pilot application. As of 2020, the pilot application is operative for undergraduate medical students at the Universidad de Talca in Chile.MOSAICO has four modules and three different user profiles: academic simulation unit, teacher, and student. These users interact under different roles in collaborative simulations. The academic simulation unit profile includes the platform administrator, who oversees user accounts, courses, supplies, and room settings; generates reports; and works collaboratively with a teacher in order to validate and schedule simulation sessions. On the other hand, the teacher profile generates clinical guidelines with differential diagnosis and supports the platform execution with medical students. Finally, the student profile participates in modules 2, 3, and 4, which involves designing, executing, and debriefing a clinical case in small groups, collaboratively see . The results of the functional requirements engineering process involved elicitation, documentation, and analysis , which wTo schedule CS sessions, the teacher requests the academic simulation unit through the educational design module where it is possible to create, edit, review, check status, and delete the request see . To creaIn an iterative process supported by MOSAICO, the teacher and the academic simulation unit can incorporate progressive changes, which might be necessary to complete the CS request see  adequateMOSAICO can track simulation activity logs of medical students, generating recorded activities ,32. TowaThe instructor divides the students into at least three small groups of 3 to 5 students, which are deployed to different rooms ,33. EachFor the collaborative design of a clinical case, MOSAICO provides standardized templates with all the required information. The students write down relevant information about the clinical case see A, includMedical students collaboratively design a clinical case by forming small groups in person—before the COVID-19 pandemic—at the Clinical Simulation Center, where one student writes the required information with the group’s consensus on the web platform. This year, with the COVID-19 pandemic, the semiology course in medicine is using MOSAICO to teach online academic activities. This web platform allows students to design a clinical case collaboratively via the internet while at home. One of MOSAICO’s strengths is that it allows communication between students in person or online through the web platform.Throughout the students’ collaborative design process, the teacher supervises and facilitates the design process through the web platform via the internet, providing advice, clarifying doubts, and guiding each group in the preparation of the short clinical case scenario  see Fig.Collaborative simulation is a face-to-face activity that is executed in a simulated clinical environment, which provides a controlled and safe environment for the acquisition of clinical skills -36. The All information is provided by the designer group as requested by the performer group when handling the patient inside the simulated room. The performer group may request laboratory results and exams, in images or video clips, and may visualize them on a desktop computer or mobile device. In parallel, the teacher controls the time and observes actions from a mirror room, ideally, and guides the designer group, which receives instructions through a hidden earpiece to help the performer group.The third group, the evaluator group, observes the development of the case and evaluates the performance of the performer group in a separate room using the evaluation guidelines and the structured Plus/Delta assessment strategy in MOSAICO. This enables participants to consider the “pluses”  and the “deltas”  in the web platform .For the last phase of the CCS session, MOSAICO offers a summary module with all the logged activities, assessments by peers and the teacher, and video recordings for the three simulated clinical cases. This module is specially adapted so that the teacher and students can perform a collaborative debriefing, where each case is discussed deeply by the design, performance, and scoring carried out in the three groups see . At the In this paper, a web platform, MOSAICO, is described in detail to facilitate the design, performance, and evaluation of collaborative clinical scenarios for medical students. MOSAICO was created to digitalize the collaborative simulation learning model that has been successfully applied for 4 years in the universities where the authors are based ,17. The The process of building a clinical case is a complex cognitive task. The students must work collaboratively to design a scenario representing a hypothetical clinical situation with enough fidelity to allow other students in a simulation phase to act collaboratively as a doctor team  to deduce a diagnosis and proceed to the medical actions. The designer group must coordinate to provide details like personal data, clinical history, laboratory or multimedia results, and vital signs to the performer group. According to simulation methodology, the last part of the session is used to analyze and discuss among all participants the experience and consequent relevant actions for solving the simulated situation in the real clinical practice. The teacher leads and stimulates reflection, allowing the students themselves to discover and assess their future behavior.In the collaborative designer module, MOSAICO enables tools for team collaboration, supporting positive interdependencies among the team’s members as well as the diversity and depth of their clinical knowledge . This isMoreover, it is essential to include technologies that will be used in real-world settings into educational CSs to better prepare students for clinical practice and to promote patient safety . In a reRecently at the CENS, we published a model of referential competencies in health information systems , which fIn this sense, MOSAICO is oriented to introducing electronic recording technologies and developing technological competencies in the curriculum of a medical faculty. Future employers expect new graduates to be competent in information technology use upon graduation. Students are often not given the significant educational opportunities needed to gain these competencies .Assessing collaboration in undergraduate education is complex and requires special dedication . How teaFor this reason, MOSAICO has the capabilities to maintain individual and group records of the simulated competencies, the assessments, and the detailed hours that each of the students had in the simulation center. This replicates the current aviation simulation models . BesidesThe collaborative debriefing module is vital for enhancing learning and participating successfully in group discussions, with all the elements registered in the web platform. In this MOSAICO module, both teachers and students give feedback to learners and assess their participation in the activities . Only 41The COVID-19 pandemic has significantly affected teaching within health career programs ,43; studMOSAICO is growing; the next version  should include more tools for the administration of simulation centers, modules for academic reports and supplies, different specialties , and improvement of the interoperability for the export of cases between different platforms or institutions.During this online academic semester, MOSAICO is being evaluated by both teachers and medical students of the Universidad de Talca. For the evaluation, we are applying the mobile health  App Usability Questionnaire (MAUQ)  to evaluThe platform, which works on computers or mobile devices, is only available in Spanish. The next version will support both English and Spanish languages. MOSAICO supports a collaborative clinical session with three small groups composed of 3 to 5 students each. It does not allow the incorporation of another group in the same session, making it necessary to create another session if four or more groups are needed.MOSAICO was implemented online and is still currently being used correctly with different simulation sessions at the Universidad de Talca, Chile, where medical students work collaboratively connected by the internet. Both students and teachers have excellent comments about the use of the web platform. An essential strength of the platform is that it is possible to use it in face-to-face sessions or online via the internet without modifications.The web platform supports all the stages of the CCS model satisfactorily, and the teachers use MOSAICO as technological infrastructure to schedule, design, and execute the simulation activities. Moreover, it allows for the teaching of clinical activities throughout the COVID-19 pandemic while the university campus is closed for student safety.The use of the web platform simplifies the application and reuse of CS scenarios, permitting its use in multiple simulation centers. Moreover, its applications in different courses  support the automatic tracking of simulation activities and their assessment.MOSAICO could allow research to be conducted between different simulation centers by standardizing the information, structure of clinical cases, and assessment instruments. This is important in comparative studies and in research regarding medical students’ learning.


As China experiences rapid aging, the mental health of older rural adults has become a major public health concern. Among other social insurance programs, the New Rural Social Pension (NRSP) scheme was established to replace part of the income for old-age rural residents in China. This article employs survey data from the China Health and Retirement Longitudinal Study (CHARLS) in 2015 and 2018 to investigate the impact of a pension on depression in middle-aged and old residents. Our results show that the pension scheme not only reduces the depressive symptoms of the rural residents but keeps down the prevalence rate of depression. Among the subscribers of the pension scheme, the pensioners benefit more from enrolling in the pension scheme than the contributors in terms of depression alleviation. The impact of pension on depression displays heterogeneity; female residents, residents in central China, and/or those from lower income households are found to be positively affected. It is also confirmed that a pension scheme contributes to easing depression via reduced labor supply, better family support, and more consumption expenditure.JEL Classification: H55, I18, I38. Due to improved medical conditions, higher living standards, and a declining birth rate, accelerated aging around the globe seems to be unavoidable. Among all the major countries, China especially is experiencing a rapid process of population aging. According to the seventh national census of China, the population of those above 60 and 65 reached 264.02 and 190.64 million in 2020, taking up 18.7 and 13.5% of the total population, respectively. The proportion of the aged in the total population is expected to surge in the coming decades.What makes the situation worse are the significant socioeconomic changes accompanying rapid economic growth in China. China used to be a dichotomous society where the urban and rural areas were different in many aspects, such as income level, social support systems, etc. . When inDepression was found to be closely associated with numerous undesirable consequences . It alsoCorrespondingly, much research has been carried out to identify the determinants of depression. Factors which could have a significant impact on depression can generally be classified into several groups. The first category of determinants are demographic characteristics, such as gender, age, education level, and income level –11 find In 2009, the Chinese government launched a new social pension scheme for rural residents. This program was designed to provide income for old-age rural residents, but it may bring other effects as well. Specifically, its impact on elder residents' depression needs to be examined. If it is found to positively impact mental health, the pension scheme should be further consolidated to strengthen the function.Even though most studies supported a positive correlation between pension scheme and mental health , 28, 30,Using a national survey database and a 10-questions version of the Center for Epidemiologic Study depression (CES-D) battery to gauge the extent of depressive symptoms, this article confirmed that the subscribers of the pension scheme, especially the pensioners who are eligible to receive benefit but do not need to contribute any longer, have fewer depressive symptoms and less incidence of depression than the contributors who are not eligible to receive benefit yet but suffer from the burden of paying the premiums. This effect is heterogeneous among populations with different characteristics, and work through some mediators, such as labor supply, family support, and consumption expenditure.This article is organized as follows: section 2 presents a brief introduction about the background of rural social pension scheme in China, section 3 introduces the methodology and data, section 4 displays the empirical results, section 5 identifies the mechanism of the effect of pension, and section 6 gives the conclusive remarks.After several failed trials, the State Council of China initiated a new round of rural pension system reform and established a new scheme called the New Rural Social Pension (NRSP) scheme in 2009. According to the design of the scheme, the pension fund will be contributed to by the subscriber, the employer, and the local and central government. The reform was first launched in 320 pilot counties; afterward, the scheme was extended to all the counties around the country by the end of 2012. NRSP was incorporated into an urban residents' pension scheme and renamed as Urban-Rural Resident Social Pension (URRSP) in 2014Compared with developed countries, the pension benefit is inappreciable in its amount. But the significance of the pension benefit should be better evaluated by its share in the net income of the subscribers. When the share is relatively high, the subscribers will have a stronger feeling of been protected financially, and their worries about their financial situation in old age will be greatly reduced. According to a survey in 2009 when the policy was formulated, the 660 yuan basic benefit of pension took up 8–30% of the net income for the rural old adults ranging 60–75. The average was about 15%, and the pension benefit became more and more important as the total net income declined with old age.http://charls.pku.edu.cn/.Even though the issue of depression in China has been investigated in the literature, most previous studies employed regional data which only reflected the situation in a specific area, and usually the volume of data was small. This article employs data from a large-scale national survey, the China Health and Retirement Longitudinal Study (CHARLS), to conduct the research. The CHARLS survey was directed by the National Development Academy of Peking University, and aimed to investigate older adults above 45 and their families. The survey was initiated in 2011, then three follow-up surveys were carried out in 2013, 2015, and 2018. Due to the scientific sampling methods and the large volume of sample size, CHARLS data was widely acknowledged and used in many previous literature to examine the health status of older adults in China, such as in Lafave  and Lei The dependent variables included in our research are the extent of depressive symptoms and the incidence rate of depression. The Center for Epidemiological Study Depression Scale (CES_D) was used to gauge the mental health of the respondents in the CHARLS questionnaire. CES_D was widely used in the field of mental health study and its validity and reliability were confirmed for the Chinese population . The scaThe core explanatory variable used in our regression is whether the respondent is a subscriber of NRSP. If the answer is positive, value 1 is assigned, otherwise 0 is assigned. Furthermore, considering different states of the subscribers, they are further classified as contributors and pensioners, and assigned to 0 and 1, respectively.With reference to previous literature –10, 29, This article employs panel data from the CHARLS data base to examine the impact of social pension scheme on the rural older adults' depression; the econometric model is constructed as follows:Yit represents the CES_D score for respondent i in year t (t = 2015 or 2018) and Yit measures the respondent's depression level. The higher the score is, the worse the mental health will be. pnsionit is a dummy variable to indicate whether the respondent is enrolled in the pension scheme. Zit is a vector of covariates including gender, age, marital status, chronic illness, average income of household members, education level, self-reported health status, etc. αi is the individual effect which does not change with time, while αt is the year fixed effect. μit is a random disturbance term. Coefficient β0 is the focus of our study, it will reveal the impact of pension on severity of depressive symptoms. In the estimation of panel data, both fixed and random effect models will be employed, and the final model will be determined by the results of a Hausman test.where To test the robustness of the previous regression results, the respondents are classified into two groups according to their CES_D score: those with CES_D score over 16 are considered as depressed and assigned to value 1, while those with CES_D score below 16 are considered as non-depressed and assigned to value 0. A Logit model is used for estimation.Endogeneity is a major problem for this research because there may be some factors which affect both the dependent variable and explanatory variables and make the explanatory variables not independent of the error term , 39. If This article explores the heterogeneous impacts of pension on depression in different subsamples according to region, gender, and income level. Furthermore, mediating effects are examined to identify the mechanism through which the enrollment of pension impacts depression; several important functioning channels are identified. These results not only contribute to theoretical understanding about the role of pension schemes in alleviating depression for rural residents, but will provide more policy implications.p < 0.01) support the adoption of the fixed effect model. Thus, only the estimation results of the fixed effect model are reported in Both fixed and random effect models are estimated, but the Hausman test results  and pensioners , the regression results in column 2 show that only the pensioners benefit from the depression relief effect of pension, the coefficient of contributors is also negative, but statistically insignificant.According to As stated previously, we follow Weissman et al.  to classFixed effect model estimation is accountable for the latent factors which do not vary with time, but there still may be latent factors changing with time, or the reverse impact running from mental health to enrollment in a pension scheme may exist. It means that the endogeneity problem should not be neglected. This article employs the instrumental variable (IV) method to solve the problem.Considering that individual decision may be affected by his/her various traits, the individual enrollment decision and depression could be mutually affected, and endogeneity problem arises. This article uses the take-up rate of NRSP of the respondent's community as an IV because the take-up rate of the community, which is usually a function of policy implementation, the strength of public finance of local government, the reputation of local government, etc., is usually positively correlated with the possibility of an individual's enrollment, while personal depressive status will not have any impact on the take-up rate of the community, which makes the take-up rate a qualified IV.To further ensure the robustness of the estimation, standard errors are clustered at the individual level within all the regressions of this article.Many previous studies identified that mental health differs among different sex groups , 42, andChina is a large country where the regional disparity is remarkable. The impact of NRSP on depression may also vary across different regions. Following many precedents in literature on regional economics, the whole territory of China is divided into three sections, namely Eastern area, Central area, and Western area, to explore the differences among these regions. From the results in The results in As was stated before, mental health may be affected by various factors. At the same time, NRSP not only provides a certain amount of income to the qualified subscribers, as part of the social security net, it also contains multiple derivative functions. It was expected that enrollment in NRSP may contribute to residents through various channels.The first channel could be the reduced labor supply. For rural residents, the concept of retirement is very vague, and most of them do not have a fixed retirement income other than pension income, so most of them have to work in their old age as long as their physical health permits . It was The second channel could be improved family relations. As documented in literature, social support was vital for people's mental health , and famThe third channel is increased consumption expenditure. The anxiety or feeling of deprivation would be magnified in individuals with experiences of unmet needs . PensionFollowing Baron et al. , the medIt is shown that enrollment in a pension scheme is negatively associated with labor supply at 10% significance level [see column (1), Regression results tested for family relation as a dependent variable in column (2). Similarly, enrollment in a pension scheme (as contributors and/or pensioners) is identified to promote the respondents' mental health (lower CES_D score) through higher consumption in This article employs China Health and Retirement Longitudinal Study (CHARLS) data in 2015 and 2018 to investigate the effectiveness of pension enrollment on mitigating depressive symptoms. The Center for Epidemiological Study Depression Scale (CES_D) was used in the survey to measure the extent of depressive symptoms. To test the relation between our interested variables, various econometrics models are used to achieve cross-validation, and an instrumental variable is adopted in regression to mitigate the endogeneity problem. Results show that the enrollment in NRSP, especially for pensioners, is negatively correlated with level of depressive symptoms. Enrollment in NRSP may also contribute to lower prevalence rates of depression. Respondents who are married, with better physical health, or with higher education are found to have better mental health, while those enrolled in a social basic medical insurance program or with chronic illness are found to have worse depressive symptoms.When we classify the sample into different groups, heterogeneity emerges. Enrollment in a pension scheme is identified to have a significant effect for female rural residents, rural residents in Central China, and/or of low-income households.As a part of a social security net, NRSP is mainly designed to provide income in old age; mitigation of depressive symptoms might be just a “by-product,” but it is interesting to find that this function works well and is socially beneficial. Further study shows that there are at least three channels through which enrollment in a pension scheme  contributes to better mental health: labor supply, family relations, and consumption expenditure.Our results contain abundant policy implications. For instance, public finance should contribute more to rural pension funds and increase the standard of pension benefit, which will not only strengthen the social security net for rural residents, but reduce the costs associated with depression. The effect of pension scheme on mitigating middle-aged contributors' depressive symptoms might be strengthened through relief of individual burden on paying premiums, so various financial sources should be channeled to achieve that. Female rural adults and low-income groups should be subsidized for the premiums to increase the take-up rate of pension schemes, so that the depressive symptoms or prevalence rate of depression for the disadvantaged will be reduced.http://charls.pku.edu.cn/.Publicly available datasets were analyzed in this study. This data can be found at: GP designs the research and leads the research group, SL processes the data and writes the early draft of the article, ZG helps in modeling and drafting. KZ helps in developing the research idea, acquiring the data, and contributing some intellectual contents to the draft. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Chronic constipation is a common gastrointestinal disorder in older adults, and it is very important to manage chronic constipation. However, evaluating these subjective symptoms is extremely difficult in cases where patients are unable to express their symptoms because of a cognitive or physical impairment. Hence, it is necessary to observe the patient’s colonic faecal retention using objective methods. Ultrasonography observation for colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Since there was no standard protocol for interpreting rectal ultrasonography findings, we developed an observation protocol through an expert consensus. We convened a group of experts in the diagnosis and evaluation of chronic constipation and ultrasonography to discuss and review the current literature on this matter. Together, they composed a succinct, evidence-based observation protocol for rectal faecal retention using ultrasonography. We created an observation protocol to enhance the quality and accuracy of diagnosis of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in ultrasound or the diagnosis of chronic constipation. Chronic constipation is a common gastrointestinal disorder in older adults. Chronic constipation occurs in 16% of adults, with higher rates in older patients . MoreoveThe Rome IV criteria categorise disorders of chronic constipation into four subtypes: (a) functional constipation; (b) irritable bowel syndrome with constipation; (c) opioid-induced constipation; and (d) functional defaecation disorders, including inadequate defaecatory propulsion and dyssynergic defaecation . FunctioDiagnostic tests are typically recommended for constipation to evaluate the rectum and colon include plain abdominal X-ray (radiography), barium enema, colonoscopy, defaecography, abdominal computed tomography and magnetic resonance imaging ,9,10. HoThe US observation of colonic faecal retention is useful for diagnosing constipation and evaluating the effectiveness of treatment. Manabe et al. ,14 reporA hyperechoic area shaped like a half-moon on a US reflects faecal retention in the rectum. Furthermore, an acoustic shadow on the crescent-shaped hyperechoic area in the US reflects hard stool retention. Tanaka et al. reported that 100% of older adult patients with a half-moon shape in the rectal hyperechoic area had a decreased frequency of defaecation and 92.9% of older adult patients with an acoustic shadow on the crescent-shaped hyperechoic area had hard stools. Several previous studies in children also support the use of rectal US in diagnosing constipation ,19,20. HOur aim was to create an observation protocol to enhance the quality and accuracy of diagnoses of chronic constipation, especially rectal constipation. This consensus statement is intended to serve as a guide for physicians, laboratory technicians and nurses who do not specialise in US or the diagnosis of chronic constipation. For a narrative review of the current literature in this area, we convened a group of gastroenterologists, sonographers, nurses and a wound, ostomy and continence nurse (WOCN) with expertise in the diagnosis and evaluation of chronic constipation and US. The criteria for the selection of the members were as follows: (1) research achievements on the evaluation of constipation via US in Japan; or (2) being the president of an academic society with high expertise in the diagnosis, assessment, treatment and defaecation care of constipation. From July to October 2020, online working group meetings were conducted once a month  to create the content of the consensus. Subsequently, another meeting was conducted for the entire membership to reach a consensus. Following discussion and agreement, they composed a succinct, evidence-based observation protocol for rectal faecal retention using US. The content of this consensus document was presented at the 22th meeting of the Japanese Society of Neurogastroenterology in Tokyo, Japan, on 20 November 2020, and a final version was developed after further discussion and agreement.The target population for this US observational protocol is individuals with suspected constipation. Subjects who can be interviewed are evaluated for suspected constipation according to the Rome IV diagnostic criteria . For subIt is preferable to perform US observation, when there is urine retention in the bladder (since the bladder can be used as an acoustic window), when the patient does not eat immediately prior to the exam  and when there is no gas retention in the abdomen.The patient should be supine and should be comfortable. The head should be propped at about 10 degrees, with a bath towel or cushion placed under the neck to relieve tension in the abdomen, and the knee joints should be gently flexed.A convex probe should be selected for the US, preferably with a bandwidth of 2–5 MHz in frequency. The required resolution is based on the following two conditions: (a) the bladder can be depicted as an anechoic area with a few multiple reflections; and (b) the boundaries and edges of the tissue can be depicted uniformly . In addition to the US device, the procedure requires echo jelly, hand towels and tissue paper for wiping off the jelly and the blanket.In both transverse and longitudinal scans, the US probe is placed at the superior border of the pubic bone, and the US beam is tilted caudally 10–30 degrees to visualise the bladder . The blaWhen there are contents  in the rectal lumen, US waves are reflected from the surface of the contents at a depth deeper than the bladder (anechoic area) and a hyperechoic area with a half-moon shape is depicted in the transverse US image A. In addThe longitudinal US image can show the location and amount of rectal faecal retention. For example, the longitudinal image can be used to determine whether the faecal retention is in the upper or lower rectum. Paradoxical diarrhoea needs to be differentiated in US findings ,24. FaecObesity, the lack of urine in the bladder and gastrointestinal gas are factors that make US observation difficult. It is believed that the increased thickness of the abdominal wall due to obesity causes attenuation and scattering of the US beam, affecting the image quality when viewing the bladder and deep tissue . Figure When observing rectal faecal retention by transabdominal US is difficult due to any of the above reasons, the intergluteal cleft approach is effective . PatientThere are several issues we need to address in the future. The first is image quality adjustment for US devices. The images presented in this article are from both portable and high-end devices, and there is no consensus on how image quality should be adjusted. The second issue is gas discrimination. As in previous studies ,14, gas This consensus document has some limitations. First, its content was not compiled through a systematic review. Just as previous studies have validated the efficacy of surgery for chronic constipation ,33, futuAn expert consensus has been reached on the use of US by multidisciplinary teams to observe rectal faecal retention, evaluate constipation and select appropriate treatment and care. This consensus statement outlined a standard procedure for using US to observe the presence, properties, location and volume of rectal faecal retention.


Thoracic surgery is the main surgical method for the treatment of respiratory diseases and lung diseases, but infections caused by improper care are prone to occur during the operation, which can induce pulmonary edema and lung injury and affect the effect of the operation and the subsequent recovery. Therefore, it is necessary to control the disease in time and adopt more scientific and comprehensive nursing measures. Based on the neural network algorithm, this paper constructs a neural network-based factor analysis model and applies the operating room management nursing to postoperative infection nursing after thoracic surgery and verifies the effect through the neural network model. The statistical parameters in this article mainly include the postoperative infection rate of thoracic surgery, patient satisfaction, postoperative rehabilitation effect, and complications. Through statistical analysis, it can be known that operating room management and nursing can play an important role in postoperative infection nursing after thoracic surgery, effectively reducing postoperative infection nursing after thoracic surgery, and improving the recovery effect of patients after infection. Nosocomial infection (NI) is also known as hospital-acquired infection. It refers to infections acquired by hospitalized patients in the hospital, including infections that occurred during hospitalization and infections acquired in the hospital after discharge, but does not include infections that have begun before admission or existed at the time of admission. Nowadays, with the development of medical science; the advancement of medical technology; the development of radiotherapy and chemotherapy for malignant tumor diseases; the popularization and application of invasive treatment; the widespread and universal use of immunosuppressants, cytotoxic drugs, and antibacterial drugs; and the morbidity and mortality of the disease itself have been significantly reduced, but nosocomial infections have always existed .Thoracic surgery can disrupt the central nervous system of the body due to the long operation time, large trauma of the patient, and residual anesthetic drugs in the operation, resulting in postoperative discomfort for the patient. Moreover, patients have varying degrees of restlessness and confusion, and severe cases may lead to various accidental injuries, such as incision dehiscence, various catheters falling off, and bed falling, which affect the patient's smooth recovery from general anesthesia . Second,In the hospital quality management system, the operating room quality management is one of the important management systems. All types of surgery, treatment, and emergency rescue of surgical patients are carried out in the operating room, so the operating room is more demanding than the quality management of the outpatient and inpatient areas. Furthermore, since the operating theatre entails a high level of risk and complexity, its quality management is linked not only to the lives of surgical patients but also to the quality of surgical output services .At present, China has taken various preventive measures to prevent the occurrence of nosocomial infections and established a nationwide nosocomial infection monitoring system to monitor the status of nosocomial infections, effectively reducing the incidence of nosocomial infections. However, adverse events caused by hospital infections still occur from time to time.Regarding the monitoring and control of nosocomial infections, we can use different methods to measure the intensity of nosocomial infections. There are also many risk factors that cause nosocomial infections, such as the research objects used for comparison and reference, the control of confounding factors, and the difference in the length of hospital stay . As a reThis paper constructs a factor analysis model based on neural network algorithm and applies operating room management nursing to postoperative infection nursing after thoracic surgery. Furthermore, this paper uses a neural network model to verify the impact, and it serves as a reference for postoperative infection nursing in thoracic surgery.Nosocomial infection monitoring refers to long-term, systematic and continuous observation, collection and analysis of the occurrence, and distribution of nosocomial infections in a certain population and its influencing factors, and the monitoring results are reported and fed back to relevant units and individuals. Moreover, it is the basis and basis for the prevention and control measures of nosocomial infection. Nosocomial infection monitoring can provide data to assess the size of the problem, determine the risk factors of nosocomial infection, provide effective control methods for high-risk patients, or evaluate the effects of preventive measures . The ultComprehensive monitoring is to monitor the nosocomial infections and related influencing factors of all inpatients and staff in the whole hospital from many aspects to understand the occurrence of nosocomial infections in the whole hospital, which requires a lot of time and human resources. As early as 1970, at the first international infection conference held in the United States, the importance of nosocomial infection surveillance was raised by people. After formulating the infection control plan, the United States took the lead in establishing the world's first nosocomial infection surveillance system, the National Nosocomial Infection Surveillance (NNIS). By 2000, 315 hospitals had joined the NNIS.Various nations' nosocomial infection surveillance systems conduct surveillance with different foci based on the epidemiological features of nosocomial illnesses in their respective countries. However, the majority of them, such as the NNIS system, can explain the epidemiology of nosocomial infections, antibacterial drug resistance, quantify the frequency of nosocomial infections, and conduct hospital comparisons .Nosocomial infections in thoracic surgery are mainly the respiratory tract, accounting for about 64.82% . There aAccording to the findings of the literature , urinarySurgery site infection (SSI) is one of the most common complications after surgery. Thoracic surgery has large surgical wounds and more invasive procedures, and most of the illnesses are critically ill, and the probability of SSI is high. SSI refers to infections that occur in the deep organs or cavities of the incision or surgery during the perioperative period. It includes ① superficial surgical incision infection: it is limited to the skin and subcutaneous tissue involved in the incision, and the infection occurs within 30 days after surgery. ② For infection of deep surgical incision, it occurs 30 days after surgery without implants and within 1 year after surgery with implants . It is a surgical infection that affects the incision's deep soft tissues (deep fascia and muscle). ③ For organ (or cavity) infection, it occurs 30 days after surgery without implants and within 1 year after surgery with implants . It is an infection of organs or cavities related to surgery  .Isolation of pathogenic bacteria based on pathogenic specimens submitted by hospital-infected patients can understand the distribution and trend of pathogenic bacteria causing hospital infections and help doctors choose antibacterial drugs reasonably. At present, most of the pathogens causing nosocomial infections in thoracic surgery patients are Gram-negative bacilli, followed by Gram-positive cocci and fungi. The distribution composition ratio of pathogenic bacteria varies slightly with the investigation hospital. Among them, the main ones are Pseudomonas aeruginosa, Staphylococcus aureus, and Candida albicans .Malnutrition is often linked with cancer patients. All components of the immune system may be harmed when a patient is malnourished, and the intensity of the effect is generally equal to the severity of the malnutrition. When patients are malnourished, nosocomial infections are common . This isThe rate of nosocomial infection caused by diabetes and the mortality rate of nosocomial infection are very high, respectively, 20.63% and 1.68% . Zhao YuRBM is generally only suitable for processing binary data. Therefore, many scholars later proposed a series of RBM variant algorithms to process real-valued data, such as Gaussian RBM (GRBM), covariance RBM (cRBM), mean and covariance RBM (mcRBM), and spike and flat RBM (ssRBM).GRBM is the earliest proposed RBM variant model for modeling real-valued data. It regards the visible layer unit of traditional RBM as a Gaussian variable with diagonal covariance. In this way, the energy function of GRBM is redefined as:σi2 represents the variance term on the i-th visible layer unit. Then, when any one of the visible and hidden layers in GRBM is in a fixed state, the conditional probability distribution of the other layer can be calculated:Among them, P(vi|h) can be expressed in terms of N; that is, it conforms to a Gaussian distribution with mean σi∑jWijhj + ci and variance σi2. In this way, when GRBM uses the CD algorithm to train the network model, the gradient of the parameter {W, b, c, σ} can be expressed as:Among them,Wj represents the column vector of the j-th column of the matrix W, and α and Λ are diagonal matrices, which are used to punish the larger values in the ‖s‖22 and ‖v‖22 terms, respectively. Then, the conditional probability distribution in ssRBM can be expressed as:Among them, N represents a Gaussian distribution with mean μ and variance σ2, and ‖v‖ ≤ R in P represents rejection of sampling when ‖v‖ is too large.Among them, RBM is a generative model, and data generation also helps to denoise data, such as Point-wise Gated RBM (pgRBM) and Robust GRBM . As shown in The pgRBM network has three levels: a visible layer, a conversion layer, and two hidden layers, as illustrated in h1 represents a hidden layer related to classification, and h2 represents a hidden layer not related to classification. Then, the conditional probability distribution in pgRBM can be expressed as:Among them, Unlike traditional RBM, the initial value of pgRBM is not randomly generated. After the network weights obtained by RBM learning (the number of hidden layer nodes in RBM is slightly larger than the sum of the number of hidden layer nodes in pgRBM), it then uses the feature selection method to determine the contribution of the hidden layer nodes to the classification based on the label of the sample to determine the initial value of the pgRBM network weight.P > 0.05), and all patients must have thoracic surgery following diagnosis. All members of the ethics committee gave their approval to this inquiry. Both patients and their families were aware of this survey and volunteer to participate. Inclusion criteria are the following: patients who take part in the survey are aware of it and consent to it, they are all patients who need thoracic surgery, and they do not have any cognitive or mental disorders. Criteria for exclusion are the following: patients or family members are aware of the survey but refuse to take part because they have cognitive or mental disorders. The control group was given routine nursing operations.The study selected 124 patients undergoing thoracic surgery in the undergraduate room as the subjects of this survey. The selected time for the survey was from January 2019 to December 2020. The patients participating in the survey were divided into two groups by lottery, the control group and the test group, and the number of patients in each group was 62. In the control group, there are 30 males and 32 males, and they are 33-65 years old, with an average of 49.6 ± 4.5 years old. There are 29 male and 33 male patients in the test group, and the age ranged from 33 to 66 years old, with an average of 49.2 ± 4.5 years old. Moreover, all patients had 28 cases of education below junior high school, accounting for 35.90%. There is no statistically significant difference in general information between the control group and the test group  Before the operation, the nursing staff should strengthen the understanding of the patient's specific information, and according to the understanding of the patient, ensure that the patient has a good mood and actively cooperate with the treatment. The specific nursing method is to understand the basic information of the patient in detail, conduct a comprehensive analysis of the patient's condition, and explain in detail the problems and precautions that may be encountered during the operation, so that the patient has a scientific and comprehensive understanding of the disease. Furthermore, medical personnel aggressively encourage patients and inform them about successful instances in order to instil faith in the disease's cure and urge patients to actively participate in therapy. At the same time, it is necessary to ensure that the operating room environment is quiet and tidy, and the temperature is appropriate to keep the patient nervous. (2) After entering the room, the nursing staff should inform the operation procedure and strengthen communication with the patient at the same time. The particular nursing technique is to expose the patient to the operating room atmosphere, massage the patient's limbs, and say something calming to the patient to alleviate the patient's stress. At the same time, it is necessary to pay attention to the patient's expression during the whole process and deal with it in time. During the operation, it is necessary to strictly carry out the correct operation and sterility awareness, pay close attention to the changes in the patient's vital signs and mental state, and find and deal with the accidents that occur during the operation as soon as possible. (3) After the operation, the relevant nursing staff strengthened the prevention and control of lung infection. The specific nursing measures are to closely monitor the patient's vital signs and lung function to prevent abnormal conditions. Moreover, it is necessary to actively guide the patient's diet, etc., and instruct the patient's diet to gradually transition from water to liquid food and then to a normal diet. In addition, nurses need to help patients knock their backs on time, instruct patients to breathe properly, keep patients' airways unobstructed, inform patients that smoking is strictly prohibited, and ask patients' families to pay attention to patients' emotional state, keep warm, and actively encourage patients.The control group's patients were all given standard treatment initially. At the same time, it is essential to pay attention to the signs and keep track of them, educate patients about key things to remember before and after the surgery, help the doctor in finishing the procedure, and securely transport the patient to the ward. Forty patients in the test group were given high-quality nursing care in the operating room on the basis of routine nursing. The main nursing measures are as follows. First of all, preoperative high-quality nursing patients will be evaluated in their psychological and physical aspects after admission to learn more about the patient's medical history and provide targeted care plans. If the patient has a history of smoking, it is necessary to introduce the hazards of smoking and cooperate with the doctor to instruct them to quit smoking. Simultaneously, patients must be encouraged, their reasons of illness and treatment methods explained, typical instances of successful surgery shown, and their faith in the operation's success boosted. The patient's transfer procedure must be gentle, with little turbulence, and keep the patient warm in order to provide high-quality intraoperative care. If necessary, a scarf can be placed around the patient's neck, and the patient's quilt can be removed when the doctor is preparing for disinfection. In addition, it is necessary to provide patients with a high-quality environment during the operation as much as possible. The laminar flow unit is turned on half an hour before the operation to purify the air in the operating room, and various disinfection tasks are strictly carried out. In high-quality postoperative care, the patient needs to be in a semirecumbent position after anesthesia is sober and blood pressure stabilizes. Moreover, it is necessary to help patients turn over and pat their backs every 2 hours, encourage and help patients cough and expectorate, and instruct patients to protect their hands when coughing to relieve pain. At the same time, it is necessary to help patients perform deep breathing exercises to ensure unobstructed airway, increase lung capacity, promote lung expansion, improve lung function, and closely monitor patients for lung infections. In addition, it is necessary to pay attention to whether the patient has new coughs, the frequency of coughs, and changes in the nature of sputum.This article analyzes the application of operating room management in postoperative infection care after thoracic surgery through the above test analysis and combines the deep neural network analysis model to perform data processing. The statistical parameters in this article mainly include the postoperative infection rate of thoracic surgery, patient satisfaction, postoperative rehabilitation effect, and complications. The research results are statistically studied.The test group's and control group's postoperative infection rates were calculated, and the results are presented in The use of operating room management nursing in postthoracic surgery infection nursing may successfully decrease the postthoracic surgery infection rate, according to the statistical analysis of the above trials. Afterwards, the postoperative patient satisfaction of the test group and the control group was counted. The results obtained are shown in From the statistical analysis of the above experiments, we can see that the application of operating room management nursing in postoperative infection nursing after thoracic surgery can effectively improve patient satisfaction. After that, the rehabilitation effects of postoperative patients in the test group and the control group were calculated. The results obtained are shown in The use of operating room management nursing in postoperative infection nursing after thoracic surgery may significantly enhance the postoperative rehabilitation impact, according to the statistical analysis of the above trials. Afterwards, the postoperative complications of the test group and the control group were counted. The results obtained are shown in From the statistical analysis of the above experiments, it can be seen that the application of operating room management nursing in postoperative infection nursing after thoracic surgery can effectively reduce the occurrence of postoperative complications in patients.In summary, operating room management and nursing can play an important role in postoperative infection nursing after thoracic surgery.The number of patients admitted to the operating room has shown an upward trend year by year. From an environmental point of view, the operating room is a special place where surgical treatment is concentrated, and it is more prone to cross-infection compared with conventional wards. Among them, surgical wound infection is a relatively common complication in surgical patients. Wound infection will directly affect the patient's treatment time and bring certain effects to the patient. Effective clinical nursing for patients during surgery can promote the prognosis of patients, increase the recovery speed of patients, and reduce the occurrence of postoperative complications. Moreover, the application of human-centered nursing and comfort nursing in operating room nursing can improve the overall nursing effect. Comfort care is primarily concerned with providing nursing services to patients based on their current circumstances and reducing the development of problems via excellent psychological and physical nursing. In addition, in the nursing process, it is necessary to adhere to the people-oriented approach, try to meet the needs of patients, and improve the quality of nursing.


Newborn screening (NBS) is a group of tests that check all newborns for certain rare conditions, covering several genetic or metabolic disorders. The laboratory NBS is performed through blood testing. However, the conditions that newborn babies are screened for vary from one country to another. Since NBS began in the 1960s, technological advances have enabled its expansion to include an increasing number of disorders, and there is a national trend to further expand the NBS program. The use of mass spectrometry (MS) for the diagnosis of inborn errors of metabolism (IEM) obviously helps in the expansion of the screening panels. This technology allows the detection of different metabolic disorders at one run, replacing the use of traditional techniques. Analysis of the targeted pathogenic gene variant is a routine application in the molecular techniques for the NBS program as a confirmatory testing to the positive laboratory screening results. Recently, a lot of molecular investigations, such as next generation sequencing (NGS), have been introduced in the routine NBS program. Nowadays, NGS techniques are widely used in the diagnosis of IMD where its results are rapid, confirmed and reliable, but, due to its uncertainties and the nature of IEM, it necessitates a holistic approach for diagnosis. However, various characteristics found in NGS make it a potentially powerful tool for NBS. A range of disorders can be analyzed with a single assay directly, and samples can reduce costs and can largely be automated. For the implementation of a robust technology such as NGS in a mass NBS program, the main focus should not be just technologically biased; it should also be tested for its long- and short-term impact on the family and the child. The crucial question here is whether large-scale genomic sequencing can provide useful medical information beyond what current NBS is already providing and at what economical and emotional cost? Currently, the topic of newborn genome sequencing as a public health initiative remains argumentative. Thus, this article seeks the answer to the question: NGS for newborn screening- are we there yet? Newborn screening (NBS) is a group of tests that check all newborns for certain rare conditions. This program covers several genetic or metabolic disorders, physical or functional, that affect the lives of newborns in one way or another. Most of these disorders may be without clear symptoms, but, in the long term, they may affect the infant’s life if left undiagnosed and untreated. Therefore, the goal of the early detection program is to identify these disorders in their infancy and programs for management and control for them are prepared to save the lives of those newborns.NBS includes heel prick and urine samples for laboratory testing, a hearing screen and pulse oximetry. However, the conditions that newborn babies are screened for vary from one country to another.The metabolic disorders are broadly classified into three parts: amino acid disorders, organic acid disorders and fatty acid disorders. In addition, various conditions are listed within each part. Amino acid disorders are caused by one of three events: enzymes that aid in the breakdown of specific amino acids fail to operate, enzymes that assist the body in excreting nitrogen contained in amino acids are unable to do so, or cofactors essential for these enzymes are not functioning. Subsequently, toxic levels of these precursors increase in the body, causing illnesses of varying degrees. Maple Syrup Urine Disease (MSUD) and Phenylketonuria (PKU) are two examples of aminoacidopathies .Fatty acid disorders are caused by the malfunction of enzymes that help in converting fat into energy. When the body runs out of glucose (primary source of energy), fat must be used to supplement the creation of energy. The cells of the body suffer from an energy crisis when they do not have any glucose to convert and cannot use fat, which can lead to coma or death. Two examples of this type of disorder are medium-chain acyl-CoA dehydrogenase (MCAD) deficiency and very-long-chain acyl-CoA dehydrogenase (VLCAD) deficiency.The third part is disorders of organic acid metabolism, characterized by the inability of an enzyme to break down amino acid, lipid or sugar intermediates. Toxic acids build up in the body when these compounds are not broken down, and, if not treated properly, these problems can lead to coma or death in the first month of a newborn’s life. Two examples of this category are glutaric academia type I (GA-I) and isovaleric academia (IVA).The challenges raised by laboratory NBS and future technological advances are highlighted as it is attempted to maintain the success of NBS in the 21st century.Laboratory NBS began as a blood test administered shortly after birth to prevent intellectual disability caused by untreated PKU, a rare, hereditary metabolic disorder in which affected individuals are unable to metabolize the amino acid phenylalanine, resulting in the accumulation of toxic metabolites and a lack of its essential product, tyrosine. For the past 60 years, NBS has served as a model for successful public health screening programs. However, the history of laboratory NBS is not without debate. With the introduction of tandem mass spectrometry (TMS), a method that has substantially increased the capability of detecting probable illnesses in asymptomatic newborns , severalIn its early stages, the NBS program began by taking a blood sample from the newborn immediately after birth by sipping the heel of the foot, taking the blood sample on a blotting paper, then saving it and sending it to the laboratory for genetic testing to diagnose some genetic or metabolic disorders. This method was easy, accessible for all and at low cost, through which many life-threatening diseases were diagnosed for infants in the first weeks after birth, such as metabolic acidosis or neuromuscular disorders, and then programs for their control and treatment were developed. However, the presence of some biochemical substances in the solutions used in collecting and preserving diagnostic samples, such as heparin, and the circumstances surrounding its collection, such as blood transfusion for the newborn, all affect the values of the results of the examinations that are conducted for newborns, especially those under intensive care, so controls must be established to ensure that these factors do not affect the test results as much as possible . FurtherThe development of such practice recommendations for use in NICUs is especially significant because many of the severe sequelae of metabolic illnesses can be avoided if recognized early. Furthermore, no standardized practice guidelines currently exist for determining who, whether primary care provider or birth hospital, is responsible for notifying the parent of a positive result and therefore ensuring invaluable follow-up care. Such standardized guidelines for screening practice are needed to prevent distressing neurologic sequelae for newborns or infants whose condition may otherwise be left unaddressed. The National Board of Surgery guidelines, produced at Johns Hopkins Hospital and Memorial Regional Hospital, is a good material to start with .Scientific and technological advances have led to a significant expansion in the number of tests from an average of one to more than 50, and there is a national trend to further expand the NBS program. Many ethical, social and legal complications have emerged as a result of the rapid updates in the NBS programs that affected healthcare programs for the management of the detected cases . In the With a few notable exceptions, NBS programs participate in quality control programs much like any other laboratory. The cards used to collect blood spots account for a large part of the success of NBS programs. Preliminary studies using Robert Guthrie’s test for PKU stated elevated false positive rates that were attributed to a poorly selected type of card. This source of variation has been eliminated in most NBS programs through standardization of the approved sources of cards to be used for NBS. In most regions, an identification card is made for the newborn subjected to the NBS program containing all personal data such as name, age, gender and family information, and attached with it the nominated filter paper for its blood sample taken from the heel and the date of collection of the sample in order to distinguish the samples sent to the examining laboratory .TMS for inborn errors of metabolism (IEM) diagnosis offers the potential to expand the NBS panels to encompass a large number of illnesses. This method allows diagnosis of many metabolic abnormalities in the same dry blood spot (DBS) in a single analytical run. TMS screening technology has quickly replaced the use of traditional techniques for the screening of genetic or metabolic disorders, which includes identification of one metabolite for each analysis for one disease at a time. Therefore, the use of TMS technology in the NBS examination provides a reliable measure of specificity and sensitivity in examination results where we can use only one metabolite for the identification of multiple disorders at the same time .The use of TMS as a second level test has also made it possible to separate and quantify the isobaric amino acids leucine, isoleucine, valine and allo-isoleucine, increasing the specificity of the NBS result for urine with a maple syrup smell . AnotherImplementing the NBS program is subjected to local resources and healthcare infrastructure . WorldwiNBS has grown slowly but steadily in the United States during the last four decades. Not simply the medical needs and benefits of the screened neonates, but also the interests of the family and society at large are now deemed crucial to its ethical validity . With thm/z) ratio. In fact, the extracted molecules of each sample are delivered to the ion source of the mass spectrometer (by a liquid chromatography system) that generates a fine spray of charged droplets from which ions are emitted as the solvent evaporates. These ions are introduced into the mass analyzer for detection.Before the use of TMS in the NBS program, there was a need to perform microbial assay testing for each case. Currently, these separate assays are required only for a few cases of either endocrine disorders , hemoglobinopathies and thalassemias , or other cases . A mass spectrometer is an instrument that separates and quantitates ions based on their mass to charge —endnote12.In the MS–MS system, the ions beam is focused and introduced into the first mass filtering quadrupole, Q1, where the ions are separated by their detector . https:/The metabolism within the mitochondria produces many metabolites that help to diagnose many genetic disorders, especially those affecting fatty acid oxidation in IDMs. These biomarkers include L-carnitine and acylcarnitines, which are not routinely measured in these tests despite their clinical importance outside of these disorders. Measurements of the carnitine pool have been used to identify the disease and predict mortality among disorders, such as diabetes, sepsis, cancer and heart failure, as well as identify subjects facing adverse drug reactions from different medications such as cisplatin, clofazimine, cyclosporine, propofol, valproic acid and zidovudine .https://bioethicsarchive.georgetown.edu/pcbe/background/newborn_screening_crowe.html (accessed on 5 September 2021)—endnote13.The quantification of acylcarnitines and amino acids is important in detecting disorders. High or low levels of these indicate that the neonate has a potentially dangerous metabolic disorder. In such cases, there is impaired function of the enzymes responsible for the breakdown of amino acids or the conversion of fat into energy. Consequently, the metabolites accumulate to toxic quantities. The determination of the accumulated compounds in the blood of newborns can be analyzed by TMS, the most available reliable method widely used in many regions . https:/Jointly, the NBS aims for the early detection and treatment of newborns with certain conditions before the symptoms’ onset for the reduction of morbidity and mortality. Furthermore, there are criteria for identifying the disorders for screening known as the Wilson and Jungner Criteria for Disease Screening .The condition sought should be an important health problem.There should be an accepted treatment for patients with recognized disease.Facilities for diagnosis and treatment should be available.There should be a recognizable latent or early symptomatic stage.There should be a suitable test or examination.The test should be acceptable to the population.The natural history of the condition, including development from latent to declared disease, should be adequately understood.There should be an agreed policy on whom to treat as patients.The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.Case-finding should be a continuing process and not a “once and for all” project.https://www.scielosp.org/article/bwho/2008.v86n4/317-319/ (accessed on 5 September 2021).Reproduced from New technologies, including genomic sequencing, have increased the number of conditions that can be detected during the newborn period. The question of whether or not infants should be screened for conditions for which there is no treatment is debatable . The proTMS’s growth in NBS is already putting strain on the current NBS infrastructure. Meanwhile, DNA microarrays, the next technological advance, is on the horizon and fast approaching . ThroughConsiderable resources are needed to refine the technology applied in expanding NBS in the community. Not only is the technology needed to initiate well-functioning programs for NBS, but also the services of optimum detection and follow-up of the spread of the disorders is required. According to Tarini 2007, “Many questions about the process of expanding newborn screening need a definitive answer. If it is proven that the examination of a newborn is positive for a certain disorder, this may represent a psychological burden on the doctor supervising the case. How to inform the family of the newborn with the positive result? And how he will determine the plan of management and follow-up for this case? What are the psychological and social burdens on the family of that newborn?” All these inquiries should be answered by coordination between families, specialists and primary care physicians to ensure the achievement of the NBS program in the 21st century ..49].The “just-in-time” information of the gene variant is used to assist the physicians interpreting the findings of the performed biochemical and enzymatic investigations within the NBS screening program, to decide the best and most suitable time to communicate with the families about the detected positive cases and to discuss with them the future management plan. This “just-in-time” information is a good means for differentiation between a disorder subtype. As an example of this in the Wisconsin NBS program, the primary marker in galactosemia is the galactose-1-phosphate uridylyl transferase (GALT) enzyme activity. The application of gene analysis is indicated in cases of reduced or absent GALT activity. DNA is extracted from the dried blood spots and amplified through PCR reaction using the Tetra-primer ARMS–PCR to amplify different variant alleles that can be distinguished by agarose gel electrophoresis .For quick detection of genetic markers for high-risk disorders, we can use the “just-in-time” information as a crucial method for instant intervention. Maple syrup urine disease is a rare disease affecting 1 in 197.714 live births in the USA in general, based on the available data of the NBS program, which proved that the severe form of the disease can affect more than 1:400 births due to the presence of a founder variant of BCKDHA  ,52. TablHemoglobinopathies, including sickle cell anemia and α-/β-thalassemia, are the most common monogenic diseases worldwide . HemogloNature 198, pp. 492–493). Later, Hb S, α- and β-thalassemia, glucose-6-phosphate dehydrogenase (G6PD) deficiency and other enzymopathies were shown to have a variable prevalence among different provinces of Saudi Arabia. Nationally, recent studies have shown α-globin gene arrangement and β-globin gene polymorphism [The presence of the sickle cell (HbS) gene in Saudi Arabia was first reported by Lehmann et al. in 1963  test, where the coding regions on the hemoglobin genes, including the four modifier genes, were designed and targeted . MoreoveNGS has been shown to allow rapid, multiplex and high-throughput detection of genetic variants . NGS tesNGS technology was used in a UK PhD research study to facilitate diagnostic procedures because of its ability to identify single nucleotide changes and large rearrangements in a single investigation. Examination using this technology included selecting DNA samples from people with thalassemia-causing mutations, fragmenting these samples and preparing them for DNA sequencing. Illumina platform was used for sequencing the two genomic regions that are affected by the variants causing thalassemia after enriching it for using in-solution bait capture. NextGene software (SoftGenetics) was used to sequence “reads” of the DNA fragments after aligning it to a reference sequence of the human genome. Changes in coverage between test and negative control samples identified dosage changing events. The presence of sequences that spanned the breakpoint region identified the breakpoints of structural variants. To improve the method, the analysis of samples with known, previously identified variants and testing them in samples with unknown novel variants was performed. Gap-PCR and sanger sequencing confirmed the findings and, in conclusion, NGS is considered as a novel technique that can improve the current diagnostic standards.An examination of the features of the structural rearrangements identified revealed that multiple mutagenic mechanisms contribute to the range of variants that affect the alpha and beta globin gene loci .In the past, the diagnosis of IEM was based on clinical findings confirmed by laboratory investigations. At that time, the trials for genetic diagnosis were costly and may have failed as there may have been several phenotypes of a gene caused by different gene mutations .Nowadays, NGS techniques are widely used in the diagnosis of IMD, where its results are rapid, confirmed and reliable, but, due to its uncertainties and the nature of IEM, it necessitates a holistic approach for diagnosis. Currently, the widely-used NGS techniques concentrate only on the diagnosis of a definite group of genetic disorders and overlapping phenotypes, and the entrance of a clinical exome approach has facilitated the instant assessment of diverse phenotypes ,67.With respect to IEM, studies of hyperphenylalaninemia, phenylketonuria , cerebraSince NBS began in the 1960s, technological advances have enabled its expansion to include an increasing number of disorders. Advances now make it possible to sequence a newborn’s genome rapidly and economically. WGS and WES clinical application is increasing rapidly with many challenges. Its implantation in the NBS requires further investigations for possible clinical profits and for the unique ethical challenges it presents .Until now, Sanger sequencing has been the gold standard method for DNA sequencing. Using this technology, a major expedition called the Human Genome project started in 1990 and lasted for 13 long years wherein USD 3 billion was expended to determine the whole human genome sequence. Challenges to be addressed before the implementation of NGS in NBS include data storage, real cost, ethical considerations, insurance disputes and medical malpractice. All these challenges are detailed in the responsibility for the maintenance and governance of a large amount of data generated, the costs for data analysis, family notification, follow-ups and confirmatory testing for each test, and for all tests, reporting uncertain results to the parents, the responsibility for the privacy of stored data and results until the maturation of the child, sharing results regarding serious, preventable genetic disorders with at-risk close relatives, will the test information make it difficult for an individual to obtain health insurance with a predisposition to a genetic disease, and whether clinicians are properly trained to interpret data generated by genome sequencing .If genomic sequencing were integrated into NBS, state NBS programs would have to decide which effects would be returned to infants’ families. In 2013, the American College of Medical Genetics and Genomics (ACMG)  publisheWhole exome sequencing is routinely used and is gradually being optimized for the detection of rare and common genetic variants in humans ,80,81,82The performance of genomic sequencing technology and the capability of interpreting variants in asymptomatic newborns creates part of the barriers to utilize this technology in any screening attempt. Even more, how parental informed consent can be obtained, the type of information that should be offered, and how the possible results will impact families are critical issues .A plausible alternative approach to “biochemical based” NBS would be applying NGS technologies to screen for mutations in the relevant disease predisposition genes. A key driving force for the “targeted NBS panels” approach is the rapidly decreasing cost of massively parallel sequencing coupled with the vastly improved read depths and accuracy of the sequencing platform .Tarini and Goldenberg, 2012). Genetic counselling for the families is crucial to obtain consent for additional diseases to be investigated in the NBS [Presently, nongenetic NBS programs do not need parental consent as they are primarily aimed for the newborn’s profit and are offered without any cost. Reporting information, which may impact the decisions of familial reproduction, also represents the secondary aim. On the other hand, NBS by genetic sequencing may require specific consent to be given by the parents, as all genetic testing does. One way to avoid these potential objections is to have mandatory NBS by WES/WGS for the disorders that could lead to immediate impact and benefit for the infant’s health, and request for consent for other diseases  or for specific genes, due to boundaries of the bioinformatics about identified variants’ interpretation, uncertain probable management, psychological issues for the family, irrelevant therapy, increased medical cost, negative impact on family insurance and, lastly, the difficulty in consent obtaining from the families .www.hugointernational.org/comm_hugoethicscommittee.php, accessed on 5 September 2021) stating that “the primary objective of genome sequencing in NBS should be the identification of gene variants conferring a high risk of preventable or treatable conditions, for which treatment has to start in the newborn period or in early childhood” [A scientifically-based recommendation has been issued from the Human Genome Organization (ildhood” ,97.The WGS and WES for clinical applications are now an integral part of medical genetics practice. The significant reduction in sequencing costs and availability have raised the inquiry about whether current practiced NBS technology should be shifted to WGS or even WES. Although the genome sequencing for newborns is beneficial for the detection of many disorders in its early stage, many ethical concerns may arise from its mandatory application as a routine in NBS.For the implementation of a robust technology such as NGS in a mass NBS program, the main focus should not be just technologically biased; it should also be tested for its long- and short-term impact on the family and the child. The crucial question here is whether large-scale genomic sequencing can provide useful medical information beyond what current NBS is already providing and at what economical and emotional cost? Currently, the topic of newborn genome sequencing as a public health initiative remains argumentative. Thus, an answer has not yet been found to the question: NGS for newborn screening—are we there yet?