The negative effect of the pharmaceuticals presence (persistence?) in various components of the environment is a global problem today. These compounds are released into the environment as a result of, inter alia, their use and improper disposal. Therefore, it is important to reduce excessive drug consumption and to develop a system for the collection of unused/expired pharmaceuticals. The effectiveness of actions in this area is inextricably linked with the need to educate society on how to deal properly with unwanted medications. The aim of the study was to show that the inappropriate handling of unused/expired drugs by society is an important problem in waste management systems, and it impacts the state of the environment. Forty-eight scientific articles published between 2012 and 2021 were taken into account that discussed the systems in various countries for the collection of unused/expired pharmaceuticals. This literature review shows that the main method of disposing of unused/expired medications, according to respondents from different countries, is either by disposing of them in household waste or flushing them into the sewage system. This is also the case in countries with systems or programs for the return of redundant drugs, which indicates that these systems are not sufficiently effective. This may be influenced by many factors, including the lack or ineffective education of the society. Developments in technology and progress in medicine have resulted in an increase in life expectancy. According to World Health Organization (WHO) data, life expectancy increased from 66.79 to 73.31 during 2000–2019 .A survey conducted by Hedendrud et al. 2019) in Sweden showed that, in total, 87% of respondents reported the use of OTC drugs in the prior 6-month period . Similar in SwedeFurthermore, the COVID-19 pandemic has caused an increase in the consumption of some OTCs , and thereby self-medication has become a serious problem . An onliAntibiotics are a group of pharmaceuticals the excessive consumption of which is of concern. These drugs are used for human and animal disease treatment, growth promotion and prophylaxis . The gloThe presence of pharmaceuticals in the environment is a consequence of both their usage and disposal. The main source of pharmaceuticals is the excretion of active substances consumed by humans and animals via urine and feces  and the incorrect disposal of unused medical products into toilets and sinks or incorrect disposal via solid waste . By limiHowever, it seems that there is no global strategy for limiting the production and disposal of pharmaceutical waste. On the other hand, the problem of the improper handling of unnecessary drugs by common people is a very important issue. For example, according to the report published by UNESCO/HELCOM , wastewater is the main source of pollution of the Baltic Sea with pharmaceuticals . At the In the view of the above, the aim of the study is to show that the inappropriate handling of unused/expired drugs by society is an important problem in waste management systems, and it impacts the state of the environment. The publication also focuses on the actions taken to reduce the impact of pharmaceutical waste on the environment, which are already implemented in various countries.This review was based on 48 articles published between 2012 and 2021, obtained from databases such as Scopus, Google Scholar and PubMed, and the references contained in these articles. In order to retrieve articles from databases, keywords (and their combinations) such as ‘disposal of pharmaceutical waste’, ‘drug disposal’ and ‘household medical waste’ were entered in the search field. This period of time was selected to include in the review countries from different continents and with different levels of socioeconomic development.-Changing the dosage of the drug or changing the drug;-The death of the patient;-The noncompletion of therapy or inappropriate use of drugs by the patient ;-The discontinuation of therapy due to side effects .Around the world, the definition of waste is different in the legal systems of individual countries . In the Sasu et al. (2012) showed that more than half (59%) of the respondents from Ghana finished their medication, and the remaining respondents stopped taking medicines when they thought they felt better . Ayele aMethods for residents to dispose of unused/expired medications depend on socioeconomic culture as well as legal regulations and regulatory guidelines . In manyIn low- and middle-income countries, there are often no guidelines regarding the disposal of medications by the public. In Ethiopia, there is no national policy that aims to control the safe disposal of unused/expired medicines or raise public awareness of this issue . SimilarIn Kuwait, there are no guidelines for the acceptance and disposal of medicines returned from households. There is only a guideline issued by the Ministry of Health that pharmacies are required to return unwanted medications generated from their stock, for any reason such as expiry or overstock, to the Central Medical Stores . MoreoveIn the European Union, the obligation to implement appropriate collection systems of medicinal products that are unused or have expired results from Art. 127b, Directive 2004/27/EC of the European Parliament and of the Council of 31 March 2004, amending Directive 2001/83/EC on the Community code, relating to medicinal products for human use . In most European countries, the collection system includes either take-back to the pharmacy or drop-off at waste collection points, depending on the policy and strategy implemented in each country or region. Some pharmacies take part in the process on a voluntary basis, while some are obliged by law to participate in a take-back scheme. Croatia is an example of a country where pharmacies are obliged to accept unused/expired medicines from patients. By law, pharmacies are considered producers and holders of drugs and therefore are obliged (in accordance with the ‘polluter pays’ principle) both to receive drugs from patients and bear the costs associated with it . AdditioIn France, by Law No. 2007–248 of 26 February 2007, pharmacies are required to accept unwanted medications from patients . The colThe current legislation in Romania is designated by the National Public Health Institute as the authority responsible for approving on-site collection by the separation of waste accumulated from medical activities. However, the legislation covers only, for example, pharmacies, drug stores, distributors of medicines and pharmaceutical products, production units, the warehousing and storage of medicines and biological products or research institutes, while expired medicines derived from the population should be submitted to the nearest pharmacy or pharmaceutical point . HoweverIn the US, in 2007, the Food and Drug Administration and the White House Office developed and published, under the National Drug Control Policy, the first guidelines for consumers on drug disposal, which indicated that the proper way to dispose of drugs was to throw them into the garbage . The SafIn order to answer the question of how residents of various countries deal with unused/expired pharmaceuticals, 48 scientific articles published from 2012 to 2021 from different sources were analyzed .The analysis of literature shows that the main way to dispose of unwanted drugs is by throwing them into the garbage . The inh− A lack of education or inadequate education in this field;− A lack of an appropriate system or program for the return of unused drugs;− Getting used to certain behaviors;− Convenience;− A lack of punishment (no responsibility).The reasons why respondents use improper methods of disposal are primarily:In Tanzania, 91.4% of respondents were not aware of the existence of proper medicine disposal methods . This isOn the other hand, most patients are aware that throwing unwanted medications into the trash or pouring them into the sewage system has a negative impact on the environment and health. For example, in Jordan, 72.5% of participants said they knew that the improper disposal of medications could harmfully affect the environment and health . These rRespondents indicate that it should be the responsibility of health care professionals and pharmacists to provide information on the handling of household pharmaceutical waste ,85. ProvAccordingly, it is important to properly educate pharmacy students, pharmacists and health care staff in this field. In the aforementioned survey, Alhomond et al. (2021) showed that among the students who received information on the appropriate disposal of medicines, 85% did not dispose of unused or expired medications in household garbage (while 15% did), and of those who had never received such information, 91% did (9% did not) dispose of medications in household garbage . Of the One source of information is educational campaigns and programs carried out by national and local governmental bodies as well as environmental organizations and private institutions. Public education campaigns on pharmaceutical waste management in the Bihor county (Romania) population resulted in a significant increase, from 1.1% to 87.3% in 6 months, in the number of patients who returned expired and/or unused drugs to pharmacies . The impThe International Pharmaceutical Federation (FIP), in 2015, prepared the document: “Green pharmacy practice—Taking responsibility for the environmental impact of medicines”, in order to provide pharmacists’ associations with useful information in this field. This reference document proposes solutions for developing green pharmacy policies, such as: creating an adequate legal framework at the national level, establishing effective pharmaceutical waste disposal practices, organizing continuous training programs for pharmacists and other health professionals and running informational and educational campaigns for patients in order to reduce and properly dispose of pharmaceutical waste .In Australia, in 1998, the Return Unwanted Medicines (RUM) project was introduced by the government. This program provides the free option for the public to return unwanted and expired medicines to community pharmacies ,90. RetuA return or take-back voluntary program was also implemented in Malaysia. Under this national program, patients can return unused drugs to pharmacies, hospitals and health clinics that are subordinate to the Ministry of Health Malaysia . AlthougCanada is one of the countries that started introducing unused drug return programs by consumers in the 1990s. In 1996, the EnviRX program introduced in British Columbia was aimed at the possibility of returning unused/expired drugs by patients . ResidenAs reasons for the inappropriate disposal of unused drugs, residents also indicate convenience or habit. Patients from Portugal indicated that in order to increase the amount of medications returned to pharmacies, it would be important for the number of collection points to be increased, thus reducing the distance to them . More thSome researchers have reported that sociodemographic factors such as education, income level, household size and gender influence a household’s environmental behavior ,99,100. An important issue that should be given attention is keeping unused medicines at home for various reasons. In Tanzania, the majority of households 96%) kept unused or expired medications . More th6% kept uUnused pharmaceuticals were kept at home for several reasons. The first is the belief that they may be useful in the future. This was the main reason for residents of Malaysia (70.4%), Portugal (43%), Cyprus 93.4%), Uganda (55.4%) and Ireland (57%) to keep unused medicines at home 3.4%, Uga,49,56,81Pouring unwanted drugs into toilets or sinks causes them to be transported through the municipal sewage system to municipal wastewater treatment plants. Wastewater treatment plants, both in undeveloped countries (if they exist) and in developed countries, focus mainly on treating wastewater with regard to nitrogen and phosphorus compounds or suspended solids. In the European Union countries, there are no regulations obliging member states to use technologies that enable the removal of micropollutants, including pharmaceuticals, from wastewater. According to Council Directive 91/271/EEC of 21 May 1991 concerning urban wastewater treatment , member states shall ensure that the treated wastewater released into water meets the requirements for biochemical and chemical oxygen demand and total suspended solids, and in the case of emissions, it is sensitive to specific nitrogen and phosphorus contents. In effect, micropollutants, including pharmaceuticals and their metabolites, end up in water reservoirs, such as seas or rivers, which may pose a threat to organisms living in them. For example, according to information contained in the UNESCO/HELCOM report, the main pathway of pharmaceuticals into the freshwater and marine environment in the area of the Baltic Sea is via the discharges of municipal wastewater treatment plant effluents .The disposal of pharmaceuticals in conventional wastewater treatment plants using mechanical, biological and chemical processes depends on the two processes of sorption and biodegradation . For exaAllivibrio fischeri, whereas its toxicity to Daphnia magna is high [Daphnia magna at a high concentration exposure, and, among analgesics, the most toxic effect was reported of EC50 below 100 mg L−1, while phytoplankton is highly sensitive to metoprolol in acute and high-level exposure with EC50 of 14.5 mg L−1 at 96 h post exposure. Diclofenac also causes gill alterations in trout fish [Pharmaceuticals are designed to elicit a biological response in organisms even at low concentrations. Accordingly, those in the aquatic environment might also produce a biological response in nonspecific organisms . Many of is high ,112. Morout fish . In addiout fish , e.g., 8out fish . At the −1 [−1 [In recent years especially, the problem related to the release of antibiotics into the environment has intensified, causing the development of antibiotic-resistant bacteria and the environmental occurrence of antibiotic-resistant genes . This ph−1 . On the −1 [−1 .Accordingly, in 2015, the WHO adopted a global action plan on antimicrobial resistance, including antibiotic resistance. The aim of the plan was, among others, to increase the knowledge and awareness of antimicrobial resistance and to conduct activities related to optimizing the consumption of antibiotics . Moreove−1 before the pandemic to 935 ng L−1 during the pandemic) [At the same time, it should be noted that the COVID-19 pandemic resulted in an increase in the consumption of certain drugs, including antibiotics, and thus an increase in their amounts in the sewage stream . Due to andemic) .Reducing the amount of drugs in the environment, and thus their negative impact, is a multistage process and includes, inter alia, the rational prescription of drugs, the limitation of drug consumption, legitimate self-medication and proper disposal. Social awareness of the problem plays a key role in each stage of the process.Prescribing excessive amounts of drugs increases their consumption and storage. Storing medicines at home and their consumption by a person other than the person for whom they are prescribed can increase the risk of adverse effects. The accidental intake of drugs by children may be a problem. In addition, the storage of drugs means that consumers will, most likely, eventually dispose of them when they have expired. In a survey conducted by Naser et al. (2020), Jordanian respondents indicated that from their perspective, the best way to reduce drug waste was by dispensing medications only as required (42.4%), prescribing medications rationally (35.4%) and giving proper advice to consumers (33.5%) . SimilarThe COVID-19 pandemic has resulted in an increase in demand for the purchase and storage of drugs, especially those for chronic diseases. The phenomenon of “panic buying” was particularly visible in richer geographical areas ,127. EleThere is no doubt that the ways in which society wrongly disposes of unused/expired drugs have a negative impact on the environment. Accordingly, safe drug return systems and programs need to be established and developed. Pharmacies play an important role in such systems as the points of return of pharmaceuticals, due to their general availability and number. In some countries, they are obliged to be included in the system of collecting unused/expired medicines from households , whereas in others, they operate on a voluntary basis . The next stage is to educate the public on the proper handling of unwanted drugs, including collection systems and drug take-back programs. For example, although the RUM project in Australia was launched in 1998, a survey conducted in 2016 showed that less than 18% of Australian respondents had heard of it. On the other hand, 91.7% of respondents who were previously unaware of the scheme stated they would now use it . At the The COVID-19 pandemic and blockades, and thus limits on the possibility of movement in different countries and patients’ fear of getting sick, could reduce the willingness and actions of patients in the pharmaceutical waste collection system . In the Pharmacy reuse (sometimes referred to as recycling) is a complex issue, facing concern, especially regarding safety and liability. The controlled reuse of drugs can be a way to reduce their negative environmental impact. Reuse can also help reduce the accumulation of drugs in society. However, the problems that appear in this case arise from the storage methods of medications in households, including poor storage conditions such as humidity and temperature, which are not regulated. Research conducted in the Netherlands and Great Britain showed that over 50% of respondents were willing to use medications returned unused to the pharmacy by another patient as long as the quality of these medicines was verified ,131. In Despite these repository programs, the collection and redistribution of unadulterated prescription drugs are not allowed by dispensing laws in EU countries. The reuse of still-usable drugs in modern, tamper-evident packaging is still dangerous with regard to unknown storage conditions.Because the main methods of disposing of unused/expired drugs by respondents from various countries include throwing them into the garbage and pouring them into the sink/toilet, waste management and wastewater treatment from pharmaceutical residues should be developed at the same time. On the one hand, some countries  started introducing additional methods of wastewater treatment  in wastewater treatment plants to remove micro-pollutants such as pharmaceuticals and their metabolites. In other countries, however, wastewater treatment systems are completely lacking. For example, in Ghana and India, only 7.9% and 30.7%, respectively, of the wastewaters are treated, which results in the presence of pharmaceutical residues in the aquatic environment . This sa2 is the most frequently used photocatalyst, other such semiconductors show good elimination of organic pollutants. For example, meso-tetra (4-carboxyphenyl) porphyrin (TCPP)/Bi12O17Cl2 shows photodegradation efficiency of 79.4% for tetracycline [0.5Zn0.5S nanoparticles and Bi2WO6 microspheres [An important area in the field of wastewater treatment seems to be the development of new, more effective and low-cost methods of the elimination of pharmaceutical residues from wastewaters. Among the treatment methods, photocatalytic methods play a special role and have been recognized as one of the most promising methods for the elimination of organic pollutants in environmental matrices . Althougacycline . In the ospheres .This study had some limitations. The selected period (2012–2021) from which the publications were analyzed allows data to be shown only from selected countries. Published studies from particular countries may not be representative of the entire population of the country because they are conducted, for example, on a specific, selected group of respondents, such as students or residents of large cities. In addition, some research was conducted using online surveys, which may also affect the results .The conducted review showed that the basic way for patients in different countries to deal with unused/expired drugs is to throw them into the garbage and/or pour them down the sink. This happens even despite the fact that many countries have systems for collecting unnecessary medications from patients. In view of the above, investigating the reasons why expired/unused pharmaceutical products become waste plays a key role in reducing the problem. There is a need for more research to explore this problem. It seems that a global system based on the obligatory collection of unused/expired medicines from households is needed. Simultaneously, with the development of this system, it is necessary to effectively educate societies about the impacts of improper drug disposal on the environment. It is equally important to conduct research on developing new or modifying existing methods of wastewater treatment from hazardous compounds, especially now that the problem of microbial resistance is becoming more and more serious.


Africa and the international community stand to gain with a deeper understanding of why the expected doom never came. This might be useful to build on the gains and better prepare for future pandemics.The most prominent of the projections was that of the United Nations Economic Commission for Africa (UNECA) on April 2020 which projected that Africa could see about 300,000 deaths from COVID-19 during the year even under the best-case scenarios (Adamset al.  have hypUnlike the rest of the world, as soon as COVID-19 was declared by WHO as a global concern, African states became tactical in their response as they initiated strategies to tackle the virus and every country went on red alert. Strict measures including travel restrictions, lockdown, and cancellation/limitation on the number of persons at public gatherings were imposed earlier. The immediate shutdown of their respective economies was highly criticized by the rest of the world, and had a lot of negative effects on their already struggling economies but, slowed the spread of the virus . Rwanda,Africans have always been united in the fight against epidemics and pandemics and this has been the same for COVID-19 , 5. SincThe continent had learned her bitter lessons from previous pandemics such as Ebola, cholera, influenza and HIV/AIDS. As such African governments took aggressive preventive measures before they even had their first confirmed cases. Her response to these pandemics and epidemics had taught her to invest in more resilient health systems as well as put in place strong and effective surveillance mechanisms and coordination reflexes to cope with future epidemics and pandemics . In the While the rest of the world was waiting for the development of some clinically tested treatment, Africans did not wait for their government to propose biomedical treatment developed elsewhere. Traditional medicine is the foundation of healthcare in Africa. It is comprised largely of herbal medications. Also making up the majority of alternative medicine, herbal medications constitute the backbone of many African countries with poorly resourced orthodox healthcare systems. The use of traditional herbal medicine, thus, increased greatly in the midst of the COVID-19 pandemic as many more people turned to herbs believing it treats and prevents many diseases. There has been a lot of misinterpretation regarding the use of herbal plants all across Africa. With no known cure for COVID-19, Africa took the lead with herbal medicine, notably in Madagascar and Cameroon , 8. The The reality presented by the failed predictions of doom for the African continent regarding the COVID-19 pandemic showcase global health hypocrisy and the fact that global health justice in research is a meaningless concept . A robusSince its emergence in December 2019 in China, COVID-19 has ravaged countries across the globe with disturbingly high mortality and morbidity rates. While there were predictions of Africa bearing the heaviest COVID-19 related morbidity and mortality globally, this never happened. Explanations for this resistance have mainly been on a hypothetical frame. Ignoring this “African Resistance” against COVID-19 as a research priority is proof of astute injustice in global health research. Africa and the international community stand to gain with a deeper understanding of why the expected doom never came. This might be useful in preparing for future pandemics. COVID-19 is still here. Staying focused on prevention and avoiding community transmission, testing and contact tracing, case management, stepping up vaccination, and investing in research are priority action areas to successfully fight the pandemic.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.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.


Current medical care deeply relies on informatics during all stages of patient care, which is significantly enhanced due to its use. The healthcare professional's formation in medical informatics results crucial for their everyday practice. However, healthcare study programs not always provide education about the use of this wide variety of systems, and young professionals find that they need to learn about it over the experience. The aim of this study was to assess the understanding of medical and dental students regarding medical informatics and ICTs.  A questionnaire was produced with 3 sections and a total of 24 questions. Students replied to the survey before and after taking the medical informatics course.  A total of 719 students from second year of medical and dental school were recruited for the study between the period of September of 2017-May 2018, September 2018-May 2019, September 2019-May 2020, and September 2020-May 2021. Medical and dental students showed a good level of understanding regarding medical informatics, as well as a good perception of the relevance of ICT learning for the professional practice. Course attendance increased the percentage of students that felt confident of their knowledge about medical informatics. However, most students felt that little or no medical informatics education was lectured at their schools and that the University should adapt the academic program to include it. After taking the course, the student's perception on this matter was improved.  Medical and dental students find medical informatics learning useful for their future professional practice and feel inclined to use it. However, they feel that Universities need to adapt their programs in order to include medical education courses and trainings; partly because they are not completely aware of the use of ICTs that already are established in their courses. The automation of medical informatics was introduced in the second half of the twentieth century . MedicalMedical informatics was not usually thought in the institutions or in training sessions. However, currently many training institutions are offering postgraduate degrees in this/related field (computer science or intelligent systems) where students mostly have a medical doctor degree. Furthermore, some programs focus on informatics of a specific medical field including dentistry or nursing for example. Informatics in the field of molecular biology and genomics or as known Bioinformatics is expected to expand dramatically due to the recent infusions of funding from the National Institutes of Health.Professionals in this domain are expected to be skilled in medical information resources and its access including medical journals, literature databases, medical textbooks, practice guidelines, and the increasing number of “synthesized” evidence-based resources (Cochrane Database). Bioinformatics must also have the ability to navigate in these resources on a specific subject using the correct vocabulary and terms involving the Medical Subject Headings (MeSH) and other full-text resources that are not manually indexed.Technology evolvement has also reached the dental profession where it is not impossible on a computer to decide treatment options and decision-making of patient's care . Dental For example, dental informatics can be used in diagnosis of oral diseases, e-prescriptions, indications, and contraindication of certain drugs in specific groups of patients and many more, therefore, dentist must be updated to improve their performances. Similar to general healthcare, dental informatics is combining both medicine practice and information technology to improve dental research, education, and treatment choices . FriedmaPrevious reports showed that the conventional method of record keeping resulted an 11% of repeated laboratory tests with misplaced results, a 30% of undocumented treatment orders, 50% of missing or incomplete medical records, a 35% loss of time of physicians and nurses due to paper work, and almost 20-30% of national healthcare expenses on these paperwork .A previous study reported 90% of dentists have a computer in whom only 25-30% use it during work  and veryIt is important to minimize the gap between dentists and computer utilization in order to enhance its practice, with many innovations including decision support, real-time information diffusion, and continuing edification . In consThis study was approved by the Ethics Committee of IRB Registration Number with KACST, KSA: HAP-01-R-059. Students registered for the course of Medical Informatics at third year of bachelor's degree of medical and dental schools were recruited. The course was designed to increase the understanding of medical informatics among healthcare students and to provide skills regarding ICTs.A questionnaire was produced with 3 sections and a total of 24 questions. Students replied the survey before and after taking the medical informatics course, using a qualitative scale . Items of the survey included if they felt confident about the benefits of learning medical informatics and if they believed that it was important to include it in their curricula. Also, items related to the student's perception of the opportunities' availability to learn about medical informatics were added.The % of students that answered each question was calculated, and mean % of students each section of the survey was compared. In order to determine if behaviour among medical and dental students was different, separate and joint analysis was performed.A total of 719 students from second year of medical and dental school were recruited for the study between September of 2017-May 2018, September 2018-May 2019, September 2019-May 2020, and September 2020-May 2021. A questionnaire was provided to the students during the first and the last lecture of a Medical Informatics Course, to evaluate the understanding of Medical Informatics of medical and dental students. A total of 322 students participated before the course  and 397 students after the course .Students were asked if they thought that communication technologies were beneficial for their practice and for the patient care and if they appreciated its advantages even if it meant that they had to invest time into acquiring skills.Forty seven % of the students expressed that they felt confident and 13.7% said that they felt very confident about using communication technologies and about knowing its benefits . InteresMost of the students (approximately 80%) believed that learning information technology skills was important, and this perception was almost twice larger among medical students . Almost As shown in It has been proposed that healthcare professional education has been left behind when it comes to medical informatics . Since mAccording to our observations, the students exhibited a good basal understanding of the benefits that learning medical informatics provides. It has been reported that medical and dental students from first year are more motivated to learning when multimedia resources and self-directed research activities are the pedagogical conditions . It coulAs expected, attending medical informatics course was able to increase the number of students who became aware of medical informatics advantages. A report by Cresswell et al.  publisheAdditionally, our findings showed that medical students appeared to show better understanding of ICTs after taking the course. A previous study showed that 63% of dental students preferred active learning lectures with use of technology over traditional classes, which shows a potential good attitude towards ICTs . AnotherThe relevance of IT healthcare has been long reported as well as the need of trained healthcare professional users –21. ThisThe perception of the students regarding the curricula offering for ICTs learning was increased after taking the course. Research studies have been carried out in order to develop a curriculum that effectively provides medical informatics knowledge and skills , 23. CurThis study was performed with over 700 recruited students, which is an appropriate sample size representative of the studied population. However, while all the students completed the survey after attending the course, approximately 322 students completed the survey before the course, which could skew the data and, consequently the conclusions regarding the effects on the student's knowledge, attitude, and importance of ICT perception. Also, there was no quantitative evaluation of the student's acquired knowledge, to produce more reliable conclusions based on mean comparisons statistical analysis with quantitative data, such as final tests with marks or employing surveys that allow calculating scores . On the Moreover, we observed that the medical and dental students considered the course as a general one and not as a training course, as intended to assess knowledge and importance perception of medical informatics, indicating that the program might need modifications in this way and that the perception of it being a general course could falsely affect the results of the study in relation to ICTs. Despite these limitations, the study is valid to evaluate the proposed aims.In conclusion, medical and dental students find medical informatics learning useful to their future professional practice and feel inclined to use it. However, they feel that Universities need to adapt their programs in order to include medical education courses and trainings; partly because they are not completely aware of the use of ICTs that already are established in their courses.


It decreased significantly between 2016 and 2020, although the reduction was only significant in women (12.27% in 2016 vs. 10.56% in 2020). Older age, comorbidity and the most recent years of hospital admission were associated with lower prevalence of depression in both men and women, while obesity, obstructive sleep apnea (OSA) and use of oxygen prior to admission were risk factors. In-hospital mortality (IHM) increased significantly over time. Older age, comorbidity, the use of oxygen prior to admission and having been hospitalized in 2020 increased the risk of IHM. Female sex was associated with a lower IHM in patients with depression and COPD. (4) Conclusions: The prevalence of depression has decreased over time in women with COPD while it has not changed significantly in men with this disease. IHM increased over time both in men and women with COPD and depression, with higher prevalence in the former. Chronic obstructive pulmonary disease (COPD) is a common clinical condition that is associated with significant worldwide morbidity and mortality . It is iDepression is amongst the most common comorbidities in COPD, with an estimated prevalence ranging between 10% and 57% , due to Risk factors associated with increased prevalence of this mental disorder in COPD patients are likely multiple and include age, smoking and COPD severity . Female There has been relatively little focus on depression in COPD patients, except for prevalence studies. In fact, there are hardly any studies that have evaluated the evolution of the prevalence of COPD and depression over time , both glThe objective of our study was to describe trends in the prevalence of depression in men and women with COPD hospitalized in Spain between 2016 and 2020, using a nationwide discharge database. Furthermore, we analyzed the prevalence of depression in women and men with COPD according to specific hospital admission diagnoses and hospital outcomes.We have conducted a population-based cohort study between 1 January 2016 and 31 December 2020 using a large registry of the hospital discharges—the Spanish National Hospital Discharge Database (SNHDD)—that covers almost 100% of admissions in Spain. The methodological description of the SNHDD, as well as the coding of the variables based on the International Classification of Diseases (ICD-10) has already been described .The study population included those subjects who presented a COPD code in any position of the diagnostic field of the database .The descriptive statistical analysis has been carried out with the calculation of total frequencies with percentages and means with standard deviations or medians with interquartile range for categorical and continuous variables, respectively. The trend was analyzed using a Cochran–Mantel–Haenszel statistic or Cochran–Armitage test for categorical variables and linear regression t test or Jonckheere–Terpstra test for continuous variables. Categorical variables were compared using the exact Fisher test. Continuous variables were compared using the t test or the Wilcoxon rank sum test as required. We used multivariable logistic regression tests to analyze the factors associated with the presence of depression among COPD patients, evaluating the effect of sex. Finally, we used logistic regression tests to assess the effect of depression on the IHM in both men and women with COPD. Models were constructed for the concomitant clinical conditions included in the CCI, obesity and pneumonia. The results were presented using the odds ratio (OR) and 95% confidence intervals (95% CI). We used version 14 of Stata to perform the statistical analysis . Statistical significance was set at To carry out this study, it was not necessary to request the informed consent of the individuals nor approval by an ethics committee, since the SNHDD is anonymous and can be requested from the Spanish Ministry of Health .During the period between 2016 and 2020, in Spain there were 1,150,809 hospitalizations of subjects over 35 years of age who had a diagnostic code corresponding to COPD, of which 55,794 (4.85%) had a depression code. The flowchart of the study can be found in p < 0.01), as can be seen in The prevalence of depression in Spain decreased significantly between 2016 and 2020  .p = 0.002) and the presence of associated comorbidity  increased between 2016 and 2020. The crude IHM also increased significantly between 2016 and 2020 , as shown in In men with COPD, the prevalence of depression did not change significantly throughout the study period (3.42% in 2016 vs. 3.79% in 2020). The mean age , while mean age did not change . On the other hand, comorbidity increased significantly over time . In the study period, the crude IHM also increased significantly  as can be seen in In women with COPD, the prevalence of depression decreased significantly throughout the study period .Older age, the existence of comorbidity (CCI), the presence of pneumonia, the use of oxygen prior to admission and having been hospitalized in 2020 increased the risk of IHM in men and women with COPD and depression, as indicated in Finally, in men with COPD and selected concomitant conditions such as diabetes, cancer and use of mechanical ventilation, the presence of depression decreased the risk of dying in the hospital . In womeTo the best of our knowledge, this is the first study to explore trends in the prevalence of depression in men and women hospitalized with COPD. We found that this prevalence has decreased over time in women with COPD and has not changed significantly in men with this disease. Even so, it is still more than three times higher in women than in men. Previous studies have demonstrated that depression, as well as other psychological disorders including anxiety and irritability, are more prevalent in women ,18,19,20In relation to the determinants of the prevalence of depression in COPD patients, we detected that obesity and OSA were associated with a higher probability. Ghaemi Kerahrodi et al. also found that obesity was associated with an increase of depression in obstructive lung disease, in addition to other factors such as being a woman, smoking, low socioeconomic status, degree of dyspnea and lower pulmonary function . HoweverThe current results showed that older age and higher comorbidity were protective factors of the presence of depression in our study population. Taking into account that older people and/or those with more comorbidities have a higher risk of mortality and that the duration of the study was 5 years, the participants in the first year could have died by the end of the fifth year. It is commonly known that the annual number of COPD cases  comprises both new and old cases.Regarding age, previous studies have shown that younger COPD patients are at a higher risk for depression than the elderly ,29,30,31A controversial issue is the influence of the number of comorbidities since, a priori, it would be plausible to think that the greater the number, the greater the possibility of depression, as it has been reported by other authors . HoweverIn relation to mortality, our findings indicate that the crude IHM increased over time, both in men and women with COPD and depression, being higher in the former. Risk factors for IHM in our study were older age, the presence of pneumonia, a higher comorbidity and the use of oxygen prior to admission. These findings could relate to known risk factors for mortality in COPD . IHM wasA surprising result of our study was that men and women with COPD who also suffered from depression had a similar or even lower risk of dying in the hospital than men and women without depression. In the same way, Martinez-Gestoso et al. found no relationship between anxiety and depression with mortality in patients admitted for COPD exacerbation, but surprisingly, mortality at 18 months was lower in patients with depression . HoweverThe major strength of this study is the large number of patients included in the analysis, providing a representative sample of patients with COPD at a national level and, thus, offering high external validity and generalizability. However, several limitations in this study should be mentioned. It is an observational, uncontrolled study based on the diagnoses described in the international code of the disease. The main cause of hospitalization of these patients is not well established and the diagnosis of depression may be underestimated because it is an additional diagnosis and not necessarily the reason for hospitalization. There was no active search for a diagnosis of depression. In addition, measurements and disease assessments were limited to the information available in the database. Thus, we were unable to determine the severity of COPD or depression or the treatment for both diseases. We also did not have information on other variables such as tobacco consumption, social relationships and social or education level, which may be related to depression . AnotherIn conclusion, this study addressed knowledge gaps regarding sex differences in the trends of depression in COPD using a large sample of hospitalized patients. Our findings suggest that prevalence of depression has decreased over time in women with COPD while it has not changed significantly in men with this disease. Despite it, such prevalence is still more than three times higher in women than in men. Regarding mortality, crude IHM increased over time, both in men and women with COPD and depression, being higher in the former. Finally, we found that men and women with COPD who also suffered from depression had a similar or even lower risk of dying in the hospital than those without depression, which may be indicative of a phenomenon known as “depression paradox”. These results call for future studies to delve into the relationship between COPD and depression and evaluate the effect of specific interventions in these patients.


Coronary artery disease (CAD) is a multifactorial disease with a high prevalence, particularly in developing countries. Currently, the investigation of telomeres as a potential tool for the early detection of the atherosclerotic disease seems to be a promising method. Telomeres are repetitive DNA sequences located at the extremities of chromosomes that maintain genetic stability. Telomere length (TL) has been associated with several human disorders and diseases while its attrition rate varies significantly in the population. The rate of TL shortening ranges between 20 and 50 bp and is affected by factors such as the end-replication phenomenon, oxidative stress, and other DNA-damaging agents. In this review, we delve not only into the pathophysiology of TL shortening but also into its association with cardiovascular disease and the progression of atherosclerosis. We also provide current and future treatment options based on TL and telomerase function, trying to highlight the importance of these cutting-edge developments and their clinical relevance. During the last two decades, scientific society has been trying to investigate the role of potential biomarkers in the early detection of atherosclerotic disease . The empThe link between genetics and atherosclerosis has recently been added to the arsenal for estimating its progression. More particularly, physicians have suggested that information from genetic material may be the most specific biomarker for an individual’s predisposition to atherosclerotic disease progression and prognostication as well. This could be an important research endeavor since it is quite clear that the first signs of atherosclerosis may appear as early as adolescence, while severe complications appear later . ObservaTelomeres are the protective end caps of chromosomes that are essential for the preservation of our genome. Telomeres are regions that are constituted by millions of repeated DNA base pairs at the very end of each chromosome, which do not express any of the known proteins . In humaTelomerase is a reverse transcriptase that uses a built-in RNA template to complete the end sequences of chromosome DNA. It is the protein part of our well-known human telomerase reverse transcriptase (hTERT) and human telomerase RNA component (hTERC) whereas a short region of telomerase is used for telomeric DNA synthesis . TelomerEvery person is born with a specific TL that ranges between 5 to 15 kb, which is affected as the years go by . The ratTelomeres, called the “biological clock” of cells, are a recognized marker of cell senescence. They are widely affected by a variety of intrinsic and environmental factors via the upregulation of oxidative stress levels. It is a condition in which increased levels of reactive oxygen species (ROS), such as superoxide anions, hydrogen peroxide, and hydroxyl radicals, are present due to a biological imbalance . DysfuncAtherosclerosis is a multifactorial condition whose progression is affected by a variety of cardiovascular risk factors . Recentl2) but not in the whole cohort. No association was observed between short LTL and common carotid artery intima-media thickness or carotid artery stenosis [Atherosclerosis is characterized by the formation of plaques in the vessel wall. These emerge as a result of complex pathophysiological pathways involving pro- and anti-inflammatory cytokines ,56. Givestenosis . Trying stenosis . In anotstenosis . LTL wasstenosis . Howeverstenosis . In the stenosis . Finallystenosis .Since observational studies illustrated that attrition of LTL is related to mortality, physicians are trying to investigate its role in cardiovascular disease (CVD), which is the leading cause of death worldwide . The HutSeveral studies also investigated the association of LTL shortening with the presentation and progression of CAD. In two studies conducted in 2010 and 2021, physicians found that LTL in patients with stable CAD was significantly shorter than in healthy individuals of the same age  which was further extended to sex analysis. It was interesting that men presented with shorter LTL than women, which could partially be related to the effect of estrogen, but this is an observation that remains hazy ,76. TryiOne of the major manifestations of CAD is myocardial infarction (MI), and the development of biomarkers for early prognosis is referred to as mandatory ,82,83,84As such, we can safely conclude there is a need for further investigation of LTL’s role in cardiovascular disease. Although the results are encouraging, the lack of uniform assessment methodologies, as well as disparities in critical parameters such as patient age, ethnicity and race, and region of residence, prevent a safe conclusion from being reached.In Stockholm, during December 2009, the Nobel Prize in Physiology or Medicine was awarded to three biologists: Elizabeth H. Blackburn; Carol W. Greider; and Jack W. Szostak. Their project on how chromosomes are protected by telomeres and the enzyme telomerase changed the way that medicine used the therapeutic arsenal in several conditions including cardiovascular diseases ,94,95. TGene therapy using adeno-associated viruses to introduce the telomerase gene into aging mice appears to be promising, with incremental improvements in several biomarkers ,97,98,99Senescent cells are subjected to immunosurveillance by multiple components of innate and adaptive immunity, including NK cells, T cells, and macrophages. Due to a decrease in immunosurveillance, senescent cells accumulate in aging and diseased tissues ,106,107.Another side of the same coin is the use of senolytic drugs not only for removing senescent cells but for suppressing the processes leading to the development of SASP. The introduction of sequence-specific telomeric antisense oligonucleotides (tASOs) seems to alter the behavior of senescent cells when critical TL is reached . These oConsidering the above-mentioned innovative therapeutic methods, there are some concerns. Telomerase activation is the most prevalent hallmark of cancer cells (approximately 90%), and it is one of the most critical cancer indicators ,116,117.Another practical concern for using LTL directly in clinical practice is that current measurement accuracy is insufficient. Although measurement bias cannot be quantified in a population, this cannot be stated for individuals. The most prevalent approach, quantitative Polymerase Chain Reaction (qPCR), allows for quick testing but does not yield an absolute kilobase length estimate until combined with standard oligos . TerminaWe are currently disregarding the potential effects of human telomere lengthening. To the best of our knowledge, shortening LTL seems to be a symptom of CAD rather than a causative factor. As such, the next step may be the use of LTL for the estimation of the biological age of the body, as well as the evaluation of the risk for future major cardiovascular adverse events. It will also be a promising alternative in examining the effectiveness of preventive medications. Further research is needed in the domain, especially in the role of telomerase function and its regulated activation. This is important not only in vascular beds but also in the therapeutic alternatives of different types of cancer. Physicians have to identify the lifestyle modifications connected with LTL preservation that contribute to increased life expectancy. One of these is the optimal intensity and duration of physical activity, as well as the type of exercise. This is a subject for extensive research due to the scourge of sedentary behavior and the Western lifestyle. Finally, research on the association of air pollution levels with LTL and major cardiovascular events, assessing patients from urban and rural areas, is needed to elucidate the impact of extrinsic factors on our cardiovascular health.


Obtaining patient feedback is an essential mechanism for health care service providers to assess their quality and effectiveness. Unlike assessments of clinical outcomes, feedback from patients offers insights into their lived experiences. The Department of Health and Social Care in England via National Health Service Digital operates a patient feedback web service through which patients can leave feedback of their experiences in structured and free-text report forms. Free-text feedback, compared with structured questionnaires, may be less biased by the feedback collector and, thus, more representative; however, it is harder to analyze in large quantities and challenging to derive meaningful, quantitative outcomes.The aim of this study is to build a novel data analysis and interactive visualization pipeline accessible through an interactive web application to facilitate the interrogation of and provide unique insights into National Health Service patient feedback.This study details the development of a text analysis tool that uses contemporary natural language processing and machine learning models to analyze free-text clinical service reviews to develop a robust classification model and interactive visualization web application. The methodology is based on the design science research paradigm and was conducted in three iterations: a sentiment analysis of the patient feedback corpus in the first iteration, topic modeling (unigram and bigram)–based analysis for topic identification in the second iteration, and nested topic modeling in the third iteration that combines sentiment analysis and topic modeling methods. An interactive data visualization web application for use by the general public was then created, presenting the data on a geographic representation of the country, making it easily accessible.Of the 11,103 possible clinical services that could be reviewed across England, 2030 (18.28%) different services received a combined total of 51,845 reviews between October 1, 2017, and September 30, 2019. Dominant topics were identified for the entire corpus followed by negative- and positive-sentiment topics in turn. Reviews containing high- and low-sentiment topics occurred more frequently than reviews containing less polarized topics. Time-series analysis identified trends in topic and sentiment occurrence frequency across the study period.Using contemporary natural language processing techniques, unstructured text data were effectively characterized for further analysis and visualization. An efficient pipeline was successfully combined with a web application, making automated analysis and dissemination of large volumes of information accessible. This study represents a significant step in efforts to generate and visualize useful, actionable, and unique information from free-text patient reviews. Patient experience improvement framework of the National Health Service (NHS) defines several quality indicators, among which patient feedback is a priority [Patient experience is described by the Beryl Institute as “the sum of all interactions, shaped by an organisation’s culture, that influence patient perceptions across the continuum of care” . It is apriority . Thus, tpriority , and heaOver the past 2 decades, there has been a greater emphasis on using patient feedback to inform and improve service delivery, largely in the United Kingdom, Europe, and the United States ,10. The star rating out of 6. These publicly available reviews are invaluable insights into the work of the NHS for the service providers themselves, national bodies such as NHS England, and the Care Quality Commission as well as patients deliberating on which services to use. This is a source of vast amounts of rich data, which has the potential to significantly influence the quality of services nationwide as well as policy regarding the NHS. Patient feedback in free-text form is typically hard to analyze on a large scale, which is why standardized scales are more frequently used to generate numerical measures for comparisons [The NHS website allows users to anonymously rate and share their experience in a public forum . All NHSparisons . The difThis type of data lends itself well to analysis using computed natural language processing (NLP) techniques, enabling high-volume automated analysis of text information. In their seminal work, Greaves et al  reportedThe advent of machine learning and the development of sophisticated NLP algorithms have significantly advanced the analysis of text corpora. A significant amount of research has focused on applying advanced NLP methods to web-based reviews. Web-based reviews provide an opportunity to explore free-text corpora that do not usually adhere to a structure or format. The free text in reviews, such as the patient experience, makes the process of automated analysis of the review challenging when compared with closed questions with an expected text input. As web-based patient feedback is extensive, the traditional text analysis methods may provide limited capabilities for analysis. The latest machine learning– and artificial intelligence–based NLP methods have been well explored for analyzing large review data sets, especially for analyzing the user experience. The latest NLP methods provide capabilities to classify the reviews as positive or negative with high accuracy. Identifying the underlying themes and topics in the user experience allows us to understand the frequently reported service areas in user feedback.The aim of the study presented in this paper is to provide an automated solution for the large-scale analysis of patient feedback on health care service providers. This study achieves this by exploring NLP techniques, including sentiment analysis and topic modeling. The objective of this study is also to present an interactive interface that provides stakeholders with a portal to analyze and identify outcomes of the patient feedback analysis. This work builds on previous work in the field ,17 and partifacts that are aimed at addressing a problem. The artifacts address the problems or enhance existing solutions and are important tools for arriving at research outcomes and reviewing them to decide how the adopted artifact can be further used [For this study, the design science research (DSR) methodology was used. The DSR paradigm is a widely popular research approach in information systems research. It is referred to as a problem-solving paradigm as it aims to build her used . The DSRher used . Furtherher used .good corpus and bad corpus based on the associated positive or negative sentiment. The good corpus and bad corpus were analyzed with topic modeling to identify topics within the reviews.cleanliness and dealt with dignity, among others.The NHS website includes a platform where patients provide both ratings and reviews for a particular NHS service. The NHS website rating system provides an outline of patient experience; the rating is an optional feature that is collected for a specific set of parameters such as how likely they are to recommend the particular hospital to family and friends? This is the central question on the NHS website in that the ratings provided are used to calculate the overall rating for a given hospital. The rating for this question provides a quick and easy indicator of a hospital’s performance in providing patient care. However, the rating is single and straightforward, and it is insufficient to obtain a detailed understanding of hospital performance. For a more detailed understanding of patient feedback, the NHS website includes questions where the patients are asked to provide ratings on five parameters: cleanliness, staff co-operation, dignity and respect, involvement in decisions, and same-sex accommodation (out of 6 stars). The website-allocated ratings for these 5 parameters are optional to the users. Finally, there is an optional free-text review of a maximum of 3000 characters. These reviews follow the NHS comment policy and are moderated. The moderators remove any personal information and ensure that the reviews do not cause any legal issues such as defamation [Patients can provide feedback about NHS hospitals in 3 main sections. First, they are asked to rate, on a scale of 1 to 6, famation . ResponsAll available reviews between October 1, 2017, and September 30, 2019, were collected from the NHS website.The NHS platform provides an application programming interface (API) that allows access to the patient ratings and reviews . A custoDate, Comment, and Label columns in the database. The Date and Comment columns referred to the posted date and the content of the participant’s comment, and the Label column was used to hold the sentiment of the comment, classified as either positive or negative.The data set underwent a few processing steps where only columns from the data set that were relevant for this study were selected. Specifically, for parsimony purposes, only relevant data fields were extracted and relabeled into Label column were not defined.Data were organized by posting date ,23 and pHow likely are you to recommend this hospital to friends and family if they needed similar care or treatment?—were used as the actual data against which the performance of the text-mining model  was tested. Owing to the skewed distribution of the numerical responses and limitations of the machine learning methods, to reduce complexity in the modeling procedure, the continuous-scale patient feedback ratings were discretized. Following discretization, rating scores of 1 and 2 were categorized as negative, and those of 5 and 6 were categorized as positive. Rating scores of 3 and 4 were discarded as they were deemed neutral ratings that did not portray polarization. This categorization served as a binary sentiment label for which each text-mining model was trained and assessed.Within the data set, the ratings given by the participants for the following question—Sentiment analysis, also referred to as opinion mining, refers to the computational study of people’s opinions, sentiments, attitudes, and emotions toward an entity. The entity can be another individual or a public figure, a product such as an electronic device, or service providers such as restaurants and hospitals. The identification of sentiment is performed based on the presence of words or phrases that are likely to refer to an opinion, sentiment, or emotion. If the sentence is identified as having a sentiment or opinion, it is then subjected to the feature selection process. During this process, the identified sentiment is associated with the feature that is being discussed. Finally, the sentiment is categorized into a chosen classification type. For instance, the sentiment can be classified into a binary, such as positive or negative. The sentiment analysis is associated with a score.The fine-grained sentiment score detects polarity within a text; in this case, whether the review is a positive or negative opinion. There are several approaches to sentiment analysis, including the strength of association, naïve Bayes (NB), and the support vector model. NB-based sentiment analysis models are popular and widely used. The NB classifier is a probabilistic classifier, which uses a mixture of models for classification and is widely popular for sentiment classification. Given a document, and based on the distribution of words in the document, the NB approach computes the probability of a document belonging to a class. This model calculates boundaries according to the distribution of the words across the labels while at the same time considering the joint probability of the words occurring independently together. Specifically, NB considers each word independently of one another and then tries to estimate the posterior distribution of a review being positive or negative according to the joint distribution of the words in the review. The probability is computed using the Bayes theorem to predict that a given word belongs to a specific sentiment.One of the popular implementations of sentiment analysis based on NB is the TextBlob rule-based sentiment analysis , which wgood or bad more quickly and consistently than a human-based process.The TextBlob implementation was used to analyze each of the 51,845 reviews to determine their sentiment value. This produced a score for each review between −1 and 1, where 1 represents a wholly positive sentiment, −1 represents an entirely negative sentiment, and 0 represents a neutral sentiment. This provided a method for evaluating whether reviews were Topic modeling is an unsupervised NLP approach where unlabeled documents are used to create a set of topics represented by a list of words that frequently occur in each topic. There are several topic modeling approaches, and most use dimensionality-reducing techniques with the goal of representing a document using fewer words. Some of the most popular topic modeling approaches are probabilistic latent semantic indexing (LSI), latent Dirichlet allocation (LDA), and correlated topic modeling (CTM).bags of words to represent documents. It aims to extract words that carry similar meanings . The LSA disadvantage of the LSI approach is that the number of parameters in the model increases as the volume of data increases, and this could lead to overfitting problems. Furthermore, when the LSI model is used on documents that were not part of the training data set, the topic probabilities have to be assigned again .The CTM approach helps in identifying the correlation between a specific topic and others. The correlation information might help the users in identifying links or associations between a specific topic from a database and other similar topics. The CTM approach uses a logistic normal distribution to identify topics from documents. A covariance matrix used for parameterizing the distribution is then used to identify the correlation between the topics. A topic graph is subsequently drawn, in which the topics are represented by nodes and their correlations with other topics are depicted . The corThe LDA approach also works under the assumption of LSI . However, this assumption is extended by using a hidden variable model of documents that consists of hidden random variables with which the observed data interact . In LDA,bag of words assumption used in the LDA approach makes it invariant to the order of words in the document. Furthermore, the order of documents in the corpus is also not a criterion for the LDA approach to extract topics from the document. This might not be suitable if the patient’s experience needs to be analyzed longitudinally . However, in this study, as the patient experience analysis did not consider the time factor, the LDA method suited its aims.An advantage of the LDA approach is that the statistical assumptions it makes for topic modeling enable it to uncover sophisticated structures in the texts. For instance, the We used the LDA topic modeling approach to categorize each review into computer-generated topics. LDA initially assumes the number of topics and attempts to calculate topics that best represent the documents. It does this by calculating the probability estimate of a word for a given topic as well as the probability of a topic for a given document .We used an LDA implementation called LDA Mallet owing to its use of a more precise sampling method called Gibbs sampling . Data weReviews were then labeled according to the dominant topic. The dominant topic was defined by the LDA model, predicting the percentage contribution of that topic to be ≥50%. The reviews that did not have any topic that contributed ≥50% were not included in the following analysis.The corpus was divided into two subcorpora, the first one being negative-sentiment–scoring reviews and the second one being any positive-sentiment–scoring reviews. Similar to the topic model for the entire corpus, we then performed experiments to determine the optimal parameters for both corpora. Using these parameters, we produced two models, one showing the topics generated from negative-sentiment reviews and the other showing topics generated from positive-sentiment reviews. Applying these new LDA models to their respective corpora produced a topic mixture for each entry of their respective corpora.The nested topic modeling approach enables the identification of the rationale behind a particular sentiment of the patient in each comment or review. The intent is to find out why the patient was happy or unhappy about a particular topic in each comment. The problem being addressed in this iteration of the study was to find the possible reason behind a patient’s sentiment for a particular topic in each comment.Visualizing the results from the NLP methods relied on a Microsoft Azure Cloud Service  to host NHS England is segmented into seven geographical regions with teams supporting the delivery of care locally: London, Midlands, North East and Yorkshire, North West, East of England, South East, and South West. Of the 11,103 possible services across these regions, 2030 (18.28%) services received a combined total of 51,845 reviews between October 1, 2017, and October 31, 2019. Among the reviewed services, the mean number of reviews per service was 26 (SD 60.3), and the highest number of reviews for a single service was 550 for Lincoln County Hospital. During the study period, the mean number of reviews per month across England was 2028 (SD 449.1). The number of reviews per month declined from 2625 in October 2017 to 1611 in September 2019.The number of services per 10,000 population was similar around England, with the lowest being in London, which also has the highest-density population . Across P=.02).To explore the opinions held within the reviews, the sentiment was analyzed for the entire corpus and for individual reviews. The analysis generated a score for how positive  or negative  the sentiment was between −1 (most negative) and 1 (most positive). Examples of reviews and their corresponding score can be found in A total of 14 clusters were identified from the entire corpus, from which themes were derived manually . Reviewsparamedic and ambulance , booking appointment , good experience , operations and surgery , and A&E . These topics comprised 46.49%  of the labeled reviews. Most topics occurred at a steady rate across the study period. No patterns in that variation in topic frequency were identified; however, procedure and dealing with anxieties increased, whereas obstetrics decreased in frequency across the study period  and negative-scoring reviews (≤0.2) were separated into 2 smaller corpora to undergo topic modeling to obtain new sets of positive and negative topics. The optimal number of topics was decided by creating a model for each number of topics in the range of 5 to 20 and using the coherence score as well as human intuition to determine the best topic model. Positive and negative clusters were identified, and the topics were labeled manually  and 5. TThe NLP analytics were then incorporated into a user-friendly web-based interface that enables the exploration of the data through the graphical user interface . Users cThe outcomes of the study presented in this paper demonstrate that NLP-based analysis using sentiment analysis and topic modeling can be used to develop an automated solution for analyzing patient feedback and reviewing the performance of a health care center. The results of the sentiment analysis showed that patient feedback can be accurately classified into positive or negative sentiments and the topic modeling approach can be used to identify topics in a patient review. Furthermore, the identified topics were associated with a sentiment based on the results of the sentiment analysis. This study also presented an interface for stakeholders to view and interact with the outcomes of the patient feedback analysis.In this study, close to 52,000 reviews from 2030 services were considered for analysis over a period of 2 years. The average number of reviews per service was 26 (SD 60.3). This is indicative of a generally low level of patient engagement with providing service feedback. Furthermore, the number of reviews over time shows that patient review activities have seen a consistent downward trend.A larger corpus of patient reviews can significantly contribute to building analytical models with capabilities to perform more granular analyses such as individual service performance, areas of concern for a selected service, and similar fine-grained analyses. They improve the communication channel between patients and services, and incentives for patient engagement are necessary for increasing the average number of patient reviews and contributing to the development of improved assessment tools.procedure and dealing with anxieties , implying that undertaking a procedure might be an anxious process for patients, and the average sentiment score of 0.33  indicates that the patients are generally happy with the service and care provided by the NHS services.The identification of a topic based on topic modeling is a useful tool as it helps in understanding the areas of performance and areas of concern for the NHS services. In this study, the most frequent topic was booking appointments  implies that the patients might be unhappy with the current appointment booking service. Therefore, topic identification, along with the associated sentiment score, allows policy makers to use the learnings from areas of success and potentially apply them to areas of concern to improve patient satisfaction with the NHS services.On the contrary, another frequently reviewed topic was The study presented demonstrates a multifactorial analysis that can be performed using topic modeling and sentiment analysis approaches. A large corpus helps in achieving temporal analysis of patient feedback, as demonstrated in A&E was most frequently reviewed across the regions. Procedure and dealing with anxieties was another frequently reviewed topic across regions. Region-based, frequently reviewed topics are a piece of beneficial information for policy makers to gain insights into the weak areas of NHS services for each region and, in general, across all regions.The combined approach of sentiment analysis of topics identified from topic modeling methods helps collect insightful information about health care services. In our study, the sentiment classification of each topic helped in assessing the public’s perception of the NHS services for a given topic, thus reflecting the service quality. With a large corpus of reviews, the sentiment analysis of identified topics over time can potentially explore the links between temporal factors, such as seasons, and patient experience for each topic. The results of this study demonstrate a decrease in sentiment during the winter. A more extensive and diverse data set of patient reviews has the potential to extract links between seasons and specific topics for further causal inferences to be made. For instance, a variation in sentiment scores for a topic across seasons can be analyzed for external causal factors such as influenza outbreaks, pandemics, staff shortages, technological hindrances, political changes, and similar outside factors.good staff, rather than just the topic itself. Although this did not affect the accuracy of the results, it could cause the topics to be less useful.We note that there are limitations to this study; the first one was that we discounted reviews that did not include a dominant topic. This reduced the population size and ignored reviews that might provide valuable insight. Second, both sentiment analysis and topic modeling inevitably have misclassification errors, especially when the user reviews can be misspelled or have a double meaning (sarcasm). The third limitation is that the topics from the topic modeling are influenced by words that carry sentiment; this causes some topics to carry sentimental meaning, such as Providing patient reviews in an easily inferable format through visualization tools to the public can foster competitiveness to improve among the NHS services. It is essential to provide analytical outcomes in an accessible format to general users to support patient autonomy and decision-making. The visualization tool developed in this study has the potential to rapidly and easily disseminate the findings of this study using maps and graph-based visual analytics. The visualization further enables users to view the feedback of an NHS service based on the key areas identified from the topics.This study presents an automated system for the analysis of patient feedback based on NLP techniques and topic modeling. The DSR methodology was adopted for this study to conduct the patient feedback analysis in 3 iterations. In the first iteration, sentiment analysis of the patient feedback corpus was performed followed by a topic modeling–based analysis of the corpus. In the third iteration, the sentiment scores and topics identified were further analyzed to associate the sentiment scores with the topics identified and categorize the corpus into good and bad corpora. Furthermore, we provided a data visualization interface with potential use for policy makers and associated stakeholders to review the performance of health care centers individually as well as by regions and identify the possible causes behind the performance of a health care center. The future work of our study aims to collect and analyze larger patient feedback databases to build more accurate analytical models. We are exploring artificial intelligence–based NLP models to include them in our analysis.