Background: Lack of physical activity (PA) is the fourth risk factor for all-cause mortality. Regular PA reduces noncommunicable disease (NCD) and mortality risk. The built environment (BE) is a determinant of spontaneous daily PA. Professionals who plan and build the BE therefore affect public health. We tested the hypothesis of a lack of formal pregraduate training about associations between the BE, PA and health in architecture, landscape architecture, and urban design academic degree programs (DPs) in Switzerland. Methods: We reached out to all DPs in Switzerland to ask if and how these associations are taught. For those declaring to teach the topic, the program syllabus and course material were inspected. Results and discussion: For 30 out of 33 identified programs, information for the analysis was obtained. A total of 18 declared teaching the BE, PA and health associations, but this could be confirmed for only 5 after verifying the course content. Teaching principles of building PA-promoting BE represents an underutilized potential for public health promotion. Conclusions: There is a need to introduce formal learning objectives in architecture, landscape architecture, and urban design DPs in Switzerland on the associations between BE, PA and health. It is likely that similar needs exist in other countries. Noncommunicable diseases (NCDs) such as cardiovascular diseases, diabetes, cancer, and chronic respiratory diseases are leading causes of mortality globally  as well The World Health Organization (WHO) recommends a minimum of 150 min/week of moderate intensity PA or 75 min/week of high intensity PA . SimilarEveryday activities such as walking to a bus stop or a shop, or cycling to work, contribute to better health outcomes . Hence, Most studies on the BE and PA focused on where people live. People also spend a lot of time inside buildings, for work, study, shopping or leisure. The site and design of buildings affect PA as well . ElementBuilding a physical activity promoting BE represents an opportunity to increase people’s PA and health. However, to allow architects, landscape architects and urban planners to implement such active designs, they need to have learned about the rational, the knowledge and the knowhow to do so. Informal contacts with active professionals in the field and with actors in various Swiss degree programs (DPs) in architecture, landscape architecture and urban design led us to formulate the hypothesis of a lack of formal pregraduate training in these DPs about the associations between the BE, PA and health and the general principles of epidemiology and public health. To test this hypothesis and to find out what is taught about the associations between the BE, PA and health, we conducted a survey of all Swiss DPs providing pregraduate training in architecture, landscape architecture and urban design.By means of online questionnaires and direct contacts we surveyed Swiss architecture, landscape architecture, and urban design DPs. The study protocol did not fall under the Swiss law on research on human subjects and formal ethical approval from the local institutional review board was waived .All existing relevant Swiss degree programs (DPs) were identified. Twelve academic institutions offer a bachelor DP in architecture. Six architecture DPs are offered at master level. The Universities of Bern, Geneva and Fribourg offer a joint master of architecture. Landscape architecture can be studied in two bachelor DPs at the university of applied sciences (UAS) in Geneva and Rapperswil, and in two master DPs, at the Swiss Federal Institute of Technology Zurich (ETHZ) and at the University of Applied Sciences (UAS) Rapperswil. The master at the UAS Rapperswil has two tracks, landscape architecture and spatial development. Although there is just one bachelor DP for urban design, at the UAS Rapperswil, there are five master DPs, at the Universities of Geneva and Lausanne, the ETHZ, and the UAS Rapperswil (double track master mentioned before). At the Swiss Federal Institute of Technology Lausanne (EPFL), there is a minor in territorial and urban design development. This interdisciplinary minor consists of a group of compulsory and optional courses offered by the faculty of Architecture, Civil and Environmental Engineering. This minor is open for all master students across the three sections of this faculty. Further education in spatial planning exists in the form of a Master of Advanced Studies (MAS), which is offered at five universities; the EPFL and the University of Geneva offer one of them jointly. Detailed information on all DPs can be found in the (1)“Does your university/college propose one or more lecture(s) in one or more course(s) that explicitly deal(s) with the relationships between the built environment, physical activity and health?”Requests to fill out an online questionnaire (in French and German) were sent by email to all of the DPs’ responsible persons. Contacts for DPs were found on the homepages of the academic institutions. Some contact persons transferred the request to someone with better knowledge of the DP content. Respondents were asked to enter their name, academic institution, function, and role in defining the DP content. They were then asked if there was a specific course in their program that discussed the links between BE, PA and health:(2)“Is the connection between physical activity and the built environment dealt with in another lecture, but not as primary learning content?”Since it was possible that this link was taught, but among other learning objectives in another course, if the answer was no, they were asked if this topic was touched upon in a different course of study:If the answer to questions 1 or 2 was yes, respondents were then asked to specify the name of the course, in which program it was taught, and if the syllabus of the course could be made available.(3)“Does your university/college have a lecture in one or more courses that deals with health, epidemiology or public health?”In the second part of the questionnaire respondents were asked if any course existed that taught health, epidemiology and public health in their program:(4)“Are health, epidemiological or public health topics dealt with in another lecture, but not as primary learning content?”If the answer was no, the survey participants were asked if there was a course in which these topics were mentioned, but not as a part of the main course content:If the answer to one of these questions was yes, respondents were again asked to enter the name of the course, the DP in which the course was taught, and if the description of the course could be made available. For all of the identified courses, further information about the course contents was requested  directly filled out the questionnaire with the contact person . If no rWhen the respondent declared that there was a course that taught the relationship between BE, PA, and/or one on public health and epidemiology, the course descriptions and learning objectives were inspected. Since it was possible that a course taught the topic, but not as one of its main objectives, course descriptions were analyzed for mentions of health and PA. The responses given in the questionnaires and by telephone were compared to the actual content of the documents. To fully analyze the content of the courses, further information was requested from course directors and professors teaching the courses. They were contacted by email or telephone, and asked to confirm that not only the association between BE and PA is taught, but also the positive effects of PA on health, as well as the links to epidemiology and public health. For the verification, they were asked to provide, if possible, the course material  that could prove that these relations were actually taught to the students. The received material was then inspected for verification. The verification was successful if, on at least one slide or in one document, the health benefits of PA in connection to the BE were described in any form. If no course material could be made available, an explicit and written confirmation from the professor teaching the subject was accepted as proof in the analysis.Responses were obtained from 29 of the 33 DPs contacted The data was provided by 16 program directors, 5 professors teaching relevant courses, 3 study coordinators, 3 administrators, 1 study advisor and 1 course co-director. Out of the 29 respondents, 25 declared that they have an active role in designing the DPs, 3 in coordinating the DPs, while one respondent did not actively participate in the design of the DPs. For one masters program, in spatial development and infrastructure systems at the ETHZ, no response could be obtained. After screening the program description online, a course was identified which mentioned a link between BE and PA. Through direct contact with the professor responsible for this course, information about the course could then be obtained and inspected.Seven DPs declared the inclusion of a specific course teaching the relations between the BE, PA and health, while eleven DPs said the subject was taught along other concepts in another course of the DP. Twelve DPs answered negatively. Subdividing, none of the 17 architecture DPs declared a specific course on the relations between the BE, PA and health, while 5 architecture DPs declared some limited teaching on the topic. Three landscape architecture DPs declared specific courses, one some limited teaching. In urban design, five declared specific courses, five some limited teaching , this could be confirmed for only 5 out of 18 DPs. Four DPs declared that the subject is taught in so-called studios  for which there was no course material available, and therefore it could not be directly confirmed whether it was formally taught. For two DPs no confirmation could be obtained. Upon verification, in seven DPs the BE-PA-health links were not taught, contrary to the declarations by the respondents .None of the architecture DPs contained a course where the topic was specifically taught. Either the link between the BE and PA was only cursory explained without considering the health effects, or a link between the BE and health was taught without taking into account PA. For the five architecture DPs for which the respondents indicated that this link was taught, it could not be confirmed. For the two DPs at the University of Bern, it was declared that the subject was taught in design studios, but again this could not be confirmed.For the landscape architecture DPs, all respondents indicated that the link between the BE, PA and health was taught. It could only be formally confirmed for the bachelor DP at UAS Rapperswil and the master DP at the ETHZ. In the master DP at UAS Rapperswil, the link was only cursorily taught. For the DP at the University of Geneva, no confirmation could be obtained.For the urban design DPs, similar findings were obtained. All respondents of the ten DPs answered either question one or two of the questionnaire positively, indicating that the topic was taught in some way. In the Master in Environmental Sciences (MUSE) at the University of Geneva, and the Master of advanced studies in Spatial Development at UAS Rapperswil, it could be confirmed that there was a course which specifically focused on the topic. In the DPs at the University of Lausanne, it was briefly mentioned but was not a focus. For one DP, no confirmation could be obtained, in three it was not taught and for two DPs it was declared that the link was taught in design studios.In questions three and four of the questionnaire, the respondents were asked if in any of the respondent’s university programs there was a course that discussed concepts of health, epidemiology and public health. Three DPs indicated that a course treating health, epidemiology or public health existed in their core curriculum: (1) ETHZ, landscape architecture: “New city landscapes and health”; (2) University of Geneva, urban design: “Environment and health”; and (3) EPFL, urban design: “Exploratory data analysis and geovisualization”. Although the other 26 DPs did not include a course on public health or epidemiology in their core curriculum, there were numerous courses in other DPs at the same academic institutions that did teach one or the other of those subjects.We inventoried what is taught in general about health, epidemiology and public health, and in specific about the relationships between the BE, PA and health in Swiss pregraduate degrees in architecture, landscape architecture and urban design. Our main finding is an important overall lack of learning objectives and formal teaching content on these topics, with some rare and rather partial exceptions. Given the state of science in this field and its articulation with the UN’s sustainable development goals, this finding is disconcerting . It is nWhile in most of the landscape architecture and urban design DPs the topic was covered, at least partially, none of the architecture DPs taught the relations between the BE, PA and health in any comprehensive way. Only five out of seventeen DPs declared having courses in which this relation was taught. However, upon verification of course content, even if PA was mentioned in a course, the link to the health benefits of PA was never made explicit. The courses at the ETHZ in which PA was mentioned were courses about landscape architecture, but did not address promoting PA inside buildings. Design studios were reported to mention this relation, but as the projects of these studios change every year, and because not all students take the same design studios, they are not part of the core curriculum. Other courses indicating a mention of the importance of BE on health in general tended to focus on health parameters like ergonomic furniture, air quality or chemicals, but not PA. According to Klepeis et al. , most peWe propose that the core curriculum of any DP in architecture, landscape architecture and urban design includes learning objectives and formal teaching material on these themes, preparing the students for their future professions. Ad minima, this core curriculum could contain a historical perspective, the current inactivity epidemic and its health consequences, the relationship between PA and NCDs, the influence of the BE on PA, BE design principles promoting PA and showcases of examples of active design. Based on a model curriculum developed by Botchwey et al.  and otheThe relationships between the BE, PA and health, especially inside buildings, are not yet fully understood ,36. NeveThose responsible for the DPs were asked to identify courses where the relations between the BE, PA and health are taught. However, no precise definition was given for PA. This led to some confusion, as PA was sometimes equated with exercise or sport. An additional limitation was that the respondents did not always exactly know what their colleagues taught in their courses and could not always provide detailed information about the actual course content. For this reason, some courses that might have mentioned the investigated subject being an aside may have slipped through our analysis. For those courses, where no further course content was received, the only way to find out if this subject was taught, would have been to attend the courses in person. Nevertheless, it was clear that for those DPs there were no clear indications for formal learning objectives and content in the program. For architecture and landscape architecture, only bachelor and master DPs were analyzed, whereas for urban design a postgraduate master of advanced studies was added to the analysis. It cannot be ignored that there are such postgraduate master and doctoral programs in other fields where the topic may attract more attention than in the pregraduate bachelor and master DPs.It is known that the BE influences our PA behavior and therefore has an impact on the leading cause of mortality—NCDs. The promotion of movement-friendly environments is a promising application area for the promotion of PA and health. Nevertheless, it is rarely taught in the Swiss architecture, landscape architecture and urban design DPs. Out of 30 analyzed DPs, only five formally and fully taught the relations between the BE, PA and health. In none of the 17 architecture DPs could it be confirmed that students are made aware of the effect our BE has on PA and on health. In contrast, two out of the four landscape architecture DPs taught the importance of promoting PA when planning environments. In urban planning, the importance of PA in our society has indeed become a part of some urban planning degrees. However, in the courses, the focus is mainly on the technical part, on how to provide infrastructure that promotes PA, without considering the health aspects. This aspect is only fully developed in 3 out of 10 urbanism DPs. These findings indicate that a lot of students of all three formations were not made aware of the consequences physical inactivity has for our health, and how in their future professions they can have an impact on our health by planning movement-friendly environments. An interdisciplinary cooperation between physicians, sport scientists, epidemiologists, sociologists and planning professionals needs to be encouraged to overcome this lack of knowledge. In conclusion, there is a need to introduce formal learning objectives in architecture, landscape architecture, and urban design DPs in Switzerland on the associations between BE, PA and health. It is likely that similar needs exist in other countries. We recommend repetition of our study in other countries combined with active advocacy for the formal introduction of the core curriculum we herein propose.


Despite decades of research on the impact of interprofessional collaboration (IPC), we still lack definitive proof that team-based care can lead to a tangible effect on healthcare outcomes. Without return on investment (ROI) evidence, healthcare leaders cannot justifiably throw their weight behind IPC, and the institutional push for healthcare manpower reforms crucial for facilitating IPC will remain variable and fragmentary. The lack of proof for the ROI of IPC is likely due to a lack of a unifying conceptual framework and the over-reliance on the single-method study design. To address the gaps, this paper describes a protocol which uses as a framework the Quadruple Aim which examines the ROI of IPC using four dimensions: patient outcomes, patient experience, provider well-being, and cost of care. A multimethod approach is proposed whereby patient outcomes are measured using quantitative methods, and patient experience and provider well-being are assessed using qualitative methods. Healthcare costs will be calculated using the time-driven activity-based costing methodology. The study is set in a Singapore-based national and regional center that takes care of patients with neurological issues. Despite decades of research on the impact of interprofessional collaboration (IPC), we still lack definitive proof that team-based care can lead to tangible effect on healthcare outcomes ,2. In anThe lack of definitive proof for the ROI of IPC is likely due to two reasons: lack of a unifying conceptual framework with which to measure the healthcare outcomes of IPC, and over-reliance on the single-method study design for examining a phenomenon as complex and multi-faceted as IPC.Notwithstanding IPC’s purported goal to improve patient care, IPC literature does not commonly report on its contribution to achieving the goals of healthcare, namely population health, patient experience, and cost of care, commonly known as Triple Aim . In a syA strong candidate is the Quadruple Aim , an expaThe other reason why IPC still lacks definitive proof of ROI could arguably be traced to the over-reliant use of a single-method  study design . While qThus, the need for an approach that leverages both quantitative and qualitative methods in a complementary manner to evaluate IPC’s contribution to achieving the Quadruple Aim emerges. Quantitative methods are useful for measuring patient outcomes and cost of care as they are quantifiable. But for patient satisfaction and provider well-being, both of which involve interactions that are dynamic, variable, and non-linear , qualitaWe would like to propose an approach that may be new or unfamiliar to IPC researchers. Extant literature shows that the impact of IPC on the cost of care is often measured by shorter length of stay or lower rate of readmission ,20,21. HIn view of the above limitations, this study presents time-driven activity-based costing (TDABC)  as an alThis study’s protocol aims to illustrate the feasibility of using the Quadruple Aim as a framework to measure IPC’s ROI by adopting a multimethod approach . The proThis protocol paper describes two studies using the four dimensions of the Quadruple Aim framework to assess the impact of IPC on healthcare outcomes. The sections entitled ‘Study Setting’ and ‘Selection of the IPC Teams to Study’ will apply to both studies. However, the information for each study will be provided in a separate section to enhance readability.The study setting is the National Neuroscience Institute (NNI) in Singapore, a national and regional center for treating the conditions of the brain, spine, nerves, and muscles. NNI operates out of two main hospitals  and four partner hospitals  in Singapore. Specialist physicians, nurses, and allied health professionals (AHP) namely radiographers, therapists, psychologists, and medical technologists from the Departments of Neurology, Neurosurgery, Neuroradiology, Neurodiagnostic, and Neuromuscular Laboratories integrate their expertise and work together to care for patients in both inpatient and outpatient settings in these hospitals. Inpatient care is delivered by multidisciplinary teams of physicians, nurses, and AHP. These teams consist of a combination of core fixed members  and fluid members (nurses and AHP of the wards). Outpatient care is mainly delivered by fixed teams of nurses and physicians (two to four members).We will use a purposive sampling strategy known as positive deviance sampling, which allows researchers to compare individuals or communities who have discovered solutions to problems (positive deviants) with those peer individuals or communities who continue to struggle with the problem . In thisPositive deviance sampling strategy is useful for facilitating culture change because it identifies examples that have found solutions to problems and difficulties within a given organization itself, rather than impose change from external sources ,26. ExamWe will use a retrospective cohort study design for the assessment of patient outcomes and TDABC methodology for the assessment of cost of care.The population for population health in this study refers to patients with neurological disorders receiving care from the three selected team-based practices in NNI. For the assessment of patient outcomes, all patients who have been receiving care in the three selected team-based clinics since the start of these clinics  and have at least one-year follow-up period as of July 2022 will be included in the study sample.The calculation of the cost of care does not involve sampling. We will survey all HCP involved in delivering care in the three selected clinics at the time of the study on the average amount of time they spend on each of the activities specified in a care pathway.For patients receiving care in the PCC for head injuries which are acute, the primary patient outcome measure will be time to symptom resolution. The symptoms include vertigo, convergence insufficiency, cognitive functioning, psychological functioning, sleep disorders, and headache. For patients with epilepsy or neuroimmunological disorders which are chronic, the primary outcome measures include both disease activity and patient adherence to medication. Disease activity for epilepsy is measured by seizure frequency, and that for neuroimmunological disorders is measured by clinical (relapses) or radiological  activity after initiation of immunotherapy. Medication adherence is based on patient self-reporting and is documented during each clinic visit. Secondary outcomes are process outcomes directly related to IPC for each clinic: rate of identification of symptoms by AHP for PCC, completion rate of screening for medication adherence, time to initiation of immunotherapy for NC, and tolerance and complications for EC. In addition to outcome measures, we will also collect data on patients’ demographic and clinical characteristics at the baseline , and treatment regimen during the study period. All data will be extracted from electronic medical records upon appropriate institutional approval.Following the TDABC methodology , calculaSurvival analysis will be used to characterize the primary outcome of time to symptom resolution for patients in PCC and the process outcome of time to initiation of immunotherapy for patients in NC. Cox proportional hazards regression analysis will be performed to examine these time-to-event outcomes after adjusting for the baseline demographic, clinical characteristics, and the treatment regimen during the follow-up period. Generalized Linear Mixed Models (GLMM) will be used to analyze the longitudinal primary outcomes of patients in NC and EC from the shortest period of one year to the longest period of eight years adjusting for baseline characteristics and treatment regimen during the follow-up period. Other process outcome results will be obtained through simple arithmetic calculations.We will calculate the cost of each activity along the care pathway by multiplying the time spent on each activity by a specific HCP and the unit cost for the HCP performing the activity. The cost of an episode of care will be the sum of the costs of all activities on the care pathway. The concept of ‘episode of care’ in this protocol will be determined by the care pathway of the respective clinics. The total cost for each clinic will be calculated by multiplying the cost of each episode of care by the volume of patients treated during the study period.For the patient experience component of Study 2, all patients who have been receiving care in the three selected team-based clinics since the start of these clinics  and have at least a one-year follow-up period as of July 2022 will meet the inclusion criterion. We will be using a purposive sampling strategy known as team sampling unit (TSU), where we interview  the patiWe will also seek the patients’ consent to shadow them ,35. We wPatient recruitment will be done by one of the research team members (QC) who is a neutral party not involved in the care of the patients. To avoid any impression of coercion, the consent form will state that, regardless of their decision to participate in the study, patients will continue to receive the same level and quality of care as before. As patient gender, age, and severity of condition may influence the team’s attitudes and actions regarding care , patientStudy 2 also aims to examine the impact of IPC on provider well-being. As PCC, NC, and EC comprise only between two and four individuals—the specialist physician, the advanced practice nurse or nurse clinician, a physiotherapist, and an occupational therapist—we will use as our sampling a strategy known as complete target population . As suggWe anticipate that some of the HCP to be recruited for this part of the study may not be identified as part of their patients’ TSU. Even so, if the HCP give consent we will interview and observe them because the small size of the PCC, NC, and EC teams does not provide us with viable alternatives. Furthermore, it is challenging to get clinicians to consent to be interviewed due to the time-consuming nature of qualitative data collection. Hence, it is prudent to engage any HCP who agree to participate in the study.We plan to also collect observation data because while semi-structured interviews have the potential of allowing us to unveil the HCP’s personal experiences, this mode of data collection may not always reflect the actual interactions and hence observations might serve as a useful complementary qualitative data collection tool . HoweverRecruitment for both components of Study 2 will continue until we reach data sufficiency, which is when we are able to construct findings that elucidate in a rich and nuanced way the impact of IPC on patient experience and provider well-being. Should the response be poor, we will seek the help of PCC, NC, and EC nurses to encourage the patients by explaining how their participation may help to improve care delivery. To avoid a conflict of interest, the nurses will not engage in direct recruitment.A team of trained qualitative researchers  with no prior relationships with or influence over the patients, their caregivers, and HCP will be involved in the data collection. The three researchers will be rostered based on availability to conduct semi-structured interviews . We willDe-identified interview transcripts and observation notes will be inductively analyzed using reflexive thematic analysis (RTA) ,39. UsinThe threat of the pandemic on healthcare systems globally may be receding but occasional surges in cases within hospital settings mean that researchers may be unable to collect data in person. In view of such contingencies, we are prepared to conduct our interviews with patients, their caregivers, and HCP over Zoom communications. This is provided that the participants have access to the internet, Zoom software, and possess the requisite technological know-how. For patients or caregivers who lack technical affordances, we will postpone the collection of data until such a time when it is deemed safe for research to resume. Patient shadowing and observations of healthcare teams will similarly be postponed. This research protocol aims to address the seemingly intractable problem of measuring IPC’s ROI. Without addressing this critical gap, evidence for the ROI of IPC will remain fragmented which makes it difficult for healthcare leaders and policymakers to appreciate the value of IPC objectively. Hence, we seek to demonstrate the feasibility of measuring IPC’s ROI by operationalizing the Quadruple Aim framework using a multimethod approach. Specifically, quantitative methods are used to measure patient outcomes and cost of care, and qualitative methods to understand how team-based care impacts patient experience and provider well-being.These aims notwithstanding, this protocol has several limitations. For study 1, the evaluation of patient outcomes adopted a single-arm design due to the unavailability of a parallel comparison group in NNI and the unavailability of electronic medical records of a historical comparison group. As a result, we are unable to make a statistical comparison of the patient outcomes of team-based care with those of usual care. Instead, a non-statistical comparison with the treatment outcome for patients with the same diseases reported in the published literature will be made to interpret the findings of this part of the study. However, as this protocol is meant to test the feasibility of our concept of how to measure IPC’s ROI, future studies could prospectively plan to collect data for a comparison study.As for Study 2, interview and observation data have inherent limitations. While semi-structured interviews may help researchers gather hard to access information such as perceptions and experiences of patients and HCP, the data may be limited by recall bias or not reflect actual interactional patterns. Observation as a mode of data collection may also raise concerns about participant reactivity, where participants may act differently because of the presence of a researcher. For these reasons, study 2 is designed to collect both interview and observation data for triangulation purposes. Projecting ahead, if the two empirical studies described in this protocol prove to be effective in measuring the ROI of IPC, researchers may proceed to examine other important issues on whether, how, and when healthcare budgets should be invested/disinvested in IPC. From the perspective of practical import, this will be helpful in guiding healthcare leaders and policymakers to make evidence-based decisions in the provision of healthcare. From the theoretical perspective, being able to strengthen the evidence base of IPC’s ROI will also help to advance this field of research.


Clostridium tetani, which causes muscle hypertonia and autonomic neuropathy. The diagnosis is based on clinical findings and not the result of specific blood and imaging tests; hence, it is very difficult to diagnose at first sight, despite typical initial findings such as lockjaw, muscle spasms, and neck pain and stiffness.Tetanus is a fatal disease caused by a neurotoxin produced by the biotrophic anaerobic bacterium This article discusses the case of a 79-year-old woman who first consulted her local doctor because of a lack of jaw opening. Seeing no improvement, she visited our hospital and was suspected of having tetanus after consulting with nine different departments over seven days from the initial visit. In developed countries, tetanus prevalence has declined due to immunization, leading to clinicians' lack of experience in diagnosing it. Furthermore, the increasing specialization in general hospitals poses a risk of missing a tetanus diagnosis when a patient consults multiple departments. Tetanus is a fatal disease in which neurotoxins, produced by the disease-causing bacteria that invade the wound after trauma, spread hematogenously or lymphatically and derepress peripheral motor, cranial, and sympathetic nerves, causing muscle hypertonia and autonomic nervous disorders.The incubation period between tetanus invasion and symptom onset can range from 24 hours to several months. The length of the incubation period is reflected by the distance the toxin travels from the wound site to the central nervous system and is related to the amount of toxins produced . The perTherefore, it is advisable to start treatment for tetanus as early as possible, but it is often difficult to make a definitive diagnosis at the initial visit, with previous studies reporting a time from onset to diagnosis of 7.6 days .The reasons for the delay in tetanus diagnosis include the low awareness of the usefulness of the spatula test , where she was diagnosed with a malfunction of the mouth and referred to the department of dentistry and oral surgery the following day. On the same day, she was also examined at the department of spinal cord surgery for neck discomfort, and a magnetic resonance imaging (MRI) scan of her neck showed no spinal disorder. The next day (day -5), the patient was referred by the otorhinolaryngologist to an oral surgeon and was deemed to have no problems with the temporomandibular joint, with an opening corresponding to 1.5 lateral fingers and a forced opening of 30 mm. The same day, on request for an internal medicine consultation, it was found that her weight had dropped from 48 kg to 43 kg over the previous two months. Additionally, she reported fatigue and imaging studies indicated a hypoabsorption zone in the left lobe of the thyroid gland. Subsequently, discharge was authorized. We decided to re-examine the thyroid hormones at a later date. Two days later (day -3), the patient visited the outpatient department of internal medicine, as she was unable to consume food orally. Dysarthria was suspected, and a computed tomography and MRI scan of the head were performed. The only finding was suspicion of right mastoiditis , the patient was admitted to the emergency department for a sense of dyspnea; however, since airway obstruction was not observed, she was sent home with a diagnosis of hyperventilation. Finally, at the return visit to the otolaryngologist (day 0), the possibility of tetanus was considered, and the patient again consulted the internal medicine department  to treat tetanus. On the second day of admission, a single convulsive seizure occurred in the middle of the night, and intensive care management was started with intubation and ventilation. The seizure was judged to be due to tetanus, and 45000 units of human tetanus immunoglobulin were administered. Tetanus toxoid was administered on the third day of admission, and considering the possibility of long-term ventilation, tracheostomy was performed the day after ventilation was started (day 3 of admission). Midazolam followed by dexmedetomidine hydrochloride were used as sedatives during ventilation. The patient was on ventilation until day 13 of hospitalization, and although her circulation was stable on admission, by day 14, the increase in blood pressure due to stimulation was poorly controlled; hence, she was started on labetalol hydrochloride (150 mg/day), which she continued to until day 36. The complications that occurred during hospitalization included pneumonia due to the use of a respirator as well as heart failure and pulmonary embolism, none of which were disabling after discharge. The tracheostomy stoma was closed on day 38 of admission; the patient was discharged after 56 days when her general condition had stabilized, following the completion of rehabilitation treatment  over a 14-year period from 2006 to 2019, which is about 5% of the total number of patients in Japan. In that study, only 17 patients (1.2 per year) were confirmed or estimated to have resided in a district that appeared to be close to our hospital . TherefoIn a study conducted in South Korea, the diagnosis of tetanus could only be confirmed in emergency care in nine out of 17 patients (53%). The diseases in the differential diagnosis included temporomandibular joint disorder, temporomandibular joint and cervical dystonia, meningitis, cerebral infarction, spinal cord injury, and hypertensive encephalopathy . ClinicaIf a patient presents with typical symptoms without a history of trauma, the likelihood of suspecting tetanus is reduced. Conversely, the number of doctors experienced in the treatment of tetanus is also low in developed countries due to the progress made in vaccination. Patients typically visit several relevant departments because their test results are unremarkable, but their symptoms do not improve. The combination of these factors is likely to be the cause of a vicious circle that delays the diagnosis of tetanus. To prevent missed tetanus diagnoses in developed countries, clinicians should receive regular tetanus education. Additionally, integrated healthcare teams involving multiple departments should collaborate to assess symptoms and make diagnoses, not just for tetanus but for various conditions.One of the problems related to tetanus diagnosis in developed countries is the lack of clinical experience with tetanus among doctors and the fragmentation of specialized diagnostic areas in acute general hospitals. These factors, including the involvement of multiple departments, can lead to the tetanus diagnosis being missed, even in patients with typical symptoms. However, considering that tetanus will continue to persist and patients may present to more than one department, collaboration between departments is essential for a timely and accurate diagnosis.


Adult and pediatric palliative care (PC) share common aims and ethical principles but differ in many organizational and practical aspects. The aim of this narrative review is to analyze these differences and focus on which key aspects of pediatric palliative care could integrate adult services for a better care of suffering patients.Interventions which are peculiar of pediatric PC respect to adult PC include: an earlier referral to the PC service to identify the needs and plan the interventions at an earlier stage of the disease; consequently, a more systematic cooperation with the disease-specific physicians to reduce the burden of treatments; a better integration with the community and the social surroundings of the patients, to prevent social isolation and preserve their social role; a more dynamic organization of the PC services, to give patients the chance of being stabilized at in-hospital or residential settings and subsequently discharged and cared at home whenever possible and desired; the implementation of respite care for adults, to help the families coping with the burden of the disease of their beloved and promote the home-based PC.This review underlines the relevance of some key-aspects of pediatric PC that can be beneficial also within PC of adults. Its findings give the chance for a more dynamic and modern organization of adult PC services and may serve as a basis of future research for new interventions. Palliative care (PC) is both a medical specialty and a way of providing medicine and care . Every tThe World Health Organization (WHO) defined PC as “the prevention and relief of sufferings of the adult and pediatric patients and families facing the problems associated with life-threatening illness” . Palliatp < 0.001) were provided with specialistic PC [Such a wide definition of PC makes the numbers for potential APC/PPC patients very large . The WHOistic PC . This unistic PC . These uistic PC , 11.The aims of APC and PPC are the same. As underlined above, both focus on control of symptoms and relief of pain and other types of suffering rather than only on curative treatments. However, PC is not mutually exclusive with curative treatments. On the opposite, PC can be concomitant to other, disease-specific treatments, such as chemotherapy, thus increasing compliance of patients to uncomfortable therapies and potentially contributing to a better outcome. PC has been endorsed as a mean to provide more comfortable care by several organizations, including WHO and European Union . The impBoth APC and PPC are underpinned by the same bioethical principles . BioethiPC can be seen to provide more compassionate care to people suffering from any disease and, as such, can be practiced by all healthcare providers, independently by their role or specialization, whenever they alleviate symptoms during their main practice  . “SecondDespite sharing general aims and ethical principles, APC and PPC are different in many aspects. In general, while the general aim would be to improve quality of life (QOL), the way it is achieved may differ much. Often, QOL for adults can be improved by cessation of cumbersome and futile disease-specific or invasive treatment and focusing on relief of suffering in its many domains. For children, QOL is much more complex concept, and termination of disease-specific treatment is not necessary part of it (see below).The first and most important point is that while APC is patient-centered and relatives are involved mostly as “surrogates” decision-makers, PPC is “child-and-family” centered, the family being active subject and object of the PC practice , 18, 19.Another key difference is the time of referral to PC services. For the adult patient, this usually occurs at a relatively late stage of a life-threatening disease and in some countries, the APC specialist is still consulted only for the dying patients, typically when the life-span is less than 6 months and/or when all “curative” treatment has been withdrawn or refused by the patient . HoweverThe role of family in PPC goes beyond providing informed consent. Families are usually actively involved in provision of PPC. Since keeping children at home in their comfortable environment is important in PPC, houses need sometimes to be adapted to the progressive loss of physical autonomy of children. Family caregivers need training on the use of physical auxilia or machines such as home ventilators or infusion pumps. Thus, family members can be progressively and actively involved in the care of their ill child. Families are also object of PPC practice: they will often need psychological support for emotional burden linked to the experience of having a child with a life-threatening or invalidating disease and to the tiring care that this implies. Institutional or financial support may be required for this or even to help caring for other, unaffected children they may have. Indeed, life-threatening disease in children affect the family as a whole, and this should be taken care of by the PPC practitioner. The quality of family-driven care will reflect on the residual health of the affected child, so those issues are all of interest for the PPC service which coordinates the process.The same coordination activity should be implemented with schools, where the child may have special needs . Indeed,When symptoms are worsening, clinical PC can be provided in residential or home settings . ResidenSome of pediatric life-threatening conditions will transition in the young adult and adult age , 28. ThuFinally, the respite care refers to a care which temporarily relieves the burden of caregiving from families . RespiteHow the pediatric palliative care can inspire the implementation of an adult service.A modern approach to APC is needed  see Tab. HospiceModern oncologic treatments, including chemotherapy and radiotherapy, as well as immunotherapy, may retain a role even late in the course of oncologic disease and, in some cases, they may have a palliative role themselves. This implies an involvement of the PC team earlier than the last months, and a coordinated, simultaneous clinical activity between disease-specific clinicians and the PC team , see. FiPreventing social isolation can be an important part of relieving the suffering of patients approaching the last time of their life and it can help them coping with the disease, since social isolation may morally anticipate physical death. A dynamic network of palliative care services can integrate this earlier approach for the adult patients . Acute pRecently, animal assisted interventions (AAI), either in the forms of assisted therapies or activities, have been increasingly proposed to contribute to a better quality of life for patients within palliative care programs . To be eTaking care of either an adult approaching end-of-life (EOL) or of a child and its family requires the PC team constantly dedicating time to build a relationship and listening . This alPC is based on a joint workforce, including physicians, advanced practice providers, nurses, chaplains, and social workers. Some teams may include art and music therapists, pharmacists, and child-life therapists as well. These providers work with disease specialists to provide relief from suffering through communication expertise, emotional, spiritual, and psychosocial support as well as EOL care, when appropriate. Community-based palliative care may be highly effective and provide a better care than just medical-centered PC .The goal of PC is to alleviate the burden of serious illness through the improvement of quality of life by addressing gaps in symptom management and communication . In someThe efficacious PC team is thus characterized by the firm professional and humanistic motivation to be a witness of the condition of the affected person and family, throughout their sufferings and vulnerability, and to provide the best evidence-based and progressive control of symptoms and relief of suffering, which can allow the person experiencing a low QOL to live better, and, possibly, longer.This cumbersome work of getting to know and pointing out to the patient's life history and connecting the various specialists with respect to the clinical status and the relative perspectives, requires an empathic and active listening to the will and narrative of the patient himself (if conscious) and his family members, and to acknowledge the need for the various steps and attempts of disease specific treatment in order to understand the need of individual PC interventions , 44. OnlIt is as if the PC team made itself available to bring the therapeutic relationship to the level of the assisted person, towards the scientific consideration that the disease may have reached the stage of incurability and that the proposed interventions must shift to the consideration and protection of everything that can be valued (affective networks) and protected . When time has elapsed and the patient is approaching the final moments, EOL therapies should be weighted and incremental according to the worsening of suffering.Pediatric and adult palliative care share common aims and ethical principles. Evidence, although needed, is not easy to obtain due to the particular clinical issues and high subjectivity of measurable outcomes. While adults are often referred relatively late to palliative care services during the course of a life-threatening disease, an earlier referral may consent a better control of pain and other symptoms associated with the disease and its specific treatments, and ultimately a better care of patients’ suffering. Caring of psychological and social issues for adults may contribute to lesser social isolation and better coping with the disease. A less “strict” palliative network, with either in-hospital, residential, and home-based care scenarios that dynamically interact, may add value to the quality of provided palliative care making easier to care at home for the patients. Respite care is a pediatric palliative care concept that can be implemented for adults as well and can contribute to a less need for hospital/hospice care at the end of life.


Introduction: the objective of our study was to systematically review the current literature and perform a meta-analysis to evaluate the effect of the level of adherence to the DASH diet on blood pressure. Methods: The identification of relevant studies, data extraction and critical appraisal of the included studies were performed independently by two reviewers. A random-effects model was employed to synthesize the available evidence using the standardized mean difference (SMD) as the appropriate effect size. Results: A total of 37 and 29 articles were included in the qualitative and quantitative analysis, respectively. The pooled effect for systolic blood pressure was SMD = −0.18  and for diastolic blood pressure it was SMD = −0.13 . Conclusions: Our findings showed that greater adherence to the DASH diet has a beneficial effect on blood pressure compared to the lowest adherence. Increased compliance with DASH diet recommendations might also have a positive effect on cardiometabolic factors and overall health status. Future studies should aim to standardize the tools of adherence to the DASH diet and utilize rigorous study designs to establish a clearer understanding of the potential benefits of the level of adherence to the DASH diet in blood pressure management. Hypertension, defined as the consistently high pressure of blood flow within vessels, is the leading cause of cardiovascular events and all-cause mortality worldwide. Hypertension bears a correlation with the incidence of cardiovascular and renal detriment . As of 2According to the current literature, the cornerstone of hypertension treatment includes anti-hypertensive drugs , as wellSeveral studies have demonstrated that the DASH diet holds a pivotal role in decreasing blood pressure, taking into consideration that people must be able and inclined to ensue this dietary pattern ,8. ThereThus, the aim of our study was to systematically review the current literature and perform a meta-analysis to evaluate the effect of the level of adherence to the DASH diet on blood pressure values.This systematic review and meta-analysis follow the Preferred Reporting Items for Systematic reviews and Meta-Analyses   and MetaThe electronic databases PubMed, Scopus and Web of Science Core Collection were searched for the identification of eligible studies from inception to November 2022. We also searched the gray literature and the references of the included studies. Only studies published in the English language without a restriction on publication date were included. Keywords related to DASH diet and hypertension, such as “DASH diet”, “hypertension”, “blood pressure” and “diet” were used for PubMed and were modified accordingly for the remaining databases. The full search string can be found in Observational and interventional studies, investigating the association between the level of adherence (high versus low) to the DASH diet and changes in blood pressure measurements in the adult population were included in our review. Studies that did not report any data for raw blood pressure measurements in adults were excluded. We also excluded studies involving the pregnant or pediatric population.The primary outcome of our review was the difference in systolic and diastolic blood pressure measurements according to the adherence level to the DASH diet.Data from the included studies were extracted independently by two researchers (LC and VC) using an identical standardized data extraction form. Information regarding the study design, first author’s name, publication year, country, sample size, participant’s characteristics , comorbidities, use of anti-hypertensive medication, blood pressure measurements (systolic and diastolic) and the level of adherence to the DASH diet as reported by an assessment tool were abstracted for each study. With regard to the statistical data, we extracted the mean difference and standard deviations, as well as baseline and post-treatment values. In case of any missing data, authors were contacted for additional clarifications regarding data collection and accuracy. Any conflicts were resolved by consensus.The quality appraisal regarding the methodological validity of all included studies was evaluated by two independent researchers using the checklists developed by the Joanna Briggs Institute (JBI). Checklists were employed according to the study design of each included record . The quality assessment was completed by answering the 11 questions of the JBI tool related to the study design, methodological validity and reliability. The risk of bias (RoB 2.0) tool and the Critical Appraisal Skills Programme (CASP) for the randomized controlled trial checklist were used to evaluate the quality of interventional studies. Any disagreement was resolved by a third reviewer.2) and the I2 index and estimated using the restricted maximum likelihood method. Funnel plots and Egger’s test were used for the evaluation of publication bias. We also performed subgroup and sensitivity analyses to explain heterogeneity and assess the robustness of our findings, respectively. All of the analyses were performed in the statistical software R Studio (version 2022.12.0 + 353) using the meta package.A meta-analysis was conducted for our outcome of interest. Blood pressure measurements were considered as a continuous variable. We used the mean, standard deviation and number of participants in each arm. When the included studies reported standard errors or 95% confidence intervals (95% CI) we transformed them to standard deviation following the guidelines by Cochrane. Furthermore, median values were transformed to mean values according to Wan and colleagues’  approachThe quality of our findings was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE), as recommended by the Cochrane handbook . DomainsThrough the electronic database search, a total of 4319 records were identified, and after the removal of duplicates, 628 articles were reviewed for eligibility. Of those, 527 were excluded based on the title and abstract, 21 were removed due to a lack of access to the full-text articles and a total of 80 records remained for full-text assessment. In the qualitative synthesis, we included 37 papers, and of which, 3 were randomized trials, 20 were cohort studies, 1 was a case–control study and 14 were cross-sectional studies, while only 29 studies were included in the quantitative analysis .The socio-demographic characteristics of the included studies are summarized in 2, the mean SBP ranged from 102.5 to 154.1 mmHg and the DBP ranged from 45.8 to 88.8 mmHg.Regarding patient characteristics, all details can be found in 2 = 94%; PI: −0.93 to 0.57). Regarding DBP, a significant difference was also observed favoring high adherence to the DASH diet .The forest plots for SBP and DBP are presented in 2 = 91%) (2 = 84%)  . Further2 = 84%) . Furthermore, a subgroup analysis according to the study design of the included studies was conducted. There was no difference between the high and low adherence to the DASH diet on SBP when cohort or cross-sectional studies were pooled together. On the other hand, there was a significant difference favoring high adherence to the DASH diet based on the randomized controlled trial . As far Lastly, we performed a subgroup analysis for subsets of studies such as different continents for the SBP and DBP outcomes. There was no difference in SBP between high and low adherence to the DASH diet when studies performed in North America, Europe and South America were synthesized. A significant difference was observed in one study, which was a multicenter one, and in the studies from Asia . RegardiTo explore high heterogeneity, we conducted a leave-one-out analysis for both of our outcomes. The findings of this sensitivity analysis showed that regarding SBP there was no significant change in heterogeneity values when omitting one study each time . The samAs depicted in p = 0.355 and for DBP it was p = 0.232, indicating the absence of publication bias.According to the funnel plots, there were no signs of publication bias in our review . MoreoveBased on the GRADE approach, the certainty of our evidence was judged as being very low for both of our outcomes of interest.The present systematic review and meta-analysis aimed to evaluate the impact of the level of adherence to the DASH diet on blood pressure based on synthesizing the available data from observational and interventional studies. Our findings demonstrate a difference in the reported values of SBP and DBP between participants in the highest and lowest adherence group.The results of our review support the notion that higher adherence to the DASH diet may have a favorable effect on SBP. However, they should be interpreted with caution due to the high heterogeneity among the included studies. This beneficial effect of the DASH diet could be attributed to its dietary characteristics and the combination of various foods including the high consumption of fruits, vegetables, whole grains, and nuts and the limited salt intake, which have been associated with numerous studies with a reduction in blood pressure .With regard to SBP, high adherence to the DASH diet had a beneficial effect compared to low adherence. It should be stated that few of the included studies presented a mean SBP > 140 mmHg, while in parallel, the majority of them presented a mean DBP < 130 mmHg. This finding is essential, as it supports the protective role of high adherence to the DASH diet in SBP even in subjects with normal SBP.Regarding DBP, the level of adherence to the DASH diet led to a difference between the highest and lowest adherence group. It should be noted that none of the included studies presented a mean DBP > 90 mmHg, while in parallel, the majority of them presented a mean DBP < 80 mmHg. This finding is of great importance, as it supports that high adherence to the DASH diet could reduce DBP values even in subjects with normal DBP.In line with our results, published systematic reviews and meta-analyses investigating the effectiveness of the DASH diet provided as an intervention, compared to the usual diet group, showed that the DASH diet is effective in reducing both systolic and diastolic blood pressure ,59,60. FIt should be noted that the DASH diet given exclusively as a dietary intervention to individuals might promote different health outcomes compared to those that emerged from simply measuring adherence to the DASH diet with the use of specific tools. It is possible for dietary interventions to not enhance compliance with a particular dietary pattern as they also require participants’ adherence. On the contrary, dietary adherence demonstrates the degree of compliance to a diet that is directly related to individuals’ preferences, without corresponding to the consumption of a specified dietary plan. In addition, the level of diet adherence may be affected by various factors, including socioeconomic status, medical history, self-efficacy, level of education, religion, and place of residence, as well as psychological factors and individuals’ attitudes .The DASH diet is not only effective in reducing cardiometabolic outcomes, but there are also published syntheses demonstrating that higher adherence to the DASH diet has a protective role in developing type 2 diabetes mellitus  and cardTo the best of our knowledge, this is the first systematic review and meta-analysis that has investigated the association between adherence to the DASH diet and blood pressure levels. It is also worth noting that our study had certain limitations. Firstly, the study design of the majority of the included studies, i.e., observational studies, limits the confidence in our findings. Furthermore, we are unable to establish causality between adherence to the DASH diet and blood pressure outcomes using observational studies. Secondly, the high heterogeneity observed among the included studies could affect the reliability of the findings; hence, they should be cautiously interpreted. Lastly, we used data from crude models as our outcome of interest was not reported in adjusted analyses.In conclusion, our findings showed that greater adherence to the DASH diet has a significant effect on blood pressure levels compared to the lowest adherence. Increased compliance with DASH diet recommendations might also have a positive effect on cardiometabolic factors and overall health status. Future studies should aim to standardize the tools of adherence to the DASH diet and utilize rigorous study designs to establish a clearer understanding of the potential benefits of the level of adherence to the DASH diet in blood pressure management and monitoring.


Insights around second victims (SV) and patient safety has been growing over time. An overview of the available evidence is lacking. This review aims to describe (i) the impact a patient safety incident can have and (ii) how healthcare professionals can be supported in the aftermath of a patient safety incident.A literature search in Medline, EMBASE and CINAHL was performed between 1 and 2010 and 26 November 2020 with studies on SV as inclusion criteria. To be included in this review the studies must include healthcare professionals involved in the aftermath of a patient safety incident.In total 104 studies were included. SVs can suffer from both psychosocial (negative and positive), professional and physical reactions. Support can be provided at five levels. The first level is prevention  referring to measures taken before a patient safety incident happens. The other four levels focus on providing support in the aftermath of a patient safety incident, such as self-care of individuals and/or team, support by peers and triage, structured support by an expert in the field  and structured clinical support.The impact of a patient safety incident on healthcare professionals is broad and diverse. Support programs should be organized at five levels, starting with preventive actions followed by self-care, support by peers, structured professional support and clinical support. This multilevel approach can now be translated in different countries, networks and organizations based on their own culture, support history, structure and legal context. Next to this, they should also include the stage of recovery in which the healthcare professional is located in.The online version contains supplementary material available at 10.1186/s12913-023-09637-8. Since the publication of “To Err is Human” by the Institute of Medicine (IOM) back in 1999, attention to patient safety has been surging . Next toThe term ‘second victims’ has been in use for over two decades and has been on the receiving end of some criticism –12. ReceWhen a healthcare professional is involved, the symptoms in the aftermath of a PSI can differ dependent on the stage of recovery healthcare professionals find themselves in. Scott et al. described the natural history of recovery in the aftermath of a PSI to first start with a chaos and accident response (1), followed by intrusive reflections (2), restoring personal integrity (3), enduring the inquisition (4), obtaining emotional first aid (5) and finally moving on (6) . The difSince 2006, several support resources have been described in the literature, most established in the United States, trying to help healthcare professionals in dealing with the impact of a PSI . In 2013As the evidence-base around SVs and patient safety has evolved, and several of the available literature reviews were published over ten years ago, the international community lacks an update of the available insights and findings. How healthcare professionals can reduce the impact of a PSI has not been explored within current evidence-base. Therefore, this review wants to describe the different kinds of impact a PSI can cause, not only on a personal and physical level, but also on a professional level. Additionally, it wants to recount which support and prevention strategies are required. The following two research questions were defined: (i) What kind of impact of PSIs on healthcare professionals can be identified? and (ii) How can healthcare professionals be supported in the aftermath of a PSI?A literature search was performed in Medline, EMBASE and CINAHL from 1 October 2010 onwards, following on two reviews published by Seys et al. , 5, and Studies were included if any of the following criteria were met. (i) They described a definition or described the term second victims. (ii) They mentioned the prevalence of health care professionals involved in a PSI, which could have occurred over the time span of their career or during a well-defined period. (iii) They studied the impact of a PSI on the involved health care professional without restrictions regarding the level of impact or harm. (iv) Finally, studies were included if they assessed what support was provided and/or needed in the aftermath of a PSI.We excluded studies not published in English, reviews, conference reports, newspaper stories, and anecdotal evidence. Publications on analyses occurring during the COVID-19 pandemic were excluded due to the fact that these publications are no longer able to purely distinguish the effect of a PSI on the second victim, but have COVID-19 as a confounding factor.All citations were imported into the citations manager, Endnote X9, and duplicates were initially removed by this citation manager. Duplicates found during the title analyses were removed manually. In the next phase, the titles and abstracts were first screened by two reviewers  to eliminate unrelated studies. Any discrepancies were resolved by two other investigators . For all remaining relevant articles, the full text was retrieved, and two reviewers examined them independently according to the eligibility criteria.Data were extracted from the full text by a single investigator (DS) using a data extraction sheet. The sheet included study summary information , study design, patient population reports  and outcome measurements . The outcome measurements related to the impact of a PSI were clustered by the researchers into psychosocial reactions, positive professional reactions, negative professional reactions or physical reactions which the authors defined before the study.Each of the outcomes related to support in the aftermath of a PSI were extracted from each article. Based on these results the support in the aftermath of a PSI could be clustered into five separate levels, whereby clustering occurred on the degree of support received by SVs. The data extraction was thoroughly discussed with the members of the review team .Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.Figure Out of the 104 included publications, eight involved opinion papers ., , 121–123It is still unclear how many healthcare professionals are in need of a specific level of support according to our five-level support system Fig.  in the aNext to learning from other SV support literature, the post-COVID era provides opportunities to enhance the SV evidence-base. A study comparing the reaction in the aftermath of a PSI by doctors and nurses with the reactions during COVID-19 showed that the impact on doctors and nurses is larger during COVID-19 than in the aftermath of a PSI . Most orSome studies have shown positive reactions in the aftermath of a PSI, such as raised attention or becoming more critical. During the COVID-19 pandemic, it was shown that the pandemic can be a trigger for developing posttraumatic growth, as it is disruptive enough to affect the individual’s values and perspectives . Being iThe strength of this review is that it draws together and reports all the possible reactions and support in the aftermath of a PSI. We chose to extract the reactions ad verbatim from the primary articles as to not lose subtle nuances that might depend on the language or culture of the respondents. Due to this type of research, recall bias in reactions is possible due to the fact that the symptoms were collected after the PSI had happened. These reactions were collected by  questionnaires or based on qualitative research. For this reason the results of the symptoms should be interpreted by general trends and with caution. Other limitations of this review are caused by the heterogeneity of the included studies, in terms of type and severity of adverse events studied, involved healthcare professionals and types of study design. A critical appraisal of the individual studies was not performed as the aim of our study was to have a broad overview of both the reactions and support in the aftermath of a PSI.Next to this, the studies have been carried out in countries with different legal frameworks, which may affect the scope and type of intervention. Besides this, some of the studies have a small sample size or were performed at one organization which limits the generalizability of the results. Aspects of the safety culture of the individual organization should be considered when interpreting and implementing these results as differences between countries may also play a role.Further research is needed to optimize the validated instruments which measure the impact and support mechanisms for healthcare professionals in the aftermath of a PSI. This five-level support system can be used for longitudinal research but can also evaluate the impact and support needed in the aftermath of different types of PSI and different levels of support, ranging from prevention to professional and cultural support. Age, gender, professional group, working experience and personality dimensions should also be included to understand the SV phenomenon better and give the most optimal support to them. Therefore, knowledge sharing networks within and across countries should be organized. Besides measuring cultural differences, possible reactions and their duration, interventional research is needed, including randomized controlled trials to solidify different interventions at different stages of recovery and evaluate the effectiveness of the interventions.The impact of a PSI on healthcare professionals is broad, ranging from psychosocial and physical reactions to negative and positive professional reactions. This review shows that support programs should be organized at five levels. It should start with preventive actions followed by self-care of the healthcare professionals, support by peers, structured professional support and clinical support. Based on this, the involved healthcare professionals can be supported in the most optimal way in the aftermath of a PSI. Finally, organizations and healthcare professionals should take preventive actions to reduce the impact of a PSI and should provide support based on the individual needs of each healthcare professional in the aftermath of a PSI and should evolve in time based on the different stages of recovery. As each SV is a unique individual, we should be careful in implementing standard protocols or generalized approaches and provide support fitting for the SV’s personal reaction and recovering stage.Below is the link to the electronic supplementary material.Supplementary Material 1: Additional information


Indigenous peoples in the United States have faced continued land dispossession for centuries. Through the reservation system as well as policies including forced removal and allotment, colonial settlers and later the federal government acquired over two billion acres from Native Nations. We argue that another important, yet understudied and unquantified, contributor to tribal land loss is through the construction of dams. By restricting water flow in rivers or lakes, dams submerge land under reservoirs and disrupt aquatic and terrestrial ecosystems. This impacts livelihoods of local communities, destroys culturally important places and resources, and displaces people from their homes and land. To quantify the amount of tribal land lost as a result of dam construction, we engage in an innovative data linkage project. We use geospatial data on the boundaries of federal Indian reservations and Oklahoma Tribal Statistical Areas (OTSAs) and overlay these data with the locations of approximately 7,900 dams in the continental US. We estimate that 139 dams have submerged over 619 000 acres of land on 56 federal reservations and that 287 dams have inundated over 511 000 acres of land on 19 OTSAs. Taken together, our lower-bound estimate is that over 1.13 million acres of tribal land have been flooded under the reservoirs of 424 dams, which amounts to an area larger than Great Smokey Mountains National Park, Grand Teton National Park, and Rocky Mountain National Park combined. In light of recent federal legislation to address aging infrastructure in the US as well as the increasing risks to dam function and safety caused by climate change, dams that impact tribal land should be prioritized for removal. In cases where removal is not a preferred or viable option, alternatives include tribal ownership or funding for repairs and improvements. Through laws, treaties, purchases, and seizures—often advanced by violence or coercion—colonial settlers and later the federal government acquired over two billion acres from tribes . Targete4We refer to Native Nations to represent the federally recognized tribes in the United States that are the colonial experience for the hundreds of Indigenous nations that are now part of the US. We refer to both ‘Native’ and ‘Indigenous’ peoples to represent members of tribal communities impacted by damming throughout the history of federal-Indian law and policy. Indigenous peoples is a broader term and Native Nations specific to the Indigenous experience in the US. are replaced by those of settlers and their descendants [Land dispossession is a foundation of settler colonialism, the process by which the societies, economies, and relationships to the land and water of Native Nationscendants , 7. Landcendants , 9. Landcendants , 10, 11.cendants  noted, ‘The colonial taking of Indigenous land has come in many forms over the past several centuries. The US initially expelled tribes from the east coast to western frontier spaces in concert with nascent imperialism and westward expansion. However, as the US consolidated most of the continent, it moved from expulsion to containment. In 1851, Congress passed the Indian Appropriations Act that set aside money to move tribes onto permanent ‘reservations.’ In the 1860s, the federal government entered treaties that established homelands for many tribes in the Great Plains and Mountain West. However, by the early 1870s, Congress banned treaty-making between tribes and the federal government, and in 1877 it passed the General Allotment Act that disregarded land rights in treaties and divided land into parcels according to tribal population under colonial surveying . Through5There are multiple kinds of land tenure, all with precarious title held ‘in trust’ by the federal government. The two main types are trust and allotment lands. Trust land is the status of federally recognized reservations in the lower 48 United States whereas allotment refers to parcels of land alienated from contiguous reservation land holdings because of the General Allotment Act.. In the US, therefore, settler colonialism has resulted in the near complete taking of Indigenous land.As a result of these various forms of land seizure, 42% of tribes that were historically present in the US no longer maintain any land, and among tribes that do have land today, landholdings average just 2.6% of a tribe’s original territory . As of 2An underdiscussed story in the history of land dispossession, however, is the construction of dams along perennial water sources designed primarily to benefit settler communities. By impounding waterways to store, regulate, or divert water, dams typically submerge land under reservoirs. This dramatically alters the landscape and disrupts aquatic and terrestrial ecosystems . Dams ofDams have displaced at least 40–80 million people worldwide and have negatively impacted over 472 million people downstream, including numerous Native communities in the US , 29. ForThis paper examines the role of dams in tribal land loss. We link geospatial data on the boundaries of federal Indian reservations and Oklahoma Tribal Statistical Areas (OTSAs) to data on the location of dams and spatial extent of their reservoirs to show how additional land was lost to tribes through the construction of dams. This enables us to identify which reservations and OTSAs have lost land under reservoirs and to provide an estimate of the total acreage of tribal land submerged due to dams. Understanding the extent to which dam construction has contributed to tribal land loss is critical to broaden our knowledge of the impacts of settler colonialism and identify opportunities for reclaiming tribal sovereignty and restoring ecosystems.2.In this section, we briefly describe our data and methods. Additional methodological details are included in the Methods in Detail section in the Supplementary Materials. To identify reservations and OTSAs that were affected by dams and calculate the land submerged under their reservoirs, we utilized geospatial data on the boundaries of federal reservations (including off-reservation trust lands) and OTSAs; the location of dams; and the extent of each dam’s reservoir. Data on tribal land were obtained from the US Census Bureau, which maintains a file of the current legal boundaries of American Indian, Alaska Native, and Native Hawaiian areas . We focuGeospatial data on the location of dams and reservoirs were obtained from two sources: the Global Reservoir and Dam Database (GRanD) v1.3 , 38 and To identify reservations and OTSAs on which land was submerged by dams, we overlaid geospatial data on tribal boundaries, dam locations, and reservoir extents in ArcMap version 10.8.1. Next, we calculated the amount of tribal land underlying each reservoir by intersecting the tribal boundaries with reservoir boundaries. While all dams in the GRanD database included the dam’s name, we had to manually identify each dam/reservoir that occurred only in the GeoDAR database. Due to the time-consuming nature of this process, we focused on identifying the names of all dams that flooded at least 100 acres of reservation/OTSA land. For all dams that flooded at least 100 acres of tribal land as well as those built on natural lakes, we obtained additional attribute information from the National Inventory of Dams (NID) including year of completion, owner type, owner name, primary purpose, dam height, and hazard potential . See theBecause the reservoir boundaries in GRanD and GeoDAR were calculated based on satellite imagery, they capture the spatial extent of a reservoir a particular point in time—potentially during a dry period or a time of increased water demand . The bouTo more accurately reflect the full acreage of tribal land flooded under reservoirs, we replaced satellite data on area flooded with better data if available. For reservoirs located entirely within the bounds of one reservation/OTSA, we replaced satellite data with information from the NID on the reservoir’s surface area . If a readditional land area flooded when the dam was constructed. As such, we include dams built on natural lakes in our overall analysis, but exclude all but one from calculations of tribal land flooded due to data limitations.Lastly, a small portion of the dams were built on natural lakes to regulate flow or expand storage capacity, which raised lake levels and submerged land along the shorelines. In these cases, data from GRanD, GeoDAR, and NID provide the spatial extent of the entire reservoir, including that which had been part of the natural lake prior to the construction of the dam. This precludes us from identifying the spatial extent of the 3.3.1.We find that 56 of the 326 federal Indian reservations have experienced land loss due to the reservoirs of 139 dams. The vast majority of these dams were built on rivers, however 15 were constructed on natural lakes. Figure For dams flooding at least 100 acres of tribal land as well as those built on natural lakes, the average year of completion was 1947, ranging from 1884 to 1994. Dams averaged 126 feet in height, however the tallest dam—the Dworshak Dam that flooded land on the Nez Perce Reservation in Idaho—rises 717 feet. On average, each flooded approximately 8,232 acres of reservation land, with the Oahe Dam flooding the most total tribal land at 160 414 acres. Dams submerged an average of 3% of a reservation’s land under their reservoirs, though the Kinzua Dam flooded nearly one-third of the Allegany Reservation. Most dams were built to serve multiple purposes simultaneously, with a primary purpose of irrigation for 39%, flood control for 22%, hydropower for 11%, recreation for 11%, and water supply for 7%. Seventy-two percent of dams are owned by the federal government, while just 6% are owned or co-owned by tribes. Finally, 88% of the dams have high hazard potential, meaning that downstream flooding due to a dam failure would likely result in the loss of human life.We then calculated the total federal reservation land area submerged under the reservoirs of dams. We estimate that together these dams flooded at least 619 268 acres (967 square miles) of reservation land. However, it is important to note that this is a lower-bound estimate, as the true extent of tribal land flooded by dams is likely greater for several reasons.First, our analysis is limited to dams included in GRanD and GeoDAR. Though over 92 000 dams currently impound waterbodies in the US , this anadditional area submerged due to dam construction. The impacts of these dams, however, have been substantial [Second, though we include dams built on natural lakes in our analysis, we exclude all but one from calculations of area flooded given that we are unable to determine the stantial –45. For stantial . Third, 3.2.Oklahoma is currently home to 39 federally-recognized tribes, however only one tribe’s land falls under federal reservation status—the Osage Reservation—with the majority of the state’s land area designated as OTSAs. OTSAs represent the boundaries of reservations from the period when the area was known as Indian Territory, prior to Oklahoma’s establishment as a state in 1907 . SeveralFigure 4.This study examined the role of dams in tribal land loss in the United States. We estimate that 139 dams have submerged over 619 000 acres of land on 56 federal reservations and that 287 dams have inundated over 511 000 acres of land on 19 OTSAs. Taken together, over 1.13 million acres of tribal land have been flooded under the reservoirs of 424 dams, which amounts to an area larger than Great Smokey Mountains National Park, Grand Teton National Park, and Rocky Mountain National Park combined. This is likely an underestimate, however, for several reasons. For example, our analysis is restricted to the approximately 7,900 large and medium dams included in the GRanD and GeoDAR databases (out of over 92 000 dams in the US). As a result of data limitations such as this, it is likely that more tribal land has been lost due to the construction of dams, with a larger number of Native Nations impacted.Large dam construction, which peaked in the early- to mid-20th century, further eroded tribal land holdings that the US government had already substantially reduced through the establishment of reservations as well as through forced removal, allotment, tribal termination, and relocation policies , 17. MorTribal communities often bear the long-term costs of dams as well as other infrastructure projects. In many key infrastructure cases affecting tribal nations, tribal governments and communities tend to be the most marginalized political actors. This was true in the case of the Dakota Access Pipeline, which led to unprecedented protests in 2016 . The oilAddressing aging infrastructure in the US, including dams, has been a key focus of the Biden administration. The Infrastructure Investment and Jobs Act, passed by Congress in 2021, allocates $800 million to dam removal . BuildinIn response, dams that impact tribal land should be prioritized for federal dam removal funding given their direct role in Indigenous land loss. In assessing the viability of removing a particular dam, however, it is important to understand tribal members’ lived experiences and concerns. Indeed, the dam removal process itself can lead to stress and financial burdens for tribal members, particularly elders . Dam remHowever, dam removal may not be viable option in all cases, for example if a dam is actively used for flood control. Further, there will be situations in which Native Nations do not favor removal, particularly cases of dams built for the benefit of tribes. In these instances, funding for repairs or improvements may be preferred. An example is the Four Horns Dam, which was built in 1931 to provide irrigation water on the Blackfeet Indian Reservation. After decades in poor condition, the dam was rebuilt in 2020 when a federal settlement provided funds for its repair . In addiS  Dam, with all profits from hydropower generation accruing to the tribes and dam-related job opportunities created for tribal members.Another possible response is tribal ownership, which enables tribes to manage a dam in alignment with their interests and values, and to benefit economically from jobs and revenue associated with a dam’s operation. For example, the Confederated Salish and Kootenai Tribes of the Flathead Reservation in Montana purchased the Kerr Dam in 2015, becoming the first tribes in the US to take ownership of a major hydroelectric dam . The triFinally, a larger point about dams is not solely about the physical infrastructure, but also the social and political context that produced them. Dams were built on the continent’s waterways with little regard for past tribal water practices and knowledge, or for reservation land claims. As we have demonstrated throughout this paper, Indian land was not simply dispossessed from tribes in a process of settler-colonial expansion, but was also submerged in the reengineering of the continent’s rivers and lakes. At the root of these multiple forms of land and water dispossession was the disempowerment of Native people. Although dam removal is not the only solution, it is an important component that should be prioritized in federal policy. A more far-reaching resolution to the issue of existing dams and the future of waterways in the US is to amplify the power of tribes in the federal system to strengthen tribal sovereignty over their land and water.


Childbirth is one of the biggest risk factors for incontinence. Urinary and anal incontinence can cause pain and social limitations that affect social life, cohabitation, and work. There is currently no up-to-date literature study on the effect of pelvic floor muscle training with feedback from a physiotherapist, which involves verbal instructions based on vaginal and anal digital palpation, compared to treatment without feedback .The objective of this systematic review was to examine the scientific evidence regarding the impact of pelvic floor muscle training (PFMT) with feedback from a physiotherapist and/or biofeedback on urinary and anal incontinence in women during the first six months following vaginal delivery, compared to treatment without feedback.The literature search was conducted in the databases PubMed, Cochrane, and CINAHL. In addition, a manual search was conducted. The search terms consisted of MeSH terms and synonyms in the respective search block including population, intervention, and study design, as well as the terms pelvic floor and postpartum. An evaluation of each included study was conducted for methodological quality, evidence value, and clinical relevance.Eight studies were included, three of which showed a significant difference between groups, in favor of the intervention group that received pelvic floor muscle training with feedback from a physiotherapist and/or biofeedback. Due to the varying results and insufficient quality for the majority of the studies, the scientific basis was considered insufficient.The study is registered in PROSPERO CRD42022361296.The scientific evidence for pelvic floor muscle training with feedback from a physiotherapist or biofeedback on postpartum urinary and anal incontinence compared to treatment without feedback is considered insufficient. Further research on the subject is needed. The online version contains supplementary material available at 10.1186/s12905-023-02765-7. Urinary incontinence (UI) is defined as the involuntary leakage of urine through the urethra . Anal inMoreover, UI and AI are associated with significant reductions in health-related quality of life –13. WomeUrinary and anal incontinence is often assessed through self-assessment questionnaires , 18 contPFMT has been shown to reduce UI and may reduce AI , 24. It Feedback is the sensory information that becomes accessible following an individual’s conducted activity . FeedbacIn recent years, various systematic reviews have been published in the field. Zhu et al.  investigTo the authors’ knowledge, there is no systematic review that specifically reports the effect of PFMT with feedback from a physiotherapist or biofeedback in UI and AI after childbirth. Previously mentioned studies have not focused on only feedback and/or biofeedback , 23. AddThe objective of this systematic review was to examine the scientific evidence from 2012 to 2022 regarding the impact of pelvic floor muscle training (PFMT) with feedback from a physiotherapist and/or biofeedback on UI and AI in women during the first six months following vaginal delivery, compared to treatment without feedback.A systematic literature search was carried out based on previously established selection criteria to achieve the purpose of this systematic review , and the remaining studies were included in the systematic review.A manual search was performed in the reference lists of the included studies and in relevant systematic reviews. Review of the reference lists was done using a process similar to the previous selection process in the database search. In each step the authors assessed the studies individually and thereafter discussed until a consensus was reached.The PEDro scale was used to assess methodological quality . It aimsAfter assessment of methodological quality, the studies were reviewed for probative value . The proThe clinical relevance of the results was assessed based on five questions  see Tab. The queGrading of evidence was based on Britton’s model . The levA total of 329 records were selected in the database searches. After removing irrelevant titles and duplicates, 35 abstracts were reviewed. Of these, 16 studies were selected for full-text reading (List of articles not included after full-text reading are presented in Additional file A total of 765 women who underwent a vaginal delivery participated in the included studies (see Table Of the eight studies included, two studies reported using biofeedback devices only , 43, twoIn five of the studies, participants in the control group received instructions to perform a correct pelvic floor contraction , 44, 46.Three of eight studies reported a significant difference between the groups, with participants in the intervention groups showing reduced incontinence symptoms , 44, 45.Methodological quality was assessed with the PEDro scale (see Table One of the studies was considered to have a high probative value . Two stuBased on the assessment of clinical relevance, no study achieved a score of “yes” on all five of Furlan’s questions (see Table Three studies reported significant between-group differences , 44, 45,This systematic review demonstrated that there is a lack of sufficient scientific evidence for the effect of PFMT with feedback from a physiotherapist and/or biofeedback for postpartum UI and AI.The majority of the included studies in this systematic review had a medium to low level of evidence, which presents the risk of systematic error . Five stIn physiotherapy studies with active interventions, it is difficult to blind participants and therapists, which is the case in all reviewed studies. It has been suggested that lack of blinding increases the risk of treatment errors, because the expectations of the participant and the therapist can unintentionally affect the outcome. However, the effect of a lack of blinding in rehabilitation research is still inconclusive . In one Despite the heterogeneity in the population and intervention groups in the included studies, the studies with significant between-group differences account for the heterogeneity , 44, 45.The included studies tended to evaluate the effect with varying time spans, which makes the results difficult to compare. One possible reason to lack of significant effects on incontinence symptoms postpartum could be time to follow up. If the time interval is too short between follow up points, the time interval may be too short to evaluate the effect of PMFT. Significant between-group differences were observed after three  and six Three studies showed statistically significant within-group differences in both the intervention and control groups , 41, 42.The instruments used were self-assessments, which are a measure of subjective experiences. Although all questionnaires were validated, there may be a discrepancy between patient-reported UI symptoms and objectively measured incontinence . Such a Together with the natural history  and contA systematic review  was perfThere is a great need for additional high-quality randomised controlled trials that evaluate the effect of pelvic floor muscle training with different kinds of feedback on UI and AI separately , 31. ConA strength of the current review is its systematic performance according to guidelines . The thrThis systematic review has limitations regarding the literature search method and selection criteria. The study aims to focus on the role of physiotherapists in the maternity care. It may increase the risk of bias, as the research question and selection criteria could have resulted in excluding relevant studies. The focus was chosen to highlight the competence of physiotherapists in the field. Despite this, the interventions can be used by several skilled professionals depending on national guidelines. The collection of literature was done in English only, as the authors did not have the resources to obtain text from other languages and guarantee a correct translation and interpretation. The language limitations could increase the risk of systematic bias and the risk of excluding relevant studies . StudiesA limitation of the current systematic review is the use of the Britton model of probative value and grading of evidence, which is not internationally established . The BriAnother limitation is the width and variation in population, intervention, control, and assessment measures, which generates results that are less specific. This also rules out the performance of a meta-analysis. The wide inclusion criteria was required to gather a sufficiently large base, since there are few randomised controlled studies in the area. However, the broad population of women with and without injury may reflect the patient group encountered in the clinic, as there is a large number of undetected injuries . It is nThere is insufficient scientific evidence for the effect of PFMT with feedback from a physiotherapist or biofeedback in postpartum incontinence compared to pelvic floor training recommendations alone. Based on the results of this systematic review, it is not possible to draw new conclusions about the evidence for pelvic floor training with feedback. In individualised treatment, the use of feedback from a physiotherapist could fill a need for certain patients. Additional high-quality studies are needed to draw scientifically based conclusions about this treatment option for postpartum incontinence.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3