This paper provides a conceptual roadmap for the use of hormonal bioinspired models in a broad range of AI, neuroengineering, or computational systems. The functional signaling nature of hormones provides an example of a reliable multidimensional information management system that can solve parallel multitasks. Two existing examples of hormonal computing bioinspired possibilities are shortly reviewed, and two novel approaches are introduced, with a special emphasis on what researchers propose as hormonal computing for neurorehabilitation in patients with complete spinal cord injuries. They extend the use of epidural electrical stimulation (EES) by applying sequential stimulations to limbs through prostheses. The prostheses include various limb models and are connected to a neurostimulation bus called the central pattern generator (CPG). The CPG bus utilizes hormonal computing principles to coordinate the stimulation of the spinal cord and muscles. Bioinspiration has been a fundamental source of ideas for the advancement of computer sciences . Becauseif then biochemical command pattern), as we see in animals with a nervous system. The factors that control hormone secretion are diverse: stimulatory and inhibitory agents, other hormones, and external factors . Such hormonal changes also affect cognitive processes, such as attention, surprise, and learning, playing a fundamental role in the release of the hormone noradrenaline  , one exaOne way to draw inspiration from hormones in the field of computer systems is by developing computer simulations that mimic certain aspects of hormonal systems to manage computer facilities. For example, in Following similar ideas, Some years later, On the other hand, exploratory research on neural networks  explainsThis is exactly the role of hormones: not only to act as triggers for some changes in the body but also as direct or indirect regulators of even high cognitive processes. Thus, the impact of the hormonal system can be understood as transversal to the whole body, underrating itself as an extended and enactive system. For that reason, bioinspired computer hormonal systems are useful for orchestrating complex systems, as we have demonstrated with previous examples.Pleurotus oyster fungi generate electrical potential impulses in the form of spike events as a response to several causes, they explored how such fungi could act as sensors of human secretions such as hormones. Consequently, they exposed Pleurotus oyster fungi to hydrocortisone  and studied their reactions. Later, the authors demonstrated the causal interaction between fungi and human hormones. They explored possible future adaptive fungal wearables capable of detecting human physiological states and then acting as biological sensors for different engineering solutions . In addition to this initially cited research, the authors provided supplementary evidence that supports ecological studies  combines ideas and practices from experts of Boston and Bordeaux universities. It also focuses on a wearable sensor for hormones using native microbial sensing  and weighted logic. DAGs are mathematical structures used to represent relationships or dependencies between objects or events. They are commonly used in various fields, including computer science, mathematics, and graphical models. In the context of graphical models or causal inference, DAGs are used to depict causal relationships between variables, and they can help in the understanding of the qualitative aspects of causal relationships. Analyzing the structure of the DAG, researchers can make qualitative inferences about the presence or absence of causal connections between objects or variables. However, it is noteworthy that DAGs alone do not provide quantitative information about the strength or magnitude of causal relationships. To determine the quantitative aspects of causality, additional statistical methods and data analysis techniques are required. In summary, while DAGs can assist in the understanding of qualitative aspects of causal relationships, they do not inherently define something qualitatively on their own. In our case, DAGs capture and explain the causal and retro-feeding cycles of hormones. Then, it can be easily adapted and translated into computational scenarios.DAGs can easily capture the functional causal directions of hormonal processes, as described previously in The option to create causal graphs like DAGs provides a reliable mechanism to map, understand, and reproduce/adapt the dynamics generated by hormonal systems. DAGs are capable of performing it and, at the same time, maintaining logical causal connectivity and connection’s transparency ; 2009. DAdding bioinspiration from the hormonal system into DAGs, we find a new option: to use weighted logic as an integrated way of adding quantitative values  to the commands, creating a hormonal network similar to neural. The functional property of our interest in relation to hormonal bioinspiration is the time-lapse of hormonal messaging and modulations. Hormonal changes inside a body follow a different speed in relation to the central nervous system (CNS): while the CNS uses fast and hardwired signal channels, the hormonal system acts much slower (and permanently) and spreads hormones using slower channels, like bloodstream through vessels . The CNSWe propose to use DAGs and weighted logic together to create bioinspired hormonal networks, by (a) defining the nodes ; (b) establishing causal relationships ; (c) assigning weights to axes (weighted logic)—a weight represents the strength of the causal relationships; (d) propagating signals—one can simulate the computational model of propagating signals through the network; and (e) creating feedback and iterative refinement of parameters during the network/model life cycle. The statistical analysis of the simulated data and comparison with biological data is possible and could be recommended. If necessary, refine the model by adjusting the weights or modifying the structure of the DAG to better capture the dynamics of the hormonal system. By combining DAGs to represent causal relationships and weighted logic to assign strengths to those relationships, computational models can mimic the behavior of the hormonal system. This approach allows for the exploration of complex interactions and emergent properties that arise from the interplay of variables, similar to how hormones regulate various processes in biological systems.An example of a pseudocode that demonstrates how to emulate a simplified hormonal process using DAGs and weighted logic is given in Figure 4.propagate_signals and propagate_messages functions calculate the weighted sum of inputs for each variable based on the network axes’ weights. They later update the parameters of nuclei and glands by applying an activation_function, taking into account delays.In This is a simplified example. Considering that real hormonal systems are much more complex, we see that this approach serves as a starting point to demonstrate the concept of using a network combined with DAGs and weights to simulate hormonal processes in a computational model.The bioinspired computational approach using hormonal mechanisms provides option design computational systems using multilevel ways of interaction, releasing specific responses only under very constrained conditions. Similar to the CNS and hormonal system, hormones cannot reach the high speed and complex role of the CNS, but they generate changes in the whole body and affect the CNS. The use of weighted logic can allow the implementation of DAG models that facilitate dynamic algorithms . The weineuronal signaling—fast electrical signal propagation along the fibers or neuronal offshoots and (2) hormonal messaging—slow diffusion-based propagation of active agents through the medium (body). For the proposed architecture, we use four types of messages: (1) a accelerates b, (2) a suppresses b, (3) a excites b, and (4) a inhibits b, where types (1) and (2) are hormonal messaging, types (3) and (4) are neuronal signaling, and a and b are nodes. We use different terms for similar transport mechanisms to emphasize the distinction and roles in the proposed approach.The previously described approach for the neuro-hormonal integration using networks and two different propagation activation mechanisms could be used as the backbone of the infrastructure of orchestrated heterogeneous implants . There aHere, (1) the first network group of nodes or nucleus consists of individual neurons that generate signals, and superposition of them forms the nucleus signal that is transmitted via fibers ; (2) the second group of nodes or neuro-hormonal gateway receives the neuronal signal and generates the hormonal messages via, for example, bloodstream  and transmits it to the fourth group of nodes—hormonal gland; (3) the gland, in turn, sends feedback via hormonal messaging transport; and (4) later, the neuro-hormonal gateway sends feedback using neuronal signaling.Activation function or fitness identifies how good the cell is for the particular hormonal message or neuronal signal processing (it could be understood as the distribution of particular receptor type densities of each cell membrane).1. propagation function includes:2. The refractory period, cells have the distribution of durations, while they are not able to generate sequential spikes if they have generated one previously.a. During the processing speed is influenced by membrane conductance and capacitance.b. The A nucleus (group of nodes) is a set of neurons (nodes) with the distributions of the following parameters.fitness reached the threshold value: this means the node fits. Further processing in the node is performed in the following way: the simplified excitation level as the representation of the membrane potential of a neuron is calculated according to the following formula:Lneuron is the abstract excitation level; w is a weight or representation of synaptic conductance, positive stands for excitatory and negative for inhibitory synapses; leakage is the value corresponding to the leakage current or the speed with which the subthreshold value L returns to the resting value; and noise is the value of stochastic input. The low computational burden of Eq. Lneuron is calculated according to Eq. Lnucleus represents the simplified superposition of neuronal levels included in the nucleus to decrease the computational burden Here, for the sake of computational efficiency, we use the sum as the primitive implementation of the superposition of the electrical fields forming local field potential. This way the overall nucleus level curve is created via the sum of individual neuron levels  instead of neuronal fibers.Lnode is computed similar to the Lneuron from Eq. delay is the time between the release of Messages and the moment of their processing in the target gland releasing Hormone.When a hormonal activation or suppression message reaches a group of nodes, Eq. Fitness values, similar to the nucleus sensitivity or concentration of receptors along the fiber, are used as the probability to generate a signal as a response to a hormonal message or neuronal signal.1. Signal transmission speed or distribution of parameters, such as membrane conductance and capacitance, influences the speed of signal transmission along the offshoot membrane.2. The fiber is the set of cells that offshoot with several compartments of axons or dendrites with the distributions of the following parameters:L is formed by excitation/inhibition signals described in detail in delay identifies the time from the signal formation in a neuron to the propagation to the particular destination site and Decay is the saturation function of the signal amplitude reduction; for a myelinated fiber, Decay = 0.The level value suppressors make nuclei and fibers that decrease the processing activity; (2) accelerators increase the processing triggered by a message. Message influence is represented in the following way: an output nucleus activity is formed by the delay in the hormonal messaging transport; thus, the relationship between triggering activity and produced hormones could be expressed using the following log–linear relationship formula: Hormone(t) = eMessages(t−delay)− /decrease (suppression) in hormone production due to messages received.Hormonal messages consist of two types, as previously described in t−delay) ; for simNeuronal signaling and hormonal messaging. The secretion of thyrotropin-releasing hormone (TRH) in the nucleus of the hypothalamus (group of nodes)  start excitatory spiking  in the form described in Eq. 2. The pituitary gland (group of nodes) receives the excitatory input  and increases TSH production Eq. .3. Hormonal messaging with TSH transmits via the bloodstream, and later (taking into account delay) it reaches the thyroid gland Eq. .4. The negative feedback is implemented via hormonal messaging, suppressing the production of TRH and TSH, thus auto-regulating the HPT system Eqs , 6.f nodes)  is activThyroidHormone is the level of thyroid hormone, TSHMessages is the amount of TSH released by the pituitary gland, and delay is the time between the release of TSHMessages and the moment of their processing in the thyroid gland.There are two types of propagation functions used in the example: neuronal from the hypothalamus to the pituitary gland and hormonal from the pituitary gland to the thyroid gland via the TSH. The messaging of TSH on the thyroid hormone is log–linear and could be implemented to save computational capacity as a power function of 2 Eq.  Geras a in the fAdvancements in artificial intelligence (AI) have led to the emergence of various novel techniques for analyzing pain levels and pain-related behaviors in gait analysis. One such innovative approach is hormonal computing in AI, which introduces a new paradigm to understand and classify pain-related data. This paper aims to provide a brief discussion of the differences between hormonal computing and conventional methods like deep learning in the context of pain level and pain-related behavior analysis in gait studies. To illustrate this comparison, we refer to a recent work, 1. The release of the active substances  is triggered by the “accelerate” message from the CPG bus.x millisecond delay, stimulation of the spinal cord segment with the EES implant is triggered by the excitatory signals from the CPG bus.2. Within y millisecond delay, the electrical stimulation of limbs with a walking pattern via swarm of the microstimulators is triggered by specific neuroprosthesis of the muscle group implemented via the set of oscillator motifs  is widely used during complete spinal cord injury (SCI) neurorehabilitation . The orcThe EES triggers the neuronal activity of the spinal cord segment to compensate for the lack of electrical activity from the brain. Active substances including quipazine facilitate the sensory input of the afferents . During The implementation and extension of the proposed approach are applied in the case of a high complete SCI C1 model . (1) TheThe Bluetooth flat antenna for transcutaneous connectivity  is attacWe proposed the orchestrated architecture of swarms of implants mounted in muscle tissue or near nerves to manage limbs as the implementation of the hormonal computing and neuro-signaling and hormonal messaging approaches. The implementation could be quite flexible in terms of the implantation of stimulators, prostheses, and neuro-hormonal buses; they could be implemented in invasive and non-invasive ways. Both ways have their limitations: invasive requires surgery but allows for stimulation of deep muscles and high subject mobility, whereas non-invasive requires no surgery but could be used only indoors for safety reasons from environmental precipitation and electromagnetic noise.When the necessity of hormone support is identified, important questions arise: how to deliver them to the proper places of the body and to release them in an adequate moment?It is possible to distinguish two situations: when the place is well defined (in the case of prosthesis or implants) and when its location can be varied, but trackable. Let us consider these two cases separately.In the case when the position of the possible release of these compounds is well defined, as in the case of prostheses or implants, the strategy can be based on the immobilization of smart microchambers on their surfaces. The technique has been known since 2011 , and it It is important to mention only that the surface of the prosthesis/implant can contain chambers, filled by the desirable compounds . Therefore, the implant/prosthesis will already have containers, filled with the pharmaceutical preparations, that will be, very likely, useful in the future function of these items. Thus, the place of the localization of the drug sources is defined, and it is necessary only to trigger their release in the adequate moment.In the past, opening of these chambers was performed one after another by irradiation using laser light, showing very high efficiency. In the case of simultaneous opening of all chambers, it is possible to use ultrasound or alternating magnetic fields. However, the simultaneous release of all encapsulated material is not suitable for the purpose of this paper, as it will work only once and then the implant/prosthesis should be substituted, increasing the cost of the operation and decreasing the wellness of the patient. Thus, these chambers must be opened one after another, allowing dosed release of hormones, when it is necessary for the organism.As it was mentioned previously, one-by-one openings can be effectively performed by laser illumination. However, this approach will demand the use of optical fiber, penetrating into the body, adequate scanning system, and feedback, monitoring the actual concentration of the drug (hormone), and comparing it with the required one. Thus, it will demand the attachment of rather heavy and complicated equipment that the patient will need to have her/his body attached to equipment, which will not, of course, improve the quality of life.Instead, recently, the principle possibility of opening chambers and inducing release by the application of adequate electrical pulses was demonstrated . The suiIn order to suggest how to perform it, let us consider a chip developed in EPSL . The chiHowever, the basic principle can be based on the original idea . In the Thus, the immobilized sensor system determines the necessary amount of the drug (hormone) to be released and sends the signal, by means of the planar antenna, to the central station , triggering the opening of the required number of chambers for releasing the necessary amount of the encapsulated hormones.The other case requires a continuous supply of pharmaceutical preparations (hormones), when the targeting area is only roughly determined and the release time can also be variable. Thus, carriers must have the possibility of moving, delivering hormones to a desirable area, and waiting for the release time. In this respect, it is interesting to consider nanoengineered polymeric capsules.Here, we will not consider the technical details, just underlining important steps of the preparation and properties of these objects.Polyelectrolyte self-assembly, also known as the layer-by-layer (LbL) technique, was used for the first time for the realization of polymeric structures by The next important step was performed by Summarizing, these objects can be considered ideal smart containers for drug delivery and release  and as pIn fact, the internal part of these capsules can be loaded with active compounds, while the shell architecture will allow directed delivery  and induce release In the case of pharmaceutical applications, the ideal container must provide the possibility to deliver the therapeutic preparation to the disease risk zone and to release it when it is required. In the case of the use in the field of unconventional biochemical computing, the loaded internal part of capsules can be considered “a main executive program,” while the shell architecture serves as a “demon listening program,” whose task is to deliver the “main program” to the required area and to analyze the environmental conditions, being ready to start it when necessary .Thus, if the place of the delivery and release is not defined, hormone-containing carriers can be injected into the blood and delivered to the defined place by, for example, an external magnetic field. Ideally, the release must be triggered automatically when it is required. In this case, the shell architecture must be realized in such a way that pores will be open only when the environment will require additional hormones . HoweverSummarizing, the current state of the art allows the effective delivery and release of hormones to required zones of the human body, which can be controlled by the internal activity of the body and/or by signals from external computers.1. Informed consent and autonomy: As hormonal computing delves into neuroengineering, there may be ethical challenges related to informed consent and individual autonomy. When using hormonal interventions to influence cognitive functions or emotions, the boundary between enhancing capabilities and potentially manipulating an individual’s thoughts and feelings becomes blurred. It is crucial to ensure that users are fully informed about the potential effects of hormonal interventions and have the right to make informed decisions about their involvement.2. Privacy and data security: Hormonal computing involves the collection and analysis of highly personal and sensitive biological data related to hormone levels and responses. Ensuring the privacy and security of this data becomes paramount, as any breaches could lead to serious implications for individuals’ wellbeing and could potentially be exploited for nefarious purposes.3. Bias and fairness: Incorporating hormonal computing in AI systems could introduce biases based on hormonal differences among various populations. These biases may perpetuate existing societal inequalities, especially if they influence decision-making processes, such as in hiring or medical diagnoses. Ethical consideration should be given to mitigating these biases and ensuring fairness and equal treatment for all individuals.4. Unintended consequences: The complex nature of hormonal systems makes the prediction of the full extent of outcomes challenging. Introducing hormonal computing into AI and computational systems might lead to unintended consequences at both the individual and societal levels. Researchers and developers must thoroughly assess and anticipate potential risks to prevent any adverse effects on users and society as a whole.5. Manipulation and control: The ability to influence emotions and cognitive functions through hormonal computing raises concerns about potential misuse. If this technology falls into the wrong hands, it could be utilized for manipulative purposes, such as altering behavior or inducing specific emotional states without the user’s consent.6. Medical and psychological implications: Application of hormonal computing in neuroengineering could have medical and psychological ramifications. The technology might offer new treatments for certain conditions, but it also raises questions about medical oversight, potential side effects, and long-term impacts on an individual’s wellbeing.Hormonal computing is an emerging field that explores the incorporation of hormone-based mechanisms into AI, neuroengineering, and computational systems. This technology holds significant promise for enhancing the capabilities of these systems, but it also raises significant ethical concerns that need to be carefully addressed. Here, we analyze the following problems:1. Informed consent and autonomy:a. Implement clear and transparent informed consent processes, providing users with comprehensive information about the purpose, risks, and potential benefits of hormonal interventions.b. Empower individuals to make autonomous decisions about their participation in hormonal computing systems without coercion or undue influence.c. Establish clear guidelines for withdrawing consent and ensure that users have control over their data and the use of hormonal interventions.2. Privacy and data security:a. Adhere to strict data protection and privacy regulations, ensuring that sensitive biological data collected for hormonal computing is securely stored, transmitted, and accessible only to authorized personnel.b. Implement robust encryption and anonymization technologies to protect individual identities and prevent data breaches.3. Bias and fairness:a. Conduct thorough audits and bias assessments of AI and computational systems that incorporate hormonal computing to identify and address potential biases.b. Promote diversity and inclusivity in the development and training of these systems to minimize bias in decision-making processes.c. Regularly update and improve algorithms to reduce biased outcomes and ensure fairness in the application of technology.4. Unintended consequences:a. Prioritize extensive testing and simulations to anticipate and identify potential unintended consequences of hormonal computing.b. Establish continuous monitoring and feedback mechanisms to detect any adverse effects or unexpected outcomes promptly.c. Collaborate with multidisciplinary teams and subject matter experts to evaluate the technology’s implications thoroughly.5. Manipulation and control:a. Establish strict regulations and ethical guidelines for the use of hormonal computing to prevent misuse and manipulation.b. Conduct independent audits and oversight of applications using hormonal computing to ensure compliance with ethical standards.c. Promote transparency in the use of hormonal computing technology and its intended purposes.6. Medical and psychological implications:a. Involve medical professionals and psychologists in the development and implementation of hormonal computing systems to assess potential risks and benefits.b. Conduct extensive clinical trials and studies to validate the safety and efficacy of hormonal interventions used in neuroengineering and medical applications.c. Ensure that the application of hormonal computing in medical contexts adheres to established ethical guidelines and principles.7. Public awareness and education:a. Raise awareness among the public, policymakers, and stakeholders about the ethical concerns and implications of hormonal computing.b. Promote public discussions and engagement to gather diverse perspectives and ensure that ethical considerations shape the development and regulation of this technology.Mitigating the ethical concerns related to hormonal computing in AI, neuroengineering, and computational systems requires a combination of measures to ensure responsible development and use of this technology. Some strategies to address these concerns are as follows:By adopting these strategies and promoting a culture of responsible innovation, we can mitigate the ethical concerns surrounding hormonal computing, fostering its safe and beneficial integration into AI, neuroengineering, and computational systems.This paper has explored two existing ways of using bioinspired hormonal models to provide some engineering responses to real-time problems, as well as two different novel ways to create computational resources for the possible implementation. With all these examples, we have shown the multiple benefits of the use of bioinspired hormonal models for the sake of solving existing engineering and computational challenges. The dynamic, decentralized, and multifunctional properties of the hormonal systems allow them the creation of innovative and complex systems.


Planning the medical services for the triathlon competition at the 2020 Tokyo Olympic and Paralympic Games was predicted to be challenging because of possible last-minute changes related to the COVID-19 pandemic and abnormally high temperatures. Therefore, event planners organized and executed a disaster medical care plan, a plan for providing care during emergencies. Based on the basic medical plan for all venues provided by the Tokyo 2020 Organizing Committee, planners for the triathlon venue prepared a medical care plan according to the CSCATTT principles: Command and control, Safety, Communication, Assessment, Treatment, Triage, and Transport. After the event, planners evaluated the number of COVID-19, heatstroke, and injury cases at the venue. The events were conducted without spectators in July and August 2022 because at the last minute, planners held the event without spectators. The triathlon competition involved 638 individuals, including athletes and staff. In total, 7 cases of injuries, 3 cases of mild heatstroke, and 13 other cases were reported, with only 2 requiring emergency transportation. No cases of COVID-19 were reported from the triathlon venue, including during the observation period after the event. This medical plan was effective in preventing heatstroke and COVID-19 cases during the big event. Efficiently and effectively responding to various situations is possible in a shorter period by planning large-scale medical services for such special circumstances according to CSCATTT, a principle of disaster medical care. When organizing a large event, it is important to take preventive measures to prepare for possible large numbers of casualties, whether from natural disaster, mass illness, or act of terrorism, and large sports events require specific plans for sports medicine care for athletes. Amid the COVID-19 pandemic that started in late 2019, the 32nd Olympic and Paralympic Games that were originally scheduled for 2020 in Tokyo were postponed to 23 July 2021. However, the pandemic was still not under control even as the postponed date for the games drew closer; both the results of public opinion surveys and opinions of health care professionals in Japan strongly supported not holding the Games. Therefore, the debate on whether to hold or cancel the games was ongoing among Japanese government officials and the Tokyo 2020 Organizing Committee until the event. However, the committee ultimately decided to hold the Games and gave two reasons for doing so: (1) the high worldwide vaccination rates and (2) the promising effective method of protective “bubbles” to separate the general population from the Olympics athletes and support staff to prevent spread of infection. High COVID-19 infection rates persisted in Tokyo, even in the latest stages of preparation, and the emergency care system was on the brink of collapse. Many expressed concerns that the Olympics could increase the number of COVID-19 patients and further burden the emergency medical care systems; at the time, the Tokyo area was experiencing a shortage of medical facilities and human and material resources. Under these circumstances, it was difficult to ensure ample medical resources for the Olympics Games under these circumstances.Another major challenge was protecting athletes from heatstroke because the Games would be conducted in the hottest, most humid time of the year. In addition to Japanese summers being extremely hot and humid, recent effects of global warming has accelerated the increase in the number of people who experienced heatstroke. This posed as a problem to medical care providers and to the general public and society  1]. For. For1]. In Japan, government-led measures against COVID-19 including (1) vaccination promotion, (2) promotion of masking and disinfection, (3) prohibition of gatherings and events with large numbers of participants, (4) prohibition of international travel, and (5) detection and isolation of positive patients had been implemented, and holding the Olympics seemed to contradict the state’s own COVID-19. In addition, COVID-19 infection and heatstroke share many symptoms , thereby making it extremely difficult to distinguish between them at the venue. Furthermore, building a medical system for a large-scale sporting event was a major challenge in these circumstances, and because it was the first such circumstance, it was difficult to perfectly prepare for it ad hoc.The triathlon for which we prepared the medical care planning and management was conducted at the Odaiba Kaihin Park . Because the athletes completed three consecutive events, swimming, biking, and running, the standard medical setup to prepare for heatstroke and trauma in a stadium would not be sufficient. Special medical conditions during swimming could include drowning, swimming-related pulmonary edema, and hyponatremia, and 2% of swimmers are known to require some kind of medical treatment during competition . MoreoveWe designed the medical plan for this triathlon to be prepared for the worst combination of circumstances—in terms of the weather and the COVID-19 pandemic—on the day of the race. As mentioned above, the special characteristics of the event were recognized by the venue medical officer (VMO), the athlete medical supervisor (AMS), and the Medical Operation Manager (MOM) recognized the special characteristics of the vent and discussed them as we formulated our disaster medicine plan  accordinIn addition to formulating a medical plan for the triathlon, we applied CSCATTT more broadly to the general medical aid plan provided by the Tokyo 2020 Games Organizing Committee. Furthermore, we made changes from day-to-day during preparations and the event itself according to the prepared plan according to plan–do–check–act. Next, we describe the tenets of CSCATTT.Command and control refers to the organization of the disaster medicine management team. For the 2020 Tokyo Games triathlon, the international federation (IF) dispatched a medical delegate (MD), who issued the directives for the VMO to manage the medical care at the venues; the medical team organization chart is displayed in The stakeholders for the medical aid teams for athletes and for the spectators are shown in The AMSV was selected from the Japan Triathlon Union. The medical staff for spectators was composed of personnel dispatched from medical facilities that the VMO was affiliated with, one of whom was chosen to be the medical officer for spectators. The AMSV managed the athlete medical station only and followed the orders of the VMO rather than those of the manager of the field of play medical team. This was because the AMS was responsible for coordinating the MD and coaches, which would have made it difficult to also manage the field of play; additionally, the VMO was in the better position to gain an overall view.Safety in a disaster usually refers to the physical safety of people in the area of the accident. However, for the Tokyo Games, safety did not include material hazards at the venue; it instead referred to concepts of environmental safety, including temperature, humidity, and preventive measures for COVID-19 infection.®); the app was used to share positive results with the entire group of medical staff, athletes, coaches, support staff and their close contacts. Finally, all athletes, coaches, tournament management staff, and medical staff took a COVID-19 PCR test each time they entered the venue from outside the bubble.In response to the numerous athletes affected by heatstroke at the 2019 Tokyo Olympic Triathlon event, the race was started at an earlier time to lessen the athletes’ exposure to dangerous conditions. Ice baths, drinking water, and ice for cooling were prepared in greater quantities and were provided at more stations than usual. Staff needed to wear full personal protective equipment (PPE) to prevent infection in the extreme conditions , which c® , (3) private phone, and (4) Google Meet and Zoom video meetings. The triathlon is characterized by a high rate of falls from bikes and a high incidence of severe injuries from falling, which requires accurate data to locate the injured riders; immediately identifying the location of an accident is critical to ensuring a rapid response.Communications in a disaster refers to transmitting information effectively; information sharing among staff is critical both in general disaster medicine and in successful mass gatherings. However, we needed to keep in-person preparation meetings to a minimum according to COVID-19 social distancing guidelines. Therefore, we communicated via (1) push-to-talk over cellular, (2) LINEHowever, the push-to-talk feature and the equipment approved by the Organizing Committee did not allow for accurate location by GPS; therefore, with the consent of individual motorbike team staff, we used a location-sharing app to track the riders. This gap in communications coverage occurred because the Organizing Committee and the different sports associations and medical teams involved did not prepare well enough, possibly for reasons related to the COVID-19 pandemic. Nevertheless, under the challenging conditions in 2021, flexible responses were required, and ultimately, the entire course was superimposed on a grid map; accident location information could then be shared with the command center and with referees, operation staff on the course, and field of play medical team staff .Assessment in disaster medicine refers to accurately evaluating the conditions on the ground at a disaster site and is an extremely essential component for planning and providing medical care under nonideal conditions. The NF, IF, VMO, AMS, and MOM held multiple meetings throughout the entire period of the 2020 Tokyo Games; before and after both the Olympics and the Paralympics, we reevaluated and modified the overall medical plan to provide the best medical care possible at each point in time. In addition, the medical staff for spectators and those for athletes met daily before and after the competition to resolve minor problems.Throughout the entire Games, we assessed and modified our medical care plans according to the plan–do–check–adjust paradigm for identifying and resolving problems. We also conducted simulations and held ad hoc meetings with nonmedical staff to pass on relevant information for application in the next competition. For instance, we determined that our rescue plan for swimming incidents was inadequate because we were using different techniques for the competitors in the Olympic and Paralympic Games. Therefore, we held two drills to train first responders in how to retrieve casualties from the water two times. However, conducting training with a large number of participants was still a high-risk activity for COVID-19 transmission. For this reason, we filmed a video of the training and shared it with the staff so that individual staff members could do the training by themselves . We alsoTriage is an extremely important aspect of disaster medicine for providing the best medical care possible with limited staff and medical resources and facilities; it entails assessing the urgency and severity of injuries and diseases and allocating resources to the worst cases first. At the OMP, the first medical staff member to encounter the sick or injured person performed the triage. A medical measures headquarters was set up to search for a designated medical facility destination for patient transport; however, the majority of that plan related to athletes and staff, and other patients were to be cared for within the general Tokyo Emergency Medical System.During the Games, the COVID-19 pandemic in Tokyo was rampant, and it was predicted that further stress could collapse the medical and transport systems; we therefore determined that there would likely be challenges in providing rapid transport and treatment for Games participants in an emergency. It would have been unacceptable to conduct the event if it aggravated this collapse; therefore, it was necessary to use the general emergency medical system only moderately. Toward that aim, we established that the field of play medical staff would assess the urgency and severity of injuries and diseases in individual patients on stricter criteria than usual to determine if they could be cared for in the field of play examination room or the Olympic Village clinic. In addition, we planned routes for transporting patients that would minimize infection.Treatment in disaster medicine does not entail simply administering therapies but requires planning what types of treatment to provide, where to deploy likely limited resources (and under likely extreme circumstances), etc. As noted earlier, patients were triaged when they appeared at a facility, and we determined the appropriate venue for their care. As a general rule, we decided to respond with full PPE for care that required contact with the patient such as resuscitation measures. We used more stringent infection controls than would have been followed for previous competitions before the pandemic. Furthermore, an ambulance was prepared that was more extensively equipped and fitted with infection control and room temperature features that served as a mobile private medical emergency facility for individuals in severe distress; for instance, injured riders in the motorbike event could be located on the grid map, and their locations were communicated to the mobile emergency room. In general, individuals with injuries and illness in the running and biking portions of the event were given first aid in the athlete medical station, which was equipped with measures against infection and heat.Transport in disaster medicine refers to moving injured parties to where they can be treated safely. For the 2020 Tokyo Games, we planned the transportation methods and routes considering infection control. Specifically, we placed two stand-by ambulances at the venue and four along the course (three for the mixed-gender relay).We examined the numbers of injuries and heatstroke cases during the Games as well as the number of positive COVID-19 PCR results during and after the Games; we also examined specific cases.The men’s individual, women’s individual, and mixed relay triathlon events were held on 26, 27, and 31 July 2021, respectively. The corresponding events for the Paralympics, Paratriathlon Standing (PTS) 4 men and PTS 2 women and Paratriathlon Visual Impaired (PTVI) for men and women were held on 28 August, and the Paratriathlon Wheelchair (PTWC) men and women and PTS5 men and women were held on the 29th. The Paralympics athletes were classed by the International Triathlon Union competition disability classification [At the Games, medical staff for athletes treated 12 athletes and coaches, two of whom had to be rushed to hospital due to injuries caused by falling off a bike. Medical staff for spectators treated two passers-by who were watching the event outside the venue (on the side of the road) and one event management staff member, all of whom had mild injuries or illnesses.In the Paralympics, the athlete medical station staff only provided care for eight individuals, and all returned home without assistance; however, one of them was a PTWC athlete who visited the Olympic Village polyclinic and was diagnosed with pelvic fracture by MRI. The individual women’s race was held on 27 July, in the rain, and three athletes fell in a 5 min period during the biking. The athletes who fell first, second, and third were contacted by motorbike team physicians 2, 6, and 18 min after they fell, respectively. The player who fell first was able to walk on her own and was temporarily observed; however, a mild disturbance of consciousness was observed, so she was transported in an ambulance. The athlete who fell second had suspected shoulder dislocation and was judged to require emergency transport. The athlete who fell third did not require emergency transport but visited the polyclinic after the event and was diagnosed with ankle sprain.Heatstroke in the OMP venue occurred in three people during the Games, and all cases were mild. Cheering or spectating on the road was generally prohibited during the 2020 Tokyo Games. Two spectators who did not conform to these rules had heatstroke and required emergency transportation.There were no positive COVID-19 PCR test results at the OMP triathlon venue among the Olympics and Paralympics staff, athletes, or spectators during and after the event. Among the 1,068,420 PCR tests performed throughout the entire duration of the Tokyo 2020 Games, there were only 359 positive cases, corresponding to a 0.03% incidence. The incidence of COVID-19 in the 23 wards of Tokyo before, during, and after the 2020 Tokyo Games is shown in Japan is located on the Ring of Fire and is home to constant earthquakes and volcanic activity. However, the extremely frequent earthquakes are not the only natural disasters that affect the archipelago, as typhoons, torrential rains, and heavy snow also occur . Japan’sAs the Japanese government was preparing for the 2020 Tokyo Games, in addition to climate change planning, it formulated the “Heatstroke Countermeasure Action Plan”. Two components of the plan for the Tokyo Games were (1) increasing awareness of and providing information on heat such as the wet bulb globe temperature for the main venues in multiple languages and (2) cooperating with the Organizing Committee and the Tokyo metropolitan government to maximize heatstroke measures during the Games. In addition, the plan mentioned the compatibility of the dual measures against COVID-19 and heat stroke prevention. However, all aspects of medical planning for individual events, aside from information dissemination, were ultimately subsumed under the role of the VMO. We followed the CSCATTT construct to formulate a plan for providing medical care in this unique context, including accounting for the characteristics of triathlon as a sport. Following the games, we conducted a post hoc review of our plans.Disaster medicine usually entails much higher medical demand than supply than during non-disaster times, and the Olympic and Paralympic Games are one of the greatest global events and mass gatherings in the world. Planning the emergency medical care for such an event is a particular kind of challenge, but it requires planning for conditions that are similar to a disaster. One challenge that was unique to planning for the 2020 Tokyo Games was that this was the first Olympic event in history to be conducted during a global pandemic and in abnormal climate conditions exceeding 35 °C . During As the Organizing Committee was drafting this medical plan for Tokyo under these conditions, the government declared a state of emergency related to the COVID-19 pandemic in early July, which was immediately before the Games. This led to the decision on 8 August, which was just 15 days before the opening ceremony, to hold the event without any spectators, and we also revised our plan. Because there were no spectators, we reduced the number of spectator medical teams and first aid. We also canceled medical team patrols throughout the venue and moved some members of the spectator medical team to the medical command.We attribute our success in executing a safe medical plan at the venue amid such challenging conditions to having incorporated knowledge from disaster medicine to respond to a wide range of possible scenarios. The fact that the incidences of COVID-19 and heatstroke at the OMP were lower than the rates of the general population suggests the appropriateness of the drafted medical plan. For instance, as part of the overall infection control measures for the 2020 Tokyo Games, even athletes were required to wear masks inside the venues when not competing, and PCR testing was mandatory each time they entered or left the venues from outside the bubble. The Organizing Committee received daily reports on the movements of infected people, which made it possible to identify those who were in close contact and to pay attention to their behavior. The venue was also well stocked with hand sanitizer. In addition, face shields, masks, and gloves were standard equipment for medical staff at the OMP, and gowns were worn during CPR and other concentrated contact procedures. Furthermore, medical staff were required to report their physical condition before and after work each day. We believe that our venue-specific infection control measures for the 2020 Tokyo Games as a whole minimized the number of infected people at the venues. However, if the Games had been held with spectators at the government’s discretion contrary to the advice of medical personnel, it is doubtful that we could have controlled COVID-19 infections and heatstroke cases at the venue as well as we did.Historically, the 1920 Antwerp Games in Belgium and the 2016 Rio de Janeiro Games in Brazil were the only Olympic and Paralympic Games that were held amid global epidemics . The AntThe greatest merit of incorporating CSCATTT in formulating a medical plan for a large-scale event without precedence is that it allows for visualizing the worst possible situation in accordance with ironclad rules of disaster medicine. In addition, even inexperienced staff and medical volunteers can understand CSCATTT plans and actions. Triathlon competitions require special measures as the sport covers a large outdoor venue, the ocean, and spectator seats, and it is accordingly very difficult to educate staff and volunteers who are active in all places individually with the same medical plan as in ordinary competition venues. Therefore, another merit of a CSCATTT plan is that it gives all staff the same understanding and awareness of the roles they can play in a disaster, what they can expect, etc. However, CSCATTT is essentially a concept for medical care in the hyperacute phase of a disaster, and therefore, such a plan on its own lacks the detail necessary for planning medical care for large-scale events. Therefore, implementing an event-wide emergency medical care plan for the 2020 Tokyo Olympic and Paralympic Games triathlon venue required support from personnel familiar with the competition.The Olympics and Paralympics are not just the largest sports event in the world. There are 33 events, and they take place every four years in different venues in a different country. This means that many people who are disadvantaged in a disaster or will have more difficulties adapting to environmental changes, such as foreign nationals and people with disabilities, gather from across the world. Under these circumstances, it is difficult to ensure adequate resources to address every eventuality throughout the duration of the Games. Given the circumstances, a CSCATTT-based medical aid management plan appeared to be what would be most effective for the Olympics and Paralympics.David Jaslow et al. assert that mass gatherings are disasters and that it is necessary to create a medical plan in accordance with the 15-component mass gathering medical care plan advocated by the National Association of EMS Physicians Standards and Clinical Practice Committee . Chad A.Next, we discuss the characteristics of injuries and illnesses during a triathlon. Triathlons in the Olympics consist of a 1.5 km swim, 40 km bike, and 10 km run. Injury rates of 17–20% per 1000 h of racing time are reported ; Paal K.Furthermore, in triathlons, the reported risk of traumatic injury is 1.65-fold that of general sprinting events . AccordiAt the 2020 Games, emergency and disaster medicine specialists planned and directed medical aid as VMOs and orthopedics and triathlon sports doctors as AMSs. In addition, the fact that a MOM was in charge of the local fire department administration and emergency department administrative staff created a common understanding of disaster medical care, making it possible to coordinate effectively with the emergency medical system. Additionally, we had tested a CSCATTT medical preparedness plan for the 2019 international triathlon competition held in Japan that was the test for the Games, and we believe our previous experience with this type of plan contributed to our positive results. We recommend that any medical plan for mass gathering events be developed in accordance with CSCATTT.The medical plan for the 2020 Tokyo Games triathlon competition, which was held in anomalous conditions of COVID-19 paired with abnormally high temperatures, was successfully planned from the perspective of disaster medicine. By following the principles of disaster, doctors who are familiar with emergency medicine and disaster medicine can formulate and execute effective medical plans for other anomalous circumstances such as large sporting events during a pandemic.


There is a growing body of literature concerning factors that can influence patients’ perception, preferences, or expectations with regard to autonomy in making healthcare decisions. Although many factors responsible for the desire for autonomy in medical decision-making are already recognized, little is known about how the desire for autonomy is related to values, which refer to important goals of human actions. The present study was designed to determine the relationship between the desire for autonomy and basic personal values drawn on Schwartz’s value theory. We conducted survey in two age groups: younger and older adults. In the group of younger adults, the desire for autonomy was associated with the need to be appreciated as a person, motivation to act independently, and the abandonment of traditional order and values, whereas in the group of older adults, with independent thinking and a lack of humility. Our study highlighted that the desire for autonomy may result from slightly different reasons in people of particular age groups. These findings might be helpful for medical professionals in developing accurate communication patterns with different age groups of patients. The principle of autonomy, which in the second half of the twentieth century became the cornerstone of medical ethics, has changed the perception of the doctor–patient relationship and has raised the importance of making decisions in medical practice. What is more, the iconic ethical codes such as the Nuremberg Code  . Concerning values, since autonomy is defined as the capacity to think, decide, and act freely and independently, we presumed that people who valued Self-direction in their thinking and actions would have a higher DA. Therefore, we formulated the following hypothesis: Participants from both groups who attribute high importance to Self-direction (thought and action) have higher DA (Hypothesis 2). In terms of the relationship between DA and the other Schwartz values, we adopted an exploratory approach and did not formulate hypotheses.Mage=20.5; SD =1.61). The second group consisted of older adults recruited by students among their friends and families based on the following eligibility criteria: (1) age ≥40 years, (b) literacy , and (c) lack of any medical condition that would affect their ability to participate. Students were trained in the proper selection of participants, and they handed out and collected questionnaires among older adults. The study was conducted in November 2020. Out of 215 respondents who agreed to participate, sixteen were excluded from the analyses, because they did not completely fill out the questionnaires. In total, 199 people were enrolled. This group comprised of 123 women and seventy-six men aged 40–90 years . The educational level in this group was as follows: 21 per cent had a basic/vocational education, 44 per cent completed a secondary school, and 35 per cent graduated from a college or university. Participation was voluntary with no compensation. All participants were informed about the research and its purposes and gave their informed consent. The study was performed in accordance with the Declaration of Helsinki and approved by the Bioethical Committee (consent no. 255/2020).The survey was conducted in southern Poland with a convenience sample. A total of 421 respondents participated in the study. The study was conducted in two age groups. The first group consisted of students from Wroclaw  aged 18–27 years  and four items from the Decision making preference subscale    = 3.43; p= .001) in the group of younger adults  as compared to the group of older adults . With regard to values, we hypothesized that participants from both groups who attribute high importance to Self-direction would have higher DA. The presumed associations between Self-direction and DA were partially supported by our findings. The results regarding the relationship between DA and values are presented in Table F = 2.31; p = .002; older adults F = 2.03; p = .009. Overall, the variables accounted for 10 per cent of the variation in the DA of the younger adults and 9 per cent in the DA of the older adults.Differences in values between younger and older adults are presented in Table t40= 3.43; The purpose of this study was to determine the relationship between DA and basic personal values drawn on Schwartz’s value theory. Our results indicate slightly different motivations behind DA among younger and older adults. In the group of younger adults, DA was associated with the desire to be appreciated as a person, motivation to act independently, and the abandonment of traditional order and values, whereas in the group of older adults, DA was associated with independent thinking and a lack of humility.We confirmed our hypothesis that DA is stronger in the group of younger adults. In Western culture, relying entirely on the physicians to make decisions on his behalf is a remnant of the past. More and more patients prefer sharing decisions with their physicians  the specific life situation of young adults and/or (2) their little experience of being ill. Younger adults, at the beginning of their professional careers, want to be appreciated, feel important and be treated as equal partners. Their need to protect their public image and avoid humiliation may be satisfied if they are informed and involved in the decision-making process. Older adults, who value Face, have already had more opportunities to satisfy this value. Moreover, older adults are more likely to have experience in health problems and, therefore, for them participating in decision-making is more about responsibility than maintaining and protecting status and prestige. For older adults, DA is more about solving real problems. Thanks to their experience, they know that participating in decision-making is difficult, and many of them are afraid to take on such a responsibility (Fraenkel and Peters In the group of younger adults, a strong desire to be informed and preferences for making medical decisions were associated with a lower level of importance attributed to Tradition. Although it has already been reported that younger adults are generally less attached to a long-established and inherited way of thinking or acting (Schwartz et al. Our study has several limitations. Firstly, its results are based on a small convenience sample. Participants were university students and their family members. Both groups included a lot of college and university graduates, which limited the generalizability of study results.Another possible limitation is that the study was conducted as a regional survey and its results may not be generalizable to other geographic settings and populations. In 1989, Poland underwent a political transformation from communism to democracy. Society and its values have significantly changed in the last decades, including an increase of individualism, westernization, and liberalization of lifestyle (Bardi and Schwartz Another potential limitation is that the study was based on a questionnaire. It is not clear whether we would obtain the same results by analysing real-life decisions. Moreover, DA depends on the person’s health status. After receiving a serious diagnosis, people are more willing to take the responsibility of being involved in the decision-making process (Chewning et al. Finally, the current research focused on two components of DA: information seeking preference and decision-making preference. Future studies will benefit from investigating the relationship between values and other ways of understanding DA, such as maintaining patient confidentiality and discussing treatment options. Such research will increase our understanding of the complicated motivational mechanisms behind DA. It is, therefore, important to be cautious not to make overgeneralizations from these findings.need for independence in both young and older adults, the additional reason which tends to favour DA among younger adults were the need to be acknowledged as equal partners in the doctor–patient interaction and the desire to contest the customs and ideas established in traditional culture, whereas lack of humbleness promoted DA among older adults.Despite its limitations, our study provided valuable insights into the axiological ground that drive patient preference for autonomy in making medical decisions. The obtained results suggested a variety of motivations behind DA. Our findings revealed that DA understood as a desire to be informed and make own healthcare decisions may result from slightly different reasons in people of particular age groups. Although greater DA in healthcare decisions was associated with a The results of our study may be useful in medical practice. The better understanding of the patient’s perspective, the easier to achieve a therapeutic alliance, which in turn promotes a better patient therapeutic care outcome. The current widely accepted approach based on the Calgary-Cambridge model (Kurtz, Silverman, and Draper


Background: Developmental dysplasia of the hip (DDH) is a condition where there is an abnormal relationship between the femoral head and acetabulum. DDH is prevalent in Jordan, where late presentations of complicated cases are common due to the absence of a national screening program and cultural behaviors that can exacerbate DDH progression. The study aims to prove that the absence of a nationwide screening program and low awareness of the population about DDH are the primary reasons for the high incidence of late-presenting DDH in Jordan. The study highlights the need for addressing modifiable risk factors like swaddling and correcting common misconceptions such as using multiple diapers as a treatment option.Methods: The cross-sectional study evaluated the awareness level of DDH among Jordan residents above the age of 18. An online questionnaire was used, containing two sections. The Chi-square test was used to analyze the level of awareness scores according to demographic variables and cultural norms such as tight swaddling and using multiple diapers. The sample was categorized into three groups based on their scores: low awareness (0-4), moderate awareness (5-8), and high awareness (9-12).Results: The study included 1013 participants. The results indicated that 48.9% had moderate awareness, 37.8% had low awareness, and 13.3% had high awareness of DDH. Gender and place of residence had no significant relationship with the level of awareness. However, the majority of participants with high and moderate levels of awareness were in the 25-40 years age group, and healthcare workers had the highest levels of awareness. The study showed that 33.9% of participants gained their knowledge from either relatives or self-experience, while awareness campaigns were the least assessed source of information with only 2.9% of participants getting their information from them. The study also revealed misconceptions regarding DDH, such as the belief that tight swaddling and wearing many diapers reduced the risk of developing DDH. Additionally, about half of the participants were unaware of the presence of screening guidelines for DDH.Conclusion: The study underscores the urgent need to establish a national screening program and awareness campaigns to increase knowledge about DDH and prevent late presentations of complicated cases in Jordan. The study findings provide essential information for the development of future DDH campaigns and screening protocols. DDH encompasses a wide spectrum of anatomical abnormalities of the immature hip that manifests in various forms at different stages of life . In 1832Ever since it was first described, multiple techniques of reduction have been attempted. However, due to the vigorous nature of the reduction maneuvers, a large number of hips that were treated developed avascular necrosis . TreatmeThe American Academy of Pediatrics defines DDH as a condition in which the femoral head has an abnormal relationship to the acetabulum . DDH is Excessive laxity of the hip capsule is the most common cause of DDH, leading to failure in maintaining the femoral head properly within the acetabulum. DDH is a spectrum disorder where, at one end, it presents as a shallow acetabulum, whereas, at the other end, it involves dislocated and irreducible hips. In between these extremes, it may consist of instability of the hip such that the femoral head can be subluxated or dislocated from the acetabulum by a medical professional. The hip may also present in a dislocated position and still be reducible on examination; however, with chronic dislocation, it may become irreducible with noninvasive management. This disorder may as well manifest later during childhood or adolescence as a dislocated hip or during adolescence as a hip with poorly developed acetabular coverage; the latter being referred to as adult dysplasia of the hip .The incidence of DDH is difficult to determine because of disparities in the definition of the condition, the type of examinations used to detect hip abnormalities, the differing skill levels of examiners, and the populations being studied. The incidence of some degree of hip instability in newborns ranges from one per 1000 to 3.4 per 100. Higher incidences are reported when screening involves both clinical examination and ultrasonography . In addiAccording to a study done at the Jordan University Hospital in 2011-2014 regarding the pattern of DDH in late-presenting Jordanian male patients, it was concluded that the incidence of late-presenting DDH among males was 3.75 per 100 infants with a mean age at diagnosis of 4.98 months [Up until now, there has not been any implementation of screening programs to diagnose DDH in Jordan. The potential early and late-term complications of untreated DDH range from leg length discrepancy to in-toeing or waddling gait, to a variety of hip joint anatomic abnormalities, eventually leading to early onset hip osteoarthritis.DDH management ranges from noninvasive management using the Pavlik harness or closed reduction and hip spica in younger patients to surgical open reduction and pelvic osteotomy in older patients, with or without femoral shortening osteotomy. Hence, developing a nationwide screening program in Jordan is crucial as it would allow the identification of patients with DDH early. In doing so, we would be able to implement nonoperative management options, which are simple to perform, cheap, and have a high chance of success and a low risk of complications. Therefore, this would reduce the financial and social burden of treating the late presenting DDH and its complications.Our aim in this study is to prove that one of the major factors leading to such a high incidence of late-presenting DDH in Jordan is the absence of a proper nationwide screening program and the lack of awareness of the population regarding the nature of this disease. The latter includes avoiding some modifiable risk factors such as swaddling and clearing up some common misconceptions such as using two or three diapers as a false treatment option.Study design and participantsThis cross-sectional study aimed to assess the awareness level of DDH among Jordan residents. Participants were recruited through convenience sampling via an online self-administered questionnaire that was shared on social media platforms including Facebook , Whatsapp , and Instagram . The study was conducted between February and May 2022, and 1013 responses were collected. All study participants were residents of Jordan and over 18 years old.Ethical considerationsEthical approval for this study was retrospectively obtained on June 6, 2023, from the Ethics Committee/Institutional Review Board at Ibn Al-Haytham Hospital, Amman, Jordan . Participation was voluntary. The anonymity and confidentiality of the data were ensured by assigning an identification number to each participant restricted to the research team. The questionnaire contained detailed information about the study objectives and returned questionnaires implied signed consent.Data collection toolThe online questionnaire was designed in English and translated into Arabic. It consisted of two sections. The first section collected data on participants' demographics, including age, gender, marital status, living area, number of children, level of education, and profession. Participants were also asked about their prior knowledge of DDH. If participants reported no prior knowledge of DDH, the questionnaire was automatically submitted at that point and signed as low awareness level. This assumption concluded from a previous study by Alshahrani et al., as they solidify the fact that prior knowledge of DDH is a key factor in understanding the condition and being able to deal with the infant or toddler in a scientific and systematic way, which will decrease the bias for assorting our participants' awareness levels .The second section assessed the awareness level of DDH among participants. It included questions on the source and reliability of information that participants had regarding DDH, as well as their knowledge of risk factors, screening tools, treatment, and complications associated with DDH. The questions in this section were in the form of multiple-choice questions, including direct and indirect questions with correct and incorrect answers. Diagrams and images were also provided to aid in understanding. These questions and answers were referenced from a previous questionnaire conducted in Saudi Arabia, Riyadh, and were reviewed by four pediatric orthopedic doctors . The secStatistical analysisAll the analyses have been conducted on R software version 4.2.2  with the proper package for each test. The statistical significance level was set at 0.05. Descriptive statistics were used to examine the demographic characteristics of participants in the sample and to analyze the distributions of responses to questionnaire items and to each scale.Inferential statistics focus on finding the correlation between different variables. Chi-square test and post-hoc analysis (using the Scheffe test where appropriate) were used to analyze how awareness level scores varied according to different demographic variables. The Chi-square test was also used to assess the relationship between awareness level scores and cultural norms habits (using multiple diapers and swaddling).This survey was conducted among 1013 participants in Jordan, with 718 (70.9%) respondents residing in Jordan's capital, Amman; the demographic variables are shown in Table Table Following the administration of the questionnaire, participants were assigned to different levels of awareness based on their scores. Those who had not heard of DDH were categorized as having low awareness. We found that almost half of our respondents had moderate awareness of DDH , more than one-third had a low awareness level of DDH n= 383; 37.8%), and only 13.3% (n=135) had a high awareness level of DDH. To assess the distribution of awareness levels across demographic characteristics, we utilized the Chi-square test as shown in Table 83; 37.8%Individuals aged between 25 and 40 comprised the majority of those with high and moderate levels of awareness of DDH, whereas half of those aged between 18 and 25 years had a low level of awareness. Furthermore, most of our respondents who finished high school had higher awareness levels of DDH compared to those who did not complete school education. As predicted, healthcare workers had the highest degree of DDH knowledge when compared to other employment groups. According to marital status and parity, those who were married or had children had the highest level of DDH knowledge . On the other hand, those who were single or did not have children had the lowest level of awareness .Our hypothesis was that the self-experience or experiences of relatives with DDH represent the best source of information for achieving a high level of awareness. We tested this hypothesis using a chi-square analysis of the relationship between the level of awareness and the source of information, as outlined in Table We examined two crucial cultural norms that may influence the risk of DDH: swaddling practices and the use of multiple diapers. Our objective was to mitigate the incidence of DDH by raising awareness and promoting a reduction in the prevalence of these practices. To this end, we conducted a chi-square test analysis to evaluate the relationship between the level of awareness and the usage of these practices, as presented in Tables The aim of this study was to assess the awareness level of DDH among the population in Jordan. Additionally, the researchers sought to investigate the association between demographic variables and DDH awareness level, with the goal of guiding future awareness campaigns and targeting specific populations. DDH is a common and preventable cause of childhood disability. Unfortunately, delayed diagnosis of the condition increases the likelihood of requiring surgery and raises the risk of long-term complications. To the best of our knowledge, this is the first study to determine DDH awareness in Jordan, serving as a foundation for future research in the field.In 2018, a study conducted in Riyadh, Saudi Arabia, indicated that approximately 68% of survey participants were already familiar with DDH disease . In a moWhen participants were surveyed about the association between breech presentation and the development of DDH, it was found that 63.5% of the participants in Jordan in the present study were aware of this risk factor, whereas only 30.1% in Riyadh, Saudi Arabia, demonstrated the same level of awareness . SimilarBoth Jordan and Riyadh demonstrated a higher level of awareness among participants with higher educational levels and those working in the healthcare sector . ConversIt is evident that except for the 18-24-year age group, the majority of the participants had moderate awareness levels regarding awareness of DDH. On the other hand, the majority of participants in the age group of 18-24 years scored low in awareness. Since this is the age group with the highest potential to have children in this society, it is safe to say that they should be the main target of any future awareness campaigns involving DDH.Linking the level of awareness to the education level of participants our survey also revealed that the percentage of participants with high school level education was significantly lower compared to university level education. That being said the majority of both groups scored in the moderate to low awareness level. As expected, the highest percentage in the high awareness category were the healthcare workers as compared to other professions. However, it is concerning that the majority of the healthcare workers scored in the moderate to low awareness level. It is worth mentioning that the healthcare workers group included nurses, radiology technicians, anesthesia technicians, and nutritionists apart from physicians.When comparing the level of awareness with marital status, we could see that the majority of the participants, whether single or married, had moderate to low awareness levels. A total of 331 (66.9%) married participants had moderate awareness levels and 194 (50.7%) single participants had low awareness levels when compared to the other marital status subgroups. Additionally, with regard to the level of awareness in relation to the number of children in a family, the majority of participants with children had a moderate awareness level, and those with no children had a low awareness level.Moreover, our survey’s results revealed that a significant majority of participants relied on personal or familial experiences as well as information from friends as their primary sources of information. In fact, these sources accounted for more than two-thirds of the respondents. Conversely, trusted sources such as physicians and awareness campaigns were unfortunately accessed by only a minority, comprising less than 15% of the respondents. These findings aligned with two studies conducted in Aseer and Riyadh ,13, bothThe main reason behind this behavior can be attributed to the lack of effective awareness campaigns organized by healthcare professionals. This underscores the necessity for such campaigns to enhance people's knowledge and understanding. Hence, it comes as no surprise that more than 86% of the individuals surveyed emphasized the necessity for additional awareness campaigns. Undoubtedly, individuals who had personal experience or witnessed the condition in their relatives possessed the highest level of awareness. These individuals directly receive information about DDH from supervising physicians, which contributes to their heightened knowledge.Swaddling is a common practice used across many cultures throughout history, in which an infant is wrapped snugly in a cloth. Traditionally, this practice involves tightly swaddling the baby, with the hips in a position of tight extension and adduction ,15. RegaThe acknowledgment of the adverse impacts associated with conventional swaddling has triggered a transformation in the notion of swaddling that is "hip-safe" . Hip-safMany previous studies have approved that swaddling and carrying methods for infants that involve forced hip extension-adduction and knee extension are linked to a higher incidence of DDH -21. ConvThe results of the current study demonstrate that traditional swaddling is a widespread cultural practice in Jordan, with around two-thirds of participants  reporting its use. However, this outcome also highlights a lack of awareness among Jordanians regarding the substantial risk that traditional swaddling can pose to the development of DDH. Pinto et al. conducted a recent study in India that aimed to evaluate the level of awareness among healthcare workers  regarding hip-safe swaddling . The stuAn effective strategy to decrease the incidence of DDH is through public awareness campaigns that promote the benefits of hip-safe infant positioning. In Japan, an educational campaign was carried out in 1973 to raise awareness of the harmful effects of restrictive lower limb immobilization . A studyAs demonstrated by the results of this study, increasing awareness about the risks associated with swaddling and DDH can lead to a significant reduction in the incidence of swaddling practices. Additionally, public awareness campaigns aimed at promoting hip-safe positioning have proven effective in decreasing the incidence of DDH in certain populations. Therefore, it is recommended that professional organizations in Jordan, such as the Ministry of Health and the Jordan Orthopedic Association, should collaborate to develop a position statement and a public awareness campaign highlighting the importance of hip-safe swaddling practices and proper techniques for carrying infants, with the goal of reducing the incidence of DDH in the country.To enhance awareness in Jordan, it is crucial to conduct a series of awareness campaigns across various domains, commencing with high schools, universities, and clinics. These campaigns can effectively encourage parents to detect and address the condition at its early stages. Additionally, to reduce the occurrence of delayed presentation of DDH, it is advisable to establish a screening protocol for early detection or employ an algorithm to identify children who require DDH screening. This approach ensures cost-effectiveness, as it avoids screening all infants for DDH, similar to the screening protocol implemented in southern Australia .This study’s main strength is that it presents a comprehensive assessment of the level of awareness of DDH among Jordan residents using a well-validated questionnaire that enables the reproducibility of the study for future comparison. In addition, this is the first study that measures the level of awareness in Jordan. The limitations encountered in this study include a bias towards respondents residing in urban areas, particularly the capital city. Additionally, our study employed an online questionnaire, enabling us to collect responses from various regions in Jordan. However, this methodology may have influenced the outcomes, potentially leading to relatively similar results among the participants.A substantial proportion of participants exhibited a moderate to low level of awareness concerning DDH in Jordan. This knowledge gap is a significant contributing factor to the prevalent issue of delayed DDH presentation. In light of these findings, it is imperative to implement comprehensive nationwide awareness campaigns, focusing primarily on age groups with the highest reproductive potential and high school students. By enhancing awareness levels and rectifying misconceptions surrounding DDH, we can effectively reduce the incidence of delayed DDH presentation, thereby alleviating the burden imposed on the healthcare system in managing both the early and advanced stages of the condition and its complications.


BackgroundMedical education is a constantly evolving and multifaceted field that requires ongoing discussion and innovation. Social media platforms have emerged as a popular medium for disseminating information and engaging in professional discourse among medical educators. In particular, the hashtag #MedEd has gained widespread recognition amongst individuals and organizations within the medical education community. Our objective is to gain insights into the types of information and discussions surrounding medical education, as well as the individuals or organizations involved in these conversations.MethodsSearches were conducted across major social media platforms, including Twitter, Instagram, and Facebook, using the hashtag #MedEd. The top 20 posts posted on these platforms were analyzed through a reflexive thematic analysis approach utilizing the Braun and Clarke method. Furthermore, an examination was conducted on the profiles of those responsible for posting the aforementioned top posts, to ascertain the degree of participation from individuals versus organizations within the broader discourse pertaining to the topic.ResultsOur analysis revealed three thematic categories associated with the usage of the #MedEd hashtag, including discussions on "continuous learning and medical case presentations," "medical specialties and topics," and "medical education pedagogy." The analysis revealed that social media can serve as a valuable platform for medical education by providing access to a diverse range of learning resources, fostering collaboration and professional networking, and providing innovative teaching methods. Furthermore, profile analysis showed that individuals were more actively involved in the discussion of medical education topics on social media compared to organizations across all three platforms.ConclusionOur study highlights the significant role that social media platforms play in facilitating the exchange of information and ideas within the medical education community. The hashtag #MedEd serves as a means of connecting individuals and organizations across the globe, enabling them to engage in professional discourse and stay informed on the latest developments in the field. Our findings suggest that a better understanding of the thematic categories and stakeholders involved in medical education discussions on social media can aid educators, learners, and organizations in enhancing their engagement with this dynamic field. Social media has increasingly become a popular medium for medical education due to its potential to enhance communication, collaboration, and knowledge dissemination ,2. ThrouPrior empirical research has shown that social media can be an effective tool for medical education. Cheston et al. carried out a systematic review on the use of social media in medical education and found that it can improve communication, facilitate collaboration, and enhance knowledge sharing among medical professionals . In addiHowever, despite the potential benefits of social media for medical education, there are also concerns about the accuracy, reliability, and privacy of information shared on these platforms . It is tData collectionThe search was conducted between January 25, 2023, and February 25, 2023, and all posts that included the hashtag #MedEd during this period were considered for inclusion in the study. The search was limited to posts in English, as this is the primary language of medical education discourse on social media.To ensure a representative sample of the discourse on medical education, we included the top 20 posts on each platform that received the highest number of likes and shares during the search period. These posts were selected as they were considered to be widely shared and hence would provide insights into pertinent themes in the discourse on medical education. Additionally, to avoid bias, the search was conducted independently by two researchers (MHS and SR) using the same search terms and criteria. Any discrepancies between the two searches were resolved through discussion and consensus. Our data collection strategy is summarized in Figure Thematic content analysisA thematic content analysis approach was employed to analyze the top 20 posts on each platform. The analysis was guided by the Braun and Clarke method, which involves a series of methodical stages, namely, data familiarization, initial code generation, theme identification, theme review, theme definition or naming, and report production . Two resProfile analysisApart from analyzing the top 20 posts, we also conducted a thorough examination of the profiles of the individuals and organizations responsible for generating these posts; in this case, we have defined organizations as accounts managed by a company, non-profit organizations, or other entity for the purpose of promoting their brand and are active and engaging with MedTwitter. This was done to ascertain the level of involvement of each group in the discussion of medical education. Specifically, we recorded the number of posts related to medical education and the number of followers associated with each profile.The thematic content analysis approach utilizing the Braun and Clarke method provided a structured and comprehensive way to analyze the top 20 posts on Twitter, Instagram, and Facebook linked with the hashtag #MedEd. In accordance with the selection of 20 high-yield posts across the three platforms, our final dataset consisted of 60 posts - 20 each from Twitter, Instagram, and Facebook - that were included in the analysis. The resulting thematic framework, presented in Table Theme 1: “Continuous learning and medical case presentations”This theme is centered around the provision of valuable learning resources and case studies through tweets and posts on social media platforms, which can aid medical students and professionals in keeping up-to-date with the latest medical information and best practices.The tweets and posts under this theme often showcase unique and novel medical case presentations that may not be encountered in daily medical practice. Figure Additionally, Table Both MHS and SR devised this structure after considering which parameters would be particularly relevant to themselves as learners in the preliminary stages of their medical careers.Theme 2: “Medical specialties and topics”The theme elucidates the broad spectrum of medical specialties and conditions that attract the attention of medical students and professionals. The posts falling under this theme furnish valuable information and perspectives concerning various medical conditions and treatments. Their aim is to equip medical students with essential knowledge regarding the presentation, diagnosis, and treatment of such conditions, thereby assisting them in preparing for clinical practice. Accordingly, these posts can prove to be an invaluable resource for medical students.To visually depict the distribution of each specialty across the three social media platforms, pie charts have been presented in Figure Theme 3: “Pedagogical and teaching strategies”The theme underscores the significance of pedagogical and teaching strategies in medical education. The posts under this theme emphasized the essentiality of employing effective teaching methods that can facilitate the learning process of medical students. Overall, they ranged from discussions on different teaching approaches to the use of technology and its impact on medical education.The posts encapsulated in this theme provide valuable insights into the diverse approaches and methods that are currently being employed in medical education. This information can aid medical educators in integrating innovative teaching techniques and strategies in their classrooms to augment the learning experience of their students.Profile analysisThe results of the profile analysis across all three social media platforms revealed that the majority of the top posts were made by individuals rather than healthcare organizations. On Facebook, 70% of the top posts were made by individuals, while 30% were made by organizations. Similarly, on Twitter, 65% of the top posts were made by individuals, while 35% were made by organizations. Interestingly, on Instagram, 85% of all top posts were made by individuals, while only 15% were made by organizations.In terms of the number of posts related to medical education, the profiles of individuals had a wider range of posts, with some having hundreds or even thousands of posts related to medical education, while others had only a few. On the other hand, the profiles of organizations had a more consistent number of posts related to medical education, with most having between 50 and 100 posts and 100+ tweets. Figure The results of the profile analysis indicate that there is a significant presence of individual users in the discussion of medical education on social media, with individuals being the dominant contributors to the top posts across all three platforms. This confirms that social media equally provides a platform for individual users such as medical professionals or medical students to engage in discussions and share their perspectives on medical education. The higher percentage of organizational posts on Facebook and Instagram compared to Twitter suggests that organizations may be more active in sharing their content and engaging with their followers on these platforms. On the other hand, the majority of top posts being made by individuals on Twitter may indicate a greater emphasis on personal opinions and experiences.This study explored the landscape of medical education on social media platforms by analyzing the types of information and discussions surrounding medical education, as well as the individuals or organizations involved in these conversations. The analysis revealed a range of thematic categories associated with the usage of the #MedEd hashtag, including discussions on medical education pedagogy, medical specialties, and continuous medical education. Furthermore, our profile analysis indicated that key players within these conversations are medical educators, learners, and professional organizations, with individuals making up 73.4% of the top 20 posts across the three social media platforms.One of the major advantages of this study is that it provides a comprehensive overview of the #MedEd hashtag on social media, which has not been explored in depth before. By analyzing the top 20 posts on Twitter, Instagram, and Facebook, the study captures the most significant themes and trends in the discourse on medical education, which can be represented in the literal sense via this hashtag. Moreover, the investigation employed the Braun and Clarke methodology of thematic content analysis, a rigorous and widely acknowledged approach for analyzing qualitative data, provided that it is appropriately applied . The utiThe findings of this study have several implications for medical educators, learners, and professional organizations. Firstly, the study highlights the importance of social media in facilitating the exchange of information and ideas within the medical education community. The hashtag #MedEd serves as a means of connecting individuals and organizations across the globe, enabling them to engage in professional discourse and stay informed on the latest developments in the field. Not only this but the case presentations mentioned theme one can serve as an excellent learning opportunity for medical students and professionals, allowing them to expand their knowledge and understanding of complex medical conditions . SecondlHowever, it is important to acknowledge the limitations of this study. Firstly, the study was limited to posts in English, which may not capture the full spectrum of medical education discourse on social media. Secondly, the study only analyzed the top 20 posts on each platform, which is not representative of the entire discourse on medical education. Thirdly, the study did not evaluate the accuracy, reliability, and privacy of information shared on social media, which are important concerns in the medical education community.Here it is important to note that while our study focused on the use of the #MedEd hashtag on social media platforms, it is important to note that social media is just one of many tools available for medical education. Traditional forms of medical education, such as lectures and textbooks, remain important sources of information for learners . HoweverThe present study provides valuable insights into the landscape of medical education on social media platforms, demonstrating that social media is a powerful tool for medical education. Our findings highlight the potential of social media to connect individuals and organizations, enabling them to engage in discussions and debates about important topics in the field. This deeper understanding of the types of information and discussions surrounding medical education on social media can help stakeholders enhance their engagement with this dynamic field. For medical educators, social media offers a valuable platform for sharing educational resources, collaborating with colleagues, and staying up-to-date on the latest developments in the field. For learners, social media can provide access to a wealth of educational materials and opportunities to engage in discussions with their peers and mentors. Moreover, for professional organizations, social media can facilitate communication and collaboration with members, as well as provide opportunities for advocacy and outreach.