People with Parkinson's disease (PD) need to exercise to have a better quality of life. The risk of falling needs to be considered when choosing and implementing exercise interventions. Flowcharts are used to facilitate referrals in Brazilian primary care network, but there is no specific one for PD.To develop a referral flowchart for people with PD in Brazilian primary care based on the risk of falls and scientific evidence in the context of a multidisciplinary approach.The development of the referral flowchart was accomplished in three steps; (1) relevant literature was reviewed (2) semi-structured interviews (in focus groups) were conducted with primary health care professionals to investigate the current care for people with Parkinson's disease, and (3) the information obtained from the previous steps were analyzed to inform the development of the referral flowchart.The fall risk-based flowchart uses the 3-step-fall-prediction tool. The primary health care professional should refer the person with a low risk of falls to activities with minimal supervision and those with a higher risk of falls to specialized neurology services. Neurology services are also the referral target for persons presenting significant mobility restrictions . The referral occurs according to what is available in Brazilian primary care.This flowchart might be the first step to build a multidisciplinary approach for people with Parkinson's disease in Brazilian primary care. The next stage of this study is the validation and subsequent implementation of the flowchart through the primary care at Unified Health System in Brazil. The progressive nature of Parkinson's disease (PD) and the range of symptoms accompanying PD is a complex challenge for the Health System to manage successfully –3. As PDFall often have deleterious consequences for people with PD, their caregiver, and the quality of life of both –3. FallsMany hospitalizations and attending primary medical care following a fall will have a significant cost impact on the health system . Such coad-hoc approach to falls' care and management, with minimal multidisciplinary care provided  literature review, (2) focus group interviews with professionals from the Family Health Strategy (FHS) and (3) refinement of the flowchart elements. The Ethics Committee for Human Beings (CESPH) of the State University of Santa Catarina approved this study under number 2,950,524.A detailed non-systematic literature review sought the highest level of evidence specific to PD . We searched for information regarding the recommended treatment according to disease severity, the occurrence of falls, and fall risk. We used the following databases - PubMed, SciELO, Lilacs, Medline, Cinahal, PEDRO - with the keywords Parkinson's disease AND falling OR fall OR falls. We included articles in English and Portuguese without the restriction of date.The study was conducted at the Health Centers (HC) of the four health districts  of Florianópolis - Santa Catarina, Brazil, that offered PC services. There are 45 HC spread across the health districts and 125 FHS teams working in them. The FHS teams, work in the HC and are the first contact with people with PD arriving at PC.The FHS teams are formed primarily by a general practitioner, or specialist in Family Health, or a Family and Community physician; generalist nurse or specialist in Family Health; nursing assistant or technician; and community health agents. It is relevant to say that rehabilitation professionals work in the HC but don't integrate the FHS teams and people who need the rehabilitation service must be referred by FHS professionals.Florianópolis is the capital city of Santa Catarina State and is the second largest in the number of inhabitants, with approximately 508,826 individuals . Also, iBefore recruiting FHS teams between January 2016 and December 2017, a survey of people diagnosed with PD was carried out through a municipality's information system management (GeI - Geinfo / DIPLAN). A list of people with PD who engaged in PC services was used to determine those health units with the highest PD caseloads. The FHS were recruited by e-mail, and the focus groups (FG) were formed.The Consolidated criteria for the REporting Qualitative research Checklist (COREQ) were used to guide FG interviews. The COREQ is a 32-item checklist to assist researchers in reporting essential aspects of the research team, study methods, context of the study, findings, analysis, and interpretations . We condAfter agreeing to participate, the FG meetings were scheduled and held in the HC of each district. A total of eight focus groups took place between January and June 2019, conducted by a moderator, member of the research team, who took detailed interview notes. The FG health professionals number ranged from two to nine, and the interviews lasted from 20 min to 40 min (average of 30 min). There were no conflicts of interest between the researchers and FGs.A semi-structured interview guided the questions and was recorded by audio. Researchers identified possible central themes, phrases, and impressions. The following issues were framed into questions that each FG discussed: (I) Experience with PD; (II) Diagnosis and Management for people with PD, (III) Referrals, (IV) Specialized Care; and (V) Options for multi-professional activities available at the health unit. Two researchers read the transcribed data and created codes using open coding to themes and subthemes. When differences in interpretation occurred, a third researcher was consulted, and the majority view was prevailing. After the eighth FG, no new information and themes emerged, and we identified the saturation point of the interviews. To assist the organization of the collected data, we used the software package ATLAS.ti8.PD care recommendations – Crucial points based on the literature review and (2) The referral flowchart based on the risk of falls - How does it work?The data obtained from the qualitative research was used to build and scaffold the referral flowchart based on the risk of falls for people with PD. In addition, the services that were available in PC in the city of Florianopolis and the data from the literature review were incorporated and assisted in the development, structure, and sequencing of the flowchart. The proposal for structuring the PC services for people with PD was structured into: (1) The results are organized in three steps: (1) Literature review results: in this section, we will aboard the PD care recommendations and show the crucial points for treating people with and without risk of falling. (2) Focus group results: Here we present the qualitative data and its contribution to the construction of the flowchart. (3) The referral flowchart structure and how to employ it: in this section, we present the creative process of the flowchart and a manual for using it.PD is a multisystemic disease with several motor and non-motor symptoms. The drug treatment available is only partially effective, requiring multidisciplinary care to complete the approach. The involvement of professionals such as physiotherapists, speech therapists, nurses, psychologists, nutritionists, among others, is as significant as the physician's attention . The EurWorldwide, several guidelines recommend multidisciplinary care for the treatment of persons with PD. These include the guidelines produced by the Dutch National Professional Allied Health Associations on speech therapy, occupational therapy, and nutrition –30. In aCurrently, it is recognized that when performing an exercise, people with PD benefit in different physical , 33 and The Brazilian UHS recognizes health as a right for the people and a duty for the state . The govWhen taking the clinical decision about exercise prescription and the need for referring people with PD with accuracy, it is necessary to consider the high rate of falls in this population. PD falls are heterogeneous, recurrent, causing morbidity , and migFalls may be associated with generic (aging-related) or PD-related factors . GenericAlthough falls can occur in the early stages of the disease, falls are not frequent, with a low level of association with the person's daily activities . With diFunctional Gait Assessment .–47.FunctThe 3-step-fall-prediction test is objective and accessible to daily use, and it is validated for people with PD , 47. It The 3-step-fall prediction test has been externally validated in 171 PD people showing accuracy to discriminate fallers from non-fallers  . The tesThose people with PD who are at low risk of falls could engage in group activities available at the PC and require less attention from the health professional. On the other hand, fallers require more outstanding care and may be referred to rehabilitation services such as Specialized Rehabilitation Centers (RECs). Another critical point to remember is the need for more focused attention for lower-mobility people. Those who are mobility-restricted and recurrent fallers also need to be referred to RECs for treatment.Approximately 120 e-mails were sent to the coordinators of HC in Florianópolis. Six HC declined to participate, and ten HC agreed. Two were excluded from the final analysis due to unpredicted events occurring on the spot , totaling eight HC and eight FHS interviewed. We interviewed 37 FHS professionals-−12 community health agents, 10 nurses, 10 physicians, two nurse residents, two medical residents, and one dentist.The results of the interviews presented in Medical practitioners report that the correct diagnosis of PD is an essential requirement for appropriate treatment. But, as it is a specific condition and not so frequent (or not correctly identified by them), they report a lack of experience in making the diagnosis. They prefer to refer them to neurologists. Thus, the proposed flowchart is intended to assist professionals with PD cases already diagnosed and confirmed by specialized neurologists. In addition, the lack of experience of these professionals also hampers the recognition of clinical signs and symptoms  that can be used to indicate/recommend activities and trigger referral to other professionals FHS professionals recognize the need for multidisciplinary care and, likewise, the need to refer people with PD to other professionals and activities offered by PC. When they do, the activities usually indicated are physical exercise, pain support, psychological support, nutrition groups, dance groups, walking groups, speech therapy, among others that occur within the HC. Usually, these groups are carried out by professionals in the indicated area. Some teams also refer people with PD to multidisciplinary services outside the HC, although most report not being aware of these services.Some professionals interviewed also believe that their role in treating people with PD is related to support / adjustment of medications and providing documents . In their perception, most people with PD use the service for renewing medical prescriptions for their disease control, failing to other possible treatments. In this way, the flowchart can help professionals visualize what is available in the primary health care network and quickly refer people with PD to multidisciplinary services.Flowcharts are practical tools for patient assessment, maintenance, and management; thus, they assist the health professional with the management and care proposal (involving risk and vulnerability assessment)  This floThe following tables must be used within the referral flowchart. The After performing the test, and in case of falls, the health professionals should go to This study aimed to develop a referral flowchart based on the risk of falls for people with PD at the Brazilian PC. Brazil does not require mandatory reporting of PD. However, the Brazilian population of 60 years of age and over (approx. 28 million) and the increasing life expectancy of Brazilians suggest that PD and resulting falls are a significant health issue for older people.We suggest that this flowchart might be the first step to build a multidisciplinary approach for people with PD in PC in Brazil. The next stage of this study might be the validation and subsequent implementation of the flowchart through PC at the UHS in Brazil.Although prevention and management of falls of people with PD emerge in the qualitative research, we did not address specific questions for the FHS teams in the qualitative interview about this subject. Another limitation of our study was that we did not address the cognitive issues of people with PD. And this can influence the rate of falls in this population, so this must be considered when using the flowchart.Also, the quality and quantity of the services offered at the PC varies among Brazilian regions. Like any standard, this flowchart cannot be taken as an absolute character, even if it applies to many situations. Therefore, a pilot study is needed for further improvements and to warrant the implementation in different regions.As future directions, continuing education programs must be offered to health professionals at Primary Care. These professionals are the first contact with the PD patients through the Brazilian Health System. Hence, knowing how to identify, treat, and refer a person with PD could improve the quality of care and potentially increase the quality of life of those who live with the disease. Also, to use the flowchart its validation must occur, so the next step of this study might be its validation through the Primary Care at Unified Health System in Brazil.The raw data supporting the conclusions of this manuscipt will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee for Human Beings of the State University of Santa Catarina. The patients/participants provided their written informed consent to participate in this study.RSM, ECG, AS, and MHALK contributed to conception and design of the study. RSM organized the database, performed the statistical analysis, and wrote the first draft of the manuscript. AS and MHLAK revised the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study aims to assess the association between daily temperature and sickness absence episodes in the Mediterranean province of Barcelona between 2012 and 2015, according to sociodemographic and occupational characteristics.Ecological study of a sample of salaried workers affiliated to the Spanish social security, resident in Barcelona province between 2012 and 2015. The association between daily mean temperature and risk of new sickness absence episodes was estimated with distributed lag non-linear models. The lag effect up to 1 week was considered. Analyses were repeated separately by sex, age groups, occupational category, economic sector and medical diagnosis groups of sickness absence.The study included 42,744 salaried workers and 97,166 episodes of sickness absence. The risk of sickness absence increased significantly between 2 and 6 days after the cold day. For hot days there was no association with risk of sickness absence. Women, young, non-manual and workers in the service sector had a higher risk of sickness absence on cold days. The effect of cold on sickness absence was significant for respiratory system diseases  and infectious diseases .Low temperatures increase the risk of having a new episode of sickness absence, especially due to respiratory and infectious diseases. Vulnerable groups were identified. These results suggest the importance of working in indoor and possibly poorly ventilated spaces in the spread of diseases that eventually lead to an episode of sickness absence. It is necessary to develop specific prevention plans for cold situations. The Intergovernmental Panel on Climate Change has reported evidence on the environmental consequences of climate crisis, such as global warming, sea-level rise, heat waves, heavier hurricanes and storms, and has projected a global average temperaturet increase of 1.8 to 4°C by 2100 .Extreme temperatures, which will be aggravated by global warming, have been identified as a major public health concern, with significant impacts on human health . The mulIn the occupational setting, extreme temperatures have been linked with other health effects metrics. For example, the relationship between heat exposure and some illnesses  have been increasingly studied in the working population –10 and tSickness absences can be a good metric to evaluate the health effects of temperature in the working population. In a seminal work, Marmot and colleagues have considered sickness absence as an integrated measure of health status and functioning in working population . Poor woTherefore, the aim of this study is to assess the possible association between daily temperature and incidence of non-work-related sickness absence in Barcelona province between 2012 and 2015, according to sociodemographic and occupational characteristics.We performed an ecological study of a sample of salaried workers residents in the province of Barcelona, who are affiliated at least 1 day to the general regime of the Spanish social security between 2012 and 2015, and have had at least one episode of sickness absence. The province of Barcelona has a population of approximately 5.5 million. The predominant climate in the region is Mediterranean, with dry, hot summers and winters with balanced temperatures and low rainfall.Data sources were the WORKss cohort , which iThe main outcome is sickness absence, a situation in which a worker affiliated to the Social Security is unable to carry out his or her work, no more than one and a half year, meanwhile is receiving health care from a health care center and an economic subsidize from the social security system . We aggrDaily new sickness absence episode counts were linked with temperature using quasi-Poisson regression and the distributed lag non-linear model (dlnm) framework . In partWe controlled for long-term trends and seasonality by including a natural spline of time using 12 degrees of freedom per year. This choice was based on visually inspecting how the splines with different degrees of freedom captured the seasonal pattern in the data. We also compared the estimated seasonal pattern with different degrees of freedom with that obtained using a thin plate regression spline of time. Since the daily number of sickness absence depends on the number of workers working on a given day, we also included dummy variables for day of the week holidays, and certain days preceding or following a holiday. The inclusion of such days was decided by aggregating all sickness absence episodes by day of year and visually exploring the resulting time series plot. Those points that appeared separated from the seasonal pattern, and were a holiday or a day preceding or following a holiday, were included as dummy variables in the model.Finally, we calculated the attributable fraction of sickness absence that could be attributed to non-optimal temperatures based on the model results using a previously established methodology . The resThis study was performed in accordance with the standards of Good Clinical Practice and the principles of the Declaration of Helsinki. The study protocol guaranteed the fulfillment of Regulation (EU) 2016/679 of the European Parliament and the Council of 27 April 2016 on the protection of natural persons regarding the processing of personal data and the free movement of such data.The study included 42,744 salaried workers and 97,166 episodes of sickness absence registered in Barcelona province between 2012 and 2015 . These eThe relationship between temperature and risk of sickness absence is summarized by the pooled overall cumulative curve shown in When stratifying by the sociodemographic and occupational variables, still we did not find statistically significant associations for heat . The assThis article aimed to assess the association between daily temperature and sickness absence episodes in Barcelona province. Our results show that low temperatures increase the risk of having an episode of sickness absence, especially due to respiratory and infectious diseases. Furthermore, women, non-manual workers and workers in the service sector seemed to be more susceptible to cold temperatures. No association was found between hot temperatures and risk of sickness absence.Climate crisis indicators, such as meteorological variables, have been considered as macro determinants of sickness absence , and havThe main result is that cold temperatures increased the risk of sickness absence. This result is coherent with other publications which showed that cold exposure increased the risk of occupational injury , 13. MorUnexpectedly, we did not find association between hot temperatures and risk of sickness absence. Most of previous studies analyzing temperature effects in occupational health showed that heat and extremely heat temperatures increased the risk of occupational injuries , 10, 12.We found an association between cold temperatures and sickness absence due to respiratory and infectious diseases, both groups of diseases strongly interrelated by infectious diseases of the upper respiratory tract. This result is in line with other studies on temperature and hospitalizations or occupational injuries . BronchiWe identified especially vulnerable groups in the association of daily temperature and the risk of having a sickness absence episode. Women, regardless of age, seem to be more vulnerable to cold temperatures. In Spain, as in most of the European countries, women have more sickness absence than men, which has been related to the gendered division of paid work and family responsibilities and the related women's double presence . MoreoveSeveral previous studies conducted in different countries have generally shown that socioeconomic status is associated with the risk of sickness absence, people in a lower occupational class have more SA than those in a higher occupational class , 38. UneThis study has some limitations. First, we are probably underestimating the association between exposure to extreme temperatures and temporary disability, due to the economic sector composition of the workers in our sample, i.e., mainly service sector workers, and few workers in agriculture and construction, who are likely to be most exposed to high risks of adverse health outcomes from heat. Second, the lack of information on whether workers perform their work indoors or outdoors, and about the specific occupation of workers and their working conditions, which could shed light to the effect of ambient non-optimal temperatures depending working conditions of each occupation; even though we have economic sector and occupational category as proxies. Third, we do not have information on living conditions, which also could be confounding the effect of temperature and sickness absence on working population. Finally, we did not have information about comorbidities or previous health status. Among the strengths of this study, this is the first one assessing the impact of ambient temperatures on workers' health through a holistic measure such as sickness absence. Diagnoses of sickness absence are not self-reported, we have official medical diagnoses made by primary care doctors. Finally, we used administrative secondary data from social security and sickness absence management institutions at cost zero for use in this research.As far as we know, there is no cross-national survey in Europe on working conditions that incorporates items on the basis of a theoretical approach to the impact of climate crisis to occupational health. So, there is a lack of information and indicators of how the climate crisis threats workers' health. Both occupational health surveillance and research are needed to identify climate-related occupational effects in order to develop preventive strategies and workplaces adaptations for vulnerable groups within working population. However, these preliminaries results can provide guidance on the definition and implementation of policies to prevent potential risks of temperature to workers health, specifically cold temperatures, which have not been usually taken into consideration.amaya.ayala@upf.edu.The data analyzed in this study is subject to the following licenses/restrictions: The data that support the findings of this study are available from the Spanish National Social Security Institute and the Catalonian Institute for Medical Evaluations but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Spanish National Social Security Institute and the Catalonian Institute for Medical Evaluations. Requests to access these datasets should be directed to AA-G, Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.XB, AA-G, MU, and FB conceived the article. XB analyzed the data. MU, AA-G, and XB interpreted the data and results. MU and AA-G drafted the work. XB and FB substantively revised it. All authors contributed to the article and approved the submitted version.


The purpose of the paper is to provide an ex-ante evaluation of banning price promotions for discretionary foods  in Scotland. The methodology consisted of the estimation of demand systems by socioeconomic groups  for 19 food groups using a highly product disaggregated dataset. These results were used to simulate scenarios consisting of eliminating price promotions on the discretionary food products for the entire sample and by group and analyzing nutritional results. The results indicated a net impact of reducing energy by 651 kcal per capita per week  An enduring issue for all health care systems is that increasing demand for health care continues to outstrip the amount of resources available. There are many reasons for this excess demand, but one key factor relates to the health behavior of the population in terms of engagement with a healthy lifestyle , 2. PoorA key policy implication that arises from recognition of the strong relationship between environmental factors and obesity is that universal policies that apply to whole population groups, such as taxation, subsidies, regulation, reformulation and labeling are now being more heavily promoted, developed and tested in many countries –7. RecenData from the Kantar Worldpanel (KWP) for Scotland from 2013 to 2018 were used. This dataset provides information about purchases at the level of products by households and whether they were made under a promotion . It also includes product nutrient data . The available nutrients in the dataset were calories, proteins, carbohydrates, sugar, fats, saturates, fiber and sodium.The KWP data are the largest available source of individual household data for Great Britain. KWP is a continuous consumer panel which is geographically and demographically representative of Great Britain. KWP recruits a representative sample of households with respect to household size, number of children, social class, geographical region and age group and collects socio-demographic data such as household income, occupational class and education. KWP panel members scan and report all purchases of food and drink brought into the home, as well as providing till receipts which verify the purchases made and provide price information. The KWP dataset covers all outlets where purchases of food and drink to bring home can be made. This includes supermarkets, corner shops and online purchases. It does not include purchases that are consumed away from home, although these only account for about 10% of total food and drink energy , 16.Nineteen food categories were included in the analysis and were classified into categories of discretionary or non-discretionary foods. Discretionary foods are defined as foods and drinks not necessary to provide the nutrients the human body needs, but that may add variety to a person's diet ; they inThe total number of observations for the analysis was 9,737 households. We calculated annual household food expenditure data, and to eliminate the difference in the number of weeks that households were observed, the data were expressed as per capita weekly averages. Only households that were observed a minimum of 40 weeks in a year were included in the analysis. To examine socioeconomic differences in household expenditure, households were classified into five household gross income bands  and five life stage groups: pre-family, young family, middle family, older family and 45+ without childrenA simulation approach was used to identify the potential impact of removal of current promotions of discretionary foods. The estimates are derived from a method published in Drèze et al. , who useThe AIDS model involves estimation of the expenditure shares  of consumers' budget spent on each food and non-food category. These are estimated as a function of prices, total expenditure on groceries in real terms and an indicator of whether products within categories are on promotion. Thus, we calculate a value for the expenditure, price, and promotion of each food category for each household. For each category, the share equation consists of the following effects:The simulation involved the subtraction of the promotions advertising effect and then re-computing the category shares, keeping the income and prices constant. Total expenditure per category was then calculated by multiplying the new shares by the total expenditure on groceries. Dividing the expenditure by the average price of the category provided the resulting quantities. To compute the energy and nutrients, the quantities were multiplied by the energy and nutrient coefficients.Following , expendiCategory Expenditure Category Price Category Promotion Where:st = price of product s during time t.ps = number of individual products in category g.t = time period from 1...T.The weights associated with products, gt) given by eq. (5):The model comprised the estimation of the shares of consumers' budget spent on category g in time t  because it contains a price component and a quality choice component , as thelh are household characteristics variables, qjh are quantities and pj are the prices; ωj0, ωjl and μj are parameters and ujh is a normal error term. Equation (6) decomposes the aggregation in: the quality, the price and the quantity effects. Assuming that a cluster of households which belongs to the same geographical area and time period face the same prices, it is possible to estimate the parameters using a within cluster equation (where k indicates the cluster) due to the fact that prices and the category-specific coefficient ωj0 are canceled out. Thus, prices were estimated as in eq.:Where zThe price index e system  was estiFor any lifestage group, the nutritional changes for nutrient i, for food category g, due to the measures were evaluated at the means of the variables using the following formula (9):ig is nutrient i coefficient  of category g. Note that promotions for products that are not discretionary are supposed to still be in place.Where D is the number of discretionary categories, Considering the different types of promotions, temporary price reductions appear to be the most important type, but there are some differences by category. For 2018, the share of temporary price reduction ranges from 16.4 per cent .As shown in The simulations show that all the groups display a reduction in energy and nutrients. For income group, For lifestage group, The analyses suggested that a policy to restrict all price promotions of discretionary foods have the possibility to result in a net change of about −651 kcal  per capita per week  taking account of substitution of different items within food category and between food categories). This indicates that the measure due to the reduction in calories, sugar, saturated fats and salt has the potential to reduce obesity related deaths such as cardiovascular deaths.All the nutritional categories showed similar results , which indicates that the impact of restricting/banning promotions could be positive in terms of reductions of the purchase/consumption of foods high in fat, sugar and salt. It should be noted that the reduction in nutrients observed on the discretionary foods was only partially compensated by the increase in quantities in non-discretionary food and drinks .With regard to energy and nutrients from the purchases of other food and drink categories, almost all the categories show increases in energy and nutrients except in the case of ready meals, which shows a slight decrease. The highest increases in terms of energy are produced by fats and eggs , which also shows the highest increases in fats (about 13 g.) and saturates (about 5.2 g.). The highest increases in total sugar come from fruit (around 4.6 g.) and vegetables (around 3.3 g.).Given that no country or jurisdiction has restricted or banned the promotion of discretionary foods, it is difficult to compare our results with findings from previous studies [an exception is , althougThe results reported in this paper were derived from data collected within Scotland. The strength of the study is that the estimation is based on a large sample for Scotland that shows variability in prices, expenditure and purchases under promotion. This is the only dataset that provides information about whether food and drink purchases were made under promotion. Standard errors and 95 per cent confidence intervals of the impact estimates indicate that the results are robust for all the studied groups.The study considers all price promotions, some of which are likely to be retained in any future policy . This suggests that the modeled impacts may be best viewed as an upper bound on the overall actual impacts that would follow from an introduction of promotion restrictions for discretionary foods.An important question relates to the transferability of study results from one country to another. There are many factors that can influence transferability, and these include the size and type of promotions, the characteristics of the study populations, differences in access to supermarkets and other retail outlets, between country differences in taxation, pricing, and differential regulation of food and drinks, including the relative availability of “unhealthy” and “healthy” food and drinks within supermarkets and other outlets. More generally, is has been noted that it is important to consider enabling policies, or the system-wide policy context where interventions are designed and delivered factors . TherefoA limitation of the analysis is that it was only possible to include food bought for consumption in the home. According to the most recent information from Defra's Family Food 2017/18 , househoIn conclusion, the results indicate that restricting the advertising of promotions has the potential to reduce the number of calories, sugar, saturated fats and sodium (even when considering the substitution effects) for most food groups. However, it should be noted that the results are aggregated across all price promotions, some of which are likely to be retained in any future policy . This suggests that the modeled impacts may be best viewed as an upper bound on the overall actual impacts that would follow from an introduction of promotion restrictions for discretionary foods.cesar.revoredo@sruc.ac.uk.The data analyzed in this study is subject to the following licenses/restrictions: The Kantar Worldpanel dataset is proprietorial data and by contract we cannot disclose them. Nevertheless the CRG planned the study, prepared the dataset, wrote the estimation, and simulation routines. PM wrote the manuscript. PN co-wrote the manuscript and prepare a literature review. FA estimated the first version of the models and compile part of the literature. WD estimated the price equations and re-estimated the models. All authors contributed to the article and approved the submitted version.via the research project Economic Modelling, Reducing Health Harms of Foods High in Fat, Sugar or Salt (reference JUN358629) and the Scottish Government Strategic Research Programme 2022–27, Project - Assessing the impact of dietary health interventions for driving long-term positive changes in diet and nutrition in Scotland.This paper was funded by the Scottish Government The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This study examines the mediating role of social withdrawal in the relationship between smartphone overdependence and quality of life in college students. These three factors were assessed in 125 college students enrolled at a college in South Jeolla Province, South Korea, from September to November 2019. Data analysis was conducted using SPSS version 27.0, including regression to test the research hypothesis and a Sobel test to assess the significance of the mediation. It was found that social withdrawal completely mediates the relationship between smartphone overdependence and quality of life in college students. Several means of improving the quality of life of college students are identified based on this finding. First, colleges could provide financial support for community programs such as membership training and club activities. Second, an in-college system could be built that enables early intervention in cases of social withdrawal in students. Third, closely linked programs could be designed to provide effective professional counseling to college students experiencing strong social withdrawal. Fourth, college faculty could receive psychoeducation on social withdrawal. Fifth, as various mediating variables may exist in the relationship between smartphone overdependence and quality of life and only social withdrawal was considered in this study, subsequent studies could consider the effects of more diverse psychological and social variables. The strong enthusiasm for education in Korean society has been a major driver of the country's rapid economic growth. This enthusiasm is reflected by its college entrance rate, which is among the highest in Organization for Economic Cooperation and Development (OECD) nations. Based on OECD Education at a Glance indicators, the Ministry of Education  reportedThe college entrance rate is high because a college education increases individuals' likelihood of receiving a high wage once employed. According to an analysis of the employment rate and wages of Korean adults (25–64 years) by the Ministry of Education , the empTherefore, college entrance plays a decisive role in life outcomes. However, colleges do not merely have the limited role of enabling employment or increasing earnings potential. Fundamentally, colleges provide young people—that is, college students—with a range of knowledge required for the socialization process. Further, college students' socialization is crucial also because they are going through the transitional period between the developmental stages of adolescence and adulthood; different scholars consider college students to be either adolescents or adults . During College students can be distinguished from adolescents or adults by the fact that they need to achieve the major economic and emotional developmental task of preparing to become independent from their parents while forming social relationships based on their own perspectives . For exaCollege students, who are future leaders, must be provided support to grow into independent members of the society. To this end, first, college students' life conditions, which can be characterized using the concept of quality of life, must be analyzed.Academia is, therefore, making varied efforts to improve college students' quality of life. Research indicates that factors such as family relationships, friendships, learning, employment, cultural activities, depression, and impulsiveness influence college students' quality of life , 5.Thus, multiple factors affect college students' quality of life. A concept that research has recently focused on is smartphone overdependence. Because a smartphone offers diverse means of leisure, including chatting, messaging, games, YouTube, and the internet, it serves to improve college students' quality of life in many ways. However, although smartphones do provide convenience and pleasure in college students' everyday lives, their excessive use also has negative impacts, such as smartphone overdependence . SmartphHowever, despite the evidence for a link between smartphone overdependence and quality of life, the detailed explanation and understanding of the relationship between the two is limited. Therefore, this study identifies and focuses on a third variable that may mediate the relationship between these two variables—social withdrawal.College students experiencing smartphone overdependence prefer relationships in the virtual world over social relationships in the real world . This caFurthermore, because social withdrawal involves avoiding social relationships and preferring isolation , it may Therefore, this study analyzes social withdrawal's mediation of the relationship between college students' smartphone overdependence and quality of life. Additionally, practical and policy suggestions are presented for improving college students' quality of life based on the research findings.The first conception of “quality of life” was presented in Pigou's work The Economics of Welfare in 1920; it focused on economic aspects of life quality .However, from 1960 to 1970, the limitations of measuring a nation's quality of life through the purely economic aspect of gross domestic product (GDP) were identified and discussed. The Korean government conceptualizes quality of life as “objective living conditions and the subjective perception and evaluation of citizens in regard to [them]” and measures it by considering both objective and subjective quality of life , 19.The concept of quality of life is thus being used socially by including both objective and subjective aspects. However, because of limitations in the data that can be collected by individual researchers, most assess quality of life using subjective measures. Subjective quality of life is the subjective evaluation of one's own life. Researchers measure subjective quality of life based on life satisfaction, happiness, or subjective well-being , 20–22.Quality of life is far from assured in college students because the need to prepare for independent adulthood puts them in a psychologically unstable state. The biggest issue they face is adjusting to a new environment, as well as becoming independent from their parents, interpersonal relations, and occupational choice. In this context, college students' quality of life is an important matter that should be given focus , 23.The smartphone is a device that performs functions of both mobile phones and computers and have become a necessity , 24. JanAs mentioned previously, while smartphones play a positive role in using time wisely and maintaining interpersonal relationships, they also carry various risks. A typical problem stemming from smartphone use is smartphone overdependence. Prior to 2016, the terms smartphone addiction and smartphone overindulgence rather than smartphone overdependence  scale . This scSmartphone overdependence was measured using the Lee's  instrumeThe control variables of this study are gender and age. Gender was processed as a dummy variable: female = 0 and male = 1.The sociodemographic characteristics of the participants are shown in The descriptive statistics for the smartphone overdependence, social withdrawal, and quality of life measures are presented in The correlations among the smartphone overdependence, social withdrawal, and quality of life scales are shown in First, the VIF (Variance Inflation Factor) values of The relationship between smartphone overdependence and quality of life is shown in p < 0.001. With gender, age, and smartphone overdependence as predictors, the explanatory power of the model for social withdrawal was 14.5%. Smartphone overdependence was indicated to have a significant influence on social withdrawal, β = 0.385. Thus, the results indicate that higher smartphone overdependence predicts greater social withdrawal.The relationship between smartphone overdependence and social withdrawal is shown in p < 0.001. Using gender, age, smartphone overdependence, and social withdrawal as predictors gave the model an explanatory power for quality of life of 14.1%. Gender and social withdrawal were significant predictors of quality of life, in that being male and having higher social withdrawal predict decreased quality of life.The relationships between smartphone overdependence and social withdrawal with quality of life are shown in p = 0.000.Finally, the results of verifying the significance of the mediating effect of social withdrawal are shown in This study examined the mediation of the relationship between smartphone overdependence and quality of life in college students by social withdrawal.First, no significant relationship was found between smartphone overdependence and quality of life. This result contrasts with the results of previous studies , 22. SmaA full mediated effect of social withdrawal was discovered in the relationship between smartphone overdependence and quality of life. This supports previous findings that higher smartphone overdependence corresponds to higher social withdrawal , 11 and College students use smartphones for purposes such as making good use of spare time during commute and between classes and maintaining interpersonal relationships  . In otheFurther, research suggests that smartphone overdependence increases college students' sense of social withdrawal because excessive smartphone use leads them to prefer relationships in the virtual world over interpersonal relationships in the real world . As a reAlso, since social withdrawal means a failure of interpersonal relationships, negative cognitions like fear of social interactions and disappointment can become solidified within the college student, which then stunts their ability to achieve a good quality of life . In a nuDespite its significance, this study has several limitations. First, although it is probable that several variables mediate the relationship between smartphone overdependence and quality of life, only social withdrawal was considered here. Therefore, more diverse social and psychological variables need to be considered as mediators of the relationship in the future. Additionally, this study only targeted college students in part of South Jeolla Province. For this reason, research should be conducted on college students throughout the nation.The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author(s).Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.Both authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Nanotechnologies have received tremendous attention since their discovery. The current studies show a high application potential of nanoparticles for plant treatments, where the general properties of nanoparticles such as their lower concentrations for an appropriate effects, the gradual release of nanoparticle-based nutrients or their antimicrobial effect are especially useful. The presented review, after the general introduction, analyzes the mechanisms that are described so far in the uptake and movement of nanoparticles in plants. The following part evaluates the available literature on the application of nanoparticles in the selective growth stage, namely, it compares the observed effect that they have when they are applied to seeds (nanopriming), to seedlings or adult plants. Based on the research that has been carried out, it is evident that the most common beneficial effects of nanopriming are the improved parameters for seed germination, the reduced contamination by plant pathogens and the higher stress tolerance that they generate. In the case of plant treatments, the most common applications are for the purpose of generating protection against plant pathogens, but better growth and better tolerance to stresses are also frequently observed. Hypotheses explaining these observed effects were also mapped, where, e.g., the influence that they have on photosynthesis parameters is described as a frequent growth-improving factor. From the consortium of the used nanoparticles, those that were most frequently applied included the principal components that were derived from zinc, iron, copper and silver. This observation implies that the beneficial effect that nanoparticles have is not necessarily based on the nutritional supply that comes from the used metal ions, as they can induce these beneficial physiological changes in the treated cells by other means. Finally, a critical evaluation of the strengths and weaknesses of the wider use of nanoparticles in practice is presented. Nanotechnologies have received tremendous attention since their discovery. Nanoparticles are a basic concept and building block, and they are particles that have one or more dimensions in the range of 1-100 nm. They can consist of many elements and their compounds, which are made of, especially, carbon, metals, metal oxides and various organic substances ,3,4,5. N2, Au, graphite and fullerene-related compounds, and the relatively unstable ones such as ZnO, CuO and those that are Fe2O3-based. The instability of the given nanoparticles does not always mean that they have a negative property, when, for example, the combination of micro/macro element-based NPs and their gradual release due to them having less stability can be used in the field of precise plant fertilization. Some other reviews describe this issue in more depth  and silver [Ag] nanoparticles on the seed’s phytosanitary state and the provision of germination support, the tested nanoparticles were found to affect chili (Capsicum annum L.) seed germination and vitality without the phytotoxicity symptoms that are associated with excessive metal use. At the same time, they had a strong antimicrobial activity against the pathogens Aspergillus flavus, Aspergillus niger, Aspergillus fumigatus and Colletotrichum capsici [Regarding the influence of zinc oxide [ZnO], titanium dioxide , palladium [Pd], gold [Au] and copper [Cu] nanoparticles displayed an antimicrobial effect in vitro but not in situ, which was explained by their adsorption by the substances in the soil complex , thereby reducing the drought stress impact during seed germination. The further observations showed that there was a reduction in chlorophyll degradation, a protection of the photosynthetic apparatus and a beneficial effect on the activity of the antioxidant enzymes [2] nanoparticles was evaluated very similarly, where a balancing of the production of the reactive oxygen species and the enzymatic activity was observed in the treated seeds. At the same time, the increase in water uptake was observed when the water was available  nanoparticles were used at various concentrations on sorghum (Sorghum bicolor (L.) Moench) seeds, both during seed activation and as a preventive treatment against increased salinity. The effect of the soil salinity caused a reduction in the chlorophyll content, photosynthesis rate and transpiration, increased the lipid peroxidation, and decreased their growth. The use of nanoparticles improved the germination process and subsequent seedling growth, along with eliminating the effects of the stress caused by increased environmental salinity  and zinc oxide [ZnO] nanoparticles. It was reported that the nanoparticles cause evident physiological phenomena that minimized the stress from the salinity of the environment  and iron [Fe] nanoparticles. There was an increase in the concentration of Zn and Fe in the roots, and thus, a decrease in Cd uptake was observed. Moreover, the tested plants showed an increased biomass production due to the improved physiological conditions and reduced Cd accumulation [The reduction of the stress impact from a substrate that was contaminated with cadmium [Cd] was achieved, also, by the treatment of wheat seeds (mulation . In a simulation . PossiblTriticum aestivum L.) seeds were observed in the study by Yasmeen et al. (2017), where the application of 25 ppm of both nanoparticles activated between 25 and 121 proteins that are involved in the process of seed germination. As a consequence, the increased production of other substances that are responsible for the activation of proteins and enzymes was found. As a result, significant physiological support for the association of seed germination and resistance to stress factors has been achieved [The physiological effects of iron [Fe] and copper [Cu] nanoparticles on wheat , gibberellic acid (GA) and others. In summary, the presence of nanoparticles in the seed tests, through several chains of subsequent events, induces the accumulation of reactive oxygen species that are a common part of the processes that are associated with the end of dormancy ,118,119.Citrullus lanatus (Thunb.)), which are valuable especially for their seedless fruits. The mechanisms of silver [Ag] nanoparticles effects, in combination with those of turmeric oil nanoemulsions (TNE), were studied after their application to cultivars ‘Riverside’ (diploid) and ‘Maxima’ (triploid) seeds. The nanoparticle application contributed to an increase in the rate of germination, metabolic activity, an increase in biomass production and therefore, a higher yield  nanoparticles have a proven antimicrobial effect, but the effect of increased seed vitality after their application was also observed. As an example, are the results of a study on the brief exposure of aged rice seeds (ncreased . The bened aging .Vigna radiata L.) seed treatment, where their germination was increased, and the elongation of the seedlings was promoted  nanoparticles were used for a mung (promoted . Mung se MgO NPs . Mangane MgO NPs  nanopartiata L.) .Pisum sativum L.) seeds resulted in the inhibition of rhizobial colonization and arbuscular mycorrhizal fungi. Despite that negative effect, the treated plants produced more seeds in shorter period of time in comparison to the control plants, nevertheless, the seeds had a lower weight. This effect can also be considered as the nanopriming of seeds as it increased the plant’s productivity [The application of platinum [Pt] nanoparticles that were stabilized with polyvinylpyrrolidone to pea  and wheat (Triticum aestivum L.) has shown a positive effect on the seeds’ germination rate and growth parameters [Zea mays L.) with Zinc [Zn]-encapsulated chitosan nanoparticles has a positive effect on seed germination. Simultaneously, zinc [Zn] deficiency in plants was compensated, and an antimicrobial effect against the pathogenic fungus Curvularia lunata was observed  that was phytochemically stabilized by an extract from the flowers of Cassia occidentalis L., and iron sulfate [FeSO4]. In the results, the FeO nanoparticles showed a more favorable effect on plant growth when it was compared to that of FeSO4 [Triticum aestivum L.) seeds with iron oxide nanoparticles [Fe2O3] to increase seed germination was described in another study. Interestingly, the treatment of the seeds caused an increase in iron [Fe] biofortification and accumulation in the produced seeds  nanoparticles confirmed that it has a beneficial influence on seed germination, but it negatively affected the subsequent development of the plants  hybrid complex was applied to the Arabidopsis thaliana L. plants, where an increased expression in systemic acquired resistance (SAR) marker genes was observed and simultaneously, a significant increase in their resistance to Pseudomonas syringae pv. tomato was achieved  nanoparticles which were grown on graphene oxide (GO). Their inhibitory effect on the bacterium X. perforans was observed under in vitro conditions and the treated plants also showed a significantly lower severity of the symptoms  nanoparticles against the pathogen Fusarium culmorum can have negative phytotoxic effects, which are comparable to the damage caused by Fusarium  nanoparticles and photoactivated zinc oxide [ZnO] nanoparticles to strawberry plants (Fragaria × ananassa Duchesne ex Rozier)  nanoparticles were also frequently evaluated as being excellent when they were used against several pathogens. For example, He et al. (2011) reported about the activity against expansum . Wani anolonifer . More spsticides ,152. Simobserved . The sig Rozier) .60), were compared on the base of their activity against Ralstonia solanacearum , all of the tested nanoparticles have significant antifungal properties  were used for a tomato root treatment (Lycopersicon esculentum Mill.) to avoid the tomato root rot that is caused by Fusarium oxysporium, and they were compared with tolclophos-methyl, a substance that is used in commercial plant protection products. The efficacy of both substances was similar; the occurrence of the pathogen was significantly suppressed. However, a significant beneficial effect on plant growth properties was observed in the variant that was treated by nanoparticles [The use of magnesium oxide [MgO] nanoparticles on tomato roots (n growth . Aluminaarticles .Further studies point to the development and use of pesticides with controlled release . The conCucumis sativus L.) from attack by the pathogen. The active substance that was used was abamectin, a pesticide from the soil bacterium Streptomyces avermitilis, which was encapsulated in polylactic acid (PLA) nanoparticles. It is an easily biodegradable material, protects abamectin from light radiation and is easily biodegraded when the leaf is attacked by the pathogen, which occurs with release of the active substance  or zinc oxide nanoparticles [ZnO] was compared by Rossi et al. (2019). The plants that were treated by ZnO showed a much higher content of zinc [Zn] than the other variants. A significant increase in the fresh weight and dry weight of roots and leaves was also observed  and zinc oxide [ZnO] nanoparticles of a similar size on tomato growth (Lycopersicon esculentum Mill.) was compared by Raliya et al. (2015). The results showed a critical concentration limit for both of the nanoparticles, up to which the plant’s growth and development are promoted, with no improvement beyond that. The better uptake of nanoparticles from foliar spraying than from the soil was also observed  was performed on the plants stigated .Triticum aestivum L.). The treated plants showed faster growth, reached harvest maturity earlier and a higher yield was observed [Chitosan-based nanofertilizers containing nitrogen [N], phosphorus [P] and potassium [K] were investigated by Abdel-Aziz et al. (2016). The chitosan-NPK nanoparticles were applied by foliar spraying, and they easily penetrated into the wheat plants (observed .Rhizobium sp. E20-8) in soil is negligible, but there was a significant improvement in their drought stress resistance. This led to an increase in the yield of corn plants (Zea mays L.) [It was also proved that the effect of graphene oxide on bacterial microflora (mays L.) .2O3] and a chelated-Fe fertilizer  were investigated by Rui et al. (2016). The nanoparticles were applied to peanuts (Arachis hypogaea L.), where the regulation of phytohormone contents and antioxidant enzymatic activities were observed. The nanoparticles caused an improvement in the plant’s growth and a greater biomass recovery  nanoparticles, chelated zinc oxide [ZnO] nanoparticles and iron oxide [Fe2O3] [Iron oxide nanoparticles [Ferecovery . Severalobserved . An incr [Fe2O3] .2] nanoparticles with an anatase or rutile structure can reduce the uptake of arsenic [As] that is performed by rice plants (Oryza sativa L.) that are grown in contaminated soil. The accumulation of arsenic in the root part, shoots and seeds was limited, with nanoparticles with an anatase structure having a slightly better effect on them [2] nanoparticles can interact with cadmium [Cd] and arsenic [As] which results in a reduction occurrence and the uptake activities by the plant from the nutrient solution. The character of these interactions are strongly dependent on the pH, which is highly affected by the root exudates, if we are to focus on the situation in the root system [2] nanoparticles by foliar spraying them onto rice plants (Oryza sativa L. ‘Kainat’) that were grown in a substrate that was contaminated with cadmium [Cd]. A lower phytotoxic effect, an increase in the biomass production and a lower accumulation of cadmium were observed in the plants, after the treatment  have stimulating effects on the growth of larch (Larixolgensis A. Henry) seedlings. At the same time, it was found that soaking the roots of the seedlings in a solution of nanoparticles which was diluted to 500 μL.l−1 causes a noticeable increase in the amount of chlorophyll [2] on hawthorn (Crataegus azarolus L.) and mahaleb , and that experiment was performed by Ashkavand et al. (2018). The application of nanoparticles caused a decrease in the water potential of RWC (relative water content), but there was a slightly increased growth of the above-ground and underground parts of the plants, more significantly for hawthorn. In addition, different concentrations of silica nanoparticles did not affect the concentration of the macroelements. However, at higher concentrations of the tested nanoparticles, phytotoxicity was observed  fertilizer, wherein zeolites appear to be more promising for the controlled release of phosphate  were better absorbed by plant roots (e plants . It is ae plants , and theardation .The selected information from articles that used nanoparticles for plant treatments are summarized in The use of nanomaterials already brings breakthrough discoveries across various disciplines. At the time of the beginning of the use of nanoparticles in plant production, theoretically, it was possible to recognize some usable general properties of nanoparticles such as their antimicrobial effect, the induction of the biochemical pathways that are included in the stress reaction, the need for a much smaller dose of them to achieve the desired effect or their higher stability with the possibility of the gradual release of the nutrients. The information that has been presented in this study, i.e., compared to the factual effects that have been observed in many different studies, and it has thus revealed the most reasonable areas for nanoparticle application. One such area represents nanopriming, where the improvement to seed germination, the reduced pathogen contamination of seeds and the improved stress tolerance that it generates are the most probable potential benefits. In the case of the application of nanoparticles directly on the plant, the improvements to the plant’s growth and the elimination of plant pathogens were the most frequently registered benefits. Thus, it is evident that by utilizing the nanoparticles, it is possible to achieve higher profitability in production, but also, the environmental aspect of their use is very important.Due to the very high efficiency of nanoparticles, for example, their use would significantly reduce the consumption of agrochemicals. This environmental benefit is even more pronounced in cases where, instead of conventional agrochemicals, the NP-based alternatives would start to be used. An example is that the environmentally problematic copper-based plant protection products that are offered could be replaced with a suitable Cu-NPs alternative and this would mean there would be several times smaller contamination quantities with this heavy metal. On the environmental aspects, it is also necessary to mention the still not well described impact that nanoparticles have on the environment and human health. In this respect, for example, there is a relatively significant gap in knowledge regarding the impact of the use of nanoparticles on soil properties, when theoretically, their antimicrobial effect can negatively affect the soil microbiome.The relatively evident beneficial effects that they have and, in contrast, an incomplete picture of their impact on the environment, also encourage fundamental questions regarding the classification of the use of nanoparticles in crop production systems. Does their use belong to the practice of precise agriculture, sustainable agriculture or something else entirely? If we recognize the environmental aspect as one of the important factors that is limiting the wider use of nanoparticles, we can emphasize, here, the existence of nanopriming, i.e., the seed treatment strategy. Here, this strategy has shown relatively conclusive improvements towards higher and more stable production and we can imagine that it would have only a minimal effect on the environment, as only a minimal amount is captured on the seeds.It seems that the wider use of nanoparticles is hindered by the reluctance that is due to the sometimes unclear properties of NPs and is also due to people not having entirely clear legislation regarding their use. From the point of view of the local governments, it is therefore, an important step to place the use of nanoparticles in a clear legislative framework. From the research side, the way forward is to offer nanoparticles with an innovative composition, for example, for them to be as similar in their properties as possible to naturally occurring substances. In this regard, bio-nano-fertilizers that are prepared by biosynthesis are a promising substance. This, together with a deeper understanding the natural cycle of nanoparticles, will determine how their application will be further perceived by the public and especially, by crop producers.


In the current information and technology era, business enterprises are focusing in performing the process effectively by reducing the waiting time in completing the work, reduce latency and deploy the resources effectively so as to service the patient, medical practitioners, societies, and other stakeholders in an efficient manner. Hence, several organisations are using the emerging technologies so as to obtain high performance and enhance competitive edge. The advancement in machine learning, deep learning, business analytics, etc. enables the health care industry to identify the patterns based on the data collected and create a pivotal position and enhance revenues and profits in a sustainable manner. Machine learning models are considered as computational algorithms which will enable in collected the data, analyze them, and provide the necessary reports to the experts and management in order to make informed decision making. The application of advanced machine learning enables the organisation to process the image effectively, recognize the voice and enable in servicing the customers, process the available data, and identify the patterns so as to make informed decision making. The basic purpose of the study is to analyze the overall implementation of advanced machine learning approaches towards health care services for providing enhanced services, better patient engagement, and support in creating better life for them, the researchers intend to collect the closed-ended questionnaire from employees in different medical centers covering: apprehend the nature of designing and implementation of machine learning approaches in the organisation and understand the effectiveness of these tools in enhancing the sustainable growth and development of the organisation. The implementation of machine learning models is focused in implementing different algorithmic models which are involved in executing the specific data set and support in realising humanoid experiences so as to produce the desired results. Artificial intelligence (AI) is considered as the overall capability of the overall processor so as to accomplish the desired jobs in an effective manner.In the current decade, companies focus in competing effectively based on analytics, the growth, and development of big data enable companies in gaining access and support in performing the analysis of large datasets. The innovations in the business analytics tend to become more desirable by the company focuses in addressing the necessity on the successful performance, and this holds more important for various forms of business operations apply them in different domains covering supply chain management, financial risk analysis, social media marketing, attracting customers, and support in managing the inventory effectively.The main objective of implementing advanced machine learning approaches in business is to focus in understanding the business process, identify the areas to improvise, cut mundane task and thereby support in implementing better business process, deliver products and services in an effective manner, and enhance profits for all the stakeholders. . The appIt is more advantageous for the business to look at the various technologies like machine learning, deep learning, Internet of Things, and Robotics Process automation . These dThe critical novelty of the study is to focus in analyzing the designing and implementation of ML approaches in enhancing health care services, and the study involves in applying the statistical tools for performing the study. The previous study was involved in using algorithms and other aspects of the ML approaches in deciphering massive volume of data; on the other hand, this study is enabled in testing using key statistical analysis. Furthermore, it also collaborates with other systems, connect through cloud and projects privacy, these features have made ML to be more unique and critical in business application and to enhance competitive position of the organisation in domestic and international markets. The critical role of artificial intelligence is shown in It has been regarded that the advancements in ML is now possessing strong competencies to enhance the business strategies across the business process. The emergence in such technologies boost innovation, collaborate effectively with the systems, individuals, and stakeholders so as to enhance communication. Moreover, with the advent of 5G technology, ML technologies can greatly support and collaborate with various businesses functions. The recent decade has witnessed that companies have been applying novel ML methods which address critical business functions. Moreover, ML has supported many businesses to improve cost, support in realising better productivity, reduce cost, and automate functions for realising efficiencies to support in profits.n each stage of customer value chain. Moreover, this study involves in applying statistical tools to test empirically the nature of ML in health care services.The research gap of the study is to identify and implement better tools and techniques in order to support the application of ML models in the health care industry, it has been regarded that the health care functions are fast changing, and there is a need for offering better treatment and protocols within the specified time so as to provide better health care services. The application of ML is considered to be highly critical for business sustainability in the future and hence the executives are focusing in unleashing the potential of such technologies to add more benefits This study is more focused in understanding the key determinants of advanced machine learning approaches which impacts the contemporary business organisation. The researchers are poised in understanding the major role played by ML influenced health care analytics; ML supporting in adding more value to patients, data analysis and security, optimisation of resources to enhance profits, and achieving sustainable growth in modern health care services. The ML supports not only in analyzing the data and information but also supports the health care services to analyze the areas of improvement and support in devising strategies so that all stakeholders benefit from such technologies.Wang et al.  have menBusiness organisations are now implementing machine learning and deep learning tools so that they can continuously engage with the customers, understand their requirements, and offer products and services which add more value. The ML also supports the organisation in understanding the customers better, analyze the topographical segment of the market, and deliver services to enhance the gratification.Artificial intelligence leaves the R&D lab to enter the business world. Millions of leading industries and companies around the world combine the power of artificial intelligence and applied artificial intelligence (AAI) . Most inMost leading companies, such as Microsoft, Facebook, Apple, Google, Amazon, Myntra, Flipkart, and IBM, fund research and development of artificial intelligence for the benefit of companies and customers. Some private functions and attributes can be predicted using artificial intelligence and machine learning algorithms from digital records of human behavior. With the help of artificial intelligence and a model for deep learning, we will be able to perform many tasks, but we will be more efficient . The exaThere is a blind spot in the progress or ownership of a state system. Innovation arises when we look at these edges. Machine learning and artificial intelligence-enabled organisms to overcome these gray areas. In medicine, it can be about analyzing the risk for the patient or launching a new analytical invention. In construction, this means predicting errors before they occur . Today, The study is confined in analyzing the key determinants of machine learning approaches in health care industry, the recent decade has witnessed an exponential growth of machine learning in modern organisation, and they are no longer focused only in collecting and storing the data, but also involved in analyzing them critically, store in a protected environment, enable in preparing critical reports, and also support in devising strategies for achieving sustainable growth and development.The implementation of machine learning approaches enables the management in analyzing and devising different strategies in a timely manner, support in creating better products and services for adding more value to the customers, perform better analysis of the data and save them in protected environment, and also deploy the resources effectively for enhancing profits . This stThe researcher uses questionnaire as the tool for collecting information from the sample respondents for purpose of primary data collection, the questionnaire will be closed ended and the respondents need to choose the available option presented for each question, and Likert scale is used in creating the options for questions related to critical variables. The researchers implemented nonprobability convenience sampling method so that they can choose the respondents effectively, and nearly 190 questionnaires were issued and 178 questionnaires were received from the respondents which are used for analysis.For the purpose of data analysis IBM SPSS is used, the researchers used correlation analysis, regression analysis, and analysis of variance for testing the hypothesis.ML influenced health care analyticsML supporting in adding more value to patientsData analysis and securityOptimisation of resources to enhance profitsAchieving sustainable growth in modern health care servicesHypothesisH1: there is no statistical relation between ML influenced health care industry and impact on organisation to achieve sustainable growth in modern health care services.H2: there is no statistical relation between ML supporting in adding more value to customers and impact on organisation to achieve sustainable growth in modern health care services.H3: there is no statistical relation between data analysis and security towards impact on organisation achieve sustainable growth in modern health care services.H4: there is no statistical relation between optimisation of resources to enhance profits and impact on organisation achieve sustainable growth in modern health care services.The data analysis is performed using IBM SPSS Package, the researchers has collected the data from respondents who are currently working in the organisation where machine learning technologies are mainly applied for various purpose, the analysis covering percentage analysis in understanding the critical influence of ML in business organisation, perform correlation analysis, regression analysis, and independent sample test of demographic variables.From t the statement, 8.4% of them have disagreed and remaining have strongly disagreed to the statement. This is shown in Based on The next analysis applied in the study is Karl Pearson's coefficient of correlation, which supports to understand the overall behavior of the independent variables and dependent variable. The value of Karl Pearson lies between -1 to +1.From After performing correlation analyses, the researcher intends to test the best fit of the model and also analyze the impact of independent variables towards dependent variable.R squared value is 0.740, hence, it can be stated that the data is best fit, furthermore, it is also noted that the major variables like ML influenced strategy; ML supporting in adding more value to customers and optimisation of resources to enhance profits has significance value of less than 0.05, hence, the alternate hypothesis is selected.Based on the output from Moreover, based on the data the regression equation is formulated as Y  = 0.134 + 0.367 × ML influenced health care analytics + 0.329 × ML supporting in adding more value to patients + 0.01 × data analysis and security + 0.204 × optimisation of resources for better services in medical industry.T test between demographic variables and independent constraints.The critical independent variables considered in the analysis are ML influenced strategy; ML supporting in adding more value to customers; data analysis and security and optimisation of resources to enhance profits. The researcher intends to perform the independent sample From Based on the overall analysis, it is identified that the correlation coefficient between the variables is more than 0.700, hence, it is stated that there exist higher positive correlation between the variables, also, it is stated that the significance value of regression analysis is less than 0.05, therefore, null hypothesis is rejected and alternate hypothesis is accepted, hence, it is concluded that the variables possess statistical relation towards the business organisation to achieve sustainable growth and development.Hence, it is noted that machine learning possesses significant support to the top management in supporting to frame strategies, deploys the resources effectively for enhancing revenues and profits, also critically analyses business process for continuous improvements so that more value can be provided to the customers.Machine learning models are seen as computer algorithms that collect data, analyze it, and provide the reports required for experts and managers to make informed decisions . By applIt was judged that ML development already has a strong ability to improve business strategies throughout the business process. The emergence of such technologies drives innovation and works effectively with systems, individuals, and stakeholders to improve communication. The organisation's executive functions are developing rapidly, and the redesign of business processes has changed all management and executive functions. Digital transformation has forced companies to constantly innovate in order to maintain their growth and achieve their goals. Therefore, ML is crucial to the future viability of the business, and managers are focused on exploiting the potential of these technologies to provide additional benefits to each step in the value chain.Based on the overall analysis, it can be stated that the critical factors of ML like influence on health care analytics, ML supporting in adding more value to patients, data analysis and security, and optimisation of resources for better services in medical industry possess stronger and effective influence on the health care services. Hence, it can be stated that the medical practitioners, hospitals, and radiologists can focus in using these advanced technologies for enhancing the service delivery and better patient care management.Advanced ML and other technologies can also help an organisation reduce costs, as management can design critical supply chain systems that reduce total shipping costs, warehousing costs, and so on. Companies today use machine learning and deep learning tools to continuously interact with customers, understand their needs, and offer value-added products and services. ML also helps the organisation to better understand customers, analyze the topographic market segment, and provide services to improve satisfaction.


Case Report. An 18-year-old female adolescent with a diagnosis of HSS was sent from the genetics service of a teaching school for the treatment of lower limb lymphedema. At around 11 years of age, the patient began to present edema in the left leg, accompanied by broadening of the face and neck. The patient reported having obstructed nostrils and breathing through the mouth her entire life. On the second day of treatment, the patient reported being able to breathe through one of the nostrils, this had never occurred before. Based on this finding, the decision was made to include linear facial lymphatic drainage using the Godoy method, which led to the complete resolution of the nasal obstruction in the first 15 minutes of treatment. Nasal obstruction in children with Hallermann–Streiff syndrome may be caused by lymphedema.  Hallermann–Streiff syndrome (HSS) is a rare congenital abnormality involving multiple craniofacial malformations, such as micrognathia, prominent frontal and nasal bones, vision defects, and dental anomalies, which can result in obstructive sleep apnea syndrome. The aim of the present study was to report a case of nasal obstruction in an individual with Hallermann–Streiff syndrome who had never breathed through the nose during treatment for lower limb lymphedema involving cervical lymphatic therapy.  A specific lymphatic drainage technique, such as cervical lymphatic therapy and facial linear lymphatic therapy, can resolve the obstruction and maintain the nostrils unblocked for months. Hallermann–Streiff syndrome (HSS) is a rare congenital abnormality involving multiple craniofacial malformations, such as micrognathia, prominent frontal and nasal bones, vision defects, and dental anomalies, which can result in obstructive sleep apnea syndrome , 2. WhenThe genetic cause of this developmental disorder is unknown . IndividLymphedema in individuals with HSS has not been described in the literature. The Godoy treatment method for lymphedema employs several therapeutic strategies, one of which is an intensive treatment, which enables reducing the volume of the edema by approximately 50% in five days .The aim of the present study was to report the case with an important improvement of nasal obstruction in an individual with Hallermann–Streiff syndrome during treatment for lower limb lymphedema involving cervical lymphatic therapy.An 18-year-old female adolescent with a diagnosis of HSS was sent from the genetics service of a teaching school for the treatment of lower limb lymphedema. The mother reported that the patient was born with HSS, had been submitted to surgery for the treatment of aortic stenosis at four months of age, and had been in follow-up with physicians throughout the years of the evolution of the syndrome. At around 11 years of age, the patient began to present edema in the left leg, accompanied by broadening of the face and neck. The patient reported having obstructed nostrils and breathing through the mouth her entire life. She also had difficulty raising her arms and combing her hair.The physical examination revealed clinical stage II lymphedema of the left lower limb beginning at the thigh, difficulty raising the arms and moving the neck, short neck, hardened region in the subcutaneous tissue of the face, and less hardened in the forehead region. The evaluation was made for lymphedema initially and after five days with multisegmented bioimpedance and volumetry by displacement water. Perimetric evaluation of the face was not performed, because the patient reported being able to breathe through one of the nostrils after cervical lymphatic therapy and linear facial lymphatic drainage, Intensive treatment for lymphedema was proposed using the Godoy Method for five days . TreatmeOn the second day of treatment, the patient reported being able to breathe through one of the nostrils, this had never occurred before. Based on this finding, the decision was made to include linear facial lymphatic drainage using the Godoy method®, which led to the complete resolution of the nasal obstruction in the first 15 minutes of treatment.The mother reported that the patient's face had become thinner with treatment, which was confirmed by the comparison of photographs. The face had previously been thin and increased in volume after 11 years of age.The patient has been in treatment for two years and her breathing has remained within the standards of normality for more than four months. When the obstruction recurs, a single session of cervical lymphatic therapy is sufficient to normalize her breathing and maintain it for months. An important improvement was also found with regard to motor aspects, as the patient was able to raise her arms and comb her hair, which was something she had not able been to do prior to treatment. This study received approval from the Human Research Ethics Committee of the São José do Rio Preto School of Medicine, SP, Brazil#5.165.749. The familiar responsible signed a consent form for publication.The present study describes an unexpected finding of the resolution of nasal obstruction in an adolescent with Hallermann–Streiff syndrome who had never previously breathed through the nose. The primary objective was to treat lower limb lymphedema, which has not previously been reported in this syndrome. The initial improvement in nasal breathing through one of the nostrils led us to include a specific nasal lymphatic drainage technique based on linear movements, which led to the resolution of the obstruction of both nostrils in approximately 10 minutes –10. The The hypothesis for the broadening of the face and neck at 11 years of age is the lymphatic deficiency in the region that led to the development of lymphedema. The nasal obstruction since birth may have become aggravated over time. One of the routine techniques employed during intensive lymphedema treatment is cervical lymphatic therapy, which enables a reduction in facial fibrosis –16.Breathing difficulty is a common finding in reports of HSS, suggesting the possibility of lymphedema. Therefore, the present case points to a novel treatment prospect that could alleviate this type of problem.Nasal obstruction in children with Hallermann–Streiff syndrome may be caused by lymphedema. A specific lymphatic drainage technique, such as cervical lymphatic therapy and facial linear lymphatic therapy, can resolve the obstruction and maintain the nostrils unblocked for months.