Suicide is a painful consequence of many psychiatric disorders and one of the most frequent psychiatric emergencies. Generally, pre-hospital technician is the first person in the treatment chain who attends the situation; hence, his/her sound clinical judgment and professional behavior can play an important role in preventing or stopping the suicide process. We tried to develop a concise, evidence-based, and step-by-step guide for dealing with a suicidal patient, which could be quickly reviewed by technicians before confronting a suicide situation.We reviewed the literature for suicide management plans and protocols, to extract the evidence-based interventions and instructions for dealing with a suicide situation. Then, we discussed the extracted material in an expert panel, and developed the initial version of the protocol considering the local socio-cultural issues and available facilities. Subsequently, we reviewed the protocol in a meeting with pre-hospital technicians and emergency physicians, to receive their feedback and address any possible executive problems. Finally, we revised the protocol to its final version considering the feedbacks.The basic principles of dealing with a suicidal patient are similar to other psychiatric emergencies and include: Patient Safety; Patient evaluation and diagnosis; and Patient  management. However, specific considerations should be taken into account and special arrangements are necessary for suicidal patients. Whether the patient has attempted suicide or not, would guide the management to one of the two major paths. In addition, the needs of the family should be considered.A locally adapted protocol considering existing facilities in the emergency system and cultural issues in Iranian society is provided for pre-hospital emergency technicians. Suicide is an intentional act to end one’s own life. Wish to kill oneself may remain limited to thought  or turn into action  and on some occasions result in death (committed suicide) . Nearly The prevalence of suicide attempts in Iran has increased in the last two decades . The preAccording to Iranian Social Welfare Organization (ISWO), the social emergency of ISWO has taken preventive action in 8400 suicide attempts through mobile teams (> 3000 cases), social service bases (242 cases), crisis intervention centers (1300 cases), and contact with social emergency hotline (3400 cases) in past year .Pre-hospital emergency has also been involved as a first line contact in suicide situations in the country and has played an important role in this case . They arIn critical cases such as suicide attempts, emergency technician should transfer the patient to a suitable medical center, after appropriate crisis management. Inadequate skills and mastery of emergency technicians in these conditions can lead to serious injury and even death in a person who threatens to commit suicide. Furthermore, poor decision-making ability in critical situations, increases psychological stress on emergency technician –16. TherThis study was performed in two stages with the mixed method. We used the literature review to access the relevant resources. First, we searched PubMed, Scopus, and PsycINFO databases for the combination of the following keywords: 1)"Suicide” (OR) “suicide prevention” (OR) “suicide risk factors” (OR) “self-harm” (OR) “suicidal patients”. 2) “Management” (OR) “protocol” (OR) “pre-hospital care. Then, we combined the two searches using AND operator. We limited the search date to the results published in the recent 10 years . Additionally, we reviewed the chapters related to suicide management in psychiatric textbooks.In the next step, we reviewed the abstract of the retrieved articles and selected 30 relevant articles. Subsequently, we used the Cochrane checklist to assess the full text of the articles and select suitable articles for further analysis. In this way, 20 articles were selected for the next stage Table . We usedThe extracted findings were then categorized according to the stage of intervention. The first stage is similar to the stages for other acute psychiatric patients, which are described in detail in the “pre-hospital emergency protocol for mental disorders in Iran” . Here, wTwo psychiatrists categorized the extracted points and prepared the first draft of the protocol. Then, an expert panel was held including the following people: 1. an assistant professor of psychiatry with clinical and research experience with acute psychiatric patients, 2. a professor of psychiatry with years of experience in the emergency department of a training psychiatric hospital, 3. a professor of psychiatry with years of experience in the field of suicide and president of the National Suicide Prevention Association, 4. a professor of forensic medicine with related clinical experience, 5. a clinical psychologist with years of clinical experience with non-pharmacological therapies of patients, 6. a specialist in emergency medicine working in the country’s emergency organization with years of experience of working with emergency technicians, 7. a general practitioner working in the country’s emergency organization with years of clinical experience, 8. a clinical psychologist working in Social Emergency of Welfare and Rehabilitation Organization.To what extent is this step necessary for a suicidal patient?To what extent is this item understandable and transparent to an emergency technician?Is this item inclusive ?Considering the existing facilities and conditions in our society, is this a plausible step to perform?Has enough attention been paid to the patient’s safety at this stage?Has enough attention been paid to the safety of the emergency technician?Has enough attention been paid to the safety of the patient’s relatives and those present at the scene?Considering the laws of the country, does this item have legal legitimacy for the technician?In the panel, participants were asked to comment about the framework and steps of the protocol and also to answer the following questions:Each question was scored on a Likert scale from very low to very high (1–5). Experts answered all of these questions for each protocol item. And the scores of 8 experts participating in the meeting for each item were added together. Finally, items with a total score of 27 and above  were selected for the protocol, and a score of 13 or less  was removed, and the items with the average score of 14–26 were discussed again and revised to a final agreed upon format for the protocol.To check the clarity and comprehensibility of the revised protocol and the feasibility of its implementation in pre-hospital emergency setting, we held two sessions with two different group of people to receive feedback about the protocol and consider possible executive problems. The first session included emergency technicians and technical and operational deputy of one of the Emergency Centers of Tehran (about 50 people). The second session was held with general practitioners (dispatch) of operations in the pre-hospital emergency department. Prior to the start of both sessions, informed consent was obtained from the participants.Then, we revised the protocol another time considering the feedbacks of the sessions and finalized the protocol in a two-page format that could be easily used in the ambulance as a quick review of important measures in dealing with a suicidal patient before confronting him/her.Basic and safety tips :The general measures that should be considered in the management of suicidal patients are not much different from those of other psychiatric emergencies, as reported in “pre-hospital emergency protocol for mental disorders in Iran”  and incl2.Important points for patient assessments:The first stage (primary action) are including a) pre-scene assessments of site security, escape routes, and safe locations in the event of violence from the patient, b) assessment of the patient’s access to weapons and equipment that could threaten his/her own life, technicians or attendees , c) AsseIt includes history taking from patient and his family as well as assessing patient’s physical condition, especially life-threatening cases, and examining the possibility of a medical origin for symptoms, and psychological assessments. The suicide threat should not preclude the consideration of medical and physical causes for psychiatric symptoms.Those who has not attempted suicide:Regarding suicide management, patients are divided into two groups:A)Try to build a relationship with patient using respect and empathy. Avoid threats, humiliation and judgmental behavior.In these patients, the following were suggested:B)Evaluate vital signs and ensure the stability of patient’s medical conditionC)Evaluate patient’s history and directly ask about intent for another suicidal attempt .D)Risk assessment of suicide: Items listed in the table below increase the risk of suicide Table .In these situations, generally both patient and family members are agitated and emotionally unstable. Therefore, it is important for technician to remain calm and patient in dealing with them . Many paVerbal threat to commit suicide and history of previous suicide attempt, especially with dangerous methods, and a history of aggression are more important risk factors , 42.In addition to the items listed in Table Although the assessment of suicide risk factors can help in providing better care and a more accurate evaluation of the patient, according to the current pre-hospital emergency guidelines in Iran, all of these patients, regardless of the assessed risk, should be transferred to medical centers. If the patient or his family refuse to go to hospital, the technician should contact the attending physician and ask for advice.Pay attention to people at risk present on the scene and maintain their safety .Use the aggression management protocol including behavioral and drug managements .Transfer the patient to the hospital.E)Collect empty containers of toxins, alcohol, and drugs, for being delivered to the hospital emergency department; even if the patient and his family claim that s/he has not attempted suicide. It is medically important to examine evidence to the contrary and can prevent legal consequences for the technician .F)Documentation of the findings: The emergency technician should document all of the relevant findings and evidence to prevent further legal problems  .2.In a person who has attempted suicide:The following points are of great importance, provided that the patients becomes agitated and behaves in a threatening way and seems to be potentially dangerous for oneself or others:A. Measuring vital signs:In a person who has attempted suicide, immediate attention to the patient’s medical risks is a priority. Therefore, the measures include the following:If vital signs are stable:2.a) The first step is to consider the patient’s immediate medical needs, initial assessment (Airway - Breathing - Circulation) and control of vital signs and its stabilization. In a conscious patient, the introduction is done simultaneously and permission is given to perform examinations, and in patients with a decrease in the level of consciousness, this is done for the patient’s family or companions)If vital signs are not stable:2.b) It is important to pay attention to the patient’s medical condition and transfer him to a medical center for further diagnostic tests and treatment measures. Medical conditions should be monitored along the route, and life-threatening warning signs should always be considered. Behavioral recommendation in dealing with these patients is similar to the previous section.Attempts to stabilize the patient’s vital signs  should be considered and then the patient should be transferred to the nearest medical center as soon as possible. Behavioral and non-pharmacological interventions can be performed as much as possible depending on the patient’s medical and environmental conditions.If the patient has diedC) It is also important to gather evidence and document findings on the scene, any findings that help to understand the means of suicide  and evidence that is effective in understanding the cause of suicide  .C) If tThe first step is to ensure the definitive death of the patient. Call the police to be present at the scene, because, this may be murder instead of suicide. In the next step, it is important to pay attention to the emergency psychological needs of patients’ families. Usually, families in such situations are in a critical situation and may show impulsive reactions reactions . Tips foSeveral studies have been conducted on suicide management, as one of the most important issues in psychiatric emergencies. However, in most studies, more attention has been paid to the management of these patients in hospital emergency department than in the pre-hospital emergency department. In 2004, for example, the Australian National Institutes of Health provided a guidance for managing suicides in the emergency department, which was a good guide for emergency room therapists.Lipton developed a clinical guideline of prevention, assessment, and management of suicide for pre-hospital technicians in 2005. However, drug management is not covered in this article . Dr. ChuReducing the risk to himself, patient, patient’s family and those present at the scene.Diagnosing the possible medical origins of the life-threatening medical symptoms and comorbiditiesQuick assessment of the risk of imminent suicideEstablishing a therapeutic relationship with the patient and his familyManagement of the suicidal patient and helping in management of the crisisCollecting and recording the evidence related to suicide in the scene, both to assist hospital staff and to protect themselves from possible future legal problems.Our purpose in writing this protocol was to increase the technician’s skills in the following areas:Similar to the protocol for dealing with an acute psychiatric patient, the first step in this protocol is preparing the scene and ensuring security of the scene , 22.The initial assessment and taking history in this protocol are the same as the general protocol for dealing with a psychiatric patient. However, it is especially important to ask about the history of any psychiatric disorder from the family of the suicidal subject. Assessment of risk factors  as well as protective factors are the next crucial steps. However, according to emergency protocols in Iran, all of the suicidal patients must be transferred to a hospital, even if the technician considers the patient to be in a low risk for suicide. Although patients with low risk for suicide can be generally effectively cared for, monitored and followed-up at home, this decision is reserved for mental health professionals working in hospitals .The protocol also emphasizes on assessment of risk factors for imminent suicide as opposed to chronic risk factors of suicide in the pre-hospital emergency setting due to time limitations , 46. FurIn the management of patients threatening suicide in our protocol, verbal intervention is the basis of treatment in line with other protocols , 47. As Our protocol, like other protocols, prioritizes physical needs and risks in patients who have attempted suicide . If behaThis protocol, like others, has emphasized on paying attention to the emotional needs of the family of the patients who have committed suicide , 48, 49.It is practical and useful to develop an evidence-based, but concise and portable protocol for pre-hospital emergency technician, which covers all of the major issues for a quick review before confronting a suicidal patient.The number of articles and protocols on the management of suicide-threatening patients in the pre-hospital emergency, which we had access to, was limited. Most articles are related to the hospital emergency department. While the pre-hospital condition is very different.This protocol should be used in next researches and in emergency operations to identify weaknesses and operational glitches.


Goats are important as food sources and livelihood in several areas of the world, mainly in low-income countries. Free-range browsing is common, but to increase productivity and improve health, supplemental or complete feeding is increasing. Ruminant feeding has often been using grasses, but as goats are browsers, they may benefit from including foliage in the diet. This systematic review and meta-analysis focuses on the effect of including foliage in goat diets. The results show that foliage was often more nutrient-rich and increased dry matter intake as well as average daily weight gain in goats.Small ruminants such as goats have a higher preference for browse species than cattle and sheep. In a meta-analysis of 42 papers describing 117 experimental treatments found by a search performed in June 2021 in PubMed and Web of Knowledge, we examined the general effect of including foliage in the diet of goats, replacing grasses, on dry matter intake and average daily weight gain. The inclusion requirement for a paper was that it described a controlled trial with a control diet of grass and with grass replaced by foliage in the experimental diet. Publication bias was estimated by calculating the Fail-safe n. Random effects analyses were conducted, using effect size calculated as Hedges’ d. The results showed that inclusion of foliage increased feed intake  and average daily weight gain  compared with a grass-based control. The positive effect of foliage inclusion on dry matter intake was associated with lower neutral detergent fiber (NDF) and higher crude protein (CP) in the foliage than in the grass it replaced. The positive effect on average daily weight gain was associated with higher CP concentration in the foliage than in grass. Foliage inclusion level showed a quadratic relationship with dry matter intake, with maximum dry matter intake achieved at a level of 50–60%. There was wide variation between the studies reviewed, and this variation was not reduced by subgroup analysis based on different kinds of foliage. In conclusion, the addition of foliage to goat diets can increase feed intake and daily weight gain, as an effect of the dietary preferences of goats and of generally higher nutritional value in foliage species compared with natural/semi-natural grass species. There are more than a billion domestic goats worldwide, distributed over almost all continents . In mostManihot esculenta), or can be grown as feeds, such as leucaena (Leucaena spp.) [Since goats are browsers, given the choice, they will include a higher proportion of foliage in their diet than sheep and cattle . Howeverna spp.) ,8,9. Somna spp.) .The aim of this review was to evaluate the overall effect of replacing grass with foliage in the diet of goats, focusing on feed intake and growth performance. Possible associations between observed effects and the nutritive value of the foliage and grass were assessed.This review used a systematic approach mainly according to the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) , but didA systematic and thorough literature search was conducted during January 2021, using the databases Web of Knowledge and PubMed. Additional papers were found in the reference list of some of the papers located by the search. The selection flowchart is presented in The inclusion criterion for a study was that it included a control group fed grass and an intervention group fed foliage. All kinds of foliage and grasses were accepted as treatment and control, respectively. Furthermore, no restrictions were set regarding the level of grass or foliage inclusion in the diet, or on the complementary feed ingredients used in addition to grass or foliage. All grass conservation methods and all feeding methods for the grass and foliage parts of the diet were accepted. However, studies in which foliage was added to the diet but did not replace all or parts of the grass fraction in the diet were excluded. For practical reasons, papers where data were found only in sections written in languages other than English were not included.No protocol was prepared, and the review was not registered. Data, including foliage species, age of goats, inclusion level of foliage, sample size, experiment duration, dry matter intake  and average daily weight gain , from each experimental treatment were extracted and imported into Excel. If standard deviation (SD) for dry matter intake or average daily weight gain was not provided in a paper, an estimated SD was calculated as standard error (SE) of the mean times the square root of the number of replicates (n) in control and treatment groups. This calculation was required for most papers included. Many of the papers stated only one SE for all treatments combined, but then applied that value to individual treatment means. The commonly occurring case of several different treatments associated with the same control group within an experiment was handled according to . This mePercentage of foliage in the diet was calculated based on actual intake (dry matter (DM) basis), while average daily weight gain was calculated by dividing average weight gain during an experimental period  by the number of days in that experimental period. Not all papers in the dataset reported enough data to extract all the required variables. In total, 107 experimental treatments in 42 different experiments were included in the analysis. Of these, 30 experiments were suitable for use to estimate the effect of foliage on dry matter intake, and 22 experiments were suitable for use to estimate the effect of foliage on average daily weight gain.2 value [2 value is that a value below 25%, 50% and 75% represents low, medium and high variation between studies, respectively.The meta-analysis was performed using the free software program OpenMee , which i2 value , a statiPublication bias was estimated by calculating Fail-Safe n according to the Rosenberg method . This meThe experimental groups in the studies included in the review contained between 3 and 16 goats. When groups were combined to take the mutual controls into account in assessing the overall effect of foliage inclusion, the maximum number of observations in the data points included in the statistical analysis increased to 48.The characteristics of the experiments and the experimental diets in the papers included in the review are shown in p < 0.001). It was also associated with increased ADG . Upon including the percentage of foliage in the diet as a continuous variable, the slope was not significant for either DMI or ADG, but for DMI, there was a significant quadratic relationship with percentage of foliage in the diet, with the resulting prediction Equation (1) being:Foliage in the diet was associated with increased DMI , and by the decreased CP concentration in the grass . The effect of foliage inclusion on ADG was positively affected by the CP concentration in foliage  and by the decreasing CP concentration in the grass it replaced .The effect of foliage inclusion on DMI was positively affected by the low nutritive value of the grass that was replaced by foliage, i.e., increased NDF concentration in the diet . This was not substantially reduced by subgroup analysis within foliage type, although the heterogeneity within a few subgroups was markedly decreased (data not shown). Several of the classified foliage types were only represented by one single study or by one group of researchers, while some foliage types were examined in multiple studies by different authors.In all analyses, the variation between studies, as measured by the IVisual inspection of the funnel plot for the studies included in the review revealed a great risk of publication bias, with larger effect size estimates in smaller studies . HoweverThis meta-analysis of 42 papers describing 117 experimental treatments revealed that the inclusion of foliage in the diet of goats, as a substitute for natural/semi-natural grasses, increased DMI and improved ADG. Goats, being small ruminants, are at a disadvantage compared with cattle in terms of the ability to utilize low-quality feed, e.g., rough grasses, as they have a higher maintenance energy requirement per kg body weight but lower feed intake capacity than cattle ,44. FreeThere are several reasons why foliage in the diet could lead to increased intake and growth when replacing grass. The higher fiber concentration can be suspected to increase time spent eating and ruminating per kg of DM . AdditioIn many of the experimental treatments included in the analysis, foliage was fed freshly harvested. However, improved methods for preservation and storage of foliage and increased use of conserved foliage in the diet could be a way to improve goat production and facilitate intensification, including in smallholder farming. The feed value of conserved foliage can be as good as that of the fresh material. For example, the authors of  tested cThe foliage species tested in the different experiments included in this meta-analysis differed depending on the region in which they were grown. The range of plants included comprised species exclusively grown for feed production, such as leucaena  and speThere was great variation between the experiments included in this meta-analysis, which was a result of differences between goat breeds, diets, environments and layout used in the studies. However, the overall results showed a positive effect on both DMI and ADG of replacing grasses with foliage in goat diets. The Fail-Safe n value indicated a large margin for adding studies with non-significant results, showing that the results are fairly robust, although publication bias can be expected. The wide range of plant materials, species and harvest times, both for foliage and grasses, together with different inclusion levels and varying use of concentrates, caused a wide variation in experimental diets. Goat feed intake has been shown to be affected not only by diet composition, but also by feed presentation or feed processing method, e.g., feeding the diet chopped or not , but theThe amount of foliage included in the diet showed a quadratic relationship with the effect of foliage inclusion on DMI, resulting in the highest estimated improvement in total DMI when foliage was included at about half of the total dry matter intake. A quadratic response to foliage, resulting in an optimum inclusion level for foliage in the diet above which DMI decreases, has been reported previously . In a stMany of the studies included in the meta-analysis consisted of small experimental groups, with an overall average number of only five goats in each group. Nevertheless, most studies located and included in the review reported a significant difference between the treatments. The funnel plot of the studies showed that the effect size was much larger in studies with large standard deviation, which is often a result of small sample size. This indicates that the likelihood of finding a study with a small effect size, which may correspond to the likelihood of publication of such a study, increases with the increasing number of animals in the treatment groups. This may indicate in turn that studies with small sample sizes have been performed but are not published, since the results did not show a sufficiently high effect of foliage inclusion in the diet of goats. This was also evident from the asymmetry in the funnel plot. However, asymmetry in funnel plots has also been shown to depend on how the plot is constructed, and interpretation of the results shown in the plot could be altered by using other effect metrics . Post-hoThis meta-analysis showed that inclusion of foliage in the diet of goats, as a replacement for grass, increases dry matter intake and average daily weight gain. At least part of this effect may stem from the improved nutritional content of diets including foliage with higher crude protein levels and lower levels of fiber (measured as NDF) than natural grasses. There was wide variation between the studies included in the analysis, but Fail-Safe n values indicated that the general findings on the effect of foliage supplementation on dry matter intake and daily weight gain are robust.


Urban green spaces (UGSs) improve the quality of life of urban inhabitants. With the acceleration of urbanization and changes in traffic networks, it remains unclear whether changes in the distribution of UGSs can satisfy the needs of all inhabitants and offer equal services to inhabitants from different socioeconomic backgrounds. This study addresses this issue by analyzing dynamic changes in UGS accessibility in 2012, 2016, and 2020 for inhabitants of the central urban area of Fuzhou in China at the community level. The study introduces multiple transportation modes for an accessibility estimation based on a framework using the two-step floating catchment area method and examines the dynamic changes in community deprivation of UGS accessibility using Kernel regularized least squares, a machine learning algorithm. The results demonstrate that spatial disparities of UGS accessibility exist among the multi-transport modes and vary with time. Communities with high accessibility to UGSs by walking are scattered around the urban area; for accessibility by cycling, the high accessibility regions expand and surround the regions with low accessibility in the core urban areas, forming a semi-enclosed spatial pattern. However, the core urban spatial orientation of UGS accessibility by public transit demonstrates a reverse trend to the above two modes. The spatial pattern of UGS accessibility also varies over time, and the growth rate of accessibility slightly declined during the study period. Furthermore, the increase in UGS accessibility tended to slow from 2016–2020 compared with 2012–2016, and the trend toward equality was also erratic. The degree of deprivation for communities first weakened and was then aggravated, corresponding to the slowdown in the growth rate of accessibility, leading to the persistence existence of social inequality. Moreover, significant deprivation mainly exists among less educated people or those using the cycling and integrated travel modes. Although public transport is developing, deprived communities, such as communities with large proportion of older people, have experienced a decline in access to UGSs by public transport. Based on these findings, the study proposes a policy framework for the balanced distribution of UGSs as part of urbanization. Urban green spaces (UGSs) primarily comprise urban land with naturally occurring and introduced vegetation. Such areas include lands used for greening within the scope of urban development land and green areas outside urban development land that positively affect urban ecology, landscape, and inhabitants' leisure life . UGSs prReasonable accessibility, which means that many people have access to UGSs services, is a precondition to realizing the value of UGSs , 14. HowThe greening of cities is an important part of the Construction of Ecological Civilization advocated by the Chinese Government. Additionally, “The Healthy China Action 2019–2030)” report issued by the Healthy China Action Promotion Committee proposes requirements for mass sports in China, which in turn, require UGSs to provide a “healthy public space” service function. “Building a healthy China” has become a mainstream and long-term topic at the national strategic level. As an important venue for sports activities, convenient accessibility and fair access are the fundamental principles for UGS spatial allocation. However, the extant research on the changes in UGS distribution is inadequate, particularly the analysis of whether urban inhabitants have equal access to UGSs. Uneven use of UGSs hinders the suitability and effectiveness of green spaces system planning and affects the sustainable development of the whole city. Additionally, although the importance of the role of UGSs in public health is gradually increasing in most east Asian countries that are rapidly aging  between the destination and origin . SpatialDeprivation can be described by indicators of community socioeconomic disadvantages . UGSs are often not distributed equitably, and the unfair spatial distribution is closely related to social injustice . A growiIn conclusion, the above variance in results is not limited to the different social backgrounds or different temporal intervals of the previous studies. They are also attributable to technical limitations such as the inability of regional units to represent the service areas of the UGSs, aggregation errors caused by the Modifiable Areal Unit Problem , and limitations caused by distance measurement options . FurtherThe few empirical studies that have focused on community deprivation of urban green spaces in China have mainly been conducted in metropolitan cities like Beijing, Shanghai, and Shenzhen. However, most of these megacity or megacity behemoths have implemented stricter policies for the control of migrants, and the permanent population growth has slowed down, and in some cases, it is negative. With the total amount of green space unchanged, the per capita possession could increase. On the contrary, as the residency restrictions on migrants have been relaxed in provincial capitals and other cities, the process of rapid population agglomeration toward some mid-sized cities is still ongoing. The local governments of most cities also intend to strengthen the construction of urban green space. Under the background of rapid urbanization, whether the behavior of the city government relieves the deprivation of green space needs to be clarified by relevant research. Additionally, while plains dominate the topography of the case city, other complex topography may restrict the space for urban development, and the area of land available for green space construction might be limited.Finally, the previous studies have adopted relatively static perspectives, and there is no rigorous explanation for selecting time nodes. Nevertheless, it is critical for dynamic research to choose more representative time nodes to test the effectiveness of the local Government's green space planning implementation. In summary, in the research on dynamic change in UGS, we need to shift our focus to non-megacities with complex topography. Meanwhile, we must be particularly cautious in choosing the research time nodes so that the research results can truly reflect the changes in spatial and social equity of UGSs during the process of green space planning.2. While Fuzhou's UGS surface per capita is higher than most other cities in China, equitable access to UGSs cannot be captured using the total UGS surface per capita  was selected as a representative case with longer and more meaningful research temporal intervals, as this city is set in a valley surrounded by rolling hills, and the available space for urban expansion is limited. Fuzhou was deemed a National Ecological Civilization Pilot Zone, with the highest green space coverage rate nationwide. Fuzhou has been awarded titles such as National Garden City, National Model City for Afforestation, National Ecological City, and National Forest City. Fuzhou's long history and geographical conditions have laid the foundation for the establishment of UGSs. Meanwhile, the local Government also attaches great importance to green space construction. According to the specific goals for constructing green space proposed by the green spaces system planning of Fuzhou city (2013–2020), the per capita green area for the central urban area was 15 mr capita .Additionally, over the past few years, the city has witnessed burgeoning population growth, which has accelerated urban land-use conversion and infrastructure development. Therefore, whether the excellent natural base combined with previous efforts results in an equal supply of green space or requires further adjustments is uncertain and needs to be explored in depth. To provide useful suggestions for urban planning by exploring UGS accessibility in southeast China and its dynamic relationship with social and economic factors, fine-scale demographic datasets at the community level were collected from 2012 to 2020. This timeframe corresponds to Fuzhou city's green spaces system planning (2013–2020) undertaken by the local Government. It is meaningful to analyze the dynamic changes in green space accessibility from the perspective of social equality to lay the foundations for future urban development.As illustrated in UGS spatial data were obtained through remote sensing (RS) image interpretation. Using remote sensing image interpretation, combined with Map World-Fujian  in related years and green space system planning, the quantity and location of UGSs were verified and validated through a field investigation. The complete data are listed in The base year (2012) of the relevant attribute data, such as the area and classifications of UGSs, were mainly obtained through an actuality investigation of Fuzhou city's green space system planning (2013–2020). Other extensions and newly developed UGSs in 2016 and 2020 were jointly determined from remote sensing (RS) interpretation, together with the green space system planning. The classifications of green spaces that were not included in the planning were mainly determined based on their area. Additionally, considering the rationality of the accessibility analysis results, belt-like open green spaces were divided into several parts according to their multi-entrances. The details of the data collection are illustrated in Furthermore, road availability for multi-mode transport was determined by RS imagery, traffic rules, and field investigations. The pre-processing for road networks included the examination and verification of road directions and built or under-construction roads. Road network access and topological relationships were evaluated depending on the actual situation. Roads were divided into different types, such as highways, city circles, and auxiliary roads. According to different travel modes, the speed was set for different road categories according to the corresponding national standards and local reality. As illustrated in The study proposes a multiple transportation mode method called the multi-mode 2SFCA, which is based on the framework of the 2SFCA. The multi-mode method is implemented using the following two steps:j, search for all populations that fall within different predefined threshold travel times by mode from j, and on that basis, draw different catchment areas. Then, compute the supply-demand ratio Vj within the catchment areasStep 1: For each UGS djk (Mn) is the travel time by mode Mn between UGS j and community k; and d0(Mn) is a predefined threshold travel time from j by mode Mn. In this way, several catchment areas by mode can be drawn around UGS j. Vj reflects the supply availability of UGS j that can be offered to a person who can reach it by different transportation modes.where i, search for all UGSs (j) that fall within the threshold travel time by mode from i. Thus, draw the different catchment areas again. The supply-demand ratios within different catchments are weighted by community population size, and the weighted values are added together to calculate the overall accessibility (Ai) of community i.Step 2: For each population community Thus, the accessibility of a community is dependent on the distribution of UGSs, as well as on its population, road network characteristics, and uneven public transport supply:According to the Traffic Analysis Reports for Major Cities in China proposed by AutoNavi and the state information center, Fuzhou has a high green travel willingness index. The cycling travel willingness index in Fuzhou ranks third in China, and the demand for public transport, such as buses and subways, is quite large.The existing reviews revealed significant spatial heterogeneity in UGS accessibility via walking and public transit. They also confirmed that significant social inequalities widely exist except for the private car mode . FurtherDuring the analysis, it was apparent that selecting a reasonable threshold travel time is the key point for using the multi-mode 2SFCA. To estimate the threshold travel time (by mode) empirically, we used a questionnaire. The results demonstrated that the travel time to UGSs varied according to the travel mode. We could then derive the frequency distribution of trips against travel time . It was A challenge for analyzing dynamic changes in deprivation is that the marginal effects are always heterogeneous across the covariate space that cannot be appropriately handled by generalized linear models (GLMs). Furthermore, GLMs have significant shortcomings as the existence of highly interdependent relationships among the demographic properties of the community does not conform to the inherent assumptions . While mThe central urban area of Fuzhou city has witnessed an overall improvement trend in UGS accessibility from 2012 to 2020 using multi-mode transport . The spaA previous study identified the relative role of local contributors, such as population and transport networks, on accessibility changes . The preThe detailed dynamic changes in UGS accessibility among communities are presented in As revealed in Overall, UGS accessibility continues to improve, while the region with restricted accessibility has gradually decreased. Fuzhou inhabitants have more opportunities to visit community-level and district-level UGSs, regardless of their chosen travel modes. The spatial distribution of UGSs is optimized through the expansion and spatial rearrangement of green spaces. In particular, inhabitants of the southeastern region, which is also along the city's development corridor, have easier access to UGSs due to the newly built green space in this area. Although the central urban area population has rapidly increased, the increased traffic network density and layout optimization of UGSs allow convenient travel to UGSs. As large-scale UGSs are primarily distributed in the urban periphery, the core urban areas have relatively poor accessibility by walking or cycling. However, core urban areas are always intensive bus route zones, making it very convenient for people to reach UGSs by public transport, particularly with the continuous expansion of Fuzhou subway lines.The Healthy China Action (2019–2030) report advocates a healthy lifestyle, insisting on low-carbon travel; prioritizing walking, cycling, or public transportation; and advocating more shared transportation. However, the multi-mode practice continues to lag in UGS accessibility research. In this study, the catchment area for walking is approximately 15 min on the physical exercise scale mentioned in the action program. Nonetheless, the results presented in Additionally, to date, more than half of the communities continue to have a limited per capita area of UGSs within the catchment, which is less than the required area for a National Ecological Garden City (beyond 12 per capita area). Confined by the pressure of rapid population growth, UGS accessibility tended to be stable in the last 4 years (2016–2020) after the definite increase, which was mainly concentrated in the previous 4 years (2012–2016). Due to the large scale of the green spaces distributed in the periphery of the urban areas, the ideal accessibility to city-level UGSs depends on cycling or public transport. In contrast, as community-level UGSs are mostly located in the core urban areas with high population densities, the accessibility and potential to improve are limited.The limited access to UGSs for disadvantaged groups at the community level reflects the existence of community deprivation. The specific disadvantaged groups have different accessibility by multi-mode transport, and this access also changes with time. Overall, significant deprivation mainly exists for less educated people or those using the cycling and integrated travel modes. Less-educated people tend to live in communities characterized by lower coverage of green spaces and fragmented and narrow lanes . This exThe dynamic changes in accessibility cannot be captured completely if only two time nodes are selected for comparison (the origin and destination). However, even with three or more time nodes, the results could be insufficiently convincing if the time intervals are short. Therefore, this study selected three representative time nodes for which the time interval was sufficiently long to observe changes. In other words, within the study period, equality of access to UGSs tended to first increase and then decrease. The social inequality from the perspective of UGS accessibility is similar to the green gentrification that has garnered widespread concern, particularly in Western countries , 55. TheIn conclusion, this study revealed the periodic characteristics of community deprivation, which has seldom been discussed to date. Although rare studies on the same topic present different conclusions , 29, it This study identified that the Government should formulate equalizing policies to improve the accessibility of the disadvantaged groups, even though the growth rate of spatial accessibility did not stall or even reversed during the study period. Similar to the importance of balancing the relationship between urban development and social justice, community deprivation in urban green space access is also an urgent problem to be solved in current urban development. Sufficient provision and dynamic spatial optimization of public green spaces are essential to relieve the deprivation of disadvantaged groups. However, the work should not be limited to UGS planning. Previous studies have only provided limited advice rather than a well-established policy framework.In the process, identifying the deprived communities with limited UGS accessibility is the prerequisite to resolving these issues. In the beginning, policymakers regularly analyzed the demographic changes through population dynamic monitoring. Recently, ubiquitous big data have been widely used in social science research, and social network applications that have check-in options, such as “microblogs” or Twitter, provide researchers with location-based data for studying user behavior when visiting UGSs. Nevertheless, as reflected in the user preferences on social networking, these social network applications are seldom used by disadvantaged groups. This means that many users who belong to a disadvantaged group or those without mobile phones are not included in the research. Big data could be used to supplement traditional sampling statistics to detect regions with poor accessibility. Some prior studies have demonstrated that high-SES groups have better access to public green spaces, partly owing to their greater ability to choose residences with high-quality living environments and participate in planning decisions relevant to their benefits . More efAdditionally, governments and relevant departments should optimize the road network structure during urban construction. By targeting varying degrees of deprivation through multi-mode transport,they should promote planning and design principles through the “Narrow Roadways, High Density Network” to improve accessibility by public transport and strengthen the construction of cycling and pedestrian lane systems. Furthermore, shuttle busses that connect large-scale UGSs and deprived communities should be incorporated into the planning. The free bus transfer to large-scale UGSs based on existing subways can also be considered, particularly for disadvantaged groups.Finally, a management system for differentiation and diversification of supply and the trade-off and compensation for UGSs needs to be established. Due to the heterogeneity of urban space and the inhabitants' characteristics, more flexible greening strategies are recommended to create better green space access and improve the inhabitants' daily recreation service experience. For example, for the limited accessibility of community-level UGSs in core urban areas, vertical greening, parkways, and greenways should be added to improve the diversity index and strengthen landscape connectivity , thus buskylers@vip.qq.com.The datasets for this article are not publicly available because of the institutional copyright issues. Requests to access the datasets should be directed to Shunqi Cheng, All authors 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.


Aedes aegypti is a vector for the transmission of diseases such as dengue fever, chikungunya, Zika fever, and yellow fever. In 2016, over 1 million cases of these diseases were reported in Brazil, which is an alarming public health issue. One of the ways of controlling this disease is by inspecting and neutralizing the places where A. aegypti lays its eggs. The Ministry of Planning, Development, and Administration of Brazil maintains the inspection statistics.A. aegypti inspections reported through the Ministry of Planning, Development, and Administration system of Brazil.We propose a multi-criteria analysis to create an index for A. aegypti breeding sites.Based on the repository from urban cleaning services combined with data on inspections conducted by government agencies in several Brazilian cities and municipalities, we selected and combined metrics, which we further ranked using the analytic hierarchy process methodology. We also developed risk maps based on the analytic hierarchy process ranking of the Based on our analysis and the available data, the priority for inspections should consider the number of sick people (weight 0.350), medical evaluations (weight 0.239), inspections (weight 0.201), mosquito breeding sites (weight 0.126), and days of absence from work (weight 0.096).A. aegypti breeding sites. This information technology application can help solve such public health challenges.The proposed index could aid public health practitioners in preventing the appearance of new  Aedes aegypti is a vector for many diseases such as chikungunya, dengue fever, yellow fever, and Zika virus. The control of these diseases is difficult as there are several hard-to-find mosquito breeding places  that can be found at any abandoned lot or in any house. In Brazil, A. aegypti is the main vector for dengue fever. However, Aedes albopictus is also a vector of such arboviruses [A. aegypti and A. albopictus tend to breed in similar sites, and researchers have documented competition between these species. A. aegypti is more prevalent in densely populated highly urbanized areas, while A. albopictus is more prevalent in rural, suburban, and forested urban areas [oviruses  and haveoviruses . A. aegyan areas .A. albopictus is still regarded as the potential vector of arboviruses in most countries of the Americas [A. aegypti. Nevertheless, our work can be applied with minor modifications to the control of breeding of A. albopictus. The challenge in controlling this vector is one of the reasons for the significant numbers associated with the outbreaks of the diseases, which shows how important it is as a public health issue. There are approximately 390 million cases estimated each year for dengue alone [A. aegypti [Although Americas , our worue alone . In Braz aegypti .A. aegypti, which has led to a reduction in the cases of disease related to it. These methods are usually combined and include contaminating the female mosquitoes with Wolbachia strains so that they cannot spread diseases [There are currently several methods to control the breeding of diseases ,7, elimiA. aegypti infestation index rapid survey (Levantamento Rápido de Índices para Aedes aegypti) is a simplified entomological surveillance method adopted by the Ministry of Health to determine the infestation rates of A. aegypti. Municipalities perform larval surveys through systematic sampling of buildings to calculate the Breteau index and the building infestation index. The sample depends on the population density and the number of buildings. The indexes predominantly identify breeding sites and are used as indicators to initiate actions to neutralize these sites and reduce the use of larvicides [In Brazil, the rvicides .A. aegypti is a transdisciplinary effort, and information technology plays a role, mainly in the creation of a data repository to support analysis and decision making. An example of information technology is the Sigelu Aedes software developed by the Brazilian company Lemobs as commissioned by the Brazilian Ministry of Planning, Development, and Administration. This software helps public workers to inspect government buildings reporting Aedes breeding sites and the actions taken to control them.Controlling A. aegypti breeding sites by proposing a georeferenced index that helps decision makers to identify places where mosquitoes could breed. We used a multi-criteria analysis, more specifically the analytic hierarchy process (AHP), to develop such an index. We tested our index by using real data from the Ministry of Planning, Development, and Administration of Brazil to produce a risk map layer in a multidimensional data model.Given this context, the goal of our work is to contribute to the effort of controlling Multi-criteria analysis has been used previously in disease vector surveillance literature for supporting decision making. We review such related literature with a special focus on the methodology and outcomes of each study. Aenishaenslin et al  identifiIn a second study, Aenishaenslin et al  adapted Cox et al  designedFruean and East  assessedHongoh et al  ranked pThanapongtharm et al  characteVinhaes et al  analyzedA. aegypti lays their eggs. The data source for this study is the Ministry of Planning, Development, and Administration of Brazil through the Sigelu Aedes software. Like Santos et al [Our proposed approach involves performing an analysis to create an index of the inspections to find places where os et al , we adopos et al -9,11-14,os et al , our appA. aegypti are abandoned sites that can be used as garbage dumps, the developers of this software decided to integrate resources to combat this mosquito species. Thus, this system contains data on inspections conducted by government agencies in several Brazilian cities and municipalities. However, the metrics used do not indicate possible future mosquito breeding sites —they only record the work done by government agents in the field.Managers of urban cleaning services provide data to form a repository. Given that the main breeding sites of Our proposed solution is presented in The AHP criteria matrix is shown in The matrix for the alternatives with respect to each criterion is presented in At this point, it is possible to calculate the final priorities of the alternatives. Firstly, we must multiply the criterion values by the values for the alternatives, as shown in We then obtained the final priorities, which are shown in This new index is georeferenced by the inspection places retrieved from the data source, as seen in Another interesting result is that a map elaborated with the new index can be more useful than the current map used by the decision makers  in prediA. aegypti breeding sites in Brazil. We applied multi-criteria analysis, specifically AHP, to prioritize the metric alternatives based on 5 criteria. By using this methodology, we were able to produce risk maps for A. aegypti disease control. This is a well-stablished approach as shown by the related works [A. aegypti breeding sites, instead of the places with more inspections or breeding sites already identified. We also tested the index’s capacity for identifying areas affected by the diseases caused by A. aegypti and showed that it can help in identifying these areas. It is our understanding that the proposed index—with its future orientation—could be another tool to public health practitioners in preventing the appearance of new A. aegypti breeding sites and in showing how information technology can be applied to help solve public health challenges. Other initiatives such as participatory disease surveillance [In this work, we proposed a georeferenced index to help in the identification of likely risk areas for the proliferation of ed works -9,11-14.eillance -31 can bA. aegypti, regarding the use of AHP in conjunction with their opinions. A form was created to help fill out the AHP spreadsheet with the pairwise comparisons. The result of this effort, as well as a comparison between the executions of the AHP by the authors and experts, can be seen in A. aegypti will allow us to improve our research.This work does not use environmental variables that affect the density and distribution of the mosquitoes , which can be added in further versions of this study. In this work, we were only able to georeference the index that resulted from the first AHP, which only involved the opinion of 3 of the authors. After presenting the results of this work as a poster at the Workshop on Big Social Data and Urban Computing that was held in the Very Large Databases Conference, we consulted a group of 3 experts on diseases caused by A. aegypti breeding sites. This new index may also be applied in conjunction with the current methodologies. Besides the criteria we used in our index proposal, we will explore environmental criteria that affect the density and distribution of the mosquitoes , which are the standard variables in the identification of A. aegypti breeding sites.The proposed approach uses unconventional indicators based on the presence of mosquitoes: number of inspections, number of sick people, number of medical evaluations, number of days of sickness absence, and number of mosquito breeding sites found. Thus, this work provides a novel paradigm for public health practitioners in preventing the appearance of new


The coronavirus disease 2019 (COVID-19) pandemic has changed many aspects of our private and professional routine. In particular, the lockdowns have severely affected the entire healthcare system and hospital activities, forcing it to rethink the protocols in force. We suggest that this scenario, in spite of the new challenges involving so far complex healthcare providers, may lead to the unique opportunity to rethink pathways and management of patients. Indeed, having to resume institutional activity after a long interruption that has completely canceled the previously existing schemes, healthcare providers have the unique opportunity to overcome obsolete and “we have always done in this way” model on the wave of the general desire to resume a normal life. Furthermore, the pandemic has highlighted some flaws in our health system, highlighting those critical issues that most need to be addressed. This article is a review of pre-pandemic literature addressing the use of Lean Six Sigma (LSS) and standardization processes in thoracic surgery to improve efficiency. Our goal is to identify the main issues that could be successfully improved along the entire pathway of a patient from the first referral to diagnosis, hospitalization, and surgical operation up to convalescence. Furthermore, we aim to identify the standardization processes that have been implemented to achieve significant improvements in patient outcomes while reducing costs. The methods and goals that could be used in the near future to modernize our healthcare systems are drawn up from a careful reading and interpretation in light of the pandemic of the most significant review articles in the literature. The coronavirus disease 2019 (COVID-19) pandemic has changed many aspects of our private and professional routine. In many countries, patients were confined to their homes and access to healthcare facilities for the non-COVID cases was not so easy as most hospital facilities shifted their focus from the care of acute patients to patients with COVID. The lockdowns have severely affected the entire healthcare system, forcing it to rethink the protocols in force. This has led to dramatic changes in surgical practice as well, in particular, thoracic surgery. At the beginning of the pandemic, the main issues were the following: how to offer surgery to patients with cancer considering that  patientsThoracic surgeons addressed these points with an enormous effort by  introducIn spring 2020, European countries ended their lockdowns and healthcare systems resumed their operations while being faced with new challenges. During the first wave, the pressing issue was to select the most urgent cases, and later on, the issues were the following: to (1) restart cancer screening programs, (2) increase outpatient appointments to cope with the backlog of visits, (3) reconstitute specialist teams that were dismantled, and (4) continue to ensure the safety of patients throughout their journey at the hospital as the virus still persisted in the community. Unfortunately, the second wave of the pandemic has hit us again, further destabilizing a so far volatile situation.We suggest that this scenario may lead to the unique opportunity to rethink pathways and management of patients. Indeed, healthcare providers have the unique opportunity to overcome obsolete models on the wave of the general desire to resume a normal life.This article is a review of pre-pandemic literature addressing the use of Lean Six Sigma (LSS) and standardization processes in thoracic surgery to improve efficiency. Our goal is to identify the main issues that could be successfully improved along the entire pathway of a patient from the first referral to diagnosis, hospitalization, and surgical operation up to convalescence. Furthermore, we aim to identify the standardization processes that have been implemented to achieve significant improvements in outcomes while reducing costs. Attention was given to those that were severely affected by the pandemic.The first issue that we would like to tackle is the reduction in the length of stay. Through standardization of protocols, all stakeholders should be aimed at eliminating non-value-added (NVA) steps allowing more efficient rates of the day of surgery admission (DOSA). As described earlier by Sofela et al. , we expeThe second topic concerns improvements in the waiting time performance in diagnostic assessment of patients with lung cancer. Through standardization of procedures and “waste” elimination, reorganization should be aimed to reduce the time from consultation to diagnosis of lung cancer and improve the experience of care of patients. A good example of this could be the use of government or even self-determined standard of care (SoC) . It is also very important to collect the opinion of the patients; we recommend the wide adoption of patient-reported outcome measures questionnaires (PROMs) as the only tool to significantly monitor the quality of care.The third topic concerns saving the cost of and decreasing the risk of surgical procedures, in particular, video-assisted thoracoscopic surgery (VATS) lobectomy. By avoiding customized protocols for individual surgeons, redesigning the process should be aimed to reduce the length of surgical operation, inefficient care transitions, and overuse of resources.Lean Six Sigma (LSS) is a method originally used to improve the capability of business processes; it combines lean manufacturing/lean enterprise and relies on a collaborative team effort to improve outcomes by systematically removing waste and variations . LSS metThe ideal program for thoracic patients should be customized to deliver an optimal care experience from referral to discharge. Such a pathway should be primarily aimed to improve outcomes and then to reduce costs. Outcome improvement concerns not only a decrease in postoperative complications but also a reduction in length of stays, fast recovery to baseline activity, and reduction in preoperative and perioperative time as previously described in enhanced recovery after surgery (ERAS) principles. The favorable impact of these issues on money saving is commonly accepted , 7.Brown et al.  establisAccording to LSS principles, the strategy adopted to improve DOSA was based on identifying and removing the NVA steps. To put it in a nutshell, their project was articulated in four steps that authors called as follows: define, measure, analyze, and improve.The first consisted in (1) general criteria for identification of patient enrollment, (2) selection of all stakeholders, and (3) creation of a value-stream mapping (VAM) to have an overview of journey state of patients (“AS IS”) from out-patient office to the access to operatory room (OR).The second consisted in the measurement of data describing the usual practice during the patient pathway and the related opinion on this practice by stakeholders. Data included surgeons, procedure, attendance to preoperative assessment clinic, and DOSA and confirmed the surgical date provided and whether preoperative tests had been completed. On the other hand, opinions of patients and nurses related to the process were obtained and recorded by the paper survey.The third consisted in data analysis to identify some NVA issues such as the elevated number of steps along the patient pathway, a large volume of rework, and other topics.The fourth step was the interventive one that consisted of the development and implementation of a presurgical checklist and the weekly planning meeting.The project lasted 6 months and then authors published their results showing a significant reduction in DOSA quantified with a DOSA>75%. Remarkably, every previous project with the same objective, but without adopting LSS methods, had failed the goal.Authors identified as major successful factors are the following: the cooperation among different professional figures and the ability of this method in involving people prompting communication and collaboration thanks to a system of the weekly planned meeting.Procedural standardization is another model adopted to improve the efficiency and safety of surgical tasks and, in particular, thoracic surgery. The standardization process by definition is an activity focused on achieving an optimal degree of order in a determined context concerning actual or potential items and provisions for common and repeated use. Standardization consists of formulating, issuing, and improving standards.Iwasaki et al.  publisheIt is a common opinion that any delay in diagnosis or in the period of time running between suspicious finding and treatment of lung cancer may reduce overall and cancer-specific survival. On this basis, many departments have developed a diagnostic assessment program (DAP) in order to boost this key point in the pathway of patients.Cotton et al. published their experience with lean six sigma to improve waiting time performance in diagnostic assessment for these patients . In partThey started with a 4-days Kaizen workshop including different stakeholders  focused on the development of a unit optimization plan. Adopting lean six sigma methodology with the help of the consultants, they were able to draw a VAM of the current and ideal patient pathway, which allowed the identification of waste, rework, bad coordination, and unneeded processes.The program improved rapidity in diagnosis with a rise from 45 to 75% of cases in the target time and allowed an increase in volumes of patients as well. The review paper is interesting since their conclusion shows how the lean six sigma model was successful in achieving their initial goal. Moreover, it emerges that the use of multidisciplinary cross-programs to improve quality could be adopted in other issues concerning healthcare, which deserve waste elimination. The review paper confirms that the strength of lean six sigma workflow analysis methodology relies on putting together different stakeholders ranging from patients and their families to surgeons, as reported earlier by Morgan et al. .The intraoperative period is the most meaningful moment along the pathway of patients in a surgical department, since it is the one where the clinical outcome is influenced most and also the one where most of the money is spent. Moreover, this is probably the activity where surgeons are more involved and that has more possibility to change. So, intraoperative time is a high-priority target for efficiency improvement and some authors have oriented their efforts in this field.Cerfolio et al. published their experience with a project that aimed to reduce the pre-incision time in the OR for lobectomy that adopts the process of lean six sigma . Their bBased on this experience, Kyle et al. in collaboration with Cerfolio, focused their attention on the standardization of surgical instruments with the aim to investigate cost saving . They adYeo et al.  focused They performed a review of perioperative procedures for VATS lobectomies and designed a process improvement map to determine the procedures that determined value. Then, they identified sources of high cost and practice variability. The project was developed by introducing standardized practices focused on quality and cost, by establishing a database to record safety and quality and a regular MDT meeting with surgeons, mid-level providers, and clinical staff to evaluate outcomes. The authors showed an overall 187% decrease of time in the OR, significant reduction in chest x-ray, laboratory tests, consultations, global costs, and length of stay.Finally, Fong et al. published a systematic review of 36 studies focused on improvement in intraoperative efficiency  concludiSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has severely decreased volumes of thoracic surgery procedures since hospitals canceled most of the non-urgent interventions. Therefore, a progressive increase in deferred cases during the pandemic is expected and will require completion within a short period once the pandemic has subsided. However, if only pre-pandemic capacity will be available, then poor operating capacity and patient management could cause substantial delays and increase morbidity and mortality.Hospitals and departments must focus their efforts to increase operating capacity, by rethinking the protocols in force, in order to quickly clear the backlog of deferred cases. In this manner, we will be able to address the emergency and at the same time to improve our models for the upcoming future. In doing so, the pandemic will be also an opportunity. However, the key point is how to drive innovation. With an eye on pre-pandemic experience, we have reported how adopting change driving methods, such as the LSS and standardization, improvement of quality, cost saving, and favorable clinical outcomes, are achievable. We advocate the use of LSS by HCPs using a bottom-up approach, with managers acting as facilitators rather than decision-makers. The pandemic situation has offered, in our opinion, the possibility of focusing on the whole pathway in a holistic fashion, rather than been forced to accept compromises dictated by local power struggles or customs.FR designed and wrote the review. RO, AR, FM, UC, MD, AG, and MS contributed to review the paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Recently, Internet of Things (IoT) and artificial intelligence (AI), led by machine learning and deep learning, have emerged as key technologies of the Fourth Industrial Revolution (4IR). In particular, object recognition technology using deep learning is currently being used in various fields, and thanks to the strong performance and potential of deep learning, many research groups and Information Technology (IT) companies are currently investing heavily in deep learning. The textile industry involves a lot of human resources in all processes, such as raw material collection, dyeing, processing, and sewing, and the wastage of resources and energy and increase in environmental pollution are caused by the short-term waste of clothing produced during these processes. Environmental pollution can be reduced to a great extent through the use of recycled clothing. In Korea, the utilization rate of recycled clothing is increasing, the amount of used clothing is high with the annual consumption being at $56.2 billion, but it is not properly utilized because of the manual recycling clothing collection system. It has several problems such as a closed workplace environment, workers' health, rising labor costs, and low processing speed that make it difficult to apply the existing clothing recognition technology, classified by deformation and overlapping of clothing shapes, when transporting recycled clothing to the conveyor belt. In this study, I propose a recycled clothing classification system with IoT and AI using object recognition technology to the problems. The IoT device consists of Raspberry pi and a camera, and AI uses the transfer-learned AlexNet to classify different types of clothing. As a result of this study, it was confirmed that the types of recycled clothing using artificial intelligence could be predicted and accurate classification work could be performed instead of the experience and know-how of working workers in the clothing classification worksite, which is a closed space. This will lead to the innovative direction of the recycling clothing classification work that was performed by people in the existing working worker. In other words, it is expected that standardization of necessary processes, utilization of artificial intelligence, application of automation system, various cost reduction, and work efficiency improvement will be achieved. Recently, Internet of Things (IoT) and artificial intelligence (AI), led by machine learning and deep learning, have emerged as key technologies of the Fourth Industrial Revolution (4IR). In particular, object recognition technology using deep learning is currently being used in various fields, and thanks to the strong performance and potential of deep learning, many research groups and Information Technology (IT) companies are currently investing heavily in deep learning –6. As a The textile industry involves a lot of human resources in all processes, such as raw material collection, dyeing, processing, and sewing, and the wastage of resources and energy and increase in environmental pollution are caused by the short-term waste of clothing produced during these processes. Environmental pollution can be reduced to a great extent through the use of recycled clothing. Therefore, there have been many efforts in Korea and other countries to recycle and rewear waste clothing. In Korea, the utilization rate of recycled clothing is increasing due to rising awareness of environmental issues and resource conservation . The amoIn this study, I propose a recycled clothing classification system with IoT and AI using object recognition technology to the problems. The IoT device consists of Raspberry pi and a camera, and AI uses the transfer-learned AlexNet to classify different types of clothing. The composition of this thesis is as follows: Section 1 provides Introduction, Section 2 describes related works, Section 3 describes recycled clothing classification system, Section 4 provides measurement results, and Section 5 provides conclusions.In Korea, waste clothing collected is classified as recycled and impossible. Reusable clothing is sold in flea markets, bazaars, etc. As shown in AI is generally distinguished into two types: machine learning and deep learning. Deep learning is defined as a set of machine learning algorithms that attempt high levels of abstractions through the combination of several nonlinear transformation techniques and is a field of machine learning that integrates people's thinking to computers. Deep learning is a technique that solves problems by stacking neural networks and relies on the amount of data. It makes a structure that flexibly responds to various patterns and cases instead of having few assumptions about problems compared to other machine learning techniques.Object recognition is a computer vision technology that uses computers to identify objects in images. People can easily recognize characters, objects, scenes, and visual details when they see pictures or videos. This ability allows a computer to learn what a person can do with a machine. To solve this problem, deep learning and machine learning algorithms, such as AI technologies, are widely used , 16.Object recognition technology using machine learning is a classification method using machine learning and a CNN and a feature extraction method for image recognition. This method requires a large amount of training data (learning dataset) and requires CNN to set layers and weights. The CNN that has been proposed since 2012 has been using an increasing number of neural layers, and in this process, technologies are used to efficiently insert several neural layers into one CNN. The CNN has a convolutional layer, a pooling layer, and a rectified linear unit (ReLU) as its core elements.AlexNet is a convolutional neural network architecture and consists of eight learning, five convolutional, and three fully connected layers –20. The The structure of AlexNet is shown in The convolution neural network AlexNet has five convolution layers (conv), two fully connection layers (fc), and one output layer. The first input image was converted to the size of 227 × 227. The first convolution layer performs the convolution calculation, and in the network, the ReLU activation function is used. The next step is to downsample the feature map, and then the images are normalized. The operation of the second convolution layer is the same as that of the first convolution layer. The third and fourth convolution layers perform only the convolution operation. The fifth convolution layer performs the same operations as the first convolution layer and then inputs the feature map to the fully connected layer. The first fully connected layer and the second fully connected layer are that each neural performs the convolution operation. In the last part of each fully connected layer, the dropout layer should be appended to effectively reduce the number of neurons to prevent overfitting. The final layer is the output layer. It is also a fully connected layer that performs classified work. The neural network uses a loss function to measure the accuracy of image recognition, and then the image recognition uses the tested accuracy to distinguish the image.Transfer learning allows one to reduce the time needed to produce results through the training of models with several images. The calculations of learning methods can be reduced by borrowing from the neural network to solve other problems. This concept is called transfer learning , 22. TraThe existing clothing classification system is the same as in The details of experimental equipment are listed in The composition of the experimental equipment is shown in First, recycled clothing data were collected from 2400 clean image data without crumpled or folded clothing and 900 loss image data with crumpled or folded clothing. These data  were used as inputs for AlexNet. To classify clothing images collected by the clothing image datasets, the CNN used transfer-learned AlexNet, written in MATLAB [We trained our model using stochastic gradient descent with a batch size of 64, epochs at 3, and an initial learning rate of 0.001.The clothing image data used in the deep learning-based clothing image classification model study were collected by crawling the clothing image existing in Google, as shown in The AlexNet model was used as a deep learning-based clothing image classification model, the metastatic learning model was the same as the table, and MATLAB was used. Learning continues in the direction of reducing the cross-entropy loss function, which is the same as defined in the following formula:ti and si are the ground truth that is the correct answer, and the last output vector of the model, which is the i-th element of the result value of the softmax layer of the model, respectively. To minimize this, learning continues using the SGD algorithm. Finally, the prediction probability of each category is derived through the softmax layer using the image characteristics of the global average pooling layer, and the classification is learned using it. The experimental conditions are the same as shown in Here, For model learning, the classification results were verified with 2400 data for learning and 900 data for testing, with a 7 : 3 ratio of all 3,300 clothing image data. The model was trained with 2310 images in nine classes and tested with 990 test images. The loss function used by the model was half mean squared error. Model visual knowledge depends on the feature activation induced by the last layer. The transfer-learning AlexNet model was used as a deep learning-based clothing image classification model, and the results of classifying the clothing image data taken using IoT as inputs are as follows.The clean and loss images are shown in AI that has been promoted by machine learning and in-depth learning along with new technology to lead 4IR was applied to the real world through various research and developments. With the recent release of GoogLeNet and LesNet's neural networks, the structure of CNN was likely to continue to deepen and become more complicated. Deep learning models were not fixed; therefore, they could be set up in various ways. Hence, if new problems were presented, new neural network models could be developed.In this paper, we proposed an intelligent classification system for recycled clothing, which classifies them using IoT and AlexNet deep learning. The clothing transferred from the recycled clothing collecting place (box) to the conveyor belt was photographed using a camera connected to Raspberry and an IoT device, and AlexNet deep learning classified the photographed clothing images into nine categories. For the measurement, 3300 clothes image datasets were used.As a result of this study, it was confirmed that the types of recycled clothing using artificial intelligence could be predicted and accurate classification work could be performed instead of the experience and know-how of working workers in the clothing classification worksite, which is a closed space. This will lead to the innovative direction of the recycling clothing classification work that was performed by people in the existing working worker. In other words, it is expected that standardization of necessary processes, utilization of artificial intelligence, application of automation system, various cost reduction, and work efficiency improvement will be achieved.


Background: Coronary artery disease as a consequence of atherosclerosis is the most common cause of morbidity and mortality in type 2 Diabetes Mellitus (DM) patients. Homocysteine (HCY), as one of the risk factors, and uric acid (UA) as the most common antioxidant in serum have their roles in the processes of inflammation and atherogenesis, which underlie the pathogenesis of acute myocardial infarction (AMI). The effect of HCY in cardiovascular disease is thought to be manifested primarily through oxidative damage, implying a potential correlation between the HCY level and antioxidant status. Since the data related to the diagnostic significance of both HCY and UA in diabetic patients with AMI are conflicting, and so far not reported in Bosnian patients, this research aimed to examine the association of HCY and UA levels with glomerular filtration rate (eGFR) and explore the pathophysiological significance of these data in Bosnian diabetic patients with AMI.Methods: This prospective research included 52 DM type 2 patients diagnosed with AMI. Blood samples were taken on admission and used for biochemical analysis. Results of the biochemical analyses were statistically analysed.Results: Elevated HCY and UA levels were observed in diabetic patients. Females have higher HCY compared to males. A positive correlation was revealed between HCY and UA and was confirmed with different HCY levels in subgroups with different UA level. A negative correlation was observed between UA and HbA1c, as well as between both HCY and UA with eGFR.Conclusions: These results contribute to the clarification of the biochemical mechanisms characteristic in AMI patients with DM. According to these results, we believe that joint measurement of HCY and UA could enable a better assessment of the prognosis for this group of patients. This kind of assessment, as well as regression analysis, can identify high-risk patients at an earlier stage when appropriate interventions can influence a better outcome in such patients. Acute myocardial infarction (AMI), occurs as a result of atherosclerotic plaque rupture and formation of thrombus. Myocardial tissue becomes inflamed and necrotic; it loses contraction and impulse conducting ability with the net result of decreased oxygen distribution and irreversible damage to the heart muscle Cardiovascular disease (CVD) and AMI are the most common causes of morbidity and mortality in patients with Diabetes Mellitus (DM) Novel studies of CVD risk factors in patients with diabetes indicate the diagnostic value of elevated homocysteine (HCY) and uric acid (UA) levels. An increased level of HCY in AMI patients compared to the group of healthy subjects was observed in the previous research So far, it has been shown that serum UA levels are elevated in patients with AMI, involving categories belonging to patients with systemic hypertension and those with DM, when compared to healthy individuals. Diabetic patients who are hyperuricemic appear to be at increased risk of developing diabetic complications, especially renal and cardiovascular Although HCY and UA have many similarities, their relation is not quite clear in diabetic patients with AMI. A detailed literature review indicated that at least so far there have been no studies trying to link the HCY level and compounds with antioxidant activity level, which are measured in routine clinical practice in percutaneous coronary intervention (PCI). Therefore, the aim of this research is to elucidate the relation between laboratory markers, mainly HCY and UA levels, to correlate these results to glomerular filtration rate (eGFR) and to determine their significance in diabetic patients with AMI.This prospective research included 52 DM type 2 patients diagnosed with AMI. Patients were admitted to the Department of Cardiology at the University Clinical Hospital of Mostar, Bosnia and Herzegovina, in the period between October 2016 and January 2019. Patients were previously diagnosed with DM type 2 based on ADA recommendations Study design, methods and statistical analysis are similar to our previous research published in August 2018 All participants in this research were informed about the details of the study. The research did not affect the treatment and hospitalisation duration of patients. It was done in accordance with ethical recommendations and practices of Mostar University Clinical Hospital and the Declaration of Helsinki.Due to the simpler interpretation of possible statistically significant results, according to previous studies 2 tests were used in cases of comparison of more than two groups (stratification of patients according to UA level in tertiles). P<0.05 was considered statistically significant.On admission, after ECG, and before the PCI, venous blood samples were taken into the vacuum tubes. A serum sample used to determine the UA and HCY level was taken with one anticoagulant-free 7.5 mL test tube . Whole blood sample for HbA1c assay was taken in a single 2.6 mL test tube with EDTA as an anticoagulant . Residual parts of the samples were taken for research after the completion of routine treatment ordered by a cardiologist. The level of the HCY (mmol/L) was measured in the serum by non-competitive immunoassay method on Architect ci8200 Integrated System analyser . The UA level was measured according to the standardised IFCC  photometric method (uricase-POX) on the AU680 analyser . HbA1c was measured on the same analyser according to standardised IFCC method-immunoturbidimetry. The statistical analysis was performed by SPSS . The Kolmogorov-Smirnov test tested an assessment of the normality of data. Correlations were tested by the nonparametric Spearman correlation. The nonparametric Mann-Whitney U test tested the differences between UA and HCY level in different subgroups of patients. The comparison of HCY and UA with respective reference ranges was performed by one-sample t-test. Kruskal-Wallis and χAs represented in Hypertension was equally distributed between males and females 65% .In order to compare HCY and UA levels with the healthy population, results were compared with gender-dependent reference ranges . A signiThe analysis of subgroups obtained by distribution according to the level of UA in tertiles revealed a reduced level of HCY in the first tertile, compared to the second and third (p=0.030) . eGFR shCorrelation analyses in different subgroups are represented in Descriptive characteristics represented in Smoking, which is previously recognised as a significant and independent risk factor for all-cause, cardiovascular, and noncardiovascular mortality and fatal and non-fatal coronary heart disease and congestive heart failure is represented in 46% patients of this research. Smoking is a risk factor for mortality and coronary heart disease in patients with hypertension as well as with DM. However, there is no evidence that the relative risk of smoking is higher in people with diabetes than in people without DM. Because DM alone is a risk factor for morbidity and mortality, the absolute risk of smoking is usually higher in people with diabetes than in people without DM In this research, HCY level is higher in females. This implies a contribution of DM to the elevation of HCY level in this population, which confirms the fact that females with diabetes are the group with the highest risk of developing CVD, and hospital mortality in female patients with AMI compared to males is significantly increased The available data in the literature on the association between CVD and hyperhomocysteinemia are contradictory; some suggest an association Hyperuricemia is also known to be a critical factor in the development of CVD in the elderly, which is why early detection of UA can identify and prevent it. UA exerts its effects in different ways, which is why it can be associated with the occurrence and development of the disease In this research, HCY level, as a marker of oxidative stress was correlated with UA level, which has antioxidant activity in the body. The association between HCY and UA can be easily explained by hydrolysis of S-adenosyl HCY when adenosine is formed, which is further degraded to UA The analysis of parameters distributed in tertiles according to UA level revealed a strong association of elevated UA level with a higher frequency of hypertension. Several previous epidemiological studies confirmed this association Negative correlations were also observed between UA and HbA1c. A negative correlation is considered to indicate the existence of hyperinsulinemia in these patients, and UA is considered a good indicator of blood glucose level. However, an increase in UA compared with an increase in glucose is a characteristic of a healthy population and patients with prediabetes, but in type 2 DM, a decrease in UA was observed with an increase in HbA1c, which was found in this study as well. The reason for the reverse association is still unclear, but insulin is thought to be a factor influencing this association According to the results of our study, both HCY and UA are factors of atherosclerosis. Hence their action in the body should not be observed independently because their metabolism, as well as the effect on the cardiovascular system, show significant overlaps. Also, both of these markers can be used as markers of renal dysfunction in these patients.Our study has several limitations. It is a singlecentre study with a relatively small group of patients. Control subjects without diabetes were not included in our study. Plasma levels of vitamin B and folate, both of which influence the plasma level of HCY, were not measured.In conclusion, this study indicates that a combined assessment of HCY and UA, as well as a regression analysis, can identify high-risk patients at an earlier stage, and appropriate interventions can influence a better outcome in such patients. Identification of hyperhomocysteinemia as a risk factor, especially in female patients, is of great importance for the diabetic population primarily because of primary and secondary prevention in these patients involving the use of a number of vitamins such as folic acid, vitamin B12 and pyridoxine that directly affect serum HCY level. Therefore, further research studying the impact of the use of these vitamins on the reduction of serum HCY level in the diabetic population of Bosnia and Herzegovina would be of multiple importance. Also, the use of HCY as a marker in prediabetes and diabetes would contribute to the establishment of sub-clinical CVD and suggest the need to take preventive measures before a possible occurrence of infarction or stroke.The authors have no conflicts of interest to declare. The authors give consent to the submission and publication of the work. Authors disclose no relationship to any organization or industrial manufacture in any material discussed.DM, diabetes mellitus; CVD, cardiovasculardisease; AMI, acute myocardial infarction; STEMI, ST-segmentelevation myocardial infarction; HCY, homocysteine; UA,uric acid; PCI, percutaneous coronary intervention; NO, nitricoxide; ECG, electrocardiogram; IFCC, International Federationof Clinical Chemistry.