The National Health Service (NHS), the health care system of the United Kingdom, is one of the largest health care entities in the world and has been successfully serving the UK population for decades. The NHS is also the fourth-largest employer globally. True to its reputation, some of the most modern and technically advanced medical services are available in the United Kingdom. However, between the acute, primary, secondary, and tertiary care providers of the NHS, there needs to be seamless integration and interoperability to provide timely holistic care to patients at a national level. Various efforts have been taken and programs launched since 2002 to achieve digital transformation in the NHS but with partial success rates. As it is important to understand a problem before trying to solve it, in this paper, we focus on tools used to assess the digital maturity of NHS trusts and organizations. Additionally, we aim to present the impact of ongoing transformation attempts on secondary services, particularly mental health. This paper considered the literature on digital maturity and performed a rapid review of currently available tools to measure digital maturity. We have performed a multivocal literature review that included white papers and web-based documents in addition to peer-reviewed literature. Further, the paper also provides a perspective of the ground reality from a mental health service provider’s point of view. Assessment tools adopted from the global market, later modified and tailor-made to suit local preferences, are currently being used. However, there is a need for a robust framework that assesses status, allows target setting, and tracks progress across diverse providers. The National Health Service (NHS) in the United Kingdom accounts for 3% of the global health market . The NHSThe NHS is also a world-renowned entity for conducting high-quality clinical research and partnering with industry and academics alike. Hence, its ability to continuously improve and promote efficiency is vital for remaining fit for purpose. Part of this aspect is the need to harness the power of advancements made in health care technologies. This requires continuous improvements in the technological literacy of both health care professionals and patients.Independently and locally, a few NHS trusts have implemented advanced IT solutions. The NHS is among the leading users of IT in health care in the world. The United Kingdom was ranked third in the world in the science and technology division of the World Index of Health Innovation ranking of 2021 [While there are challenges across global health care systems to adopt technologies due to various factors such as resources, infrastructure, and costs, the mental health care organizations, in particular, have seen these to be the furthest behind in comparison to acute care ,4. EvideDigital maturity is an important facet to consider at this point given it measures an organization’s ability to develop value-based models through digitizing key tasks to better manage, predict, and sustain transformation from a clinical service and business provision perspective. Digital maturity is an indicator of the capability and compatibility of the IT systems to interface and interact both within and across organizations. However, it is vital to use a standard digital maturity assessment (DMA) across NHS foundation trusts, district general hospitals, and community hospitals to understand the current IT infrastructure versus the requirements for the population they serve and budgetary allocations provided. The digital maturity of organizations are evaluated using frameworks like DMAs. In the next section, we present some of the widely used DMA tools.One of the most widely used assessment tools to evaluate the digital maturity of health care providers is the Electronic Medical Record Adoption Model (EMRAM) . EMRAM iIn Europe, around 2500 hospitals have undergone the EMRAM assessment, with HIMSS stating that there is much opportunity for advancement and maturity. The latest reports from EMRAM Analytics  show 3 NThere are limitations , nonetheIn another example, the origins of patients seeking mental services are in primary care, and they are referred to secondary care mental health providers only when their condition worsens. This can be avoided if digital services are used to remove the disconnect between the two service providers. Efficient care pathways ensure that patients get a timely diagnosis, and health care workers can efficiently share the care to guarantee safe and effective treatment. In the case of cancer care pathways, for instance, there is a waiting target time set for the diagnosis and start of treatment in the United Kingdom. A patient should not wait more than 28 days from referral to diagnosis, and there should not be more than 62 days of wait between an urgent referral and the start of treatment. In the case of obstetrics, the NHS assesses the quality of care provided during antenatal and postnatal phases by relying on surveys of women’s experience of care. Survey results of 2019 report that most women had a positive experience of maternity care with possible improvements in the continuity of carer, postnatal care, and perinatal mental health area. EMRAM fails to capture this aspect of care pathways across health care sectors.To measure progress toward digital transformation, HIMSS has a broader framework called the digital health indicator (DHI). The DHI assessment is layered across 4 components, namely, governance and workforce, interoperability, analytics and traceability, and digital capacity leading to consumer-enabled health. Though HIMSS offers a host of other assessment tools like the INFRAM, CISOM, CCMM, etc, through the DHI framework, their penetration into the global market is lower.NHS England has combined components of EMRAM with aspects that assess infrastructure, interoperability, readiness, etc, to come up with its version of a Digital Maturity Index . The DMAReadiness: 30 questions focused on strategy alignment, leadership, resourcing, governance, and information governance to evaluate the ability to plan and deploy digital servicesCapability: 134 questions focusing on the extent to which technology is currently being used to deliver care, including questions that cover records, assessments and plans, orders and results, management, transfers of care, medicines optimization, decision support, remote and assistive care, business and clinical intelligence, standards, asset and resource optimization, etcInfrastructure: 15 questions to assess the quality of underlying IT systems, focusing on aspects like the availability of Wi-Fi networks, hardware performance, provisions for business continuity/disaster recovery, etcAn NHS trust can rate itself for each question as low (<40%), medium (40%-69%), or high (≥70%). The assessment questionnaire developed in 2016 was last revised in 2017 by tailoring the questions to suit acute, mental health, community, and ambulance organizations. There is a separate self-assessment questionnaire by NHSE&I for general practitioners (GPs). The Local Government Association relies on an assessment tool similar to that of NHSE&I to gauge the digital maturity of local authorities that carry out social care responsibilities.In 2017, self-assessment reports of digital maturity from trusts across the NHS revealed grim statistics. Only 54% of trusts reported that their staff could rely on digital records, while 16% of trusts’ IT systems were Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) compliant, which is an international standard for clinical terminology, and 16% of trusts reported themselves to be low in their capability to use digital technology to deliver care. It is to be noted that self-assessed scores reported by the trusts are not all validated by NHSE&I. Only a sample number of trusts that marked themselves “high” were validated by NHSE&I. Since the current assessment model is self-based and not peer-based, there is also the possibility of trusts and organizations gaming the system by understanding the consequences of their self-reported assessment scores to, for example, get more funding. For instance, in the 2017 report, while 77% of the trusts completely agreed that they participated in initiatives across the health and care community to achieve digital record sharing, only 48% completely agreed that digital technology was used to support improved collaboration and coordination across different parts within their organization. Owing to the limitations and lack of agility of the current maturity assessment models, members of the Global Digital Exemplar program’s independent evaluation team proposed an alternative framework that measures digital maturity considering the existing institutional and technological infrastructure and is tailored to the needs of the local population .Infrastructure and processes aside, the success of a transformation drive depends on the willingness and capability of end users to adopt and adapt to the change. The UK population, both young and old, is largely technologically literate although the disparity between those who have access to the internet varies. To understand the areas of learning needed so that effective and efficient training can be provided, HEE is working on a digital literacy self-assessment tool  through There are multiple programs launched by the NHS to promote the adoption of innovation and technology. The Innovation and Technology Payment program helps remove financial and procurement barriers to introducing new technology. Rapid Uptake Products promotes stronger adoption of innovative products with lower-than-expected uptake to date. Through its Digital Academy, the NHS hopes to generate excellent leaders and drivers of digital transformation. Code4Health  is a proOn the other hand, with more dependence on technology, there needs to be a robust IT support system, as any form of technology failure can seriously disrupt patient care. Currently, with 4% to 5% of the NHS workforce holding roles in informatics, there is a shortage of digital and data skills. The profession of informatics is not widely recognized within NHS , while tThe EHR or EMR systems used by trusts across the country need to have a common standard to ensure compatible sharing of data and information as and when needed. Without interoperability, sharing of data across systems becomes challenging. Currently, there are three options  that theApart from being used for the direct care of the patients, the data collected in EHRs are also used for medical research and other secondary purposes like service evaluation and planning. However, the public has the right to opt out of their data being used for secondary purposes. Currently, only 3% of patients chose to opt out. The larger the volume of data, the better it is for secondary purposes. So, it is important to keep the data secure against possible cyberattacks and maintain public trust.The general medical service contracts fund the core IT systems of all GPs. This central system gives far greater control to the policy makers in GP systems than in hospital systems. However, studies  report tIn recent years, integrated care systems have been developed through partnerships between primary and secondary care organizations with a view to combine the management of physical and mental health, improve population health, and minimize health care inequalities. A key system for this purpose is the patient record system. There are various providers although Cerner Millennium appears to be a common system that is Java and cloud based. This system supports the maintenance of long-term health care records in a secure manner. However, there are acute care–specific systems based on clinical specialty needs such as the Picture Archiving Communication System (PACS) that provides reports and images of radiological examinations. These are stored and reported digitally in a secure manner. Some NHS organizations also use cloud-based systems to support PACS.The digital maturity of the NHS has improved with the establishment of various programs as demonstrated by the independent report published by the National Audit Office in May 2020 . With inIncreasingly, the health support systems are concerned about introducing themselves to the technology. The NHS, for instance, has worked to implement the technology in all areas of health care. To improve the intercommunication between systems, the NHS has implemented a digital maturity. In addition, DMAs can offer a pragmatic method to establish a “roadmap” or inform a path, and this enables organizations to understand and engage their staff meaningfully to challenge existing workflows with digital technology . HoweverHealth and social care operate as separate independent systems managed in silos though they are required to work hand in hand to deal with multiple, long, and complex care requirements of patients. This separation has complicated coordinating care due to difficulties with data sharing . DespiteThe various components that together make up the health and care system in the United Kingdom are vastly diverse and complex. After the failed attempt by an overly centralized approach to digitize secondary care at a national level and repeated delays in reaching “paperless” status, policy makers are now working on the more realistic albeit challenging task of achieving “a core level of digitization” by 2024/2025. Programs and policies are touching upon various pieces of the puzzle that can come together to help achieve the target objective. People, process, and technology infrastructure are the three pillars that need equal focus and attention to achieve success in an initiative like digital transformation. All three factors are receiving their due attention in the renewed plan, which is promising. As with any problem-solving exercise, the first step is to get a thorough understanding of the problem itself. DMA tools are used for this purpose. Direct adoption of a prominent tool used internationally has its limitation, as it does not cater to the local nuances and idiosyncrasies. Building on top of such a tool that is considered a reliable benchmark, the NHS is currently relying on its tailor-made version. In our opinion, the current assessment framework is limited in its scope, and it is vital to have a robust framework that assesses the status and continually tracks the progress of all participating trusts and organizations to boost the overall digital maturity of the NHS.


Objective To detect depression during pregnancy and in the immediate postpartum period using the Edinburgh postpartum depression scale (EPDS).Methods Cross sectional study of 315 women, aged between 14 and 44 years, who received perinatal care at the Leonor Mendes de Barros Hospital, in São Paulo, between July 1st, 2019 and October 30th, 2020. The cutoff point suggesting depression was ≥ 12.Results The screening indicated 62 (19.7%) patients experiencing depression. Low family income, multiparity, fewer prenatal appointments, antecedents of emotional disorders, dissatisfaction with the pregnancy, poor relationship with the partner, and psychological aggression were all risk factors associated with depression in pregnancy or in the immediate postpartum period. Antecedents of depression and psychology aggression during pregnancy were significant variables for predicting perinatal depression in the multivariate analysis.Conclusion There is a significant association between the occurrence of perinatal depression and the aforementioned psychosocial factors. Screening patients with the EPDS during perinatal and postpartum care could facilitate establishing a line of care to improve the wellbeing of mother and infant. The pregnancy-puerperal cycle, either due to psychosocial factors or hormonal changes, is a time of high risk for the development of depression.According to Martins,rdtrimester of pregnancy.Perinatal psychiatric disorders usually occur within the first months postpartum, but can happen earlier,Perinatal depression is multifactorial, involving psychosocial and sociodemographic variables, physiological and biological factors, hereditary predispositions, and hormonal changes. It relates to the body, mind, and lifestyle of the puerperal woman, and is deemed difficult to prevent, as no single strategy has so far been capable of preventing the disorder effectively.As suggested by Salum e Morais et al.,We highlight, thus, the importance of the health professional for the early awareness of the aforementioned factors in the effort to prevent depressive disorders and their consequences in the perinatal period. Difficulties, however, such as lack of time, the stigma related to mental illnesses during pregnancy and in the postpartum, and insufficient or inadequate training in graduate school hinder the early detection by obstetricians.Developed by Cox et al.The authors evaluated its psychometric properties in the United Kingdom, obtaining a sensitivity of 86% and a specificity of 78%. Different scores (between 9–13 points) were compared in the EPDS, with a good correlation.The cross sectional study included 315 women, aged between 14 and 44 years, who received perinatal care at the Maternity Hospital Leonor Mendes de Barros (HMLMB), in São Paulo, between July 1, 2019 and October 30, 2020. The interview was conducted with 136 pregnant women with more than 28 weeks of gestation, and 176 postpartum women within the first postpartum week. The research protocol was approved by the local research ethics committee before the study began, and all of the women provided written informed consent prior to participating in the interview. After signing the consent form, the patient was enrolled in the study and replied to the interview conducted by one of the authors of study (T. A. O./G. G. C. M. L.). In the interview, the women first answered a questionnaire to identify the major risk factors associated with depression. Afterward, the patient herself filled out the EPDS. The scale was completed in ∼ 5 minutes. The interviewers had been trained in the use of the EPDS, and any doubts that eventually came up were jointly discussed. All such interviews took place in ambulatory or maternity ward settings. The interviewer remained blind to the score or the answers because after EPDS to be completed by the mother then it was placed together with the questionnaire in an envelope.p-value < 0.1 in the bivariate analysis were entered into a multivariate logistic regression model to calculate the adjusted Odds Ratio and to eliminate the effects of confounding. Analyses by means of logistic regression were performed using the BioStat version 5.3 software.The statistical significance level was set top < 0.05 for all analyses.The cutoff was ≥ 12 to indicate whether the patient had depression. The exclusion criteria were: absence of prenatal care, women pregnant with fetuses with congenital malformations and/or diseases incompatible with life, assisted fertilization, stillbirth, and neo-mortality. The collected data was assessed on Microsoft Office Excel 10 spreadsheets , the Epi Info 7 program was used to analyze the frequency distribution of categorical variables, and the Mann-Whitney test was used to analyze the continuous variables. The independent variables were categorized to analyze the association between each independent and outcome variable using a bivariate analysis to calculate the crude odds ratio with 95% confidence interval. Those variables that were associated with aAmong 315 patients, 62 (19.7%) patients scored ≥ 12 in the EPDS screening, experiencing probable perinatal depression. The demographic characteristics of the patients are shown inAs seen inThe behavioral aspects of the couple during the third trimester and the first postpartum week were analyzed inStandard multiple regressions were performed to differentiate the independent effects of predictor variables on the occurrence of perinatal depression . AnteceThe lower income in group 1 demonstrates the lack of social support for the exercise of motherhood, as concerns, doubts, and domestic conflicts can be triggered due to the lack of economic resources to support the newborn or even the family, also considering that multiparous women are associated with an increased risk of depression. Our study shows that psychosocial risk factors are strongly related with the onset of depression in the sample group, whether due to dissatisfaction with the pregnancy or poor relationship with the partner, even when the experience of childbirth was positive.The study did not relate physical or hormonal factors as some authors have done,Gauthreaux et al.The occurrence of perinatal depression may lead to the discontinuation of breastfeeding, family conflicts, and the neglect of the infant's physical and psychological needs. By compromising the ability to create healthy and stable bonds, the disorder can negatively influence the relationship between mother and child, in addition to cause damage to the psychomotor and language development and, as a result, lead to relevant cognitive and social impairments.This study emphasizes the importance of identifying risk factors based on an individual's subjective experience. The scales for diagnosing depression are tools that facilitate tracking and diagnosing the disorder during prenatal care and the immediate puerperium. The use of validated scales can contribute to the production of new evidence concerning the correlation of risk factors and protective measures during pregnancy. Evidence is necessary to support health professionals in the preventive implementation of an adequate approach to coping with the problem.Antecedents of depression, physical and emotional stress, either caused by socioeconomic factors such as income or by the lack of support from the partner, are risk factors for perinatal depression. The creation of prenatal programs based on a psychological approach, as stated by some authors,This study suggests that all pregnant women should undergo screening in the third trimester of pregnancy or the postpartum period. The EPDS is a simple and useful instrument for screening, as it presents an easy method for diagnosis. To treat the vulnerable group, alongside screenings, professional references and therapeutic resources are also needed.In conclusion, there is a significant association between the occurrence of depression and certain psychosocial factors, notably antecedents of depression and psychological abuse, which were predictive factors in a multivariate analysis. To face this challenge, prenatal care must provide a comprehensive psychological approach to identify and treat the disorder. Offering an appropriate line of care to the vulnerable group will contribute to the improvement of the wellbeing of the mother and the future of the infant.


The vestibular system is responsible for motion perception and balance preservation in the body. The vestibular function examination is useful for determining the cause of associated symptoms, diagnosis, and therapy of the patients. The associated cerebral cortex processes and integrates information and is the ultimate perceptual site for vestibular-related symptoms. In recent clinical examinations, less consideration has been given to the cortex associated with the vestibular system. As a result, it is crucial to increase focus on the expression of the cortical level while evaluating vestibular function. From the viewpoint of neuroelectrophysiology, electroencephalograms (EEG) can enhance the assessments of vestibular function at the cortex level.This study recorded nystagmus and EEG data throughout the caloric test. Four phases were considered according to the vestibular activation status: before activation, activation, fixation suppression, and recovery. In different phases, the distribution and changes of the relative power of the EEG rhythms  were analyzed, and the correlation between EEG characteristics and nystagmus was also investigated.The results showed that, when the vestibule was activated, the alpha power of the occipital region increased, and the beta power of the central and top regions and the occipital region on the left decreased. The changes in the alpha and beta rhythms significantly correlate with nystagmus values in left warm stimulation.Our findings offer a fresh perspective on cortical electrophysiology for the assessment of vestibular function by demonstrating that the relative power change in EEG rhythms can be used to assess vestibular function. The vestibular system is vital in perceiving spatial position and maintaining balance , 2. DamaElectroencephalogram (EEG) and sensory-evoked potentials contain abundant physiological and pathological information, which can reflect the excited or inhibited state of the cortex . MoreoveExisting EEG studies on the vestibular system are mainly aimed at patients with a specific vestibular-related disease or symptoms to explore changes in EEG characteristics. For example, in patients with chronic balance disturbance, alpha rhythm activity in the posterior cingulate cortex rose significantly, while beta activity in several brain regions decreased . The sevThe following two categories of relevant studies are currently available: resting state and evoked state. The EEG microstates in this study were classified into four categories  as in most resting state studies, and the results showed that patients with recurrent otogenic vertigo have a longer duration of the A state and an increased probability of transitioning from A state to D state compared to healthy people . The privia significant changes between phases (p < 0.05) dominated by the occipital region, and the beta power was reduced in channels selected by the same criteria mainly in the central, top, and occipital regions on the left. It is interesting to note that both changes significantly correlate with nystagmus values in the left warm condition.In this study, we aimed to explore the characteristics of EEG rhythms in different vestibular activation states in the caloric test and to find the characteristics of EEG rhythms for assessing vestibular function. We examined relative power distribution and changes in each EEG rhythm under various vestibular activation states and searched for a relationship between these changes and the caloric test findings. It was found that the alpha power was enhanced during vestibular activation in channels selected A total of 18 healthy subjects  were included in this study. All participants complied with the following requirements: no history of seizures, cardiovascular disease, hypertension, severe head and neck illnesses, ingestion of alcohol within the previous 48 h, ingestion of central excitatory or inhibitory drugs, damage to the external auditory canal or tympanic membrane, or otitis media. The study was approved by the medical ethics review committee at Tianjin University. All subjects gave written informed consent and received payment for participation.As illustrated in During the caloric test, EEG and nystagmus data were concurrently captured.Before conducting the experiment, calibration was performed. The purpose of calibration is to measure the relationship between the eye movement of a certain angle of view and the corresponding recorded signal , which is used to calculate parameters such as amplitude and speed of the eye movement. Then, using video nystagmus (VNG), the maximum slow-phase velocity of spontaneous and caloric test-induced nystagmus from both experiments was captured.Saline electrode caps  were used to record EEG data throughout the caloric test, amplified by a Net Amps 400 amplifier. The distribution of electrodes was based on the international 10–20 system, and the impedance was guaranteed to be less than 50 kΩ during the experiment. The volunteers were reminded before the experiment to refrain from unnecessary head and body movements while collecting data to prevent significant data contamination. EEG data for PBA was defined as the data from 50 s before stimulation, for POVA as the data from 20 s centered on the time point of the strongest nystagmus, for POFS as the data from 10 s following the turn-on of the fixation lamp, and for POR as the data from 10 s following the turn-off of the fixation lamp.Raw EEG data were preprocessed using EEGLAB, an open-source toolbox of Matlab (R2021a). To lessen the impact of high-frequency noise and low-frequency interference on the data, 30 Hz low-pass filters and 0.5 Hz high-pass filters were first used. We averaged the reference value of data across all electrodes. The spherical approach was used to interpolate the data of electrodes that were detached from the skin during the experiment. To improve the computational efficiency of subsequent processing and analysis, data were down sampled to 200 Hz. Independent component analysis was performed to eliminate artifacts like a heartbeat, muscle tension, and eye movement.The Welch method was employed to determine the power spectral density of data. The energy of each EEG signal was normalized to reduce the potential difference among subjects. The relative power of EEG rhythms delta (0.5–4 Hz), theta (4–8 Hz), alpha (8–14 Hz), and beta (14–30 Hz) was calculated for each phase. The topographic maps of each phase were created using the relative power findings of all channels to explore the distribution of certain EEG rhythms. Variations in the global brain distribution of each EEG rhythm were observed and examined between phases.p < 0.05) were selected as the region of interest, and the changing trend of the region of interest was calculated. Additionally, the Pearson correlation test was utilized to determine the discrepancy between the relative power change of the particular EEG rhythm and the result for nystagmus.The statistical analysis was carried out using SPSS (26.0). The Wilcoxon signed-rank test was used to examine the relative power findings for each channel for each EEG rhythm across phases shown in The whole-brain delta rhythm was observed to have a relative power distribution that was strongest in the forehead in PBA, slightly enhanced in the forehead in POVA, the whole brain enhanced in POFS, and then returned to its previous state between PBA and POVA in POR, leaning more toward POVA. The center frontal region was comparatively strong in PBA, while the forehead and occipital regions were slightly weaker in POVA, according to the observation of the relative power distribution of the whole-brain theta rhythm. The central frontal and occipital regions were considerably enhanced during POFS; even after enhancement, the central frontal region remained the strongest. While the distribution in POR was comparable to that in POVA, the frontal center was weaker. According to an analysis of relative power distribution in the whole-brain alpha rhythm, the energy of the occipital region was more pronounced in PBA and increased in POVA. In POFS, the entire brain was repressed. The relative alpha power in the occipital region in POR was high, and its intensity was midway between PBA and POVA. The relative power of beta rhythm in the temporal region was relatively strong in PBA and suppressed in POVA. The relative beta power in the frontotemporal and occipital regions was enhanced in POFS, and the enhancement of these regions was weakened in POR (as shown in P < 0.05) were chosen when theta, alpha, and beta rhythms were evaluated in each phase, as illustrated in Channels with significant differences P < 0.0 were choThe nystagmus value is an index to evaluate the response to vestibular stimulation in the clinic. The nystagmus results were collected synchronously during the EEG recording in the experiment, as listed in p = 0.025), and the reduction of beta power in the region of interest was also significantly correlated with the nystagmus value .In the four conditions, a significant correlation between the relative power of EEG rhythms and nystagmus values was observed in the LW condition for both alpha and beta rhythms, as shown in This study aimed to examine how the brain reacts to vestibular stimulation and evaluate vestibular function from a cortical electrophysiological standpoint. A caloric test was used to provide direct vestibular stimulation, and brain responses were compared among the following four phases: PBA, POVA, POFS, and POR. The results revealed that the changes in EEG cortex expression under different vestibular activation conditions were significantly different. Notably, in the case of LW stimulation, the enhancement of alpha power and the decrease in beta power in specific brain regions were related to nystagmus values. Therefore, the study offers a novel perspective for assessing vestibular function using characteristic EEG rhythms.via the tympanic membrane, the tympanic chamber, and the bone wall. In the outer semicircular canal, the specific gravity of the endolymph fluid changes due to thermal expansion and contraction, resulting in the convection phenomenon of “warm rises and cool drops” of the endolymph fluid (The semicircular canals in the peripheral vestibular receptors sense rotational angular acceleration stimulation. Caloric stimulation is an examination that uses caloric vestibular stimulation to stimulate the horizontal semicircular canals to induce and observe vestibular responses . When thph fluid . NystagmRegular changes in beta rhythm activity were found in the caloric test, in accordance with the observation made in a study by Brkić about EEG abnormalities in patients with central vertigo utilizing vestibular caloric stimulation. Compared to the control group, more patients showed changes in beta activity during warm stimulation . ConsistWe discovered that the relative power of the beta rhythm significantly decreased during the vestibular stimulation response phase. Many classical observations have linked this rhythm to motor function . Beta-rhThe regulation of changes in beta power found in this study corresponds to the activation and inhibition phases in the caloric test. We suggest that beta rhythm is closely related to the state of vestibular activation, and the degree of beta power suppression, especially in LW stimulation, correlates with the intensity of nystagmus. Therefore, it is reasonable to conclude that the relative power of beta rhythm caused by caloric vestibular stimulation reflects the vestibular function condition.In a PET study, the unilateral caloric test was used to provide vestibular stimulation to healthy subjects, and it was found that the cortical activation pattern of healthy people during vestibular stimulation was identical to that in patients with vestibular neuritis –40. AccoAccording to some studies, in the closed-eye state, or when the individuals kept their eyes open and were alert in the dark field, alpha power was higher than that in the open field –46. We uSome previous studies have attempted to classify patients and healthy individuals based on resting-state EEG characteristics  or auditVideo nystagmus is widely used in the clinical examination of vestibular dysfunction, but some patients, especially elderly patients, have difficulty keeping their eyes open required by the nystagmus test during the caloric test, resulting in inaccurate results. The EEG responses to vestibular stimulation are not limited by this, increasing its clinical utility. We conclude that EEG characteristics can be used as complementary indicators to evaluate vestibular function in clinical applications in the future.To overcome the lack of specific biomarkers at the cortex level in the current vestibular function assessment, we combined EEG technology and the caloric test to compare the characteristics of EEG rhythms in different phases of the caloric test. We investigated the correlation between changes in EEG rhythm and nystagmus indicators. The results indicate that the inhibition of beta power in the central top and left occipital regions and the enhancement of alpha power in the occipital region in the EEG rhythm can be taken as the cortical electrophysiological characteristics of the response to caloric vestibular stimulation. The changes in the relative power of alpha and beta rhythms in designated brain regions are significantly related to the intensity of nystagmus induced by caloric vestibular stimulation, which verifies the effectiveness of the selected EEG characteristics to be used for assessing vestibular function.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Review Committee of Tianjin University. The patients/participants provided their written informed consent to participate in this study.GN, YB, TC, and WW contributed to the conception and design of the work. YH and QL collected data. YH and YZ analyzed data. GN, YB, and YH drafted and revised the manuscript. All authors contributed to the article and approved the submitted version.


The social network of the core members of elderly care service social organizations could affect the performance of the organization, while studies concerning its related factors are limited. We aimed to explore factors that are associated with the social network of core members from elderly care service social organizations and provide references and suggestions for improving elderly care services.This cross-sectional study employed a multi-stage stratified sampling method, and collected data concerning social network, demographic information and occupation. Univariate analysis and binary logistic regression were used to analyze factors that could affect the social network of the core members.Our results demonstrated that there is low social network of core members of elderly care social organizations. Out of the total membership, men , those with senior high school education , those with a college degree and above  and those that receive awards related to elderly care services  were associated with higher social network scores.Our data successfully characterized the social status of core members of elderly care organizations. Therefore, health care professionals and policy makers in social organizations should use this knowledge in the care and service provision to the elderly; and implement actions that would promote networking in social organizations.The online version contains supplementary material available at 10.1186/s12913-022-08545-7. Rapidly growing aging population has posed major challenges in the world . It is eOther studies have shown that cross-sector collaboration, which refers to the cooperation of government, social organization, and other institutions , could iThis study was conducted in November and December 2019, in Anhui Province, China, and was approved by the Biomedical Ethics Committee of Anhui Medical University (No. 20180181).We employed a multi-stage stratified sampling method to collect samples used in this study. According to the 2016 statistics of Anhui Statistics Bureau and related literature research, the economic level of Anhui Province is high in the middle, medium in the south, and low in the north , 18. In The investigators were trained and experienced graduate students from Anhui Medical University, and the investigation was coordinated by the civil affairs departments of each district. The investigators were divided into 4 teams, headed by workers from the civil affairs department, and conducted a face-to-face interview questionnaire survey on the subjects. Prior to the survey on the subjects, the investigators explained the contents of the questionnaire, assured the confidentiality of the subject's personal information and privacy, as well as obtained informed consent. In this study, a total of 315 core members of social organizations in the elderly care services participated in the questionnaire survey, seven core members were excluded due to missing values. Finally, 308 of 315 (97.8%) core members were included in the data analysis.Based on the World Bank’s Social Capital Assessment Tool coupled with previous studies –23, we dInformation on the demographic variables of the core members included gender , age , nationality , education  as well as marital status . We also collected occupational information such as professional title , full-time staff , organization's length of service , length of service in the elderly care field , obtained practice certificate , obtained professional qualification certificate , received training related to elderly care services , reported by the media for elderly care services  as well as whether received awards related to elderly care services .We first tested the normality of the scores of the social network. We used the median (interquartile range) to present the data since it was non-normal. We then took the social network scores as a dependent variable, while demographic characteristics and occupational information were taken as independent variables, and were used to perform univariate analysis of the potential influencing factors of core members’ social network. Non-parametric test was used to examine the differences in social network scores of the core members in different groups, and the variables were expressed in the form of numbers and percentages. Mann–Whitney test was used for the examination of variables with only two groups, while variables with three or more groups were evaluated using the Kruskal–Wallis test.We used individual social network scores as dependent variables , and then statistically significant variables in the non-parametric test were included in the binary logistic regression model and used for analysis. The analysis adjusted for the potential covariates such as gender, education, organization's length of service, reported by the media for elderly care services, and received awards related to elderly care services. Results of the binary regression logistic analysis were expressed in adjusted odds ratio (AOR), with an associated 95% confidence interval (95% CI).P-value < 0.05 was taken as statistically significant.All the statistical analyses were performed in IBM SPSS Statistics 23.0 software, and a We characterized the social demographics of core members and performed the univariate analysis of the social network as shown in Table On the other hand, results of social network scores of core members of the elderly care service social organizations showed that the lowest score was 7 points, while the highest score was 35 points, and the median score was 14 points. The univariate analysis results showed that among all the variables, gender, education level, organization's length of service, being reported by the media for elderly care services, and awards related to elderly care services had a significant impact on the social networks.P = 0.808). Besides, social network scores were related to gender, education level, and whether one received awards related to elderly care services. Compared with the reference groups, men , people with senior high school education , people with a college degree and above , as well as those who received awards related to elderly care services  were associated with higher social network scores.Data from the binary logistic regression analysis of the relationship between social network scores and the basic personal situation of core members were as shown in Table This study first examined the factors related to the social network of core members of elderly care service social organizations. Our analyses revealed that gender, level of education, and awards related to elderly care services were associated with social network scores. Our data demonstrated that the median social network score of the 308 core members of social organizations in the elderly care service was 14 points, showing an urgent need for improvement of the social network level of the core members of social organizations in the field of elderly care services. Previous studies showed that core staff with richer social networks could frequently benefit from social network and had easier access to external resources and information, thus the social network could affect individual performance in organizations , 25. BesBesides, the binary logistic regression analysis results showed that gender was one of the factors that affected the core members of social organizations in elderly care services, showing that the scale of men's social network was larger compared to that of women. This was partly consistent with a previous study , and wasIn addition, our results revealed that core members in social organizations who had higher education or with a college degree or above were more likely to have a better social network. This was in sync with a previous study, which showed that educational level was related to social network, and those with high education levels had a higher social network . Thus, wReceiving awards related to elderly care services was also one of the factors associated with social network of core members of social organizations in the elderly care service organizations, and core members who had received awards had a higher social network. Receiving awards is a recognition of personal and professional ability, and could help core members gain a better reputation and popularity. There is a strong correlation between reputation and social network . A good In general, respondents who had received training related to elderly care services would have a richer social network. Our study showed that employees could acquire more knowledge through management training. Previously, it had been reported that the more the employees acquire knowledge, the faster the growth . In addiThis study quantitatively measured the social network level of core members of social organizations in the field of elderly care services in Anhui Province for the first time, providing a reference for future research on the social network of core members in the field of elderly care services. In the current situation of the elderly care environment, there are limited resources for the construction of elderly care services, and thus intangible resources such as social network in elderly care services could be helpful. Therefore, the use of social network is an innovative and feasible part of the social capital theory to study the participation of social organizations in elderly care services. According to the research results, we have the following suggestions. First, we should pay more attention to female core members in the field of elderly care services and strengthen the cultivation of their social network. Secondly, when recruiting core members of social organizations in the field of elderly care services, we should try to select highly educated personnel. Finally, the government and organizations should encourage and help the core members of social organizations in the field of elderly care services to apply for awards related to elderly care services, so as to enhance the reputation and popularity of core members and enrich their social network.Whereas our study has interesting findings, it is a cross-sectional study conducted in Anhui Province, and thus the findings are only applicable to Anhui Province. In addition, we have only preliminarily explored the social network scale and related influencing factors of the core members of social organizations in the field of elderly care services in Anhui Province, and have not conducted further research on their social network level. Besides, due to time, funding, coordination, and other factors, the sample size we collected are small. More survey areas and larger sample size are needed in future studies.This study explored the factors that influence the social network of core members of elderly care service social organizations in Anhui Province, China. We demonstrated that there is a low social network among the core members of social organizations in the elderly care services in Anhui Province. Furthermore, we showed that gender, education level, and award-winning status are some of the factors that influence the social network of core members. This study provides references and suggestions for strengthening the construction of elderly care services.Additional file 1. Questionnaire for core members of social organizations in the field of elderly care services.


Innovative digital twins (DTs) that allow engineers to visualise, share information, and monitor the condition during operation is necessary to optimise railway construction and maintenance. Building Information Modelling (BIM) is an approach for creating and managing an inventive 3D model simulating digital information that is useful to project management, monitoring and operation of a specific asset during the whole life cycle assessment (LCA). BIM application can help to provide an efficient cost management and time schedule and reduce the project delivery time throughout the whole life cycle of the project. In this study, an innovative DT has been developed using BIM integration through a life cycle analysis. Minnamurra Railway Bridge (MRB), Australia, has been chosen as a real-world use case to demonstrate the extended application of BIM  to enhance the operation, maintenance and asset management to improve the sustainability and resilience of the railway bridge. Moreover, the DT has been exploited to determine GHG emissions and cost consumption through the integration of BIM. This study demonstrates the feasibility of DT technology for railway maintenance and resilience optimisation. It also generates a virtual collaboration for co-simulations and co-creation of values across stakeholders participating in construction, operation and maintenance, and enhancing a reduction in costs and GHG emission. At present, passengers choose the railway transport system as it is safe, reliable and fast ,2,3. CurToday, LCA is a widely used technique to assess the environmental impact across the life cycle of a product, process or service. When considering an infrastructure’s LCA, it is essential to measure the carbon footprint and consider other environmental effects . In pracA critical literature review has been conducted to assess the MRB infrastructure using the digital twin to enhance the sustainability of the construction, and to avoid possible accidents that can occur during operational phases. The literature review establishes the definitions of BIM and LCA, assesses the maintenance of the railway using BIM and proceeds to identifying the problem statement. BIM is an approach for creating and managing an inventive 3D model simulating digital information that is useful for project management, monitoring and operation of a specific asset during the whole LCA . BIM is BIM integration spans the entire life cycle of a project. According to Doumbouya et al. 2016), the life cycle stages of a construction project consist of design, production, construction, maintenance and operation. LCA can be defined as the approach to determining a system’s environmental, economic and social impacts. Some previous studies have used LCA on construction, bridges and on structure elements, but its applications are limited in rail projects , the lif, used thThe railway industry is currently facing the challenge of preventing unpredictable and catastrophic failures, leading to hazardous accidents across the entire network . Therefore, risk management and maintenance play an essential role in the prevention of accidents such as derailment, degradation and track movement due to the environmental conditions. In common construction projects, the material cost can contribute up to 50% to 60% of the overall cost of the project, and will affect 80% of the project schedule depending on the management method . MoreoveTo design an effective railway maintenance schedule, all possible scenarios should be considered. Kaewunruen et al.  showed tThe importance of maintenance is to provide efficiency and productivity of a system by retaining and restoring functions of the technical system throughout the life cycle of the railway infrastructure. Inaccurately performed maintenance activities will lead to deterioration of the track, which will cause significant incidents and accidents .The resilience of a railway transport system can be defined as a comprehensive system that has the capability to produce effective service in normal conditions, as well as to resist and recover quickly from disruptions and disasters . The rapTo manage maintenance in practice and to improve the efficiency of maintenance, a powerful simulation in BIM can be applied using the AutoCad Revit software (Suite 2022). Revit is a software for BIM which has tools for creating 3D models and can be used to generate construction documentation ,41,42. BA railway transport system is a complex system by nature, and it requires effective maintenance to produce safe, economical and sustainable transportation of goods and passengers . RailwayThe application of BIM has been widely used to support the construction of buildings, and its technology and methods have shown the potential for benefiting the transportation infrastructure industry . SeveralThis section provides an approach to the critical methods used within this study to develop digital twins for the MRB to help manage maintenance and resilience by providing a powerful railway bridge section for visualising the workflow in controlled systems. According to the literature review, the whole life cycle can be divided into various levels, showing the different main stages with the critical tasks inside. BIM of the MRB has been modelled using the AutoCad Revit v.2021 software, based on two-dimensions (x and y) or 2D (CAD) accurate drawings obtained from Transport NSW and Sinclair Knight Merz. In contrast, a three-dimensional  or 3D model has been developed using Revit software, as shown in The Minnamurra Railway Bridge is located in Kiama, New South Wales (NSW), and has been chosen as a case study, as shown in 2 emissions in the construction industry is very apparent, making it a significant concern for the engineers to have green construction [GHG emissions can be calculated using Equation (1):f is the coefficient factor of GHG emissions, I is number of activities, and GWP is the global warming coefficient. For carbon dioxide, it is 1. f). It is assumed that each track section  will have similar installation and construction techniques for the track and bridge components so that the components constitute similar raw material ingredients and emit a similar level of carbon footprint [The extent of COtruction . Moreovetruction , the GHGootprint . Note thThe frequency of track inspection is a major aspect that influences the maintainability, reliability and quality of the railway infrastructure, whereas if the regular period of maintenance inspection is taking more time, it will affect the safety of the railway system. Alternatively, if the maintenance inspection period is short, it will significantly increase costs and reduce time efficiency. Moreover, in railway systems the maintenance activities are essential to maintain the structure in a condition that allows it to be used in a safe way . These aDeveloping a 5D model facilitates the stakeholders or participants of the project to visualise the reconstruction activities and their cost over time. If any design changes occur, the 5D model can update any changes in terms of the budget or schedule. According to Bryde et al. , when usLife cycle cost can be defined as the cost incurred by a product or service in its life cycle . In thisThe material inventory is essential to the whole project, and effective management which observes the material and components’ flow is necessary. The 6D BIM model comprising the 3D Revit model of MRB, maintenance cost estimation, maintenance timeline schedule and carbon emission estimation was produced using Navisworks and Revit software.The GHG emissions of the materials have been integrated into the manufacturing process. The quantity of the main structural materials of the MRB infrastructure—which are concrete, steel and rebar—can be determined for the calculation of the GHG emissions by using the developed DTs of the MRB infrastructure. The MRB infrastructure consists of a high number of complex components and materials and adopting the traditional inventory method would compromise efficiency. The traditional inventory method in construction projects for producing a bill of quantities, is based on information extracted manually from (2D) drawings and specifications. A traditional bill of quantities is a draft document showing a material plan that outlines part of a project’s management, which typically involves estimating costs and developing a structured framework for construction projects. In addition, the current traditional approach is not smooth, and has several issues such as, the loss of information, the time-consuming preparation and issues of document integration. Nevertheless, The costs have been calculated using Equation (2) and are based on the information provided in Navisworks v.2021 is a software that has the ability to link several elements in the Revit model with specific project tasks. The 3D model of the MRB has been developed using Revit v.2021, based on 2D drawings obtained from Transport NSW and Sinclair Knight Merz. The establishment of the 3D model validates the geometry and information inside the corresponding model in order to monitor the accuracy of each detailed part. The Revit model demonstrates the detailed 3D components of a railway bridge, which will help to visualise any hidden complex components. Engineers can use the developed BIM to observe and identify the location or the component that has damages, and whether it requires further maintenance activities. Furthermore, Revit has an enormous database containing all different types of materials where the material type can be chosen and applied to each 3D component. The materials’ information has the component model, dimension, shape and quantity.The results show that steel has the highest GHG emissions as the majority of the GHG emissions are derived from the box girders. This is due to the majority of the MRB infrastructure components being constructed from steel, and the design of the steel box girder (dimension and volume) being overly large, which contributes to higher material consumption, GHG emissions and costs. A study conducted by Raeisi et al.  has deveCurrently, there is no specific BIM or DT standard that supports implementation in railway bridges or the bridges industry. The case study of the MRB showed that DTs can be fully integrated with the bridge industry to enhance risks, sustainability and resilience in asset management. The study showed that uncertainties such as environmental impacts will lead to frequent track inspection and the use of DTs can increase the maintenance efficiency when damages occur in the railway bridge components. This is because DTs can: (1) monitor the condition of the bridge such as locating damages accurately; (2) provide real-time information on the infrastructure’s condition through the detecting sensors (3) have the ability to share and visualise data among stakeholders in order to identify technical issues and prioritise maintenance options accordingly; (4) generate virtual collaboration between engineers and stakeholders; (5) identify the capacity of materials and components’ information through the 3D model for maintenance or repair activities; (6) aid engineers in determining life cycle costs and GHG emissions or to develop low cost and low carbon solutions to emerging hazards, as well as improving resilience, sustainability and maintenance of railway bridge infrastructures.In most cases, the materials used to construct the components are the most vulnerable to failure. In practice, over a significant operational life, damages occur in the ageing components and materials . ThroughSteel/Aluminum Alloy:Corrosion is a primary cause of carbon steel bridge corrosion, posing a severe danger to the safety of civil structures and infrastructure systems . CorrosiConcrete:2 into concrete, resulting in cracks within the concrete and increasing the steel corrosion rate [Carbonation of concrete occurs due to ingress of atmospheric COion rate . Carbonaion rate .Railway Bridge Repair Activities:Railway bridges are considered the most vulnerable infrastructure and inadequate maintenance, age of the infrastructure, and environmental conditions can have a serious impact on the safety of the structure . TherefoDue to the wide variety of geographical circumstances in Australia, railway networks experience a huge variation of high heat each year. Moreover, the MRB being located in the south coast of NSW, has experienced unpredictable temperatures and weather conditions such as wind, extreme heat, rainfall and snow. The weather conditions and environmental impact implications need to be considered in order to avoid any unanticipated situations that result in infrastructure damage or risk. Climate change is a significant issue to the rail network infrastructures due to the increase in average temperature . Global In practice, the construction of railway bridges is considered a complex and massive project that consists of a large number of engineers, stakeholders and organisations that can benefit from sharing and visualising the data. The traditional asset management has suffered from ineffectiveness, which has led to drastic accidents in construction, operation and maintenance phases. DTs performing as a visual and information platform for project participants through the use of Revit and Navisworks, can improve the efficiency and reduce the risks in the project process. DTs can act not only as an information platform, but they also have the ability of immediate real-time updating and enable access to several data layers throughout the whole life cycle of a project. By using DTs all project parties can collaborate, visualise and share data of the updated progress. DTs can help to improve sustainability, resilience and maintenance by enabling an effective asset management tool; they can evaluate and determine cost estimation, GHG emissions and time schedules. This paper mainly studies the ability of DTs to achieve the project sustainability of a railway bridge infrastructure through the integration of BIM and Navisworks. The Minnamurra Railway Bridge, Australia, has been chosen as a case study to demonstrate the extended application of BIM  for the LCA of railway bridges. In addition, the integration of the 3D model using Revit and Navisworks, the maintenance timeline schedules, cost estimations and GHG emissions have been obtained to develop the 6D model. The present case study has also demonstrated that the material inventory can be obtained and monitored using Revit . Moreover, the study showed that the maintenance and repair activities should be considered and that Navisworks can help to monitor the activities efficiently. It is noteworthy that climate and environmental factors have a crucial impact on track inspection activities, and the resilience of the materials and components is essential to the MRB infrastructure reliability and safety. Furthermore, improper maintenance management has accelerated the deterioration of the MRB ends, which has tended to cause more frequent maintenance operations, which is time consuming and costly. This study showed that DTs can enhance asset management, operation and maintenance to a more sustainable level for railway infrastructures. This study reveals some limitations of the DT in dealing with the durability aspects of components  where additional co-simulations will be required to gain better insights for effective maintenance management. Future work will incorporate real-time weather conditions into BIM, which can be used to assess bridge vulnerability to natural hazards.


The COVID-19 outbreak has raised several global challenges related to disease management while highlighting the need to embrace a multidimensional approach in dealing with events such as. Due to the singular features of SARS-CoV-2, an appropriate medical response was required to develop new vaccines able to tackle it effectively. Mass vaccination plans were thus promptly launched around the world. However, vaccine uptake has been coupled with growing concerns that have affected people’s willingness to get vaccinated. To promote compliance with vaccination campaigns, many governments introduced the use of vaccination certificates and immunization passports. Studies have discussed some benefits and cons coupled with the rollout of vaccine passports or certificates. This paper takes up and extends this discussion by showing the results of a mini- narrative review we undertook with the aim of critically summarizing the existing scholarly research on the Green Pass in Italy. In analyzing the 12 included records, we explored the scientific viability of this measure, as well as the concerns and criticisms it has raised and the recommendations that have been proposed to address them, as a starting point to consider how the lesson learned in the Italian context can contribute to informing future reflections and strategies in view ofanother pandemic event. The COVID-19 outbreak has raised several global challenges related to disease management while highlighting the need to embrace a multidimensional approach in dealing with events such as these, beyond the close implications of pandemics on public health and wellbeing , strainiIn an attempt to promote compliance with vaccination campaigns toward reaching herd immunity while reducing the spread of the virus, several strategies were deployed worldwide ,15. Out covid”, “vaccine”, and “green pass”. Because these search terms were broad, to the point of including several items referring to similar programs both generally and in other countries, we then refined the search range in order to identify the studies relevant to the aims of our work. Therefore, we added the word “Italy” to the above ones, and combined them with the terms “certificate”, and “passport”, as our preliminary investigation showed that descriptions of the Green Pass policy are also associated with these words. These search terms were entered into three electronic databases, PubMed, Scopus, and the Web of Science . Then, the authors independently scanned the remaining 31 items by analyzing first the title and abstract and then the full-text manuscript to assess its eligibility. Concomitantly, the reference list of this sample was inspected to identify any additional relevant papers, as appropriate. In these phases, we included all records focused on the Italian Green Pass, specifically mentioning, describing and discussing its scientific viability, emerging concerns and criticisms related to this measure , as well as feasible solutions to the challenges surrounding it. Papers that did not meet these inclusion criteria, that were not in English or Italian, focused in general on COVID-19 certificates or vaccine passports in general, or mentioned the Italian Green Pass without contributing significantly to the discussion upon the targets of this literature review, were removed. After a thorough evaluation and debate about few discrepancies on the identification of eligible articles, which were easily resolved between the authors, our final pool consisted of 12 publications see .overview of the Italian Green Pass by itsscientific viability; (2) concerns and criticisms; and (3) proposed recommendations and alternatives.Among the 12 records included in this narrative review, six papers explicitly focus on the Italian Green Pass experience, while the rest refer to this COVID-19 health measure in the context of a broader coverage on other issues somehow related to it, such as vaccine uptake and acceptance (n = 3), vaccine hesitancy (n = 1), Italian pandemic waves (n = 1), and the European Public perspective on vaccine mandates (n = 1). The results of reviewing the 12 chosen articles are presented in summary and were grouped into three main themes, which are not mutually exclusive. Consistent with our review targets, these are: (1) an Many references were made to Italy’s Green Pass approach as being an incentive-based model, showing potential in encouraging vaccine uptake, and allowing the decrease in virus circulation along with the gradual release of constraints. This topic has been approached from different perspectives in the included studies, mostly based on empirical investigations. Among the vaccination strategies, the Italian Green Pass is framed as an alternative approach to mandatory vaccination, which was adopted with the aim to promote immunization by prompting people to become vaccinated, as the recruitment trend was largely imperfect with respect to the goal of containing virus circulation at the time ,30. ThesThe introduction of the Green Pass in Italy was also coupled with protests and concerns by a segment of the population which refer to a variety of issues, such as privacy, discrimination based on one’s vaccination status, limitations on personal freedoms, expansion in the powers of control by the government, etc. Among the articles included in the final pool, three are focused on analyzing the nature and arguments underlying such opposition ,36,37, fIn this regard, most of the criticism of the Green Pass revolving around its being a discriminatory measure would have no scientific grounds . In ordeA range of recommendations and proposals about how to deal with the issues raised by and related to the introduction of the Green Pass in Italy has been considered in ten of the selected studies ,35,36,37This article has provided an overview of the literature about the Italian experience of the Green Pass, showing how this measure was mostly positively perceived as a public health instrument that could make an effective contribution to addressing specific challenges, namely that of incentivizing the population to become vaccinated to reduce virus outbreaks and gradually returning to the normalcy of daily life. Several studies have supported with empirical data the assumption of the scientific viability of the Italian Green Pass ,32,34,35The analyses featured in this study can be also considered a seminal reflection for future issues that need further deepening, such as increasing people’s confidence in public health management, improving the relationship between policymakers and scientific and technical bodies, and increasing transparency over the use of medical data collected within the population. Previous studies have pointed out that building and maintaining trust in public health institutions, their messages and the science upon which their communication is based, is essential for improving access to, use and outcomes of public health programs ,46. For This review was limited by the small number of articles that specifically addressed the Green Pass experience in Italy. Given the growing interest and debate raised by this policy even under future pandemic emergencies, we believe that more research will be needed on this topic and the issues highlighted by this study. Despite this limitation, we believe that our sample captured the targets under investigation and also highlighted the difficulties of extensively covering such a broad topic in a review. We decided to focus our literature search on the COVID-19 certificate in Italy as, to the best of our knowledge, studies overviewing the subject were lacking. However, this focus led us to disregard the consideration of discussing any relevant similar programs in other countries with potential advantages which may be translatable to the Green Pass in Italy. We thus believe that the results of our review could inform future exploration aimed at better understanding the specificity of the strengths, challenges, and recommendations associated with the Italian Green Pass when compared with similar experiences. Finally, Mesh Terms are not used in the search strategy, not considering, for example, possible iterations with COVID-19 mentioned in the literature. This may potentially have excluded some items addressing the targets of our study. Without ensuring the comprehensiveness of this review, however preliminary research leads us to an early summative overview of the complex experience of the Italian Green Pass.Our study highlighted how the adoption of the Green Pass in Italy has contributed to coping with the COVID-19 health emergency, along with showing that this program was mostly perceived as a useful tool in pandemic management. However, the present review also identified some of its clear limitations, rooted mainly in the restrictions imposed on individuals who had not been vaccinated or recovered from COVID-19. In this context, several recommendations were suggested as an opportunity to generally rethink the role of scientific, political and health authorities and educational programs in our society, especially when it comes to affecting choices that impact health behaviors at the individual and collective level.


The purpose of this study is to collect available evidence on the feasibility and efficacy of stereotactic arrhythmia radio ablation (STAR), including both photon radiotherapy (XRT) and particle beam therapy (PBT), in the treatment of atrial fibrillation (AF), and to provide cardiologists and radiation oncologists with a practical overview on this topic.Three hundred and thirty-five articles were identified up to November 2021 according to preferred reporting items for systematic reviews and meta-analyses criteria; preclinical and clinical studies were included without data restrictions or language limitations. Selected works were analyzed for comparing target selection, treatment plan details, and the accelerator employed, addressing workup modalities, acute and long-term side-effects, and efficacy, defined either by the presence of scar or by the absence of AF recurrence.in silico and 8 in vivo; doses ranging from 15 to 40 Gy) comprised a total of 59 animals, 12  focused on humans, with 9 patients undergoing STAR: average follow-up duration was 5 and 6 months, respectively. Data analysis supported efficacy of the treatment in the preclinical setting, whereas in the context of clinical studies the main favorable finding consisted in the detection of electrical scar in 4/4 patients undergoing specific evaluation; the minimum dose for efficacy was 25 Gy in both humans and animals. No acute complication was recorded; severe side-effects related to the long-term were observed only for very high STAR doses in 2 animals. Significant variability was evidenced among studies in the definition of target volume and doses, and in the management of respiratory and cardiac target motion.Twenty-one works published between 2010 and 2021 were included. Seventeen studies concerned XRT, three PBT, and one involved both. Nine studies (1 STAR is an innovative non-invasive procedure already applied for experimental treatment of ventricular arrhythmias. Particular attention must be paid to safety, rather than efficacy of STAR, given the benign nature of AF. Uncertainties persist, mainly regarding the definition of the treatment plan and the role of the target motion. In this setting, more information about the toxicity profile of this new approach is compulsory before applying STAR to AF in clinical practice. Atrial fibrillation (AF) is one of the most common cardiac arrhythmias, with an estimated number 8.8 million of affected subjects in Europe. As the prevalence of AF increases with age, it is expected to affect approximately 18 million in the European Union by 2060 .Despite being benign in nature, AF represents a well-recognized independent risk factor for stroke  and has While alternative techniques are available, including ethanol, needle, and bipolar ablation, they are not without disadvantages or side effects, including the uncertainty of properly and completely damaging the target , cardiacOther than the well-known applications in cancer, radiation therapy has been used for the treatment of benign medical conditions, showing both satisfactory efficacy and a good safety profile –22.®  accelerator : most of the literature is about the treatment of recurrent ventricular tachycardia (VT) and involves both conventional linear accelerator (CLA) , 24 and elerator –27. The elerator , 29 haveAn increasing body of literature has focused on intracardiac malignancies undergoing stereotactic radiosurgery, and on its possible related side effects –32. SimiAlthough photons are the most known form of energy in radiation therapy, PBT (both heavy ions and protons) are an emerging alternative to conventional treatments. Advantages of this form of radiotherapy are the favorable physical characteristics and the major relative biological effectiveness (RBE), especially when referring to carbon ion radiotherapy . As a coGiven the lack of comparable works, this article aims to review the current evidence on the feasibility and efficacy of external beam radiotherapy for AF and to provide radiation oncologists and cardiologists with a practical overview of this theme.In compliance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) , 40, litArticles were researched in multiple database sources: NCBI PubMed, EMBASE, PMID, and Scopus. The strings of research employed and the PRISMA’s checklist are available in Both preclinical and clinical studies were considered; no data restrictions or language limitations were applied. The inclusion of gray literature was allowed. Studies whose focus were other forms of arrhythmias  were considered out of the scope of this work and were therefore excluded.An independent re-assessment was performed by a second reviewer; in case of any disagreement, a third reviewer was engaged. Selected works were independently screened by two reviewers; whenever disagreement occurred regarding the inclusion criteria, a third reviewer was called to resolve the discrepancy.Summary and definition of the radiation oncology-related terms are available in Following reviewing and duplicate removal, a total of 21 articles presented from 2010 to 2021 was included in the analysis.They consisted of one and 8 preclinical studies on treatment plans for animals and humans treatments, respectively, 8 preclinical studies on animal models, and 4 clinical studies on human subjects. Here follows an overview of selected articles, categorized according to the above-mentioned criteria.in vivo cardio ablation for AF was performed in 2010 by Sharma et al.  were necessary to evaluate target motion. A CLA was used in 3 cases –46. In aThe target of the procedure was different across the studies: some works evaluated either left pulmonary veins alone  or the rA different approach was chosen by Gardner et al. , where tIn the category of dosimetric studies, a total of 122 treatment plans on both photon radiotherapy (XRT) and PBT were considered, with a median dose of 25 Gy .A dosimetric study is a preclinical work in which subjects undergo simulation CT without experiencing radiation treatment or in which the treatment plan is delivered to a phantom. These permit the evaluation of dosimetry in the target region and organs at risk, avoiding any toxicity.Meanly treatment plans consisted of one single fraction and were delivered with CK in 2 cases , 51. ConOnly Ipsen et al.  involvedThe above-described preclinical studies considered PVA as the only target of irradiation. Only Gardner et al.  compared® Lung, Accuray) or ultrasound tracking  is deemed necessary to improve the accuracy of the procedure.It is worth saying that, despite the interest in the topic, a limited number of humans has currently undergone STAR for AF and only 2 articles including more than one patient have been published , 64. In In conclusion, available evidence reports acceptable tolerability of the cardio-ablation treatment on humans; further analyses, together with the newest results coming from the current “gray literature,” however, are deemed necessary to reach the highest level of efficacy.We observed a prevalence of preclinical studies, the majority of which involved mini pigs. This choice can be explained by their relative growth stability and the consequent capability of weight maintenance during follow-up. Three of the analyzed studies also considered a canine model –44. HoweWhen evaluating the preclinical studies on animals it has been shown that the efficacy is higher when mini pigs , 47 are Total prescription doses in the considered works ranged from 15 to 50 Gy/fraction and the minimum dose threshold for efficacy was 25 Gy. Most of the studies encompassed stereotactic radiosurgery delivered in a single fraction except for few articles describing 5-fraction treatments with a dose of 10 Gy/fraction . This comparability is based on the BED which was calculated by the authors  using a A discrete number of studies based on the treatment plan evaluation or delivery of the treatment on a dynamic phantom can be found in the literature: even if they appear to be more acceptable from the ethical standpoint, someone may question if the evidence acquired from these studies are comparable, in terms of efficacy and safety, with those acquired from the clinical setting; in some cases , authorsThe role of the target motion was furthermore discussed in almost all studies. This topic gains importance since the natural motion of the organs influences not only the myocardial or the conduction tissue around the target but also the other organs at risk, the most important one appearing to be the esophagus. The problem of organ motion was solved by some authors , 59, 60 Grimm et al.  and AbelIn the end, it is important to remember how it is possible that a dilated heart with AF appears to have less movement than a healthy one , 72: so,At last, it is worth noticing the interesting application of MRI to approach the problem of target motion , 73: on Supporting this hypothesis, a recent article by Lydiard et al. , not incBoth XRT and PBT involve ionizing radiations, but the second one can deliver its maximum dose at a specific depth  and the possibility of smaller beam foci and less lateral scattering.In the included articles, pencil beams were used to better modulate the beam on the TV; the limit of these thin rays is a major sensibility to motion and setup errors, then the correct position of the beam’s distal edge remains unknown . Ren et An interesting biological hypothesis about the effectiveness of carbon ions in arrhythmia ablation was formulated by Amino et al. : they stAlthough photons and carbon ions are so different, according to the articles selected, the time to detect a scar in an anatomopathological analysis is similar and it spans from weeks to months. As further evidence, the process of fibrosis and scar creation starts after the activation of the apoptotic cascade , 78, accDuring the evaluation of the efficacy and safety of STAR in AF, some considerations about the comparison between AF and VT are necessary. First, it is worth underlying that specific peculiarities characterize the anatomical and structural substrate for AF as for VT, which reflect in different treatment approaches and need to safeguard surrounding healthy structures. For these reasons, some assumptions that have been preliminarily validated in the field of VT may not be true for AF. Ventricular arrhythmias, that may deserve STAR, are usually life-threatening; patients present with recurrent and/or refractory VTs and are not eligible for conventional approaches or these have proven ineffective. In this clinical setting, STAR represents a promising option, thus more risks, even unknown ones, are allowed. To the best of our knowledge, in literature few severe adverse events, definitely correlated to STAR, are reported. In particular, one patient died of esophagopericardial fistula after 9 months from STAR: of note, the patient had previous bypass surgery with a gastroepiploic artery that might have contributed to this severe adverse event ; few cliBeing AF a benign arrhythmia, more attention to the safety rather than the efficacy of STAR is mandatory.In this setting, more information about the toxicity profile of this new approach is compulsory before applying STAR to AF in clinical practice; this is also the reason why not many clinical articles are available in the literature so far.All the above-mentioned works and other already published reviews discuss every type of tachydysrhythmias without a specific focus on AF. The strength of this review is the specificity of the topic treated: stereotactic radio ablation of AF through both XRT and PBT. In this regard, we would like to underline once again that these considerations do not necessarily apply to other patients’ conditions .The main limitations of this work are the relative paucity of works, which is in line with the novelty of the field, and the low evidence of available literature. Moreover, given the nature of our work , and the relative paucity of studies, it was not possible to fully estimate publication bias—if any—through a funnel plot. To at least account for such potential weakness, gray literature was also included. As a matter of fact, while these works are not peer-reviewed, good-quality gray literature is a source of up-to-date information on ongoing clinical efforts.Stereotactic radio ablation is an innovative non-invasive procedure already in use for ventricular cardiac arrhythmias. Radio ablation of AF, with a prescription dose at least of 25 Gy, might be considered among the future therapeutic option for AF, especially when an interventional ablation procedure is contraindicated or proved ineffective.Carbon ions are a highly promising radiation technique due to their TV coverage and, at the same time, their greater capability to spare organs at risk; this may be a strong point to achieve an effective safer alternative application for the heart.Essential issues, such as:–duration of AF before treatment,–target definition and motion, and–doses delivered to the target and organs at risk,deserve further evaluation to define proper indications and modalities to benefit the most from the use of STAR in patients with AF.The original contributions presented in the study are included in the article/JF contributed to conception of the study and wrote the first draft of the manuscript. SV wrote the first draft of the manuscript and was the third reviewer of the literature. VC performed the literature research and contributed to write the first draft of the manuscript. CP was the first reviewer of the literature. EC, GP, and FC contributed to write sections of the manuscript. MP designed and prepared the tables. AMC was the second reviewer of the literature. DA and CT critically revised the final version. BAJ-F contributed to conception of the study and critically revised the final version. CC designed the study and contributed to wrote the first draft of the manuscript and the final revision. All authors contributed to manuscript revision, read, 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.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.