The clinical features and treatment experiences of these children are summarized. (3) Results: A total of 40 children were enrolled in the study, 17 boys and 23 girls. A majority of the boys (median age: 11.8 years) were of puberal age, and the main cause of the UFBs was sexual gratification (94.1%). Girls were almost always in early childhood (median age: 1.8 years), and most of the UFBs were related to specific clothing in specific regions and seasons. Ultrasound had a high accuracy in the diagnosis of female UFBs; the sensitivity and specificity were 88.9% and 85.7%, respectively. Most UFBs could be removed using a cystoscope . All the children had a good prognosis and no complications occurred during follow-up. (4) Conclusions: Ultrasound is a reliable and sensitive method for the diagnosis of UFBs in girls. Cystoscopy is a reliable surgical method for UFBs. Urethral foreign bodies (UFBs) are very rare in children . For boyAlthough the incidence of UFBs is low in children, their treatment remains challenging; for example, due to infection caused by improper removal of UFBs in boys; serious complications, such as fistula and even urethral stricture; and the risk of missed diagnosis in girls . In addiHence, we reviewed the cases in our center in the last decade to determine the clinical features of urethral foreign bodies in children and summarize the experiences in management in order to raise awareness of the disease for early diagnosis and improve the outcomes of such rare conditions.A single-center retrospective analysis was performed on patients who were admitted to the Children’s Hospital of Chongqing Medical University due to UFBs from June 2011 to June 2021. This study was approved by the Ethics Committee of the Children’s Hospital of Chongqing Medical University . This retrospective study involving human participants was in accordance with the 1964 Declaration of Helsinki and its later amendments and comparable ethical standards. Written informed consent for their data to be used anonymously for statistical analysis was signed by the guardian of the child upon hospitalization.The demographic data, chief complaint symptoms at the time of visit, imaging findings before surgery and conditions during surgery were analyzed.® Ltd., KARL STORZ China Center. Shanghai, China), Fr9.5, 0°) was used as a routine means of examination and treatment, and open surgery was performed according to the specific situation for special types of UFBs that are difficult to remove under a cystoscope (After general anesthesia, a rigid cystoscope or colposcope (STORZstoscope .Special type of UFBs: electric wires, which cannot be removed under cystoscopy.Antibiotics were administered based on whether the child had a urinary tract infection. In children who required intravenous treatment, tobramycin or gentamicin was used and normal kidney function was confirmed. When abnormal kidney function was suspected, ceftriaxone or cefotaxime were alternative treatment options. In children who can receive oral treatment without any known resistant urinary cultures, cefixime or amoxicillin-clavulanate are the empirical treatment options. The selection of antibiotics was flexible according to the actual situation . WhetherChildren returned to the outpatient department for review once within 1 month after surgery. In addition to asking about clinical symptom relief, a routine urinalysis and ultrasonography were usually performed to evaluate the outcome of the surgery.All patient information is descriptively presented as averages and standard deviations. Formal analysis was performed.A total of 40 patients were admitted to our hospital , aged frPreoperative X-ray examination was performed on all boys to determine the location and size of the foreign bodies. All 23 girls underwent preoperative ultrasound. Among them, the ultrasound reports of 12 girls were negative, and one of these 12 girls did not undergo surgery because their parents refused it. The surgical results of the remaining 11 girls were negative, and no foreign bodies were found, which was consistent with the ultrasound results. The other 11 girls with positive ultrasound findings received surgical treatment, and nine cases of foreign bodies were found, all of which were successfully removed, while no foreign bodies were found in the other two cases. It is worth noting that the parents of one of these two children clearly reported a history of self-removal of foreign bodies after preoperative ultrasound examination . The avePostoperative recovery was satisfactory. The follow-up period was 3 months to 2 years. No perforation or fistula was found, and boys had no urethral stricture.The occurrence of UFBs in children is very rare, but it is challenging. Our study provided a large sample size, and we summarized the clinical features and management experiences of UFBs to improve the management of such rare conditions.On the age and the cause, boys and girls had distinct characteristics; for boys, most occurred in adolescence, mostly out of autologous sexual stimulation, and most of these UFBs could not be removed by the patient themselves after insertion. Metal needles or tubes may stay in the urethra, causing pain or hematuria in children, while some other UFBs, such as magnetic beads, can cause pain, urinary tract infection and other discomfort after falling completely into the bladder. In our study, we found that early UFBs were mainly metal needles, sticks and wires, while in recent years, the incidence of magnetic beads has been increasing year by year, which may be related to incomplete sex education and unhealthy influences brought about by the use of social networks .In girls, on the other hand, UFBs tend to occur at a very young age, caused by an accident. In the summer, children in China are often dressed in split pants; as a result, children dressed in split pants playing in drying paddies may result in UFBs occurring. This is consistent with literature reports of accidental damage to the urinary organs happening during the summer . These cThe particularity of children makes it very difficult to collect their medical history, and diagnosis is difficult both for young children, who have difficulty expressing themselves, and for older children, who may hide medical problems out of shame . TherefoCystoscopy/colposcopy is an ideal treatment for UFBs. In this study, UFBs were successfully removed under cystoscopy, except for one case of coiled wires in the bladder, the first case of magnetic beads and one case of stones caused by surgical sutures accidentally sewn into the bladder after oblique hernia.Different from the female urethra, the male urethra is narrower and physiological bending often occurs, making male UFBs more difficult to remove, especially for UFBs in the bladder. Magnetic beads, for example, once inside the bladder, are magnetically attracted to each other, making them very difficult to remove ; as a reConsidering the unreliability of the history, the limitations of auxiliary examination and the limitations of endoscopic probes, it is necessary to carry out relevant checks again before the end of surgery, especially for some special types of foreign bodies. For example, in our recent processed cases, before surgery, a boy told us he had placed about 30 magnetic beads, and preoperative pelvic radiographs could not clearly show the number of beads. However, a total of 52 beads were removed intraoperatively . TherefoAdmittedly, there are some limitations to the study, such as its retrospective nature and data from a single center. Therefore, the conclusions of this study—that boys and girls have completely different ages and causes of onset, that ultrasound is a reliable method to diagnose UFBs and that cystoscopy is a reliable surgical method to treat UFBs—still need to be further verified by other prospective studies with larger samples.The occurrence of UFBs in children is very rare, but it is challenging. Timely and effective management can improve outcomes for these children.Boys and girls have completely different clinical features. Ultrasound is a reliable method to diagnose UFBs, and cystoscopy is a reliable surgical method to treat them.We hope that our study can provide diagnosis and treatment experiences for such rare conditions, improve the outcomes of such conditions, and improve treatments for these children.


The patients' attitude is critical in disease control. This study aims to explore the determinants of patients' attitude and satisfaction.A total of 844 patients in the rural areas of Shandong, Henan, and Sichuan provinces with hypertension or diabetes were randomly selected for investigation. The outcome variables were the patients' attitude and satisfaction toward chronic disease control, which were measured through patient self-reported. Binary logistic regression models were used to explore the determinants of patients' attitude and satisfaction.Teachers were more likely to regard that chronic disease management was helpful in their chronic disease control than that in farmers  = 1.309–12.188). Moreover, the probability of health institutions recording chronic diseases changes and guiding rehabilitation for patients regularly is considered helpful 2.688 times more than those that are not. In addition, receiving chronic disease management services can make patients repute that chronic disease management services are helpful in controlling chronic diseases more capably . In terms of satisfaction, patients who do not know regular follow-up tend to be dissatisfied with chronic diseases control result .The government increases the promotion of chronic disease management in rural areas to improve patients' awareness. Health institutions also can provide diversified services to meet the needs of more people. At last, paying more attention to the timeliness of health services need to be considered to develop a health plan. Chronic diseases have been becoming the main cause of death and disability in the world . DiabeteAdhering to chronic disease management is critical to improving health and quality of life for patients . It has Nevertheless, the effect of chronic diseases on control is dissatisfied by the public . The disA cross-sectional survey was conducted in rural areas of Henan, Shandong, and Sichuan Province in China, from June to August 2016. Stratified random sampling was used to select rural areas in 53 cities from three provinces. To ensure the quality of the investigation, investigators had been trained before the investigation started. During the implementation of the survey, the quality of the survey was controlled by reviewing the questionnaires on the day. The validity of the questionnaire was evaluated and verified through expert consultation and group discussion. Because the survey questions are simple, and most of them are established facts, the quality of the survey can be guaranteed, and the reliability test has not been carried out.In total, 997 patients were investigated, and 844 of them provided valid information in the end . Interviewers were face-to-face conducted with each participant. All participants read consent before they participate in the interview.Neither patients nor the public was involved in the design, planning, conduct, or reporting of this study.The outcome variables were the patients' attitude and satisfaction toward chronic disease control, which were measured through patient self-reported. For the attitude, participants were asked “How about the chronic diseases services provided by health agencies for your disease control?” Possible responses ranged from very helpful, helpful, moderate, and unhelpful to very unhelpful. “Very helpful and helpful” were categorized as helpful, and the rest as unhelpful. Similarly, satisfaction was measured by the answer to the following question: How satisfied you are with the result of chronic disease control? The answers ranged from very satisfied, satisfied, moderate, and dissatisfied to very dissatisfied. Participants were classified as satisfied (containing very satisfied and satisfied) and dissatisfied . Various demographic, socioeconomic, and chronic disease service variables were included in the analysis based on the literature review. Detailed indicators and codes are shown in P-values < 0.05 (two-sides) were set as a statistically level in this study.The database was established using EpiData version 3.1  and double-entered independently to avoid entry errors. All statistical analyses were carried out by SPSS version 24.0 . Chi-square tests were used to explore differences in covariate values between helpful and unhelpful (satisfied and dissatisfied) groups. Associated factors were filtered by the Wald statistic of the backward stepwise method, and finally, statistically significant variables were included in the binary logistic regression model. The characteristics of patients are shown in The comparison of patient satisfaction and self-reported is shown in Approximately half of the patients reported chronic disease management was helpful for their health status. The significant differences in the attitude were found among the subgroup of occupation, self-reported household income level, the nearest medical institution, whether health institutions establish health records, whether record chronic disease changes and guide rehabilitation regularly or not, and whether aware of the services of blood measurement and health promotion or not, the timeliness of health services, whether received the services of chronic disease management, free blood measurement, and follow-up services or not.Results of binary logistic regression analysis are shown in Compared to the farmer, the CDM seemed more helpful to the teacher . The higher income the patients were, the more helpful to the health status they reported. Besides, the odds of the effect of health records on disease control were 1.539 times greater than those who did not have health records . Moreover, updating the health record and guiding patients or rehabilitation regularly was reported more helpful . It is noteworthy that those who received chronic disease management services reported more help than that who did not receive them before . The effect of those who received service timely to disease control was 2.927 times greater than that of those who did not . More details are shown in Although the Chinese government has established a relatively wide rural tertiary service network since 2009 , 31, finThe results indicated that the occupation of patients had a significant impact on their attitude and satisfaction. Compared with farmers, teachers tended to consider CDM services helpful to their health. Nevertheless, they were less likely to satisfy with the current services. According to surveys by the National Bureau of Statistics (China), teachers generally receive a higher level of education than farmers do. Previous studies have shown that education is negatively correlated with satisfaction . We, theFindings also revealed that patients who were aware of free services were more likely to be satisfied with CDM services than those who did not know. With the rapid development of China, the investment in essential public health services (EPHSs) has also been increasing. The per capita funding standard has increased from 15 RMB in 2009 to 55 RMB in 2018, and the type of services has increased rapidly , 38. PatFinally, the study found that the timely service of primary healthcare institutions had a close relationship with patient attitude and satisfaction. Timely service provision was significantly correlated with a more positive attitude and higher satisfaction than that was not delivered timely. Chronic diseases are usually with longer causes and were cured slowly, and patients have more opportunities to seek health services from healthcare providers . It meanPatient adherence is critical in chronic disease management. The attitudes toward chronic disease management and satisfaction with the result of chronic disease control are inextricably linked to their adherence. In this study, we intend to identify factors that influence patient attitudes toward chronic disease management and satisfaction with the result of chronic disease control. The study showed that factors such as awareness, service utilization, timeliness, and initiative of health institutions all have a significant effect on patient attitudes and satisfaction. Based on the survey results, we recommend that the government increase the promotion of chronic disease management services in rural areas , provide diversified services to meet the needs of more people, and pay more attention to the timeliness of health services.This study has several limitations. First, participants only include patients affected by chronic hypertension and/or diabetes, which may neglect patients affected by other chronic diseases. Next, factors such as the self-assessment of household income levels and timeliness of health services are very subjective and difficult to estimate. We have to assume that the evaluation criteria for each participant are the same in the analysis. Finally, patients' attitudes toward chronic disease management and satisfaction with the result of chronic disease control may be affected by the attitudes of the servant, but we have not taken them into account.hys19810612@163.com.The datasets presented in this article are not readily available because the data involves personal privacy, please consult the corresponding author for more details. Requests to access the datasets should be directed to RH, The studies involving human participants were reviewed and approved by Xinxiang Medical College Ethics Committee (ID: XMU71804159). The patients/participants provided their written informed consent to participate in this study.BL and RH designed and planned the study. YL and YZ analyzed the data and drafted the article. All authors participated in the survey, completed the data acquisition, participated in data analysis and result interpretation, carefully revised all contents of the manuscript, critically reviewed, and approved the submitted manuscript.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. The reviewer XG declared a shared affiliation with author(s) YL, YZ, XS, and RH to the handling editor at the time of the review.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.


The intestinal microenvironment is composed of normal gut microbiota and the environment in which it lives. The largest microecosystem in the human body is the gut microbiota, which is closely related to various diseases of the human body. Pancreatic cancer (PC) is a common malignancy of the digestive system worldwide, and it has a 5-year survival rate of only 5%. Early diagnosis of pancreatic cancer is difficult, so most patients have missed their best opportunity for surgery at the time of diagnosis. However, the etiology is not entirely clear, but there are certain associations between PC and diet, lifestyle, obesity, diabetes and chronic pancreatitis. Many studies have shown that the translocation of the gut microbiota, microbiota dysbiosis, imbalance of the oral microbiota, the interference of normal metabolism function and toxic metabolite products are closely associated with the incidence of PC and influence its prognosis. Therefore, understanding the correlation between the gut microbiota and PC could aid the diagnosis and treatment of PC. Here, we review the correlation between the gut microbiota and PC and the research progresses for the gut microbiota in the diagnosis and treatment of PC. Pancreatic cancer (PC) is one of the most lethal malignancies in the world. It was the tenth most common cancer in men in 2021 and the eighth-most frequent cancer in women in the United States in 2021 . PC is t14 microbes belonging to more than 1000 different species. The intestinal microbiota plays an important role in human physiology by influencing metabolism, regulating the mucosal immune system, promoting digestion and regulating the intestinal structure. When humans are threatened by some diseases, the gut microbiota can protect the human body by regulating inflammatory responses, providing nutrition and hormonal homeostasis, and producing bacterial metabolites with metabolic effects  can also be considered a risk factor for PC and is indirectly involved in the occurrence and development of PC. Some studies have found that the incidence of H. pylori infection is higher in patients with PC, and the positive rate of H. pylori serum antibody is also higher , Bacteroides (31%) and Firmicutes (22%) were the most abundant  that can predict long-term survival in patients with PC. Using fecal microbiota transplantation from STS, LTS, or control donors, they found that the tumor microbiota could be differentially regulated and affect tumor growth and tumor immune infiltration  refers to the process of transferring the gut microbiota and its metabolites from a healthy donor to the recipient. This is currently the best way to rebuild the intestinal microecology and treat intestinal and extraintestinal diseases Figure 2d cancer . FMT mayd cancer . High abrognosis , suggestcontrols . It has Bifidobacterium is an important intestinal probiotic that can inhibit tumor development and promote the high expression of some tumor-suppressive metabolites. These effects may possibly act via mechanisms that prevent harmful bacteria from colonizing the intestinal tract. This would produce acidic substances and reduce the pH of the microenvironment to maintain the intestinal microecological balance. The metabolism of gut bacteria can affect cancer treatment, including chemotherapy and immunotherapy. Although not directly used in PC, oral Bifidobacterium operational taxonomic unit OTU_681370 combined with anti-programmed cell death-ligand 1 (PD-L1) immunotherapy can almost completely inhibit the growth of mouse melanoma. It can also promote the infiltration of T cells into the tumor microenvironment, regulate the activation of cytokine receptors to produce interferon-γ (INF-γ) and then promote the growth of monocytes , and the Key Research and Development Program from the Science and Technology Department of Jiangxi Province (No. 20192ACBL20037).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.


Ghana shows remarkable differences in employment and welfare between the southern and northern regions. The promotion of policy focus on the development of the northern regions requires the elaboration of specific databases describing the regional economies. Hence, this work outlines the construction of a Social Accounting Matrix (SAM) for Ghana for the year 2015 with a high disaggregation of sectors, household income groups and education levels across 10 administrative regions. Linear multisectoral models have been applied to this SAM to estimate socio-economic impacts of potential final demand policies down to a regional level in the Ghanaian economy. Further on, the structural path analysis is used to investigate the role played by different agriculture commodities in transmitting income to different types of households. The results allow for an identification of the most suitable sectors to be promoted due to their ability to generate the highest increases in output, employment and value added in the rest of the economy, as well as those with a significant impact on household income generation. As a result, the primary sector will play a key role in the economic and employment growth of the country. Notably, sorghum and millet, pulses, tobacco, cotton and fibres can be considered favourable crops for development in the Northern region. The Ghanaian economy is experiencing a structural change with an increasing importance of the services sector in the GDP. However, Ghana’s primary sector accounts for 19% of the GDP and employs 34% of the workforce. It is also an important source of income for many households GSS  so it reIn Ghana, as in other developing countries, households play a dual role as consumers as well as producers of commodities. As in a typical subsistence agriculture sector, households produce for their own consumption and for the market. Based on the Ghana Living Standards Survey (GLSS), Ghanaian households show notable differences in employment and welfare across regions, with the northern regionsAs part of Ghana’s Strategy Support Programme Growth, the Poverty Reduction Strategy, Medium-Term Agriculture Sector Investment Plan (METASIP) and the Food and Agriculture Sector Development Policy (FASDEP), Ghana designed policies to develop the agricultural, fishing, and forestry sectors with a main focus on the development of the Northern region (World Bank According to the Ghana Strategy Support Programme (GSSP), promoting agricultural growth will have a great effect on reducing poverty at the regional level because of the strong linkages between income and consumption. Stimulating agricultural output would lead the growth and the structural transformation of the Ghanaian economy IFPRI . To thisTo promote the expected development, these policies must be based on knowledge and on the analysis of the sectors and agents of the economy and the linkages between them. The analysis of the Ghanaian economy requires a specific database that describes the regional economies, with the primary sector disaggregated, and considers the interlinkages between all agents and regions. This paper employs a Social Accounting Matrices (SAM) for Ghana   that has been applied to both households, as productive units (activities), and as institutional units, and for labour and land factors. The regional breakdown in the 2015 Ghana SAM includes for the north of the country the Northern, Upper East and Upper West administrative regions. The south is defined by the Brong-Ahafo, Volta, Ashanti, Western, Central, Eastern and Greater Accra regions GSS   GSS  and the The SAM accounts for an agricultural households’ activity for each region that produces 14 “subsistence commodities” and 20 marketed ones. The remaining 35 marketed commodities are produced by specific national activities. Household are disaggregated so that each region accounts for rural and urban representative household groups disaggregated by per capita expenditure quintiles. Such classification allows for an analysis of redistributive aspects and the specific impact of different policies in different regions. The factors of production are separated into three broad categories: labour, land and capital. The labour factor is disaggregated into three types of labour: skilled, semi-skilled and unskilled labour , regionalised in the 10 regions and further separated into rural and urban. Four types of capital are considered: crops, livestock, mining and other. Each region also accounts for a land factor . In summary, the 2015 Ghana SAM contains 299 accounts detail in Table The richness of the information in the SAM allows for the analysis of the linkages among sectors and all other accounts. SAM models are simple tools to analyse the structure of an economy. They enable to evaluate the transmission mechanisms of potential shocks through economic sectors, showing the effects generated on the economic activity of different agents due to the relationships of the circular flow of income Pyatt .To obtain a multiplier matrix that traces the impacts on the endogenous account of impulses on the exogenous accounts, it is necessary to define the endogenous and exogenous accounts of the model Acharya . FollowiThe analysis of the multipliers ranks commodities according to their capacity to generate economic growth and identifies those sectors that should receive more attention from policies. Multipliers allow knowing how much output will be generated in the economy and in each activity due to exogenous shocks, how many jobs will be created and the effect of the shock on households’ income . The SPA allows to disaggregate the influence transmitted from pole i (origin) to pole j (destination) through the analysis of the different paths. A ‘path’ includes one or more arcs connecting the account on which the exogenous shock takes place (i.e. ‘origin pole’) to the final account where income changes are evaluated (i.e. ‘destination pole’)  and “unskilled” (51%).For the food industry, the employment multiplier shows low values because the sector is more capital intensive, and the jobs generated are concentrated among “semi-skilled” workers. Within this group, only the employment multiplier of fats and oils and grain milling stand out, with slightly above average values and whose jobs generated impact predominates for “unskilled workers” as in the primary sector. Regarding the impact on employment generated by region, commodities within the food industry have a greater impact on the southern regions, with an impact also in the northern regions for tobacco processing and cereal milling.Comparing the employment multiplier with products that have high output effect it can be observed that within the primary sector, all the commodities that show large output multipliers also have large employment multiplier, except for forestry.Table For the manufacturing sector, only wood and paper have a slightly above average output multiplier, the impact of which is more concentrated in forestry, manufacturing, and services activities. The service sectors show above-average values in terms of output and value added for trade, information and communication, finance and insurance, public administration, health, and education, but significantly lower in terms of employment. Only wholesale and retail trade, accommodation and food services, education, health and other services have employment linkages above the global average. The impact of the services multiplier is clearly concentrated on services-related activities.In terms of employment, commodities related to manufacturing and services generate impact mostly in the southern regions, in Ashanti and Greater Accra, except in the case of non-metal minerals, which is mainly in the Central region and petroleum also distributed among the Western region. Considering the employment by skill-level, for manufacturing, 60–70% of jobs created are directed towards "semi-skilled workers” and in the case of services, it also stands out but to a lesser extent, with increasing influence towards jobs "skilled workers".The described SAM includes a special disaggregation for households, divided between rural and urban zones and disaggregated by regions. Additionally, the SAM as disaggregates households also considering income quintiles. This is relevant for the analysis of impacts on household’s income. This sub-section analyses how shocks in final demand for each commodity affect household income considering the different household groups by region.The income multipliers are shown in Table The income generated through the promotion of these agriculture commodities are concentrated in the rural zones, which benefits the income generation of rural households. The impact on rural areas is particularly strong in the northern regions. Furthermore, the results of the analysis show that considering the average impact on each quintile group, the income received by 60% of the population with the lowest income  comes from the primary and food sector. Hence, this multiplier shows the importance of the primary sector in household income generation, especially for low-income rural households in the northern regions.The value chain analysis traces the impact of value added induced by the increase on each commodity demand, embodied on the activities or group of activities in the economy. Considering the primary sector, Fig. The distribution of the value added generated by other activities is shown in Fig. Table First, for the commodities with the greatest influence of the rural income multiplier towards the northern regions, Fig. Regarding the transmission mechanisms, most of the contribution of the multiplier has an initial effect on households as producers, which generates household income though the remuneration to land use, rural unskilled and semi-skilled labour and capital (crops and livestock) . These transmission mechanisms are the most important for agricultural commodities, covering between 72 and 86% of the global multiplier effect.In the case of ‘sorghum and millet’ at least 68.3% of the increase in rural household incomes in the northern regions due to an exogenous shock is channelled directly through an increase of production in household activities, impacting on the necessity of land (27.6%) and unskilled rural labour (40.7%)  strategy MoFA  promotesTo implement policies aimed at the country's socio-economic development, it is necessary to develop suitable databases that can be used for economic modelling. This article presents an analysis of the multipliers based on the Ghana's SAM for 2015. The significance of this new matrix is the incorporation of the HPHC approach and the high disaggregation of its accounts. This breakdown includes the disaggregation of several products within the primary sector and details by region, educational attainments, and rural and urban zones. These details allow for an in-depth analysis of the structure of the country's economy that enables the formulation of policies focused on equality and development in the low-income regions.To evaluate a public policy, it is important to estimate not only socio-economic impacts, but also where the impacts will be felt .The SPA shows how the influence on rural household income is transmitted in each northern region, demonstrating that income boosting in the northern areas of Ghana requires taking into account regional specificities. For example, an increased demand of pulses, sorghum, and millet has a similar influence in the Northern and the Upper East regions, highlighting the effects derived by labour rural unskilled, followed by land and labour rural semi-skilled. However, the same commodities generate higher income on rural households in the Upper West region transmitted by a larger influence of land, labour rural unskilled and livestock and crops capital.Overall, the SPA shows that when boosting demand for the specified commodities in Upper East and Northern, income effects are more related to rural labour (unskilled and semi-skilled) and land. However, for the Upper West the effects are more diversified across income streams, including mainly unskilled rural labour, land, capital crops and capital livestock, which are not prominent in the other regions. Finally, for those commodities where the region captures the smallest share of the multiplier effect, the influence is more associated with ‘other effects’, meaning that specific policies to boost demand for these commodities would produce effects that are more difficult to trace.In summary, policies should focus on promoting Ghana's primary sector because it can improve the economy by generating more output, but also by creating jobs in many regions and consequently increasing household income. Thus, this article suggests adjusting policies and incentives in a way that promotes commercial agriculture and its better integration into markets. This involves supporting the development of exportable agricultural products and strengthening agricultural marketing and trade infrastructure and facilitation while refocusing the regional distribution of agricultural spending towards northern regions for crops with high agricultural potential.In addition, public investment should focus on agricultural R&D to improve the productivity of the country's most important commodities, as well as related infrastructure. This will help to promote the development of the agricultural potential of the Northern Savannah Ecological Zone, with a potential positive impact on economic growth, job creation with rural income generation and poverty reduction. A special case is the Upper West, for which the impact of changes in demand for agricultural products is low, with only cotton standing out. Given that the region has a long dry season, investment in better infrastructure can ensure market access and thus the integration of this region.The methodology is a useful tool which allows for an analysis of an economy structure and ex ante policy assessments. Nevertheless, considering the limitations of the methodology above-mentioned in the article, each multiplier value should not be taken as an exact forecast of the impact in the economy, but as an indicator of those commodities with greater impact due to demand shocks Round . Notably


Premenstrual syndrome (PMS) is one of the most widespread menstrual disorders in women of reproductive age. This recurrent syndrome is a combination of physically, mentally, or behaviorally disturbing changes occurring during the secretory phase of the menstrual cycle. The aim of this study is to determine the effect of a cognitive-behavioral therapy-based educational intervention using social networks on PMS in female health center employees in Rudbar, Iran.A randomized superiority controlled trial will be conducted involving 140 female employees of health centers affiliated with the Guilan University of Medical Sciences, Rudbar. The study involves a block size of 4 and 6 in a randomly varied order, 140 women who meet all the inclusion criteria will be randomly and equally divided into 2 groups: the intervention and the control groups. Those in the former group will receive a cognitive-behavioral therapy-based treatment for eight consecutive weeks on the social network platform WhatsApp; however, those in the control group will not be offered any treatment except usual care practices . The study’s primary outcome is the severity of PMS symptoms, and the secondary outcomes include general self-efficacy, work-related quality of life, the impact of PMS on daily life, coping with the symptoms, and experiencing anxiety and depression at the beginning of the study to identify people with PMS. A daily record of the symptoms will be completed for two consecutive months by all female employees aged 20–45 years who wish to participate in the study. According to the initial screening, those with moderate to severe PMS will be included. We will use the MLwin software for the analyses. All questionnaires will be completed by both groups immediately and 8 weeks after the termination of the treatment. The data will be analyzed using linear mixed-effects modeling with random intercepts and slopes.It is anticipated that the findings of the present study may demonstrate the effectiveness of the cognitive behavioral therapy intervention on the severity of PMS symptoms that could guide healthcare providers in opting for suitable treatment alternatives for the syndrome.The research proposal is approved by the Human Ethics Committee of Qazvin University of Medical Sciences (IR.QUMS.REC.1399.252). The results of this intervention trial will be submitted for publication in a peer-reviewed research journal.IRCT20180218038789N4. Registered prospectively on October 28, 2020Iranian Registry of Clinical Trials  Premenstrual syndrome (PMS) is one of the most common menstrual disorders in women of reproductive age . This syThe high prevalence of PMS is a major concern in many settings ; howeverThe PMS symptoms affect women’s quality of life and disrupt many aspects of it, including daily activities, interpersonal relationships, social activities, sexual function, and occupational function. Additionally, they can cause disturbances in couples’ relationships, incompatibilities with children, absence from workplaces, and social consequences such as increased accidents and abuse . The surTherapeutic goals for treating PMS include reducing the extent and severity of symptoms as well as their impact on personal activities and relationships and improving the quality of life . BecausePharmacological treatment of PMS includes vitex agnus-castus , combination oral contraceptives, and selective serotonin reuptake inhibitors  . BecauseNon-pharmacological treatment includes lifestyle modification, dietary supplementation, and cognitive behavioral therapy . NonetheCBT is based on the idea of how we think (cognition) and feel (emotions) and the manner in which we interact with each other (behavior). Therefore, negative and irrational thoughts can cause discomforts and problems . CBT conDue to the serious consequences and negative effects of this syndrome on the activity and performance of individuals, the very important role of women in the family and society, increasing the number of workers, and very few studies on the effects of PMS in the workplace, the target group of this study was health workers. They are one of the most important occupational groups in promoting community health and are themselves role models for different groups of people. Therefore, the present study was designed to determine the effect of a CBT-based educational intervention using social networks on PMS in female employees of health centers in Rudbar, Iran.The present research is a block randomized superiority controlled trial that will be performed in the health centers affiliated with Guilan University of Medical Sciences, Rudbar, Iran. Figure The research population in the present study includes female employees aged 20–45 years in the Rudbar health centers who will be invited to participate using the convenience sampling method.Willingness to participate in the studyAge 20–45 yearsModerate-to-severe PMS or PMDD (based on PMS screening using a daily symptom registration form)Having internet accessPossessing a smartphoneThe following are the inclusion criteria:Diagnosis of psychosis or bipolar disorder, ED, and moderate-to-severe depressionParticipated in a psychotherapy program for PMS at present or in the pastAcute suicide tendenciesChildbirth or breastfeeding during the past three monthsPregnancyGynecological diseases Using any kind of antidepressants, benzodiazepines, antipsychotics, oral contraceptives, or hormones over the past 3 monthsThe following are the exclusion criteria:The intervention effect will be evaluated by comparing the mean score of PMS symptom severity (primary outcome measure) between the two groups. Thus, the sample size was calculated based on the ability to detect a clinically relevant difference of 30% between the two groups in 8 weeks after intervention (30% reduction in the mean PMS score). This sample size accounted for a type I error rate of 0.05, any-pair power of 0.95, and all-pair power of 0.85. Based on the evidence from a previous study  and assuFirst, all female employees of the health centers will be invited to participate in the study using an announcement. Second, women will be screened for having moderate-to-severe PMS. Third, after a run-in period, primary evaluation of study subjects, and obtaining written informed consent, women who had our eligibility criteria will be randomly assigned to two groups (intervention and control) by using the permuted random blocking method with four and six blocks. Considering that two groups will be studied, four and six blocks in a randomly varied order are utilized and each group is assigned a letter . Since we have a list of all eligible women, the formation of permuted blocks and random allocation of individuals to two groups of intervention and control will be determined prior to the initiation of the research. Indeed, block size of 4 and 6 in a randomly varied order is used to conceal the allocation sequence.In order to hide the allocation sequence, the type of intervention is written on the cards based on it, and placed in envelopes in a matte package numbered from 1 to 140. In this case, the person who receives intervention code 1 completes a questionnaire with the same code. The assignment of participants to their allocations will be done by an independent healthcare provider. Due to the nature of the study intervention, modification of random allocation during the study and blinding of study participants and outcome evaluators is almost impossible. Although the content of the intervention will be delivered online using the social media platform and blinding is difficult, we tried to maintain the confidentiality of data through coding of study subjects and not asking their identity.The content of the intervention will be based on the principles of CBT and will be delivered online using the social media platform WhatsApp Table . The intThe first part includes psychoeducation about PMS/PMDD, its causes, and treatment. The cognitive strategy section provides information and strategies for identifying and correcting ineffective thoughts, especially PMS-specific cognitions, misbehaviors, and misconceptions. The sections cover suggestions for lifestyle changes, such as stress reduction, exercise, and a balanced diet. In the final section, a summary is provided, along with a plan to sustain the benefits and prevent relapse. All sections include practical exercises for applying and practicing the theoretical content. Additional audio files are provided to facilitate the performance of these exercises, such as an advanced muscle relaxation training program or an audio instructional exercise to gather thoughts related to PMS. Textual information and audio files are delivered through social networks. Weekly feedback on the intervention is obtained to assess the participants’ compliance with the intervention. If they do not submit their feedback, they will receive two reminders.Severity of PMS symptomsThe following is the primary outcome:General self-efficacyQuality of working lifeThe effect of PMS on daily lifeCoping with premenstrual symptomsAnxiety and depressionThe following are the secondary outcomes:A self-reported measure will be used for the purpose of data collection. Data will be gathered using a multi-part questionnaire that includes the following sections.Demographic information will be examined using items such as age, marital status, level of education, height, weight, number of children, work experience, and type of employment.normal, 1 = low, 2 = moderate, 3 = severe). The effects of these symptoms on social aspects are examined. According to the DSM-V criteria for severe PMDD and PMS, a minimum of 5 symptoms  of the 27 primary items should be present (more than 2), with at least one of them related to the impact on social aspects (greater than 2) for no less than 2 days in the luteal phase [The severity of premenstrual symptoms was assessed based on the severity of 27 physical, and behavioral symptoms as well as 3 items related to interference with social activities were measured using a PMS symptom diary validated by Janda et al.  prospectal phase .For each woman, scores related to symptom severity (SI score) and severity of the interference with social activities (INT score) will be calculated. The first 27 items are used to calculate the SI score, and items 28 to 30 are used to calculate the INT score, which indicates social and occupational interference. These scores are calculated for the luteal phase. Luteal phase scores are calculated according to the last 7 days before menstruation. Only symptoms that are rated higher than or equal to 2 for at least 2 days will be entered into the calculation. The values of all items with a score greater than or equal to 2 for at least 2 days are added together and divided by 7 . TherefoIt should be noted that the symptom record sheet should be completed 2 months before the intervention starts, in order to diagnose PMS symptoms and assess the severity of PMS; the average of these 2 months will be considered as a baseline score. The severity of PMS will be assessed for 1 month immediately and 8 weeks after the end of the intervention to evaluate the short-term and long-term effects of the intervention.This questionnaire was designed by Kues et al. in 2015. Its 18 items measure the impact of PMS on daily life through two subscales of psychological and functional effects. The validity of the measure was confirmed using exploratory factor analysis. Cronbach’s alpha coefficient of 0.9 for both subscales showed an acceptable level of reliability . In the In the present study, the Hospital Anxiety and Depression Scale (HADS) will be used to assess anxiety and depression. This instrument was developed in 1983 by Zigmond and Snaith to screen for anxiety disorders and depression in non-psychiatric clinic patients. This scale comprises 14 questions in 2 subscales, namely, anxiety and depression. Each item is scored on a 4-point Likert scale ranging from 0 to 3. The maximum score that can be obtained for each subscale is 21. Scores above 11 on each subscale are considered abnormal, scores from 8 to 10 indicate borderline cases, and those from 0 to 7 are deemed as normal . Bjellannot at all true) to 4 . A higher score indicates a better status of coping with PMS [The Premenstrual Change Coping Inventory is a self-report 17-item scale that measures individual strategies to deal with PMS. It includes three subscales, “seeking positive affect-inducing activities,” “seeking support,” and “healthcare use behavior” that are scored on a 4-point Likert scale from 1  will supervise all stages of research implementation and content preparation.In this study, the data obtained from the questionnaires will be coded and entered into the SPSS software version 23. It should be noted that baseline data of all women identified as satisfying the eligibility criteria would be recorded initially. Data of discontinuing cases will be compared with the same data from those who agree to remain in the study. This will allow determining the representativeness of study subjects and generalizability of the finding. As mentioned above, this is an intervention study, and we did not find any adverse events for CBT in the literature; however, researchers plan is to report any unforeseen events or incidents during the study.The effects of the intervention will be analyzed using a two-level linear mixed model in which repeated assessments will be time (variables from the beginning of the study to the end of the intervention and 3 months after its completion) at the first level and female employee at the second level. The model will be adjusted for the impact of potentially confounding variables . Mixed models are commonly used to handle missing data. Therefore, no additional steps will be taken to manage the missing data. Restricted iterative generalized least square estimation will be performed to produce unbiased estimates of the random parameters. The data will be analyzed by the intention to treat with the MLwiN 2.27 software.The research protocol has been reviewed and approved by the Ethics and Human Research Committee of the Qazvin University of Medical Sciences (decree code: IR.QUMS.REC.1399.252). It is registered at the Iranian Clinical Trial Registration Center under the decree code IRCT20180218038789N4. In addition, the following ethical considerations will be taken into account throughout this study: obtaining written informed consent, voluntary nature of participation, ability to withdraw from the research at any time, and confidentiality of information even during the publication of the findings. All ethical issues related to clinical trials will be considered. Moreover, informed consent during the recruitment phase will be obtained. CBT is a defined intervention protocol that has been used in many previous studies and is almost unchanging. It should be noted any change in protocol or its implementation will be informed to the main stakeholders of the study including the study subjects, trial team, and research deputy of Qazvin University of Medical Sciences. Ethical committee affiliated to the Qazvin University of Medical Science will select one independent expert as an independent trial audit. This person will monitor all steps of conducting the research including data.PMS is one of the most common menstrual disorders in women of reproductive age  that reqFirst, in previous studies, the target group of healthcare providers was not taken into consideration. Previous studies have shown positive results regarding the effect of online CBT interventions for reducing functional and psychological dysfunction caused by PMS, its impact on daily life, the severity of symptoms, and the related disability in different groups including urban women , rural wSecond, designing an intervention program within the framework of self-efficacy theory is an attempt to minimize the limitations of previous studies. Perceived self-efficacy is a judgment of an individual’s ability to perform a particular set of actions. It is developed through skillful practice, substitution learning, verbal persuasion, and physical responses to specific situations. Overestimation of capabilities can lead to failure, while underestimation can reduce challenges and improve capabilities. It is closely related to perceived health control and the belief that a person has the skills to perform certain functions that actually affect their health level. Confidence in a person’s abilities to perform these tasks can increase the likelihood of attempting them. In addition, self-efficacy is a significant component of hard work and the capacity to withstand stress and change . Some stThird, CBT will be provided via an Internet platform. Internet-based CBT is readily available and has several benefits –62. For Additionally, the use of a randomized controlled trial design with a concurrent control group and significant sample size are other strengths of this study. It is expected that these findings may demonstrate the effectiveness of the CBT intervention on the severity of PMS symptoms that could guide healthcare providers in selecting appropriate treatment alternatives for this condition.The recruitment has not yet begun; however, all necessary permissions have been acquired; the estimated date of recruitment is December 20, 2020. The expected date for completing the recruitment is February 30, 2021.


All but two (IPF) included patients with COPD. Based on the FEV1, patients with COPD were mainly categorised as moderate and severe. The teleactivities were heterogenous in terms of proposed exercises and way of settings and often not in agreement with the guidelines about pulmonary rehabilitation. Despite this, the effects of the interventions were globally positive on functional exercise capacity, quality of life, anxiety and depression, and impact of COPD on personal life but not on dyspnoea. The PEDro scores varied from 4 to 8. The adherence was higher than 80% when supervision during the exercise was included. Conclusion: This review demonstrated that the telerehabilitation is safe and well accepted by the patients, and could be considered as one option of classical pulmonary rehabilitation to improve the functional exercise capacity, quality of life, anxiety and depression, and the impact of COPD on personal’s life. This conclusion cannot be extrapolated to the other chronic lung diseases due to the lack of data.Introduction: Tele-rehabilitation is increasingly used to deliver pulmonary rehabilitation. The aim of this systematic review was to compare the effect between tele-pulmonary rehabilitation and classical supervised pulmonary rehabilitation. Method: Three databases were analysed . The selection and evaluation of studies followed the PRISMA guidelines. The risk of bias was evaluated using the PEDro Scale. Results: From the initial selection ( Pulmonary rehabilitation is an important part of the treatment of all the chronic respiratory diseases even if the benefits and the levels of evidence differ between these diseases . It has Until now, the pulmonary rehabilitation has been mainly provided in specific centres even if it can also be efficiently practised out of these centres as it was more recently highlighted in some studies . Some imTele-medicine used different technological means to provide a medical approach at home in place of the traditional face-to-face approach of medicine. Tele-rehabilitation is one branch of tele-medicine adapted to the world of the rehabilitation. It tends to maintain the advantages of a classical rehabilitation and to overcome its disadvantages by providing easier access to healthcare services at home with an improved adherence . The feaThe aim of this systematic review was to summarise the different forms of pulmonary telerehabilitation to highlight its effects and to compare them with a classical supervised pulmonary rehabilitation.The systematic literature search was based upon the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement . It was The search strategy used in PubMed was divided based on PICO criteria without including the comparison and outcomes in the equation and using key terms combined with Boolean operators: (a) participant: (suffering from chronic lung disease); (b) intervention: all the forms of telerehabilitation; (c) comparison: usual care or pulmonary rehabilitation; and (d) outcomes: functional exercise capacity, dyspnoea, QoL, and anxiety or depression. The strategy was adapted to the other databases. The lead author (GR) also performed manual tracking of citations in the selected articles.The RCTs comparing the effects of telerehabilitation with a classical pulmonary rehabilitation or usual cares in adult subjects diagnosed with a chronic lung disease  were included. The definition of the telerehabilitation was the use of at least one technological tool  to follow a home-based program. An isolated phone call to stimulate an active behaviour was empirically considered as not a telerehabilitation tool. Studies had to report at least one of the following parameters as an outcome: functional exercise capacity, dyspnoea, QoL, and anxiety or depression. We included studies published in English or French and with no date restriction. Abstracts, reviews, prospective and retrospective observational cohort studies, editorials, letters and case reports were not included in the systematic review. Studies related to lung cancer or including duplicated data reported in earlier publications were excluded.Eligible studies were identified and reviewed independently by two reviewers (GR and GL) against selection criteria. After removing duplicates, studies were first screened based on titles and abstracts. Full-text articles were then screened when the title and abstracts were unclear. Discrepancies in selecting studies were resolved by a third independent reviewer (EP).Characteristics of studies , patient data , characteristics of the intervention , and outcome data were manually extracted by one qualified reviewer (GR) and presented in tables. The clinical significance thresholds were fixed at 35 m, 1 point, and 4 points for 6MWT, Borg scale, and Saint-Georges Respiratory Questionnaire, respectively. Data presented in graphs were extracted by software tools. The missing data were mentioned as “non-reported” (NR). The collected values were presented as mean ± SD or median (IQR).The methodological quality of the selected studies was assessed using the PEDro scale. This tool contains 11 items with a maximum score of 10. The studies were scored by the lead author (GR) and compared to the PEDro database. Any uncertainty was discussed with a second assessor (EP) until consensus was reached.The selection process is highlighted in the PRISMA flow diagram . The seaThe characteristics of the studies are reported in Participant characteristics are reported in The characteristics of physical telerehabilitation programs are summarised in About the studies compared to usual cares, the length of the interventions was highly variable, from 4 weeks to 4 months and even 12 months for a study assessing the impact of a maintenance program. Again, the frequency of the sessions was often different between IG and CG. Moreover, when the duration of each session was mentioned, it was sometimes under the recommended duration.Regarding the studies comparing the telerehabilitation to a classical or adapted pulmonary rehabilitation, the most frequent length of the programs was 3 months. Two studies assessed a shorter program. Some studies did not compare a similar frequency of sessions in the two groups. The duration of the sessions was relatively short and mainly around 30 min.The quality assessment of the studies is shown in Three kinds of outcomes were investigated in this systematic review. They are presented in the To assess the functional exercise capacity, the six minutes walking test (6MWT) was used in the majority of the studies. Studies also included incremental or endurance shuttle walk tests, or a sit-to-stand test. The training time and an accelerometer were used without 6MWT in one study, respectively.The dyspnoea was only assessed in ten studies and the evaluation was classical , Borg scales, CRQ-D). Another study included the dyspnoea assessment in the BODE index without isolated data about dyspnoea.Health-related quality of life and psychogenic outcomes were largely assessed in the retrieved studies. Different questionnaires were used by the authors even if the COPD assessment test (CAT), the Saint-Georges Respiratory questionnaire (SGRQ) and the Hospital Anxiety and Depression (HADS) scale were mainly found.The results of the studies were divided based on the type of CG. The effect was considered as positive when there was an inter-group difference when IG was compared to usual cares, whereas the lack of inter-group difference was considered as positive for comparisons with a classical PR.Regarding the functional exercise capacity, all the interventions showed positive results when compared to PR. Indeed, no difference was observed with the control group for 6MWT. When the comparison was performed with usual care, there was a benefit for all studies even if one of these demonstrated only a benefit in endurance shuttle walk test but not in the 6MWT .The dyspnoea was mainly assessed by the mMRC scale. No difference was observed neither for the comparisons to the usual care nor to another intervention. The clinical significance on the Borg scale was reached in the study comparing a telerehabilitation to the usual care  and onlyNo positive effect was observed on the quality of life when the intervention was compared to usual care. However, one of these studies assessed a maintenance program after a pulmonary rehabilitation in patients with COPD  and anotThe effects on quality of life, anxiety and depression, and the impact of COPD on personal life were similar in all the studies comparing intervention to pulmonary rehabilitation and even better on anxiety and depression, and the impact of COPD on personal life in one study . This laThe adherence reported in the studies ranged from 39% to 93% and always higher than 80% when a supervision during the exercise was included . NeitherNo study reported serious adverse events even if all except one clearly mentioned the specific assessment of the eventual adverse events. The only observed adverse event was pain in two studies ,19. In oThis systematic review aimed to summarise the different telerehabilitation programs related to a chronic respiratory disease. It highlighted positive effects on functional exercise capacity, quality of life, anxiety and depression, and impact of COPD on personal life but not on dyspnoea in COPD patients. Although, the investigated forms of telerehabilitation were often not in agreement with the guidelines about pulmonary rehabilitation.Initially, telerehabilitation has been developed to counteract the burden of the rehabilitation, mainly the distance from home to the rehabilitation centre and the transportation difficulties for the patients. This modality was proposed as an initial rehabilitation or as a prolongation of an ongoing rehabilitation. This modality of treatment was widely developed in cancer  and receIn 2021, the authors of an American Thoracic society workshop about the future of the pulmonary rehabilitation reported that the concepts of “access,” “uptake,” and “completion” are key to the challenges facing pulmonary rehabilitation programs and they mentioned that telerehabilitation could improve accessibility, and completion of pulmonary rehabilitation programs . HoweverThe different telerehabilitation programs improved quality of life, and anxiety and depression. Similar benefits were previously demonstrated in line with telemedicine  even if Surprisingly, the dyspnoea was not improved after telerehabilitation. It can be explained by the assessment tool used in studies . On the one hand, the MMRC dyspnoea scale is not very sensitive, and this scale is rather used to assess COPD severity . On the The patients with COPD were the main population of patients with a chronic respiratory disease investigated in the telerehabilitation field. This is not surprising due to the high prevalence of this disease and the highly demonstrated place of pulmonary rehabilitation in the care of this disease compared to the other chronic lung disease. Moreover, these patients are particularly good candidates to the telerehabilitation due to their difficulties related to transportation . Based oMaintenance strategies are required  because Unfortunately, this systematic review highlighted that the telerehabilitation has not yet been studied enough in the chronic lung diseases. Concluding on the effectiveness is then difficult. Moreover, we observed that some studies did not investigate a pulmonary rehabilitation that follows the international standards transformed into a telemodality with or without supervision, but only remote exercises. For example, the duration of the session was frequently shorter than 30 min which are under the recommended duration.Some limitations related to this systematic review have to be addressed. First, the studies related to other diseases than COPD are sparse and extrapolation of the results to these diseases is not possible. Second, there is not enough studies about a specific pulmonary telerehabilitation and the programs showed a great disparity in the settings. This explains why we did not perform a meta-analysis. The choice of not-considering a phone call without other interventions as telerehabilitation can be questionable but the aim was to avoid the studies assessing home-based program without the use of new technologies. Home-based programs were previously studied.In conclusion, this review demonstrated that the telerehabilitation has to be considered as one option of classical pulmonary rehabilitation to improve the functional exercise capacity, quality of life, anxiety and depression, and the impact of COPD on a person’s life. Until now, this conclusion cannot be extrapolated to the other chronic lung diseases due to the lack of data. As a perspective, a definition of the acceptable forms of telerehabilitation should be provided and a particular attention to the compliance of the telerehabilitation should be paid with the international guidelines on pulmonary rehabilitation. Moreover, there are missing studies about the combination between classical and tele- pulmonary rehabilitation.


Sickle cell disease (SCD) is considered a rare disease in Germany. Due to the increasing prevalence, the acute and chronic morbidities associated with the disease and the sharp increase in the mortality rate of young adults, a need-based transition structure for patients with SCD in Germany is explicitly required. This is the first multicenter German consensus statement addressing the importance of implementing a standardized transition guideline that allows adolescents and young adults to safely transition from pediatric to adult care. Early identification of medical needs and intervention remains important in the context of chronic diseases. Effective measures can improve health care in general, as they lead to a reduction in disease and the consequential economic burden. It is noteworthy that improving structural barriers remains a key challenge even in highly developed countries such as Germany. Inclusion of these transition services for patients with SCD into the regular care of chronically ill adolescents and young adults should be ensured, as well as the coverage of costs associated with a structured transition process. Transition is the purposeful, planned transfer process of adolescents and young adults with chronic diseases from child-centered to adult-centered health care, with the goal of providing coordinated, continuous high-quality medical care without interruption. Transition encompasses the entire process of becoming an adult, and, in addition to enhancing autonomy and personal responsibility, it includes the effective use and provision of structures that enable the transition to adulthood for patients with chronic disorders .The prevalence of SCD in Germany has been increasing tremendously over the past years ,4,5,6,7.The increase in the mortality rate of patients with SCD coincides with the period of transition to adulthood in Germany .Emergency care utilization among adolescents and young adults is increasing due to acute and/or progressive disease severity in this age group ,10,11,12These patients suffer from reduced quality of life (QoL) and increased psychological distress as compared with their unaffected peers and/or patients with other chronic disorders ,14,15,16To date, no uniform transition recommendations for patients with sickle cell disease (SCD) in Germany exist. However, the medical need for the implementation of a national structured and uniform transition process for patients with SCD is obvious considering the following facts:To address this need for guidance related to a transition structure for SCD patients, a network of pediatric and adult hematologists established an initiative to develop a standardized transition concept for patients affected by SCD in Germany.The expert panel consisted of four pediatric and five adult hematologists representing either university medical centers or large community hospitals or working in private doctors’ offices in different parts of Germany.The development of the consensus recommendations was based on the evidence-based guidelines for the transition from pediatric to adult care developed by the German Society for Transition Medicine (GSTM) (AWMF S3-guideline 186/001), which was published in April 2021 [The process of the consensus statement development started in October 2021, with an initial online conference to create working groups, each drafting a statement concerning a subset of questions based on the general GSTM guidelines. Drafts were circulated and commented on through a Delphi-like process. Then, statements were discussed in two additional conferences, with another circulating in between. Finally, they were agreed upon by all participants.The transition from pediatric to adult care is a dynamic process rather than a cross-sectional event and, first and foremost, must be adapted to the adolescent’s individual developmental status. Adolescents with chronic diseases have specific needs compared with healthy peers. These needs must be considered in the decision-making process to ensure the best possible successful transition to adult care. In addition to individual development, family structures must be considered. Particular attention should be paid to SCD-associated complications that might have manifested in early childhood, which can further complicate the process of transition ,18,19,20Core StatementsThe transition process should always be considered in the context of the family structure and must include the personal needs and developmental requirements of the family .The patient (depending on age and maturity) and their parents/guardians are full partners and should be involved in the entire treatment and transition process.From the onset of puberty at the latest, adolescents with SCD should be encouraged to develop essential skills to manage their disease independently. The potential risks and consequences of not following recommendations/therapies should be known.Patients and parents/caregivers should have a good understanding of the disease. They should have learned how to recognize and manage signs, symptoms and associated complications in patient and family training sessions. Training sessions need to be repeated at regular intervals to discuss the specifics of the different ages, repeat what is known and discuss new medical developments as appropriate.In case of presentation in an outpatient clinic where the patient is unknown, he/she needs an emergency card in which the diagnosis, useful initial measures and emergency interventions are noted.In this regard, it is recommended to conduct age-adapted training sessions with the adolescents and their parents/guardians to discuss the specific aspects of the disease across different age groups  or other complications, sufficient hydration, the necessity of vaccinations related to functional asplenia, etc.). Pre-existing knowledge should be refreshed, and, if necessary, new medical treatment options discussed. This will improve awareness of one’s disease, promote adherence and increase transition readiness and autonomy. Responsibility for disease management should gradually pass from the parents to the adolescent. Adolescents should become aware of the potential risks and consequences of not adhering to medical recommendations and therapies. When reaching the legal age of maturity, all adolescents should know important contacts outside of pediatric care to turn to in the event of acute complications  .Core StStructural factors  that might complicate the outcome of transition should not play an important role. However, they continuously represent a significant problem and a barrier to successful transition throughout Germany. For professional legal reasons, further treatment by pediatricians is generally not permitted after the age of 21, in some places even after the age of 18. The only exceptions are vaccinations and therapies in the context of emergencies. However, this conflicts with the general recommendations of the GSTM, as the timing of the transition to adult care should be adapted to the specifics of the disease and the individual patient and should not be rigidly tied to the age of maturity (18 years). Notably, in the case of inadequate treatment options by specialists, treatment can be provided by all pediatricians in accordance with the “pseudo-fee schedule item 99155” [Core StatementsThe transition process is led by the pediatrician in charge, who is responsible for providing comprehensive medical care in an interdisciplinary network.Every patient with SCD, as well as their parents/guardians, should be offered the option of psychological support.Adolescents or their parents/guardians should be actively informed about the availability of specific self-help and patient organizations.Patients should be informed of the availability of websites and mobile phone services  at regular intervals to improve adherence and keep appointments. The pediatric hematologist caring for the patient is responsible for determining the appropriate time for initiating the transition process. He develops an individual transition plan in which specific measures are precisely defined and scheduled, and he identifies potential challenges threatening the outcome of transition in the long term. The adolescent, as well as parents and caregivers, should be offered psychosocial support in advance. The involvement of self-help and patient advocacy groups additionally contributes to minimizing barriers. Therefore, adolescents and their parents/guardians must be actively informed about the availability of such organizations. Data have shown that personal involvement in self-help and patient advocacy groups, through sharing experiences among peers, has a positive impact on the self-determined management of chronic diseases ,23,24.CTransition readiness is reached when all decisions are made and actions are taken to build the capacity of the individual adolescent, and that of others involved in the patient’s environment, to prepare for, begin, continue, and finish the process of transition.To assess transition readiness, the panel recommends the use of a standardized questionnaire, which can be used repeatedly to assess the personal capability of each adolescent individually ,30,31,32It should be mentioned that despite the accessibility of continuous medical care in Germany, adolescents with chronic disorders often cannot benefit from specific therapy options due to individual psychoemotional deficits ,34. TherCore StatementsThe patient’s readiness for transition should be assessed by means of a structured questionnaire, which might also be presented to the parents/guardians (form provided as part of the transition initiative). Neurophysiological testing should be carried out for every child with SCD before starting school, at the time of any change in school and again when the child reaches the age of 16. Of course, any corresponding medical abnormality would indicate such intervention as well.A joint exchange with the ambulant pediatrician, the future general practitioner as well as specialists should be guaranteed.Close contact with the general pediatrician and future general practitioner is demanded and essential. Specialists should be consulted at an early stage, taking already manifest disease-associated morbidities into account. They should also be known to the adolescent and their parents. Cooperation with a tertiary referral hospital in the field of adult medicine with expertise in SCD is demanded, as well as adherence to the guideline of the Joint Federal Committee on Quality Assurance Measures for the Inpatient Care of Children and Adolescents with Haemato-oncological Diseases .Core StOnce the adolescent has reached transition readiness, the adolescent and parents/guardians—in agreement with the patient—should be assigned an adult medical professional with expertise in SCD .Core StatementsContinuous specialized medical care throughout the vulnerable life phase of adolescence into young adulthood is crucial and must be ensured.The initial meeting with the adult physician should take place in the presence of the parents/guardians, and if logistically possible, be accompanied by the pediatrician.A structured transition letter for information transfer from pediatric to adult hematology is mandatory to ensure the adequate transfer of information and potential therapeutic options (form provided as part of the transition initiative) .Once an appropriate adult physician with the necessary expertise has been identified, the adult physician should be informed, ideally three to six months prior to the first joint meeting. As part of a comprehensive summary, the adult physician and general practitioner should be informed about the clinical course, including disease-specific complications and any current or planned upcoming therapies, to allow for a well-ordered medical transition. It is suggested to schedule an initial joint meeting in the presence of the parents/guardians, possibly with the involvement of social services. This first meeting should take place before the young adult reaches the age of maturity. Ideally, the pediatric expert would participate in this first visit. Optionally, this could also be conducted in the context of a virtual meeting. Depending on the needs, but especially in the case of emerging challenges that might endanger a successful transition outcome, the adolescent and the parents/guardians should be offered the opportunity for an additional joint meeting. For legal and other reasons, the patient’s consent for parental involvement at that time is required. This not only allows the adolescent the opportunity to build trust, but it also allows the opportunity for timely changes or the clarification of any misunderstandings that may exist from the patient’s point of view.An option for follow-up by the pediatrician, at least within the first year after the transition has taken place, is recommended. Another measure to monitor transition is the inclusion of patients in the “Sickle Cell Disease” registry, supported by the Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH). Based on the registry, follow-up complications will also be recorded as part of the annual status survey, thus offering the opportunity to measure the effectiveness of the transition . It shouCore StatementsAlways give the patient the opportunity to transiently return to his pediatric specialist if this is desired .In the first year after the transition, provide feedback on patient status to pediatric colleagues.In the context of adult care, young adults and their families/guardians should continuously be offered regular psychosocial support. It is well known that leaving a familiar environment presents an emotional stress factor. The goal is to improve care for these chronically ill young adults, strengthen compliance and ensure integration into the adult world, including medical care ,39.CoreSCD is a multifaceted, multisystem disorder associated with acute and chronic complications due to complex pathophysiological mechanisms that can affect patients physically, psychologically and mentally. The increased morbidity and mortality as compared with unaffected peers, as well as the rarity of the disease in Germany, together with structural requirements, lead to a particular need for national guidance on a standardized process and structure for the transition of adolescents and young adults with SCD in Germany .In addition to the national newborn screening (NBS) for SCD, which was introduced in October 2021, and guarantees the early identification of patients, the development and implementation of such a structured transition will further improve medical care, lead to a better quality of life and even increase chances of survival in the future, based on the prevention or at least early diagnosis and treatment of foreseeable chronic organ changes ,41. In a