Increased utilization of health services due to population growth affects the allocation of national resources and budgets. Hence, it is important for national policy. Home hospitalization is one of the solutions for dealing with the growing demand for hospital beds and reducing the duration of hospitalization and its costs. It is gradually becoming part of the regular care in many health systems, yet, studies on the economic aspects of Community-Based Home Hospitalization (CBHH) implementation in Israel are few. The aim of this study is to examine costs of CBHH in comparison to costs of inpatient hospital care in the Israeli public health system.Retrospective data was collected using document research in databases. A review of the costs of patients in CBHH at Maccabi Healthcare Services (MHS) was conducted. A total of 3374 patients were included in this study: 1687 patients who were in CBHH, and 1687 age- and sex-matched patients who were hospitalized in an internal department (the control group). The study population included the patients admitted to CBHH from January 2018 to July 2020, and patients admitted to internal medicine departments during the same period.The number of hospitalizations during the follow up period were statistically significantly lower in the CBHH group compared with the control group . In addition, the mean number of hospitalization days was also statistically significantly lower for 4.3 (SD = 4.5) for CBHH patients compared to the control group . Furthermore, the mean cost per day was statistically significantly higher for inpatient hospitalization compared to CBHH . Older patients, patients with diabetes and patients hospitalized in hospitals had a higher number of hospitalization days.The costs of CBHH seem to be lower than those of inpatient care. Managing CBHH is characterized by constantly measuring financial feasibility that would be an impetus for further development of this service. Population growth, and specifically the growth in aging populations, the rise in the rate of chronic morbidity, and grave budgetary predicaments that led to a lack of resources and medical personnel, have formed a situation in which many public health systems must deal with the challenge of deficient resources versus the growing demand for services .These challenges have not bypassed Israel’s public health system. The national expenditure on health in Israel is 7.3% of the gross domestic product (GDP), which is low compared to the average of 8.9% of the GDP in OECD countries ; NationaHome hospitalization is one of the solutions for dealing with the growing demand for hospital beds, and reducing the duration of hospitalization and its costs. Home-based hospitalization has several definitions. These include: “hospitalisation or active treatment of a patient at home for a predefined period in order to shorten an existing hospital stay or to prevent it in defined facilitating conditions” , and “a Notably, home care that does not replace hospital care is not included under the definition of home hospitalisation. Home hospitalisation is intended for suitable patients of all ages, but in practice more than 90% of patients are elderly, mainly aged 75 and older, who are hospitalised often and normally for lengthier periods than average. Therefore, home hospitalisation has entered medical consciousness and practice as a therapeutic tool in the world of geriatric medicine [Furthermore, hospitalisation is costly for health systems and is a health risk for many patients, including medical complications related to the hospital stay, such as infections that might be contracted during a hospital stay, falls, unnecessary tests, and mistaken medications, as well as potential cognitive and functional harm to patients, particularly the elderly, due to being in a strange place where they have no control over their fate , 33, 37.Since then, many countries have adopted and exploited the principles of the program and have developed similar services. For example, in Canada, the multifaceted evidence-based INSPIRED COPD Outreach Program  was first implemented in Halifax, Nova Scotia in 2010. Multidisciplinary healthcare teams provide a holistic home care services to the patients and their families . In the Australia (in the state of Victoria) Spain and France. Other countries such as Canada and England have local initiatives. In the United States, home hospitalization was recognized for Medicare funding at the end of 2020 as part of the Corona emergency provisions and the service has been in an accelerated support process since then., 24, 35.In recent decades, Israeli health maintenance organizations (HMOs), established various services to care for the population in the community and at home, but a home hospital service–where a patient receives services at home instead of being admitted to a hospital–did not exist. The HMOs are, not-for-profit health maintenance organizations which provide universal coverage to all citizens and permanent residents of Israel with access to a statutory benefits package. Specifically, to home care in Israel–inpatient hospitalization and home care are both paid in full and have a budgetary coverage by the HMO . Generally, Israel has a national health insurance system that provides. The healthcare system is financed by general taxes and an earmarked payroll tax . These funds are allocated to the health plans according to a capitation formula, with risk adjustment intended to sufficiently compensate the plans for the cost of members.In 2018, Maccabi Healthcare Services (MHS), the second largest HMO in Israel, was the first to establish a community-based home hospitalization (CBHH) program, because it understood that the patient’s place was in the community, and following the wish to improve patient's well-being and their responsiveness to care. This CBHH program constitutes a breakthrough and a first-of-its-kind model in Israel, and it is expected to result in reducing hospital overload and costs, while providing best personal care to patients requiring hospitalisation. CBHH represents a dramatic change to the traditional concept of acute hospitalization, as well as an organizational change that must be managed within the Israeli health system.Maintaining financial resource management and reducing health costs is a significant challenge and a necessary need for the continued existence of any health organization. According to Perroca and Ek , who revA three-year comparative study between patients in home hospitalisation and a control group of patients in hospital care, conducted among 507 adult patients in New York showed that patients in home hospitalisation had shorter acute hospitalisation, less complications, less repeat hospitalisations, and lower costs than the control group , 14. repWhile, in the long run, the introduction of new medical services and technologies has the power to reduce future health costs as shown in several studies that have examined the economic effects of chronic illness , 25, in There are many studies on home hospitalization in the Western world; however, there are limited studies about the cost compared to inpatient hospitalization. Specifically, in the State of Israel where CBHH is a new phenomenon, the subject has hardly been studied.Thus, the objective of this study was to examine costs of CBHH in comparison to costs of inpatient hospital care in the Israeli public health system. The provision of an empirical assessment of costs enables understanding the economic feasibility of the service.What is the cost of CBHH compared to the cost of inpatient care in the Israeli public health system? Our hypothesis was that the cost of CBHH would be lower than the cost of inpatient care.In order to examine and compare the total cost of CBHH to that of inpatient care, retrospective data was collected using document research in databases.A review of the costs of patients in CBHH at Maccabi Healthcare Services (MHS) was conducted. The study population included patients admitted to CBHH from January 2018 to July 2020, and patients admitted to internal medicine departments during the same period. Admission criteria require that the patient suffer from.chronic diseases, such as cardiovascular diseases, Hypertension or Diabetes. Oncology patients or those who had undergone transplantations, were excluded from the analysis. The control group was matched 1:1 by sex and age to the CBHH population. A total of 3374 patients were included in this study: 1687 patients who were in CBHH, and 1687 age- and sex-matched patients who were hospitalized in an internal department (the control group). Baseline characteristics of CBHH patients vs. the control group were compared using chi-squared test for categorical variables and t-test for independent samples for continuous variable. No statistically significant differences in sociodemographic characteristics were found between the study groups. The descriptive statistics of the study population are presented in Table Data were collected from the MHS Business Intelligence (BI) system. The MHS database contains longitudinal data on a stable population of 2.3 million people insured by MHS. Data are automatically collected, and include comprehensive laboratory results from a single central lab, full pharmacy prescription and purchase data, physician visits, imaging, and extensive demographic information on each patient. The database includes several automatically formulated registries including diabetic, cardiovascular and hypertension registries.Significant differences in baseline characteristics between the analysis groups (CBHH vs. control group) were determined using chi-squared test for categorical variables and t-test for independent samples for continuous variables. A two-sample T-test for independent samples was applied to test the statistical significance of the difference between the CBHH group and the control group in the dependent variables, hospitalization days, and cost. All tests were two-tailed, and a p-value of 5% or less was considered statistically significant. All statistical analyses were performed using SPSS version 25 (IBM Corporation Inc.).In this study, the hypothesis was that CBHH would have lower cost compared to inpatient care. Table The number of hospitalizations during the follow up period (January 2018-July 2020) were statistically significantly lower in the CBHH group compared to the control group .The mean number of hospitalization days was also statistically significantly lower for 4.3 (SD = 4.5) for CBHH patients compared to the control group .The mean cost per day was calculated by dividing the direct hospitalization cost by the number of hospitalization days (presented in cost units). The mean cost per day was statistically significantly higher for inpatient hospitalization compared to CBHH. .Hence, the hypothesis was confirmed.2 = 5.6% (p < 0.001). So older patients, patients with diabetes and patients hospitalized in hospitals had a higher number of hospitalization days  on hospitalization days, showed that age, diabetes and study group were significant, with an explained variance of Rys Table .Table 3MIn summary, the analysis showed that the costs of CBHH are significantly lower than those of inpatient hospitalization. The cost of CBHH is lower despite the fact that the CBHH group included more chronically ill patients than the control group, but nevertheless they did not utilize more days of hospitalization. This fact strengthens the hypothesis that the costs of CBHH are lower than those of inpatient hospitalization.This finding is consistent with the literature discussing the fact that contemporary health care organizations face a shortage in many areas and require quality, low-cost alternatives to first-line appointments with medical service providers and inpatient wards .The perception among stakeholder managers in the Israeli public health system is that aside from the health benefits of CBHH for patients, it is also very important to develop the service as one that may reduce the costs of hospitalization in the entire health system. HMOs have begun to develop CBHH services in the last three years under the assumption that they will be able to save hospitalization costs.The findings of the current study show that the costs of CBHH are significantly lower than those of inpatient care, in the research group versus the control group. Moreover, although in the research group there were more chronically ill patients than in the control group, patients in CBHH still had less hospital days and their cost was lower.This finding can be explained by the fact that chronic patients have a higher probability of complications in inpatient care due to their underlying health problems, which may lead to extended hospital hospitalization days and expenses for additional tests and treatments. These additional expenses are saved in the treatment of chronic patients with CBHH. Reinforcement to this finding is provided by the literature. Several studies have reported that CBHH costs were lower than the costs of inpatient care , 34, 35.The discussion should be concluded with the understanding that even if there is no blanket agreement at present that CBHH services are necessarily financially feasible for all public health systems, many countries in the Western world are constantly developing additional innovative CBHH services, while expressing trust in the service and recognition of the need and of the many advantages, including long-term financial feasibility. The current study sheds new light regarding the financial feasibility of Home hospitalization (HH). As a substitute to in-patient care, this is an interest growing domain, particularly amongst the elderly, but there is still a debate about the general economic justification.The study included relatively small sample size, its cross-sectional design, which only allows to view the results in a specific point in time. It is possible that the study population does not represent all the insured patients in Maccabi Health Services. Furthermore, much more clinically robust and detailed information on function, cognition, frailty, mental health, and medical complexity is required to have any confidence that the groups are comparable. It is possible that the study population does not represent all the insured in Maccabi Services and Health and in Israel in general. In addition, the calculation of the specific medical costs and medical dimensions that may affect the costs should also be examined in follow-up studies. This is a preliminary study and more studies should be done in order to claim that home-based care is more cost-effective than hospital-based care.The findings of this study promote the understanding that CBHH is an economically viable service to the healthcare system. The conclusion emerging from this discussion is that managing CBHH is characterized by constantly measuring financial feasibility that would be an impetus for further development of this service.


Human Papilloma Virus (HPV) infection is the most common sexually transmitted disease and the leading cause of cervical cancer. The undeniable causal link between HPV and cervical cancer led to the creation of HPV prophylactic vaccines. Health professionals are key in counseling parents about their children's immunization, as they are considered valid and reliable sources of information. The systematic review aimed to determine doctors' and nurses' knowledge of HPV, their awareness of the vaccine, and their willingness to accept vaccination. Systematic studies were conducted from 2015 to January 2022 in Medline/PubMed and Google Scholar online databases. The systematic review included 10 good-quality cross-sectional studies and a total of 6700 participants who were administered self-administered questionnaires or personal interviews. From the analysis of most of the studies, it is demonstrated that health professionals have a satisfactory level of knowledge about HPV infection and its effects on human health, even if their knowledge gap in essential details regarding the virus and HPV vaccination is apparent. It was found that various factors regarding health professionals, such as their specialty, gender, working environment, weekly working hours, and the interval since their last HPV training, contribute to forming their knowledge level about HPV and vaccination. In addition, most studies show that most healthcare professionals knew about the existence of HPV vaccines but did not know many details about how their work and their potential benefits. In conclusion, the provision of counseling by health professionals is currently estimated to be the strongest predictor of target group compliance with the HPV vaccine. Consequently, it is essentially considered to investigate the HPV-related knowledge level among health workers and to intensively reeducate them regarding the HPV infection risks and the necessity of HPV vaccination to improve their awareness and strengthen their attitude in favor of vaccination against cervical cancer. Human Papilloma Virus (HPV) is a small DNA virus that interacts with squamous epithelium. HPV infection is the most common heterosexual and homosexual sexually transmitted disease worldwide ,2. AlthoMore than 170 different HPV types have been identified that infect stratified epithelium . DependiPersistent viral infection with high-risk HPV genotypes causes almost all cervical cancers (99.7%): 60% of vulvar cancers, 70% of vaginal cancers, and 93% of anal cancers -10. HPV Establishing a causal relationship between HPV and cervical cancer led the scientific community to decide to create HPV prophylactic vaccines. Today, three vaccines are available: the bivalent vaccine, which protects against types 16 and 18; the quadrivalent against types 6, 11, 16, and 18 and the nine-valent HPV vaccine, which protects against types 6, 11, 16, 18, 31, 33, 45, 52 and 58. Despite the wide availability of prophylactic HPV vaccines over the past 15 years, vaccination coverage remains low . In low-MethodologyThe method used with the research hypothesis of our study is the systematic review of the literature. Our study aims to determine health professionals' knowledge about HPV, awareness of the vaccine against the virus, and willingness to accept HPV vaccination. Studies conducted up to December 2021 were included. The systematic bibliography review aims to identify, assess, and select well-designed studies relevant to our research hypothesis according to predetermined and clear scientific criteria. After defining the research question and searching for the relevant studies in the international literature, the inclusion and exclusion criteria of the studies, the searching process flowchart and selected studies, the summary table, and the evaluation of the quality of the selected studies are in each case steps of decisive and prominent importance for the successful realization of the systematic literature review.Description of Search StrategyThe international literature search was carried out in the electronic database Medline/PubMed and Google Scholar with keywords, as shown in Table The literature search was also carried out through additional records relevant to the subject under investigation and resulted from searching other data sources, such as communication with specialized health scientists, conference proceedings, and doctoral thesis.Study Inclusion and Exclusion CriteriaThe search was based on the following study inclusion and exclusion criteria:Language of publication: Research published in the English language.Date of publication: Research published after 2015.Study content: Surveys analyzing the relationship between recording health professionals' knowledge of HPV and acceptance of HPV vaccination.Type of Study: Contemporary studies, cohort studies, observational studies, and quantitative studies published in scientific journals and conducted in different countries can be included. Only studies of which the full article is accessible will be included, considering that the study's design has recorded the available literature without altering the final non-results.Study sample: The sample size of the included studies should be >-50 to consist of male and female health professionals.Reporting: Participants in the included studies should answer the questionnaires or interviews by themselves; in studies where others answered the questionnaires, the study participants will be excluded.Outcome: Studies demonstrating the relationship (or lack thereof) between HPV knowledge and awareness and acceptance of vaccination will be included in the review. Ideally, studies that identify the influencing factors and the best interventions to increase awareness of the HPV vaccine will also be included.Studies from the most authoritative medical science journals, all peer-reviewed, were included.Flow ChartThe visualization of the results of the strategic research was done with the flowchart Figure , in whicSelection and Presentation of StudiesTable Evaluation of the Quality of the StudiesThe evaluation of the studies, as shown in table This scale assesses eight items and uses a star system with a maximum of 9 stars to evaluate non-randomized studies on three criteria: selection of patients or study groups (4 stars), comparability of study groups (2 stars), and its finding on the exposure or outcome of interest for case-control or cohort studies, respectively (3 stars). Studies that scored six stars or more are considered good quality. The above rating scale provides an easy and reliable way to assess the clarity, completeness, and quality of non-randomized studies to be used in a systematic review .ResultsOf the 60 studies that emerged from the systematic online search using the keywords, individually or in combination, as shown in table In most studies, it appears that health professionals worldwide, despite showing severe knowledge gaps in essential details regarding the virus and HPV vaccination, had a satisfactory knowledge level about HPV infection and its effects on women's and men's health. Also, most studies show that most healthcare professionals worldwide were aware of the existence of the HPV vaccine but did not know many details about how the vaccines work and the potential benefits associated with the HPV vaccination.An important result of the present research study was that health professionals, especially those in low-income countries, are unwilling to recommend the HPV vaccine to young women and girls. Nevertheless, it is found that after completing some educational processes - interventions during the study, health professionals seem to change their attitude and are more willing to recommend the vaccine to their patients. This fact indicates the need for regular re-education of health professionals regarding the risks of HPV infection and the necessity of vaccination against cervical cancer.DiscussionSeveral studies, mainly from developed countries, have shown that the level of knowledge about HPV, vaccines, and acceptance of prophylactic HPV vaccines among healthcare providers varies from low to high. Health professionals in both developed and developing countries play an essential role in immunization programs, especially those related to childhood diseases, as they are used to administer prophylactic HPV vaccines and contribute significantly to the health education of the general population. It is now estimated that the success of an immunization program against cervical cancer is highly dependent on health professionals' knowledge, attitude, and behavior towards HPV, the infection caused by the virus, and prophylactic HPV vaccines.From the analysis of the results of the present study, it appears that worldwide the knowledge of health professionals about HPV is at a reasonably high level. It is estimated that 60%-80% of participants demonstrate a high to very high-level knowledge of HPV infection. Nevertheless, various factors may influence the level of knowledge of health professionals. In half of the studies included in the systematic review, it appears that the level of awareness of a high risk of oncogenic HPV types was observed to be significantly differentiated between health professionals of different specialties -22. MoreAlso significant were the differences observed in the level of knowledge about HPV and prophylactic vaccination between health professionals working in regional and urban health centers. Health professionals in urban centers presented a higher level of knowledge than their colleagues working in health centers in rural areas uniformly across all income countries ,22. In aThe present study also investigated participants' attitudes toward HPV vaccination and their willingness to be vaccinated or to recommend the vaccine to others. In most studies, it appears that although most participants had a moderate to a high level of knowledge about HPV, the knowledge regarding the characteristics and pharmacological properties was relatively low. This resulted in participants needing help to commit to participating in the vaccination program and recommending the vaccine to the population. More specifically, in 2016, Chawla et al. showed that only 47% of participants would recommend the HPV vaccination to young women, even though 81% were aware of vaccines to prevent cervical cancer . Later iIn contrast, a recent study showed that the medical staff was more willing to recommend the HPV vaccine than health professional students. This may be related to greater work experience and easier acceptance of the cost of the vaccine by healthcare professionals rather than the level of knowledge about HPV and vaccination. However, a high level of knowledge appears to positively influence willingness to be vaccinated, independent of education and per capita family income .Also, Ebu et al., analyzing the reasons for a negative attitude toward vaccination, found that the largest percentage of unvaccinated participants agreed with the statement that there was limited information about HPV vaccination. Also, in the same study, statistically significant correlations were found between age, marital status, level of education, and duration of work in a health facility with the acceptance of HPV vaccination . In contAn important finding of the present study is that health professionals had relatively good self-awareness regarding the level of knowledge about HPV and vaccination.Specifically, in Sherman et al. 2018 study, it was found that 63.7% of participants agreed that they were adequately informed about HPV, and 73.3% agreed that they could confidently answer patients' questions about HPV [The results of the present investigation suggest that education about HPV, particularly the use of HPV testing in the screening program, is necessary to address some worrying gaps in healthcare professionals' knowledge levels. The need for healthcare professional education is further reinforced by the fact that over a third of participants in the studies included in the systematic review did not agree that they felt adequately informed about HPV. Some made suggestions for training the health professionals of the participants. A good suggestion made by UK nurses was online education . Online Also, the important results of the present research include the fact that knowledge about HPV infection and transmission was worse among medical students compared to medical staff. It cannot be ignored that a significant proportion of medical staff and a greater proportion of medical students are unaware of basic information about how HPV is transmitted. This fact is a strong reminder of the lack of education about HPV in developing and developed countries. It is imperative to formulate educational programs to improve the knowledge level of the community and health professionals. A recent study from Sweden showed that 68% of patients prefer to receive preventive knowledge about HPV from doctors and health professionals, which may be a method to help increase awareness worldwide .Study limitationsThis review is subject to certain limitations. First, there are studies by research groups published in a language other than English, with the result that the published material used may have been underrepresented. It is also possible that some studies explore the knowledge of HPV among healthcare professionals but did not record the other recommended keywords and were not included in the studies under analysis, as they were considered not to meet all the criteria. Finally, the design followed in this review has recorded the available literature without altering the final results.Health professionals play a key role in providing advice to parents on their children's immunization, as they are considered valid and reliable sources of information. Counseling by healthcare professionals is currently estimated to be the strongest predictor of compliance of target groups with the HPV vaccine. Therefore, it is considered very important to regularly and systematically investigate the knowledge related to HPV among health workers to improve their awareness and strengthen their attitude toward cervical cancer vaccination.Healthcare professionals must be prepared to support their role, recommend the vaccine, and address their patients' potential concerns about HPV. To this end, health professionals should have access to multiple sources of information, such as seminars, conferences, and scientific literature, which can make a significant contribution through general education to increasing the level of knowledge and awareness about HPV and vaccination. Regarding the improvement of education for HPV, it is pointed out that continuous online medical training in the context of cervical cancer screening has favorable effects, especially in increasing knowledge and enhancing the adoption of clinical guidelines.


Most school myopia results from an excessive axial length of the eye that develops in childhood. In the past three decades there were significant increases in the prevalence of childhood myopia. By 2050, half of the world population is expected to have myopia, a 2-fold increase compared to year 2000 . In the Shi et al. conducted a study on temporal and spatial characterization of myopia in China. The authors showed that there was an increase in the prevalence of myopia in children aged 7–18 years old from 1995 to 2014. The study results also showed a shift of myopia to the southeast, identifying the existence of high-risk areas. Those results are important for targeted myopia prevention.Myopia has become one of the fastest-growing eye health challenges of the twenty-first century, with a disproportionate burden on urban Asia regions . Shi et Li, Tan et al. showed that sleep quality, duration, timing, and the consistency of specific sleep factors were not associated with myopia among school-aged children. Xu et al. reported that puberty status among adolescents may be an independent risk factor for myopia in girls but not boys, suggesting that earlier puberty in girls explained a significant proportion of the sex disparity in myopia prevalence. However, detailing the public health implications of both study findings requires further longitudinal studies with more accurate measures of sleep and puberty status.Myopia is a leading cause of visual impairment and blindness across many countries . Many myLimwattanayingyong et al. reviewed the evidence supporting the association between environmental and social factors and myopia resulting from the COVID-19 Pandemic. The authors found sufficient evidence to support the association between an increase in near work from home confinement or a reduction of outdoor activities and worsening of myopia during the COVID-19 lockdown. The findings from this review may help to better understand myopia development and progression, and lead to recommendations to prevent myopia and its progression. Efforts to reduce the prevalence, progression, and severity of myopia could have a profound impact on public health. Keel et al. propose a digital message program named “WHO-ITU MyopiaEd Programme” targeting education on myopia and its prevention. The program aims to strengthen countries' efforts to develop sustainable, cost-effective, and acceptable activities to support education on myopia and its prevention. Those programs may need to be implemented taking in consideration the diversity of eye care behaviors among adolescents. According to Li, Wang et al. there are differential profiles related with basic demographic characteristics and visual acuity development. Personalized group intervention for students in different latent classes behaviors may enhance the intervention results.The pandemic lockdowns established by the authorities for curving COVID-19 pandemic led to detrimental effects on myopia development due to a significant decrease in outdoor time and increase in near work activities , 5. LimwShan et al. conducted a bibliometrics analysis to help researchers to comprehend the global trends of myopia research from 1900 to 2020. Research Topics were clustered into six groups, with “prevalence and risk factors of myopia” and “surgical control of myopia” being the largest groups with higher number of publications. With the increasing prevalence of myopia, interventions to control myopia progression are a potential research hotspot and pressing public health issue. Shinojima et al. conducted a mini review on the current evidence-based treatments for myopia progression, such as atropine eye drops, optical treatment with defocus and orthokeratology. New research with optical treatments also showed good efficacy in the control of myopia progression. However, there are other factors that need to be considered, such as the uptake by eye care practitioners that can be improved if more education is given. Yang et al. conducted a study on eye care practitioners and their influence in prescribing myopia control. The authors found that the cost of myopia control is of concern to eye care practitioners. Further research is also required to establish the minimum age, amount of myopia, and progression to start prescribing myopia control interventions.Myopia is a chronic condition where the evidence is changing at an accelerated pace and 1,000's of research studies about myopia have been published within the last 100 years. Matsumura et al. outline the importance of obtaining an accurate family history of myopia to identify at-risk children before they develop myopia and to raise awareness on lifestyle-based myopia prevention. You et al. analyzed longitudinal changes in refractive error among preschool children and found a myopic shift of 0.20 D on average per year. The most important change in spherical equivalent occurred in 3-years-olds prompting the need for more prospective studies to better explain the factors related to refractive status changes and to prevent myopia in preschool children.Previous epidemiological research on myopia has been mainly focused on school-age children. However, it is essential to identify children at high risk of developing myopia to prevent myopia in an early stage, especially during the preschool period. The findings of a cross-sectional study by Tao et al. suggest that during the growth of school-age children, a significant correlation exists between axial length and height, and between axial length growth and height growth, especially in children with newly developed myopia. This indicates that during the period of rapid height growth, the elongation of axial length also needs to be considered. On the other hand, Lee and Mackey reviewed the findings from the Raine study in young adults with myopia. The results support that myopia can progress in the third decade of life, with some individuals progressing at alarming rates. Thus, it is also critical that longitudinal birth cohort studies in other populations increase their focus on research in young adults. Lan et al. showed that about half of the interviewed adults patients believed laser refractive surgery could cure myopia and its complications. The results of this study show that patients with myopia need to receive more education on laser refractive surgery and rhegmatogenous retinal detachment to increase early detection and potentially prevent the disease complications.To prevent myopia and its complications it is essential to unravel the causes that have produced the myopia epidemic in East and Southeast Asian urban environments. More research is necessary on the lack of outdoor exposure since an early age in childhood, and early high academic load of more than 10 h of schooling a day 6 days a week with short annual vacations, at which Asian children in many urban cities are exposed. The manuscripts published in this Research Topic show that the myopia epidemic has occurred along with urbanization and that myopia develops early since kindergarten years, continuing to progress in young adulthood. Recent changes in the tutorial classes education system by the government in China have been accepted by the society but myopia education programs are welcome to prevent myopia. One of the main concerns about myopia control is the cost effectiveness of the new available treatments. Thus, much has still to be learned and we hope the Research Topic of studies presented in this Research Topic of Frontiers in Public Health inspires, informs, and provides directions and guidance to governments and researchers in the field of myopia.CL prepared the original draft. RI and AG critically reviewed and edited the manuscript. All authors have reviewed and approved the final manuscript.All 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.


Polar codes are a relatively new family of linear block codes which have garnered a lot of attention from the scientific community, owing to their low-complexity implementation and provably capacity achieving capability. They have been proposed to be used for encoding information on the control channels in 5G wireless networks due to their robustness for short codeword lengths. The basic approach introduced by Arikan can only be used to generate polar codes of length  Polar codes offer many advantages for channel coding of information bits to be transmitted across a noisy channel, such as low complexity, provably capacity achieving capability and robust characteristics for short codeword lengths. Therefore, they are selected to be used for 5G wireless control channels . Additioshown in ,7,8,9. Ashown in ,14,15,16ormed in ,18. It wThe redundancy of bits in polar codes is implemented by segregating them in two sets, one to encode information bits and the other to encode frozen bits. Ideally, the bits that are polarized to high capacities should be used to encode information bits and the bits with lower capacities for frozen bits. However, different parameters such as channel condition, coderate and codeword length, can create a difference in the optimal choice of the sets of information and frozen bits. A wrong choice could lead to sub-optimal utilization of available channel capacity and consequently sub-optimal error rate performance. By including different kernel circuit designs and multi-kernel layouts in this paradigm, the optimal choice of information and frozen bits is complicated even further. Additionally, for higher kernel sizes, there exist a higher number of possibilities for valid polarization circuits and therefore a higher number of configurations of the corresponding multi-kernel designs. The increment of possible circuit designs to kernel sizes is exponential as shown in .This necessitates a technique to determine the optimal design configuration of polarizing circuits by taking into account all the aforementioned degrees of freedom. It is necessary to determine optimal code design before hardware-based implementation. Additionally, simulating Bit Error Rate (BER) or Block Error Rate (BLER) curves for all possible design configurations is an exceedingly time-consuming process due to an enormous number of design possibilities and the choice of frozen-information bits. Therefore, a simple analytical parameter that can predict polar code design optimality based on system requirements would significantly expand the usability of polar codes for many applications. To address this artifact, posed in , which iposed in . It was The rest of the paper is organized as follows. In The idea of channel polarization was proposed in . This inz-parameter values are obtained as follows ) dified by  for kerne C3/1d,  provide given in , the genW denotes the real bit channel. At the final output stage, for simplicity, we denote CnThe order in which the sets of two kernels would be concatenated;The position (stage #) at which the second kernel is to be placed if used just once.Limiting the analysis for two different kernels and sizes, we divide the aforementioned optimization problem into the following degrees of freedom to be tuned:Case 1 involves determining whether a kernel is used either in the initial or in the latter stages. Case 2 is used to determine at which intermediate stage would it be optimal to place a different kernel. The goal is to identify regularities that can be generalized to any kernel.In this section, we analyze the first case of kernel ordering mentioned in posed in  to quantUsing In In shown in  that C3/Comparing Overall, a general best kernel order, that fits all design parameters, is difficult to determine, since the behavior of the SDTS parameter depends on the coderate, the particular kernel used and the corresponding kernel order. Nevertheless, based on desired system parameters, optimized circuit design and kernel choices can be determined and vice-versa.n being the total number of stages in the polarization circuit. The In this section, we analyze the second case of kernel ordering mentioned in n. For the The same analysis is presented for different positions of A general observation is that performance optimality based on kernel position gets gradually less relevant with the increasing number of stages. This pattern is as expected since, with an increasing number of stages, the polarization effect from one specific stage gets diluted and becomes less significant within the overall polarization circuit. Therefore, it is more important to optimize the kernel order for a smaller number of stages, i.e., small finite codeword lengths. Additionally, erved in . Hence, In order to validate this hypothesis, a profile of the polarization over the position of From each of the four subplots, one can observe that it is beneficial to place In Based on In this section, the BLER results are presented for the case in In In Comparing mined in . Most imIn addition to the group-wise kernel order permutation, the SDTS parameter performance of different positions for a ervation b that foThe authors of  presenteThe effectiveness of the SDTS parameter has been successfully investigated for polarization kernels of sizes 2, 3 and 4 in the single kernel and sizes 2 and 3 in the multi-kernel paradigm. Naturally, an extension of this research would include identifying how useful The performance characteristics of higher ordered kernels have been identified by the SDTS parameter and its utility for optimization of polarization circuits to generate polar codes has been validated for single kernel polar codes in  and multFor the


In ideal circumstances, a fractured bone can heal properly by itself or with the aid of clinical interventions. However, around 5% to 10% of bone fractures fail to heal properly within the expected time even with the aid of clinical interventions, resulting in nonunions. Platelet gel is a blood-derived biomaterial used in regenerative medicine aiming to promote wound healing and regeneration of damaged tissues. The purpose of this paper is to review relevant articles in an attempt to explore the current consensus on the treatment effect of platelet gel on reconstructing bone defects and nonunions, hoping to provide a valuable reference for clinicians to make treatment decisions in clinical practice. Based on the present review, most of the studies applied the combination of platelet gel and bone graft to reconstruct bone defects and nonunions, and most of the results were positive, suggesting that this treatment strategy could promote successful reconstruction of bone defects and nonunions. Only two studies tried to apply platelet gel alone to reconstruct bone defects and nonunions, therefore a convincing conclusion could not be made yet regarding the treatment effect of platelet gel alone on reconstructing bone defects and nonunions. Only one study applied platelet gel combined with extracorporeal shock wave therapy to reconstruct nonunions, and the results were positive; the hypothetical mechanism of this treatment strategy is reasonable and sound, and more future clinical studies are encouraged to further justify the effectiveness of this promising treatment strategy. In conclusion, the application of platelet gel could be a promising and useful treatment method for reconstructing bone defects and nonunions, and more future clinical studies are encouraged to further investigate the effectiveness of this promising treatment method. Bone is a specialized tissue rich in cells including osteoblasts, osteoclasts, and osteocytes responsible for remodeling . BecauseThe U.S. Food and Drug Administration defines a nonunion as a fracture that is at least nine months old and has not shown any signs of healing for three consecutive months, while some authors define a nonunion as a fracture that has no possibility of healing without further intervention according to the treating physician ,20. The In current clinical practice, bone grafting including autograft and allograft is still the gold standard treatment method used to reconstruct bone nonunions ,24,25,26The drawbacks of current clinical treatment methods for reconstructing bone nonunions motivate researchers to search for alternative strategies in the field of biomaterials and tissue engineering ,34,35,36Platelet gel is a blood-derived biomaterial used in regenerative medicine aiming to promote wound healing and regeneration of damaged tissues ,41,42. PThe purpose of the present paper is to review relevant articles in an attempt to explore the treatment effect of platelet gel on reconstructing bone defects and nonunions. The information provided in the present review paper not only can be useful for clinicians to make treatment decisions in clinical practice, but also can motivate researchers to further investigate the treatment effect and underlying mechanisms of platelet gel on reconstructing bone defects and nonunions. Please note that, since the author of the present paper believes that the conclusions drawn from in vivo studies involving humans as subjects can most appropriately meet the intention of the present paper for providing information for clinicians to directly apply in clinical practice, the studies reviewed in the present paper are those in which the subjects are humans while the studies involving animals as subjects are not included.Studies using platelet gels in the clinical applications relevant to the reconstruction of bone defects in vivo were searched using two electronic databases including PubMed and Google Scholar. The combinations of keywords were used for the search, and the keywords included platelet gel, platelet gels, platelet-rich plasma gel, platelet-rich plasma gels, bone, bones, bony, defect, defects, fracture, fractures, non-union, non-unions, nonunion, nonunions, surgery, and surgeries. One of the four keywords, platelet gel, platelet gels, platelet-rich plasma gel, or platelet-rich plasma gels and one of the remaining keywords described above, must have been included in the title of the article. For each database, the time period for the search was from the earliest available date to 18 August 2022. The inclusion criteria for the search were: (1) original research articles and case studies using platelet gels in the clinical applications relevant to the reconstruction of bone defects in vivo; (2) the subjects involved are humans. The exclusion criteria were: (1) the article was not an original research article or a case study; (2) the study did not belong to the field of orthopedics, and the type of the tissue investigated is not bone; (3) the study was not an in vivo study; (4) the subjects involved are animals; (5) the language of the official website of the article is not English.There were 15 articles that met the search criteria. In the following, the main findings and methods of these articles are concisely and comprehensively described. The presentation below is organized into three sub-sections, categorized on the basis of the types of medical problems for which platelet gels are used in treatment. In each sub-section, the review of each article is presented in chronological order of publication. The treatment effect (positive or others) is mentioned in the first sentence in each paragraph describing the review of each article. The treatment strategy and effect of each article are summarized in In a study presented by Rughetti et al. , the autIn a study presented by Chiang et al. , the autIn a case study presented by Smrke et al. , the autIn a study presented by Mariconda et al. , the autIn a case study presented by Dallari et al. , the autIn a case study presented by Lusini et al. , the autIn a study presented by Leonardi et al. , the autIn a brief report presented by Franchini et al. , the autIn a similar study presented by Franchini et al. , the autIn a study presented by Savarino et al. , the autIn a similar study presented by Dallari et al. , the autIn a study presented by Feiz-Erfan et al. , the autIn a study presented by Sabbagh et al. , the autIn a study presented by Loquercio et al. , the autIn a study presented by Mostafa et al. , the autTo the best of the author’s knowledge, this is the first review paper that intends to conclude a current consensus on the treatment effect of platelet gel on reconstructing bone defects and nonunions. One of the hopes of the present review paper is to provide a valuable reference for clinicians, so that clinicians can decide whether they should apply platelet gel to reconstruct bone defects and nonunions in clinical practice or not. In addition, the author hopes the present review paper can motivate clinicians and researchers to conduct more clinical trials and clinical and basic studies to further justify the treatment effect of platelet gel on reconstructing bone defects and nonunions. In the present review paper, only 15 relevant studies were found using the designated keywords. This means that, to date, there are still few clinical studies intending to investigate the treatment effect of platelet gel on reconstructing bone defects and nonunions. More future clinical studies are encouraged to further investigate the effectiveness of this promising treatment method for reconstructing bone defects and nonunions.Most of the studies reviewed in the present paper applied the combination of platelet gel and bone graft  to reconstruct bone defects and nonunions. Of these studies, most of the results were positive, suggesting that the combination of platelet gel and bone graft could effectively enhance bone healing and regeneration and could be a promising and useful treatment strategy for reconstructing bone defects and nonunions. In this treatment strategy in which platelet gel and bone graft are mixed together, platelet gel can be regarded as a biomaterial used to tremendously enhance the treatment effect of bone graft. Numerous types and large amount of growth factors contained in platelet gel can largely enhance the healing and regeneration potential of the bone graft. In addition, the gelatinous and viscous platelet gel can help to strengthen the structure of the bone graft by keeping the bone graft firm, making it easier to fix the bone graft at the site of the bone defect and to densely fit the bone graft into the bone defect.Only two studies to date tried to apply platelet gel alone to reconstruct bone defects and nonunions ,60. In tOnly one study to date applied autologous platelet gel combined with extracorporeal shock wave therapy to reconstruct nonunions . The resBasically, in the studies reviewed in the present paper, there are two methods to apply platelet gel treatment. In most of the studies, platelet gel was applied by densely fitting it into the bone defect during surgery. In other two studies, platelet gel was percutaneously injected into the site of bone defect ,51. It cMost of the studies reviewed in the present paper lacked a matched control group, and it was a common limitation shared by these studies. However, the design of these studies was to investigate the treatment effect on recalcitrant atrophic nonunions that had been treated using previous clinical interventions but showed no signs of healing for a long period of time, and the results showed that most of the nonunions successfully healed after treating using platelet gel. Hence, the treatment effect could still be justified with such a study design even though there was no matched control group. Nevertheless, more clinical studies with matched control groups are still necessary to further justify the effectiveness of platelet gel to reconstruct bone defects and nonunions.Since firstly introduced in the early 1990s, the application of platelet gel has been successful in numerous clinical fields including oral and maxillofacial surgery. In fact, reconstructing bone defects in oral and maxillofacial surgery is one of the fields in which platelet gel was firstly applied. Some promising results have been reported ,66,67,68In conclusion, based on the review of the present paper, the application of platelet gel is a promising and useful treatment method for reconstructing bone defects and nonunions. The information provided in the present paper not only can be useful for clinicians to make treatment decision in clinical practice, but also can motivate researchers to further investigate the treatment effect and underlying mechanisms of platelet gel on reconstructing bone defects and nonunions. The present review found that most of the studies applied the combination of platelet gel and bone graft to reconstruct bone defects and nonunions, and most of the results were positive, suggesting that this treatment strategy could promote successful reconstruction of bone defects and nonunions. Only two studies tried to apply platelet gel alone to reconstruct bone defects and nonunions; therefore, a convincing conclusion could not be made yet; more future clinical studies must be conducted to understand the treatment effect of platelet gel alone on reconstructing bone defects and nonunions. Only one study applied platelet gel combined with extracorporeal shock wave therapy to reconstruct nonunions, and the results were positive; the hypothetical mechanism of this treatment strategy is reasonable and sound, and more future clinical studies are encouraged to further justify the effectiveness of this promising treatment strategy. Platelet gel can be applied by densely fitting it into the bone defect during surgery, or can be applied through percutaneous injection; it can be imagined that these two application methods are fundamentally different and could lead to different treatment effects, and more future clinical studies are needed to further understand the difference in the treatment effect between these two application methods. Overall, in the present review paper, only 15 relevant studies were found using the designated keywords. This means that, to date, there are still few clinical studies intending to investigate the treatment effect of platelet gel on reconstructing bone defects and nonunions. More future clinical studies are encouraged to further investigate the effectiveness of this promising treatment method for reconstructing bone defects and nonunions.


The post Covid-19 era steer towards stakeholder thinking, which demands to look for sustainable solutions in terms of other epidemics and food security is one of the most notable for the developing world. In South Asia, China Pakistan Economic Corridor could be an avenue for multi-layered socio-economic assistance where Pakistan can seek solution for one epidemic (food security) while engaged with the effects of pandemic through studying all the stakeholders. This could be a roadmap for the west-east or developed-underdeveloped countries reliance on one another for food security through economic corridor alike settings. Academically, it has been projected by the plethora of research that holistically and inclusively, stakeholder analysis is lacking in the available reservoir of research. Methodologically, the stakeholder analysis was performed in three layers–identification, investigation through social networks, and communication by prioritization matrix. The findings suggested that apart from stakeholders’ differences in regard to interest, influence and knowledge, all of them agreed with the argument that China Pakistan Economic Corridor has enviably and irrefutably positive effects on food security. The policy implications project the need for integrated reports of various ministries to be unidirectional for having synergical effect and taking all the stakeholders into consideration as leaving any group behind will repeat the past results. The pre-pandemic ages were projecting the need, the epidemic highlighted it and now its more vital to have the readiness and prepare for bracing in the future as food security has gained significant importance and has become a part of sustainable development goals. Nevertheless, over the last three consecutive years, world hunger has risen, clearly indicating the intensifying intensities of food insecurity among nations. According to Food and Agriculture Organization  depictedth out of 189 countries; the value of Pakistan is 0.557 out of one, which is lower than the average value of South Asia and the World 0.641 and 0.957, respectively. The ranking of Pakistan’s undernourished population is “serious” hunger level with a score of 24.6, ranks 88th out of the 107 countries, by Global Hunger Index [According to a report by the World Food Program , about 3Behind the situation of hunger in Pakistan, the possible reasons might include a lack of adequate research and development programs to produce a worthy assortment of seeds; pitiable formation; an inappropriate supply chain system; incompetent marketing; and a dearth of accurate government involvement in the agriculture sector. The pitiable performance in the agricultural sector is heading towards the severity of food insecurity. It is also hazardous to health and economic conditions in the future , 6. To gIn this regard, the covid-19 outbreak also proved to be an important factor that causes food insecurity not only in Pakistan but all over the world. In the year 2020, COVID-19 destructed the world economy and pulled it into a recession that was not even recorded after WWII. The recession of the world economy has rung the bell of food security in developing economies and well as some populations of developed economies too. This population includes women, children and older.According to the report of WFP , an estiThis study comprises of the literary synthesis that theoretical framing and review of literature, followed by the methodology section that includes research design, ethics statement the Institutional Review Board statement. The identification level section is about stakeholder listing, data collection, challenges in data collection for stakeholder analysis and outcome, perspectives and characteristics of stakeholders. The investigation level (prioritization) and communication level lock the three stages of stakeholder analysis. The results underline the social network analysis and the prioritization matrix. Afterwards, the discussion of qualitative analysis, conclusion, limitations, recommendations for policies formation and lastly the future research encapsulates the research endeavour.The theoretical framework of the study is projected by the fact that in Pakistan, about a quarter of the population (around 53 M people) lives below the national poverty line . AccordiThe pressing question is how it can happen?. Practically, the most important question for a developing nation like Pakistan with little savings, having a lesser capability to utilize its resources, and fewer internal investment opportunities available is how efficiently can we tackle it? So, while taking proactive actions, least developed countries are supposed to think about cost-effectiveness as well. Among the various solutions, as suggested by several developmental organizations, FDI might be the best one for developing nations because of its prospective to regulate the variations  and closThe active role of foreign investment, through its impact on agricultural productivity, cannot be denied , 17. WhiHistorically, Pakistan has faced a series of challenges regarding food access to the masses and agricultural sector productivity, and now China-Pakistan Economic Corridor provides a way to cultivate stability within Pakistan . The imaPakistan has been blessed with the world’s best fertile land and irrigation system, and it is greatly dependent on its irrigation system for food production as it supplies 80% of the country’s wheat, pulses, and nearly all other crops . With coScientists are concerned that with traditional methods of cultivation, the agricultural output in Pakistan is likely to reduce, which further generates a risk of food insecurity. Ms Sonny Tabbaba (The director of biotechnology affairs of the organization) and Dr. Siang Hee Tan discussed that modern technology ought to be adopted in the agriculture sector of Pakistan. They urged on the need for government involvement to introduce modern agriculture techniques to grow more crops for the growing population of Pakistan. The executive director of Crop Life Pakistan, Dr. Muhammad Afzal, said that it is vital to obtain enough healthy food for the country without the use of modern technology in the agriculture sector. Reference to the researched data reservoir of , countriAlthough the literature is growing on the linkage between economic corridors, FDI, and food security, there has still been a dearth of studies conducted in developing countries. As per our best knowledge, none of the studies has investigated the relationship between CPEC and food security in Pakistan.In this context, the main intent of this research is to examine the perceptions of various stakeholders involved in the recent FDI of China in Pakistan, namely, the “China-Pakistan economic corridor” on the food security situation of Pakistan and, to further analyze these perceptions by a mixed approach to construct a somewhat evocative conclusion that may guide Government and policymakers to develop and advance the food security measures. The academic literature on this theme is altogether missing in the context of CPEC, so it requires a deep discussion to direct researchers for future work.Our research uses stakeholder analysis to study the food security situation from the CEPC perspective in Pakistan. Firstly, as per our best knowledge, none of the previous studies attempted to use a qualitative analysis by using an innovative method of analysis, i.e., stakeholder analysis (SA) in the field of investment programs related to the no hunger goal. Stakeholder analysis would be helpful to include all those people who have an interest in it or are affected by the programs, strategies, and plans of the CPEC’s initiatives.In the field of management, many scholars used stakeholder analysis according to their scope of studies , 33. MarFurthermore, stakeholder analysis has also been used in the field of the marine environment , coastalThe design of stakeholder analysis is aimed to assess the vitality of CEPC and its understanding of the stakeholders. In conducting the analysis, the researchers ask questions from the stakeholders about their status, stake, influences, interest, interrelationships, links, and potential dynamics ranging from past to future –54. TheiThe consent was informed and documented as well as witnessed because all the respondents were experts and leaders/competitive authority chairholders of their institutions. Moreover, the consent was initiated through verbal consent followed by email as well.At university level, the ORIC  exercised the role of an IRB  and approved the study. It was then forwarded to the Higher Education Commission of Pakistan (HEC) for vetting and approval at national level, in order to be awarded the grant under the Start-Up Research Grant Program (SRGP). Finally, the National Academy of Higher Education of HEC approved the research project. After that the research project was initiated by going through exhaustive assessment and approval at university and national level.Freeman  proposed3.4.1.1. Stakeholder listing. The diverse groups of stakeholders were identified after carefully examining their link to CPEC and food security. To select these stakeholders, it is very important to keep in mind that their perceptions could help us with policy implications as well. An initial list of stockholders was chalked out using the following criteria: (1) national professionals working on development policies, specifically FDI-related and food security policies; (2) academic institutions; (3) affiliation to professionals’ agriculture development networks. After identification of stakeholders, they were asked to refer other actors who have a stake with CPEC. A snowball method has been applied here, and the list of stakeholders be extended by every new stakeholder [keholder .3.4.1.2. Data collection. Out of the 225 distributed questionnaires, 131 responses were received, while 127 were assessed to be valid only. The overall response rate amounted to 58% as the rejection rate for the survey that is self-managed goes around 20% [ound 20% . In addiound 20% , who obt3.4.1.2.1. Challenges in data collection for stakeholder analysis and outcome. The researchers faced difficulty to obtain data from the officials, due to the significance of their status in the respective organisations. This led to struggle for data collection that resulted in responses from 27 representative stakeholders from Government, 48 from academia, 29 from food security and agriculture departments and companies, and 23 from other food security consultancies, media, side area farmers, and NGOs. The stakeholders were categorized into the following groups: (a) Government; Ministry of National Food Security and Research (MNFSR), Planning and Development Department (P&D), National Agriculture Research Centre (NARC), Sustainable Development Policy Institute (SDPI); (b) Academic institutions; researchers mainly in the fields of food security management systems (FSM), Food Technology (FT) and agricultural engineering (AE); (c) Enterprises; energy, food engineering, storage, planning, climate and waste management businesses; and (d) others; media and NGOs.3.4.1.3. Perspectives and characteristics of stakeholders. To understand the perspectives and characteristics of stakeholders, more investigations were carried out after the identification of the stakeholders’ list. Stakeholder mapping or stakeholder analysis has recently been developed as a method to analyse the probable benefits and activities of stakeholders [eholders . This reStakeholder characteristics have been judged by respondents while asking questions related to their knowledge, interest, power, and their attitude towards CPEC in Pakistan, on a scale system from 1–5. Stakeholders’ power is valued by synthesizing their participation (Involvement), their information, and influence. The power/interest grid , as being the most suitable method for the problem concerned, was applied to investigate the relationships and concerns of the stakeholders. The respondents were asked further to list other actors or organizations with which they interacted as well as mentioned their interaction level by scoring 1–5. The scoring system of 1–5 indicates the rate of interaction level between individuals, groups, and institutions. Strong and close ties between the nodes are shown by higher scores. This is completely unpractical to give the same weight all the time to the stakeholders having the same group; rather, their level of intensity should be based on the stakeholders’ relevance which can promote stakeholder engagement .The term centrality in SNA points out the stakeholder’s position with high power, concern, status, importance, and popularity. The centrality position can be determined by its three attributes titled degree, betweenness, and closeness. The degree centrality attribute reflects the number of nodes having a direct connection with other nodes, regardless of the indirect connections between nodes. In the same way, betweenness centrality measures the level of the ‘intermediary’ effect. The third attribute, closeness centrality, about the distance between nodes, basically indicates the capability of the stakeholders for assessing the methods, information, and resources by being in the network . A reseaThe most centralized network has the characteristic of having a relatively large number of ties with other individuals in the network. Though centralized networks are beneficial and assistive in the initial stage while making groups and building support for collective activity , 64 but d = distance of the geodesic linkage between nodes Ni and NkLet’s take Nkis Cc(Nk)-1 = Nk and others. However, this is a simple measure, as it is a sum distance, Cc(Nk)-1 has a natural explanation. Of course, it only makes sense for the connected graphics. In an unconnected graphic, each point remains infinitely spaced from at least one other point, therefore,Then according to Sabidussi’s  de-centrAll other distance-based metrics are functions of this sum and are therefore subject to the same limitations. In addition, they tend to increase pointless and confusing complications, making them difficult to explain. Sabididsi’s measure is proposed by his straightforward explanation.Nk [d projecting the Ni and Nk. geodesic-linkage distance.Sun et al.  argued tNk , 68, havTherefore, the centrality could be determined by a point by referring to any of the three different structural properties of the point: its degree, betweenness, or its closeness. The choice of specific structural attributes and their related measures depends on the context of the expected substantive application . Hence, To make a prioritization matrix of basic concerns of the stakeholders related to food security issues in the process of CPEC in Pakistan, the key problems and challenges to CPEC’s initiatives to cope with have already been discussed in the introduction section. In this section, a survey was conducted to evaluate the impact of CPEC’s initiatives in improving the food security issues in Pakistan. The questionnaire was initiated with basic information about One Belt One Road, a project of China, as well as a brief explanation of CPEC’s initiatives and its part in food security issues, and main issues of food security in Pakistan and its key factors, were discussed. The respondents were asked to give a rank to the impact of CPEC initiatives based on their understanding (from strongly negative to strongly positive). Further, their concerns were recorded for food security issues with a scale marked as ‘not at all concerned’ to ‘extremely concerned’. In addition, the stakeholders were persuaded to give their comments and suggestion at the end of our questionnaire. In the end, the results were calculated through categorisation based on weightage given by stakeholders, extracted through SNA.Stakeholder Analysis: From 127 valid respondents, all were aware of OBOR and CPEC.In The stakeholders from the academic sector, ranging from training initiatives to universities and research centres presented diverse knowledge and interest points. The highest level of knowledge and interest had been observed for FSM in terms of CPEC, as a direct connection with an investment in the agriculture sector on the strategic level of OBOR in Pakistan. On the other hand, FT and AE have less knowledge and interest in the Chinese FDI (CPEC). FT has general or common knowledge, but some degree of interest bearing in mind the investment impact on food production processes. In contrast, AE has less knowledge but more interest in the CPEC initiatives. The reason behind this is that most experts of AE are focused on the design, construction, and improvement of agricultural equipment. Academics and researchers have a strong positive attitude toward China’s foreign direct investment in Pakistan and have a strong positive attitude towards food security departments.Regarding enterprises, they have very little power and knowledge of CPEC, though their attitude towards it is positive. It is unexpected because enterprises are more concerned about economic development opportunities and investment. Finally, the stakeholder group like media and NGOs are not playing an important role, for the reason that they have the least level of knowledge and minimum level of power and interest regarding CPEC in Pakistan.In this step, the respondents had been requested to list other participants with whom they interacted  and their interaction level with them. Nevertheless, a maximum number of P&D and MNFSR. P&D is the chief in this system of interaction and information exchange, as it is closely linked to all other stakeholder groups of Government, enterprise, academia, and others. MNFSR is also central in the network for the reason that it has a strong bond with P&D and companies, as well as it is a national food security monitor in the process of Chinese FDI in Pakistan (CPEC). Compared to other groups in the network, the highest degree of closeness with other stakeholders is observed in terms of companies.In To assess the CPEC’s anticipated impact on the various objectives of different stakeholders, some food security-related issues were selected based on the great concern of governments, enterprises, academia, and other organizations . Besides this, as per the Chinese investment in the clean energy sector, all stakeholders were persuaded that CPEC in Pakistan can fetch a positive and strong effect on all dimensions of energy, ranging from access to effective utilisation and management of renewable energy. Likewise, the employment rate, transportation as well as innovative techniques for the agriculture sector are elevated and anticipated for a strong positive impact. Accessibility to market received the most positive results from 2 groups of stakeholders as they believe that CPEC can bring a positive impact on infrastructures, which will help to improve the access of farmers and others to the markets.Some issues showed divergent impacts by different stakeholders. The results show that enterprises and the government have considered the important issues of water consumption and resources. It is expected by the government actors that a positive effect is connected to the consumption of water resources (0.74) because they seem to believe that the Government will propose positive actions. For example, under international observation, strict legislation and implementation will emerge. According to NARC, CPEC will facilitate better planning, management, and monitoring related to water consumption in an agricultural area. Therefore, with the improvement of composition and technical effects through advancement in industrial structure and access to technology-backed production, there can be a positive effect on water consumption .Contrariwise, the negative effect on consumption of water resources is believed by the actors of enterprises and others (-1.55 and -1.01), which sources the reason from the fact of water consumption in infrastructure construction and power plants operational requirements.The Government, the key informer, believes that innovative agricultural techniques would be a positive impact on CPEC initiatives’ which will definitely increase the nutrient food production and thus enhance the availability of food; further, this food will be easily accessible to common people.Furthermore, some stakeholders also mentioned the international relations with neighbouring countries as a concern and threat to the CPEC initiatives. For example, in India, the Indian Government is particularly concerned about the China-Pakistan Economic Corridor, as it encompasses projects in conflict areas. It is a vital economic opportunity for Pakistan and the region as well but possesses the element of a dominance-losing threat to the Indian regime, in terms of the Indian Ocean –74.Overall, investment opportunities in energy and human settlements are evident, particularly in terms of energy use and employment rates, and respondents rated them as “highly concerned” and “positively impacted”. Except for the status of farmers, Others mentioned the negative (-1.01) impact of CPEC initiatives on farmer’s status , as they believe that CPEC’s strategy to lease and purchase agricultural lands may affect the possession of farmers, also advanced agricultural machinery will replace the workers and will cause of unemployment. So, here the challenge of Chinese investment is to enter the agricultural sector of Pakistan to put a positive part in food insecurity in Pakistan. Also, more attention should be paid to water consumption, considering the large amount of water required for infrastructure construction and power plant operations. These issues have been identified as priority areas for high assessments and pose a real challenge to China’s foreign direct investment. There is an element of degradable effects of CPEC initiatives on the Pakistani biodiversity-ecosystem, but these effects can be mitigated by long term planning and are not urgent.Stakeholder analysis has been a broadly used technique in the field of waste management, ocean management, and natural resource management. However, as per the exhaustive study and best knowledge of the researchers’, limited efforts have been made to the application of stakeholder analysis to assess the management of FDI. The case becomes even more apparent by researching developing economies. This gap has been addressed by studying the strategic investment projects, through stakeholder analysis, related to food insecurity and expounds on the network of investment amongst the stakeholders and the food security issues priorities of the Belt and Road in Pakistan.Our prioritization matrix  outcomesSince many of China’s investments is in energy and infrastructure, the belt and road could reduce manufacturing ratios over the long term, which could lead to some de-industrialization in Pakistan. In this regard, the non-intensive methods of food production could be employed in the long term. Furthermore, according to interviewees, there are many benefits and opportunities in the energy sector, particularly energy use. For the belt and Road focus on energy investment, the available energy reserves could be increased. As for Pakistan’s optimistic energy outlook, the energy consumption sector, such as manufacturing, is likely to benefit from economic growth. This can ultimately raise the use of advanced technology and technical equipment in the agriculture sector and hence help in improving food production, availability, and access. The transport sector investment, a vital project under CPEC could increase the transmission of agro-products between the provinces, which will overcome the problem of food wastage and enhance the food access of common people as the availability of food will also be increased via quick transport.Water consumption is the third biggest investment centred issue and an alarming problem area in Pakistan, as every sector like agriculture, energy, infrastructure, and industries must need water to work properly. Pakistan is facing a water shortage problem, and it is assumed that in 2025 country could run dry as this problem is reaching an alarming level. Therefore, the investment industry needs to shift focus toward productivity centred technological usage for water consumption. As a crux, in response to the international pressure, this needs to be done for the management and conservation of natural resources of the country and mitigate water-based pollution and safety hazards.The results revealed that road and transportation would generate employment opportunities, which will reduce unemployment and minimize poverty. This will decrease social problems and improve living standards. Moreover, it will provide access to education, health-care centres, banking, etc., to the local dwellers of Pakistan, which will lead to development and prosperity in Pakistan and will help in reducing food insecurity in Pakistan. The improvement has been done in terms of the stakeholder analysis model through a communication-based priority matrix, which projects the need for stakeholders’ investment concerns connected to food security and social issues.The bottom-line of the discussion stretch above, it has been also revealed that stakeholders of CPEC are optimistic to defeat the poverty caused by COVID-19. Approximately a quarter of Pakistan’s population (around 53 million people) lives below the national poverty line [This research studies the stakeholder characteristics, interaction, and priority issues of CPEC through stakeholder analysis and focusing on social networks for investigation and prioritization matrix regarding communication. Notably, all the stakeholders involved in this research have unanimously agreed on the argument that CPEC has a profound positive impact on food security issues in Pakistan. It has been made clear by the analysis that the improvement in infrastructure and other sectors would eventually have a positive impact on sustainable development goal 2 (food security) as there had been a narrow viewpoint on CPEC to be confined to infrastructure only.According to the stakeholders, the main issue related to food security in Pakistan is the low food production and accessibility of food. These two issues can be solved by the government policy to grant permission for easy entry of Chinese investors in the agriculture sector as they are leasing or purchasing agricultural land to produce more food with the latest technology, advanced machinery, superior seed quality, pesticides, the access to better agri-technology and smart financial assistance. Moreover, the infrastructural development through CPEC initiatives had a positive impact on agricultural growth and enhanced its market. The improved transportation facility eventually  would heOnce the impact of the investment becomes clearer, a similar survey can be conducted at a later date. The limitations of this research endeavour are steered by the need for crafting an improved list of social and food security issues based on a deeper insight into the problem. Moreover, investigate the reasoning behind the diversity in attitudes of stakeholder groups involved in the system. The exploration of measures that could identify the means and measures for mitigating the set of negative impacts through stakeholder analysis. To need to study the transnational effect of CPEC in terms of stakeholder actors of neighbouring countries and the international community. The problem of weightage in connection to the level of expertise and influence differences in stakeholder groups needs to be deeply assessed. This research is confined to the weightage of stakeholders based on their closeness and strength in social networks. Moreover, the hospitals and ministries related to health have not got updated data on health conditions of common people related to the food security specifically so the predictive capabilities of related to CPEC and food security were not recorded.The concerns of many participants of this research should be addressed to give some valuable points and clues for the policymakers involved in Chinese FDI and food security. Some stakeholders believe that the lack of government planning could cost Pakistani farmers a far-reaching agreement with China. Farmers in Pakistan complain that the lack of detailed public information makes them ignorant of their expectations of CPEC-related agricultural projects and that they cannot verify what the Government has done to protect their interest’s vis-a-vis China. This lack of transparency–perhaps a lack of government preparation–could plunge the country into the failure of other promising economic partnerships at a time when Pakistan is driving CPEC’s prosperity for decades to come. Moreover, the absence of uniformity in diverse reports from numerous government and other organisations creates information clutter that could inhibit factual clarity for workable, action-oriented and insightful policy formulation endeavours and exercises.The further studies need to focus on the CPEC in terms of health, nutrition based disease control and food security by making it a trilogy with the corresponding SDGs. Another step towards future research would be take the stakeholder analysis to deeper level and applying various softwares that have the capability of extracting more complex and overlapping links. The human development index and SDGs linked to food security through the developmental and growth effects of socio-economic projects like CPEC could be a better research study for near future.


Mycoplasma pneumoniae and the measures taken to successfully complete cell therapy in a patient with focal chondral lesion. A 45-year-old male patient, complaining of chronic pain on the knee and no history of trauma. He had a chondral lesion in the trochlear region of the femur and clinical tests compatible with pain in the anterior compartment of the knee. Conservative treatment failed to alleviate symptoms. Surgical treatment was indicated, but due to the size of the lesion, membrane-assisted autologous chondrocyte implantation was the technique of choice. Cartilage biopsies were collected from the intercondylar region of the distal femur. After isolation, chondrocytes were expanded ex vivo in a trained laboratory, for three weeks, and seeded onto a commercially available collagen membrane prior to implantation in the knee. Two days before surgery, a cell culture sample tested positive for Mycoplasma pneumoniae. The source of contamination was found to be autologous blood serum, extracted from the patient´s peripheral vein, and used to supplement the cell culture medium. After treating the patient with antibiotics, all procedures were repeated and the new final cell product, free from contaminants, was successfully implanted. We discuss the strategies available to deal with this situation, and describe the results of this particular case, which led to modifications in the autologous chondrocyte implant protocol.To describe a case of autologous chondrocyte implantation after cell culture contamination by  Since the number of cells obtained in the biopsy is insufficient to obtain the desired therapeutic effect, a 3 to 4-week period of ex vivo cell expansion is required before the definitive implantation.-4Autologous chondrocyte implantation seeded in collagen membrane is the gold standard surgical technique to treat focal chondral lesion of the knee. It is especially indicated for larger than 2cmMycoplasmataceae. Their size is intermediate between bacteria and viruses; they differ from the former by lack of a cell wall, and from the latter by the fact they grow in cell-free media. The lack of cell wall allows direct contact with host cells, leading to exchange of cell elements. Mycoplasma contamination is a major concern for in vitro cell culture for several reasons: due to its small size, it is able to pass through sterilizing filters that would otherwise prevent contamination; the absence of a cell wall makes it resistant to many antibiotics; it causes altered metabolism, morphological changes, and decreased cell viability; it changes the expression of eukaryotic cell genes, potentially altering cell culture performance and final cell therapy product quality.Therefore, mycoplasma detection and elimination are necessary for in vitro cell culture.-12Mycoplasmas are the smallest free-living microorganisms in nature. They belong to the family  We report a rare case of autologous chondrocyte implantation seeded in collagen membrane product contaminated by Mycoplasma pneumoniae, and the procedures adopted to overcome it, which eventually resulted in a successful autologous chondrocyte implantation therapy.Cell therapy laboratories are required to operate under strict good manufacturing practice conditions to minimize possible mycoplasma contamination. Nonetheless, occasional mycoplasma contamination of cell therapy products may also derive from the biological sample donor.A healthy 45-year-old man complained of right knee pain for over one year, with no history of trauma. The onset of symptoms was insidious, and the pain gradually worsened, until it began to hinder the recreational practice of his favorite sport, soccer. Six months before, he had undergone surgery on the left knee to treat another focal chondral lesion, at another hospital.Physical examination, radiograph and magnetic resonance image of the knee were compatible with an focal chondral lesion in the trochlear region in the right knee .Due to failure of conservative treatment, surgery with autologous chondrocyte implantation seeded in collagen membrane was indicated. The lesion was confirmed by knee arthroscopy, and biopsy was performed with approximately three grams of cartilage from the femoral intercondylar notch. This tissue was sent to proper facility in the hospital, according to the good manufacturing practice, for isolation and expansion of the chondrocytes.ex vivo chondrocyte expansion protocol uses 20% autologous blood serum (AS20%) to supplement the cell culture medium. To ensure greater comfort to patients, the peripheral blood is harvested in the operating room during cartilage biopsy. A total of 200mL of blood was collected in a donation bag without anticoagulant. Patient answered a clinical interview with questions similar to those applied to a blood donor, but since the product is autologous, screening was performed according to Blood Bank guidelines. However, the mycoplasma test was not done before use in cell culture; it was only performed as a release test, according to Brazilian Cell Therapy Guidelines (RDC 214/2018).To avoid using animal products and considering the high cost of xeno-free medium, the local 6 cells per cm2 on the membrane .After three weeks of cell expansion, a slow cumulative cell population doubling level was detected , but it Mycoplasma pneumoniae  was positive for eumoniae .In view of the lack of guidelines on how to proceed in this situation, it was decided to discard the material. The surgery was cancelled, and the patient was referred to an infectious disease physician. Serological test was positive for IgM (851U/mL) and IgG (543U/mL). Patient recalled he had symptoms of cold on the day of the biopsy. Polymerase chain reaction analysis of the cell culture medium and plasma showed that the source of cell contamination was autologous serum . The patThe autologous chondrocyte implantation seeded in collagen membrane protocol in the institution was modified because of this episode. Blood collection started to be performed before, with RT-PCR test for mycoplasma before use in cell culture.Mycoplasma pneumoniae. And it was neither detected in cell culture media  approved the study (CAAE: 7800821.5.0000.0071 – # 4.792.019) and the participant signed an informed consent form.The Research Ethics Commitee of ,14,15 The advantage of this blood product is its low cost and lower risk of transmitting infectious diseases. Regulatory agencies have recommended avoiding the use of fetal bovine serum and other products derived from animals, both because of the risk of disease transmission and the ethical issue of suffering caused to animals to obtain them. On the other hand, many xeno-free and chemically defined serum-free culture media have appeared on the market, but their price is still prohibitive in less economically developed countries.-20Autologous serum has been used to enhance cell expansion in cell cultures for autologous chondrocyte implantation.Mycoplasma pneumoniae in RT-PCR, before the release of the cellular product for implantation in the patient. If the patient had performed the RT-PCR for Mycoplasma pneumoniae before cartilage collection, he could have been diagnosed and previously treated, preventing the loss of the cell culture product and autologous chondrocyte implantation seeded in collagen membrane delay.For autologous use, donor is not required to microbiological tests before collection. The tests are done during and for cell release to ensure adequate safety and quality of the cell therapy product. However, we herein described the dilemma caused by the positive finding of in vitro. Methods for eliminating mycoplasma from cell cultures include physical, chemical, immunological, and antibiotic-based approaches. However, there is no report on the use of chondrocytes from decontaminated cultures in the clinical setting. Moreover, decontaminating a cell culture with mycoplasma is a very difficult task, with no guarantee of success at the end of the process.Since the mycoplasma contamination came from the patient’s blood and not from the laboratory environment, it is plausible to question whether release of the final cell product for autologous implantation in the patient would be deleterious or not. In fact, all other parameters, including karyotype, cell viability and cell counting, were normal. Some authors described methods to decontaminate cell culture Mycoplasma pneumoniae, which led to the modification of the institutional protocol to perform the autologous chondrocyte implantation seeded in collagen membrane. Even though it is an autologous product, reverse-transcriptase polymerase chain reaction for Mycoplasma pneumoniae was adopted for all patients before the collection of the material for culture.This case report describes our experience with a case of contamination of a chondrocyte culture by