The Staff Attitude to Coercion Scale (SACS) was developed to assess mental health care staff's attitudes to the use of coercion in treatment. The staff's attitudes to the use of coercion may also influence their willingness to engage in professional development projects aimed at reducing use of coercion. This study systematically reviews the existing evidence related to the measurement properties of the SACS in papers published since the publication of SACS in 2008.Seven databases were searched for studies published until October 2021 assessing the measurement properties of SACS or using SACS. All original studies reporting data relevant for the assessment of measurement properties of the SACS were eligible for inclusion. The methodological quality of the studies was assessed and rated using the COnsensus-based Standard for the selection of health Measurement INstruments (COSMIN).Of the 81 identified publications, 13 studies with a total of 2,675 respondents met the inclusion criteria. Most studies reported data on structural validity and internal consistency, with high methodological quality, but there were almost no data on any other measurement properties.We found evidence for adequate structural validity and internal consistency of the SACS, while other important measurement properties were not addressed in any of the reviewed studies. Caution is needed when interpreting results of the SACS in terms of aspects such as reliability, criterion validity and measurement error. The relationship between staff attitudes to coercion and the actual use of coercion also remains unclear and needs to be further investigated.https://www.crd.york.ac.uk/prospero/, identifier: CRD42021239284. The use of coercion in health care is ethically problematic and challenge the fundamental health care principle of respect for patient autonomy , 2. All In recent years, attitudes to the use of coercive interventions in mental health care have evolved, with increased focus on user participation, respect for autonomy, and human rights . DiffereIt is therefore important to have a validated questionnaire for assessing staff attitudes to coercion in mental health care. In 2008, Husum et al. developed and published the Staff Attitude toward Coercion Scale (SACS) for this purpose . SACS meThe SACS is to our knowledge the only instrument measuring staff attitudes to coercion, and the instrument has now been used worldwide and translated into several languages, including German, Polish, Chinese, Japanese, Italian, Turkish and Arabic, indicating a potential for cross-cultural applicability. The questionnaire has also been used in some populations with other participants, like patients and caregivers. However, to the best of our knowledge, no systematic review has been performed to assess the measurement properties of the scale. To date, there has been no attempt to examine the results of its use in practice and research, and no meta-analysis has been done.This review aims to gather results relevant for measurement evaluation of the SACS questionnaire. Assessing measurement characteristics is essential for comparing results from different countries and populations. In particular, the aim of this study was to conduct a systematic review of the measurement properties of SACS using the COSMIN Risk of Bias checklist –23. The (1) Summarize and evaluate the available evidence regarding the measurement properties and use of the Staff Attitude to Coercion Scale (SACS) in health care settings.(2) Assess the reliability and validity of the SACS as reported in these studies.(3) Examine the performance and factorial invariance of the three SACS dimension ratings across subgroups .This systematic review was carried out following the “COnsensus-based Standards for the selection of health Measurement Instruments” (COSMIN) , 22, 23 The review protocol was registered with PROSPERO (Record ID = CRD42021239284).All original studies reporting data relevant for the assessment of measurement properties of the SACS were eligible for inclusion. There were no restrictions on setting or publication language. The systematic review includes studies reporting data from any eligible SACS measures on one or more of the domains defined by the consensus-based standard for the selection of health measurement instruments (COSMIN) taxonomy: reliability ; validity ; responsiveness; and interpretability , 22.All relevant studies that met the inclusion criteria were identified by searching the following seven electronic databases: MEDLINE by EBSCOhost, PsycINFO by APA PsycNET, Embase by Elsevier, CINAHL by EBSCOhost, Web of Science by Thomson Reuters, Google Scholar, and OpenGrey. The following terms were used in the search for studies: SACS, Staff attitude to coercion scale, Staff attitude toward coercion scale, Staff's normative attitudes toward coercion. Studies published between 2008 and October 2021 were considered. The full search string is attached as The selection of studies was made by two review teams . Each review team reviewed half of the articles. A third reviewer (TR) was involved when there was discrepancy between the two reviewers. Any discrepancies regarding selection were resolved by consensus. First, titles and abstracts were screened for eligibility. Then, the full text of the potentially relevant studies was read to decide whether the study met the selection criteria. Studies that did not fulfill all the inclusion criteria were excluded, and the reason for exclusion was noted. A flow chart of the selection process is presented in For assessing the measurement properties of SACS we used the COSMIN Risk of Bias checklist , 22. In Using the checklist, two reviewers independently assessed the methodological quality of measurement properties reported in each study with discrepancies in assessment resolved by consensus. For this review of a single instrument, already developed, we did not rate the studies on content validity. Each of the eight other measurement properties were rated on a four-point scale  according to the definitions and instructions in the COSMIN manual , 22. TheTwo reviewers (JL and JS) extracted the data, and a third reviewer checked the data being extracted (TLH). Data related to internal consistency , structural validity , reliability , and responsiveness (correlations) were collected. In cases of uncertainty about the extracted data, another reviewer (TR) was consulted. For further definition of the measurement constructs, please refer to the COSMIN manual.Our search resulted in 81 hits, which were reviewed at the title and abstract level. Altogether, 31 studies were read in full text. Finally, 13 studies were included, while the rest were excluded, with reasons for exclusion at the full text level given in The 13 included studies had between 39  and 424 We identified five studies assessing structural validity , 28–31. Husum et al.  was the Efkemann et al. reported four factors meeting the common factor analysis criteria of eigenvalue <1; however, the last factor was only marginally larger than one. A scree plot inspection indicated that a three-factor solution might better represent the underlying structure. When testing the original three-factor solution reported by Husum et al. , howeverThe study reporting subscale correlations found that the “coercion as offending” subscale correlated to 0.34 with the “coercion as care and security” subscale and to −0.12 with the “coercion as treatment” subscale. The “coercion as care and security” and the “coercion as treatment” subscales correlated to 0.65  Table 2Table 2.The studies investigating structural validity were overall of good methodological quality; two studies were rated very good and one adequate, fair .This was the most frequently reported measurement property, with 12 studies reporting relevant analysis , 32–35. Only two studies reported data on other measurement properties reported in The SACS has been used in many studies and countries since its development in 2008. This indicates concern in many cultural settings about use of coercion in mental health care. However, to the best of our knowledge, this is the first systematic review of the measurement properties of the SACS.Structural validity and internal consistency were the most frequently reported measurement characteristics in the identified studies. All studies reported adequate internal consistency. Most studies replicated the original three-factor structure and the correlation between the factors were medium to low as expected. Merging the model into one factor has been considered, but the measurement findings in this review suggest that the three-factor is better fit to the available data. Keeping the three-factor model is supported by another study who found that professionals could be divided in three groups concerning their thoughts about use of seclusion in mental health care. The authors of this study identified three types of professionals: Transformers, Doubters, and Maintainers .While the available data support the SACS as being psychometrically sound, some important data are missing. For example, there are no measurements across more extended periods of time , which cTesting of criterion validity by comparing SACS to a gold standard is lacking because there are no other instruments on staff attitude to coercion to compare with. There is also very limited research on the relationship between staff attitudes and the use of coercion. Several studies have suggested that there is a relationship between staff attitudes toward use of coercion and actual use of coercive interventions , 38–43.Other studies have found important differences between explicit and implicit attitudes . ExpliciAs shown in A challenge in using the COSMIN method for this systematic review is also that the COSMIN taxonomy is originally developed for the assessment of patient-outcome measures. The SACS measures staff attitudes, which is another kind of phenomenon. In general, the scientific study of staff attitudes in mental health care seems to be scarce, and this field needs to be methodologically developed.Limitations in this review could be that the two pairs of assessors that assessed the studies could develop different consensus about how to interpret the findings in the papers. Another possible limitation could be that two of the authors were also involved in the development of the original SACS questionnaire and could possibly be biased. We sought to take this into account by collaborating in pairs with the authors not included in the development of the scale. All authors were also involved in the final quality assurance and interpretation of the findings. It is also a challenge and possible limitation in this review that the validation process differs between different studies and countries. Further the studies have used the scale differently. The SACS was developed and validated 15–20 years ago. While not formally investigated in this review; changes in attitudes to toward coercion in the society at large may indicate that a revision of the SACS item may be warranted.The SACS is, to our best of knowledge, the only questionnaire measuring staff's attitudes to the use of coercive interventions in mental health services. It is used widely, which demonstrates the need for such a tool. The widespread use also indicates that the tool is perceived as feasible and useful.The assessment found evidence for adequate validity and internal consistency of the SACS. However, there were very limited support for other important measurement qualities such as reliability, criterion validity and measurement error.Future research should focus on the stability of these attitudes, whether they are amendable by interventions and the relationship between staff attitudes to coercive interventions and the actual use of coercion. Another related topic is to more thoroughly investigate the relationship between staff's explicit and implicit attitudes toward use of coercion. Further future research could investigate formation of staff attitudes. Staff attitudes to the use of coercive practices may also influence the staff's willingness to engage in projects to reduce the use of coercive interventions. Another possible topic for research is to investigate barriers to engage in projects aimed at reducing use of coercive practices in mental health care.Until future studies have evaluated more measurement properties of SACS, users of SACS must interpret the results based on the current knowledge of its properties.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.All authors have been involved in the process of assessing the studies for inclusion, analyzing the results, writing article, contributed to the article, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


As health care becomes more fragmented, it is even more important to focus on the provision of integrated, coordinated care between health and social care systems. With the aging population, this coordination is even more vital. Information and communication technology (ICT) can support integrated care if the form of technology follows and supports functional integration. Health TAPESTRY  is a program centered on the health of older adults, supported by volunteers, primary care teams, community engagement and connections, and an ICT known as the Health TAPESTRY application (TAP-App), a web-based application that supports volunteers in completing client surveys, volunteer coordinators in managing the volunteer program, and primary care teams in requesting and receiving information.This paper describes the development, evolution, and implementation of the TAP-App ICT to share the lessons learned.A case study was conducted with the TAP-App as the case and the perspectives of end users and stakeholders as the units of analysis. The data consisted of researchers’ perspectives on the TAP-App from their own experiences, as well as feedback from other stakeholders and end user groups. Data were collected through written retrospective reflection with the program manager, a specific interview with the technology lead, key emailed questions to the TAP-App developer, and viewpoints and feedback during paper drafting from other research team members. There were 2 iterations of Health TAPESTRY and the TAP-App and we focused on learnings from the second implementation (2018-2020) which was a pragmatic implementation scale-up trial using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework at 6 primary care sites across Ontario, Canada.TAP-App (version 1.0), which was iteratively developed, was introduced as a tool to schedule volunteer and client visits and collect survey data using a tablet computer. TAP-App (version 2.0) was developed based on this initial experience and a desire for a program management tool that focused more on dual flow among users and provided better support for research. The themes of the lessons learned were as follows: iterative feedback is valuable; if ICT will be used for research, develop it with research in mind; prepare for challenges in the integration of ICT into the existing workflow; ask whether interoperability should be a goal; and know that technology cannot do it alone yet—the importance of human touch points.Health TAPESTRY is human-centered. The TAP-App does not replace these elements but rather helps enable them. Despite this shift in supporting integrated care, barriers remained to the uptake of the TAP-App that would have allowed a full flow of information between health and social settings in supporting patient care. This indicates the need for an ongoing focus on the human use of ICT in similar programs. Currently, health care is provided by multiple providers across various disciplines and through different organizations. With patients receiving care from multiple people, it is crucial to have a system that can integrate providers and information horizontally and vertically across the health care system. The concept of integrated care is to deliver coordinated care that brings together services from across health and community-based social systems . This tyInformation and communication technology (ICT) is an important enabler that supports the delivery of integrated and coordinated primary care ,7. ICT iWith the growing population of older adults in Canada and globally, the need to provide care that wraps around patients is even more important. In shifting to more integrated care, the changes that organizations make will need to be supported using all available resources. ICT can connect users across organizations and disciplines to share information. Appropriate communication to enhance these connections is critical for successful integrated care systems . HoweverHealth TAPESTRY  offers an opportunity to describe the development and evolution of ICT as part of a pragmatic complex intervention rooted in primary care. The program creates connections among trained community volunteers, interprofessional primary health care teams, novel technology, and community engagement and connections through improved system navigation ,13. The social context information on the TAP-App about their own perspectives of the client. Volunteers were also invited to write narratives on the TAP-App, which were stories of their own experiences with the potential to be used for research or program development purposes, as needed. A volunteer coordinator at each site handled the management and scheduling of volunteer and client visits through the TAP-App .The key ICT within Health TAPESTRY is the Health TAPESTRY app (TAP-App), a web-based application that has 3 interfaces (briefly described below). In Health TAPESTRY, trained volunteers conduct visits in older adults’ homes to discuss the clients’ health and life goals, while identifying their health and health-related social needs using validated tools or surveys adapted by the research team. These surveys were administered by volunteers, facilitated by and recorded in the TAP-App on tablets through the volunteer interface. During the visits, the volunteers had the opportunity to answer client questions and provide relevant information on community programs and services that may be of interest to the client. After visits, volunteers write The TAP-App creates an automated PDF TAP-Report that is shared with the huddle team at the patient’s primary care site through a huddle interface. The huddle is a subgroup of people within the primary care team who meet weekly to discuss with clients in the program. The huddle is composed of at least 3 providers from different disciplines . The huddle members view TAP-Reports from their own interprofessional lens and work together to create individualized plans of care for clients based on the information collected. The huddle teams are then able to document a summary of their review and plan of action on each TAP-Report through the huddle interface. They also have the option to send volunteers back to clients through the huddle action checklist, which contains a list of options for engaging volunteers in the plan of action, including discussing changes in clients’ health needs, planning the achievement of goals, or connecting clients to community-based health and social services. These recommendations are communicated to volunteers via volunteer coordinators who receive this information on the TAP-App. After volunteers follow-up with clients, they communicate any new information back to the huddles through the Follow-Up Report, another automated PDF report created by the TAP-App. A detailed description of Health TAPESTRY is in the published protocol .In this paper, we describe the development and evolution of a specific ICT in Health TAPESTRY, the TAP-App. This story is presented as a case study to share the lessons learned during its development, evolution, and implementation.Setting section below.The case under study is the TAP-App itself, and the units of analysis are the perspectives of end users and stakeholders . We usedThe data in this study came from the direct perspectives of key members of the research and implementation team, who are also represented as authors in this paper. The lessons learned in this paper constitute the key themes from the team’s perspectives in implementing the TAP-App in Health TAPESTRY. Specific data sources to understand how the TAP-App was implemented in its 2 phases were a written retrospective reflection from the program manager, an interview with the technology lead (facilitated by SD and JG), and key questions administered via email to the software developer.lunch and learns, volunteer narratives submitted via the TAP-App, and during verbal debriefs with volunteer coordinators. Furthermore, we gathered viewpoints and feedback from other research team members who developed and implemented the TAP-App at each of the 2 main stages. SD and JG collected this information and combined it with the direct observations of the research team to add detail and clarity to understanding the lessons learned in this work.Although the lessons learned in this paper came directly from the program team, their understanding of the implementation of the TAP-App was informed by the feedback that the team received from many other stakeholders and end users . This feedback came to the team via email, volunteer Lessons Learned section in this paper based on the key themes that continued to arise in these project conversations and their own perspectives as implementers. JG and SD then edited the lessons learned after collecting more information from key informants . Throughout this process, member-checking was continued, that is, feeding back the written lessons learned to the key informants, to ensure that the written representation fit their understanding of the process.Although there was no traditional qualitative data set for this study’s data because of the structure of data collection, the project team members  discussed lessons learned throughout and after project implementation. LL and SD developed the initial We used several methods to enhance rigor in this case study. We worked to enhance credibility and confirmability through triangulation of various data sources , data collection methods, and individual interpreters of the data ,17. We fThe TAP-App was developed, hosted, and driven by an academic university department, McMaster University’s Department of Family Medicine. The department includes subgroups—2 of which are devoted to information technology and research—and were the 2 areas of the department that managed the TAP-App. During the implementation of Health TAPESTRY–Ontario 2018-2020), which is the period of focus of this study, the TAP-App was used in 6 family health teams (FHTs) across the province of Ontario, Canada to support older adult clients. FHTs are primary health care teams that bring traditional family physician–led practices together with an array of interprofessional providers such as nurses, social workers, dietitians, pharmacists, and others -2020, wh,20. In aThe first version of the TAP-App was programmed in-house at McMaster University’s Department of Family Medicine, using Java. The technology was still in active development at the start of implementation, which led to an iterative nature of development and the opportunity to integrate feedback from users. During the initial implementation of Health TAPESTRY that took place at just 1 FHT in Ontario (2014-2015), the technology was a single log-in webpage with different interfaces for volunteers and administrators  and for the 2 clinical sites within this FHT. The volunteer interface was where surveys for each client could be accessed during home visits. Upon completion, the automatically generated PDF TAP-Report was not shared with the primary care team via a huddle interface; instead, the research staff uploaded the TAP-Reports to the clients’ electronic medical records (EMRs) for the primary care team to review. Therefore, they also did not have the huddle action checklist, nor did volunteers have the follow-up visit or Follow-Up Report options, though volunteers did conduct preplanned 3-month follow-up visits which were not a part of the second implementation of Health TAPESTRY. As in the second version of the TAP-App, the volunteer coordinator interface held client and volunteer information but also had a scheduler for coordinating volunteer availability and visit times. The question data could be extracted from the TAP-App for research purposes, although it was not in the ideal format for data analysis.Building on the initial Health TAPESTRY experience, the McMaster University Department of Family Medicine invested in a new iteration of the technology that would be supported on Research Enterprise Management of Information (REMI), a new multi-tenant software platform built using Java and Angular to facilitate collaborative research initiatives. The second large-scale implementation of Health TAPESTRY at 6 sites (2018-2020)—enabled by the TAP-App—was the first department project to use REMI, with modifications specific to the program.There were several advancements in the existing technology with the goal of establishing a 2-way versus 1-way flow of information between clients and interprofessional huddle teams . First, Data Collection section).The design was again iterative and implementation was stepwise in nature, as rollout of the program and technology did not occur in all 6 FHTs simultaneously. Each site was able to customize its survey packages based on community or clinic needs and preferences. The TAP-App was still in active development when implementation began on the first site, which allowed the team to solicit and receive feedback from users  that provided organizational support, management of clinicians and community partners, logic in data collection, and the opportunity for information to flow among users in a scalable and customizable tool that could support research and education enterprises  lead, program manager, research coordinator, practice model lead, software developer, data manager, executive lead, and evaluation lead. Of the 10 authors, 5 (50%) were women, 4 (40%) were men, and 1 (10%) was gender nonbinary. Of the 10 people, 7 (70%) were present in both phases of the Health TAPESTRY program, and 3 (30%) were present only in the second phase.As developers, implementers, and evaluators of the technology under study, we had an implicit bias in the shared hope for program success. However, the 2 phases of project work allowed us to reflect on our unique position and further develop the app to overcome barriers and maximize its success. Beyond that, we aimed to take a pragmatic approach to understanding our lessons learned, considering both what worked and what did not work.The introduction of any new technology will inevitably have both expected and unexpected effects on operations and workflows, even beyond the initial implementation. Therefore, continuous iterative feedback is necessary from users throughout. Given the many end users  involved in a complex program such as Health TAPESTRY, there is a need to develop a process for managing feedback. It is also important to prioritize suggestions into high-, medium-, and low-priority categories. Some potential questions and guidelines that we found helpful—and encourage others to consider using in determining the end users’ needs—during our implementation are as follows:Would this alter the mechanisms in which data moved among users?Would this require retraining for end users?Would this change the way in which a client experienced the program?Was this outside of the scope and capacity of the technology?human element being a critical component of health technology implementation, which emphasizes the importance of provider feedback and buy-in. As the literature has identified, it is important to plan ICT early and deliberately, with monitoring and end user involvement throughout [A key to the successful implementation of ICT is the involvement of end users. Buntin et al  highlighroughout . The invroughout  because Computer-assisted data collection for research use has been considered acceptable and has been widely adopted for at least 25 years . Howeverinformation ecology, the activities in which users are already served by technology, such as the current channels of communication and storage of information [The integration of ICT into existing practices and workflows takes time and requires an understanding that there will be challenges until it becomes a normalized part of the regular experience. This is not a new learning on its own; the literature in the field describes how introducing new ICT introduces new ways of working, which organizations and providers may be resistant to and often, an inadequate understanding of the clinical work environment causes new ICT systems to fail ,24,25. WTherefore, technology needs to support and enable the workflow of clinicians and not dictate it. By developing a new iteration of the TAP-App on REMI, the technology’s ability to achieve a level of flexibility and scalability allows the technology to be implemented in multiple existing contexts. However, despite including flexibility, scalability, and the human element of feedback within our development of the TAP-App in both iterations, there were still some difficult areas when fitting it into the usual practice. One of these was the log in to a secondary website by providers, that is, the use of the huddle interface. This additional step added time, already at a premium for health care providers, and an issue that can be a major constraint in introducing new ICT into practice .It is also important to implement ICT that is flexible enough to change per the local context, but neither the technology nor the end users can be too rigorous in the application of the technology. Although end users need to see value in adopting a new ICT , its devIn the adoption of ICT, the concept of interoperability, specifically between external software and EMRs, will likely always need to be considered and is often seen as the end goal for any new health-related technology . InteropEven if we had pushed for full interoperability between the TAP-App and EMRs, it may have addressed some of the disruptions in workflow. However, it has been shown that providers need to first see a great enough value in the ICT to fully integrate it into their work. In Health TAPESTRY, the value of ICT is not only the TAP-App itself but also the program elements that the huddle can access with the TAP-App, which introduces an additional barrier to access, as the primary care team should see a great enough value in the information contained in the TAP-Report and in the work of volunteers who are following up with their patients. In observing the challenges of integrating new health ICT, Planitz et al  found thinstead. Technology as the solution is not a true solution, as a human element is important in programs such as this; form should follow the function for an ICT to be successful.There are inherent benefits and growing knowledge of the importance of developing human-centered ICT, including both the uptake and usability of the technology, which has been described in this case study and in other literature ,32. At tAnother human touch point within Health TAPESTRY was the addition of volunteer coordinators to interprofessional huddles, which further enabled the practice of integrated care, helping reach out to the community beyond the volunteer organizations themselves. While the TAP-Report to the huddle team provided necessary information, the volunteer coordinator was able to provide further narrative. In addition, this connection allowed the huddle teams to liaise directly with volunteer coordinators about possible follow-up actions for volunteers and resources to connect with patients. It also allowed the volunteer coordinator to remind the huddle teams of the community-based health and social-service options within their context and the role volunteers can play in connecting patients to these, as well as helping with any TAP-App–related issues. However, although this was an in-person activity, the volunteer coordinators’ connections to the huddles were fully internet-based. As the entire world shifted to a more internet-based environment during the COVID-19 pandemic, we have seen many fields turn to more internet-based methods of connection. Through internet-based inclusion of community-based partners in interprofessional primary care huddles, we could keep the human element of connection, using it to further humanize the use of technology , while sWe acknowledge several limitations to this study. First, the authors of this paper understand the development and implementation of the TAP-app were themselves the developers and implementers of this ICT. This may introduce bias. However, we were not aiming for an entirely unbiased picture. Instead, we were directly looking to further understand perspectives of the people closest to the technology. We also practiced reflexivity in understanding our position in the project. Another limitation was that there was no direct data set with actual quotes that could be used. This was a restriction of the way we set up the evaluation. Finally, while there were a great number of stakeholders who provided perspectives to the authors throughout implementation, these perspectives were filtered through authors’ understanding and positionality.Although ICT systems are used to support coordinated and integrated care through information sharing, access to care, and continuity of services -7,24,34,


Migrasomes are a new type of organelle. Cells migrate and produce retraction fibers (RFs) with migrasomes on their backsides. When the RFs break, the migrasomes detach from the cell and the contents are taken up by surrounding cells. Migrasomes can integrate and transmit information, thereby regulating the physiological activities of the body. It has been confirmed that migrasomes are related to the occurrence and development of some diseases. In some cancers, the high expression of migrasomes is closely related to the occurrence and development of tumors. This review introduces the research progress of migrasomes and new ideas for research directions.Migrasomes are organelles that are similar in structure to pomegranates, up to 3 μm in diameter, and contain small vesicles with a diameter of 50–100 nm. These membranous organelles grow at the intersections or tips of retracting fibers at the back of migrating cells. The process by which cells release migrasomes and their contents outside the cell is called migracytosis. The signal molecules are packaged in the migrasomes and released to the designated location by migrasomes to activate the surrounding cells. Finally, the migrasomes complete the entire process of information transmission. In this sense, migrasomes integrate time, space, and specific chemical information, which are essential for regulating physiological processes such as embryonic development and tumor invasion and migration. In this review, the current research progress of migrasomes, including the discovery of migrasomes and migracytosis, the structure of migrasomes, and the distribution and functions of migrasomes is discussed. The migratory marker protein TSPAN4 is highly expressed in various cancers and is associated with cancer invasion and migration. Therefore, there is still much research space for the pathogenesis of migratory bodies and cancer. This review also makes bold predictions and prospects for the research directions of the combination of migrasomes and clinical applications. The first prototype electron microscope, the transmission electron microscope (TEM), was invented in 1931 by German physicists Ernst Ruska and Max Knoll . Long tuWhen the cells migrated further, the RFs continued to elongate until they broke. The PLSs broke away from the cells. PLSs destroyed and released the contents, and then the contents were absorbed by the surrounding cells. The formation of PLSs depends on cell migration, so PLSs are officially named “migrasomes” . During In 2015, migrasomes with PLSs with a diameter of approximately 0.5–3 μm outside the NRK cells were observed under TEM using an in situ embedding method. The number of small vesicles in them varies, up to 300 or less than 10 . ObserviTSPAN4 is enriched on migrasomes and can be used as a marker protein for migrasomes . TetraspIntegrins are transmembrane receptors that mediate the connection between cells and the extracellular matrix (ECM) . IntegriROCK1 is a regulator of migrasome formation, as determined by chemical screening . By consZebrafish embryos have the characteristics of rapid growth, are large and transparent, and can develop in vitro ,38. ZebrIntegrins can promote cell adhesion and migration . By consQuantitative mass spectrometry analysis revealed that migrasomes are rich in 18 kinds of signaling molecules such as Tgfβ2, PdgfD, Cxcl12b, Cxcl12a, Wnt8a, Bmp7a, Cxcl18a, Wnt5b, and Bmp2. A lack of Cxcl12 will cause changes in organ morphology . FurtherMigrasomes can be phagocytosed by surrounding cells to achieve material transport and information transmission between cells . ResearcMitochondria are double-membrane organelles in eukaryotic cells . In addiIt has been confirmed that migrasomes are very likely to be used as markers for disease diagnosis and prognosis in the fields of cardiovascular and cerebrovascular diseases, kidney disease, and bone-related diseases . MigrasoKidney diseases are often accompanied by the appearance of proteinuria . In the The development and remodeling of bone are inseparable from osteoclasts (OCs) . This prMigrasomes have the function of information transmission. They release the cell contents into the extracellular environment through migracytosis, and can also be taken up by neighboring cells to transmit biochemical information and location information. In terms of neural network formation and immune response, the transmission of location information is particularly important, so migrasomes may play a huge role in these two aspects ,74.Peptides are a new direction of regenerative medicine. Peptide interfaces containing cell-penetrating peptides (pVECs) were found to promote cell migration and migrasome formation using primary normal human dermal fibroblast (NHDF) studies . FibroblResearch on migrasomes needs further exploration. It is currently known that migrasomes are monolayer membrane organelles containing many small vesicles . It is sMigrasomes have the function of information transmission. They release the cell contents into the extracellular environment through migracytosis and can also be taken up by neighboring cells to transmit biochemical information and location information. In terms of neural network formation and immune response, the transmission of location information is particularly important, so migrasomes may play a huge role in these two aspects ,74.The generation of migrasomes depends on cell migration . In the Therefore, it is still necessary to explore whether migrasomes play a role in these physiological activities, and what role they play. Some of them have preliminary verification, but further research is needed. Researchers can build simple, easy-to-observe biological models that are similar to zebrafish, and study the important role of migrasomes in biological development. Integrin and rock1 mediate the adhesion of migrasomes to the extracellular matrix . Cell adWith the development of technology and the deepening of multidisciplinary cooperation, research on the mechanisms of the generation, transfer, and release of migrasomes will become increasingly thorough. Researchers can combine research results with clinical cases to realize the conversion of the theoretical knowledge of migrasomes into the diagnosis and treatment of diseases.


Monitoring the condition  of small water bodies presents a challenge for the relevant authorities in terms of time and resources  due to the extensive length of the stream network or the sheer number of small standing water bodies. Citizen science can help address information gaps, but the effort required should not be underestimated if such projects are to generate reliable and sustained data collection. The overall aim of this paper is to propose a framework for operationalisation of citizen science targeting collection of data from small water bodies. We first consider the data gaps and the elements  to be addressed, in order to define where citizen science could best make an impact. We review examples of tools and methods that are appropriate for small water bodies, based on experience from a selection of freshwater citizen science projects, and the support that is needed for effective and sustained small water body projects across Europe. Consequently, small waters largely remain the least monitored freshwater resources with significant gaps in terms of spatial and temporal coverage. For example, in Ireland less than 10% of the river sites in the national water quality monitoring programme are on small streams. At the same time small streams, as well as other small water bodies such as ponds, are highly susceptible to anthropogenic pressures due to high connectivity with adjacent land and low dilution capacity.The predominance of small water bodies in the landscape, their significance in terms of biodiversity and the influence of 1st and 2nd order streams on catchment water quality are well recognised  of small water bodies presents a challenge for the relevant authorities in terms of time and resources  due to the extensive length of the stream network  to be addressed, in order to define where citizen science could best make an impact. We review examples of tools and methods that are appropriate for small water bodies, based on experience from a selection of freshwater citizen science projects (see Table https://www.plasticorigins.eu/). Key physical and chemical measurements include nutrients (NO3 and PO4) in terms of eutrophication risk and deposited fine sediment, which is widely considered to be a master stressor  assessment of the number of small ponds, (b) assessment of the overall condition of ponds and small lakes, (c) identification of water bodies that are of importance for biodiversity and (d) assessment of trends in the condition of water bodies and the status of specific protected species. Current approaches to these data gaps were reviewed specifically for the UK by Biggs et al.  but are A central challenge is identifying methods which can be easily and safely applied by citizen scientists yet produce data that are of sufficient quality to support practical monitoring of water quality, species and habitat assessment and inform decision making and policy  has gathered over 30,000 data points since its foundation in 2012, each using the same methodology and platform, leading to data that can be comparatively analysed  investigating a small chalk stream in suburban London, UK. Here, with support of citizen scientists, sensors record selected water quality indicators at thirty-minute intervals  and is linked to other citizen science initiatives (see Anglers’ Riverfly Monitoring Initiative below). The aim of the project is to develop an informed consensus on the management of this small river by linking citizen scientists with regulators and water companies through a common understanding of the issues and pressures.The use of citizen scientists to provide more detailed hydrochemical data is generally constrained by the availability of equipment and the training required to enable citizen scientists to maintain the equipment and interpret the data. However, at small spatial scales the two-way interaction between citizen and professional scientists can lead to better engagement and understanding of water quality issues, as exemplified by the Chesswatch project (http://volunteermonitoring.org/) and according to Peeters et al. . Whilst monitoring water quality can be based at relatively high-level taxonomic identification (e.g. order or family), biodiversity studies involve identification to levels that require much longer training periods. However, it can be useful for selected invertebrate groups such as Odonata. For example, Dragonfly Ireland 2019–2024, is an all-Ireland citizen science survey of dragonflies and damselflies, and their habitats, coordinated by the National Biodiversity Data Centre in the Republic of Ireland, and by the Centre for Environmental Data and Recording in Northern Ireland. Interestingly, this project offers volunteers three levels of participation; Spotters submit casual records; Recorders conduct timed surveys and Monitors conduct repeated surveys (https://biodiversityireland.ie/surveys/dragonfly-ireland/). Training, including online modules, and identification swatches are provided, and an online record entry system is available. The data collected by the National Biodiversity Data Centre are available as Open Access data (CC-BY 4.0) via the Biodiversity Maps system. In Ireland, a recent citizen science initiative has provided two macroinvertebrate-based schemes  and the Small Stream Impact Score (SSIS) based on 5 groups of indicators . All participants start with the CSSI and those wishing to learn a wider range of taxa or to become trainers are instructed in the SSIS.Many of the long-standing citizen science programmes have involved the collection of biological data, but these are often confined to a few countries and focussed on macroinvertebrate water quality indicators. For example, in the USA there are approximately 1700 volunteer water quality monitoring programmes . Despite the popularity of amphibians, it is often difficult to get people to visit enough sites, in the right places, without substantial organisational support. This is partly why the great crested newt eDNA project, described below, has been successful as it has enabled large numbers of sites to be surveyed comparatively quickly, resulting in a larger dataset than was possible with ‘traditional’ methods. Good data can be collected on water birds by citizen scientists and there are major survey programmes , as well as channel form and connectivity  and the use of eDNA to detect a protected species, the great crested newt (described in a later section). Several large-scale projects evaluating nutrient pollution as an indicator of overall water quality in contrasting landscapes, known as ‘Clean Water for Wildlife’ have been run. These projects have provided (a) the first data in all of the areas studied which describe nutrient pollution in water bodies representative of the whole water environment, including small water bodies such as ponds, streams, rivers, lakes, ditches, fens, bogs, springs, flushes, (b) the first comparative water quality data on large and small water bodies and (c) a simple way of demonstrating the particular role of smaller waters as ‘refuges’ for ‘clean’ water in the landscape. In this case, ‘clean’ water has a precise definition, being as far as possible equivalent to High status in the WFD, allowing for the fact that nutrient testing kits cannot produce results with the same level of precision and sensitivity as laboratory water quality analyses. The methodology is summarised in Biggs et al. . As far Prior to participating in ‘Clean Water for Wildlife’ projects, volunteers are trained in the survey methods in workshops lasting half to one day, and the role of the survey in understanding impacts of nutrient pollution are explained. Training is conducted by members of FHT with standard explanatory resources, including written documents and video guides. Training courses are also provided online where circumstances require. During the workshops methods are demonstrated and participants test a range of nearby water bodies. The online recording system is demonstrated to participants.Volunteers normally interact with a specific project coordinator who organises site permissions. As all surveys in the UK require the permission of the landowner, a substantial part of the work involves FHT staff planning survey locations  and obtaining permission from landowners to visit sites.‘Clean Water for Wildlife’ survey results are captured in online forms embedded in the FHT website. A simple screening step is incorporated to ensure that results are correctly recorded. Recording of data has been designed for standard PC platforms. This is often as convenient as field observations because the optimum approach to the use of PACKTEST kits is to collect water samples in the field and then analyse samples in batches at the volunteer’s home or workplace where standard temperature (PACKTEST kits should be used at room temperature) and lighting conditions can be most easily provided.‘Clean Water for Wildlife’ data have been collected at a number of scales including national and regional surveys. From 2012 onwards around 1500 volunteers have collected data throughout England and Wales, with a special focus on four key demonstration landscapes: Greater London , permissions to visit sites, supporting data collection and reporting findings to volunteers. Working with volunteers also brings specific requirements and limitations in terms of health and safety. Hence, volunteer-based surveys can take as much time as professionally organised surveys: survey organisers and funders must be realistic about the pros and cons of such surveys, and be careful to avoid presenting citizen surveys as a low-cost alternative to professional surveys.The use of environmental DNA to monitor freshwater biota has grown explosively over the last few years , Ephemeridae (mayfly), Ephemerellidae (blue-winged olive), Baetidae (olives), Heptageniidae (flat-bodied mayfly), Plecoptera (stonefly) and Gammaridae (shrimp)] were chosen because they are easy to identify at this taxonomic resolution, cover a range of sensitivities to pollution, have national applicability, are present year-round (with the exception of Ephemerellidae), and are familiar to most anglers. An ARMI score for the site is then generated by allocating a score of 1–4 according to the log10 abundance category of each target taxon and summing the scores of all the target groups. Local regulatory authorities give each sampling site a trigger level score based on their long-term data for the site. Higher ARMI scores indicate higher river quality, and the trigger level is set significantly below the expected ARMI score for the site. An ARMI score below the trigger level will therefore indicate that a serious pollution incident may have occurred. If the trigger level is breached, the ARMI volunteer confirms the breach by resampling the site and then informs the local agency officer who will investigate the cause and take appropriate action.ARMI, a nationally coordinated project, was officially launched in the UK in 2007 as a means for citizen scientists to assess river water quality based on the abundance of certain key invertebrate taxa  and Projecte Rius (www.projecterius.cat) projects were initiated by the Ecology Department of the University of Barcelona. The main difference between these two projects is the commitment required of the citizen. RiuNet can be applied where and when one wishes to survey. In contrast, Projecte Rius has a network of volunteers that study the same river reach two times a year, in spring and autumn, to provide data from Mediterranean rivers in the high and low flow periods.The RiuNet (https://www.ub.edu/fem/docs/Riunet/RiuNet_NOU_thebook_ENG.pdf). In terms of macroinvertebrates, users may recognise up to 40 different organisms, usually identified at family level, using pictures or the app's dichotomous key. Most organisms are insects: Diptera, Coleoptera, Odonata, Heteroptera, Trichoptera, Ephemeroptera and Plecoptera. However, they also consider some taxa from the Mollusca, Oligochaeta, Hirudinea and Crustacea. Each indicator has its value of sensitivity or tolerance to pollution or impacts based on the IBMWP index, the official biological index for Mediterranean rivers of the Iberian Peninsula , however, to date only 122 studies have been in small water bodies  with thousands of people involved. The data collected add a new layer of information that can be used to better manage freshwater ecosystems. As noted, few sites on small water bodies are visited. In conclusion, there is a need to enhance the potential of Projecte Rius and RiuNet to be used to study small water bodies, and in consequence, provide new information on macroinvertebrate biodiversity, riparian forest quality, or hydrologic impacts in sparsely populated areas.In 2015, Earthwatch Europe ran their first Freshwater Watch WaterBlitz on the Thames (UK), to engage citizens within the Thames basin collecting as many water quality data points as possible over a four-day period. In 2019, this was extended out to other European cities, including Dublin. Due to the restrictions caused by COVID-19, no WaterBlitz was run in 2020. In May 2021, the WaterBlitz was again run over four days in the Thames (UK) and in the Greater Dublin Area (Ireland). The Dublin WaterBlitz was led by the Dublin City University (DCU) Water Institute.3-N) and phosphate (PO4-P) Kyoritsu PackTest  water chemistry kits supplied by FWW (described above).Nitrate and phosphate were measured in freshwater sites chosen by citizen scientists across the city of Dublin and surrounding areas over the 4-day period. The water was collected from local streams and water bodies using sampling devices created by the participants, such as a clean bucket attached to a rope, or a cut-away plastic bottle attached to a bamboo stick. These sampling devices were rinsed with river water before taking the test sample to avoid contamination. Participants were provided with sampling cups to ensure that all participants used the same volume of water. Testing of nutrients took place in situ using nitrate (NOhttps://freshwaterwatch.thewaterhub.org/). This training assured that all participants were using the same methodology. After conducting the tests, participants added their data to the FWW database, including observational notes or photographs of any of the following: presence of algae, surface foam, oily sheen, pollution discharges, litter and signs of aquatic life. Location coordinates were entered manually or by map geolocation from the smart device to the database on the FWW website or smartphone application. Many of the volunteers were involved in pre-existing environmental groups . Other issues causing attrition amongst trainers as well as trained volunteers, such as the availability of resources  need to be considered, as highlighted by Mormina & Pinder . Projectcontributory where participants collect data in projects designed by scientists; (2), collaborative where participants provide data, but may also help with project design, data analysis or dissemination of findings and (3) co-created where participants engage in the design and all stages of the project  In terms of data collection, schemes that are adjusted to varying levels of expertise (e.g. CSSI and SSIS schemes in Ireland and the’Riverfly Plus’ in the ARMI project) help maximise participation and allow progression as interest, knowledge and skills develop. Capacity building of teams of volunteers for the long term should consider training of trainers (ToT), known as the cascade approach. This approach has been widely and successfully used in many sectors and typically involves external experts training a group of local trainees in specific technical skills and how-to train others in that subject. It enables relatively quick upskilling because it focuses on the practical and knowledge skills deficits of the trainees. The TRAIN framework of Mormina & Pinder  providesEducational material and tools are obviously essential, and these must be geared to the level of expertise of the participants. Examples range from identification sheets and manuals to phone applications. As noted by Graham et al.  smartphoIt is widely recognised that citizen science data are underutilised because of, often unfounded, concerns about data reliability (Bonney et al., Finally, effective communication channels between participants and coordinators, and between participants within and between hubs must be established early in the project. This is a critical, but is often an underestimated element of successful citizen science projects. The project also needs to be visible to the general public and this can be achieved through a web presence and regular blogs etc. shared through social media. As noted by Vohland et al.  the projIn summary, there is an identified need to obtain better spatial and temporal coverage of water quality, biodiversity and the physical habitat condition of small water bodies. Citizen science can help address the information gaps, but the effort required should not be underestimated if such projects are to be sustained and to generate reliable and sustained data collection. A vision for sustainable citizen science should involve co-creation of projects and long-term monitoring under a defined supportive framework as illustrated in this paper.


During the COVID-19 pandemic, various lockdown policies were put in place by the governments in different countries and different levels, which effectively curbed the spread of the virus, but also cause substantial damage to the mental health of local residents. We use statistics provided by the Household Pulse Survey and OxCGRT between 23 April 2020 and 30 August 2021 to analyze the impact of lockdown on overall mental health levels in US states during the COVID-19 pandemic at the macro level. The results show that the lockdown policies implemented by the state governments lead to a deterioration in psychological conditions, and this relationship varies to some extent depending on the level of high-quality economic support, that the state governments implement to alleviate the symptoms of depression and anxiety associated with the lockdown. Therefore, we argue that although lockdown policies are necessary during the COVID-19 pandemic, further government efforts are needed to give high-quality economic and mental health support to mitigate the negative effects of lockdown on mental health. As of mid-December 2021, more than 27 million people worldwide have been diagnosed with pneumonia caused by COVID-19, resulting in more than 5.37 million deaths  can prevent or mitigate the effects of stress on mental health –25. In pWe investigate such impact based on the statistical analyses provided by the Household Pulse Survey and the Oxford Covid-19 Government Response Tracker (OxCGRT) from 23 April 2020 to 30 August 2021. To our knowledge, this is probably one of the first study to track the mental health-related effects of state government lockdown policies at the macro level. Compared to other short-term studies at the individual level, our study better conveys the true effects of the “lockdown,” with the aim to provide a theoretical consideration for improving the adverse effects of lockdown policies on mental health and to contribute practical implications for improving individuals' mental health during the lockdown period.We used the National Center for Health Statistics (NCHS) and the Census Bureau's ongoing Household Pulse Survey as our primary data sources. To detect changes of individuals' mental health during the COVID-19 pandemic, the NCHS, in collaboration with the Census Bureau, set up this survey dataset, which includes individual-level information on age, gender, race and ethnicity, educational attainment, and location, administered electronically to adults aged 18 years and elder in each U.S. state through an Internet-based questionnaire supplemented by email and text messaging. The survey began on 23 April 2020 and continues to date. Based on the survey data, we collected data from April 23, 2020 to August 30, 2021 and created panel data with a 12-day statistical period with a total sample of 1,734. In addition, we added data on government lockdown policies adopted during the COVID-19 pandemic from the OxCGRT. Our state-level control variables, such as the number of hospital beds, was obtained from the Statista database; the average hourly wage was from the Federal Reserve Economic Database (FRED); GDP and unemployment rates were from the US Bureau of Labor Statistics; all other control variables were from the OxCGRT.The dependent variable in this study is the degree of individuals' mental health. We used the estimates of depression and anxiety disorders published by the NCHS and the Census Bureau as proxies for measuring mental health, which has been shown to be an important measurement in previous studies –28. HighThe independent variable is the government lockdown policies during the COVID-19 pandemic. We carefully selected the stringency index developed by the OxCGRT to measure the intensity of lockdown policies implemented by each state government . SpecifiIn this study, the economic support policies adopted by the government during the COVID-19 pandemic are used as a moderating variable. This variable is also derived from the OxCGRT, from which we selected the economic support index to measure the intensity of economic support policies implemented by the government in each state . The indWe controlled for a number of regional pandemic and macroeconomic factors that may affect the estimates. We first controlled for the severity of the COVID-19 pandemic, measured as the number of confirmed cases in each U.S. state . The amoWe mainly considered two dependent variables, depression and anxiety disorders, in this study, and therefore two regression equations were included in our estimation models. The first equation examines the effect of government lockdown policies on individuals' depression and the moderating role of government economic support. The second equation examines the effect on individuals' anxiety and the moderating role of government economic support. In summary, the following OLS models were developed for the baseline regressions:i = state, t= year, μit is the standard error term, and δt is the regional fixed effect.where i= state, t= year, εit is the standard error term, and γt is the regional fixed effect.where Panel A of Table 1Estimation results.Lockdown), and the results suggest a significantly positive relationship between government lockdown policies and depression , in line with our expectation. We argued that the government economic support can mitigate the depression brought about by the lockdown, representing a negative moderating role. As shown in Model 3, the coefficient on the interaction term between government lockdown policies and government economic support (Lockdown × Economic support) is negative and significant , which supports our expectation. To gain more insight into this interaction, we plotted these relationships in Panel B of Lockdown) in model 5 to examine the relationship between government lockdown policies and anxiety disorders. The results show a significantly positive relationship , in line with our expectation that lockdowns will lead to more severe mental health problems. Model 6 examines the moderating effect of government economic support, and the results show that the coefficient on the interaction term (Lockdown × Economic support) is negative and significant , suggesting that the relationship between the lockdown and anxiety disorders is weakened by higher levels of government economic support. Similarly, we plotted the slope of the simple regression reflected in Model 6. Models 4–6 examine the impact of government lockdown policies on anxiety disorders. Model 4 is a baseline model only including control and moderating variables. Similarly, we added the independent variable  do government lockdown policies lead to a worsening of individuals' mental health? (2) to what extent does the relationship between lockdown policies and mental health vary across states depending on the level of government economic support? Specifically, we find that government lockdown policies are associated with increases in post-lockdown estimates of depression and anxiety disorders across states. Depending on the spread and infection of COVID-19, state governments have implemented different levels of lockdown policies. The most common types of lockdown are those requiring self-isolation and home quarantine of patients and close contacts, even urban closures in areas with severe outbreaks. Lockdowns appear to be the most effective way to deteriorate the spread of the virus, but it can lead to very serious mental health problems. It is well-documented that lockdowns trigger anxiety and insecurity , 35 and Secondly, our study also shows that economic support from the government alleviates the symptoms of depression and anxiety associated with the lockdowns. Another important source of stress is economic hardship , and ecoThis study makes several important contributions to the relationship between government lockdown policies and mental health during the COVID-19 pandemic. First, our study uses the data from the Household Pulse Survey and OxCGRT, takes the mental health values of all 50 states in the United States as the research samples, to examine the actual impact of government lockdown policies on mental health at the macro level, whereas most of the existing research on the relationship between lockdowns and mental health has been conducted at the individual level using first-hand survey data , 42, 43.Furthermore, by exploring the relationship between the lockdown and mental health during the COVID-19 pandemic and the moderating effect of economic support, we aimed to provide a theoretical lens for ameliorating the negative impact of the lockdown on mental health and to provide practical strategies for improving the mental health of the population during the lockdown. On the one hand, from the government perspective, the implementation of lockdowns is necessary to deteriorate the spread of the pandemic . AlthougThere are several additional limitations to this study that need to be addressed. The first limitation relates to our measurement of regional mental health in the lockdown situation. We used only two measures of mental health, anxiety, and depression, in this study. Although these two measures are probably the most important indicators of mental health, subsequent studies will need to design and use tailored measures for psychosocial characteristics of different populations, such as loneliness and sleeping quality. In addition, due to the limitations of the dataset we used, we were unable to control for individual-level characteristics, which may have led to some bias in our results. Further research is expected to measure and compare in depth the effects of variables such as age, gender, education, work, and health conditions on mental health, providing more detailed and accurate information.The original contributions presented in the study are included in the article/All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.This work was supported by the National Social Science Fund Youth Project of China (Grant No. 17CJY019).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The subjective and demanding nature of olfactory testing means that it is often neglected in clinic despite loss of smell leading to significant limitations in everyday life. The list of diseases associated with loss of olfaction far exceeds the field of otorhinolaryngology and can also be seen in neurodegenerative disorders. Knowledge of possible clinical testing is essential to determine a proper differential diagnosis for the loss of olfactory sense. Causes of olfactory impairment can be divided into either failure in transferring odour to the organ of perception or damage to the olfactory pathway structure itself. Examination should therefore include methods evaluating cross-sectional area and patency of the nasal cavity as well as subjective or objective assessment of olfactory function. In this report we summarize several articles, studies, and our own experiences to provide a comprehensive review of their current clinical usage including their benefits, limitations, and possible outcomes. We also discuss the mechanism of olfaction step by step to provide a full understanding of the possible errors depending on the localization in the pathway and the methods designed for their detection. We discuss the correlation of the microbiome in nasal polyposis and chronic rhinitis with olfactory impairment using objective olfactometry. The topic of objective olfactometry and the examination of olfactory event-related potentials (OERP) is commented upon in detail. The aim of this article is to provide a closer look at the current methods of olfactory assessment and provide an algorithm that could be used in clinical practise as a part of a routine otorhinolaryngological examination. Smell is one of the basic senses by which we explore the world, although unlike in other mammalian animals, its function is limited in humans. Proper function of this sense is essential to human behaviour personally, socially, and professionally. Olfactory loss in connection with upper respiratory tract diseases is a relatively common finding in the otorhinolaryngology clinic, but it can also occur in connection with neurological, genetic, or metabolic diseases. Therefore, correct diagnosis can be essential for further diagnostic considerations. Perception of the olfactory stimuli relies on conduction; i.e., the delivery of the odourant stimulus to the olfactory region and the sensorineural processing in the olfactory organ itself.2 .,33.32,33The advantages of this test are its speed, simplicity, and the ability to test the smell threshold (odour detection threshold). Disadvantages include the short expiration and therefore greater costs of this method. A more affordable, and likewise time-saving, variant is OMT in the form of impregnated coloured markers. This method was developed and put into practice by Czech medical specialists . In the The outcome of objective methods is independent of the will of the patient. These are represented mainly by objective olfactometry. It is based on the principle of presenting the odourant by a special device (olfactometer) into the patient’s nasal cavity and detecting the odourant-evoked electric activity of neurons (synaptic activity) in the olfactory pathway. The major advantage is the objectification of the response to the odourous substance and straight assessment of the preserved function of the olfactory nerve. This also helps in detecting patient’s malingering. However, obtaining valid results is not easy and many aspects, not only technical aspects, need to be taken into account ,36.2 for the trigeminal nerve, are used as odourants. The odourant is dissolved in a liquid (most often distilled water), through which air is bubbling, creating an aerosol. This provides adequate humidity, preventing drying the nasal mucosa during the experiment as well as maintaining constant temperature and preventing unpleasant and undesirable trigeminal response. When choosing a solvent, its physicochemical properties must be considered. Different pH values or direct interactions between the liquid and the odourant can significantly change the perception, and thus the results cannot be valid. The resulting aerosol with odourant must then be properly humidified (≥80%), heated to a temperature close to the body temperature (36 °C/96.8 F), and administered in a constant flow rate (8 L/min). Dry, too cold/warm air, or a higher flow rate irritates the trigeminal terminal fibres, and the result is the summation of signals from the trigeminal and olfactory fibres  ,42 41,42-Detailed research on the objective assessment of olfactory loss in patients after COVID-19.-Detailed research on the objective assessment of olfactory loss in patients with Parkinson’s disease.-Leading outlook for the future: research on the objective assessment of olfactory loss in patients with chronic rhinosinusitis (CRS) and nasal polyps (NP)—correlation of the microbiome in nasal polyposis and chronic rhinitis with olfactory disorders using objective olfactometry ,30,41.-Leading outlook for the future: in collaboration with neurosurgery—detailed research on the objective assessment of olfactory loss in patients before/after pituitary adenoma endoscopic surgery .-Leading outlook for the future: in collaboration with radiodiagnostics—detailed description of MRI findings of the olfactory bulb in IOL and traumatic olfactory loss ,40.Impaired olfactory function is a problem that affects an individual’s life at many levels. These are not just personal or social limitations. Loss of smell also represents a safety risk, for example, if an individual cannot smell the smoke of burning objects or escaping natural gas. Mercaptan is added to natural gas as a safety precaution to indicate its leakage or ingestion of liquids in bottles by mistake. It is increasingly evident that olfactory loss is a side effect of some neurodegenerative diseases and appropriate screening could lead to early diagnosis. At present, olfactory loss is also widely discussed in connection with COVID-19 disease. It is one of the first symptoms and it persists for several weeks or months after the disease. Leading outlook for the future is a call for new projects concerning the correlation of the microbiome in nasal polyposis and chronic rhinitis with olfactory impairment using objective olfactometry and research on the objective assessment of olfactory loss in patients before/after pituitary adenoma endoscopic surgery ,41,42.Examination of this sense should therefore not be neglected. Objective olfactometry appears to be the method with the greatest potential, and further research and data collection in practice could lead to its routine use across medical disciplines soon.


We report the results of a pilot study regarding the adaptation of the group eye movement desensitization and reprocessing (EMDR) protocol for the treatment online, for the management of trauma associated with the COVID-19 Pandemic in Italy. The target group were healthcare workers in a nursing home  who decided to live and stay on site during the most acute phase of the Pandemic in order to protect the residents of the home. Scores for perceived post traumatic stress disorder (PTSD) symptoms and quality of emotional experience improved significantly following participation in the therapy programme. These preliminary results confirm the innovative potential of the EMDR protocol when used online on early intervention, to prevent the development of later psychological disturbances. The COVID-19 Pandemic undoubtedly qualifies as a mass disaster, with significant negative effects on the social, cognitive and emotional functioning of everyone involved. One group that has been at the frontline throughout are health workers, who have had to deal with the emergency in hospitals and emergency services, in prevention and epidemiology services and in nursing homes . These workers have been in a constant state of high physical and psychological alert : emergenOf the therapeutic options available for the treatment of PTSD, eye movement desensitization and reprocessing (EMDR) is one of those that has been demonstrated to be highly effective . It is bThe current emergency leads to the use of a group EMDR protocol, as has already been done in many countries worldwide following mass disasters. Group EMDR has been used both on adults and on children and has been adapted in many cases to suit specific contexts and circumstances . The groThe study was conducted in a nursing home for the elderly where the healthcare staff had decided to live inside the facility in order to protect the residents from infection of COVID-19. Not only were the healthcare staff exposed to the risk of infection and to exhausting shifts, hard physical work and a reduction in personnel resulting in an emotional overload, but they had to bear these burdens without the support and presence of their families. Other complexities arose due to the measures necessary to prevent the spread of the virus, which lead to changes in the nursing home routines and restricted contact between residents and their families and between healthcare workers and their families.The goals were to further test the feasibility of online group EMDR treatment and to qualitatively and quantitively assess its effects on the emotional and psychological health of participants. The expected outcomes, in line with these goals, pertained to two main areas: prevention of the chronicization of psychological disturbances; and strengthening of protective psychological resources.Participants were healthcare workers employed at a nursing home in Capoterra (CA). They had chosen to isolate themselves within the facility for 30 days in April, 2020 in order to avoid outside contact and the potential consequent infection of residents with COVID-19: it was well-established by then that therapeutic communities were among the hardest hit by the COVID-19 emergency. The owning company provided live-in accommodation to staff and the manager of the facility contacted the Italian EMDR association to request an intervention to support the operative team over this period.The intervention was implemented online, and two groups were held by trained EMDR therapists whose job was both to evaluate stress levels and to help reprocess the disturbing experiences and promote self-protective resources.There were 11 participants: 7 women and 4 men with an average age of 46, divided into two groups therapy of 6 and 5 participants, respectively. All of them had chosen to isolate within the nursing home for the 30-day period from April 1 to April 30, 2020.Two programmes of group therapy were carried out. Each consisted of five meetings: an initial pre-test and psychoeducational meeting, followed by three EMDR group therapy meetings, and a final post-test and debriefing meeting.The interventions were conducted by therapists trained in EMDR, at a Consultant level (certified by EMDR Europe Association). All the meetings were carried out on a virtual conference platform to preserve social distancing. The aim of the project was to provide support to the care team to help them bear the emotional burden of isolation, to reduce stress and to contain anxiety and anger. This was done by offering a space where they could “describe” their most stressful experience, their negative feelings and process them through EMDR, in order to reduce their risk of developing post-traumatic stress.The first meeting (meeting 1) in each intervention was dedicated to introducing the participants, presenting the project and conducing an initial pre-test of emotion and post-traumatic stress levels  and a Critical Incident Stress Orientation CISO, . PatientSince the goal of the intervention was to improve participants’ psychological wellbeing, initial screening of their symptoms in the acute phase was carried out.The CISO has the following features:•It provides a symptom grid showing Normal and Common reactions to post-traumatic stress. This allows participants to identify their own symptoms as common, albeit disturbing. It also provides explanations and descriptions of what is meant by a traumatic event, the psychological reactions that can arise following one, and vulnerability factors (in this case level of absurdity and level of involvement);•It provides indications for emotional self-protection to support coping strategies and resilience;•It provides explanations of the EMDR approach, and in particular on the short group protocol (EMDR-IGTP).Accordingly, the CISO phase of meeting 1 started with normalization of participants’ emotional reactions using the symptom grid, followed by introduction of techniques to prevent distress due to acute reactions to stress and to post-traumatic stress disorder. It was then explained that the EMDR support programme was intended to prevent and/or treat symptoms arising from participants’ experience of isolation and to allow them to maintain and develop their coping resources. The intervention was expected to be useful to cope not only with the quarantine period inside the nursing home, but also with the separation from their families, with a view to facilitating a smooth reunion and return to normality following the separation period.Defusing, a standardized method used in rapid treatments and emergencies, was employed to give relevant information on post-traumatic stress reactions and to enhance individual coping resources. The butterfly hug was taught to develop participants’ awareness of their own emotional reactions. This technique , generalOne of the most recent publications on the Cost-effectiveness of psychological treatments for post-traumatic stress disorder in adults, The three following meetings  focused on the distress and the needs of the team and group EMDR (EMDR-IGTP) treatment protocol was carried out. Participants reported feelings of helplessness, being unable to see their loved ones and at the loss of their normal pre-COVID routines, feelings of absurdity but especially for the residents about missing Easter festivities and contact with their families due to isolation. They also reported a wide variety of traumatic memories. Some of the worst memories treated included seeing their elderly patients struggling to breathe, watching them die without being able to touch them, having to rush continually from room to room, the lack of space in the morgue for dead bodies and others that show the dramatic situation the healthcare workers experienced. In addition, somatic symptoms like difficulty sleeping, anxiety and worry and irritability and restlessness were also reported.Sessions can range from 1 h to 1 h and 30 min. The participants were guided through a safe/secure place exercise or breathing exercises. The EMDR-IGTP leader asked them to think about the worst part of the event (the current crisis) and then to draw that image on the paper provided. They were then asked for the related Subjective Units of Disturbance (SUD) rating and told to write the corresponding number on their picture. After that they were asked to look at their picture and to provide their own alternating bilateral stimulation with the Butterfly Hug. The participants were then instructed to draw another picture of their own choice related to the event and rate it according to its level of distress. Processing continued with the adults looking at the second picture and using the Butterfly Hug. The process was repeated twice more so that each participant drew four pictures, and provided a SUD rating for each. The final level of distress associated with the current crisis was then assessed by asking to focus on the drawing that was most disturbing and to identify the current SUD level. This number was then written on the back of the paper and was the 5th SUD rating for the session. The participants then drew a final picture that represented their future vision of themselves, along with a word or a phrase that described that picture. No SUD rating was provided for this picture. The drawing and the phrase were then paired with the Butterfly Hug. The clients were instructed to close their eyes, scan their body, and do the Butterfly Hug or grounding techniques for the stabilization.The last meeting (meeting 5) was conducted using the same procedure as the previous three, but some time was dedicated to post-test administration of the IES-R scale and the emotion thermometer and to allowing participants with EMDR to share their impressions of the experience. The intervention ended with concluding comments and a wrap up.Pre- and post-intervention measurements were carried out in meetings 1 and 5, respectively, to verify results. A follow up measurement was carried out 9 months after the intervention.The following questionnaires were administered to participants.1.Impact of Event Scale-Revised (IES-R) in accordance with the criteria of the DSM IV-TR  validate2.The emotion thermometer, a non-standardized instrument, used to measure on a scale of 1–10 participants’ subjective experience of six emotions and their consequences: stress, anxiety, depressed mood, anger, difficulty sleeping, and need for help.The following is the coordinator’s summary of feedbacks given by the healthcare team.We had to close the gates to visitors. It was the toughest moment for two reasons: the first was because we were gradually but surely realizing how serious the situation was; the second was the feeling that one of the cornerstones of our service, a “safe haven” was being removed: the constant presence of our residents’ family members. In our value, family members are an essential element: there have never been limits to visiting times or the duration of visits, and their presence is an important resource, that we are loosing with the Pandemic and that we have to cope without.”The first topic is the most difficult moment the team had to face, i.e., “EMDR interventions helped immensely to process the critical moments and to connect with each other. It enabled all of us to acknowledge our tiredness, our longing for our families, and the desire to get out of the nursing home…without making us feel less important, less efficient or less worthy!! It allowed us all to express our fragilities and transform them into resources! One of our colleagues compared the EMDR meetings to weaving silk: any of the single threads would break under the pressure of the loom and personal dynamics. EMDR brought all the threads together to make one strong, tenacious, resistant one.”Regarding the EMDR intervention, the coordinator describes its efficacy as follows: “The graphs in M = 16,18 , avoidance M = 10,18 , and hyperarousal M = 11,18 . All the average post-test scores are lower: avoidance M = 1,18 ; intrusiveness M = 1,91 ; hyperarousal M = 1,09 .The difference between pre-and post-treatment average scores is statistically significant.With regards to the results obtained with the emotion thermometer, shows that all participants reported a substantial improvement in all the dimensions following the EMDR treatment.M = 7,36; SD = 2,73), anxiety , sleeping problems . The high average need for help score shows that the EMDR intervention would indeed potentially be very helpful.Overall, as Average scores for the same dimensions were lower following the intervention. The difference between pre- and post-intervention scores is statistically significant.M = 7,5; SD = 6,48), avoidance , and hyperarousal . This total increase  may be attributable to the prolonged psychophysical stress caused by the continuing COVID emergency situation, and by the effect of the second wave of COVID-19 arrived in Italy in that time, as it reported in The IES-R questionnaire was administered to participants again at follow up, 9 months after the end of the intervention. The numbers obtained show a slight increase on all subscales: intrusiveness (Our results confirm that the isolation, that was a fundamental strategy during the COVID-19 pandemic was a disturbing event that had a strong emotional impact on the nursing home healthcare workers; and that EMDR was effective in contrasting this impact. However, due to the lack of a control group, it is not possible to exclude that any other type of intervention, interrupting the social isolation, would have been effective in reducing the effects of stress-induced PTSD.Participants’ post-intervention IES-R scores were significantly lower on the intrusiveness, avoidance, and arousal subscales. Post-intervention scores on the emotion subscales also showed significant decreases in levels of stress, anxiety, depressed mood, anger, sleep problems, and perceived need for help. Although preliminary, these results are statistically significant and show that the EMDR programme we conducted was effective in reducing the effects of stress-induced PTSD as a result of isolation during the COVID-19 pandemic. The outcome was an improvement in the psychological wellbeing of participants, also confirmed in participant feedback. In addition to reducing the negative emotional charge of the event and the PTSD symptoms, it also improved the general emotional climate within our group.Our results thus confirm that EMDR treatment can be applied in the short term and/or in emergency situations. The protocols and techniques can be used on their own or integrated into broader programmes with a wide variety of applications in individual or group settings.Group EMDR seems to be a useful instrument for both prevention and treatment. It is of economic value because it lowers the cost of downstream management of mental health problems . Our resNevertheless, online administration of the EMDR protocol opens new possibilities in terms of timely intervention and prevention of long-term psychological disturbances as a result of acute stress.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.EF, MG, EG, IF, and MP contributed to conception and design of the study and wrote first draft of the manuscript. EF and MG organized the database. MP performed the statistical analysis. All authors wrote sections of the manuscript and contributed to manuscript revision, read, and approved the submitted version.