Eulemur macaco) living in human care at a zoo in the United Kingdom, the potential for SNA as a practical tool in assessing animal wellbeing is presented. SNA of the lemur group revealed patterns of female dominance, with one individual male being the most frequent target of aggressive interactions from the group. Using this technique, animal caregivers can identify social pressures, monitor social dynamics and dominance, and examine causes of suboptimal social wellbeing among the individuals living in their care. Understanding the social networks of individual groups can facilitate improvements and interventions to the benefit of individuals, groups, and wider populations.Social network analysis (SNA) has the potential to be a vital element of a holistic animal care toolbox, which allows in-depth examination of the social roles of individuals and the dynamics at a group level. By studying a case study of a group of four (1.1.2) black lemurs (Eulemur macaco), a primate whose social organisation is characterised by patterns of female dominance, it is demonstrated that SNA can be used to examine the affiliative and agonistic interactions between individuals living in human care. SNA showed species-typical forms of female dominance that were largely directed towards the two males, characterised by the initiation of aggressive interactions and male submission. More intricate relationships and consistent social roles across networks were revealed through the examination of SNA. It is concluded that SNA has wide-ranging benefits in the assessment of effects of environmental changes, such as informing social management decisions, developing enrichment and intervention programs, and guiding overall improvements to the housing and care of individual animals. SNA, as part of an animal welfare toolbox, could, therefore, be a pivotal technique for modern animal welfare assessment that considers individual animals and their social lives. By sharing a case study of the technique in use, it is hoped that animal collections may adopt similar modern and evidence-based assessment methods.Social network analysis (SNA) is an increasingly utilised technique in the literature examining the social structures and organisation of animals and understanding the bonds between groups and individuals. Using a case study as an illustration, the applications of SNA are explored, including the identification of dominance hierarchies and detection of sources of social pressure, with a particular focus on the applications of SNA to holistic assessments of animal welfare alongside other methods. Based on the examination of social dynamics in a family group of four black lemurs ( Social relationships are essential to the wellbeing of many species living in zoos and aquariums worldwide. The bonds that animals form with each other provide numerous benefits to their physical and psychological health, and as such, many modern models of animal welfare consider the complex implications that the social lives of animals can have on individual wellbeing. The Five Domains model is a well-known modern framework for assessing animal wellbeing, highlighting the five key areas of nutrition, environment, health, behaviour, and mental states as essential to good animal welfare . This moGood welfare encompasses all interconnected elements of an animal’s physical and psychological state, including their perceptions of the social environment. For brevity, the terms welfare and wellbeing are used synonymously within this paper. Maintaining and promoting appropriate social groupings and interactions that are positive, beneficial, and meaningful from the perspective of the animal is, therefore, a key challenge for zoos and aquariums, where the human-managed environment can impact the social behaviours of animals in unexpected and complicated ways. As, when combined with all other areas of their lives, the social environment is important to physical and psychological health , it stanWhile some level of aggression is unavoidable, as it is a necessary component of the maintenance of group cohesion and dominance structure ,15,16,17Traditional approaches to measuring social behavioural patterns for management purposes include assessing proximity to others ,26 and oSNA has been presented as a valuable tool for the management of zoo animals  owing toWith appropriate training, SNA can be conducted by student researchers, visiting academics, and animal caregivers themselves, with simple and practical graphical user interfaces for conducting the analyses, such as UCINET and NetDraw, being available. For animals living in zoos and aquariums, evidence-based insights into social structures can be essential in terms of guiding management strategies to improve animal wellbeing, management outcomes, and other goals, such as conservation breeding success ,33. A reOften, limited sample sizes preclude much zoo-based research concerning husbandry and management evidence from being published in the peer-reviewed literature . ConsequEulemur macaco), a social species of cathemeral primate that, in zoos, is commonly housed in family groups consisting of a breeding pair and their offspring. Within these groups, complex patterns of female-dominated social hierarchies are present, with impacts on individual and group wellbeing [In the present article, a case study is presented alongside a discussion of the applications of SNA to provide an example of how SNA can be used to benefit the management of individual social groups through an understanding of the complexities of the social dynamics involved in individual groups. This study was conducted on a family group of four black lemurs  in Hertfordshire, the United Kingdom, over a two-month (August–October) period in 2018. At the time of the study, the zoo housed a family group of 1.1.2  black lemurs . The aduThe group was housed in two alternative habitats throughout the study, transferring to the second habitat halfway through data collection stage. The first habitat, namely “Habitat A”, was adjacent to one other habitat, which housed black-and-white ruffed lemurs. The second habitat, namely “Habitat B”, was the same size as Habitat A , but we instead placed the group between two habitats containing different species of ruffed lemur. The move was unrelated to the management of the black lemurs and to the study itself and was instead related to reducing the prevalence of interspecific aggression between the ruffed lemur habitats. This was accomplished by moving the black lemurs into the existing black-and-white ruffed lemur habitat while moving the latter into the black lemurs’ previous habitat. Excluding the specific arrangement of enrichment, such as climbing frames, all other provisions in the two habitats were identical.Both habitats included indoor housing, which was always open and available to the lemurs across 24 h days. There were additional shelters at the rear of both habitats with heat lamps that could be switched on during cold weather conditions. Habitats incorporated multiple and dynamic furnishings to provide varying levels, including logs, hammocks, ropes, and shelves. Both habitats had a single feeding table where a bowl of water was provided, and some food would be placed during feeding. Other feeding instalments included buckets attached to the side of the wire barrier. The animals were fed three times a day at the time of the study. The first feed occurred before the zoo opened at 08.00 and consisted of 360 g of Mazuri exotic leaf eater pellet with 90 g soaked for Bolek and scattered separately from the rest of the food items. The second feed took place around 13.00, and the third took place at around 15.00, with both feeds consisting primarily of a range of leafy, root, and other vegetables. Categories of vegetables fed were highly variable and, thus, not studied as a factor. Feed times did not occur at the same time every day and were variable depending on caregiver routines, but they generally fell within the hours described.An ethogram of social behaviours within the measured categories  was deviBehavioural observations took place across ten total days, with three behavioural observation periods being used. As feeding has been associated with increased aggression in previous studies of animal behaviour ,12,13,14Data were collected using a continuous event sampling method, wherein every instance of behaviour within each set of behavioural categories outlined via the ethogram was recorded. Data points were recorded according to which animal instigated the behaviour (the actor) and towards which animal the behaviour was directed (the reactor). Only the initiation of the behaviour was recorded; for example, if animals were engaged in huddling behaviour for ten minutes, only the moment that they started to huddle was recorded. Behaviours were recorded by an independent student observer who did not work with the study group directly and was not informed which individuals were involved in aggressive behaviour prior to the research. Video recordings were taken during the pilot study to allow the primary researcher to compare and confirm behavioural observations with those who possess experience working with the species. Video recordings were not used during the study itself due to logistical issues surrounding the positioning of the cameras and safety in an area that is open to the public. Direct observations were recorded using a pre-prepared observation sheet.Social network analyses were conducted via UCINET and NetDraw . These sUtilised descriptive analysis indices included reciprocity, centralisation, and degree centrality. Reciprocity was used to determine whether interaction rates between individuals were mutually linked and, due to the limited sample size, measured using arc reciprocity. Reciprocity was measured on a scale of 0 to 1, with a result closer to 0 indicating “anti-reciprocity”, or a lack of reciprocal ties, while a result closer to 1 indicated “perfect reciprocity”.Group centralisation was measured as a proportion on a scale of 0 to 1. Centralisation is an indicator of whether or not a group contains individuals who are more important than others, with a score closer to 0 indicating that social interactions are more evenly distributed, while a score closer to 1 indicates that there is a hyper-central individual with more importance. Degree centrality can then be used to identify which nodes hold more importance based on the number of connections that they hold with other individuals within the network. The “out” degree centrality indicates the extent to which a node initiates a behaviour towards another, while the “in” degree centrality refers to the extent to which a node is the recipient of a behaviour. In the present case study, degree centrality was indicated by the total number of interactions initiated or received compared to the network average for that behaviour. As the primary focus of this study was on examining the network structure in terms of describing the interactions between individual actors, rather than making inferences or testing hypotheses regarding the prediction of behaviour, further statistical analysis of the significance of SNA data was not required. Prior to analysis, the data were checked with Shapiro–Wilk tests to determine the normality of variances. The variables analysed were the rate of the different social behaviours, whether animals were fed during that observation, and the habitat. Since the data were not normally distributed, non-parametric tests were deemed appropriate. The associations between feeding and the instance of different social behaviours were analysed using Kruskal–Wallis one-way ANOVA tests. To compare individual conditions, Mann–Whitney post hoc comparisons were separately conducted between each category. All data analyses excluding SNA were carried out utilising GENSTAT .As the enclosure changed partway through this study, it was not possible to gather enough data to carry out significant analysis of the impact that the enclosure change may have had on social behaviour. Despite this, preliminary comparisons were made in the total behaviour counts for each day of the study for both enclosures . Based op < 0.05). There was significantly more aggression during both the noon and afternoon feeds compared to when there was no feed (p < 0.05). However, there was no significant difference between the noon and afternoon feeds.Statistical analysis of the data demonstrated that agonistic behaviour was variably impacted by feeding. Intragroup aggression levels  were sigp < 0.05). There were significantly more aversive behaviours during feeding compared to the no-feed condition (p < 0.05), with no significant difference between the two feeding times. The rates of aversive behaviours were similarly affected by feeding . Post hoc comparisons indicated that there was no significant difference between the no-feed condition and the noon feed; however, affiliation was significantly higher during the afternoon feed compared to both the no-feed and noon feed conditions (p < 0.05).The impacts of feeding on affiliative behaviours were significant  and juvenile male (216) were the two individuals most likely to be the recipients of aversive behaviours , compared to the network mean of 146.80 ± 132.240 s.d. Notably, the adult female was never aversive towards the other members of the group, and the adult male was never avoided.SNA for affiliative behaviours indicated perfect reciprocity at a level of r = 1. The centralisation of this network was reported at C = 0.41. The network average for initiating affiliate behaviours was 427.50 ± 198.008, with the youngest female (670) initiating the most behaviours, followed by the juvenile male (524) and the adult female (383). The adult male was involved in fewer affiliative interactions compared to the rest of the group, initiating only 133 behaviours compared to the mean. Furthermore, he was the recipient of 171 affiliative interactions compared to the network mean of 427.50 ± 154.694 s.d.Anecdotal information was collected from caregivers involved in the care of the lemurs and extracted from ZIMS behavioural records following the study. Six months after the conclusion of data collection in March 2019, the adult male “Bolek” was separated from the group following increased bouts of chasing from the rest of the group and a physical altercation. Attempts to reintroduce the adult male to the juvenile male were unsuccessful. The juvenile male was transferred out of the zoo in December 2019.Over the next seven months, several attempts to introduce the adult male back tfemales were unsuccessful due to physical aggression from the adult female. The juvenile female was transferred out of the zoo in July 2020, after which point the adult male and adult female were successfully reintroduced without issues. As of August 2023, the pair have remained together since their reintroduction.The present case study demonstrates the value of social network analysis as a practical tool for managing social groups living in human care and analysing the social roles of individuals. The findings of the present case study show how SNA could be used to identify causes of and solutions for social instability after caregivers raised concerns surrounding aggressive behaviours within the black lemur group. It is worth highlighting that the observer in this case study, while not aware of which individuals were involved in the aggressive behaviours described, had been made aware of aggressive behaviours occurring prior to the observations. Awareness of these behaviours occurring may have inadvertently contributed to some level of bias in the recorded scores, as vigilance towards expected behaviours may be present. Should SNA be implemented by animal caregivers on a wider scale, it is worth both highlighting and acknowledging that observer familiarity with the animals, in addition to an awareness of concerns that have been raised surrounding behaviours, may lead to observer bias within the recorded results. Nonetheless, the social roles of all four individuals were consistent across SNA for all three behavioural categories following behavioural observations. The adult female was the most central individual across all networks, with a dominance style characterised by aggression towards the males, congruent with what would be expected of wild conspecifics ,47. The Notably, rates of aversion were higher than rates of aggression, which indicates that aversion occurred in the absence of any aggressive instigation. Individuals who were targets of aggression, particularly the adult male, demonstrated avoidance and social submission towards those who were aggressive towards them. Aversion is a useful measure of social fear and submission , being aIt was not possible to gather enough data to carry out a significant analysis of the impact that habitat change may have had on social behaviours and, thus, what impact the change may have had on social wellbeing. Preliminary comparisons made based on the limited data collected indicated that there were no significant differences in the instances of aggression, aversion, or affiliation due to the move. As the new habitat was within the same facility, possessed the same dimensions, and was directly adjacent to the original, it is unlikely that this change would have impacted the results in a meaningful way.The analysis of behavioural rates indicated that the presence of food played an important role in catalysing bouts of aggressive behaviour. As observations surrounding non-feeding times occurred in the morning, it is also possible that the time of day was a factor. However, as black lemurs are cathemeral and, thus, irregularly active across a 24-h period , establiWhile some aggression is a fundamental aspect of sociality and stable social group dynamics ,55, aggrLemur catta) and black-and-white ruffed lemurs (Varecia variegata) [Solutions aimed at reducing aggression could be focused on feeding times, such as through alternative feeding presentations and strategies. Solutions could include wider food distribution within the habitat, which would provide the choice for animals to eat together or apart and reduce the likelihood of conflict . Providiriegata) ,61. FutuSNA could also guide housing decisions, such as determining when and which individuals may need to move on from their current social group or if separation is necessary to safeguard wellbeing. Following this study, the adult male lemur required separation from the rest of the group due to a severe instance of targeted aggression from the adult female. Based on an assessment of the SNA, one option for improving the social wellbeing of the adult male could have been to move the juvenile male to a new social group at another facility. The juvenile male, coming towards the age of sexual maturity, may have shown increased levels of aggression towards the adult male to bolster his social position within the group. The juvenile male was less central to the networks in comparison to the primary aggressor, the adult female, and so moving this individual would have a lesser impact on the overall social structure compared to moving the female. There was also the potential for the presence of a dependent juvenile to be a catalyst for increased aggression from the adult female, as she may have perceived the adult male as a threat to her access to resources. Aggression has been observed to increase around the time of birth in wild lemurs ,62, whicThe younger male was eventually moved to another facility; anecdotal post-intervention observations suggest that these changes to the social group may have been effective at alleviating aggression and increasing affiliation for some time, though it was only once both juveniles had left the group that the successful reintroduction of the two adults was possible. To this end, SNA may aid in planning for conservation breeding programs, such as the black lemur EEP, by identifying the ideal age for offspring to move on to new social groups before social issues begin to occur. Longer-term monitoring via SNA would be beneficial to confirming any lasting improvements in social position and wellbeing as a result of these changes and monitoring for early indicators of compromised social wellbeing in the future. While a small study, the present case demonstrates how network analyses of social groups including as few as four individuals can provide empirical insights that can be used to the benefit of practical management strategies and animal wellbeing. Holistic animal wellbeing assessments should incorporate measurements of social wellbeing alongside all other aspects of their physical and psychological health, with an understanding that the social environment can have profound impacts on the mental states of animals alongside all other elements of their lives . TowardsCollecting longitudinal SNA data has broad applications for future research into the social behaviour of many species. Retroactive studies of SNA data may examine the factors that influence social changes over time, for example, and the impacts of various husbandry events on social structures can also be assessed. An understanding of species- and individual-level responses to changing group dynamics is broadly useful for future animal care decisions, such as the planning, monitoring, and evaluation of introductions and translocations with respect to the social lives of animals. Continued monitoring could reveal subtle long-term effects on individual relationships . Longitudinal SNA will also facilitate the observation and identification of natural fluctuations in social roles and relationships unrelated to husbandry. For example, there may have been an increasingly dominant role of the juvenile male as he approached sexual maturity, as demonstrated by his aggression towards the adult male. Such interactions may reflect the natural life history of the species, though these effects would be better understood via SNA conducted throughout the animal’s lifespan. Ongoing SNA could further aid proactive welfare assessments and the management of animals by monitoring for early signs that negative social pressures may be intensifying, such as the declining social position of the adult male, and facilitate timely interventions. SNA could also evaluate the impacts of future interventions aimed at improving welfare. Comparing networks before and after implementing such changes would reveal if these actions successfully altered social dynamics and improved social wellbeing as intended. More broadly, case studies applying SNA to a diverse range of groups across populations contribute valuable insights to inform best practices and compassionate care of animals in general.It must be recognised that there are obstacles to implementing SNA on a wider systematic scale. A straightforward method to complete, time, personnel, and expertise is nonetheless required to collect and collate the data, as is relevant training and guidance regarding planning and conducting data collection as well as analysis of the data itself. While the data may be straightforward to collect, a thorough understanding of the social behaviour of the species, as well as of analysing data itself, is required for any assessment tool to be meaningful. Furthermore, many smaller zoos may lack the time and resources to conduct social network analyses on a continuous and systematic scale. There is, often, a research bias towards zoos with larger sample sizes , which cWhile sample sizes preclude broad generalisations, limited population numbers should not dissuade researchers from conducting SNA case studies. Such studies aid in improving our understanding of species-typical social structures and individual variations, which may aid care decisions for related taxa in other collections and improve individual and group wellbeing. By demonstrating SNA as a practical, evidence-based tool even for small groups, this case study supports the increased application of SNA and contributes to the advancing multidisciplinary approach to optimising individual- and group-level wellbeing.The presented case study demonstrated that even with limited scope, social network analysis can reveal useful insights into the social dynamics of wild animals living in human care. As such, this case study is a useful demonstration of how SNA can be used on an individual group scale within zoos and aquariums. Mapping the affiliative and agonistic interactions between group members identified differences in social roles, including a subordinate individual receiving high aggression and potentially experiencing compromised wellbeing due to his social position. Anecdotal follow-up observations demonstrated that removing an individual identified as a possible cause of social tension had some success in temporarily improving the social status of the targeted individual. Though this is a preliminary study, SNA as a complementary tool in monitoring and managing the complex social lives of animals and in informing management strategies is showcased. Larger studies across diverse taxa are needed to confirm the generalisability and optimise methodologies, as are longitudinal studies, which track changes in social networks over time and in response to changes in housing or husbandry. Overall, despite having limitations when applied to small social groups, SNA holds great promise as part of a systematic, proactive, and holistic wellbeing management toolbox, presenting a prospect for fundamentally improving how zoos and aquariums monitor and manage the social lives of the animals in their care.


Giant omphalocele (GO) is a complex condition for which many surgical treatments have been developed; however, no consensus on its treatment has been reached. The benefits and efficacy of botulinum toxin A (BTA) in the repair of large abdominal wall defects in adults has been proven, and its reported use in children has recently grown. The goal of this study is to describe a novel technique for primary repair of GO using BTA during the neonatal period and report our initial experience.  patients were followed from August 2020 to July 2022. BTA was applied to the lateral abdominal wall in the first days of life followed by surgical repair of the abdominal defect.  while awaiting surgery, patients had minimal manipulation, without requiring mechanical ventilation, were on full enteral feeding, and in contact with their parents. The midline was approximated without tension and without the need for additional techniques or the use of a prosthesis. Patients were discharged with repaired defects.  this approach represents a middle ground between staged and the nonoperative delayed repairs. It does not require aggressive interventions early in life, allowing maintenance of mother-child bonding and discharge of the patient with a repaired defect without the need for additional techniques or the use of a prosthesis. We believe that this technique should be considered as a new possible asset when managing this complex condition. Omphalocele is a congenital defect of the abdominal wall that occurs due to the persistence of physiological herniation of the midgutIts prevalence is estimated between 1 to 3.8/10,000 live births,Giant omphalocele (GO) is considered a more complex variation of the spectrum and is characterized by the association of a large wall defect (>5cm) and a voluminous hernia sac , with an important visceroabdominal disproportion,There are two main strategies for managing GO: staged surgical closure and non-operative delayed closure. However, there is no consensus and there is evidence to support both approaches,,Recently, the use of botulinum toxin A (BTA) in the repair of abdominal hernias with loss of domain in the adult population has become more frequent, and its use has already been shown to facilitate the closure of the abdominal wallThe aim of this study is to describe the technique and methodology for applying BTA in patients with GO during the neonatal period and to report the initial experience, favorably resulting in primary closure of the abdominal wall without the use of additional techniques or prostheses.Written consent was obtained from the patients’ legal guardians. This study was approved by the Ethics in Research Committee on October 20, 2022 .The application of BTA was performed in the Neonatal Intensive Care Unit (NICU) under sedation, ultrasound guidance, and sterile conditions. We chose a neonatal spinal needle, burt a regular 25mm x 0.7mm (22G 1/4) needle could also be used.The ultrasound transducer was transversely positioned on the lateral abdominal wall to obtain an in-plane image A.The three muscle layers were infiltrated with BTA: external oblique, internal oblique, and transversus abdominis B.WE marked six sites, three on each side of the lateral abdominal wall C.th rib, and may be even more lateral, over the 10th to 12th ribs. The most caudal site is at or slightly above the iliac crest, and the middle site is the most lateral, at the average distance between the first twoOne must carefully choose the sites based on the ultrasound images, where the surgeon can visualize the three layers of muscle and achieve the most lateral position possible. The most cranial site is generally subcostal, at the level of the 9There is a correct dose for each muscle groupDue to the limited space for infiltration, a volume of 1 to 2ml at each site was generally sufficient. Based on the patient’s weight, the total dose was calculated and diluted in a volume of 6 to 12ml and distributed equally among the six sites. Excessive volume can cause more pain and compromise ultrasound images.Definitive closure was planned between 30 and 45 days after BTA applicationDuring this period, dressings are applied with silver sulfadiazineUnder general anesthesia and use of prophylactic cefazolin, the patient was placed in a supine position. Foley and nasogastric catheters were placed, two peripheral venous accesses, a central venous access can be used if necessary.A median incision below the defect was made to enter the abdominal cavity. By opening and protecting the internal organs, the remaining sac was separated from the skin around its entire circumference, and the adhesions carefully divided.The median incision was then extended cranially to the xiphoid process, and the edges of the defect were delimited and exposed. We actively searched for malrotation and performed the Ladd procedure as needed.The adipocutaneous flaps were dissected laterally until there was enough space and the “corset” appearance came undone and the midline was easily approximated with tweezers C. At thiWe sutured the aponeurosis with interrupted PDS 2-0 stitches, and fixed the skin to the aponeurosis with Vicryl 5-0. The skin was closed with an intradermal, absorbable suture.A drain may be placed if there is excessive skin dissection.Patients returned to the NICU, receiving prophylactic antibiotics for 24 hours. The decision to extubate was based on ventilatory needs and clinical judgment. No sedation or muscle paralysis is required if the IAP is at adequate levels and there have been no large increases in peak ventilatory pressure during closure. Oral feeding was started immediately after extubation.rd day of life. BTA (Botox®) was applied on the 4th day of life, in a total dose of 12U/kg of BTA. Dressings with silver sulfadiazine, sterile gauze, and bandages were applied with light compression and were changed more frequently in the first week (every 2-3 days) and once every 5-7 days in the last week before surgical treatment. During the period between the application of BTA and the surgical correction, the patient remained in room air, with full enteral nutrition and breastfeeding, without the need for parenteral nutrition (PN) or antibiotics. Surgical correction was performed 32 days after BTA application  on the 2nd day of life. Dressings were done in the same way as in the other patient and full enteral feeding was achieved on the 7th day of life. While awaiting surgical correction, the patient remained in room air, predominantly breastfed, without the need for PN, antibiotics, or a venous catheter, and in contact with his parents. He underwent the surgical procedure 37 days after the BTA application (th postoperative day. The total length of stay was 45 days.Male patient born at 35 weeks and two days of gestational age weighing 2.100kg. The abdominal wall defect measured 8cm in its lateral extension, and the maximum diameter of the omphalocele was 12cm A, contailication B. Primarlication C, and a lication D. The inAt the 24-month follow-up, the first patient had no complications and no sign of recurrence A.The second child had two suture-related granulomas that drained spontaneously and did not require additional treatment. At the 8-month follow-up, the patient showed good child development, with no other complications or signs of recurrence B.Both patients presented child development within normal standards, and the families demonstrated extreme satisfaction both during the treatment and with the surgical result.,Despite decades of study and the description of various techniques, the treatment of GO is still the subject of debate. Currently, two main strategies are available: staged surgical closure and non-operative delayed closure, and there are data in the literature to support both approaches,Late, non-operative closure is usually performed with dressings and topical agents that stimulate scarification and epithelialization of the omphalocele membrane, and is followed by a late closureSeveral techniques for staged surgical closure have been described to promote complete reduction of GO content, such as the placement of surgical silosMost of these techniques require more than one procedure under general anesthesia, and these patients usually require mechanical ventilation, sedation, and/or muscle paralysis throughout the process, known to have repercussions on neurodevelopment in the long term,,-,In addition, all these methods, including the non-operative approach, usually require the application of additional techniques at the time of surgery, such as component separation, skin or fascia flaps, negative pressure therapy, and/or use of prostheses,The benefits and effectiveness of applying BTA for repairing large abdominal wall defects in adults have been previously reported,We recently reported the first cases in the literature of the application of BTA in children with hernias secondary to GOIn both cases reported herein, the approximation of the midline was easily obtained, even in the subxiphoidal region, where the defect is usually larger, there is less aponeurosis, and the rigidity of the rib cage can hamper closure.Both patients needed minimal manipulation, requiring sedation only during BTA application. They were maintained on complete enteral nutrition since the first week of life, including breast milk, and in close contact with their parents.,,,We observed only minor complications, and the aesthetic result was favorable in both cases. We found no adverse reactions related to the use of BTA, since they are rare,The time for surgical correction can vary. The onset of BTA action appears to be within 48 hours of application, but its peak may occur between one and four weeksAlthough it was possible to easily approximate the midline without additional techniques such as separation of the abdominal components or the use of prostheses, we recommend having a biological mesh available in case primary closure is not possible or there is hemodynamic repercussions at the time of midline approximation.,-Our technique represents a middle ground between staged and late closure techniques. It does not require early aggressive interventions and the patient is discharged with the defect repaired, with a high probability of primary closure and without the need for additional techniques or prostheses. Although there are other reports in the literature on the use of BTA in children with GO, all are patients with a secondary ventral defect at an older ageWe recognize that the patients in our study did not have major cardiovascular malformations or significant pulmonary hypoplasia, which certainly contributed to the favorable results. However, this does not negate that this approach leads to a more gentle process until closure by not requiring aggressive and invasive interventions.Application of BTA to the abdominal wall is a relatively simple technique that can be performed in any center, given the availability of BTA and ultrasound equipment. The use of ultrasound is mandatory for proper visualization of the needle and toxin infiltration, minimizing possible complications.Due to the complexity of GO, there will always be room for developing new techniques or the improvement of the existing ones. The objective of this study was to describe our technique for approaching GO and to report the first experience in the literature with the use of BTA in neonates, presenting an additional tool for managing this complex condition. However, this technique is still very new and we encourage studies to confirm its benefits and long-term results.


Being overweight or obese at the end of the first year of life is associated with an increased risk of obesity in later life and an increased risk of developing other diseases, like type 1 diabetes mellitus, cardiovascular disorders and psycho-social problems ,3. In a In this Special Issue, Wood et al. showed that positive affect from caregivers might reduce the incidence of overweight and obesity . They foDiseases related to obesity are most likely not related to the overweight per se but to the high-fat content of an infant. Body fat content seems much more important than weight. A high weight does not necessarily indicate a high fat content, and an average weight does not mean a low fat content . In a grAnother factor that might affect the development of overweight is environmental pollutants. Several studies reviewed by Berghuis et al.  reportedOverweight is also related to the type of food consumed by infants. Infants seem to prefer unhealthy food products, like hamburgers and sweetened drinks, and do not like healthy products, such as vegetables and fruits. Their dislike of healthy foods might be related to a lack of exposure to these food items. In this Special Issue, a large-scale study by Hanraths et al. examined if repeated vegetable and fruit exposure at a primary school  might imOne highly debated topic in the development of overweight and adiposity in infants is the role of breastfeeding. Some studies have shown a lower risk of developing overweight in breastfed infants , while tFirst, for ethical reasons, it is impossible to conduct a randomized controlled study on the potential effect of breastfeeding. At the same time, mothers who are willing to breastfeed might be different from mothers who prefer bottle feeding. Secondly, studies can only compare the risk of overweight among breast- and bottle-fed infants or between infants receiving different formulae. A higher risk of developing obesity in bottle-fed infants might be related to the composition of the formula used, and not to the positive effect of breastfeeding. Different nutritional components, which are different between breast milk and formulae, might be responsible for the higher risk of overweight/obesity in formula-fed infants. Macronutrient components that have been studied in more detail are the protein content and the fatty acid composition of formulae, the gut flora, and differences between fore- and hindmilk.n-6) and linolenic (n-3) fatty acids, have many effects on our human metabolism. Studies using cell cultures and animal studies have shown that these derivatives, especially arachidonic acid (AA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), influence lipogenesis and might, therefore, influence the development of overweight and obesity in children. In this Special Issue, Demmelmaier and Koletzko [Essential fatty acids, which are the derivatives of the parent compounds linoleic (Koletzko  showed tA highly debated and studied factor that might explain the higher risk for overweight and obesity in formula-fed infants is the protein content of infant formulae. Rolland-Cachera was the first to show a relationship between protein intake and the incidence of overweight in infants . The proAnother difference between breast and bottle feeding is the difference between fore- and hindmilk, with the composition of the formula being constant during formula feeding. Hindmilk is richer in fat and energy than foremilk. The protein content of hindmilk is higher than foremilk, while foremilk contains a higher level of free amino acids . KaratasBased on their own studies and a review of the literature, van Kouwenhoven et al. conclude in their paper in this Special Issue that the protein level of formula feeding should mimic the decrease in protein content of human milk with increasing postnatal age and be less than 1.6 g/100 kcal . AdditioWhen comparing the risk of developing overweight and obesity in breast- and formula-fed infants, it is essential that studies provide the exact composition of the formula used in the study. When formulae were first introduced more than 50 years ago, they contained a rather high protein content. These formulae were introduced shortly after the discovery of essential amino acids, and the higher protein content was chosen to prevent insufficient essential amino acid intake. Secondly, there were fears of low absorption of animal protein. The higher risk of formula-fed infants compared to human milk-fed infants to develop overweight or obesity in the first years of life might, therefore, be related to the higher protein intake of infants fed older formulae and not to a particular component in human milk.The risk of developing overweight is also related to the mode of delivery and the mother’s microbiome. Children born by cesarean section are more likely to develop overweight/obesity . The micAll recommendations on optimal feeding for young infants to reduce the risk of developing overweight and adiposity are based on studies in groups of infants. These recommendations are not adapted to individual cases. In their contribution to this Special Issue, Baranowski et al. investigated precision pediatric nutrition adjusted to individual infants’ needs . In otheIn conclusion, many prenatal and early postnatal factors influence the risk of a newborn infant for developing overweight and obesity in the first years of life. Nutrition is one of the essential factors, and it is a factor that can be influenced. The mother’s nutrition before and during pregnancy is vital, as well as the infant’s nutrition during the first year of life. Breastfeeding should be recommended, but the risk of developing overweight might not be higher when a modern formula with a lower protein content is given. The feeding of a newborn infant must be adjusted to the infant’s unique needs.


BackgroundThe COVID-19 pandemic fundamentally changed the way healthcare is delivered in most healthcare systems around the world. It is now known that, in addition to the medical and economic impact of the pandemic on societies, there is another unmet medical need due to the difficulties and barriers that have existed and may still exist in the provision of health services at the primary care level in public hospitals. In Greece, there appears to have been a similar problem in citizens' access to health care in the country's public hospitals, which negatively affected the satisfaction of outpatients and significantly prevented them from receiving the medical care they needed. MethodsThis study relied on two international questionnaires; the Visit Specific Satisfaction (VSQ-9), an instrument measuring patients' satisfaction with their visit to the physician, and the Patient Satisfaction Questionnaire Short-Form (PSQ-18), consisting of 18 questions measuring both satisfaction and dissatisfaction. The questionnaires were collected electronically between 01.03.22 and 20.03.22 from two hundred and three outpatient residents of the region of Eastern Macedonia and Thrace in Greece.ResultsThe results of the study show that satisfaction of hospital outpatient department users is positively influenced by both access to medical care after the last visit (p=0.008 < 0.05) and frequency of visits . In addition, lower satisfaction with access to care was found among participants with the lowest income (p=0.010) and those with a chronic illness (p=0.002), which was attributed to pandemic limitations in access to health care services in public hospital outpatient departments. Regarding the overall satisfaction of participants, 40.9% were dissatisfied, and 32.5% were dissatisfied with specific hospital services.ConclusionsIt was found that patients were hindered from accessing medical care in the hospital due to the restrictions caused by the pandemic. This seemed to cause problems both in accessing a specialist and in making appointments. Half of the outpatients in the sample reported having difficulty communicating with the hospital to make an appointment or to access medical services in general. A relationship was also found between patient satisfaction and the quality of services provided, in terms of medical services offered, such as their availability, and patient satisfaction with the appropriate information they receive from physicians during the pandemic period. The study also found that long-term care hospitals need to improve patient satisfaction with existing medical services. Quality of healthcare is one of the most frequently cited principles of health policy and is currently high on the agenda of policymakers at national, European, and international levels. In the past, the process of quality assessment was conducted without considering the patient' perspective. Today, more emphasis is placed on patient feedback, which is important for several reasons. First, satisfactory quality of healthcare services is related to issues such as adherence to medical guidelines or reuse of services. The Institute of Medicine (IOM), for example, defines quality of care as "doing the right thing, at the right time, in the right way, for the right person, and with the best possible outcomes". In addition, public and private initiatives to develop healthcare measures have been guided by several important quality assessment factors. One of the most influential concepts is the framework established by the IOM, which includes six goals for the healthcare system. These concepts - safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity - are considered essential to quality .Patient satisfaction in health care affects all healthcare systems in the world, even if it is classified in a spectrum of ambiguity and subjectivity. Nevertheless, the influence of patient feedback in relation to the management of healthcare services is an important factor in identifying problems and difficulties encountered in healthcare facilities, as well as quality gaps in service delivery ,3. The iAt the national level, the quality of health care can be improved through continuous monitoring of health services and patient satisfaction in order to take appropriate action. From a policy perspective, soliciting patient opinions is a democratic necessity that is a central feature of the harmonious functioning of modern societies. Moreover, patient participation restores trust in health services, ultimately improving their performance and contributing to social cohesion , 7. FromService quality assessment can help managers of healthcare facilities identify patient needs and service delivery problems to develop solution programs that improve both financial performance and patient satisfaction , 10. AccTo measure patients' satisfaction with their hospital care, several instruments examine their experiences in this regard. Some of them are the Visit Specific Satisfaction Questionnaire (VSQ-9), developed by the American Medical Group Association; the Patient Satisfaction Questionnaire Short-Form (PSQ-18); and the Client Satisfaction Questionnaire (CSQ-18/CSQ-8), which measures patients' satisfaction with medical care . In addiImpact of COVID-19 on healthcare in GreeceIn Greece, the COVID-19 pandemic brought significant changes to the healthcare system, with 13 hospitals declared major referral hospitals for COVID-19 cases. Clinics were closed and wards evacuated to establish negative pressure units and intensive care units for COVID-19 cases, while scheduled outpatient appointments were canceled. Scheduled surgeries were canceled and only emergency surgeries were performed while all attention was focused on managing the pandemic without considering the health needs of the population. The pandemic highlighted the limited resources and gaps in the NHS .The increased need for medical care for COVID-19 cases during the pandemic also led to a large demand for healthcare workers. Greece strengthened its healthcare system with more than 6,800 new hires, including medical, nursing, paramedical, and other personnel. Staff shortages continued in public hospitals, and private physicians were allowed to work in public hospitals in April 2020. Redistribution of health care to fill beds with COVID-19 patients, staff shifts from primary care to hospitals, and additional overtime by healthcare workers were just some of the additional demands the pandemic placed on the healthcare system .The COVID-19 pandemic also radically changed the way cases were treated in the hospital outpatient departments of the Greek health system. Many of the regular outpatient clinics discontinued or restricted their outpatient appointments, depending on the medical specialty. The role of the outpatient clinics was mainly taken over by the emergency department, which, by its nature and the objectives of the hospitals, is mainly and in some cases exclusively responsible for medical emergencies. This phenomenon prevailed in most hospitals in the country due to the decisions of the central political leadership to limit visits to Greek public hospitals because of the high caseload. The difficulty for outpatients to access medical services during the pandemic period has also been described in other countries . In addiAnother study found that inpatient visits increased because of the need for medical follow-up after hospitalization or surgery, which somewhat offset the decrease in regular outpatient hospital visits. An important factor in the variability of visits was the use of telemedicine care or remote diagnosis in some specific cases. The results of this particular survey showed a transition from in-person visits before the pandemic to predominantly virtual care during the pandemic . HoweverThe aim of this study was to determine the level of satisfaction of outpatients of a public hospital in the province of the Greek Health System in relation to the availability of medical services during the period COVID-19. Subsequently, other factors related to health service users were investigated, such as waiting times, correct medical information, and adequate examination times.Data collection instruments and populationThe collection of the questionnaires was carried out entirely electronically to the citizens of the region of Eastern Macedonia and Thrace. The completion of the questionnaires lasted from 01/3/2022 to 20/3/2022. It was indicated that participation was voluntary and that the anonymity of the personal data of the sample was guaranteed.The survey was conducted with two international questionnaires prepared in Greek according to the guidelines of RAND Health Care ,25. One The VSQ-9 examines appointment scheduling and waiting time, accessibility, telephone communication, waiting for an examination, the amount of time the physician spends on the examination, the physician's explanations of the health condition and treatment, the physician's professional skills and demeanor, and finally the overall impression of the visit. The scale is five-point and ranges from one to five, with a score of one corresponding to the "poor" option and a score of five corresponding to the "excellent" option. The score is obtained when the values are converted to percentile values, with zero corresponding to the "poor" option and one corresponding to the "excellent" option. The responses to the nine questions should then be summed to obtain a VSQ-9 percentile score for each person .The PSQ-18 also examines patient satisfaction and focuses mainly on seven dimensions: overall satisfaction, technical quality, physician behavior, physician communication, financial, physician time spent with patients, and access to care. The scale is five-point, ranging from one for "strongly agree" to five for "strongly disagree." The score is the sum of the individual scores for the questions that make up each dimension after reverse coding the responses where appropriate. The score reflects the patient's satisfaction with each dimension, with a high score reflecting a higher level of satisfaction .Statistical analysisCounts and percentages were used to describe categorical measures such as gender and employment status, whereas means and standard deviations were used for continuous measures such as questionnaire scores. Questionnaire reliability was assessed using Cronbach's α-index. Mann-Whitney  tests were conducted for two independent samples to differentiate VSQ-9 questionnaire scores by characteristics or other parameters expressed in categories after Shapiro-Wilk normality tests were conducted. Accordingly, two independent-sample t-tests were conducted to differentiate PSQ-18 questionnaire scores by characteristics or other parameters expressed in two categories. At the same time, the influence of marital status and other categories on more than two options was evaluated using the analysis of variance criterion. Finally, to study the dependence of two quantitative variables, Pearson's correlation coefficient was used. The analysis was performed using Statistical Product and Service Solutions (SPSS) v23.0 software , and the significance level was set at 0.05 in all cases.Demographic data of the study population As shown in Table Distribution of the dimensions of the PSQ-18 questionnaire according to demographic characteristicsRegarding the correlation between the demographic characteristics and the level of satisfaction in the VSQ-9, no statistically significant relationship was found. However, in PSQ-18 Table , the typResults related to participants' experiences with the hospitalIt was found that participants who had or had not recently visited an outpatient clinic (p=0.008 < 0.05) and frequency of visits  influenced questionnaire scores. When the surveyed sample was asked a clarifying question about reasons for waiting for a doctor's appointment, 54% of responses related to pandemic constraints. In terms of VSQ-9 satisfaction Table  of thoseIn addition, the results of the PSQ-18 questionnaire Table  show thaIn the dimension of the questionnaire that includes technical quality, 36.5% responded negatively to the question of whether outpatient clinics provide comprehensive medical care, while to the question of whether there is doubt about the accuracy of the medical diagnosis received from the medical staff, 28.6% of patients responded positively or affirmatively. In addition, 36% of survey participants reported difficulty in getting an appointment at the outpatient clinic in a timely manner, and 28.1% reported not receiving treatment when they needed it.Outcomes related to participants' access to medical services based on COVID-19 limitationsIn this section, the survey focused on the potential barriers patients face in accessing health care in hospital outpatient departments. The questions they were asked were adapted accordingly and included questions related to limitations in accessing hospital care due to the pandemic. The questions in Figure Benchmarking with corresponding surveys on the duration of COVID-19The COVID-19 pandemic has revealed several problems in patient-physician interactions in various healthcare systems. Several countries have focused on limiting the problems in meeting the medical needs of non-ill patients by providing solutions mainly with remote patient care. Specifically, the Centre Hospitalier de l'Université de Montréal (CHUM), a university hospital in Montreal in Québec, in Canada, has developed a platform that includes two innovative technological applications that were developed before the pandemic for online consultations and remote patient monitoring, among other things. During the pandemic, these applications were adapted for remote monitoring of patients with COVID-19 -27. In GDespite a dramatic decrease in physician visits before, during, and after the lockdown, most patients did not feel that access to pain physicians and medications was significantly affected. However, higher levels of anxiety and depression were noted, which appeared to be influenced by several factors related to quality of life and medications received, but also appeared to affect patients' overall satisfaction with the services they received. In addition, we can conclude that the effects of the lockdown affected patients more than the pandemic itself. Most patients' perception of pain was not affected by the pandemic and was only slightly affected by the lockdown. One study highlighted both the need for and the complications of implementing telemedicine for Greek patients with chronic pain . AnotherBenchmarking with similar surveys to assess patient satisfactionAccording to corresponding studies -34, probIn a survey conducted among regular outpatients of the General Hospital of Larissa in Greece, high satisfaction rates were found with various services provided by the hospital. Specifically, 79.5% were satisfied with medical care, 67% with administrative services, 75.9% with nursing services, and 59.1% of visitors were satisfied with facilities . In contLimitationsThe survey was conducted by filling out the questionnaire electronically, which limited the participation of patients because of their low knowledge of using electronic media, especially in the older age groups. In addition, we believe that the electronic transmission influenced the age group of the sample because the elderly did not have access to electronic media or did not have the aforementioned knowledge that would have helped them to complete the electronic participation form. An important factor that was not taken into account and that we believe would explain some of the results of the study is that the participants were not asked to indicate the health problem they had or the medical specialty they needed to consult. Finally, we must point out that it would be useful to compare the results in corresponding health districts or hospitals in the same period to see if the results of our study are confirmed in other areas with public hospitals.The aim of the present study was to assess the satisfaction of visitors to a public hospital during the pandemic and to investigate the possible obstacles faced by patients in receiving adequate medical care in hospital outpatient departments. The ratings given by patients generally indicate the presence of barriers to accessing medical services, and it seems that their satisfaction is significantly related to the number of visits they were able to perceive in the past year. The results of this study also indicate that chronically ill patients experience difficulties in accessing care. Given the low patient satisfaction with waiting and examination times, it would also be useful to consider and implement measures to provide medical care without long waiting times by improving appointment management and medical examination times.An important factor in improving patient satisfaction seems to be the possibility of providing medical services remotely, especially in times of a pandemic, especially in provincial hospitals, to reduce unmet medical needs due to limited access or availability of doctors. In summary, continuous assessment of facilities is considered essential for the continuous improvement of the quality of health services.


Colonoscopy is the most effective method for colorectal cancer prevention but has several drawbacks that result in polyp miss rates. Microwave imaging is a novel solution that can obtain images of the colon based on the capacity of detecting changes in the dielectric properties of tissues. The aim of the current study is to evaluate, for the first time, the feasibility of a microwave-based accessory device for colonoscopy in an in vivo porcine model. We developed a device provided with microwave antennas and attached it to a conventional endoscope. In this preclinical model, the device did not impair endoscopic vision and was compatible with endoscopic tools; deep mural injuries were not observed and different signals were obtained from polyps and healthy mucosa, confirming its usability and potential of detecting polyps.Background and Aims: Colonoscopy is currently the most effective way of detecting colorectal cancer and removing polyps, but it has some drawbacks and can miss up to 22% of polyps. Microwave imaging has the potential to provide a 360° view of the colon and addresses some of the limitations of conventional colonoscopy. This study evaluates the feasibility of a microwave-based colonoscopy in an in vivo porcine model. Methods: A prototype device with microwave antennas attached to a conventional endoscope was tested on four healthy pigs and three gene-targeted pigs with mutations in the adenomatous polyposis coli gene. The first four animals were used to evaluate safety and maneuverability and compatibility with endoscopic tools. The ability to detect polyps was tested in a series of three gene-targeted pigs. Results: the microwave-based device did not affect endoscopic vision or cause any adverse events such as deep mural injuries. The microwave system was stable during the procedures, and the detection algorithm showed a maximum detection signal for adenomas compared with healthy mucosa. Conclusions: Microwave-based colonoscopy is feasible and safe in a preclinical model, and it has the potential to improve polyp detection. Further investigations are required to assess the device’s efficacy in humans. With almost two million new cases and one million deaths globally in 2020, colorectal cancer (CRC) is the third-most diagnosed and the second-most lethal malignancy. Thus, CRC has become a substantial burden to global health, especially in countries with a Westernized lifestyle . The tumCurrently, colonoscopy, by identifying and removing polyps with good accuracy, is considered the most effective diagnostic and therapeutic technique for preventing colorectal cancer (CRC). Studies show that colonoscopy with polypectomy can reduce the incidence of colorectal cancer by 40–90% ,3. HowevMicrowave imaging is another potential and innovative solution that can generate images without field-of-view restrictions and can penetrate light opaque tissues with non-ionizing radiation ,13. It cAs an active and invasive device, strict regulatory requirements apply, such as biocompatibility, water tightness, electrical safety, electromagnetic compatibility, usability, and ergonomics, to avoid injuring the patient and affecting the maneuverability or changing the clinical practice. The manufacturing cost is also an important concern as colonoscopy accessories are recommended for single use. Finally, the overall system must have a real-time response to notify the doctor of the presence of a polyp at the same time as when the endoscope tip passes through the lesion. All these requirements have been considered as design inputs for the version of the prototype used in the present study.The preclinical validation of a medical device consists of a series of increasingly realistic experiments with growing complexity. The device has recently demonstrated its capability of detecting lesions in a phantom simulating a colon  and in eExperiments were performed in 4 healthy female Yorkshire pigs and in 3 gene-targeted pigs with 1311 truncated mutations in the APC gene . AnimalsThis current imaging system is an improved version of the previous one . It compThe microwave imaging method for colonoscopy utilizes several antennas surrounding the colonoscope tip to emit microwaves and capture the resulting waves produced by the interaction with the colon. These antennas, operating at 7.5 GHz, are designed to cover the full perimeter of the colon. To obtain information for imaging purposes, the antennas are sequentially switched as follows: The total received field is measured at the receiving antenna adjacent to the active transmitting antenna and at the two closest diagonal antennas. This process is repeated for each transmitting antenna surrounding the colonoscope’s tip to obtain information on the entire colon or rectum perimeter. The received field includes information on the spatial changes in dielectric tissue properties, and by processing the field using an imaging algorithm, an image of the colorectal tissue’s dielectric property contrast can be obtained in real time. This image represents a cross-sectional slice of the colon or rectum, which is known as a frame. As the colonoscope moves, the acquisition device continuously measures the microwave field and obtains frames, covering the entire colorectal lumen surface. The frames that correspond to a healthy section of the colon have a homogeneous appearance, while when bright pixels appear, it indicates the presence of a polyp. The detection of the polyp can also be displayed as an acoustic signal.The distal colon and rectum of pigs were explored using the microwave-based device. In the 4 healthy pigs, safety and compatibility with endoscopic tools and the electrosurgical unit were assessed. The overall usability  of the current design was also assessed using a five-point Likert scale.Thereafter, the detection capability of the microwave-based device was tested in 3 further gene-targeted pigs with adenomas. The endoscopic image and the microwave image obtained during the retrieval of the endoscope were recorded and stored. Using an external computer, the microwave image was timely correlated with the endoscopic image and used as the ground truth.In the initial animal trial, which involved four healthy pigs, colonoscopies were performed without causing any significant damage to the colon wall, as confirmed by histological analysis. The use of electrocautery and water instillation did not interfere with the device’s ability to emit and receive microwaves, and none of the device components were disassembled during the procedure. Usability scores of 4 or higher were given to all components.During the second animal trial, which involved three pigs with mutations in the APC gene, a total of 7087 frames were recorded over a period of 15 min. However, a significant number of frames were not useful due to direct contact with the mucosa or stool remnants (14%). When the accessory touched the colon walls or stool remnants, the antennas were mismatched and lost their normal performance. Due to the pigs having a large number of polyps that were clustered together, many frames were discarded (59%). These frames were excluded as they were not a true representation of patients that were referred for a diagnostic or screening colonoscopy .n = 3), and these are represented in yellow; frames were also grouped in segments containing healthy mucosa (n = 4), and these are represented in blue in the bottom image in The remaining valid frames correspond to a sequence of 600 frames with only three isolated polyps found in one of the pigs. This sequence was processed with the microwave imaging algorithm to obtain the aggregated dielectric contrast of each frame. All frames of the sequence are concatenated to obtain the center image in The present study showcases preclinical findings on a novel approach to colonoscopy utilizing microwave imaging for automatically detecting polyps. While microwave imaging has already demonstrated its diagnostic abilities in breast cancer research ,22, thisUnlike other technologies that are limited to what is visible in the optical image, our microwave-based colonoscopy has the ability to distinguish between healthy mucosa and neo-plastic lesions by detecting changes in their dielectric properties, thereby complementing the endoscopic image. This device could prove particularly useful in identifying small flat adenomas and polyps hidden behind mucosal folds that often remain unnoticed. In a previous study, we showed that the dielectric properties are not dependent on the shape of polyps . Polyps Besides the potential improvement in the detection of polyps, the differences in the dielectric properties showed by the different types of polyps and degrees of dysplasia  could alThe system has been designed to maintain compatibility with colonoscopy, provide full 360° coverage, and minimize any changes to current clinical procedures. The final dimensions of the acquisition device are 30 mm in length by 20 mm in diameter, with a total thickness of 2.5 mm, in consideration of size restrictions. The shape and size of the device have been chosen to avoid blocking the front tip of the colonoscope, prevent injury to the patient, and enable the smooth maneuverability of the colonoscope. To validate the system’s performance, the device has been tested on ex vivo human colons with polyps and a colon phantom, which realistically simulates a colonoscopy examination, including the haustrum and placement of different polyps . The phaThe idea behind this technology, as well as one of the further planned developments, is to implement an acoustic signal that may warn the endoscopist at the precise moment a polyp is detected thanks to the shift in dielectric properties. Hence, the endoscopist can focus his attention and concentrate on the standard endoscopic image. This constitutes a big difference compared to other existing devices that use artificial intelligence, which depict boxes on the screen , or sideThis microwave-based device has initially been conceived as a disposable accessory to be used as a complement to colonoscopy and, ideally, could be used in colonoscopies performed by any indication. However, similarly to what happens with other endoscopic accessories, the fact that the device has to be mounted at the tip of the colonoscope before starting the exploration adds some difficulty and can limit its use in clinical practice. Therefore, we envisage that the solution could be to integrate the antennas inside the colonoscope.The main limitation of this study is the use of a pig model. As the anatomy of pigs differs significantly from that of humans, it is not an ideal model for assessing the feasibility of conducting a complete colonoscopy. Additionally, these genetically modified pigs have an excessive number of adenomas that are clustered, making it nearly impossible to identify them individually. Furthermore, the pigs were not administered a standard bowel preparation lavage, and although manual cleansing was performed, fecal matter remnants remained and appeared as short bright areas that may have triggered false positive detections. Lastly, only a small number of pigs were examined, which is another significant limitation. Another crucial limitation is the absence of data on relevant models for polyp detection using microwaves. The algorithm has only been finetuned with unrealistic data, such as simple phantoms or ex vivo colons. However, this study was planned in order to test security in in vivo animal models and perform a performance check.This study demonstrates, for the first time, that microwave-based colonoscopy is safe and feasible and has the potential for detecting polyps in an in vivo animal model. The microwave imaging method utilized multiple antennas to capture spatial changes in dielectric tissue properties, allowing for the identification of polyps based on their contrast with healthy mucosa. The study involved experiments in healthy pigs and pigs with adenomas. In the first group, the device showed compatibility with endoscopic tools and demonstrated the ability to emit and receive microwaves without causing damage to the colon wall. With the second group, the device successfully detected polyps, but this model showed important limitations, including a high number of discarded frames due to direct contact with the mucosa or stool remnants and the clustering of polyps in the pig model. Further investigations are required to comprehensively assess the device’s efficacy in humans and the benefit of presenting the results by emitting an acoustic signal, and whether it can identify additional polyps that would have otherwise been undetected during a conventional colonoscopy should be further examined.


This study focuses on the potential of health big data in the South Korean context. Despite huge data reserves and pan-government efforts to increase data use, the utilization is limited to public interest research centered in public institutions that have data. To increase the use of health big data, it is necessary to identify and develop measures to meet the various demands for such data from individuals, private companies, and research institutes.The aim of this study was to identify the perceptions of and demands for health big data analysis and use among workers in health care–related occupations and to clarify the obstacles to the use of health big data.From May 8 to May 18, 2022, we conducted a web-based survey among 390 health care–related workers in South Korea. We used Fisher exact test and analysis of variance to estimate the differences among occupations. We expressed the analysis results by item in frequency and percentage and expressed the difficulties in analyzing health big data by mean and standard deviation.The respondents who revealed the need to use health big data in health care work–related fields accounted for 86.4% (337/390); 65.6% (256/390) of the respondents had never used health big data. The lack of awareness about the source of the desired data was the most cited reason for nonuse by 39.6% (153/386) of the respondents. The most cited obstacle to using health big data by the respondents was the difficulty in data integration and expression unit matching, followed by missing value processing and noise removal. Thus, the respondents experienced the greatest difficulty in the data preprocessing stage during the health big data analysis process, regardless of occupation. Approximately 91.8% (358/390) of the participants responded that they were willing to use the system if a system supporting big data analysis was developed. As suggestions for the specific necessary support system, the reporting and provision of appropriate data and expert advice on questions arising during the overall process of big data analysis were mentioned.Our findings indicate respondents’ high awareness of and demand for health big data. Our findings also reveal the low utilization of health big data and the need to support health care workers in their analysis and use of such data. Hence, we recommend the development of a customized support system that meets the specific requirements of big data analysis by users such as individuals, nongovernmental agencies, and academia. Our study is significant because it identified important but overlooked failure factors. Thus, it is necessary to prepare practical measures to increase the utilization of health big data in the future. The fourth industrial revolution has ushered in a data economy in which data utilization serves as a catalyst for the development of other industries and creates innovative businesses and services. In the 21st century, data have emerged as the new oil, becoming the key resource in determining the competitiveness of individuals, countries, and companies . In healThis study focuses on the potential of health big data in the South Korean context. South Korea has a world-class health big data reserve and information technology infrastructure. The amount of public health and medical data held by the National Health Insurance Corporation and the National Health Insurance Review and Assessment Service is approximately 6.4 trillion cases based on the number of insurance claims for medical expenses in South Korea , and 92%Despite the availability of health big data and pan-government efforts to increase data use, the use of health big data is restricted to public institutions that hold big data and conduct research in public interest ,14. IndiIn this study, we conducted a survey to identify the perceptions and demands of health big data analysis and use among workers in health care–related fields.Among the survey panels held by South Korean research, URLs were sent via email and mobile phone to those who met the criteria for this study, and snowball sampling was conducted by sending URLs through social media, mainly to acquaintances of researchers who were engaged in health care–related fields. The specific criteria for selecting participants were as follows: (1) currently working in South Korea as a doctor, nurse, medical technician, pharmacist, hospital employee, pharmaceutical company or medical equipment company employee, health care–related department professor, or health care–related field researcher and (2) those who voluntarily agreed to participate. The number of participants was calculated as 384, which satisfies the confidence level of 95% and the maximum sampling error of 5%, and finally, 400 people were surveyed in consideration of the dropout rate -18.We prepared the questionnaire based on the health insurance big data usage experience and data opening demand survey conducted by the National Health Insurance Corporation  and baseWe conducted a web-based survey to collect data from May 8, 2022, to May 18, 2022, after obtaining approval from the bioethics committee of Keimyung University. South Korea Research (a polling company) commissioned the web-based survey. The company sent emails to health care workers in its survey panels. It distributed URLs through emails and simple notification services using the Naver form. We received 400 responses. However, we deleted 10 questionnaires with incomplete responses. This filtration yielded a final sample of 390 questionnaires. We surveyed participants who provided consent to participate after understanding the study’s purpose and their rights to anonymity, confidentiality, and withdrawal. We also gave participants a gift as a token of gratitude for participation.We analyzed data using SPSS 23.0 (IBM Corp). We used Fisher exact test and analysis of variance to determine the differences among occupations. We expressed the results of the analysis by item in frequency and percentage and expressed the difficulties in the health big data analysis process in mean and standard deviation.This study was approved by the institutional review board of Keimyung University (40525-202112-HR-083-04). The research purpose, methods, and participants’ rights, including that they could cease participation at any point without penalty, were explained. All questionnaires were completed anonymously, and participants were told that the results would not be used for anything other than research purposes. Participation was voluntary, and all respondents provided written informed consent. Those who participated in the web-based survey were given an e-voucher worth US $10.We compared the difficulties faced by different professionals during the big data analysis process. Professionals from 5 health care fields had the lowest score during the process. Among them, doctors had difficulties integrating different data and matching units of expression. This finding confirmed that participants experienced common difficulties, regardless of occupation. Among all the professionals, nurses and pharmaceutical company employees had the lowest scores .We received 210 answers to the subjective questions regarding the development of a system that helps analyze big data. The respondents who highlighted the need to improve access to personal health and medical care data and to develop a system to support data collection of these data accounted for 18.1% (38/210). This was followed by the need for professional guidance on the selection and configuration of appropriate data , providing advice on questions arising during the overall process  and easier data analysis module development . Other recommendations included the need to compare analytical techniques and provide guidance on appropriate analytical techniques ; increase the ease of use and access ; and provide training and guidance manuals for program use , guidance , and simple procedure data integration systems . In relation to increasing the usability of health big data, respondents highlighted the need to provide education on and promote such data . This was followed by opinions on the need to consider views on developing measures for protecting personal information . Few respondents also provided opinions on the need to develop a data classification system, provide expert feedback on the interpretation of analyzed data, and revise law for convenient procedures.This study was conducted to understand the perception of and demand for health big data analysis and use among domestic health care–related workers in South Korea. According to our survey of 390 health care–related workers, 86.4% (337/390) of the respondents felt the need to use health big data and 95.1% (371/390) recognized the need to use big data in the future. However, only 23.6% (92/390) of the respondents stated that health big data are being satisfactorily used and that it is yet to reach its full potential. Only 47.9% (187/390) of the respondents had seen the use of health big data, which reflects the low awareness and knowledge of health big data use among health care professionals. Among the 65.6% (256/390) of the respondents who had never used health big data, 39.6% (153/386) attributed their nonuse to the lack of awareness about the source of the desired data (the most cited reason for nonuse).Despite various attempts to increase health big data use, such as government-level efforts, legal reforms, and the establishment of health big data systems by public institutions, individuals still have difficulty accessing health big data. Currently, a service that guides the introduction and access procedure of public big data that are also available on the government-built health care big data platform is provided. However, even this can be considered difficult for beginners with no analysis experience; thus, a system that enables immediate question-and-answer with a more specific explanation should be combined. Many of those who have experience using health big data have experienced significant difficulties in tasks such as “defects in other data sources” and “missing value processing and noise removal,” which are part of the data preprocessing stage during the big data analysis process. However, these data integration and purification processes are closely related to the quality of the data. As the quality of data plays a significant role in the accuracy of the analysis results, it is important to solve these issues . AlthougIn this study, many respondents wanted to use the health big data actively to develop useful programs or products that contribute to health care and promotion in the future. To date, health big data use has primarily been limited to the collection or utilization of work-related data or the purpose of academic research. In addition to the innovative development of digital technology after COVID-19, various digital health care services are rapidly emerging in the health and medical field ,24. If aIn this study, one of the main factors hindering the use of health big data was the difficulty in the analysis process, and most of the respondents expressed wanting a support system to help with the big data analysis process. In particular, many respondents noted the need for services that provide expert guidance or advice in the overall process of data collection, preprocessing, analysis, and interpretation of analysis results. However, it is not easy to establish a support system that provides real-time communication with experts in the current situation, wherein there is a substantial shortage of experts in big data analysis. Therefore, it is expected that users’ difficulty can be largely addressed if an interactive system is developed to enable them to communicate with real-time users on behalf of such expert roles. In addition, with the increasing demand for non–face-to-face services in the post–COVID-19 era, an intact system can be more useful . HoweverCurrently, various national policies and projects are being promoted for the effective use of health big data based on large public health data holdings and advanced digital technology, and as a representative example, a health care big data platform has been developed and provided. However, these achievements developed with substantial financial input have not led to the active use of health big data in the actual health care field. Therefore, to ensure that new health care data–related projects that are currently or continuously promoted in the future do not merely remain as tangible results, it is urgent to specifically identify and resolve the barriers to entry to health big data for end users. Based on this study, we propose a study on the development of customized health big data analysis and utilization support services tailored to users’ needs, and ahead of that, a follow-up study is needed to identify the specific needs of health big data users.This study has several limitations. First, to check the answers of the participants related to health big data collection and analysis, we selected some participants through snowball sampling, starting with those who had analyzed health big data; however, this is not a probability sample for health care workers, and the investigation is limited to the situation in South Korea. Second, as the questionnaire has not been verified for objective reliability and validity, there may be limitations in interpreting the results. Third, this study was conducted over a relatively short period of time, and the contents confirmed in the study are the general experiences and requirements of various workers in the health care field; therefore, it is difficult to identify specific needs subdivided by the participants. In the future, a follow-up study is needed to subdivide the participants and divide them by type to confirm participants’ in-depth experience by type.In this study, respondents strongly perceived the need for health big data. However, the actual use was low in the related field. They attributed the reasons for low utilization to difficulty getting access to data and difficulty in the analysis process. They highlighted the need to develop a system that can assist them at each stage of the data analysis process. This is expected to increase big data use. Therefore, this study attempts to identify the main issues hindering the use of health big data by investigating the perceptions of the health big data and the experiences and needs related to big data analysis among various health care workers. This study is meaningful as the first attempt to identify critical failure factors that are easily overlooked in health big data utilization, and it is hoped that various attempts and studies will continue to discover and solve more specific and detailed utilization problems in the health big data area in the future.