Refugees constitute a vulnerable group with an increased risk of developing trauma-related disorders. From a clinician’s integrative perspective, navigating the detrimental impact of the social, economic, structural, and political factors on the mental health of refugees is a daily experience. Therefore, a collective effort must be made to reduce health inequities. The authors developed a treatment concept which provides broader care structures within a scientific practitioner’s approach. The resulting “Trauma Network” addresses the structural challenges for refugees in Middle Hesse. Accompanying research provided a sound basis for further discussions with policy-makers to improve the situation for refugees in the short- and long-term. The potentially harmful effects of social, political, and ecological factors on the health of individuals and populations urge for joint efforts within and beyond health services ,2,3. ThiFrom the perspective of clinicians and clinical psychologists, the often detrimental effects of social, economic, structural, and political factors on the mental health and wellbeing of refugee patients is particularly clear. Refugees and asylum-seekers are known to constitute a highly vulnerable group with an increased risk of developing mental illnesses. According to international studies, 30 to 70% of refugees are suffering from trauma-related disorders such as post-traumatic stress disorders (PTSD), depression, and anxiety ,16,17,18In the experience of the authors, however, one of the most relevant upstream factors, and thus a critical determinant of refugee’s mental health, is legal status ,32. ThisThe consequences of trauma, but also structural conditions in the care of refugees with, among other things, uprooting, poor social integration, subjectively perceived helplessness, and limited access to health care, as well as legal conditions with often prolonged “legal limbo” and uncertainties regarding the future with uncertain residence status, can negatively influence the coping resources of refugees as well as the process of recovery and healing . CognitiThe aforementioned factors must be understood as ongoing stressors that severely impede progress in psychotherapeutic treatment, exacerbating existing psychological problems, or triggering the development of other complaints. From a human rights perspective, it is therefore essential to provide care to refugees using a multidisciplinary framework, one not only focused on psychiatric–psychotherapeutic treatment, in order to ensure that their comprehensive needs are being met. Consequentially, the authors would like to present the development of a scientist–practitioner model for preventing trauma and decreasing its negative effects in refugees from a clinician’s perspective. This effort was made possible and expanded by the outstanding commitment of many engaged people and should ideally serve as a proposal and source of inspiration for building systems that adequately address mental illness among refugees.Giessen, a small university town located in central Germany, has a long history of taking in displaced people and refugees over the last three quarters of a century. In 1946, and as a result of the Second World War, the “Giessen government transit camp” was founded in the US-occupied zone in Germany to accommodate displaced people from the Soviet zone. After the violent suppression of the uprising on 17 June 1953 in Eastern Germany  and the building of the wall, Giessen and its centrally located transit camp became a symbol of freedom for nearly 900,000 people who fled or were relocated from East to West Germany. Approximately 120,000 of them arrived within the first year following German reunification in 1990. Since 1993, the Giessen initial reception center is the main location for asylum applicants arriving in the state of Hesse. While around 17,000 asylum-seekers reached Giessen in 2014, this number increased to almost 80,000 people in 2015 and has dropped again to 61,075 people since 2016 to date . Given this formative tradition and the current high demand, a group of committed people began collaborating across various sectors to address the dearth of psychosocial resources for refugees. Following numerous personal contacts, it became clear that the motivation to help those in need was shared by supporters across different professions and positions. To bring these supporters together, the “Trauma-Network Middle Hesse” was founded. Soon, regular consultations began taking place (for a detailed description see below). At the beginning, these consultations consisted of members exchanging diverse viewpoints from their respective fields of expertise on selected cases of refugees in need of help. It became clear that providing adequate help in the long run for these kinds of cases would need to be a consistent, collaborative, and cross-sectoral undertaking. The authors additionally recognized that all action would be related to or at times contingent on specific medical, political, and legal context factors. Taken together, it had to be determined that the intention to provide support immediately exclusively through psychotherapy for potentially traumatized refugees was neither sufficient nor did it approach the potential of what could be possible. How could the gap between the high need for support on the part of the refugees and the inadequate offers of support be closed? What was needed in addition to the engagement of a few committed individuals? Thinking about these core questions in the network, it became clear that good comprehensive care could only succeed if the groundwork had already been laid in the form of appropriate and reliable multisectoral offers. The authors came to the conclusion that two paths should be pursued further, from which solutions and success in the short and longer term could be expected: First, at the practitioner level, it was decided to continue the procedure of joint care with consistent advancements through direct and rapid exchanges amongst one another. Through this process, existing alliances and collaborations within the network were deepened and new ones were established so that the sharing of knowledge and access to expertise became more and more routine. Secondly, the authors decided to use their scientific expertise to evaluate and improve operations and strategies. Using scientific methodologies, the authors aimed to provide empirical data to help inform policies to support refugees in the short- and long-term .In summary, by applying a scientist–practitioner lens, the authors aim to address the urgent unanswered questions related to providing support to refugees on a local level. The aim is to show how to establish an actionable framework for comprehensive refugee care by using and expanding existing local structures. This paper presents the current status of the framework as it exists in Giessen and the steps that were taken in the process of its evolution. The authors hope to demonstrate how collaborative synergies can be used in service of refugees’ well-being. For this reason, the various structures that make up the Giessen Trauma Network will be presented one by one from a practical point of view, followed by a description of the scientific collaborations, which will then be contextualized in the broader body of research literature.In an effort to promote structural change and raise awareness of the political, social, legal, and cultural determinants of mental health among refugees, the regional multidisciplinary Trauma Network was established in 2012. This network is an association of people actively contributing to and advocating for the improvement of psychosocial care for refugees in the Hesse region of Germany. Its professional diversity provides the opportunity to offer support on a variety of levels. The network is open for participation and membership is not formally tied to any obligations or conditions. It can be stated that the voluntary and altruistic idea of additional involvement in a trauma network is beneficial, not least to the supporters of the network. In several studies it could be shown that altruistic behavior and voluntary, honorary engagement leads to the improved well-being of the engaged themselves ,39,40,41There are Trauma-Network meetings about four to six times a year, forums that can be used for mutual exchange, advice, and further training in the rooms of the Clinic for Psychiatry and Psychotherapy of the University Hospital in Giessen or one of the local training institutes for psychotherapy. The exact content of meetings and trainings is adapted in order to best serve the attendees’ needs. The network operates a homepage in order to increase awareness and visibility to the general public as well. Members of the Trauma Network include: medical doctors and psychologists from various clinics in the area , pastors, medical and psychological psychotherapy residents, interpreters and language/cultural mediators (some of whom have their own refugee experiences), volunteers, members of the Refugee Law Clinic Giessen, asylum procedure counselors from the Protestant Church, charity employees, members of three Centers for Psychosocial Counselling in Hesse, as well as members of Medinetz. The aforementioned participants provide their support to the network according to their respective expertise. In the following, the authors introduce some of its many important contributors and their activities.Clinic for Psychiatry and Psychotherapy at the University Hospital in Giessen, there are two specialized units where refugees can obtain psychiatric and/or psychotherapeutic help: First, the Trauma Therapy Center offers outpatient help for traumatized people. As mentioned previously, the Trauma Therapy Center also acts as an intermediary between inpatient and outpatient treatment and relays relevant information on to other network partners. Second, an integrative treatment plan for the psychiatric care of refugees was implemented in the clinic. In designing this plan, the authors relied on suggestions for “syndemic care” as put forth by Singer, Mendenhall, Willen and colleagues in the Lancet Series on Syndemics in 2017 [Within the  in 2017 : a syste in 2017 ,44. GuidIn clinical care for migrant patients, addressing culture and perceived cultural differences is crucial and challenging. Cultural stereotypes and essentialist beliefs about culture represent a serious barrier for true patient-centered care, since they hinder opportunities to more deeply engage with the patient’s unique lived experiences  . FurtherRefugee Law Clinic (RLC) is a hands-on, interdisciplinary training program in refugee law. The goal is to impart knowledge of German, European, and international refugee law to students during their studies and to deepen this knowledge through practical application by counseling refugees. For one, it enables students to develop their competencies, and additionally, it expands access to legal advice and support for people seeking asylum. The education begins with a theoretical part: the students first listen to lectures on German, European, and international refugee law to create a baseline of legal knowledge. At the same time, the first interdisciplinary basics are acquired in group project meetings. From the very beginning, the students learn about the existing structures in the field of refugee and migration issues that are locally available. The students grapple with topics such as racism and discrimination, gain insights into the psychological support of refugees, and the social and labor law framework conditions for refugees in Germany. The networking with other disciplines is of great importance to the activities of the RLC Giessen. The collaborations with the Clinic for Psychiatry and Psychotherapy at the University Hospital in Giessen and the Giessen Medinetz are particularly essential and are not to be missed. In cooperation with the Clinic for Psychiatry and Psychotherapy, a psychological supervision is offered to the students in which they can reflect on their own role and experience in counseling refugees [The refugees . The stuMedinetz is a network of volunteer medical students and health professionals with active groups in Giessen and many other German cities. It organizes medical assistance for refugees without health insurance and/or without valid identification documents or a valid resident status, because they are largely excluded from medical care.Outpatient treatment of refugees is offered by resident therapists as well as the Outpatient Clinic of the Institute for Psychotherapy and Psychoanalysis Giessen and the Behavioral Therapy Outpatient Clinic at the University of Giessen. The latter two institutions are also educational institutes for trainee psychotherapists. Following an inpatient stay, the Trauma-Network helps to ensure that receiving outpatient psychotherapy can be started as soon as possible. In addition, the Trauma Network also fosters scientific collaboration, since some of its members are affiliated with the complementary Research Network on Migration and Human Rights (see below).Center for Psychosocial Counselling could be presented and justified with epidemiological data collected by the authors. Subsequently, in 2017, a founding association was established by several members of the Trauma Network. As a main outcome, it receives annual funding from the Hessian Ministry for Social Affairs and Migration and currently operates the Center for Psychosocial Counselling Middle Hesse (https://www.psz-mittelhessen.de (accessed on 10 September 2022)) with a team of psychotherapists, social workers, administrative staff, and cultural mediators. This interdisciplinary team offers psychological assessment, psychoeducation, skills for stress and anxiety management, psychological crisis intervention, and referrals to further psychiatric and psychotherapeutic treatments if needed. The services are available to refugees living in the initial reception centers but can also be accessed by those in private accommodations in Middle Hesse. Counselling sessions are mostly held within an individual context, but group sessions are also available. Psychosocial counseling sessions are translated with the help of cultural mediators that are trained to provide precise and professional translations, both of language and of culture, in this specific work context. The professional involvement of cultural mediators with their own migration backgrounds and associated lived experiences adds an important layer of additional expertise for the practitioners. The Center for Psychosocial Counselling also offers supervision for cultural mediators, anonymous expert advice for cases within other institutions, and workshops on mental illnesses related to trauma. To strengthen existing networks and optimize psychosocial care for refugees more broadly, the Center for Psychosocial Counselling cooperates with institutions and associations all over Hesse. The founding association also reports psychosocial issues relevant for the improved mental health of refugees back to the Hessian Ministry for Social Affairs and Migration.In regular exchanges between members of the Trauma Network and policy-makers of the Ministry of Social Affairs, the need for the establishment of a https://www.baff-zentren.org/english/ (accessed on 10 September 2022)) and carry out public relations work. At the local level, however, we are not aware of any similarly differentiated and multiprofessional participatory networks.To the best of our knowledge, there are superordinate umbrella organizations in Germany, some of which operate on a nationwide basis, which, for example, network individual psychosocial care centers with one another , As described above, the Center for Psychiatry and Psychotherapy at the University of Giessen decided not only to promote and bundle regional activities in refugee treatment and care, but also to support, through research activities, the process of building up structures and treating refugees from the very beginning. In addition, the authors draw on the scientific expertise of various members of the network from various disciplines. To develop and promote suitable offers for refugees, first and foremost the demand must be determined and measures to identify those in need of help must be implemented. In this sense, the European Parliament and the European Council stipulation from 2013   made it As concrete measures have yet to be taken by the responsible authorities to identify refugees in need of protection, the authors have considered how this could be implemented in practice. It was decided to investigate the feasibility of identifying the most common trauma-related disorders as validly as possible, and thus proposed a two-step procedure that includes a screening questionnaire and, if positive, further diagnostic procedures. For the first step, screening, the Refugee Health Screener-15 (RHS-15) by Hollifield et al. , which iIn another project, and in cooperation with a general practitioner who was responsible for the initial medical examination of unaccompanied refugee minors (URM), the prevalence and patterns of trauma-related disorders in 561 URM who spoke four different groups of languages  was studied using a sequential mixed methods approach . Due to Additionally, the Clinic for Psychiatry and Psychotherapy at the University Hospital in Giessen is involved in two collaborative projects targeting refugee support and treatment. The first project, in cooperation with another regional Clinic for Psychiatry and Psychotherapy (Vitos Clinic Giessen) and the Clinic for Family Psychosomatics at the University Hospital in Giessen, focuses on the psychological stress of children in families that fled to Germany. The authors are trying to understand the connections with the parents’ own escape experiences and possible psychological illnesses of the parents. The results of this ongoing trial will then be compared with a large sample of children whose parents did not experience escape/fleeing, but have a pre-existing psychiatric disorder, so to get more detailed information about the unique needs of refugees’ children in Germany. The long-term goal is to use this information to further develop appropriate treatment approaches for these children, as many treatments for adults are already available and empirically backed. In another project, the Clinic for Psychiatry and Psychotherapy at the University Hospital in Giessen is participating in the clinical evaluation of a portable communication system which can be used on-site during psychiatric diagnosis for Arabic-speaking people. The aim of this joint project, funded by the German Federal Ministry of Education and Research, is to minimize obstacles in providing mental health care for refugees: RELATER—Removing Language Barriers in Treating Refugees .All of the above studies were approved by the local ethics board. In the studies presented, care was taken to minimize the burden on participants and Good Clinical Practice guidelines were followed. Only staff trained in dealing with refugees and trauma sequelae were used in the implementation. In this process, participants were informed in detail that the interview was voluntary and that there would be no consequences if they refused to participate or terminated the interview prematurely. In particular, if they were in a treatment setting, they were informed that refusing the survey would not affect their treatment. When recording indications of the presence of a trauma sequelae disorder, potentially traumatic events were not asked about, but only indications at the symptom level—e.g., restlessness, startle, nightmares, or pain—were recorded.Representatives of the Clinic for Psychiatry and Psychotherapy at the University Hospital in Giessen are also members of the interfaculty research network which tries to promote research under a comprehensive human rights-based approach, which will be explained further in the next subsection.In summary, the authors demonstrated that the RHS-15 is a useful, economically valid, and efficient tool to screen individuals for trauma-related mental health problems in a first step. In a second step, positive screenings should be followed by further diagnostic measures. This structured two-step diagnostic approach allows to fill the gap between legal requirements (EU directive) and individual needs. The alarming prevalence of mental health complaints in URMs highlights the need for early symptom detection and timely psychosocial interventions to prevent chronic courses of disease  and sevehttps://www.migrationundmenschenrechte.de/de/topic/542.english-description.html (accessed on 10 September 2022) exists complementary to the Trauma-Network. Members are researchers from various academic fields at the University of Giessen, coordinated by the Chair of Public and European Law at University of Giessen Law School. While the Trauma-Network focuses mainly on the treatment and care of refugees, the FMM mainly deals with issues concerning refugees from a human rights perspective. Therefore, the FMM requires contributions from all academic fields. The research network was founded by members from the Schools of Law, Educational Sciences, Sociology, and Health in 2014. It now includes more than 50 academics from various fields such as law, history, sociology, political sciences, peace and conflict studies, educational sciences, theology (Christian and Muslim), and health. In addition to its involvement in multiple research projects, it also offers a teaching program on migration and human rights that links disciplines, perspectives, theory, and practice. The group meets regularly for joint workshops where current research activities or external inputs are discussed.The Research Network on Migration and Human Rights (FMM, Mr. S., a 35-year-old man from Mali, was presented to the trauma outpatient clinic by Medinetz. He was threatened by Islamist groups in Mali because he has two nonmarital children. During his escape, he was detained and tortured for over 8 months in Libya. He entered Germany via Italy and became homeless without valid documents. He was hospitalized due to paranoid psychosis and post-traumatic stress disorder. Despite a gradual improvement of the paranoid symptoms, nightmares, intrusions, and frightfulness, no lasting stabilization could be achieved due to persisting fears of deportation. The case was discussed with the Refugee Law Clinic as well as in the Trauma Network, and the addressed contents were included during further inpatient treatment. The team of the ward reflected on the treatment process in transcultural supervision. With the help of a lawyer, a ban on deportation could finally be achieved. Currently, the patient is undergoing outpatient treatment at the clinic; he has valid residence papers and is receiving additional support from the Psychosocial Center. He is attending a German course, is learning very quickly and intends to start training as a geriatric nurse.willingness to accept the treatment offers, his ability to accept the treatment and implement the change in everyday life was also constantly worked on during the treatment. This is a fluid process of empowering the patient more and more to be able to transfer traumatizing events experienced in the past into the personal narrative.This example shows in a prototypical way the cooperation of different stakeholders of the trauma network for the benefit of the affected person. Different treatment and support services of the network met with a victim who, despite his severe illness, had a high level of commitment and motivation for change. In addition to the patient’s Trauma-related disorders are complex diseases that can be challenging to treat. Factors such as refugee experiences, sequential traumatization, legal uncertainty with uncertain resident status, and language barriers further complicate the treatment of these disorders and can lead to a significantly increased treatment effort. At the same time, inadequate or lack of treatment leads to an aggravation of individual suffering with the risk of chronification. This can become a significant obstacle to integration, which is consecutively associated with social problems and follow-up costs. A key finding from the research initiated by the trauma network is that the care of refugees requires a two-step approach which should be established as a useful best practice. First of all, in addition to the physical examination, a broad screening for possible mental health risks should take place as early as possible, which could be repeated in the further course. In case of positive findings, further diagnostic measures should then be taken quickly and appropriate treatments initiated to prevent the worsening of the mental health status.The treatment of refugees requires looking beyond the horizon: social, political, legal, and economic factors mutually influence the mental health of refugees and essentially determine what kind of psychotherapeutic work should be done. In particular, the legal context determines more than just the external framework; it directly influences the associated medical categories of “illness and health.” Improvements in the health status of refugees in the context of inpatient treatment are therefore often only temporary and fragile, because additional negative developments in the asylum process can impair or even reverse improvements that have been made. In the case of traumatized refugees, the interaction of legal and medical aspects must be taken seriously by the medical, legal, and political authorities involved. Residential and asylum law, and the administrative practices involved with them, can dramatically amplify the consequences of the trauma experienced in the country of origin. In essence, this corresponds to “sequential traumatization” , which iAt this point, however, it should also be pointed out that the effects of legal conditions on health and forms of so-called structural violence do not manifest themselves through anonymous forces that unfold autonomously in a Kafkaesque sense. There are often several options for action within legal requirements, laws, and structures, which can be used by the respective actors as well as the practitioners to the benefit of the refugee. The authors assume that the adequate handling of the special needs of traumatized refugees can only be achieved in a multiprofessional network. Those who face this difficult task alone quickly reach their limits, become helpless and frustrated, or refuse to treat refugees, choosing instead to refer them to “specialized centers”. Cooperation in networks, on the other hand, enables the development of solutions and the use of individual competencies specific to each professional group efficiently and sustainably. Mutual knowledge of existing competencies and direct personal exchange between the actors always ensures that they feel part of a common cause and can face the structural challenges for refugees in the region as a team.What are the lessons learned from building the trauma network? Starting from individual case discussions, we quickly realized that a network is necessary in order to understand traumatized refugees in their different areas of life from different professional perspectives and to be able to offer individualized help based on this. In this context, it is necessary for individual stakeholders of the network to provide the framework and structure of the network. The supporters of the network contribute their expertise from their respective professional backgrounds. It is possible to rely on the infrastructure and facilities of the institution where the supporters work full-time. Individual facilitators take responsibility for inviting members to regular meetings and for setting up and maintaining a platform for online communication between members of the network. Under this “umbrella”, voluntary help and activity can additionally be brought into the network in a complementary way to one’s own professional background. For many supporters of the trauma network, it is not always possible to make a clear distinction between professional and volunteer activities; rather, there are often fluid transitions between both. Since the network does not currently have its own financial budget beyond the infrastructural use of existing institutional structures, professionals with financial or economic expertise are not currently represented in the network. Through the network, existing professional collaborations between the network’s supporters could be intensified, even beyond the context of flight and trauma. Some of the network’s supporters have their own refugee experience. In the future, it would make sense to recruit more supporters with their own refugee experience for the network, because it seems likely that such experience would increase the ability of the care providers to show greater empathy and understanding to the refugees. An additional active initiation of contact and involvement of official decision-makers, who only made limited use of the opportunity to participate in the network, has proven successful.On the individual level, patients who sought treatment often appeared rather overwhelmed and helpless at the beginning of treatment. This may result from cultural beliefs but may also be a symptom of the disease itself. Accordingly, patients often expect an active part of the practitioner with clear instructions for their own actions. On the other hand, treatment providers may even be experienced as incompetent if they demand patients to be active and equal partners in treatment planning and implementation, and if therapeutic interventions take the form of questions rather than clear instructions for action. However, if the treatment providers show interest in the prior experiences and presuppositions of those affected with regard to the working methods of psychiatric institutions, including in the country of origin, and see themselves as being learners, mistrust can be reduced, mutual trust can develop, and a fruitful discourse about different treatment concepts as well as empowerment for treatment “at eye level” can emerge.The development process outlined here can and should be used as a template for other regions and countries—entirely new systems do not need to be erected to care efficiently and compassionately for refugees. Refugees are, of course, not the only vulnerable group for whom attention to syndemic factors is important in overcoming structural health inequities. Health adversities resulting from upstream determinants such as poverty, unemployment, stigma, ethnic minority status, social exclusion, or gender-based violence may, on the one hand, reinforce each other and, on the other hand, promote the occurrence of various somatic and mental diseases, i.e., infectious diseases such as HIV/AIDS, tuberculosis, but also addiction, diabetes, or depression ,8. At thEfficient care networks can emerge by rethinking and strengthening existing structures, selectively adding and flexibly adapting them to individual needs and particularities that come with caring for refugees. Accompanying research offers the opportunity to evaluate and further develop one’s own actions and can contribute to an enrichment in the discourse on refugee care, backed by scientific evidence. Thus, over a period of more than 10 years, a structured framework within a scientist–practitioner’s approach has been developed. This framework offers room for individual adjustments and benefits from human cooperation, synergisms, and the cohesive group efforts of a multiprofessional, interdisciplinary network. Recalling one’s roots, traditions, values, such as the universality of human rights, and skills can help to establish the framework for one’s own actions and how to involve others from a syndemic perspective.


Federated learning is a distributed machine learning framework that enables distributed nodes with computation and storage capabilities to train a global model while keeping distributed-stored data locally. This process can promote the efficiency of modeling while preserving data privacy. Therefore, federated learning can be widely applied in distributed conjoint analysis scenarios, such as smart plant protection systems, in which widely networked IoT devices are used to monitor the critical data of plant production to improve crop production. However, the data collected by different IoT devices can be dependent and identically distributed (non-IID), causing the challenge of statistical heterogeneity. Studies have also shown that statistical heterogeneity can lead to a marked decline in the efficiency of federated learning, making it challenging to apply in practice. To promote the efficiency of federated learning in statistical heterogeneity scenarios, an adaptive client selection algorithm for federated learning in statistical heterogeneous scenarios called ACSFed is proposed in this paper. ACSFed can dynamically calculate the possibility of clients being selected to train the model for each communication round based on their local statistical heterogeneity and previous training performance instead of randomly selected clients, and clients with heavier statistical heterogeneity or bad training performance would be more likely selected to participate in the later training. This client selection strategy can enable the federated model to learn the global statistical knowledge faster and thereby promote the convergence of the federated model. Multiple experiments on public benchmark datasets demonstrate these improvements in the efficiency of the models in heterogeneous settings. With the rapid development of computation and storage capabilities, IoT devices are now widely applied in multiple areas, such as health monitors, smart homes, and smart plant protection systems. These devices are used to collect critical data during operation and provide a statistical foundation for services, such as health prediction, house management, or the direction of plant production. However, the broad deployment of these devices will lead to the expansion of the data scale and the general growth in the demand for privacy preservation of sensitive data, and the traditional centralized machine/deep learning mode that collects all data in a central node to train a statistical model has difficulty meeting demand. Specifically, transmitting distributed-stored data to a central node and training a model on that scale of data can lead to long computation and communication times. In addition, privacy leakage of sensitive data may occur during transmission. Therefore, federated learning  because the data distribution of these clients is the same as the global data distribution P. Therefore, instead of enabling all clients to participate in training, only a portion of clients can be selected randomly with a specific fraction to execute local updates in the model training of federated learning. This strategy can promote the efficiency of federated learning because it can markedly decrease the load and number of network transmissions.In IID scenarios, the local optimization object of any client is an unbiased estimate of the centralized optimization object fi could be an arbitrary approximation to Fc(ω) when data across the clients is non-IID, which Pi can be markedly different P, leading to the deviation between the federated model and centralized-trained model and a marked decrease in the performance of the federated model. The convergence of the global model can be unstable due to the non-IID data because it is difficult for the model to learn the knowledge of the global data distribution by randomly selecting clients to participate in training. Therefore, we use ACSFed to solve the problem mentioned above. The goal of ACSFed is to make clients with heavy statistical heterogeneity and poor model performance selected with a larger possibility in the early training rounds, thereby enabling the global model to learn unknown data information as quickly as possible and providing more stable, faster convergence than random client selection. The theory and design of ACSFed are described in the next section.However, In this section, the structure and principles of ACSFed will be shown in detail. In ACSFed, a probability matrix representing the probability of each client being selected is maintained and dynamically updated after each communication round. The updated probability is based on an index called the cumulative model strength of each client, which was first proposed by this study and considered the statistical heterogeneity and previous training performance. The calculation of cumulative model strength is defined as follows:i at the current and the previous communication rounds, respectively; Lossi denotes the training loss; ρ represents the attenuation coefficient; EMDi is the index of statistical heterogeneity on the client i, and N is the total number of clients. Therefore, a client's latest cumulative model strength depends on its history cumulative model strength and current training status. This calculation method uses an exponential-weighted average. It is widely applied in the optimization algorithms of deep learning, such as RSMProp  is the set of all possible joint distributions that combine the distributions p and qi. Then, for a specific joint distribution γ belonging to ∏, a sample pair x and y can be sampled, and their distance can be calculated, thereby calculating p and qi.where ∏, the client with a larger cumulative model strength will have a smaller probability of being selected again because the model's performance on the client is sufficient. The probability of a client being selected can markedly increase when its cumulative model strength is 0, indicating that it has not participated in previous training and should be more likely to be chosen in the following training epoch. Finally, normalization is applied to ensure that the sum of all possible values in the matrix is equal to 1 and is calculated as:matrix_porbi is the client's probability i, and then the clients participating in the following training epoch are selected based on the normalized probability matrix. Based on the theory and design demonstrated above, the process of ACSF is shown in where After introducing the theory and design of the ACSFed algorithm, the theoretical analysis of ACSFed regarding the convergence of federated learning in statistical heterogeneity scenarios is performed and is described in the next section.i is Pi when the data distribution across the clients is IID (Pi = P), the expectation of the local optimization object in any client is an unbiased estimate of the centralized optimization object Fc(ω):In this section, the theoretical analysis of FedAvg and ACSFed in statistical heterogeneity scenarios is performed. In statistical heterogeneity scenarios, the data across the distributed clients is non-IID. Assuming that the data distribution of the client Ff(ω) as follows:Then, we calculate the expectation of the global federated learning optimization object Ff(ω) is equal to centralized optimization object Fc(ω) when data across the clients is IID. Therefore, instead of enabling all clients to participate in training, only a portion of clients can be selected randomly with a specific fraction to execute local updates in the model training of federated learning because the local optimization object of any client is an unbiased estimate of Fc(ω). However, fi could be an arbitrary approximation to Fc(ω) when Pi is different from P, leading to the deviation between the federated model and centralized-trained mode, and E[Ff(ω)] is no longer equal to Fc(ω). The convergence of the global model can be unstable due to the non-IID data because it is difficult for the model to learn the knowledge of the global data distribution by randomly selecting clients to participate in training. Therefore, statistical heterogeneity must be considered when selecting clients to participate in model training every communication round. The previous training performance should also be regarded to make the model learn the global knowledge faster. Specifically, the client with heavier statistical heterogeneity and poor training performance should be more likely to be selected to accelerate the convergence federated model, and this client choosing strategy is based on the research of Cho et al. (Equation (8) shows that the expectation of federated learning optimizing object o et al. , which gTheorem 5.1:The expectation of the difference between the training parameter and the convergence parameter is shown below, and the smaller it is, the faster convergence will be achieved:where Γ is the difference between centralized optimization object and federated optimization object; γ, μ are parameters that control the learning rate; and the critical factor is S(π) is the client selection strategy and assumes the strategy would select m clients to participate in the training; t is the model parameter to be evaluated during training.where Theorem 5.1, the larger fk of each client will be much bigger than simply random selection, and thereby the Theorem 5.1, faster convergence will be obtained by ACSFed. After the theoretical analysis of ACSFed, performance experiments will be introduced in Section Evaluation.Then as can be concluded in In this section, the results of the experiments are reported. Three public benchmark datasets are used for evaluation: MNIST, Fashion MNIST, and CIFAR 10, and the details of these datasets are shown in As shown in As shown in In addition, the curves of ACSFed will fluctuate much more violently than FedAvg in the earlier communication round due to the client selection strategy of ACSFed that untrained clients and clients with stronger statistical heterogeneity or worse training performance are more likely to be selected, which can feed the model with much more unknown knowledge compared with selecting clients randomly in earlier communication round. However, the ACSFed's loss curve will decrease faster. Its training accuracy curve will increase faster than FedAvg after an earlier communication round as the global model of ACSFed already learned relatively more knowledge than FedAvg in earlier training.Similar results in two statistical heterogeneity scenarios can be obtained on Fashion MNIST. In the 2-class non-IID scenario, which is shown by However, because Fashion MNIST is more complex than MNIST, ACSFed will take much more time to learn sufficient knowledge about the data in the 1-class non-IID scenario compared to the 2-class non-IID. Results are shown in Finally, Moreover, the comparison result between ACSFed and FedProx is illustrated in Finally, based on these experimental results, the more complex the data are and the stronger statistical heterogeneity is, the more time ACSFed will take to fluctuate in both loss and accuracy; we refer to this time as the fluctuation period, which is due to the client selection strategy of ACSFed. Specifically, the loss and accuracy curve of ACSFed fluctuates more violently than FedAvg in the fluctuation period, indicating that the model keeps learning unknown knowledge. Then, the performance of ACSFed can exceed FedAvg rapidly after the fluctuation period because the model has already learned sufficient knowledge about the non-IID data.In addition, the ToA@x (the epoch to reach the accuracy of x) of ACSFed and FedAvg are recorded to demonstrate the improvement in training efficiency more clearly, and results are shown in Based on Federated learning will play an essential role in the future as the computation capability of remote edge devices increases and local data privacy increases. However, statistical heterogeneity can markedly affect the efficiency of federated learning methods and lead to unstable convergence. In this study, we proposed an adaptive client selection algorithm for federated learning called ACSFed to promote the performance of federated learning. Experiments on three different datasets demonstrate the improved performance of ACSFed compared to the current federated learning method. Additionally, ACSFed adds little computation and communication burden because updating the probability matrix of clients is simple. However, there is still the possibility of promoting the performance of federated learning in statistical heterogeneity scenarios by combining ACSFed with methods that focus on global model aggregation. The challenge of model protection still exists, and further research is required to address this and related challenges to apply federated learning methods more effectively.http://yann.lecun.com/exdb/mnist/; https://tensorflow.google.cn/datasets/catalog/fashion_mnist; http://www.cs.utoronto.ca/~kriz/cifar.html.Publicly available datasets were analyzed in this study. This data can be found here: AC: conceptualization, methodology, writing—review and editing, and supervision. YF: conceptualization, methodology, data curation, formal analysis, software, and writing—original draft preparation. ZS: conceptualization, methodology, project administration, and investigation. GL: supervision and project administration. All authors contributed to the article and approved the submitted version.This work was supported by National Natural Science Foundation of China (NSFC) (U19A2059), and Sichuan Science and Technology Program (No. 206999977).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.


Complete genome sequences of 30 microbial species have been determined during the past five years, and work in progress indicates that the complete sequences of more than 100 further microbial species will be available in the next two to four years. These results have revealed a tremendous amount of information on the physiology and evolution of microbial species, and should provide novel approaches to the diagnosis and treatment of infectious disease.  It has been estimated that microbial species comprise about 60% of the Earth's biomass. The genetic, metabolic and physiological diversity of microbial species is far greater than that found in plants and animals. But the diversity of the microbial world is largely unknown, with less than one-half of 1% of the estimated 2–3 billion microbial species identified. Of those species that have been described, their biological diversity is extraordinary, having adapted to grow under extremes of temperature, pH, salt concentration and oxygen levels. Microbes were the first organisms on Earth and preceded animals and plants by more than 3 billion years. They are the foundation of the biosphere, from both an evolutionary and an environmental perspectiveHaemophilus influenzae2; since that first report another 27 microbial genome sequences have been published, with at least 10–20 other projects at or near completion (for details see http://www.tigr.org/tdb/mdb/mdb.html). This progress represents, on average, one completed genome sequence every two months and all indications are that this pace will continue to accelerate. Included in the first completed microbial projects are many important human pathogens, the simplest known free-living organism, ‘model’ organisms, Escherichia coli and Bacillus subtilis, thermophilic bacterial species that might represent some of the deepest-branching members of the bacterial lineage, five representatives of the archaeal domain, and the first eukaryote, Saccharomyces cerevisiae. All of the organisms that have been studied by whole-genome analysis are species that can be grown either in the laboratory or in animal cells. It is important to remember that the vast majority of microbial species cannot be cultivated at all, and these organisms, which live in microbial communities, are essential to the overall ecology of the planet. Nevertheless, the study of ‘laboratory-adapted’ microbes has had a profound impact on our understanding of the biology and the evolutionary relationships between microbial species.Perhaps no other area of research has been so energized by the application of genomic technology than the microbial field. It was only five years ago that The Institute for Genomic Research (TIGR) published the first complete genome sequence for a free-living organism, H. influenzae is a shotgun sequencing strategy  reduces problems associated with repetitive elements in the final assembly.For the 5 and RNA genes6. Once the protein-coding genes have been located, the most challenging problem is to determine their function. Typically, about 40–60% of the genes in a newly sequenced bacterial genome display a detectable sequence similarity to protein sequences whose function is at least tentatively known. This sequence similarity is the primary basis for assigning function to new proteins, but the transfer of functional assignments is fraught with difficulties. The identification of genes in prokaryotic genomes has advanced to the stage at which nearly all protein-coding regions can be identified with confidence. Computational gene finders using Markov modelling techniques now routinely find more than 99% of protein-coding regionsMycobacterium tuberculosis at the time that the genome was being sequenced. All six of the best matches are kinases, but the specific names differ. A conservative naming strategy might use a family name that includes all six matches. Another strategy might use curated protein families (if they exist) to assign names; for example, the FGGY family named in the fourth line of 7, a set of 1,815 hidden Markov models based on multiple alignments. By a closer examination of the literature, one could determine which of these protein names were based on laboratory experiments and which on sequence similarity. In any case, the assignment of a function to this protein requires the expertise of a skilled biologist. The rapidly changing nature of genome databases means that database searches must be repeated regularly to keep annotation accurate and up to date.To illustrate this problem, One possible solution to the annotation problem is to bring more of the resources of the scientific community to bear on each genome. No single centre can annotate all the functions of a living organism; experts from many different areas of biology should be encouraged to contribute to the annotation process. One possible model would be for geographically separated experts to deposit annotation to a central repository, which might also take on a curatorial or editorial role. An alternative model is one in which annotation resides in many different locations (as it does today), but in which new electronic links are created that allow scientists to locate rapidly all the information about a gene, genome or function. This latter model scales more easily and avoids the problem of overdependence on a single source.Comparison of the results from 24 completed prokaryotic genome sequences, containing more than 50 Mbp of DNA sequence and 54,000 predicted open reading frames (ORFs), has revealed that gene density in the microbes is consistent across many species, with about one gene per kilobase . Almost 8. Although the archaea possess bacterial cell structures, it has been suggested that they share a common ancestor exclusive of bacteria.Our molecular picture of evolution for the past 20 years has been dominated by the small-subunit ribosomal RNA phylogentic tree that proposes three non-overlapping groups of living organisms: the bacteria, the archaea and the eukaryotes12. For example, an analysis of the genomes of two thermophilic bacterial species, Aquifex aeolicus and Thermotoga maritima, revealed that 20–25% of the genes in these species were more similar to genes from archaea than those from bacteria14. This led to the suggestion of possible extensive gene exchanges between these species and archaeal lineages. But before one jumps to this conclusion it is important to consider the difficulties in inferring the occurrence of gene transfer. For example, the high percentage of genes with best matches to archaea in A. aeolicus and T. maritima  could also be due to a high rate of evolution in the mesophilic bacteria  or the loss of these genes from mesophilic bacteria15. For T. maritima, many lines of additional evidence support the assertion of gene transfer, including the observation that many of the archaeal-like genes occur in clusters in the genome, are in regions of unusual nucleotide composition, and branch in phylogenetic trees most closely to archaeal genes14. Most of the lines of evidence leading to assertions of horizontal gene transfer can have other causes. For example, unusual nucleotide composition can also arise from selection16, and differences in phylogenetic trees can be caused by convergence, inaccurate alignments17, long-branch attraction18 or sampling of different species19. It is therefore important to assess the evidence carefully and to find multiple types of evidence. This has yet to be done systematically, so we believe that it is too early to assign quantitative values to the extent of gene exchange between species.Analysis of complete genome sequences is beginning to provide great insight into many questions about the evolution of microbes. One such area has encompassed the occurrence of genetic exchanges between different evolutionary lineages, a phenomenon known as horizontal, or lateral, gene transfer. The occurrence of horizontal gene transfer, such as that involving genes from organellar genomes to the nucleus, or of antibiotic resistance genes between bacterial species, has been well established for many years  recombination between homologous genes encoding outer-surface proteins as described for Mycoplasma genitalium28, Mycoplasma pneumoniae29 and Treponema pallidum30, and (3) clonal variability in surface-expressed proteins as described for Plasmodium falciparum31 and possibly Borrelia burgdorferi 32. Experimental evidence from studies of clinical isolates of some species has demonstrated phenotypic variation in the relevant cell-surface proteins33, suggesting that, at least for human pathogens, the evolution of antigenic proteins probably occurs in real time, as cell populations divide. The ability of human pathogens to alter their antigenic potential and thereby evade the immune system has the potential to hinder vaccine development by conventional methods.One of the expected benefits of genome analysis of pathogenic bacteria is in the area of human health, particularly in the design of more rapid diagnostic reagents and the development of new vaccines and antimicrobial agents. These goals have become more urgent with the continuing spread of antibiotic resistance in important human pathogens. Moreover, results from the whole-genome analysis of human pathogens has suggested that there are mechanisms for generating antigenic variation in proteins expressed on the cell surface that are encoded within the genomes of these organisms. These mechanisms include the following: (1) slipped-strand mispairing within DNA sequence repeats found in 5′-intergenic regions and coding sequences as described for Neisseria meningitidis (MenB) was reported by Pizza et al. using a genomics-based approach34  pathway that are required for the synthesis of isoprenoids such as cholesterol37. The DOXP pathway functions in some bacteria, algae and higher plants to produce isopentenyl diphosphate, a precursor of isoprenoids. In P. falciparum, the enzymes of the DOXP pathway are probably associated with a specialized organelle derived from algae called the apicoplast; they are expressed when the parasite is growing within red blood cells. Inhibitors of one of the key enzymes in the DOXP pathway, DOXP reductoisomerase, had previously been identified and had been shown to inhibit the bacterial enzyme and the growth of some bacterial species. Jomaa et al.36 demonstrated that two inhibitors of DOXP reductoisomerase, fosidomycin and FR900098, were able to inhibit the growth of P. falciparum in vitro and cure mice infected with a related species of Plasmodium . Both of these compounds exhibit low toxicity and high stability and are relatively inexpensive to produce, suggesting that they might be the basis of a potentially important new class of anti-malarial drugs.Another example illustrates the potential of genomics to accelerate the development of novel antimicrobial agents. Jomaa So far, studies in genomics have only scratched the surface of microbial diversity and have revealed how little is known about microbial species. In the next few years, more than 100 projects for sequencing microbial genomes should be completed, providing the scientific community with information on more than 300,000 predicted genes. A significant number of these genes will be novel and of unknown function. These novel genes represent exciting new opportunities for future research and potential sources of biological resources to be explored and exploited. The benefits of comparative genomics in understanding biochemical diversity, virulence and pathogenesis, and the evolution of species has been unequivocally demonstrated and the usefulness of comparative techniques will improve as more genomes become available. One of the major challenges is to develop techniques for assessing the function of novel genes on a large scale and integrating information on how genes and proteins interact at the cellular level to create and maintain a living organism. It is not unreasonable to expect that, by expanding our understanding of microbial biology and biodiversity, great strides can be made in the diagnosis and treatment of infectious diseases and in the identification of useful functions in the microbial world that could be applied to agricultural and industrial processes.


Cities are areas featuring a concentrated population and economy and are major sources of carbon emissions (CEs). The spatial differences and influential factors of urban carbon emissions (UCEs) need to be examined to reduce CEs and achieve the target of carbon neutrality. This paper selected 264 cities at the prefecture level in China from 2008 to 2018 as research objects. Their UCEs were calculated by the CE coefficient, and the spatial differences in them were analyzed using exploratory spatial data analysis (ESDA). The influential factors of UCEs were studied with Geodetector. The results are as follows: (1) The UCEs were increasing gradually. Cities with the highest CEs over the study period were located in the urban agglomerations of Beijing–Tianjin–Hebei, Yangtze River Delta, Pearl River Delta, middle reaches of the Yangtze River, and Chengdu–Chongqing. (2) The UCEs exhibited certain global and local spatial autocorrelations. (3) The industrial structure was the dominant factor influencing UCEs. IncreCities have a high population density and high intensity of energy consumption, because of which they are a major source of CEs. A total of 85% of direct CEs in China come from cities . The conPrevious studies have analyzed the spatial differences in CEs at different regional levels. First, at the international level, Ding and Zhang  analyzedExisting studies have also analyzed the effects of relevant factors on CEs. First, the relationship between economic growth and CEs has long been a focus of research. Whether the environmental Kuznets curve (EKC)  is appliSystematic and in-depth studies have been carried out on the spatial differences and influential factors of CEs at the national and provincial levels. Although some studies have taken cities as the basic unit, most of them have considered specific urban agglomerations and river basins as research objects, which could not be generalized to the entire country. This significantly reduces the reference value of such research for policymaking. If we choose cities as the basic research unit, what are the spatial differences among them in terms of UCEs in China? What are the factors affecting them? To answer these questions, we selected 264 cities at the prefecture level in China as research objects. We used the calculated UCEs from 2008 to 2018 along with exploratory spatial data analysis (ESDA) to explore the spatial differences in UCEs. We also employed Geodetector to examine factors affecting them.The contributions of this study to the existing research are three-fold: First, most existing studies focused on national and provincial areas, whereas this study takes 264 cities at the prefecture level as the research unit across the country. Second, this study explores the spatial differences in UCEs using ESDA and contributes to revealing the characteristics of spatial correlation. Third, this study also delves into the factors influencing UCEs with Geodetector, which can provide a reference for making policies on urban emission reduction to achieve carbon neutrality.The remainder of this paper is arranged as follows: https://data.cnki.net/, accessed on 17 January 2022), which Chinese government departments provide with authority and credibility. In case data were missing or unavailable, they were collected from the statistical yearbook of the province to which the city belongs . The standard energy conversion coefficient (SECC) for coal and the carbon emission coefficient (CEC) for alternative energy resources used in this research referred to the China Energy Statistical Yearbook , General Rules for Calculation of the Comprehensive Energy Consumption (GB/T 2589-2020) , and Guidelines for Compilation of Provincial Greenhouse Gas Inventories . https://data.cnki.net/, accessed on 17 January 2022).The consumption of fossil energy is the primary source of CEs in Chinese cities. Drawing on previous studies ,45, we uThe SECC and CEC were used to calculate the UCEs, as shown in Equation (1):i after converted to standard coal; i. This calculation method for carbon emissions features broad applicability, convenient data acquisition, and consistent statistical caliber [ caliber . It appl caliber , which dI and Local Moran’s I. The Global Moran’s I was used to explore the spatial distribution of UCEs in the entire region. If it is >0, the UCEs have a positive spatial autocorrelation. If it is <0, the research object has a negative spatial autocorrelation. The equations are as follows:i and j, respectively;i and j. If the two cities have a common boundary, I, respectively.ESDA, proposed by Messner et al. , is a meI. The LISA clustering map combined with the Moran scatterplot, and Local Moran’s I can reflect the agglomeration types of UCEs. Local Moran’ I was defined as:To explore the heterogeneity of UCEs in sub-regions, we resorted to Local Moran’ p = 0.05) could be divided into four types, as shown in Its significance was also tested by Equation (5). By comparing the signs of Geodetector, proposed by Wang , is a stD refers to the factor affecting UCEs; n and m stands for the number of categories of an influential factor; D in class i. The results showed two significant characteristics of the UCEs in China. First, cities with the highest UCEs over the years were all located in the Beijing–Tianjin–Hebei, Yangtze River Delta, Pearl River Delta, middle reaches of the Yangtze River, and Chengdu–Chongqing urban agglomerations (UA). Moreover, the UCEs showed a trend of gradually increasing. To make the representation more direct and concise, the average values of UCEs in China and its four regions  are usedI was positive every year and passed the 1% significance test. This illustrates that the UCEs in China had similar spatial characteristics of agglomeration. However, the Global Moran’s I was not large—its highest value was only 0.2602—which indicates that the global spatial autocorrelation of UCEs in China was not very significant.The global spatial autocorrelation of UCEs in China between 2008 and 2018 was tested using ArcGIS 10.2 software. The results  demonstrThe local spatial autocorrelation of UCEs in China between 2008 and 2018 was also tested by ArcGIS 10.2 software. The UCEs showed some local spatial autocorrelation, which could be divided into four types : High-hiPrevious studies on spatial differences of CEs in China concluded that the carbon emissions in China showed spatial autocorrelation ,22. The With reference to the previous studies ,56 and t(1) Economic scale. It is expressed by urban GDP. The expansion of economic scale increases the output of products, whereas the expansion of output may increase CEs at the same technological level. When economic growth reaches a certain stage, that is, after the turning point of the EKC, the expansion of the economic scale may lead to a reduction in CE changes in the technology level and production model .(2) Industrial structure. It is expressed by the proportion of the added value of the secondary industry. The industrial structure upgrading is an important indicator of economic growth. Different industrial structures have different effects on CEs . A stage(3) and (4) Population urbanization and land urbanization. They are expressed by the proportions of urban population and land for construction, respectively. The urban population is growing, and the land for urban construction is expanding. The demand for energy will continue to increase with rising urbanization and may lead to a corresponding increase in CEs. When the urbanization rate exceeds a certain level, the application of new environmental protection technology and improvements in energy efficiency will be conducive to reducing CEs .(5) Resident income. It is expressed by the average wage of urban workers. The awareness of energy conservation and emission reduction among residents and enterprises improves with the increase in the urban resident income, which is conducive to reducing CEs . However(6) Technological progress. It is expressed by the expenditure on science and technology. On the one hand, environmentally friendly technological progress can improve energy efficiency in the production process. On the other hand, technological progress may not be environmentally friendly, and the expansion of the production scale accompanied by technological progress may increase CEs .(7) Energy structure. It is expressed by the proportion of coal consumption. It can directly determine the intensity of CEs. When the proportion of clean and new energy is high, CEs at the same level of energy consumption are lower. While the chemical energy dominated by coal is the main source of CEs, the high proportion of coal is not conducive to reducing CEs .(8) Openness. It is expressed by the amount of foreign capital used. Opening up is conducive to attracting foreign enterprises that can help save energy and reduce emissions to carry out more green production, thus reducing CEs . At the (9) Environmental regulation. It is expressed by the investment in environmental pollution control. A higher intensity of regulation forces enterprises to reduce emissions ,65. TherSome studies have found that the population size or economic scale is the main factor affecting carbon emissions ,22. ThisThis study attempted to explore the spatial differences and influential factors of UCEs in China. In total, 264 cities at the prefecture level in China from 2008 to 2018 were taken as research objects. ESDA was used to analyze the spatial differences in UCEs, and Geodetector was employed to analyze the factors affecting UCEs. The conclusions were as follows: (1) The UCEs showed a gradual upward trend, and cities with the highest emissions were located in the Beijing–Tianjin–Hebei, Yangtze River Delta, Pearl River Delta, middle reaches of the Yangtze River, and Chengdu–Chongqing UAs. (2) The UCEs had significant spatial differences with certain global and local spatial autocorrelations. (3) The industrial structure had become the most dominant factor affecting UCEs. We used ESDA alone to analyze the spatial differences of UCEs. In the future, it is necessary to further study the spatial differences of UCEs using Dagum’s decomposition of the Gini coefficient, kernel density estimation, and standard deviational ellipse. Our analysis of the influential factors of CEs focused on the macro socio-economic aspect. How micro factors such as individual heat sources and communication affect CEs merits more attention in the future.(1) Due to spatial differences in the UCEs in China, cities with the highest CEs are from the five national UAs. UAs should thus be the key areas for China to make policies on emissions reduction. China has five national UAs, nine medium UAs, and six small UAs. These twenty UAs are regions with the most concentrated economies and populations and the highest level of industrialization and urbanization in China. They have thus become regions with the most concentrated CEs. The UAs have established a relatively sound infrastructure and an integrated mechanism of market and basic public services. They also need a cooperative mechanism of low-carbon development. This can improve their threshold of industrial access, restrict industries with high energy consumption and emissions, and help build an integrated mechanism of low-carbon governance. The UAs are also the most developed areas in science and technology. These advantages need to be used to develop technologies that can save energy and provide technical support for reducing CEs.(2) Due to the spatial autocorrelation of the UCEs in China, an “urban carbon reduction community” should be established. First, a community of all high-high-type cities should be established. These are cities with large and concentrated CEs that need to control the expansion of their industries that are high emitters, formulate emissions standards for these industries, and require them to implement the relevant standards. In addition, such cities need to optimize their industrial spatial layout and encourage their high-carbon industries to reduce emissions through orderly regional transfer, clustering development, transformation, and upgrades while conforming to national industrial policies. For low-low-type cities that emit carbon, it is necessary to establish a low-carbon mode of industry, construction, transportation, and energy system and advocate a green and low-carbon lifestyle and mode of consumption. Low-carbon industrial demonstration parks can be built in such cities to support the construction of a low-carbon city.(3) As the industrial structure has become the dominant factor affecting UCEs, its continual optimization should be promoted. All cities need to use the development of ecological civilization and green development as the basic guidance and promote low-carbon technology and modes of clean production in various industries and sectors. Energy conservation and environmental protection have the advantages of a long industrial chain, driving employment, energy conservation, and emission reduction. Cities with such prerequisites need to develop energy conservation and environmental protection. For cities dominated by the secondary industry, advanced technologies need to be used to improve the traditional manufacturing industry, formulate emissions reduction targets for high-emission industries, and control CEs. For energy conservation, a system for the control and evaluation of energy consumption should be established to promote energy conservation in power, steel, building materials, nonferrous materials, and chemical industries while promoting energy saving in new buildings and transportation. For cities in which the tertiary industry is the leading industry, it is necessary to develop strategic emerging industries and service industries and use representative commercial institutions such as shops and hotels as pilot projects to implement supply chain management to reduce emissions.


Endoscopic thyroid surgery has gained popularity with the advances in laparoscopic and endoscopic instruments and techniques. Of all endoscopic approaches for thyroidectomy, the transoral endoscopic thyroidectomy vestibular approach (TOETVA) is the most promising procedure as it avoids neck scars and has less tissue dissection than other endoscopic techniques. This study aimed to present our first impression and initial experience with TOETVA in Erbil city. Twelve patients underwent surgery between November 2020 and April 2021, including eleven females and one male. Eleven total thyroidectomies and one lobectomy were performed. We found no significant postoperative complications. TOETVA is a safe and effective procedure, but it is challenging, needs good skills, and is a promising technique. Thyroid nodularity is a common condition among thyroid diseases, being more prevalent among women. Surgical intervention is the primary intervention in managing this condition . The popThe development of minimally invasive procedures for the thyroid gland dates back to the mid-1990, going through many changes and trials. Many changes and modifications have been described and shifted from one procedure to another in an attempt to hide the scars or improve cosmetics in the cervical region .When endoscopic thyroidectomy was invented, the procedure became popular, and many different ways were described, such as cervical endoscopy , axillarThe transoral endoscopic thyroidectomy by vestibular approach (TOETVA) was described by Anuwong et al. in 2016. The results were comparable to the classic open thyroidectomy but without any visible scars in the neck region . What maMany studies that performed TOETVA reported that the approach is very safe in preserving the recurrent laryngeal nerves –13. TOETTwelve patients were included in this study. All surgeries were performed by one surgeon (Dr. Samir A. Jabbar) at Medicano Hospital in Erbil City, the capital of the Kurdistan Region of Iraq, in cooperation with Dr. Nooraddin Ismail , who had a great role as a consultant to review and select patients for this procedure. Patients were informed of their surgical options, which included conventional open surgery and TOETVA. The risks and benefits of both techniques were discussed with the patients, and each patient signed informed consents.A thyroid gland diameter not larger than 10 cm or a thyroid volume not more than 45 ml;A benign tumor, such as a thyroid cyst, single-nodular goiter, or multinodular goiter (nodule not more than 5 cm);A follicular neoplasm;Grave's disease;A papillary microcarcinoma without evidence of metastasis.Patients unfit for surgery;Patients with previous surgery or radiation at the neck;A huge thyroid gland (more than 10 cm in diameter).The following variables were taken into account: age, sex, nature of the thyroid disease, type of surgery , duration of the surgery, skin bruising and other complications. The surgical technique was the same as described by Anuwong et al. .Here we describe the standard technique used in TOETVA worldwide, which was first described by Anuwong et al. , but witThe surgeon stood at the center behind the patient's head while the two assistants stood on the right and left side of the patient's neck .2 insufflated through it and maintained at 6 mmHg. Two 5 mm ports were inserted lateral to the canine teeth on the lower lip parallel to the 10 mm port  .The dissection of the thyroid gland was started by elevating the isthmus and dividing it. The next step was to open the Joll's space to identify and cut the superior thyroid artery. Then medial retraction of the lobe was necessary to expose the recurrent laryngeal nerve (RLN). Dissection of the gland was continued to the end carefully to preserve the RLN and the parathyroid glands . We madeThen the specimens were extracted through the 10 mm incision, and large lobes or nodules were cut once or more to ease their extraction. After finishing the procedures, the strap muscles were approximated, and the incisions were closed. We did not place surgical drains for lobectomy or total thyroidectomy cases. A pressure dressing was placed around the chin for one day. Postoperative antibiotics were prescribed for the patients for five to seven days to prevent infection.Twelve patients underwent surgeries between November 2020 and April 2021, including eleven females and one male. Eleven total thyroidectomies and one lobectomy were done. The youngest patient was 23 years old, and the oldest patient was 50 years. The clinical data regarding the age of the patients, the volume of the gland, the size of the nodules, fine needle aspiration cytology, type of surgery, duration of surgery and time of discharge is shown in Although we prescribed postoperative antibiotics for all the patients who underwent TOETVA, one case developed an infection and abscess one week after the procedure. Aspiration under antibiotic cover was not successful in treating the condition, so we decided to drain the pus under general anesthesia with a small incision about 2 cm in the upper part of the neck, which resolved the condition with no complications left behind.Two pictures of the first postoperative day of a patient show anterior and lateral views of the neck , and oneThree weeks postoperative picture of intra-oral incision of a patient which shows complete healing of the vestibular scar .Since the first endoscopic parathyroidectomy done by Gagner in 1996 , differeCosmetic issues have entirely been eliminated by TOETVA. Compared to other endoscopic methods, it has some advantages, like smaller dissections and access to the right and left lobes of the thyroid gland through the same incision .After transoral thyroidectomy, minor skin injuries are not uncommon. Chin and anterior neck skin injury and ecchymosis are frequently encountered in the immediate postoperative period , 28. We Despite not having concomitant intraoral infections like tooth abscesses or other infectious conditions, transoral thyroidectomy is considered a clean-contaminated case as it violates the oral mucosa . AdequatHigh complication rates and violation of mental nerve in terms of injury have been documented in previous reports , 33, 34.The risk of mental nerve injury is one of the concerns among the authors, but it seems to be no real risk of nerve injury with the most recently described technique , and we A total of 82 patients were included in a study published by Mi Ra Kim et al., in which 44 cases underwent TOETVA and 38 classic open methods. No significant drop in pitch was noted in TOETVA cases .TOETVA is not an easy surgery, and it is challenging even for experienced surgeons, with a steep learning curve, and it should not be undertaken by non-expert thyroid surgeons . One sho2 insufflation and insertion of the first lateral port).The most challenging and difficult part of the surgery for an inexperienced surgeon is the dissection of the superior pole because it is poorly visible, as, during the procedure, we see the thyroid gland craniocaudal . Apart fTwo other issues should be mentioned, which are the cost and the time of the surgery. Both of them are higher in TOETVA in comparison to the classic open method; this has been mentioned by other authors as well. We noticed the long surgical time in our cases, but it was not longer than the surgical time published by many other authors , and it Permanent hypoparathyroidism has not been reported in TOETVA , and forWe did not observe major complications, such as recurrent laryngeal nerve injury, definitive hypoparathyroidism and hematoma, nor the need to convert to the cervical approach. Although postoperative antibiotics were given to all the patients who underwent this procedure, we had one case of infection and abscess formation, which did not resolve with aspiration under antibiotic cover. Therefore, we decided to make a small incision and drain the pus under sedation, and the patient completely recovered after one week with no other complications.There are articles published worldwide detailing the safety and effectiveness of TOETVA; therefore, this procedure should no longer be regarded as an experimental operation .We noticed that TOETVA is safe and feasible, nearly with the same complications as the classic open method but completely avoiding the neck scar. Operation time is long, but it decreases with experience. It needs a good knowledge of the neck and thyroid anatomy, training and very good laparoscopic skills to perform this surgery, and it should be performed cautiously. Our initial experience is completely positive for this amazing technique of thyroidectomy. We will publish more articles with a larger number of cases in the future.


The COVID-19 pandemic is a major public health problem with millions of confirmed cases and deaths described. Nurses are among the health care professionals most involved at the front line, caring for those affected by COVID-19. Patients and families have been subjected to a high emotional burden of fear, anxiety, and uncertainty. The COVID-19 pandemic has had a significant impact on the approach to patients, the organisation of care, and communication with patients and their families, all requiring considerable adaptation on the part of nurses and health care professionals. The overall aim of this research was to find out the needs of patients with COVID-19, the nursing interventions provided and their outcomes, and to explore the experiences of the nurses, patients, and caregivers. A mixed method study will be performed with a convergent design. The study was divided into three phases. Quantitative methods involved nurses and patients affected by COVID-19 with a questionnaire. Qualitative methods involved nurses, patients, and caregivers with interviews and finally a quantitative analysis of the nursing documentation of the interviewed patients. We hope that this study will help us to understand and identify the main nursing and support needs expressed by patients and their families at different stages of their illness. The SARS-CoV-2 pandemic represents a major public health problem. At the time of writing, over 455 million confirmed cases and over six million deaths have been reported globally .Nurses are among the health professions most involved at the front line, caring for those affected by COVID-19. Nurses have been subjected to significant demands for sacrifice, in terms of personal risk, increased workload, and difficulty in maintaining the usual standards of care and assistance ,3. HealtNursing, centred on personalised and holistic patient care , has found itself having to provide exceptional care, finding innovative strategies to ensure the best possible quality, despite sometimes extremely unfavourable conditions. The COVID-19 pandemic has had a significant impact on the approach to patients, the organisation of care, and communication with patients and their families, all requiring considerable adaptation on the part of nurses and health professionals ,6,7.Patients directly affected by COVID-19 were subjected to notable emotional burdens related to fear, uncertainty, and anxiety, with health care staff having to provide significant support in order to address the patients’ emotions, needs, and experiences. The risks of depression, insomnia, post-traumatic stress disorder (PTSD) and psychological distress are significant for patients and have been described in other infectious disease outbreaks including interventions to address organisational issues ,11,12,13The physical presence of families for hospitalised patients had to be interrupted in order to maintain public safety. Hospitals and health services had to quickly adapt procedures in order to facilitate regular communication between patients and families despite the restrictions. Solutions based on information technologies were introduced and were essential for family-centred care ,15.Following previous epidemics , numerous studies have investigated the experiences of health care professionals, focusing on stress factors present both during and after the pandemic ,18,19,20These studies were mainly aimed at exploring the experiences of nurses and physicians, while there is limited literature considering the experiences of patients and their relatives. Furthermore, the literature shows that it is always essential to investigate, understand, and consider the needs of patients and their families. This knowledge can help to develop specific nursing interventions to better meet the needs of patients and their relatives ,23,24,25Even less research has been conducted to investigate what nursing interventions have been implemented and whether, and to what extent, they have responded to the needs expressed by patients with COVID-19 and their families.Our study therefore aims to contribute to filling this gap in the literature. The knowledge of these variables will be useful in the case of new pandemics, in order to understand what kind of nursing interventions could be performed, which aspects are effective or ineffective and why, identify areas of best practice and allow for the adoption of improvement strategies where necessary, in order to face similar pandemic situations with greater preparation.Given the important role nurses play in health emergencies, it would be important to know if and what nursing interventions have been instrumental in ensuring appropriate care and improving patient outcomes.We would like to clarify that, at the time of this publication, the various research projects contributing to this mixed methods study have been initiated following ethical and regulatory approvals. While data collection has been completed, the strategy for data analysis is outlined within this protocol but has not been completed. For this reason, some sections of the paper are in the past tense, and some are in the future tense.The overall aim and research question of this study was to find out about the needs of patients with COVID-19, the nursing interventions provided and their outcomes, and to explore the experiences of nurses, patients, and caregivers.(1)To identify the needs expressed by COVID-19 patients and their caregivers/families, whether they were addressed or not and for what reasons, from the point of view of the nurses, patients, and caregivers;(2)To determine which nursing interventions were performed to address the patients’ needs;(3)To investigate which interventions were perceived by the patients, caregivers, and nurses to be effective or ineffective;(4)To determine which factors and/or conditions favoured or hindered the effectiveness of nursing interventions;(5)To explore the experience of patients and their families during the period of hospitalisation and that of the nurses who cared for them.Our objectives were:This study was performed in a multisite hospital in southern Switzerland. In our country, over three million cases of COVID-19 and 12,000 COVID related deaths have been reported .We proposed a mixed methods study, with a convergent design that involved quantitative data collection and qualitative data collection . This deThe study is divided into three phases :Phase 1: Quantitative investigation of the needs of patients affected by COVID-19, the nursing interventions employed, and their effectiveness through questionnaires to the patients and nurses.Phase 2: Qualitative investigation of the needs of patients affected by COVID-19, the nursing interventions employed and their effectiveness—data collection from nurses, patients and caregivers.Phase 3: Quantitative analysis of nursing documentation (electronic patient records). We consulted the electronic patient records of the patients who agreed to be interviewed.Nurses who worked in inpatient units where patients affected by the COVID-19 were cared for.Adults (aged 18 years or older) who contracted COVID-19 and had a medium to high level of severity of the disease, defined as having been transferred to intensive or semi-intensive care units and after admission to an inpatient unit caring for patients affected by COVID-19. The rationale for this criterion is that it is assumed that such patients have gone through all stages of the disease and have a more complete experience of its different phases.The family members of patients (aged 18 years or older) who were willing to be interviewed and who do not have cognitive, psychiatric, or speech problems.The participants had to be able to answer a questionnaire and take part in an interview in Italian.Patients diagnosed with cognitive disorders and people with insufficient knowledge of Italian language;Individuals who were unable to provide written informed consent to participate in the study.NursesThe aim of this phase of research is to determine, from the nurses’ perspective, the main care needs of patients affected by COVID-19 (and their families/caregivers), and the nursing interventions that have been implemented and considered as the most useful in addressing these needs.The instrument used for data collection was a study specific questionnaire constructed by the research team, and based on Marisa Cantarelli’s Nursing Performance Model (2003)  28,29].,29.28,29The usefulness of this model for this investigation lies in the fact that it establishes precise correlations between the needs, professional actions, and expected results. The model is used as a data collection instrument and aggregation system. The additional needs that the questionnaire will assess include the need to maintain cardiovascular function, the need to maintain a safe environment, the need for therapeutic procedures, and the need for diagnostic procedures.The questionnaire was created and tested by involving nurses who had worked in inpatient units where patients affected by COVID-19 were cared for, in order to obtain feedback on its ability to measure the survey phenomenon. Before being used in the study, the questionnaire underwent pilot testing with five nurses, other than those who were involved in the development phase, in order to assess its clarity and content validity.The questionnaire also collected demographic variables such as gender, age, years of experience as a nurse, and clinical specialisation. Questions regarding their work experience during the COVID-19 are also included .The questionnaire was sent electronically by email to all nurses who worked in COVID-19 wards at the multi-site hospital. At the end of the questionnaire, the respondent was asked if they were willing to participate in an interview.PatientsThe aim of this phase of research is to find out what needs were expressed by the patients. This should give an overview on which of the patients’ needs were best met and through which professional actions.The instrument for data collection will include a section of a validated questionnaire, the Newcastle Satisfaction with nursing scale , integraThe questionnaire has been tested by five patients to check its clarity and comprehension.This questionnaire was sent by post to patients who had been treated for COVID-19 who had been admitted to one of the multi-site hospitals and received intensive or semi-intensive treatment and who had showed a prior willingness to participate in research. These were patients who have gone through all phases of the disease including the acute phases. At the end of the questionnaire, the patient was asked if they were willing to participate in an interview as well as a member of their family.Recruitment of patients and caregiversEligible patients were identified through hospital databases of patients with COVID-19 admitted to COVID wards at the multi-site hospital during the pandemic period, aggregating them by ward. A letter of introduction was sent to the patient, along with an informed consent form (one for the patient and one for the caregiver), the questionnaire to be completed by the patient, and a stamped addressed envelope. Patients were invited to return the completed questionnaire in the envelope provided and state if they were available to be interviewed. Caregivers were also invited to state if they were available to be interviewed.This was followed by the selection of patients and family members available for the interview and organisation of the interview.A comparison with the data from the patient investigation may reveal areas of agreement or discordance between the needs of the patients and the interventions implemented by nurses and their perceived effectiveness.Nurses:Amongst the nurses who provided their availability, 15–20 subjects were identified for an in-depth interview on the topics of the research. The interviews were semi-structured and digitally recorded. The selection of the professionals was made using the criterion of maximum possible variability . The exaSemi-structured interviews with initial open-ended questions and then with questions more focused on the research question were performed. The thematic areas  were the same as the questionnaire, but with the possibility of further investigation and/or clarification to gain an in-depth understanding of the professional response to the patients’ needs. The interview also explored which factors and/or conditions favoured or hindered the effectiveness of nursing interventions. Interviews were performed in a place agreed with the persons concerned .Patients and caregivers:Among the patients who provided their availability, 15–20 subjects were identified for an in-depth interview on these topics. The interviews were semi-structured and digitally recorded. The selection of patients was made using the criterion of maximum possible variability  and who The instrument used was a semi-structured interview with initial open questions and with later questions more focused on the objectives of the research. The thematic areas (patients’ care needs) were the same as in the questionnaire, but with the possibility of further investigation and/or clarification to gain an in-depth understanding of the professional response to the patients’ needs. The interview with family members was free form and narrative.The interviews were carried out in a place agreed with the patient and their family  and audio-recorded.The nursing documentation of those patients willing to be interviewed will be analysed. It will be used as an additional source of data to supplement and compare with the results of other sources (interviews and questionnaires).A descriptive analysis of the participants’ data will be carried out for the main characteristics investigated.The patients’ needs and nursing interventions will be considered as dependent variables. The characteristics of the patients will be considered as independent variables.Nominal or categorical variables will be described in terms of the frequency and percentage, ordinal and rational variables in terms of the mean and standard deviation, if normally distributed, or the median and interquartile range, if not normally distributed. The Kolmogorov–Smirnov test will be performed to test the normality of the distributions. If the distributions are not normally distributed, a two-step transformation will be attempted using SPSS 26.0 software, if necessary.If possible, a multivariate analysis will be performed in order to understand which characteristics of the patients might have influenced their needs.To compare the nominal or categorical variables, the chi-square or Fisher’s exact test will be used as appropriate.t-test will be used if the variables are normally distributed or a Mann–Whitney test if the variables are not normally distributed.To compare the ordinal or continuous variables between two groups, the Student’s p < 0.05 [The analyses will be carried out using SPSS 26.0 software. Statistical significance will be considered with values of p < 0.05 The interviews of nurses, patients, and caregivers will be audio recorded and transcribed verbatim. The interviews will be independently analysed by three experienced qualitative researchers and compared. A thematic analysis according to Braun and Clarke will be applied . The anaThe analysis of the nursing documentation will take place after the qualitative phase . The extrapolation of the data from the medical records will be conducted by three people in the research group following the sections of the questionnaire (needs of the persons according to Cantarelli’s model).To guarantee rigour in qualitative data analysis, the criteria of credibility, transferability, dependability, confirmability by Guba and Lincoln , and fitWe will use joint displays as described in the literature ,37,38,39To guarantee rigour, based on the mixed methods literature, we will use the legitimation criteria described by Younas et al., 2020b; Onwuegbuzie A.J. and Johnson R.B. ,41.With this research, we expect to understand the main nursing care and assistance needs expressed by COVID-19 patients at different stages of their illness to uncover which of these needs received adequate professional responses from nurses, and which of the professional actions or interventions were considered as the most useful or effective by those concerned. In the same way, it should be possible to identify some of the needs of patients or their families who, for various reasons, may not have had adequate responses. We believe that this information is important and should be brought to the attention of all professionals in order to be better prepared to deal with similar situations. We hope that this study will help us to understand and identify the main nursing and support needs expressed by the patients and their families at different stages of their illness. The knowledge of the patients’ needs and nursing interventions that were considered useful can be important information to improve patient care in other similar crises, but also during normal care activities.