Most people who sustain a stroke are likely to experience sexual difficulties during their recovery. However, few people get the opportunity to address sexuality during their rehabilitation because of factors related to the organization , managers , clinicians , and clients . A multifactorial program tailored to stakeholders' needs with various complementary interventions is needed to lead to a change of practice in post-stroke sexual rehabilitation.To co-design with stakeholders  a theory-driven multifactorial program to improve post-stroke sexual rehabilitation services.This qualitative study will be conducted in four steps using an Intervention Mapping approach and a co-design methodology divided into four phases: (1) exploration; (2) co-design; (3) validation; and (4) development. Persons with stroke, partners, clinicians and managers from five distinct stroke rehabilitation centres in the province of Quebec (Canada), and researchers will be recruited to either participate in an advisory committee or working groups throughout the study. A combination of contributions from three different types of groups  will be used for data collection. Qualitative data analysis will first be realized by two independent reviewers using the Theoretical Domains Framework, and preliminary results of analysis will be validated with the advisory and working groups.This study will lead to the co-design of the first theory-driven program intended to optimize post-stroke sexual rehabilitation services. Stroke is the second leading cause of disability around the world  and can According to the World Health Organization, sexuality is “a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction” . Stroke However, few persons with stroke get the opportunity to address sexuality during their rehabilitation , 17 evenTo overcome sexual difficulties, Canadian , AmericaConsidering the multiple barriers experienced by people with stroke, clinicians, and other stakeholders in relation to post-stroke sexual rehabilitation, it appears important to develop complex, or multifactorial, interventions that can improve the implementation of clinical practice guidelines recommendations. For example, A recent systematic review of 114 studies on inclusion of sexuality in the care of people with disability or chronic illness by McGrath et al.  includedThis study is being conducted to address the concerns of five participating organizations regarding the lack of services related to post-stroke sexuality. Considering that changes in provision of sexual rehabilitation is complex, multiple interventions simultaneously targeting people with stroke, partners, clinicians, and clinical managers are needed to support the development and delivery of better services related to sexuality post-stroke.To date, two studies have aimed to improve the provision of post-stroke sexual rehabilitation with a focus on changing clinicians' behaviors by creating and implementing sexuality interview guides , 31. TheIntervention Mapping is a structured process that aims to optimize a practice  by identifying the behaviors underlying the practice and acting upon the factors  that influence the behavior , 33. AccThe general aim of this study is to co-design with stakeholders  a theory-driven program to improve post-stroke sexual rehabilitation services. The specific objectives of this study are to:Describe the factors that influence the actual provision of sexual rehabilitation services in post-stroke rehabilitation from the perspective of various stakeholders.Identify stakeholder's priorities and needs regarding sexual rehabilitation services and develop a preliminary theory-driven program.Identify the behavior change strategies that can be used to address the prioritized factors and describe their expected action mechanisms.Develop and test the behavior change strategies that will target the identified determinants.This qualitative study is guided by an Intervention Mapping approach  and co-dThe Intervention Mapping approach  will oriThe co-design methodology has evolved in recent years, into a paradigm whereby various stakeholders work toward the same objective throughout the research process. The aim of co-design is for the entire team to focus on one challenge to better understand it and to work collaboratively toward finding creative solutions to resolve or improve it –43. The To consider a variety of perspectives, persons with stroke, partners, clinicians, managers, and researchers will participate actively in the research process and/or development of the program by taking either part in an advisory group, Lego® groups, or work groups at different stages of the project. The perspectives of persons with stroke and partners will be considered by using three different strategies. First, a review of the literature regarding persons with stroke and partners' priorities and needs related to post-stroke rehabilitation and sexuality will be realized. Second, a person who received post-stroke rehabilitation and the partner of a person with stroke will be involved in the advisory group. Finally, two work groups will be conducted with post-stroke individuals and partners. Clinicians and managers will participate in the Lego® or work groups, and a subset will be included in the advisory group. Researchers will be included in the advisory group. Participation methods for each of the three groups, along with the study timeline and related deliverables, are presented in We will draw from a well-known determinant framework, the Theoretical Domain Framework (TDF), and on the International Classification of Functioning, Disability and Health (ICF) core set for stroke  to guiden = 3), Laval (n = 1), and Quebec City (n = 1) in the province of Quebec (Canada). These rehabilitation centers offer services to people who sustained a stroke in the subacute (<3 months post-stroke) or chronic phases (>6 months post-stroke) of stroke recovery  and in the development phase .n = 2) will each rally five clinicians from varied disciplines and rehabilitation centers. One group will be composed of clinicians from inpatient or early supported discharge, and the other group will include clinicians from outpatient or community-oriented rehabilitation. Therefore, for each participating rehabilitation center, one clinician corresponding to each Lego® group will be selected . This division between each group is related to the substantial difference between the needs of the clientele and clinicians' respective work contexts. Participants in the Lego® groups will be recruited by convenience to optimize heterogeneity by varying the disciplines included in each of them.The Lego® groups (n ≤ 4 clinicians and n ≤ 3 managers/coordinators per rehabilitation center) and (C) up to 12 persons with stroke and partners. The work groups will take part in the validation phase  and in the pretest phase, aimed at improving the preliminary behavior change strategies. Considering their different perspectives, the three work groups will operate separately to facilitate discussion and ensure that participants are comfortable sharing information. This methodological choice is related to the pretest of the co-design methods that was conducted with a group of five-graduate students.The three work groups will be composed of (A) up to 20 clinicians from various disciplines and (B) up to 15 managers and coordinators, equally representing each of the participating rehabilitation centers  will be conducted using iterations between preparatory work by the research team and presentation to the group associated with each phase  and collecting participants' feedback for improvement.Participants in every group  will provide sociodemographic information, such as age, gender, occupation, and professional experience (if applicable). Every group activity will be conducted online, recorded digitally, and co-animated by two experienced facilitators. In the Lego® groups, pictures of the Lego® models that participants will create will be stored by the research team. During group activities, the two facilitators will use guides tailored to each activity's specific purpose  by the research ethics board of the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR). To be included in the study, each potential participant will have to read and sign a consent form. Participants will be free to withdraw from the study at any time.This study will be conducted in collaboration with five Canadian post-stroke rehabilitation centres, using innovative methods combining the Intervention Mapping approach, co-design methodologies, and a rigorous theoretical framework. First, these methods will allow for a better understanding of the challenging situation regarding the lack of post-stroke sexual rehabilitation, according to the experience of persons with stroke, partners, clinicians, managers, and researchers. Secondly, these methods will orient the production of a multifactorial program with tools and strategies aiming to improve sexual rehabilitation. The program will likely be more relevant and useful for persons with stroke, partners, clinicians, managers, and organizations since stakeholders will actively participate in each phase of the study . We beliThis protocol is characterized by numerous methodological strengths. First, the data collection methods using an adapted version Lego® Serious Play® method has been successfully pretested with five postgraduate students in preparation of this study. Secondly, by combining in-depth  and exhaustive  data collection methods with each relevant group of stakeholders, namely persons with stroke, partners, clinicians and managers, results will be more likely to provide an accurate representation of participant's perceptions and experiences. Finally, the methods were chosen in concordance with the COREQ  and answThe methods included in this protocol also have certain limitations. First, the sample of participants included in this qualitative study could limit the transferability of the results as they may not be representative of all the stakeholders in their category. In fact, since participants will be recruited in stroke rehabilitation settings, results are likely to be contextualized to this specific reality and may not be representative of stakeholders from other contexts of care, such as acute settings and community-based services. This could especially limit the transferability of results regarding the experiences, priorities and needs of persons with stroke and partners. However, a thorough consideration of the literature regarding people with stroke and their partners will be used in the assessment of needs and the program's development to complement the participant's contribution in each step of the study. Moreover, the inclusion of five different stroke rehabilitation centers from various geographic locations and various disciplines of clinicians will mitigate the impact of specific organizational or professional cultures. Nevertheless, the results will be contextualized to Quebec's healthcare system context and the stroke population. Therefore, results will need to be interpreted with caution in the context of other settings or populations. Secondly, the fact that data collection will be realized remotely may hinder participant's involvement during activities and limit the depth of data collected. However, the presence of trained facilitators in every group and the variety of data collection methods will foster participant's involvement and ensure rich and in-depth discussions during data collection.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Research Ethics Committee of the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR). Written informed consent was not provided because this manuscript is a protocol for a study that was not started yet. Therefore, no participants were recruited at the time of the submission of this article. In the future, when we will recruit participants, each of them will have to provide consent by signing an information and consent form. The recruitment of participants has been initiated.L-PA was primarily responsible for writing all of the sections of the article. DA, EM, AT, JF, BV, and AR have contributed to the development of the methods that will be used in the research and have revised and improved the manuscript. All authors contributed to the article and approved the submitted version.This research project was supported by funding from the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR). The authors gratefully acknowledge that L-PA was supported by doctoral scholarships from the Canadian Institutes for Health Research, the Fonds de recherche du Québec en santé (FRQS), the School of Rehabilitation of the Université de Montréal (UdeM), the Canadian Occupational Therapy Foundation (COTF), and the Ordre des ergothérapeutes du Québec (OEQ). DA was supported by doctoral scholarships from the Mission Universitaire de Tunisie, the School of Rehabilitation of UdeM, the graduate and postdoctoral studies of UdeM, the CRIR, and the Fonds Wilrose Desrosiers et Pauline Dunn. AT was supported by a career award from the FRQS.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.


Six recommendations to facilitate rehabilitation research and supplement existing research practices were identified. Rehabilitation practice requires research addressing different long-term multi-faceted needs and perspectives of end users, including service users, professionals, politicians, and administrators. Research in rehabilitation should therefore integrate different research traditions and methods. Rehabilitation research with a broad focus is sparse, and most of the research takes its starting point in the biomedical research tradition. Through a nominal group process, we developed recommendations to emphasize important issues in rehabilitation research. A growing recognition of the potential of rehabilitation has led to higher prioritization and acknowledgment of the need for high quality rehabilitation research , 2. RehaThe benefits of a biopsychosocial approach in rehabilitation to reduce negative consequences of health issues has attracted growing attention and recognition . An incrAccording to WHO, rehabilitation addresses different aspects of the lived life and is “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment” . Thus, rThe Nominal Group Technique (NGT) was used to identify recommendations for rehabilitation research practice. This method is designed to explore opinions, generate ideas, and determine priorities in e.g., the health sector –20. Our The take-off of the nominal group process was a collaboration initiative between research, education and clinical practice in Central Denmark Region with focus on rehabilitation development in the region . DiscussThe nominal group-process was initiated through the chairperson's presentation of the framework for rehabilitation, research obligations, and existing research within the field. Common challenges to rehabilitation research addressed at the inaugural meetings were presented.Participants were asked to individually consider what they perceived as appropriate and high-quality rehabilitation research. All ideas were documented and accessible to all group members.To elaborate and clarify the ideas, each member presented their ideas to the group, who posed in-depth questions.Structured discussion of all ideas from the common document. Large variations were identified, explained by the participants' different theoretical and scientific foundations. In-depth discussions led to a common understanding and nuancing of possible ideas related to complexity and processes in rehabilitation .In this step, our process deviated from the NGT, as we omitted individual ranking of the generated ideas; instead, ideas were discussed until reaching consensus. This process led to a synthesis of recommendations of special importance within rehabilitation research. It became clear that some of the identified recommendations coincided with established, generic research practice; they were therefore deemed unnecessary to include. To avoid group processes and dominance influencing recommendations, and to consult the end users, the recommendations were subsequently discussed and amended at an expert group meeting also involving the service users.The NGT process resulted in six recommendations for rehabilitation research as presented in with or by the public (including service users) who act as participants, rather than research on the public/service users as subjects , often the default choice for intervention studies, has been claimed unfeasible for some clinical questions  . The WHOUsing our recommendations can be a way to establish common ground for future discussion and development of holistic rehabilitation research, e.g., by using the biopsychosocial perspective of the ICF and the new ICF-matrix and the perspectives of the people receiving rehabilitation services to define the specific area of interest in each research project. It is important to emphasize that these recommendations are intended to guide researchers, decision-makers and funders within rehabilitation and rehabilitation research, all of whom do not necessarily have long experience with the discipline.Although the recommendations are targeting rehabilitation researchers, there should be no doubt that we find it absolutely crucial that end users, including service users and stake holders, participate in the rehabilitation research process. End users are to be involved at distinct stages of the process: (1) priority setting and formulating research questions (2) study design, data collection and analysis (3) dissemination of findings and knowledge translation. This will improve the relevance and quality of rehabilitation research. Thus, the ultimate aim of the recommendations is to increase the knowledge base for rehabilitation by improving the actuality, relevance and implementability of rehabilitation research. Therefore, an important part of the recommendations stresses the involvement of all end users in the field of rehabilitation, in line with Solvang et al.'s emphasis on identifying and involving all agents in the field of rehabilitation at micro, meso, and macro level .The NGT has been used in several fields including multidisciplinary health care integrating a patient-centered approach , 41, 42.Rehabilitation can be defined both as a health strategy and a set of interventions based on the biopsychosocial model of functioning and disability . The IntThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.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.


In order to verify the safety and effectiveness of tirofiban combined with statins in the perioperative period of intracranial aneurysms, this study adopts systematic review and meta-analysis, so as to comprehensively understand the situation of intracranial aneurysms in the perioperative period, and tirofiban combined with statins was finally determined as an effective treatment drug.  This study used systematic retrospective analysis and selected 80 patients with intracranial aneurysms treated in our hospital from June 2021 to June 2022 as the research objects. Through conventional drugs and tirofiban combined with statins used in this study, the intracranial levels, the probability of aneurysm rupture, and postoperative complications of the two groups were observed and recorded.  The analysis of 80 patients with intracranial aneurysms showed that the influence of intracranial levels in the observation group was better than that in the reference group, the rupture of aneurysms in the observation group was lower than that in the reference group, and the incidence of postoperative complications in the observation group was lower than that in the reference group.  Through simulation verification, it is concluded that tirofiban combined with statins is safe and effective in the perioperative application of intracranial aneurysms. This drug can improve vascular recanalization, reduce the incidence of cerebrovascular disease events, and reduce the incidence of rebleeding. Its therapeutic effect is worthy of wide clinical application and promotion. Intracranial aneurysms are tumor like protrusions caused by abnormal changes in local blood vessels of the intracranial cerebral artery wall, resulting in local vascular wall damage. Under the action of hemodynamic load and other related factors, they gradually expand and form abnormal protrusions. Aneurysm is a kind of cerebrovascular disease, which is very likely to have rupture and bleeding. Once rupture and bleeding occur, it will have a great impact on health, and there will be sequelae of nerve loss. When the amount of bleeding is large, it is easy to cause death. Tirofiban, as a more powerful antiplatelet drug, has an effect on platelet aggregation induced by various factors. It can inhibit platelet aggregation by inhibiting fibrinogen and platelet synthesis-related receptors, so as to prolong the time of bleeding, inhibit thrombosis, or reduce the size of thrombosis. Tirofiban, as a representative inhibitor, is used in the treatment of intracranial aneurysm vascular embolism. This drug can not only be used for remedial treatment after thrombosis but also play a preventive role. Statins can effectively reduce the level of blood lipids; reduce the inflammatory response of vascular endothelial cells; regulate vascular endothelium, anti-inflammatory, and antioxidant; improve vascular reactivity; and play a positive role in reducing the incidence of cerebrovascular disease events. Statins can limit the occurrence and development of intracranial aneurysms and effectively reduce the risk of aneurysm rupture. Tirofiban combined with statins provides a new treatment method and direction for intracranial aneurysms and has a great application prospect in perioperative treatment. Xiaojuan and Danfeng  discusseTirofiban as a nonpeptide high selective antagonist can inhibit platelet aggregation and adhesion most rapidly, directly, and completely and can effectively prevent the binding of fibrinogen and receptor. Statins can effectively reduce the blood lipid level of patients and reduce the inflammatory reaction of vascular endothelial cells. Statins are not only aimed at cardiovascular diseases but also benefit the blood vessels of the whole body. They can reduce sclerotic plaque and prevent thrombosis. They can play an obvious therapeutic effect in the treatment of cerebrovascular diseases and have high safety.The reference group of this study was treated with conventional drugs such as aspirin and nimodipine. Aspirin is an anticoagulant. For the thrombotic pathway, it can inhibit one or more of the many conduction pathways leading to platelet aggregation, so as to inhibit platelet aggregation and avoid the occurrence of thrombosis caused by platelet aggregation. Nimodipine is used to improve blood circulation and prevent and treat ischemic nerve injury caused by aneurysms. The drug has a good effect on patients with vascular dementia.In this study, meta-analysis was used to compare and synthesize the discussion of tirofiban combined with statins in the perioperative period of intracranial aneurysms. According to the statistical method of the research results of the problems related to the topic, relevant studies were comprehensively collected through retrieval and strictly evaluated and analyzed one by one, and those that did not conform to the topics related to tirofiban combined statins and intracranial aneurysms, as well as the repeated publication of tirofiban combined statins. The relevant literature of intracranial aneurysms, after systematic detection, evaluation, and summary, and quantitative combined analysis in the systematic review, is helpful to explore the consistency and other differences of the therapeutic effect of tirofiban combined with statins in the treatment of intracranial aneurysms. Rigorous meta-analysis can make a more objective evaluation. The clinical similarity and methodological similarity of the included studies are good. The results of tirofiban combined with statins in the perioperative period of intracranial aneurysms in this study finally proved to be safe and effective. It has super high reliability.t-test, the general data of the two groups were not statistically significant (p > 0.05), which was comparable.This study adopts systematic retrospective analysis and selects 80 patients with intracranial aneurysms treated in our hospital from June 2021 to June 2022 as the research object. The patients are divided into two groups according to odd and even grouping, with 40 patients in each group. Among them, 40 patients treated with conventional drugs, such as aspirin and nimodipine, were used as the reference group, including 15 male patients and 25 female patients. The age range was 40 to 75 years old, and the median age was (55.4 ± 3.8) years old; 40 patients treated with tirofiban combined with statins were used as the observation group, including 13 male patients and 27 female patients. The age range was 42 to 73 years old, and the median age was (54.1 ± 3.7) years old. After univariate The patient and his family members have given their informed consent and signed the informed consent formNo Alzheimer's disease or other cognitive impairment, clear consciousness, and certain expression abilityThere were no other serious complicationsNoncompliant patientsHave acute and chronic infectious diseasesPatients with a variety of basic diseasesObserve and record the influence of intracranial levels in the two groupsThe probability of aneurysm rupture was observed and recorded in the two groupsThe postoperative complications of the two groups were observed and recordedBefore the perioperative period, the patients were given psychological intervention to relieve the tension of the patients, explain the disease knowledge to the patients, reduce the pressure and tension of the patients, enhance the confidence of the patients, and receive treatment with the best psychological state.After the operation of intracranial aneurysms, the patients in the reference group were treated with aspirin and nimodipine, the changes of vital signs were monitored, and the changes of the patient's condition were recorded. After the operation, the patients were asked to take an absolute lying position, and the patients were asked to relax their heads, do not use force, and do not shake their heads. Let patients have a good rest, ensure adequate nutrition and sleep, reduce intracranial pressure, pay attention to posture, and prevent rebleeding. The observation group used tirofiban combined with statins to ensure vascular recanalization. Observe and ask the patient's condition changes in time during the treatment. Observe the clinical symptoms and adverse reactions of patients after medication. The effect of a reasonable safe dose of medication on a high dose will lead to aneurysm rupture. Monitor the ECG, blood vessel level, and vital signs of patients; and deal with them in time once abnormalities are found. Strictly follow the doctor's advice on medication. If the patient is found to have a slight headache, or accompanied by nausea, vomiting, and other conditions, it should be reported to the surgeon in time to check whether the patient has increased intracranial pressure.Eat more crude fiber food, digestible food, and drink more water after operation. Drink water slowly to prevent choking reaction. Pay attention to rest, and avoid fatigue and emotional excitement. After the operation, take drugs strictly according to the doctor's advice to improve the patient's medication compliance.p value of statistical data is considered to be in the confidence space when p < 0.05, and the statistical result is considered to be in the absolute confidence space when p < 0.01.The systematic review of clinical data was studied by meta-analysis using IBM SPSS 24.0 data analysis platform and Revman 5.3 software. Observe the law of data distribution, use Spearman correlation analysis method to discuss the correlation of data, and use curve estimation and linear regression analysis to observe the statistical law of data. In all analyses, the significance α, after activation, will cause intracranial inflammatory reaction. After drug treatment, it can inhibit the spread of inflammation and hinder the development of aneurysms.After the occurrence of intracranial aneurysms, they often develop further, leading to the expansion of aneurysms, which seriously causes the injury and dysfunction of intracranial arterial endothelial cells. When drugs are used, it will have a direct impact on the diameter of aneurysm. Collagen fiber is an important part of extracellular matrix. Changes in collagen fiber synthesis will lead to changes in the thickness of aneurysm wall. Aneurysmal inflammatory factors such as TNF-α. The influence of intracranial level is made into At this stage, the relationship between aneurysm diameter, aneurysm wall thickness, and TNF was observed-α More than observation group. There was a statistical relationship between t < 10.000 and p < 0.05. Through visual analysis of the above data, Figures α. According to two sets of TNF- αThe results of the level comparison can be seen intuitively that tirofiban combined with statins has a better therapeutic effect than conventional drugs. There is a wide gap between the two groups. This drug combined with statins can reduce inflammatory factors and improve the progress of aneurysm. All levels of intracranial are better than those of conventional drugs. It can be indirectly concluded that tirofiban combined with statins can effectively eliminate inflammation and inhibit the development of intracranial aneurysms.As shown in Figures The incidence of thromboembolism in intracranial aneurysm surgery is high. Embolizing intracranial aneurysms has certain risks, and aneurysms are very fragile, so, in order to prevent and treat thromboembolism, drug intervention is needed. However, after drug intervention, platelet function will be abnormal, increasing the risk of aneurysm rupture. Tirofiban combined with statins can effectively improve the rupture of aneurysms.Now, we study the probability of aneurysm rupture under the two methods; analyze the probability of intracranial hemorrhage, subarachnoid hemorrhage, and head pain after rupture; and make T < 10.000 and p < 0.05 between the two comparisons of the data, that is, there is a statistical difference between the data, which can be considered that different drugs have a certain impact on the rupture of aneurysms. According to the above data, As shown in Tirofiban has a short half-life, and the recovery rate of platelet function is higher after the withdrawal of combined statins. According to the analysis of For intracranial aneurysms, surgery should be actively used to maintain normal blood flow. There may be a series of complications after operation, such as hydrocephalus, new cerebral infarction, or recurrent aneurysm, so drugs should be used after operation to improve the prognosis. Now compare the incidence of postoperative complications between the two groups, study and analyze the prognosis of the two groups, and make the data into In order to better analyze the incidence of postoperative complications in the two groups, the following Complications are the main problem after aneurysm surgery. In This study focused on the observation and analysis of the safety and effectiveness of tirofiban combined with statins in the perioperative period of intracranial aneurysms. Through statistical methods and meta-analysis, logistic regression method for systematic review and the influence data of intracranial levels in the observation group were significantly better than those in the reference group, and the aneurysm rupture rate and postoperative complication rate in the observation group were also lower than those in the reference group. It can be concluded that tirofiban combined with statins can improve vascular endothelial function, protect nerves, and resist thrombosis. It has been proved that intravenous tirofiban combined with statins is safe and effective in the perioperative period of patients with intracranial aneurysms. Tirofiban combined with statins has an exciting prospect in the treatment of intracranial aneurysms, which can provide a good basis for subsequent treatment. To sum up, tirofiban combined with statins has an important impact on its clinical effect and has the significance of clinical treatment promotion.


Plastic pollution has become a major environmental concern worldwide. As the circular economy is increasingly seen as a means for achieving sustainable development, it is imperative to promote the more efficient use of plastics worldwide. An integral part of the circular economy model, trade in waste, and the scrap for recovery is a part of the solution to achieve sustainability. This paper studies the changing geography of the international trade in plastic waste. It reveals increasingly complex patterns of the transboundary trade in plastic waste over more than two decades. The movement of plastic waste from high-income countries to developing nations has been the largest flow, but trade flows of other directions turn out to be significant. The findings of the paper debunk the North–South or core–periphery dichotomy that is embedded in the international environment justice tradition  as well as in international environmental regulatory regimes such as the Basel Convention. The paper contributes to the discussions about value that are central in political economic approaches to global trade  by demonstrating the relative, spatial, and dynamic nature of the concept. As the transboundary trade in plastic waste has exacerbated pollution and marine litter in some major receiving countries, it needs to be better monitored and regulated to ensure it is conducted in a transparent and environmentally sound manner. The paper also explores several policy measures that could help tackle the plastic pollution crisis and achieve sustainable development. Plastic has become one of the most widely used materials in industry and our daily life. After World War II, the production of synthetic plastics skyrocketed from 1.7 million tons in 1950 to 368 million tons in 2019 .The rising consumption of plastic has led to an accelerated generation of plastic waste. The global trade in plastic waste has exploded since the early 1990s, growing into a multi-billion dollar business. With plastic pollution, especially marine litter, becoming a major environmental concern worldwide, people have started questioning the role that the global trade in plastic waste plays .A burgeoning literature has emerged on the international trade in waste and scrap. The mainstream of the literature tends to perceive the waste as the throwaway that consumer societies of the Global North have dumped on the people and environments of the Global South. Framed by the global environmental justice (GEJ) paradigm, this stream of studies, especially those under the umbrella of the ecologically unequal exchange (EUE) theory, often treats international trade in waste as a one-directional flow of waste that externalizes the environmental costs of the Global North using the Global South as the waste sink . In receAs the circular economy (CE) is being recognized as a solution to sustainable development , the conIn this paper, we aim to reveal the evolving patterns of the global trade in plastic waste and to explore the future of plastic waste trade. We hope to contribute to the debate on issues related to the global trade in waste in general and plastic waste in particular: does global waste trade represent toxic colonialism? An impeccable search for new value? Or a plausible move toward sustainability? By doing so, the paper provides links to the EUE and GVC/GPN concepts by offering evidence of the power asymmetries that drive the dominant movement of plastic waste. Meanwhile, by revealing a complex geography of plastic waste trade flows, the study reexamines some stylized forms of thinking associated with the EUE theory (such as the North–South or core–periphery dichotomy). We will also discuss the concept of value that is central in the GVC/GPN approaches and use the concept to explain the changing geography of plastic waste trade. The paper will contribute to the discussion on CE as one potential solution to the plastic pollution crisis that the world faces.The rest of the paper is organized as follows: In this paper, we situate our work within three streams of literature that relate to international trade, including a recent discussion of the CE and two political–economic traditions: the EUE theory and the GVC/GPN approaches. We seek to make several contributions to the literature on the international trade in waste. First, we will contribute to the discussion of the CE as a potential solution to the current plastic pollution crisis. Second, we debunk the North–South (or core–periphery) dichotomy that is embedded in the EUE theory as well as in international environmental regulatory regimes (such as the Basel Convention) by revealing an increasingly complex pattern of plastic waste trade at the global scale. Third, the study will make a contribution by expanding the conceptualization of the value that is central in the GVC and GPN approaches by demonstrating the relative, spatial, and dynamic nature of the concept.The drawbacks of the plastic economy are becoming increasingly apparent. Today, 99% of plastics are derived from fossil fuels, consuming about 6% of global oil. If the current trends in oil consumption and plastic production continue, it is projected that by 2050, the consumption of oil by the plastics sector will account for 20% of the total oil consumption in the world . As the Compared to the economic costs, the environmental impacts of plastics consumption are more detrimental. Between 1950 and 2015, an estimate of 8.3 billion tons of plastics were produced, from which 6.3 billion tons of plastic waste were generated. Among the wastes, 9% and 12% were recycled and incinerated, respectively, while 79% ended up in landfills and nature. If the current production and waste management trends continue, the amount of plastic waste entering landfills or the natural environment will likely double by 2050 . If the The heightened awareness of the plastic pollution crisis calls for a CE model to mitigate the environmental externalities of plastic production and consumption. The term “circular economy” was first coined in 1990 by Pearce and Turner in their now widely cited book that explored the relationship between the economy and the environment . The conThe EUE theory is grounded in Wallerstein’s (1974) world-systems perspective and the pioneering work of Bunker  and other critical development scholars ,25,26. IThe EUE theory provides an important perspective that enables analyses of the unequal power structure and trade relationships among nations and facilitate a better understanding of many global environmental problems. As Hornborg and Martinez-Alier 2016: 329) argue, the EUE “is an underlying source of most environmental distribution conflicts in our time.” 9 argue, ,33. In rThe North–South dichotomy is also embedded in the Basel Convention, or the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and their Disposal, a United Nations Convention based in Geneva. Considered to be the most comprehensive global environmental treaty governing the classification and cross-border movement of hazardous wastes and other wastes , the BasSeveral studies have evaluated the limitations of the Basel Convention and the Ban Amendment ,38. One Regardless, the Basel Convention provides a framework for countries to manage their own wastes and control the illicit movement of wastes across borders. The principle of prior informed consent (PIC), the “keystone” of the Basel Convention and other major international environmental agreements , requireLike other types of waste, plastic waste has been predominately flowing from developed to developing countries. The central argument of the “Global South as dumping sites for wastes” in the EUE theory and the GEJ movement likely find some support in the case of plastic waste. Nonetheless, this study contributes to the EUE literature in two ways: (1) the complex geography of plastic trade observed in this study will expose the limitations of some stylized forms of thinking associated with the EUE theory, such as the North–South dichotomy, which is also embedded the Basel Convention; (2) the discussion of the value of using China as an example will show that the ecological colonialism thesis may be too simplistic.The second stream of the literature is built on conceptually related perspectives, the GVC and the GPN perspectives. The origins and evolution of the GVC/GPN approaches have been reviewed in depth elsewhere ,44,45. OThe GVC/GPN frameworks are powerful tools to understand the trade and flow of goods and services on a global scale. By mapping the relations of production, they have demonstrated an effectiveness in revealing the creation, capture, and distribution of value in commodity chains or production networks. Meanwhile, these approaches also have limitations in studying the international trade of waste. These approaches, especially the GVC approach, have been criticized for their linear assumptions ,47,49. IAlongside proliferating discussions of GVCs and GPNs has emerged a small but growing literature on waste, with studies concerning the disassembly of ships ,46, autoCompared with other types of waste or end-of-life product, such as e-waste, scrap metal, and old automobiles, plastic waste is less valuable but more voluminous, with more profound environmental and public health impacts. Thus, it is important to study the trade flows of plastic waste. Our paper will contribute to this new literature and the broader GVC/GPN literature by revealing the breadth of the global network of plastic waste trade. As a significant amount of value is recovered with massive flows of plastic waste, this study will show that end-of-life plastic products are not valueless. Plastic waste deserves more attention in future GVC and GPN studies as post-consumption value needs to be accounted for. Through the case of China , plastic waste, if not collected to be exported overseas, would largely be treated as garbage with little value to recover and reuse, ending up in landfills. By contrast, in many developing countries, especially in newly industrializing economies, a variety of factors  contribute to a booming recycling industry and create opportunities for important plastic and other waste. With the interest and ability to rekindle value in recalcitrant waste materials and transform them into resources, these countries treat plastic waste and scraps as valuable resources for industries. In this respect, value is a relative concept as waste means different things in different countries and carries different weights in their economies. Moreover, the ability to rekindle value from waste and used things is geographically uneven ,46. ThatTo trace the pattern and measure the volume of the international trade in plastic waste, we used data which were extracted from the United Nations (UN) Comtrade database . The harIn the reporting scheme of the UN Comtrade database, the reporters—countries or territories that report the trade data—and trading partners are countries in most cases. In some cases, however, they represent other types of territories . The data used in mapping the flows of plastic waste between territories and regions were the import data reported by the trading territories. It is believed that import data are more accurate than export data , becauseTo analyze the flows of plastic waste among different types of countries and territories, including the flow from developed to developing countries as emphasized in the EUE literature and GVC/GPN approaches to international waste trade, we adopted the delineation of countries and territories in the Basel Convention .To visualize the evolving patterns of the global trade in plastic waste, we employed an approach similar to what was used in the work by Lepawsky ,65. GephChina has been one of the most important players in the international trade of plastic waste for over two decades. The country introduced a strict ban on waste imports, including waste plastics, with a far-reaching impact globally. In In this section, we first provide a general overview of the global trade in plastic waste in relation to the global production of primary plastic. We then reveal China’s role in the international waste trade by applying the notion of value and demonstrating the relative, spatial, and dynamic nature of the concept. The last part of the analysis reports the spatial patterns of international transboundary flows of plastic waste during 1996–2019. The main findings that emerge from the analysis lead us to reexamine some stylized forms of thinking, such as the core–periphery dichotomy inherent in the world systems theory and its application .Throughout the 1980s, plastic recycling was mainly limited in a small number of developed nations in North America and western Europe, before it became more commonplace in the 1990s. As a result, there was a very limited trade in plastic waste in the 1980s. The UN Comtrade data show that in 1988, the total volume (import plus export) of the global trade in plastic waste was less than 0.32 million tons, with a total trade value of USD 149 million. After a steady growth in the 1990s, the global trade in plastic waste skyrocketed in the 2000s. In two decades, the plastic waste trade became a large and lucrative business. From 2001 to 2011, the trade volume on average increased by almost 12% annually, while the trade value increased by 19% each year . The totIn the 1990s, Hong Kong, a former British colony that was returned to China as a special administrative region (SAR) in 1997, was the leading importer of plastic waste in the world. In 2000, China  became the largest importer and retained that position until 2017, with Hong Kong SAR being the second largest. Other major importers that made to the “top five” list most frequently included the USA, the Netherlands, Belgium, Denmark, and Canada. However, compared to mainland China and Hong Kong SAR, the number of imports by these countries was significantly smaller. In recent years, industrializing economies in Asia, such as India, Malaysia, and Thailand, have seen an increase in their import of plastic waste. Malaysia emerged as the largest importer in 2018 after China imposed a ban on importing plastic and other solid waste. From the early 1990s to 2017 (except for 2013), Hong Kong was the largest exporter of plastic waste, but it had largely served as a “collector” of plastic waste from around the world and reexported much of its massive imports to mainland China. Other major exporters of plastic waste on the global market included the USA, Japan, the Netherlands, Germany, France, the UK, and Belgium. It is worth nothing that for some large high-income economies, such as the USA, Japan, Germany, France, the UK, and others, their export data appear to be underreported. If we consider the sum of all other countries’ imports from a country as a reasonable estimate of the country’s actual export, for these high-income countries, their reported export numbers appeared to be significantly smaller than their actual exports, varying from 90% to less than 30% depending on the year of the reporting. As Lepawsky (2015) explained, a trading territory tends to be more careful about what is imported into its borders than what is exported out  .In order to understand the evolution and changing geography of the international trade in plastic waste, special attention needs to be paid to China, which has been one of the most important players in the international trade of waste (including plastic waste) for over two decades. After emerging as a major importer in the 1990s and rising to the top importer in 2000, China’s import volume of plastic waste increased by 14.6% annually during 2002–2012, while its import value increased by 28% each year. During 2006–2016, China alone imported about a half of the world’s plastic waste. Indeed, in line with the EUE theory, the country became a global dumping ground or waste sink. That said, this status was more or less self-imposed. Beginning in the 1990s, the demand for raw materials in China exploded to fuel the rapid economic growth. A continuous massive inflow of rural migrants into cities and towns provided cheap labor for the labor-intensive recycling industry, which in return created millions of jobs in cities. Many “plastic villages” sprung up, most of which are located near cities, building their economy almost entirely on recycling plastic waste. The plastic recycling industry became a highly lucrative business. By 2017, the plastic recycling sector was valued at CNY 108.1 billion (about USD 15.8 billion), only after the iron and steel recycling and non-ferrous metal recycling sectors . The hugChina’s example also illustrates that value is also a dynamic concept as it changes over time and with circumstances. The country’s seemingly insatiable appetite for imported plastic waste has dwindled in recent years. Plastic scarps imported into China for recycling, often mixed with other waste and hazardous elements including medical waste, are usually collected in open dumping grounds or landfills. Much of the plastic waste treatment takes place in the informal sector. Due to lack of oversight, workers are exposed to hazardous materials and toxic air. The plastic scraps collected from landfills require a large amount of water to clean, which are often processed in primitive, family-owned, or other small workshops with no facilities to treat wastewater before it is discharged into local rivers and streams. Recycling only makes a small dent in the amount of plastic waste generated each year. While some is incinerated or goes to landfills, a large amount is left at open dumping sites and washed to the surrounding environment or burned on the site, causing severe pollution to the land, water, and air. Citing these environmental and health concerns, China launched the National Sword campaign in 2017, implementing an outright ban of 24 categories of solid waste including tires, textiles, plastic, and glass (unless recyclables were at least 99.5 percent pure) and limiting the importation of other waste, which started in 2018.In addition to the widely cited environmental and health concerns, a less examined factor for China’s changing attitude toward scrap imports might have to do with economics. Over time, China has greatly expanded its plastic production capacity. For over two decades during 1996–2017, the production of primary plastic averaged an annual growth of nearly 14%  As a resTaken together, China’s regulatory shift of in its waste import policy was likely a result of a combination of environmental concerns and economic considerations. Even though most of the waste and scraps feeding China’s massive and inadequately regulated recycling industry comes from domestic sources, restricting waste imports understandably was a first easy step to take. Plastic scraps, largely treated as valueless waste in developed countries but once regarded as valuable resources in China, are being rejected in the country due to their diminished value. It is worth pointing out, though, that China is not unique or the only case of this. Plastic waste imports by India, for example, increased by more than 9 times during 1996–2013. From 2014, the country’s import started to level off and decline. Following China, India started to ban the import of plastic waste from August 2019. Other countries in Southeast Asia, such as Malaysia, the Philippines, and Thailand, are following a similar path. After increased import for years, especially after becoming the new hotspot destinations in the last two years for western countries to reroute their export of plastic waste, these countries have seen the massive inflow of plastic waste and scraps that are beyond their needs, overwhelming their environment. Therefore, they are reportedly sending an increasing number of shipping containers back to their countries of origin.By examining the flows of plastic waste between and within Annex VII and non-Annex VII territories, several observations can be drawn . First, The visualization of the plastic waste flow offers several snapshots of the global plastic waste trade for the period 1996–2019 . While these EU countries increased their export to China, Hong Kong SAR, and other Asian economies , much of their remaining trade still took place within the EU. By contrast, for the USA and Japan, their top recipients included China, Hong Kong SAR, and their respective neighbors . Both of them also shipped a substantial amount of plastic waste to other Asian countries including Malaysia, Thailand, Vietnam, Indonesia, and the Philippines.The 2019 trade network looks drastically different from previous years, as China’s ban on plastic waste imports indeed became a game changer. Although large flows into China vanished, the country remained visible on the map, as it still received imports from a fairly large number of trading partners . Hong Kong SAR’s imports also declined significantly, and it reexported much of its imports to Southeast Asian countries . Malaysia and Thailand became the top two receivers, with major flows from the USA, Japan, Hong Kong SAR, the UK, and Germany. The imports by Turkey, India, Indonesia, and Vietnam also increased substantially. For Indonesia, one interesting finding was that the small island state the Marshall Islands became the country’s largest supplier. As for the global sources, the volume of trade decreased for almost all the trading territories. Except for Hong Kong SAR, all the top ten exporters were Annex VII members. For major EU countries, trading within the EU remained a very large part of their trade.Does global waste trade represent toxic colonialism? An impeccable search for new value? Or a plausible move toward sustainability? Unfortunately, there does not appear to be a simple “yes” or “no” answer to these questions. Indeed, with a large volume of plastic waste  flowing from developed to developing nations, the main challenge of international environmental injustice has not changed. Nevertheless, unlike before, when poor nations accepted hazardous waste from rich countries in exchange for much needed foreign currency, entrepreneurs in developing countries are now actively buying plastic waste (and many other types of waste) for recycling business to make profit. The economic logic behind dumping waste in lowest-wage countries, which used to be considered “impeccable” for high-income countries , also beOver time, however, the transboundary trade in plastic waste has exacerbated pollution and marine litter in some major receiving countries where solid waste mismanagement is a challenging issue. Facing mounting environmental challenges, many developing countries no longer see waste as a resource or revenue-generator. After China banned the imports of foreign waste, many developing counties have started to introduce restrictions or bans out of similar environmental concerns. Southeast Asian countries such as Malaysia, the Philippines, and Indonesia have already started sending waste shipments back where they came from. The PIC procedure in international agreements and recent amendments to the Basel Convention will empower them to reject illicit or unwanted inflows of plastic.Given the changing circumstances, the global plastic waste trade will likely continue to decline. There are increasing calls from environmental organizations and the media for there to be a ban on the transboundary trade in plastic waste. If in place, a ban on the international plastic waste trade will help alleviate pollution and health concerns in some developing counties. It will also likely lead to an increase in the production of virgin plastics in developing countries, which will also cause much more used plastics to end up in landfills or the natural environment in developed countries.In the long run, the CE needs to be considered as a solution for resource scarcity, waste management and pollution control, and sustaining economic growth. Recent discussions of the CE point to the 3R approach—reduce, reuse, and recycle—that needs to be adopted to tackle the plastic pollution crisis and achieve sustainable development. To way to address plastic pollution, first and foremost, is to limit the amount of plastic produced and reduce an individual’s or society’s use of plastic products. Policy makers at different levels should reckon with building impactful public policy that is conducive to conservation. An increasing number of countries, territories, and localities are taking actions to ban or tax the use of disposable or single-use plastic products, such as plastic bags, plastic straws, and non-recyclable single-use plastic containers. This should be adopted as a universal ban. There is also a need for policy interventions focusing on the production (manufacturing and packaging) processes that produce or use plastic materials. The OECD recommends that countries tax the use of virgin plastics and reform the support for the production and consumption of fossil fuels .Recycling and reusing, facilitated by trade, are important in reducing waste, curbing the demand for virgin plastics, and making a more efficient use of resources. Countries and localities need to expand or upgrade their recycling capacities to better recover the value and reduce litter and pollution. While the insufficient sorting and collection of infrastructure is often cited as a contributor to plastic waste accumulation and pollution in developing regions, it is causing the low availability of sorted waste to reach recyclers in developed regions like the EU . The traThe future of the global plastic waste trade lies in a tighter regulation and a better enforcement, as well as a closer cooperation among countries. The Basel Convention needs to develop clear mechanisms for the enforcement of the PIC procedure. To effectively regulate the exports and imports of plastic waste and scraps, countries party to the Basel Convention need to transform the provisions of the Basel Convention into national law . In 2021, the European Commission proposed new rules about the transport of waste, including plastic waste, to ensure that the EU does not export waste that is difficult or too expensive to recycle, tackling waste trafficking more effectively by ensuring that it only exports what is permitted if the recipient countries can guarantee that the waste will be processed responsibly . Other pThis paper has examined the changing geography of the global trade in plastic waste. The research reveals that the transboundary trade in plastic waste has grown significantly and become increasingly complex over time. For over two decades, China was the single largest receiver until very recently. Hong Kong SAR was another extremely important player, playing a “middleman” role between mainland China and the rest of the world. China’s ban on plastic waste imports has led to a redrawing of the map of global trade, with Hong Kong SAR’s role and trade status being greatly influenced, and more trade flows being directed to countries in Southeast Asia, South Asia, and Turkey . Developed nations including the USA, Japan, Germany, the Netherlands, France, the UK, Belgium, Italy, etc., have been the largest exporters of plastic waste. Among them, for European countries, intra-EU trade flows accounted for a large part of their total trade.The findings of the paper debunk the North–South or core–periphery dichotomy that is embedded in the GEJ tradition (including the EUE theory), as well as in international environmental regulatory regimes such as the Basel Convention. The movement of plastic waste from Annex VII to non-Annex VII territories has been the largest flow, but trade flows of other directions , which have often been overlooked in the EUE literature and other GEJ traditions, turned out to be significant. There is a small but growing flow of plastic waste from non-Annex VII to Annex VII territories. These findings call into question the grouping of countries into Annex VII and non-Annex VII signatories in the Basel Convention as well as the primary goal of the Ban Amendment to restrict the waste flow from the former to the latter.The paper contributes to the discussions about value that are central in political economic approaches to global trade by demonstrating the relative, spatial, and dynamic nature of the concept. Value is a relative concept in the sense that waste means different things in different countries and carries different weights in their economies. Post-consumer-used plastics, especially when mixed with other waste, are largely considered to be valueless, recalcitrant waste in developed countries due to the high labor and environmental costs associated with their recovery and reuse. In some newly industrializing economies where there is a booming recycling industry and an ever-increasing need for resources, plastic waste and scraps becomes a profitable commodity and valuable feedstock. Related to the relativeness of value is the spatiality of the concept. The interest and ability to recover value from used things is geographically uneven. It is that spatiality, or geographically differentiated ability, that enables and drives the global plastic waste trade network to operate. Meanwhile, we must not forget about the temporal and dynamic nature of value. The value of waste and scraps changes over time. It could also change when the country’s domestic circumstances change.


A healthy society is the foundation of development in every country, and one way to achieve a healthy society is to promote healthy nutrition. An unbalanced diet is one of the leading causes of noncommunicable diseases globally. If food was correctly selected and correctly consumed, both the problems of overeating and lack of nutrition could be largely solved while also decreasing public health costs. Interventions such as presenting necessary information and warning labels would help consumers make better food choices. Hence, providing nutritional information to consumers becomes essential. The present study investigates the importance of nutrition information labels on consumers’ preferences by estimating their willingness to pay for features and information provided by a dietary software program (app). An application can easily display the information to the consumers and help them make informed food choices. A discrete choice experiment investigated consumers’ preferences and willingness to pay to receive nutritional information. Mixed multinomial logit and latent class analysis were applied. The results showed the existence of heterogeneity in consumer preferences for different nutritional information provided by the application. Consumers are willing to pay more for salt and fat alerts. The results of this study allow for the analysis of consumers’ interest in nutritional information. Such results are essential for the industry for future investments in similar applications that potentially could help consumers make better informed choices. According to the World Health Organization , noncommMost early deaths are related to well-known risk factors, such as an unhealthy diet, harmful use of tobacco and alcohol, and lack of physical activity . DietaryNumerous factors affect consumers’ food choices ; among tAlthough the information on the food package is simple, consumers seem to use such information less than one might expect . BecauseTime pressure and cognitive limitations are significant constraints in using and understanding label information in real shopping scenarios. Consumers are not willing to consider the health labels, especially when constrained by time . GrunertUsing interpretation guides, such as software programs (or applications–apps) and keeping a tally of nutritional information on food products while shopping could help consumers to make more conscious choices ,14,18. TAccording to the literature, food labelling, by providing relevant information to consumers, has a significant role in healthy food choices . Front OConsumers consider nutrition labels essential in evaluating the product . HoweverIn addition, background knowledge is needed to understand the information on the nutritional labels ,27. Low A possible efficient solution to all the mentioned issues is using technology; usability is of paramount relevance here . In otheThis information could also be sold based on the subscription method. Several economic factors explain the existence of subscriptions. First, subscriptions can reduce transaction costs. In other words, several products can be exchanged only once and not every time the product is supplied and used. Second, the risk of price change is less for the consumer, although the seller may encounter uncertainty about future prices. However, the payment in advance is a premium for running that risk. Finally, subscriptions can lower market uncertainty by fixing the number of products sold. Subscriptions allow sellers to segment buyers into groups with demand elasticities and thus permit price discrimination, which can benefit both producers and social welfare, so long as the marginal cost of production is positive. There are no binding capacity constraints .Another critical issue in using the app is the information provision format. Previous studies presented and analysed two main label formats: the Guideline Daily Amount (GDA) and Traffic Light System (TLS). The GDA shows nutritional information numerically and positively influences healthy food choices . The TLSHowever, the information provision format plays a crucial role in forming the consumers’ perspective toward the nutritional information provision. Consumers like nutritional labels with nice colours, symbols, and easy-to-understand information, whether graphically or numerically . In a stAnother factor influencing consumers informed food choice is the difference between displaying food information for every single product in the shopping basket or the total number of items in an aggregate basket. The limited number of studies on this issue have found that consumers prefer to process each product’s information individually rather than obtain aggregate information for the total basket ,14. HoweA Discrete Choice Experiment (DCE) is a survey-based methodology widely used to model consumers’ preferences . Accordii by the individual n is represented as the sum of two utility components, a systematic component .nμ represents an individual-specific scale parameter Furthermore, due to the impossibility of direct interpretation of coefficients in the preference space, the willingness to pay was also calculated. As the ML models accounts for the heterogeneity of preferences, the WTP was directly estimated in the WTP-space which allows to interpret coefficients of attributes and compare them with each other in and easier way, while providing more reasonable distributions :(3)Uni=αi is:c is the vector of class c associated with a segment-specific vector of coefficients, while ni|cε follows a Gumbel distribution.Although the ML models consider variety in preferences, the source of the heterogeneity of tastes is unknown. Moreover, their specification requires an a priori assumption for the β distribution. These limitations can be overcome with the latent class (LC) models ,50, provi for each segment c is:The class membership of the individuals is a priori unknown to the analyst, as it depends on the observable attributes and the latent unobservable components . The optThe WTP for each attribute was estimated for each segment. The WTP was calculated as the price change related to a unit increment un a specific attribute in that segment:A new digital mobile application that helps consumers make informed food choices during grocery shopping was selected for the analysis. It can provide consumers with personalised information on potential unhealthy components  in the food products. A warning on possible allergies is also available. This information can be provided individually or as a basket for all products simultaneously. Moreover, the information can be displayed using a TLS or GDA. The service has a price in local currency, which varies according to the affiliation program . Hence, seven attributes were selected based on previous literature: basket ,14,53, fThe data were gathered through personal interviews between August and September 2019 in Sari, the capital of Mazandaran (Iran). A convenient sample in the province of Mazandaran was selected given the predominance of nutritional-related diseases. In Mazandaran, the leading cause of death is cardiovascular disease. Moreover, Mazandaran presents the higher levels of obesity prevalence in all of Iran and is among the top five provinces regarding the prevalence of hyperlipidaemia and hypertension .The individuals included in the study were over 18 years old, currently living in Sari and had an income or could use the household income for food expenses. For the sample collection, three leading chain supermarkets were selected during quiet hours of the department store (excluding Thursdays and Fridays), so the respondents would not get distracted. Customers and staff present at the moment of the study were randomly recruited. Out of the 207 distributed questionnaires, three incomplete questionnaires were excluded. The final sample included 204 questionnaires.The questionnaire was developed in English on the Qualtrics platform. Then, it was translated and back-translated to Farsi . Close cGiven the seven attributes and their levels, 384 (25 × 3 × 4) possible alternatives could be created. The number of combinations was reduced to obtain a more reliable and statistically efficient design. A fractional factorial design of 12 unlabelled choice sets was developed employing a D-efficient design in the Ngene software (D-error = 0.35 and A-error = 0.40). Each respondent was presented with 12 choice sets with two alternatives and a “no choice” option in case the respondents would prefer not to choose either the application services. All choice sets and alternatives were presented in a randomised order to avoid any bias .Before the choice experiment, participants were introduced to the purpose of the research. Then, the respondents were presented with a list of products, in their local language, based on the criteria of “optimal food basket for Iranian households” introduced by the Ministry of Health, Treatment and Medical Training of Iran . The lisIndividuals were asked to imagine they were in a store and choose the groceries they usually buy during their shopping trip to simulate purchasing decision-making. The participants could choose as many products as they wanted. The weight/volume of each product was specified . The objThen, the respondents were introduced to the diet application. The participants were told that a new diet application was being launched to aid customers in making healthier food choices. The service would allow them to keep a tally of the main nutritional components of the food they purchase, as well as the presence of specific harmful substances for them . Therefore, the application would display in an easy-to-read format the nutritional information by scanning the bar code of the selected product. All attributes of the application and the attributes’ levels were presented and thoroughly described to inform participants equally. Participants could also request help or ask for clarifications to the interviewer present at the moment of the development of the study. An example of a choice set  was alsoIn the DCE, participants were asked to select the alternative with the features they would like the most for the healthy application at the given price and payment method. All alternatives were simultaneously presented as in the example in The data were analysed through the APOLLO package in R . An MNL 2), indicating that people in the sample suffered from being overweight [The characteristics of the sample are shown in erweight .Regarding the results of the ML Additionally, the coefficients of salt alert, fat alert, and allergy alert were positive and statistically significant, indicating that consumers in Sari would like to know whether their chosen products have a high intake of fat and salt in compared to not having such information (reference level). They also preferred to be informed about the products that could cause them food allergies compared to not having such informationRegarding payment frequency, respondents prefer a quarterly payment over a monthly payment (reference level). However, a monthly payment was preferred over a yearly one. The price coefficient was significant and negative, which means that participants preferred to pay less. Dispersion parameters (standard deviation estimates) were statistically significant, exhibiting heterogeneous preferences for all attributes.Based on the Mixed Multinomial Logit (ML) results in the willingness to pay space in Most of the standard deviation estimates for the WTP model were significant, indicating a great variety among consumers’ preferences for these attributes. However, the standard deviation estimate for the format coefficient was not significant, meaning that there was no heterogeneity among respondents regarding their willingness to pay for this attribute. In general, respondents are not willing to pay to get their nutritional information in the TLS format over the GDA, and this is quite a homogeneous result across the sample.A latent class model was estimated to investigate the source of such heterogeneity in consumer behaviour. The number of classes was based on the model with the lower BIC (3281.51) and the best interpretability. Thus, participants were divided into two groups with different behavioural characteristics. Accordingly, 14% of consumers belonged to class one and 86% to class two. The result of the model is reported in Results of the latent class model showed significant differences between the two classes. The respondents in class 1 were indifferent to receiving the information for each product or as a basked. Moreover, the format was negative and statistically significant, demonstrating consumers’ preference for GDA rather than TLS. The coefficients of the salt and fat alerts were positive and statistically significant, indicating the preferences of the consumers to receive the alerts related to the prevention of health issues. The allergy alert estimate was only significant at 10%. In this class, the quarterly and annual payments coefficients were negative and statistically significant, indicating the respondents’ preferences for a monthly subscription over a quarterly and annual subscription. The coefficient of the price was negative as expected and statistically significant.In contrast to class 1, in class 2, the basket attribute was significant, which indicated that people in this class preferred that the diet app presents nutritional information for each product separately rather than for the entire basket. The influence of format attributes on consumer preference was not statistically significant in class 2. Moreover, salt alert, fat alert, and allergies alert were positive and statistically significant. Unlike in class 1, the payment attributes were not statistically significant. Participants were indifferent to monthly, quarterly, and annual subscriptions. The coefficient of the price in this class was also negative, as expected.In summary, although the salt alert and fat alert coefficients were higher in class 1 compared with class 2, the willingness to pay for the salt alert and fat alert in class 2 was larger than in class 1. Similarly, the willingness to pay for the allergy alert was higher in class 2 than in class 1. While the consumers in class 1 had clear preferences for the format (GDA) and the payment frequency (monthly), consumers in class 2 were indifferent to these attributes. On the other hand, participants in class 2 preferred to receive information for each product, while participants in class 1 did not have any specific preference for it. In addition, the ASC was positive and significant, indicating positive preferences for using the application.The present study uses a discrete choice experiment to investigate consumers’ preferences and WTP for receiving nutritional information provided by a dietary application during grocery shopping. The findings from the ML model indicate heterogeneity in consumer preferences for the different attributes of the app. The aggregated results from the ML and the latent class models showed that participants were willing to pay for customised information at the point of the purchase. This result is consistent with previous literature ,14, whicMoreover, considering both models’ positivity and the significance of salt and fat alert coefficients, respondents are willing to pay for information that helps them make informed and healthier food choices. In this regard, it is recommended that the food industry in Iran insert alerts  on food packaging, similar to the action taken by the tobacco industry.In addition, the ML and latent class models results inferred that most participants preferred to receive the customised information from the application for each product individually, rather than for the whole basket as aggregated information. In other words, individuals, similarly to previous findings , prefer The result of the ML indicated that consumers were indifferent about the format of the nutritional information. However, the latent class analysis showed that the smallest of the resulting classes (14%) preferred nutritional information displayed in Guideline Daily Amount rather than the Traffic Light System. Although this finding is in line with previous research , the resThe results of the ML also indicated the existence of a strong preference for monthly payments rather than yearly. Consumers are unwilling to undertake a long-time commitment . MoreoveIn general, the results of the present paper contribute to the literature in two ways. First, to the authors’ best knowledge, there are no previous studies on the WTP of Iranian consumers for features of an app that could help them make a more informed decision ,14,18. SIn this study, a DCE was developed and analysed to examine the effect of a diet app, which included the characteristics of the basket, format, salt alert, fat alert, allergy alert, payment, and price on consumers’ preferences and their willingness to pay in Sari, Iran.Our findings provide new insights into consumers’ preferences for the nutritional information provided by the application as an effective tool in helping consumers to make conscious choices during their shopping experience. In this regard, policymakers could benefit from our results by encouraging the implementation of diverse systems  that assist consumers in making an informed decision during their grocery shopping. Meanwhile, future research should also explore how to effectively deliver this information to the consumers, studying the diverse tools that could be used for this purpose , how to frame the messages effectively, as well as consumer acceptability.Policymakers should also promote campaigns that increase consumers knowledge regarding the presence or lack of nutrients in certain foods. This could collaborate in reducing the incidence of non-communicable diseases by encouraging more conscious food choices. Such a process should also motivate the food industry to increase sales by changing food formulation to low-salt and low-fat productsThe present study also presents some limitations. First, the study includes a convenient sample of 204 people living in Sari, the capital of Mazandaran (Iran). Although the geographical area of the study was chosen on purpose given the predominance of nutritional-related diseases in the area , the resSecond, the present results are based on a hypothetical market, which means that the hypothetical bias may arise . Respond


Cardiovascular disease remains an integral field on which new research in both the biomedical and technological fields is based, as it remains the leading cause of mortality and morbidity worldwide. However, despite the progress of cardiac imaging techniques, the heart remains a challenging organ to study. Artificial intelligence (AI) has emerged as one of the major innovations in the field of diagnostic imaging, with a dramatic impact on cardiovascular magnetic resonance imaging (CMR). AI will be increasingly present in the medical world, with strong potential for greater diagnostic efficiency and accuracy. Regarding the use of AI in image acquisition and reconstruction, the main role was to reduce the time of image acquisition and analysis, one of the biggest challenges concerning magnetic resonance; moreover, it has been seen to play a role in the automatic correction of artifacts. The use of these techniques in image segmentation has allowed automatic and accurate quantification of the volumes and masses of the left and right ventricles, with occasional need for manual correction. Furthermore, AI can be a useful tool to directly help the clinician in the diagnosis and derivation of prognostic information of cardiovascular diseases. This review addresses the applications and future prospects of AI in CMR imaging, from image acquisition and reconstruction to image segmentation, tissue characterization, diagnostic evaluation, and prognostication. Cardiovascular disease remains an integral field on which new research in both the biomedical and technological fields is based, as it remains the leading cause of mortality and morbidity worldwide . DespiteArtificial intelligence is the aim to develop computers with human intelligence ,16. MachML algorithms can be subdivided into supervised, unsupervised, and reinforced learning ,21. In sLogistic regression is a supervised machine learning technique. It is based on the use of the logistic function (sigmoid), which converts real values to a value between 0 and 1. In the training phase, the algorithm receives a training dataset consisting of N examples. Each example consists of attributes X and a label Y indicating the correct classification. At the end of the training, the algorithm produces a model that can be used to classify any other example not included in the training set. Support vector machines (SVMs) are supervised ML models segregating the data into two or more classes, obtaining a linear, binary, nonprobabilistic classifier. An SVM model is a representation of the examples as points in space, mapped in such a way that the examples belonging to the two different categories are separated by as large a space as possible. New examples are then mapped in the same space, and the prediction of the category to which they belong is made based on the side in which they fall. In addition to linear classification, it is possible to make use of SVMs to effectively carry out nonlinear classification using the kernel method by implicitly mapping their inputs into a multidimensional characteristics space.The random forest (RF) method is an ensemble learning method for classification, a regression that operates by building a multitude of decision trees during training. For classification activities, the random forest output is the class selected by most trees. For regression activities, the mean or mean forecast of the individual trees is returned. Cluster analysis finds subgroups within the input data in an unsupervised manner. Clustering algorithms group elements based on their mutual distance, and therefore, whether or not they belong to a set depends on how far the element under consideration is from the set itself.Artificial neural network (ANN) is a computational model composed of artificial “neurons”, vaguely inspired by the simplification of a biological neural network, determined by the propagation of input data through a nonlinear transformation network. Convolutional neural networks (CNN) are the backbone of DL applications. A convolutional neural network is a type of feed-forward artificial neural network in which the connectivity pattern between neurons is inspired by the organization of the animal visual cortex, the individual neurons in which are arranged in such a way as to respond to the overlapping regions that tessellate the visual field.Input layer: the input layer is used to take input data from sources and then pass it to the hidden layers of the neural network. It does not perform any calculations.Hidden level: this level consists of many hidden levels. All the calculation is performed at this level. After all the calculations are complete, it proceeds to the output level.Output level: this level is used to provide the output to the outside world.Deep learning (DL) evolved from ML . It workMachine learning will have an impact on all aspects of CMR, from patient programming to image analysis and prognosis. Optimal CMR imaging requires correct patient positioning and precise image planning . The acqSeveral AI solutions have been proposed by different vendors in terms of image acquisition and reconstruction  31,32].,32.31,32Automatic slice positioning was one of the first applications of AI during image acquisition . Frick eImprovement of image quality has been developed by several vendors by decreasing the noise of pictures . The “DeAIR Recon DL reconstruction is another technique that is able to increase signal-to-noise ratio, reduce truncation artifacts, and increase spatial resolution compared with standard reconstruction . Using tCine images in CMR result from a compromise between temporal and spatial resolution; in particular, decreased time of acquisition may cause image quality impairment . HoweverThe delineation of the contours of the heart chambers and myocardium (segmentation) is the first step in the processing of CMR images  50], as, as50], Romaguera et al. used a CNN for segmentation of short-axis CMR images, while Bernard et al. showed how using ML methods in segmentation could give accurate results ,54. AutoBai et al. showed that an automatic method based on the use of DL in the process of segmentation and measurement of quantitative parameters in CMR imaging presented a performance equal to that of human experience . SimilarML methods have been applied for the automatic quantification of LGE, overcoming the limits related to its irregular and multifocal appearance, the variation of gadolinium kinetics, and the variability among different centers in regard to accuracy and reproducibility  59,60,66,67. ML ML can help physicians in the accurate and early image-based diagnosis of cardiovascular disease. Several papers have used conventional imaging indices as input data to diagnose various heart diseases such as HCM, DCM, MI, and ARVC .Machine learning methods offer simplification and acceleration of the diagnostic path of MI and are useful as a guide for treatment strategies . BaessleMachine learning is an excellent method that allows for the differentiation of various cardiomyopathies . GopalakHeart failure (HF) is a clinical syndrome due to a structural and/or functional abnormality of the heart that results in elevated intracardiac pressures and/or inadequate cardiac output at rest and/or during exercise. Because of the progressive aging of the general population, heart failure has assumed an increasingly relevant epidemiological problem and currently represents the cardiovascular disease with the greatest increase in incidence. Baessler et al. applied texture analysis on cardiac MRI T1 and T2 mapping and obtained quantitative imaging parameters for the diagnosis of acute or chronic heart failure . Moreno Machine learning facilitates postprocessing and image analysis for the characterization of wall motion . MantillCardiac magnetic resonance has demonstrated the ability to prognosticate various cardiovascular conditions ,96,97,98Although machine learning methods have proven effective and have been validated, there are practical difficulties in implementing them in the clinical setting for several reasons, including data quality. Homogenization of clinical data and imaging protocols from different centers is an essential element to check before using datasets as input into a standard ML model. In addition, since clinical data add critical information to images, it is essential to integrate clinical data in electronic medical records to the imaging dataset. Cost is another critical issue, as substantial investment would be required to develop more complex ML methods. Although DL has shown promising results for image processing in the context of high-dimensional datasets and supported by the possibility of real-time reconstruction, in the use of powerful computational algorithms, additional limitations must be recognized. The lack of large, publicly available CMR datasets that can be used to objectively compare different algorithms; the lack of generalization capabilities when previously unseen samples are presented; the difficulties with rare diseases ; and the “black-box” nature of DL algorithms, in that it is often unclear what information is used to arrive at a particular classification or result, represent just a few of the real limitations of this intriguing technique.In this review, we report the use of ML in all aspects of CMR, from the acquisition and reconstruction of images to the derivation of prognostic information. Despite the significant advances described above, there is a need for controlled prospective clinical trials in which ML techniques are compared with human evaluation of magnetic resonance datasets to establish the effectiveness of such methods in clinical practice. The algorithms must be validated using other cohorts besides that under consideration, including data coming from different centers and from different acquisition devices. Furthermore, to compare the performance of different algorithms, it would be important to evaluate the efficiency of each algorithm on a common dataset. Finally, to enable progress in this field, publicly accessible software would be required to allow other groups to run, study, modify, and thus improve software and monitor potential bias in the algorithm . An inevThe advancement of techniques in the field of AI can be attributed both to the fact that AI is able to manage high-dimensional data, integrating information from multiple fields, and to the increasing availability of data through mobile applications and data transformation from the healthcare system into digital form. However, the applicability of these approaches in cardiovascular applications remains limited because of the intrinsic peculiarities of cardiac imaging, studies based on small samples that involve a risk of overfitting, and the lack of interoperability of many systems used. However, the use of AI in cardiovascular medicine could pave the way towards better diagnosis and precision medicine and revolutionize the monitoring and treatment of individual diseases.