Chronic kidney disease (CKD) is one of the most prevalent national health problems in the United States. According to the Center for Disease Control and Prevention (CDC), as of 2019, 37 million of the US’s adult population have been estimated to have CKD. In this respect, health disparities are major national concerns regarding the treatments for patients with CKD nationwide. The disparities observed in the healthcare interventions for patients with this disease usually indicate some significant healthcare gaps in the national public health system. However, there is a need for immediate intervention to improve the present healthcare conditions of minorities experiencing CKD nationwide. In this research, the application of system dynamics modeling is proposed to model the CKD progression and health disparities. This process is based on the health interventions administered to minorities experiencing CKD. The graphical results from the model show that there are relationships among the dynamic factors influencing the incidence and prevalence of CKD. Hence, healthcare disparities are inherent challenges in the treatment and management of this disease. Chronic kidney disease (CKD) is a prevalent global and national health concern, affecting people from all backgrounds, ethnicities/races, and genders in the United States. It is an irreversible and progressive disease that results from the kidneys’ inability to filter blood and adequately eliminate wastes and poisons.There are five stages of kidney disease. The eGFR (estimated Glomerular Filtration Rate) is generally used to determine the stage of the disease. As the kidney stage progresses, the eGFR number decreases .CKD starts with undiagnosed kidney damage and develops into complete kidney failure, end-stage renal disease (ESRD). At this stage, the individual involved will require a total kidney transplant or replacement for survival . Often, The study dives deep into the root causes of CKD and its different challenges present in the minority-populated communities using system dynamics to model, simulate, and visualize the possible healthcare disparities involved. In addition, the system dynamics modeling tools are utilized to analyze the causes and impacts of the various CKD risk factors involved. A simulation of the system dynamics model design is performed in different run tests and scenarios. This research employs a systems engineering application to address the complexities of CKD incidence, prevalence, and the health disparities involved in the treatment interventions, specifically in the state of Tennessee.Furthermore, mathematical equations of the variables that represent the non-linear (dynamic) relationships and the nature of the CKD risk factors, and their connections are developed using system dynamics modeling.The health of different cultures and societies can vary dramatically, and specific populations may have higher disease rates than others. As discussed earlier, inequalities in health or medical issues can substantially impact a community’s public health. Moreover, CKD health disparities represent the disproportionate outcome of the affected populations’ treatment, particularly the minority communities. At the same time, CKD is the outcome of a complex interaction of genetic and environmental factors, which adversely affect the lifestyle and wellbeing of humans.CKD is prevalent in its causes and effects on the minority populations in the US. Therefore, this section of the paper reviews the literature of the previous studies on the health disparities involved in the healthcare intervention for CKD patients in these minority populations. Because various interacting factors  are associated with the cause and incidence of CKD, it is necessary to delve deeply into the root causes of the disease.In the case of CKD care, primary care providers have considerable roles to play in educating individuals to identify the causes and symptoms of this disease early on. At the same time, creating awareness of known racial, economic, and ethnic disparities in CKD care can improve the healthcare intervention for the most vulnerable populations. A disproportionate number of Americans, mainly African Americans, die from CKD . The issJenna et al. suggested that CKD results from complex genetic  and environmental factors that reflect the balanced interaction of nature and nurture . Their rTo transparently address the incidence, prevalence, and healthcare in CKD, it is clinically and socially necessary to understand the basics and the sources of these health inequities by independently considering the patients’ lifestyle and the social determinants of health. We also need to address the bias on the side of the physicians and the healthcare system. To this end, this research study addresses the health disparities surrounding CKD by factoring in the vital variables involved in its occurrence and how these variables influence the disparities therein.Systems engineering and system dynamics have been applied to many areas within healthcare and sustainability ,33,34,35Generally, factors associated with the incidence of CKD are interrelated. These factors create dynamic and complex challenges that cannot be addressed at the surface using a conventional approach. Because these factors are interactive, analyzing them linearly to provide a possible panacea to CKD’s causes and health disparities would be tasking. For this reason, to proffer equal, fair, and considerable healthcare intervention for CKD patients across the board nationwide, it is necessary to carefully consider the root causes of CKD health disparities rather than addressing the after effect involved. Furthermore, to address the overburdened healthcare disparities associated with CKD in Tennessee, a systems engineering concept called the system dynamics modeling approach is employed in this research.System dynamics is a mathematical modeling technique that simulates, analyzes, and helps comprehend complex subjects, problems, and systems. It adopts causal loops (cause and effect relationships), stocks, flows, time delays, and feedback concepts to understand the non-linear characteristics of dynamic systems. It employs a real-time mathematical technique to present the policy-oriented results of events. It also observes how the feedback mechanisms of complex systems create or cause events around us. This concept of modeling was developed originally in the mid-nineteenth century, in the 1950s, at MIT by Jay W. Forrester  to addreThis section explains the methodology, design, simulation software, data collection, and study analysis for addressing CKD health disparities using system dynamics modeling. Because health disparity is prevalent in the nation’s healthcare system, it is necessary to find the root causes. Because CKD is irreversible, a well-planned healthcare intervention is needed to curtail its progression. As health disparities are inherently associated with CKD nationwide, this study focuses on Tennessee’s CKD healthcare disparities. Despite the Medicare, Medicaid, and Medigap health insurance plans provided by both the federal government and Tennessee, these health disparities are still prevalent in the state.The methodological approach adopted involves simulating various interactive factors involved in the CKD incidence, prevalence, and healthcare disparities. CKD has several risk factors associated with it, and these factors are complex and dynamic with interrelated characteristics. To understand the inequities in the care of patients with CKD, a dynamic modeling approach is appropriate. This study employs a systems engineering modeling concept called system dynamics modeling to simulate various instances associated with health disparities in CKD. This modeling concept creates graphs to illustrate the relationships that exist among the CKD factors. Hence, the results are analyzed based on the correlations to provide a proper CKD healthcare intervention for the minority communities in Tennessee. To do this, all the variables necessary in CKD care are utilized for transparency and policy decisions.The system dynamics modeling software used is Vensim PLE , which sThe causal loop model is a cause-and-effect tool used in system dynamics modeling to create interactive relationships between variables such as causes, events, and processes. It utilizes descriptive arrows to explain the balancing and reinforcing loops involved in events. This looping idea is essential to critically explain the causes and effects in complex situations that an ordinary linear approach cannot illustrate. A causal loop model is basically of two types: balancing loop (B) and reinforcing loop (R). A balancing loop is produced when a variable change (effect) is generated due to an opposite variable’s change (cause). While when a variable change (cause) in one direction results in more variable change (effect) in another direction, a reinforcing loop is generated. A positive sign (+) is assigned to the path of X to Y when a variable, Y (effect), moves in the same direction as a variable, X (cause). Additionally, when the variables move in opposite directions, a negative sign (−) is assigned to their path. The causal loop diagram approach is appropriate to illustrate the challenge with CKD care in Tennessee. As initially explained in the previous sections, there are factors associated with CKD incidence, prevalence, and management. CKD health disparities are better understood, considering the biological, environmental, and social factors involved.In this model, to describe the minority communities for better understanding, a single system dynamics stock is used to represent these communities .It is essential to have a clear grasp of how social determinants of health may affect kidney health. Many patients learn that they have chronic kidney condition after the disease has already advanced. The delayed diagnosis of kidney illness can be attributed to social determinants of health, such as inaccessibility to preventative care in one’s community or challenges in traveling to a physician’s office.The causal loop model in The social determinants of health play a vital role in the incidence of CKD because it is highly connected with risk factors associated with this disease. The influence of these social factors can necessitate the earlier incidence of the risk factors. People with risk factors for chronic kidney disease, such as diabetes mellitus, high blood pressure, poor dietary patterns, and unhealthy lifestyle patterns, are disproportionately represented in low-income communities and neighborhoods.To fully understand CKD’s root causes, impacts, and health disparities, it is crucial to view the relationships among the dynamic complex factors involved in its incidence and prevalence. System dynamics model can establish the relationships within these varying factors and shows the possible CKD healthcare disparities presented by the patients (populations), healthcare system, the primary care providers, and nephrologists. In this research, the system dynamics model displays vital graphs of the relationships and correlations with CKD health disparities. These graphs depict the implied interacting factors to establish possible healthcare disparities at every stage of CKD. The rate variables are on percentage rate units. All other stocks are kept at zero initial values except the population stock. Moreover, each rate variable is based on a percentage rate approximated to two decimal places to avoid model complications and variable overflow.In this model, some variables are used as stocks, while others as flows. Stocks are quantities or variables that can increase or decrease in value. At the same time, the term “flow” refers to the ability of an element or a variable to change over time.The system dynamics model employed in this research  involvesThis section explains the relationships among the varying factors associated with CKD, resulting from the system dynamics model in the previous section. The CKD incidence occurs due to the prevalence of the risk factors present in the general population, specifically the minority populations susceptible to CKD. As noted in various studies ,43,44,45This section interprets the results generated by the graphs in the system dynamics model using the modeled variables: CKD risk factors, the population at every stage, the nature of the treatment, bias, and the progression of CKD to different stages. Each of these variables are plotted against each other to initiate the desired results of the study. The following graphical illustrations show and explain the variations of the different biases that can exist at every stage of CKD and how these bias impacts can result in the progression of this disease. In the figures below, the primary care providers’ bias rates, which are part of the bias influence in CKD treatment at every stage, are plotted against the CKD progression to subsequent stages. In the following graphs, the base simulation of the model is displayed. Afterward, the current simulation presents the change in the results when one or two CKD factors are altered. The current simulation is based on the change in diabetes rate (0.80 to 1.15 Percentage Rate) and hypertension rate (0.80 to 1.25 Percentage Rate). To have proper simulations and graphical results, the current population of Tennessee, which is 6,910,840, according to the 2020 census , is enteHealthcare disparities can occur at every stage of CKD, from its incidence to its prevalence. At the earlier stages of CKD, especially at stages 1 and 2, most patients are asymptomatic, that is, they do not know they have this chronic condition. Any slight form of bias from the patients themselves, in the form of nonadherence to CKD care, or unmonitored CKD treatment by the primary care providers, the nephrologist, or even from the healthcare system, can trigger the prevalence and the progression of kidney disease at these earlier stages to further stages. Moreover, it is crucial to examine the inequities that might arise at stages 1 and 2.From At stage 2, the overall bias experienced is also from the bias in CKD treatment, which is in the form of bias from the patients, the primary care providers, and the healthcare system. The primary care provider’s bias toward unmonitored CKD at stage 2 influences CKD development to stage 3. The graph shows a change in CKD progression to stage 3 when the bias in CKD treatment in stage 2 is increased correspondingly. In this case, the primary care providers’ bias rate is changed from (0.08 to 1.55 Percentage Rate), giving rise to CKD progression in stage 3 to a value of  in 2022 from 0 in 2010.The primary care provider’s bias at CKD stage 3 in terms of unmonitored CKD treatment at this stage affects CKD progression to stage 4. The graph depicts a proportional increase in CKD progression to stage 4 when the bias in CKD treatment in stage 3 is changed. The bias rate, in this case, is increased from (0.16 to 1.32 Bias), giving rise to CKD progression in stage 4 to a value of  in 2022 from 0 in 2010.The progression of CKD to stage 5 is influenced by the bias initiated by the primary care provider in CKD stage 4. The graph shows a corresponding increase in CKD progression to stage 5 when the bias in CKD treatment in stage 4 is altered. The bias rate is changed from (0.073 to 1.151 Bias), giving rise to CKD progression in stage 5 to a value of  in 2022 from 0 in 2010.The CKD unmonitored treatment experienced by the patients in stage 5 impacts CKD progression to ESRD. This arose as a result of the bias involved in stage 5. The graph shows an increase in CKD progression to ESRD when the bias in CKD treatment in stage 5 is changed. The bias rate is changed from (0.152 to 0.275 Bias), giving rise to CKD progression in ESRD to a value of (1000 Progression) in 2022 from 0 in 2010.The death incidence occurred because of the bias involved at the ESRD stage. The graph shows an increase in CKD death incidence when the bias in CKD for dialysis and transplant is changed. The bias rate is changed from (0.33 to 0.72 Bias), giving rise to CKD death incidence of a value of (650 Incidence) in 2022 from 0 in 2010.Disparities in healthcare relate to the systematic inequalities that can be observed in the health status of various population groups. These disparities have significant consequences, both socially and economically, for individuals and society. Most patients from minority-populated areas, in one way or the other, usually experience some type of healthcare disparity. As previously mentioned, there are many agents involved in CKD healthcare treatment and management, and any form of healthcare disparities can advance the disease to ESRD, or even death.ESRD attracts more attention globally, and hence, it takes a large part of the medical allocation to kidney treatment nationwide. Therefore, more concerns are raised at this stage of CKD because the kidney often requires dialysis or transplant. As previously mentioned, in Tennessee, the minority populations bear the most burdens that come with ERSD. For this reason, this research addresses the challenges associated with the bias present in the management of this disease.According to the American Kidney Fund in Tennessee , 15,662 From the models, the use of the causal loop model is to investigate the sources of the disparities. What differentiates this study from other studies regarding health disparities in CKD is the system dynamics modeling involved that can present mathematical and numerical results of bias in different stages. Conclusively, the model generated graphical results that showed the effect of the disparities in CKD healthcare interventions in the minority communities. The simulation result graphs depict the trends required to ascertain the existence of bias in CKD.From the graphical illustrations and interpretations of the results, it is deduced that health disparities usually occur in the incidence of CKD and its progression. Often, these disparities are present inherently, whether intentionally or unknowingly, and their influences, most of the time, initiate the progression of CKD at every stage. Moreover, the CKD system dynamics simulation model can accommodate different bias rates presented by the patients, the primary care providers, the nephrologists, and the healthcare system by plotting various factors associated with bias in the incidence and progression of CKD. However, for the graphical illustrations in Furthermore, the varying values in Unlike other chronic diseases, CKD comes with overwhelming physical, mental, and financial burdens. In its earlier stages, most people are asymptomatic, not knowing they have it. It is becoming a global concern with rising incidence and prevalence. Often, if CKD is not discovered and monitored earlier, it progresses gradually to kidney failure or ESRD, giving the patients two alternatives, either continuous dialysis or kidney transplant. Furthermore, CKD treatment and management involve loads of medical attention and expenses. The weight of all these conditions disproportionately affects the minority populations nationwide. Hence, it creates several burdens in these communities. As a result of the challenges involved in CKD incidence and prevalence, it is essential to address the treatment of this disease across the board. The healthcare intervention provided by the healthcare system should be unbiased to improve the health of CKD. Because the US is home to a diverse population with different racial and ethnic backgrounds, the minority populations’ CKD healthcare needs to be addressed as equitably as other populations. Therefore, specifically, this research focused on the minority communities in Tennessee. A systems engineering application was employed to address the healthcare interventions provided to these communities in Tennessee. The application was based on the system dynamics modeling to simulate various interrelated dynamic complex factors associated with CKD, beginning with the risk factors involved to the nature of the treatment rendered and the health disparities involved. Moreover, any form of CKD healthcare disparities can arise from the bias presented by either the CKD patients, the primary care providers, the nephrologists, or the healthcare system. Therefore, in this research, the various healthcare disparities that occur in CKD care are modeled with the risk factors and the nature of CKD treatments to observe the relationships between the bias in CKD treatment and its progression. The system dynamics model can also simulate different graphs that represent how the biases in CKD care from patients, nephrologists, primary care providers, and the healthcare system affect the progression of this disease.The research showed that system dynamics could be applied to model various dynamics, interrelated factors in CKD incidence and prevalence to uncover the healthcare disparities associated with it. The development of the system dynamics model and the underlying simulation results would aid policymakers and decision-makers in the healthcare area to make more informed decisions regarding CKD health disparities.


Compound odontoma is a malformation typical of young adults below the age of 20, with a slight preference for the male gender and the anterior region of the maxilla. Clinically asymptomatic, it can be detected during a radiological investigation in connection with the persistence of deciduous dental elements and the impaction of definitive ones. The treatment of choice is excisional surgery and recurrence is a rare event. The need for orthodontic therapy for impacted elements is usually not necessary because in most cases, odontomas are small, circumscribed lesions the size of a permanent tooth. In this article, the diagnostic and therapeutic surgical excision procedure is presented in three patients at developmental age with large compound odontomas associated with at least one retained canine, and in two of the cases, with serious transmigration to the impacted tooth elements. Odontomas are hamartomatous developmental malformations of the dental tissues . AccordiOdontomas are developmental anomalies consequential to the growth of totally differentiated epithelial and mesenchymal cells that generate ameloblasts and odontoblasts . These cTypically asymptomatic, they are revealed on routine radiographs or upon assessing the origin of delayed tooth eruption ,5,6,7,8.Very rarely, the spontaneous eruption can occur with exposition within the oral cavity of the odontoma, and it may be associated with pain, localized inflammation, or infection with suppuration .Odontomas can be diagnosed at any age and in any location of the oral cavity, but more frequently during the second decade of life, on average at 14.8 years . OdontomOdontomas are commonly asymptomatic and constitute casual findings. Clinical signs may be delayed eruption and persistence of the deciduous teeth. In severe cases, infection or regional lymphadenopathy may be observed .Management usually consists of surgery to prevent further complications with the permanent tooth eruption in the paediatric population ,10, and Following surgical removal of the odontoma, orthodontic therapy is often not prescribed to reposition any impacted tooth elements . In the This article presents three clinical cases of patients at developmental age diagnosed with large compound odontomas, associated with the inclusion of at least one permanent canine and impacted teeth transmigration in two of the cases. The diagnostic process and surgical treatment of choice are described, in which the two transmigration cases led not only to the removal of the odontoma but also to the extraction of the impacted and transmigrated tooth elements. In all cases, histopathological diagnosis was performed and was compatible with compound odontoma.Besides, literature searches of free text and MeSH terms were performed using PubMed and Google Scholar from 2000 to 2022. All searches were conducted using a combination of subject headings and free-text terms. The keywords used in the search strategy were as follows:(“compound odontoma” AND “complex odontoma”) AND  AND (“tooth impaction” OR “impacted teeth” OR “impacted tooth” AND “tooth transmigration”).The aim of this review was to hightlight the anatomical, demographic, gender and dental parameters associated with complex and compound odontoma.Inclusion criteria were as follows: (a) prospective studies; (b) retrospective studies; (c) case series; (d) in-vivo studies; (e) studies published in English, French, Polish and Albanian. These criteria have been broadly selected to be as sensitive as possible. The exclusion criteria were as follows: (a) in-vitro studies; (b) articles without statistical analysis; (c) abstracts and letters to the editor.A manual search was also conducted to try to find other additional studies as well. Based on the inclusion criteria, two authors (MM and GDG) reviewed the titles and abstracts and selected the studies from the literature independently. The full text of each study was then read to decide whether it could be included or not. Disagreements in this case were set on by consensus between both authors or by discussion with another author (AN).A 14-year-old female patient, treated in our paediatric surgery unit in 2021 .The second clinical case concerns a 14-year-old male patient who was referred for consultation to our paediatric oral surgery unit. The patient was operated on in November 2021 . The diaThe third case presented here is that of a 15-year-old male patient. The surgery was performed in July 2021 .The search strategy identified 124 potential articles: 33 from PubMed and 91 from Google Scholar. After removal of duplicates, 91 articles were analysed. Subsequently, 71 papers were excluded because they did not meet the inclusion criteria and were not relevant to the subject of the study. The remaining 20 papers were included ,30,31,32The studies included  in the pCompound odontoma is a benign odontogenic tumour and it is usually diagnosed in young adults during regular radiological examination performed to assess the reason of a missing or mispositioned tooth in permanent dentition .At the clinical level, compound odontoma can often be associated with anterior teeth misalignment and tooth eruption disorders, with possible impaction and delayed tooth eruption. One quarter of patients are asymptomatic, but compound odontoma can also be characterized by pain (13.3%) and swelling (8.9%) . The preSurgical removal is the usual treatment and recurrence is rare . In the clinical cases presented here, it was possible to refer the patient for orthodontic treatment of the impacted canine only in the first case, when the inclusion concerned the upper left canine. In this case, the odontoma blocked the physiological eruption of the canine, but did not cause it to be misaligned. In fact, the canine position was vertical, even if slightly vestibular, placed above the odontoma.In the remaining two cases, the position of the odontoma was in the front part of the mandible and was associated with the inclusion of the canine, which was unfavourable for orthodontic treatment. In fact, in both cases, we proceeded with both the surgical enucleation of the odontoma and the extraction of the impacted canine, and in one case, also the extraction of the lateral impacted transmigrated incisor. In both cases, the large volume occupied by the odontoma, and late diagnosis certainly contributed to the displacement of the canine from its physiological site towards the mesial position, almost completely horizontal towards the bottom of the mandible on the inferior cortex, in line with the entire symphysis area of the chin. This type of tooth displacement is called transmigration. Transmigration most commonly concerns the permanent canines and is characterized by the movement of a non-erupted tooth that crosses the median line of the mandible and goes to position itself in the opposite part of the anterior mandible, as in cases 2 and 3 of this report . TransmiThe presence of cysts and tumours can alter the eruption pathway and cause tooth transmigration. The transmigrated teeth typically present unilaterally with a certain degree of angulation. In case 2, the angulation was almost horizontal to the lower jawline, while the transmigrated canine in case 3 presented a 60-degree angulation to the corresponding long axis of the first lower premolar ,39.The treatment of choice for transmigrated canines in association with vast compound odontoma is extraction. Orthodontic reposition of transmigrated canines is usually reserved for mild cases .Few cases in the literature could be found with transmigrated canines being transplanted following endodontic therapy .However, the management of bone gaps after surgical excision treatment of large lesions may require regenerative approaches using a combination of three-dimensional structures and new therapeutic means .This article has documented three cases of compound odontomas: one in the upper premaxilla and two in the mandible in patients at developmental age. All the cases were associated with canine impaction; however, only the maxillary-impacted canine underwent orthodontic treatment after surgery. The two mandibular canines associated with compound odontoma were transmigrated and no orthodontic therapy was possible due to the challenging near-horizontal position at the lower portion of the anterior mandibula.Although the radiological and macroscopic features following surgical removal are pathognomonic, histological examination is always performed. As a diagnostic investigation in preparation for surgery, CBCT offers details on the morphology of the odontoma, its relationship with the surrounding dental structures, and the cortical bone profiles of the affected jaws.


Witnessing or experiencing of incivility affected the nurses’ perception of the ethical climate and quality of their work life. The aim of this study was to investigate the effectiveness of educational intervention and cognitive rehearsal on perceived incivility among emergency nurses.This study was conducted as a randomized controlled parallel group clinical trial. Eighty emergency nurses participated in this study and were randomly assigned to intervention and control groups during December 2019—March 2020. Cognitive rehearsal program  was delivered in five two-hour sessions over three weeks on different working days and shifts. The control group received only written information about what incivility is and how to deal with it before the implementation of intervention and one month after the completion of the training sessions, the demographic information form and the incivility scale were completed by the nurses.The results showed that there was a significant effect on overall incivility, general incivility, and supervisor incivility between the intervention and control groups. However, these significant reductions were seen in control group who received only written education. There were no significant differences in nurse's incivility towards other nurses, physician incivility, and patient/visitor incivility between the two groups.The cognitive rehearsal program did not decrease perceived incivility among emergency department nurses in the short term.IRCT20200714048104N1, first registration 16/07/2020.Our research was registered on clinicaltrials.gov. Registration number:  Incivility is a dysfunctional interaction that is a recognized problem in the nursing workplace . NationaThere is a high level of incivility in the emergency department (ED) . 62.6% oNowadays, it is obvious that any kind of disrespect and incivility can change the organizational climate and increase the severity of burnout among nurses, lead to negative consequences such as clinical errors, and thus threaten patients' lives. Therefore, it is necessary to study how to deal with these behaviors .One hypothesis for the continued prevalence of incivility in nursing is that nurses are socialized to maintain uncivil behaviors when a culture of incivility exists in nursing practice or academia . This asSome studies have hypothesized that the use of a series of interventions based on Bandura's social learning theory may help nurses cope with experienced incivility , 15. RehIn some studies, all participating nurses reported feeling able to recognize, cope with, and manage these behaviors after the cognitive rehearsal program , 19. SomAlthough it appears that training and use of cognitive programs improves nurses' awareness of incivility and increases their ability to manage these behaviors and reduce the incidence of incivility, these changes vary across studies. The findings of a non-statistically significant decrease in the occurrence of incivility and a slight increase in nurses' awareness of incivility following the cognitive training programs are examples of these findings . A cultuGiven the commonality of the lived experience of incivility among Iranian nurses  and the This study was a single-blinded, parallel randomized clinical trial with two intervention and control groups. The codes and outcomes of the groups were blinded to practically and effectively reduce interpretation bias by the investigators.The setting of the study was the emergency departments of two public hospitals affiliated Shahid Beheshti University of Medical Sciences in Tehran, Iran. N = 120) of two public hospitals A and B of Shahid Beheshti University of Medical Sciences in Tehran, Iran, between December 2019 and March 2020.The study population consisted of the nurses employed in the inpatient departments of the emergency rooms  and a control group  by tossing a coin. The inclusion criteria for the nurses were having a bachelor's degree in nursing or higher, being a nurse working in the emergency departments of hospital A or B, willingness to participate in the study, and that they had not received any education or cognitive rehearsal based on Bandura's theory in the previous six months. The exclusion criteria were nurses who did not attend the first education session, who did not attend two education sessions, who did not complete the research instrument, and who did not complete the cognitive rehearsal. In Hospital A, 16 individuals dropped out during the study or did not participate in more than two sessions, leaving only 40. Of the 50 nurses from Hospital B, only 47 completed the scales, and 7 scales were completed incorrectly or incompletely, leaving 40 scales for analysis  [Sample size was calculated based on results of Alshehry's study (2019) measuring the incivility using the Guidroz Nursing Incivility Scale (S = 0.64) , and witThe intervention group received the cognitive rehearsal program and the control group received only the written instructional material. The difference between educational programs in two groups is related to the nature of cognitive rehearsal. Cognitive rehearsal has a three-part didactic process that involves learning and rehearsing specific phrases to use during uncivil encounters . Cognitive rehearsal program  was delivered in five two-hour sessions over three weeks on different working days and shifts. The intervention was delivered by an emergency nurse and a mental health nurse to make the program scenarios more professional. The content validity of the program was verified using the opinion of a 5-member expert panel (Kappa’s agreement coefficient = 0.80) and the standards of Kile's study .The first session of the training covered definitions of incivility, its impact on nurses, patient safety, and the organization as a whole. The second session taught ten common incivilities and appropriate practical methods for responding to each. Role plays were conducted in the third, fourth and fifth sessions of the training. The interventions and sessions took place in the training classes of the hospital Table .Table 1CScenarios were distributed to the participants consisting of 10 common types of specific incivility, which were used following Kile's study , along wIn Hospital B, participants were asked to complete the Incivility Scale at the beginning of the study and after one month without intervention . For equity and ethical reasons, the control group was offered training and a cognitive exercise after the study was conducted.Written informed consent was obtained from the selected nurses before completing the questionnaires at baseline. The nurses' right to autonomy was protected. That they could make an informed decision to voluntarily participate in the research because they were informed of the potential risks and benefits of the research. Anonymity was maintained by using codes in the questionnaires and not linking the subject's identity to personal responses. on the confidentiality of the nurses' dialogues during meetings about the problems of incivility they face in the workplace, they assured.Thereafter, nurses in the Emergency Department of Hospital A participated in five two-hour sessions over three weeks on different work days and shifts. Prior to conducting the training program and one month after completing the training sessions, the nurses completed the Demographic Information Form and Incivility Scale. The Incivility Scale was originally developed by Guidroz (2010) . This stp < 0.05 for all analyzes performed.Data analysis was performed in SPSS version 21. An independent t-test for homogeneity of groups after random assignment was performed for the demographic variables. Analysis of variance (ANOVA) was used to compare the responses of the two groups before and after the intervention. General incivility, supervisor incivility, and total incivility before intervention and after intervention in two groups were compared using analysis of variance (ANOVA) after adjusting for nurse age and work history. Comparison of overall incivility, supervisor incivility and total incivility for the two groups was analyzed using repeated measures ANOVA. The significance level was set at There were 40 samples from each hospital whose statistical data were analyzed. The mean age of nurses in the intervention and control groups was 31.6 ± 5.5 and 29.1 ± 4.4 years, respectively. The majority of nurses in both groups were female. It was found that there was no significant statistical difference between the intervention and control groups in terms of mean age, emergency department work experience, and work hours , the cognitive rehearsal program did not reduce the bullying behaviors among nurses. They attributed this to the fact that the program focused only on nurses and did not address organizational issues, as well as the very early measurement of outcome variables .It is hypothesized that the non-significant subscales of incivility, particularly patient or visitor incivility, and physician incivility are dependent on other structural causes inherent in nursing workplaces. Hosseinpour-Dalenjan et al. (2019) showed that there is a high correlation between nurses' work engagement and patient or visitor incivility . CharrieClark et al. (2013) study showed that nurses experienced incivility before and after the intervention and also indicated that they tried to control their body language, tried to reduce or stop arguments with a colleague, and were aware of their behavior and reactions . Warner It appears that the structural factors such as organizational culture are important in preventing and eliminating incivility in the nursing workplace . The phrThe authors recommended that given the importance of incivility to patient, organizational, and caregiver outcomes, incivility in medical centers needs to be assessed regularly as a measure of organizational performance; and that necessary management actions should be taken based on the outcomes achieved. In this regard, it may be helpful to hold team meetings, address group dynamics, teach management skills, determine organizational values, recognize the organizational culture and history of organizational incivility as well as existing leadership techniques, and recognize the risks of incivility , 35. TraEducation and cognitive rehearsal were effective in increasing nurses’ recognition of incivility and ability to confront it. Educational intervention improves civility in nursing practice and promotes a positive work environment in which patients are cared for safely and efficiently . The useOur hypothesis about the effect of the training and cognitive rehearsal on improving nurses’ ability to deal with incivility in emergency departments is not confirmed by the findings of this study. Workplace incivility seems to be a multifaceted phenomenon that is affected by various variables such as time, gender, leadership model, organizational culture, etc. The study also has an important secondary finding, which is the mediated role of managers on perceived incivility among employees. In future studies, it is necessary to consider the mediated variables in the effectiveness of interventions affecting incivility.The current study has some limitations, including the lack of blinding, which may cause the Hawthorne effect. The small sample size and focus on only nurses rather than all emergency professionals limit the generalizability of the results. Also, the changes in hospitals due to the pandemic COVID-19 could affect the results and led to a limitation in the long-term follow-up of participants. Another limitation of this study was the change in emergency department leadership in the control group during the study. Most of the participants in this study were women. The incidence and determinant of workplace incivility can differ by gender . Future The study contains some promising insights for the existing body of knowledge. It appears that the transformation of awareness of a relational problem into a behavioral reduction of that problem is more complex than it appears and may have a reverse effect. It is recommended that future studies be conducted to track the effects of the intervention over a three and six months’ period. Considering that only nurses participated in this study, it is recommended that training and sampling with nurses, physicians, and supervisors be conducted in future studies. Therefore, Future studies with longer interventions and higher frequent measurements are required to draw greater empirical conclusions regarding the outcome variables.The results of the study suggest that incivility in nursing is a widespread phenomenon in which several latent confounding variables that should be considered. Continuing education and cognitive rehearsal, greater emphasis on teamwork among nurses, physicians, nurse managers, and emergency department managers could prove effective if incorporated into continuing education, which warrants further study. However, the cognitive rehearsal program did not decrease incivility among emergency department nurses in the short time of our study. One reason for this could be the focus on individual levels and nurses, the other reason seems to be the limited time to measurement outcomes.


To ensure that residents are equipped with the necessary skills for practice, competence-based medical education (CBME) represents a transformative change in postgraduate medical education, which is being progressively introduced across Canadian specialty residency programs. Successful implementation will require adjustments to curriculum, assessment, and evaluation, with careful attention to the unique needs in the local context, including resident and faculty development. This narrative review of the literature aimed to determine the potential barriers to the successful implementation of CBME and the strategies by which they can be addressed, with a specific consideration of the author’s program in pediatrics in Manitoba. Eleven articles were identified with a specific focus on the implementation of CBME in the post-graduate setting, and 10 were included in the review after critical appraisal. Three key themes emerged from the articles: the value of broad stakeholder engagement and leadership, the importance of faculty and resident development, and the development of specific support systems for the educational curriculum. Different strategies were considered and contrasted for addressing these important themes. This review provides important insights and practical approaches to the barriers that should be useful as programs prepare for the implementation of CBME. In light of the increasing complexity of health care and the importance of social accountability in its delivery, a competency-based approach to medical education is meant to ensure that recently graduated doctors, generally called residents, are equipped with the necessary skills for their ultimate specialty practice . CompeteIn his commentary on outcomes-based medical education, Holmboe  describeIt is evident that these major cultural shifts in post-graduate medical education will require widespread stakeholder engagement, consideration of interpersonal and group dynamics, and careful evaluation of implementation needs in the local context . In prepPediatric training in Canada is scheduled to implement CBME with the residency cohort starting July 2021. As the program director for pediatrics at the University of Manitoba, the author will be directly responsible for leading this transition in our program, with 40 residents and a faculty of nearly 120 physicians. Drawing on the experiences of other programs, the aim of this narrative review is to determine the potential barriers to the successful implementation of CBME in pediatrics in Manitoba and the strategies by which they can be addressed.www.twu.ca/library). Databases included in this review were the university library’s OneSearch, ERIC (Education Resource Information Center), MEDLINE, Academic Search Ultimate, and CINAHL. The following key subject terms were used to search the databases with Boolean ‘AND’ to combine the search terms, limited to English language: ‘competenc*-based medical education’, post-graduate OR residen*, transition OR change. This search strategy was designed deliberately to focus on those papers with a focus on change management efforts in the introduction of CBME to PGME programs. After removing duplicate results from the different databases, a total of 80 papers were identified. Those articles were then manually screened by title and abstract, and 15 articles were identified as potentially relevant to this review. The same search was performed on Google Scholar which did not result in any new results. It is important to note that the search parameters did not limit results by region or country, although this could be implicit in the English language limitation.This literature review identified scholarly research in CBME through the electronic databases available at the author’s university library  according to criteria established a priori for this narrative review. The reviewed articles were required to meet the following criteria: 1) peer-reviewed papers published between 2011 and 2021, 2) accessible through online sources, and 3) implementation of post-graduate CBME as a central theme. Conversely, articles were excluded based on the following criteria: 1) focus on undergraduate medical education, independent practice, or continuing professional development, or 2) health-care transformation as the central theme. Of the 15 articles identified, 11 articles met the inclusion criteria and were considered in the review. These 11 articles were drawn from a variety of scholarly journals.Each of the 11 articles was critically appraised using the methods described by Plano-Clark and Creswell , for quaThe articles included in this review represent a variety of perspectives and approaches to the challenges in implementing CBME within post-graduate medical training programs. Three articles provided a broad systems review . Three wStrong leadership is needed to champion the changes of CBME, which requires program leaders ‘to engage in a community of shared learning and leadership’ , p. e32.Another frequently raised concern was commitment and engagement from the faculty and residents directly impacted by CBME ,16,18. BUltimately, stakeholder engagement needs to include and be driven by the institutional leadership and priorities, which may be challenging to affect in that they are often external to the program itself . ReturniFraser et al. , define Stefan et al.  uncovereThese observations highlight the need for faculty development programs, addressing the curricular format of CBME and the process of workplace-based assessment . In theiCrawford et al.  surveyedThe resident-focused approach to training was highlighted in several articles ,11,14–16In addition to the administrative reorganization of training experiences, appropriate curriculum delivery, assessment, and evaluation will also require educational and technological support ,12. SimuThese core pedagogical elements require rapid introduction in the early implementation of CBME, to provide appropriate systems, support, and leadership as foundations for the subsequent faculty and resident development . SolutioIn exploring the barriers to implementation of CBME and how to address them, this literature review highlights three key themes: the importance of stakeholder engagement and leadership, the value of faculty and resident development for the specific tasks and requirements of CBME, and the implementation of the necessary educational and technological solutions for this new training paradigm. These themes are similar to the high-level priorities identified by Dagnone et al. , while tIt is reassuring that the barriers and solutions described were consistent across the different articles and research types, suggesting saturation in the focused literature search. From a practical perspective, it is also important to note that the findings of the broad systems reviews  were echOne limitation of the review is the generalizability of the results. Many articles reflected the perspectives and findings of a single residency program ,14,16 anFor future evaluation of CBME implementation, action research will allow iterative reviews as knowledge and experience is gained to highlight those barriers that are most significant and suggest implementation strategies to overcome them. Action research can look specifically at the impact of the local training program context on the barriers to implementation and their solutions, identifying the technological and human resources that are most applicable in that program and more broadly. Further qualitative studies will also be valuable to assess the changing perceptions and impact of CBME over time and may identify previously unexpected or unappreciated challenges that will need to be addressed. This is analogous to the continuous quality improvement advocated by Hall et al. .As pediatrics training programs across Canada prepare to implement CBME, we are collaborating on strategies through our national program directors’ working group. This has been a valuable community of practice to share experiences and has already influenced our faculty, resident, and curricular development efforts. While the opening perspective of this narrative review was the implementation of CBME in a single postgraduate medical education program, the combined experience reviewed herein bears informative witness to the common challenges. It will also be valuable to capture the undergraduate medical education experience of CBME to add to the depth and breadth of the identified themes.This narrative review is meant to provide an introduction to the challenges in the implementation of CBME and to inform future efforts by medical education programs and communities of practice. The three identified themes provide important insights and practical approaches to the barriers that we are likely to encounter. Identifying and understanding them will benefit the Manitoba pediatrics program in our transition, and our experience will add to this knowledge for those programs who have yet to move to CBME.


The brain is one of the most metabolically demanding organs—it requires 20% of the body's energy supply yet forms only 2% of the body's weight. Therefore, brain activity is supported by a dynamically regulated supply of blood and, hence, energy substrates through the cerebrovascular network. Furthermore, the post-mitotic nature of neurons and their longevity makes the brain very sensitive to extracellular perturbations. Thus, the cerebrovasculature also has to be specialized to minimize perturbations of the brain microenvironment, a property mediated by the blood-brain barrier that is formed by the neurovascular unit (NVU).The NVU is a multicellular structure formed by neurons, glia and vascular cells. The NVU is fundamental to the distribution of cerebral blood flow, regulation of extracellular homeostasis and, as recently shown, waste clearance from the brain. Therefore, the NVU represents a pivotal point of vulnerability for the brain. In this Research Topic, 12 contributing articles address the potential of the NVU and provide evidence demonstrating the importance of the NVU as a biomarker and therapeutic target for cerebrovascular disease.Shaw et al. provide a thorough and detailed characterization of the cerebrovascular bed, highlighting differences in its structure and function as it branches from penetrating arterioles to capillaries. Using immunohistochemistry and by assessing vasomotion along the vascular tree in awake mice via two-photon microscopy, they provide novel data characterizing points of contractility, angiogenic capacity, and vasodilatory potential across the vascular tree and branch points . The differences in vasodilatory response across the vascular tree are also highlighted in the study by Rosehart et al., in which they show that stimulation of capillaries with prostaglandin E2 elicits vasodilation of upstream arterioles. This was blunted in a model of small vessel disease, suggesting a reduction in capillary-to-arteriole signal propagation as a potential mechanism for the pathologies associated with cerebral small vessel disease, while also suggesting a new biomarker for NVU dysfunction .It is important to first understand the structure and function of the healthy NVU to identify abnormal events and therapeutic targets. Lemon et al.Hayes et al. provide novel data on another parameter, the neuroprotective hormone insulin-like growth factor-1 (IGF-1), demonstrating a difference in vulnerability to glutamate-induced toxicity across different cell types of the NVU when IGF-1 is inhibited.Specific modifiable physiological parameters of the NVU are also highlighted within this Research Topic. Inhibitors of carbonic anhydrases, the pH regulating enzymes, can protect the NVU in stroke and Alzheimer's disease, as reviewed by Together, these data highlight multiple structural and functional points within the NVU that may potentially serve as targets for therapeutic intervention. The differential regulation at the various vascular segments and the transitional zones between them in the vascular tree is also noteworthy; each segment could be differently affected during disease, or be targeted for therapy.Beishon and Panerai emphasize the importance of mid-life therapeutic targeting and lifestyle alterations targeting known risk factors for dementia. The comprehensive review by Ouellette and Lacoste highlights the shared vascular abnormalities associated with neurodevelopmental and neurodegenerative disorders, despite their distinct clinical presentation at different life stages.The biomarker and target potential of the NVU across the lifespan is another key focus of this topic. In an opinion piece, Lecordier et al. provide a detailed review of early risk factor events for NVU dysfunction leading to dementia, highlighting triggering pathological events. They specifically underscore the importance of air pollution as a risk factor for dementia, and provide a detailed summary of its impact on NVU components . Exercise is suggested to reduce cerebrovascular disease and alleviate the risk for developing dementia. Ohtomo et al. report that, in a model of chronic hypoperfusion, exercise was able to alleviate fewer behavioral deficits in middle aged mice compared to their previous study on young mice, suggesting the value of early lifestyle interventions. Altogether, these reports showcase the potential of the NVU as a biomarker and the importance of protecting NVU function across the lifespan.Wang et al. demonstrates the role of cerebral small vessel disease in negative prognosis following intravenous thrombolysis treatment for acute ischemic stroke, highlighting the value of NVU pathology in predicting treatment outcomes.The significance of using the NVU, or the pathologies associated with it, as a biomarker and therapeutic target in the clinical setting is also emphasized in this Research Topic. A systematic meta-analysis by Monteiro et al. report a reduction in neurovascular coupling in patients with hypertension while hypercapnic hyperemia is preserved, prior to detectable cerebral small vessel disease. This impairment was further exacerbated when hypertension was comorbid with diabetes, suggesting that NVU dysfunction may contribute to the cerebral effects of chronic hypertension and diabetes . Staszewski et al. provide further support for the NVU as a biomarker for disease progression, demonstrating that decreases in cerebrovascular reactivity are measurable over a 24 month follow-up period in patients with small vessel disease, irrespective of initial radiological disease assessment.In addition, Ren et al. suggest that disruptions in the glymphatic system, a hypothesized route of paravascular waste clearance, may be the cause of, and serve as a biomarker for, peri-operative neurocognitive disorder. Their review highlight anesthesia choice and management as potentially modifiable risk factors for peri-operative neurocognitive disorder .Lastly, This Research Topic provides both preclinical and clinical evidence of the importance of the NVU as a contributor to cerebrovascular disease and, thus, a therapeutically targetable fulcrum, while underscoring its value as an accessible biomarker for disease etiology and progression. The additional targeting of co-morbidities and detrimental lifestyle risk factors that lead to NVU dysfunction, which change over the lifespan, are also essential for disease management. It is clear that further characterization of the NVU, including its functions in health and different pathological contexts, and how it is modified by lifestyle choices and comorbid conditions, are all important avenues for future work. Findings from such studies may suggest potential therapeutic targets for cerebrovascular diseases, and may even be applicable to related dementia conditions.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.


Crimean-Congo hemorrhagic fever (CCHF) is a zoonotic arbovirosis. Humans are infected by tick bites or contact with blood of infected animals. CCHF can be responsible for severe outbreaks due to human-to-human transmission. Our aims were to increase awareness and promote the search for risk factors and disease monitoring to prevent CCHF epidemic, capacity building, appropriate measures to treat patients, and information for the local population.During the outbreak of hemorrhagic fever from February to May 2022, blood samples were collected from 88 patients suspected to be infected with the virus. Diagnosis was established by reverse-transcription polymerase chain reaction (RT-PCR) and/or enzyme-linked immunosorbent assay.CCHF was confirmed by RT-PCR in 7 of 88 (8%) patients. Ticks were found in cattle, sheep, or goats in the areas where the subjects resided, with the exception of 1 CCHF-positive patient in close contact with fresh animal meat. Exposure to potential risk factors was found in all patients. The interval between the onset of symptoms and hospital admission was 2–3 days. All 7 patients were admitted to our hospital and treated promptly by blood transfusion. Two patients died.Mortality is high in patients with the hemorrhagic form of CCHF. Disease prevention is necessary by strengthening vector control, avoiding contact and consumption of organic products from diseased animals, and vaccinating animals in areas where the disease is endemic. Furthermore, it is essential to establish management procedures for patients infected with CCHF virus. Hyalomma, followed by Rhipicephalus and Dermacentor, serve as the major vectors of this virus ) of the patients reported a history of tick bites few days preceding the onset of the initial symptoms. They reported repeated contact with ticks. Among the 7 CCHFV-positive patients, 4 (57%) were residents in the region (“wilaya”) of Trarza .All patients who were positive for CCHFV had bleeding symptoms and had been taken to hospital rapidly. For all of these patients, their ELISA results were negative for all other tested viruses, namely Rift Valley fever, yellow fever, West Nile, dengue, and chikungunya. The affected patients were cattle breeders or shepherd (n = 3), butcher (n = 1), or housewives with agropastoral activities (n = 3). Among these 7 patients, there was no epidemiological or family link, and they lived in separate localities. No other members of the families of CCHFV-positive patients were affected, and they remained asymptomatic. The risk factor found in this study was contact with ticks (86%). Blood samples taken from patients after the onset of clinical signs were positive for CCHFV RNA. The interval between the onset of the initial symptoms and hospital admission was 2–3 days. Five of 7 patients were admitted to 1 of the collaborating hospitals in Mauritania  and were treated promptly by blood transfusion as soon as they were admitted, and they were cured. Two other patients, who were referred late to the hospital, died.CCHF is a viral disease that is asymptomatic in infected animals but may cause serious health problems in humans . The areHyalomma ticks are the principal source of human infection, probably because both immature and adult forms actively seek hosts for blood meals required at each stage of maturation [CCHFV is maintained in vertical and horizontal transmission cycles involving ixodid ticks and a variety of wild and domestic vertebrates, which do not show any sign of illness. The virus circulates in a number of tick genera, but turation , 22. CCHturation . Most lituration .Clinical diagnosis alone is difficult to establish due to the nonspecific nature of symptoms. Therefore, laboratory diagnosis is necessary for patients residing in or travel to CCHFV-endemic regions in whom the disease is suspected . The incDuring the dry season (November to June), the movement of livestock and herds is intense between different regions, and the tick vectors move along with livestock. The virus can be transmitted between animals and humans. The movements of fauna and populations and nomadic pastoral practice could explain the progressive extension of the CCHFV in the southern regions of the country. This explains the notification of cases even in Nouakchott, the capital city of Mauritania. Two of the patients included in this study transported their cattle to Nouakchott to sell them at the city market. The virus could have circulated with viremic animals transported by truck between various grazing areas, including the region of Hodh El Gharbi toward Nouakchott and to other regions in southeastern Mauritania where CCHF is endemic. However, because of the small sample size of the present study, further epidemiological studies would be required in Mauritania, as well as in other countries, to assess the association between CCHF and various risk factors , 27.In the absence of medical prophylaxis and effective means of combating the natural reservoir, the prevention of CCHF requires measures of epidemiological surveillance and rapid response to outbreaks in animals or humans to avoid the spread of the disease. It is therefore necessary to implement the means to inform the population and caregivers  in endemic and enzootic areas about the disease and its prevention. Similarly, it would be necessary to have information tools that would quickly inform physicians and the population in endemic areas in the event of a resurgence of infections. It would be necessary to strengthen the capacities of the diagnostic laboratory for hemorrhagic fevers, to set up an active surveillance system, especially during the rainy seasons, and to carry out large-scale human and animal serological surveys to assess the prevalence of CCHF in the country.


The application of Building Information Modeling (BIM) in fire protection discipline has been sufficiently proved to be useful, but has encountered many barriers in China. Among which, small- and medium-sized enterprises (SMEs), which are considered sensitive to adoption costs and external funding support, play a critical role in the BIM adoption process in fire protection discipline. Therefore, identifying and analyzing the barriers of BIM application are essential to help small- and medium-sized fire protection enterprises to overcome these barriers. In this study, semantic analysis, which includes word frequency analysis and coword analysis, based on literature review was utilized to identify the main barriers. 20 main barriers, which were classified into software, people, organization, and environment group, were obtained. Then, Interpretive Structural Modelling (ISM) approach and Cross-Impact Matrix Multiplication Applied to Classification (MICMAC) analysis were utilized to hierarchically analyze and categorize the main barriers of BIM application in Chinese SMFEs. The findings revealed that the lack of external support and the lack of BIM laws and regulations applicable to fire protection discipline are the key barriers in general for the application of BIM in SMFEs. For the barriers at the enterprise level, through further analysis and discussion based on barriers in the people and organization clusters, the lack of funding support for proper BIM training and the lack of organization culture support were concluded as the key barriers of BIM application inside the scope of SMFEs. According to 80-20 principle, more effort should be focused on the key barriers to gain maximum management effect. The research result categorizes the barriers for easy intervention of fire protection enterprises' managers and policymakers. It contributes to the nascent studies of BIM application and provides guidance for the application of BIM in fire protection discipline. In the global construction market, with the development of informatization and industrialization, fire protection has received more and more attention. Over the past few years, many considerable fire accidents happened in construction building sites were reported. Many construction sites do not contain a permanent fire protection system, and even some current fire protection systems only consist of fire extinguishers. Traditional safety planning lacks a justified approach for the firefighting equipment installation planning in the construction site. Low efficiency of fire protection engineering seriously hindered the sustainable development of construction industry. As the largest construction market worldwide , China'sThe advent of Building Information Modeling (BIM) is claimed to offer a promising opportunity to harness the effectiveness and efficiency of the fire protection engineering. BIM is a digital representation of a constructed facility  and offeTherefore, this study aims to identify and hierarchically analyze the application barriers of BIM for small- and medium-sized fire protection enterprises (SMFEs) in China. Three subobjectives are to be achieved: (1) to discover the main barriers of BIM application in China's SMFEs, (2) to assess the interrelationships between these barriers and prioritize these barriers based on their interrelationships, and (3) to analyze the key barriers and classify them according to their independence.By doing so, the contributions made by this study are four-folded: (1) it bridged the gap of systematic research on the barriers of BIM application in SMFEs, (2) it introduced an innovative barrier identification method that formed the main barriers, (3) fire protection enterprises can develop coping strategies to promote BIM application by controlling the key barriers and avoiding derivative incidents based on the recognized interactions of BIM application barriers, and (4) dynamic barriers and categories help strategy-making of policymakers and managers.Fire protection discipline is an important part of the construction industry. According to the report released by Autodesk, BIM is mostly associated with design and preconstruction, it absolutely benefits every phase of the project life cycle . Fire coSo many advantages of BIM technology have been discovered in fire protection discipline. However, the current status of BIM application in the field of fire protection is not very good. BIM application in software, knowledge, investment and the legal environment is still facing many dilemmas. Research pertaining to BIM in the fire protection discipline have emerged only recently. Thus, it is necessary to systematically sort out and analyze the barriers for BIM application in fire protection discipline. According to the definition given by the Ministry of Industry and Information Technology of China, small, medium, and micro enterprises are ones with operating income of less than 800 million yuan or total assets of less than 800 million yuan. Among them, medium-sized enterprises with operating income of 60 million yuan and above and total assets of 50 million yuan and above; small enterprises with operating income of 3 million yuan and above and total assets of 3 million yuan and above. Among China's fire protection enterprises, SMEs account for about 28%, occupying a relatively large ratio. Besides, comparing with large enterprises, the composition of small- and medium-sized enterprises is more complex. They will encounter more barriers such as costs and lack of external funds; on the other hand, the functions of small- and medium-sized enterprises in BIM cannot be ignored. Large enterprises can participate in the formulation of BIM standards, while small- and medium-sized enterprises are the key subjects in the application of BIM standards, which is a more critical issue for the widespread application of BIM in fire protection discipline. Therefore, identifying and analyzing the barriers of BIM application in Chinese SMFEs are extremely critical to promote the process of BIM application in fire protection discipline.Application barriers of BIM have always been a hot topic. Researchers from different disciplines tend to study related barriers for BIM application. BIM can facilitate the delivery of prefabricated construction. Wu et al. (2020) have studied the BIM application barriers of industrialized building construction systematically, which concentrated more on data integration and information models . Tan et Amount of research on the barriers of BIM for SMEs is also raising, Li et al.  studied There are many studies focusing on BIM application barriers in the construction industry, nevertheless, the study with respect to BIM application barriers in fire protection discipline is still scarce. Although Kincelova et al.  pointed In order to fulfill the research objective, a three-step method was utilized in this study, and the detailed research procedure, as shown in The goal of the data collection was to find literature regarding barriers that hinder the application of BIM in fire protection discipline. The data collection started with a literature search. Scopus, WoS, and Google Scholar engines were selected as the target databases, “BIM”, “barrier”, “obstacle”, “application”, “application”, and “implementation” were used as keywords for literature search. There are 45 articles found in the above process. The abstracts of each paper were read by the research team members in order to screen out articles relevant to these two topics: BIM application barriers in SMEs and fire protection discipline.After the search was completed, 20 articles were selected as the basis for the next step of barrier extraction. In the barrier extraction, the lists of barriers or subheadings about the barrier in the selected literature were extracted one by one. After filtering by removing duplicates, each barrier was filled in each row of the first column of the table, resulting in a total of 355 barriers. The results were summarized in Totalbarrier.xlsx.Semantic analysis is the process of drawing meaning from text. It allows computers to understand and interpret sentences, paragraphs, or whole documents by analyzing their grammatical structure and identifying relationships between individual words in a particular context. In this study, semantic analysis was applied for barrier identification. To be specific, word frequency analysis and associated coword analysis were used to complete the process of transforming barriers texts to keywords abstraction to main barriers list. The detailed procedure is shown in Word frequency analysis is a statistical analysis of the number and percentage of words in a text. It is an important tool for text mining. It determines keywords and their trends by calculating the frequency of words appearing in the text. In this study, word frequency analysis was used to analyze the barriers from the literature. These barriers are usually expressed in the form of a single statement, and similar barriers often have the same keywords. For example, BIM software cost is a high frequency barrier, so the keywords like “software”, “cost”, and “difficult to pay” and other keywords may appear frequently. Therefore, this paper finds out the high frequency keywords of these barriers and then classifies these words simply according to their meanings.In the process of word frequency analysis, Totalbarrier.xlsx is used to create a plain text file containing only barriers. The specific method is to copy and paste directly from the first column of the table into the text document, and ensure that each barrier occupies a separate line. This operation is more convenient for Nvivo analysis. Then, the high frequency words in the text were extracted using the word frequency function in the Nvivo software. The result is shown in As to the specific description of each section of barriers, the word frequency analysis alone is not sufficient, therefore, the associated coword analysis was used to form the final main barriers list.The association rule is a knowledge mode that describes the law of the simultaneous occurrence of items in a thing, that is, the emergence of quantified data A affects the emergence of B. The coword association analysis takes this as the principle, and the dependence relationship between the subject words is revealed through the correlation statistical method. For example, for the keyword cost, the related modifiers include high, highly, etc., indicating that the cost is high, not low, or an appropriate cost.It is hard to match the BIM software and hardware in fire protection discipline). After importing the classification results in The COOC software was utilized for obtaining keyword cooccurrence matrix. The rows and columns in the matrix represent any two keywords and the number in the cell indicate the cooccurrence frequency of the two words in the barrier total list. The matrix was then modified in Excel to output the node file, which contains the keywords and their frequencies, and the edge file, which includes the keyword cooccurrence relationships (the direction was set to “undirected”). The node file and edge file were imported into Gephi software. The visualization map of the interrelationships between barriers was achieved shown in . HoweverDo you think our barrier factors are more comprehensive?Do you have any other comments on the barriers to BIM application in fire protection enterprises?In addition to above research, we combined interview in the main barriers. For the purpose of getting practical opinions about barriers, we conducted an oral interview. A total of 20 experts suitable for this survey were contacted through telephone or email. The experts were chosen based on their professional background, experience, and ability to ensure that they have extensive knowledge and experience in the field of fire protection discipline. Finally, five experts agreed to participate in the survey, and their profile is shown in We have received valuable feedback from which we have summarized several barriers that were not on the initial list of barriers but were very important.In the end, combining the results of semantic analysis and interview, 20 main barriers of BIM application in SMFEs were identified, which is demonstrated in ISM method was applied in this study for level partition of the main barriers, and the key barriers were identified through MICMAC matrix. The analyzing procedure is shown in The initial data for ISM method was obtained through interviews with experts of fire protection discipline. The interview questionnaire involved basic information about the experts and the relationships between the barriers. After sorting, the structural self-interaction matrix (SSIM) of the selected barriers was generated. The accessibility judgment and processing of the SSIM was conducted for the reachability matrix. Accordingly, the main barriers were hierarchically analyzed. After that, the MICMAC analysis was applied to classify the barriers into four categories, independence, dependency, linkage, and autonomous, based on the calculation of driving powers and dependence powers represented in the reachability matrix. Among which, the independence barriers were considered as the key barriers in this study.i and j were represented by four symbols:W refers to “barrier i can result in barrier j”X refers to “barrier j can lead to barrier i”Y refers to “barriers i and j can lead to each other”Z refers to “barriers i and j are not related”In the process of data collection, we conducted an interview with selected five experts by phone or in person, as shown in In cases when different experts made different judgments towards the relationship of two barriers, the “minority gives way to the majority” principle was applied in order to determine the interrelationships.W, X, Y, and Z were then converted into 1 and 0, consequentially, the developed SSIM was converted into a binary matrix. An initial reachability matrix was established, which is shown in In this way, contextual relationships between the 20 barriers were constructed from feedback. For further calculation and analysis, i affects factor j and factor j affects factor k, then factor i will definitely affect k. The reachability matrix can reveal whether there is a path connecting one factor to another. If the cell  in the reachability matrix is equal to 0, then there is no direct or indirect relationship from factor i to factor j. According to this principle, the reachability matrix can be computed according to the following Boolean rules:Transitivity is one of a basic assumption of ISM method. If factor A is the initial reachability matrix, I is the unit matrix, and R is the reachability matrix. According to Equation (https://spssau.com/indexs.html) by input and output, as shown in In Equation , A is thEquation , the reaReachability sets and antecedent sets are extracted from the reachability matrix . ReachabAs shown in Independent factorsAs explained from previous studies , 37, MIC(ii) Linkage factorsBarriers in this category have high driving power, but low dependence power, which is used to be the key factors in this study. The barriers in this category are lack of BIM laws and regulations applicable to fire protection discipline and lack of external support such as funding from local government. These barriers should be prioritized, and relevant managers should try to avoid or minimize the negative impact of these barriers. (iii) Dependent factorsThe barriers in this cluster are high in both driving power and dependence power, making it unstable. The barriers in this category are high cost of BIM software, lack of domestic-oriented BIM tools, high cost of supporting hardware upgrades required, lack of suitable simulation models for fire protection engineering, lack of knowledge and experience in applying BIM, lack of funding support for proper BIM training, lack of organizational culture support (a shared vision for the BIM application), ambiguity about the benefits of BIM, lack of investment in BIM experts, lack of demand for BIM application from clients, lack of pilot projects for BIM applied in fire protection projects to learn from, and lack of BIM contract standards suitable for fire protection enterprises. These barriers are considered the second most critical barriers that companies should make their efforts on. (iv) Autonomous factorsFactors in this group have low driving power and high dependence power that makes it vulnerable to change. The criteria in this category are top managers are not adapting to the new requirements for coordination and scheduling capabilities, low level of cross-functional coordination and collaboration, lack of knowledge and experience in cross-organizational collaboration, difficulty accepting the instability of business development brought by changes in organizational structure, and lack of appropriate government regulatory measures. These barriers show indirectness to the core problem. What companies should consider is to focus on the effectiveness of improvement measures on these barriers. Because of the low driving power and dependence power of the barriers in this group, the barrier in this category can be separated from the assessment system. No barrier factor is located in this category.In the end, we conducted informal interviews by phone or email. The interviews included thanking the respondents and asking them for their views on the results of the analysis. Although some relationships differed from the content of the initial response for some experts, but generally they are acceptable. Experts gave a reasonable judgment of the results, either verbally or by mail.From the results of ISM and MICMAC analysis, government, project owners, consultants, designers, contractors, and software vendors are the key participants and real executors in applying BIM technology. They must work collaboratively to improve the effect of BIM application. Extensive effort should be focused more on the root barriers, the roots on the level V and level IV in the partition diagraph, which are also located in the independent and linkage clusters as shown in Results of the MICMAC analysis revealed that the environmental barriers are the most influencing barriers for BIM application in fire protection discipline. Among which, the most critical barriers were B15 and B17. The lack of BIM laws and regulations applicable to fire protection discipline (B15), especially the limited funding and technology assistance of government to make BIM suitable for fire protection enterprises  in China's local context, is the most fundamental barrier in the hierarchy. This finding suggests that the application of BIM in fire protection enterprises should seriously consider the unique external environment for SMFEs. The lack of external support such as funding from local government (B17), which located on the bottom level of the level partition diagraph  and the lack of organization culture support (B10). The findings underscore that the SMFEs can drive BIM adoption through internal will and actions such as organization-wide reforms. Moreover, on the contrary, the improvement of management's ability is not as urgent as the improvement of employees' knowledge and skills related to BIM application.The contribution made by this study is firstly bridging the gap of systematic research on the barriers of BIM application in SMFEs. This study promoted an innovative combination of semantic analysis method for barrier identification, which is more scientific and objective. Moreover, the partition of the barriers prioritizes the focus of efforts to apply BIM in the fire protection discipline. According to the result, the mechanisms by which these barriers affect BIM application in SMFEs are elucidated, which enhances the understanding of BIM application and can accelerate the BIM knowledge popularization process in SMFEs and the dynamics of the barriers and categories for easy intervention by policymakers and stakeholders.Regardless of the contributions of this study, it has also created a need for further exploration. For example, although the experts selected for data input for the ISM and MICMAC analysis in this study were knowledgeable and with sufficient BIM experience, the number of the experts is small. Thus, further study with a bigger sample should be conducted to validate the result of this research. Besides, the data collected was from China, albeit the barriers identification and analysis process has considered the characteristics of the SMFEs on a general level, research aiming at a wider scope is also necessary. The identification and analysis method combination and the barriers framework proposed in this study can serve as a solid departing point for further exploration on BIM application barriers in fire protection discipline.