The current review is an update on experimental approaches in which birds serve as model species for the investigation of typical failure symptoms associated with autism spectrum disorder (ASD). The discussion is focused on deficiencies of social behavior, from social interactions of domestic chicks, based on visual and auditory cues, to vocal communication in songbirds. Two groups of pathogenetic/risk factors are discussed: 1) non-genetic  factors, exemplified by embryonic exposure to valproic acid (VPA), and 2) genetic factors, represented by a list of candidate genes and signaling pathways of diagnostic or predictive value in ASD patients. Given the similarities of birds as experimental models to humans , avian models usefully contribute toward the elucidation of the neural systems and developmental factors underlying ASD, improving the applicability of preclinical results obtained on laboratory rodents. Furthermore, they may predict potential susceptibility factors worthy of investigation , with potential therapeutic consequence. Experimental models are essential for evidence-based studies, especially those of the interventional type . They also help finding the appropriate level of explanation, blissfully avoiding the traps of Scylla and Charybdis, extreme reductionism  factors in the etiology of ASD (Autism Spectrum Disorder (ASD) is one of the most common neurodevelopmental disorders associated with altered social behavior. The variable and multifaceted character of the disease necessitates reliable animal models and multilateral approaches. Birds as evolutionary alternatives to mammals, with a wide behavioral repertoire, may well represent a special window of observation. Animal models may help discern genetic vsy of ASD . Experimcf. previous thorough reviews, The current summary is not intended to give a comprehensive account of available animal models for different autism related syndromes . Remarkably, however, no studies known to us have been reported on effect of embryonic VPA treatment on the vocal behavior of songbirds .Relevant VPA based  models should also consider the importance of innate calls. Parental care requires intense cooperation through coordination and synchronization of behavior, and an intense communication between the parents. Zebra finches change their vocal communication over pair formation and during nest building and incubation . They reA well-established ASD model for laboratory rodents is prenatal exposure to valproic acid (VPA), a known antiepileptic substance  and moodVPA has been used in birds first as a teratogenic agent. Domestic chicken eggs were injected with VPA at critical times of development to study malformations , or modiin ovo caused impairment of social behavior (but not imprinting) in chicks , albeit at a later phase of post-embryonic development, VPA exposure did not affect the innate approach preference of birds for the larger over smaller group of conspecifics, or for companion birds with natural facial features over those with blurred features . Knockdown of FoxP1 expression in juvenile birds led to a selective learning deficit, affecting the ability to form memories essential for the cultural transmission of behavior (adult model song)  .Cntnap2)   has beenCntnap2) . This geCntnap2) . A speciCntnap2) , pointinFragile X syndrome (FXS) is the most common inherited form of ASD, characterized by hyperactivity, impulsivity, and anxiety, as well as by defective language development. Many FXS symptoms appear early in life, together with emerging autistic features . A trinuIn addition to songbirds, FMRP has been located also in the brainstem auditory nuclei of domestic chicks, with a specific role in dendritic dynamics  and axonAdnp± mice develop impairments of cognitive and social behaviors  of the zebra finch , the important study by In most of the cases described above the genomic risk factors had been identified first in humans, then confirmed in mammalian model systems, and avian experiments “followed suit” as logical sequels. Notably, however, in the last two paragraphs examples were given for a reverse order of events: avian studies taking the lead to predict potential susceptibility factors worthy of investigation.The past decade witnessed a tendency for coupled/comparative studies, in which the results obtained from avian and human subjects were jointly analyzed. Most of these studies tackled different behavioral features of diagnostic or therapeutic significance of ASD . In addiNotion from comprehensive animal experiments will likely be extrapolated to normal and impaired regulation of social behaviors in humans. By model building of causal and therapeutic significance, avian experiments continue to contribute toward the elucidation of anatomically traceable neural systems and developmental factors underlying human autism spectrum disorder.


Despite the public health system’s critical role in non-communicable disease (NCD) surveillance in Vietnam, limited evidence exists on the implementation of NCD surveillance activities within these systems and the need for capacity building across different system levels to meet expected NCD surveillance goals. This study aimed to evaluate the status of and describe factors affecting the implementation of NCD surveillance activities and to identify the NCD surveillance capacity building needs of the public health system in Vietnam.We used a mixed-methods approach in four provinces, conducting self-completed surveys of staff from six Preventive Medicine Institutes (PHI), 53 Centres for Disease Control (CDC) and 148 commune health stations (CHS), as well as 14 in-depth interviews and 22 focus group discussions at four PHI, four CDC, and eight district health centres and CHS.Study findings highlighted that although Vietnam has a well-functioning NCD surveillance system, a number of quality issues related to NCD surveillance data were salient. Multifactorial reasons were identified for incomplete, unconfirmed, and inaccurate mortality data and current disease surveillance data. Data on NCD management and treatment were reported to be of better quality than data for screening, targeted treatment, and counselling communication. Main factors affected the effective implementation of NCD surveillance, namely lack of complete and specific guidelines for NCD surveillance, limitations in human resource capacity within NCD departments, and shortage of funding for NCD surveillance activities.Study findings provide practical strategies for strengthening health system capacity for NCD surveillance through developing policies, guidelines, and standardised tools to guide NCD surveillance and a road map for integrated NCD surveillance, developing training packages and manuals for all levels of the health system, and conducting utilisation-focused surveillance training programs.The online version contains supplementary material available at 10.1186/s12889-023-14986-4. What is already known?What does this study add?Vietnam’s public health system has a critical role in non-communicable disease (NCD) surveillance, yet surveillance structures are not well understood and underdeveloped, with continual reliance on global NCD estimates as NCD data at the national level is lacking. Understanding and bolstering NCD surveillance capacity could strengthen the NCD surveillance system and meet expected NCD surveillance goals.What do the new findings imply?This was the first study to investigate the context and capacity building needs of NCD surveillance in Vietnam which highlighted several quality issues related to NCD surveillance data, including lack of guidelines for NCD surveillance, limitations in human resource capacities within the public health system, and shortage of funding for NCD surveillance activities.A comprehensive understanding of the context and capacity building needs of NCD surveillance can support the development of policies, guidelines, and standardised tools to guide NCD surveillance and training manuals at all levels of Vietnam’s health system.Monitoring country progress towards the Sustainable Development Goals’ health-related targets, including those on non-communicable diseases (NCD), has resulted in widespread uptake of global health estimates from the World Health Organization (WHO) and the Institute of Health Metrics and Evaluation Global Burden of Disease study . The useHowever, national health studies or surveillance systems’ estimates can differ from global health estimates. For example, using data from the most recent Global Burden of Disease study, the percentage of total deaths attributed to NCD in Vietnam was 78% in 2014, 79% in 2016, and 80% in 2018 . DiscrepIn Vietnam, NCD surveillance relies on both curative and preventive systems. The General Department of Preventive Medicine, the MOH, serves as the central management body providing NCD surveillance technical guidelines and policy development and monitors their implementation nationwide. At the regional level, the six public health institutes (PHI) are responsible for two main functions: the implementation of national surveys on risk factors, nutrition and morbidity as well as training provision to provinces in assigned geographic areas. At the province level, Centers for Disease Control (CDC) oversee the development of local budgets and activity plans for NCD surveillance as part of the general NCD program. They aggregate provincial NCD data from hospitals and preventive units at district and commune levels to then report to the MOH. CDC also conduct NCD surveillance training to a cadre of districts and communes in the provinces. At grassroots levels, commune health stations (CHS) serve as critical nodes in the health information system; CHS collect, synthesise, and manage information and statistics as well as report health data—including data on NCD—to district health centres that aggregate CHS’ health data to report to provincial CDC . The disChallenges to effective NCD prevention and control in Vietnam include limited awareness of NCD within communities, regional disparities in medical services, healthcare staff shortages, and poor NCD surveillance . ImproviIn 2015, the Vietnam government endorsed a national Strategy for NCD Prevention and Control. While Vietnam has made steady progress on different facets of NCD surveillance, a stronger and more integrated NCD data collection system needs to be established along with a trained workforce able to analyse and use data at CHS and community levels . CurrentThis study assessed the implementation status of NCD surveillance activities in Vietnam, described factors affecting the implementation of NCD surveillance activities and identified capacity building needs of the public health system for NCD surveillance.A cross-sectional, mixed-method study was conducted between July and December 2020 to define the current state of NCD data capture within existing systems and to assess NCD data collection, reporting, and analytical capacity needs at CHS and preventive medicine systems at provincial, regional, and national levels.The analysis was grounded in a theoretical framework that considered input capacity, process and implementation capacity, and outputs, as demonstrated in Fig. All six Public Health Institutes (PHI) 100%)—the National Institute for Hygiene and Epidemiology, the Pasteur Institute in Nha Trang, the Pasteur Institute in Ho Chi Minh City, the Tay Nguyen Institute of Hygiene and Epidemiology, the Institute of Public Health in Ho Chi Minh city, and the National Institute of Nutrition—and 53 provincial CDC among 63 CDC in Vietnam (84.1%) returned filled questionnaires. Four provinces of the North (Bac Giang), Central (Khanh Hoa), Central highlands (Daklak) and South (Ho Chi Minh City) were selected for primary health care data collection to represent the geographic regions of Vietnam. Four districts, one district in each selected province, were randomly selected where all CHS in the four districts were invited to complete the questionnaire and two CHS were randomly engaged in qualitative inquiries ; reports related to NCD control and monitoring at CHS; and existing logbooks, tools, and reporting templates on NCD data at all levels.The study used a self-administered survey to collect data on capacity, utilisation, and gaps within the collection, management, and use of NCD information at the PHI, CDC, and CHS. The questionnaire was developed by the research team based on the functions assigned to each level regarding NCD surveillance. The questions were divided into three parts: implementation of NCD surveillance at each of the levels  through multi/single selection options and open-ended questions; the capacity and influencing factors through table/matrix filling, multi selection options and open-ended questions; and the obstacles, solutions and needs with additional types of ratings  currently being used for NCD surveillance. Each in-depth interview and focus group discussion lasted approximately 45 and 60 min, respectively  conducted thematic analysis on qualitative data using a pre-existing coding scheme as well as emerging themes. In addition, the study team reviewed technical guidelines on CHS NCD surveillance, reports related to NCD control and monitoring at CHS, and existing logbooks, tools, and reporting templates on NCD data at CHS. While data were collected at the regional level, the situational analysis primarily focused on the country-level context and did not provide an in-depth examination of regional differences in NCD surveillance capacity.In 2019, the Ministry of Health issued a new circular on health statistics indicators (20/2019/TT-BYT), which included increased indicators on NCD, mandating these to the provincial, district, and commune health care services and management systems, as demonstrated in Table PHI are not involved in the health data reporting system. Rather, these institutes provide information to the Ministry of Health and stakeholders on health system capacity and NCD risk collated through periodic standardised surveys such as WHO’s risk factor surveillance survey, Global School-based Student Health Survey, Vietnam General Nutrition Survey, and others. PHI, including the Institutes of Hygiene and Epidemiology and Pasteur Institute, as well as CDC, are responsible for synthesising and reporting this information and have been involved in mortality surveillance from the beginning of 2020. The National Institute of Nutrition and Institute of Public Health Ho Chi Minh City are not involved with mortality surveillance, as these institutes are not mandated to collect and monitor mortality data and have not been assigned this task by the Ministry of Health.As demonstrated in Table All PHI and approximately one-third of the CDC have established NCD databases, though they consist primarily of screening, treatment, and mortality data. Study findings indicate that CHS were likely to perceive their data quality was sufficient compared to PHI and CDC, especially regarding data completeness and accuracy All PHI, CDC, and most CHS implemented morbidity surveillance, focusing on hypertension and type 2 diabetes. A limited number of these units were involved in chronic obstructive pulmonary disease (COPD) and asthma diagnosis and management surveillance even though such surveillance was required in CHS. NCD morbidity data were collated from the NCD management book and other medical examination books at CHS, as noted as follows:“This data [NCD treatment] report is not complete because many clinics and hospitals are treating this kind of disease and we cannot collect their data. Some people are treated in other places. Data inaccuracy and incompleteness occurred often, including underreporting of new NCD cases and erroneous or incomplete NCD records from CHS. Qualitative data results from this study indicated that many CHS staff only obtained training on how to record, compile, and report data, but not how to collect data and check sources. The following quote illustrates data incompleteness:n = 148), population collaborators  (70.9%), and judicial and commune public security officials (42.6%)  levels, I obtain the cause of death information from hospitals and record it in the A6 logbook [this is the mandated documentation for all deaths]. In addition… information is also obtained from the village population collaborator or relatives. We [the CHS] have not re-examined the diagnosis of the cause of death, but only reviewed the list.” (CHS group discussion)Nearly 86% out of 148 CHS reported that they have a system for determining cause of death, drawing from multiple sources, with 54.1% collating information from interviews with the deceased individuals’ relatives, 49.3% based on death certificates of which cause of death was reported by family members of the deceased, and 37% based on hospital discharge papers prior to death. The least used source of mortality data was the mortality survey conducted with the deceased individuals’ families (13.5%). A CHS representative elaborated:n = 148) were trained in collecting information on mortality and 46.6% (n = 148) trained in diagnosing and coding mortality causes. In addition, no CHS reported having guidelines and standard tools that supported collecting data for cause of death identification.Findings from secondary data analysis show that approximately 70% of CHS staff shared that their station reported cause of death with ICD-10 codes according to the new Circular on health statistics. “Old age” was frequently observed as the cause of death for individuals 60 years and older. Instead of reporting the cause of death details with ICD-10 codes listed in the Circular, some surveyed stations reported grouped causes, such as “cancer” , even though 51.3% Qualitative interview and focus group results demonstrated that provincial PHI and CDC staff collated mortality data according to the statistical system reporting data (A6 logbook) from CHS without any inspection and supervision on the quality of these metrics:n = 6 and 73.6%, n = 53, respectively), lack of staff training and capacity building (66.7 and 52.8%), and lack of specific guidelines (66.7 and 52.8%). High workloads were identified as a primary challenge for CHS (56.8%). The following subsections provide details regarding capacity issues.Survey results Fig.  demonstrThe NCD framework and surveillance indicators have been established, with NCD policy documents on control and surveillance gradually being refined. However, a lack of national regulation and technical guidelines on NCD surveillance system structure and operations persists. In addition, guidelines for statistics and reporting (including NCD reporting) provide no specific guidance on coding standards or definitions for disease descriptions, particularly for morbidity data, though instructions on recording cause of death with ICD-10 codes for reporting mortality data do exist. Several CHS still use outdated regulations, impacting NCD data content and quality. Technical advisory agencies, such as the WHO, have provided resources to develop and standardise materials for NCD risk and health system capacity surveys. In addition to technical tool availability, such support assists in establishing a surveillance system structure and governance for periodical survey implementation.n = 148) have ever participated in training courses on collecting and managing data related to health education, screening, treatment management, and drugs and equipment for NCD prevention and control. Most CHS (approximately 90%) have assigned staff responsible for NCD who collect information and indicators on NCD according to the national health statistics mandate. However, frequent staff attrition and turnover in stations affect their capacity to collect and report data.Among surveyed CHS, more than 80% “We lack human resources for CHS and the CDC. These are young staff members, and they are still rotating a lot.” (In-depth interview of a PHI leader)The quality of technical support including training and supervision from PHI and CDC to lower-level agencies in NCD surveillance might be an issue when they still lack qualified staff for NCD surveillance. Most PHI developed training materials and guidance on NCD data collection and reporting, though they have not been standardised across the different institutes. Training on statistical reporting has been integrated into treatment management courses.All CHS have adequate guidelines and tools, such as logbooks and reporting templates for health statistics data collection and reporting as required, even though they lack guidelines on NCD surveillance. The use of logbooks for health education and hypertension are more common compared to other health topics, with logbook use for COPD and asthma the least common, explained by limited treatment and follow-up for these diseases in the CHS. Because CHS are the focal point for gathering information at the community level, stations manage multiple health programs and projects. However, reporting templates and information systems are not integrated, burdening staff with multiple rounds of data reporting and contributing to overwork in stations.As presented in Supplementary Table n = 148) used at least one software program to manage NCD-related data, and 8% (n = 148) used two or more types. In 2019, the Ministry of Health released health statistics software based on the District Health Information Software 2 (DHIS2) system. However, the software focused on electronic statistics reporting, not individual data entry and management. Meanwhile, the other local software to collect individual data on examination, treatment and monitoring by different vendors at CHS and other facilities cannot communicate and export data to the health statistics software. The use of local software has also been unstable sometimes. Therefore, all CHS kept paper-based logbooks to record NCD data. One CHS staff member shared:“Currently we have new software. It’s the only software used in our CHS. I heard that it’s very comprehensive, but I have not explored it thoroughly…. Meanwhile, we still enter data into 12 paper-based logbooks. Paper-based logbooks are our tangible properties which we can retrieve data anytime without fear of losing them someday. We have experienced software changes in our CHS, and we don’t know how to get our data back.” (A group discussion with CHS)CHS employed a variety of mechanisms to track and collect data, such as simultaneous use of paper and electronic forms , NCD management logbooks, outpatient paper-based and electronic records, and different statistical reporting software. Although health information software has been installed in all CHS, the lack of a standardised platform that can streamline information systems for all data management and reporting components has resulted in delays in reporting and inaccurate data. Among surveyed CHS, 52%  only had examination and treatment information fields. In contrast, other NCD management software at the community level had more fields available. Each software served a different purpose, elaborated on as follows:“The medical examination and treatment software could not export data by the patient, only containing the number of patient visits. In addition, CDC data reporting personnel have not been trained in medical examination and treatment software.” (A group discussion with CDC staff)“At present, there is no link between software. Data from the examined patient needs to be entered into a second or third software, and staff [at CHS] are afraid of [using and relying on multiple software].” (A group discussion with CDC staff)At CDC, the majority 94.3%) used Excel tools and 60.3% used Google Drive tools for statistics and reporting (Supplementary Table .3% used n = 6) of PHIs, 86.9% (n = 53) of CDC, and 26.4% (n = 148) of CHS have funding for NCD surveillance activities . However, only 83% (Funding for NCD surveillance within PHI was mobilised from their own budgets (33.3%) and from the targeted population health program budget (66.7%). Similarly, half of the CDC have funding from targeted programs. About 73.5% of CDC have mobilised local funds for NCD surveillance. From 2021 onward, no central government funding will be allocated to targeted programs in the health sector. The budget for provincial agencies is being reviewed and funded by the local government, of which the level of funding is consistent across provinces.“Population health targeted program funding has gradually decreased; there are many problems with financial resources as the Institute tends to be self-reliant. The appropriate program was applied but not enough [funding]. There are no resources for scientific research, and implementation of NCD surveillance activities only consists of training and supportive supervision.” (A group discussion with PHI staff)NCD data collection and reporting are integrated as a minor component in the annual plan for CHS. PHI staff shared thoughts as follows:Most stations did not have a separate budget for data collection and routine reporting, as these activities were considered regular responsibilities within the stations. The budget, if any, will be allocated for other activities and professional tasks.This was the first study to investigate the context and capacity building needs of the NCD surveillance system in Vietnam, examining the status and factors affecting the current implementation of NCD surveillance activities and identifying capacity building needs of the public health system for implementing NCD surveillance. Analysis of NCD surveillance-related issues has rarely been conducted in low- and middle-income country settings and could contribute to a holistic approach to maintaining high-quality NCD surveillance activities in Vietnam.The public health system has implemented NCD surveillance activities but not synchronously and comprehensively. In addition, several quality issues related to NCD surveillance data were uncovered in this study. Regarding mortality surveillance, the mortality data were relatively complete, but several limitations in data accuracy (particularly cause of death) existed. Limited activities have been established to supervise nor provide quality assurance of mortality data collected from CHS. In addition, although according to Vietnamese studies –19 more Regarding the perceived quality of surveillance data, most units at PHI and CDC claimed that data reporting was often conducted in a timely manner. However, these units believed that data quality was considered average or below average and that it would be difficult to sufficiently assess data for completeness and accuracy. CHS perceived a higher level of data accuracy than PHI and CDC. A high workload was considered a prominent challenge for NCD data collection and reporting compared to technical issues such as lack of capacity and guidance. Meanwhile, PHIs and CDC that provided training and guidance to CHS perceived a lower level of data accuracy and attributed this to a lack of technical guidance. The lack of technical guidelines on NCD surveillance, standardised process of data collection and quality control, and manpower from PHIs and CDCs for monitoring possibly contributed to poorer perceptions of data quality at CHS.It is recommended to consolidate the organisational structure of the NCD department within PHI and CDC to have adequate human resources and assign a dedicated team to manage NCD surveillance. In addition, only approximately half of CHS have received training to use data recording books and statistical reporting. A study conducted in Vietnam highlighted similar capacity building needs of the public health system staff for the prevention and control of NCD in CHS . SimilarThe qualitative data indicated that staff were aware of underreported cases of NCD when people access health facilities outside the residential location. Despite data source collection at the provincial level, cases were likely inaccurate because reporting data sources were aggregated, not patient level. Although some CHS and hospitals have used the software to collect individual data on care and treatment, no data connectivity between the care and treatment data software and DHIS2 based health statistics software cause an increased likelihood of data error, which is also reported elsewhere . In addiThis study identified a complex set of interrelated health system factors impacting the implementation of NCD surveillance in Vietnam and related capacity building needs. Concerning policy and governance, although the policy environment for NCD surveillance has improved and an NCD framework and indicators have been established, no complete and separate guideline for NCD surveillance exists. Higher-level guidance on statistical reporting focused on meeting the requirements of individual programmes and projects. Many CHS have not yet been instructed to implement statistical reporting according to newly issued regulations. A similar finding was reported in a qualitative study in Hanoi which demonstrated that health staff at CHS noted the lack of NCD informational materials for management and planning .As suggested by our study findings, the national NCD program in Vietnam should review policies, legal documents, and technical guidelines regarding NCD surveillance and develop new, amended, and supplemented legal documents for the collection, management, reporting, and use of NCD information at all levels of the health sector. The program could then develop a simple and standardised NCD reporting form that captures required NCD indicators to meet national data needs and minimise overlap of reporting responsibilities. In addition, standardised NCD reporting structures could be developed to use results at primary healthcare levels for patient care.Funding has a large impact on the sustainability of the NCD surveillance system. No direct funding stream for NCD data collection, management, and reporting current exists, as NCD surveillance funding has only been integrated into specific programs such as NCD screening and care communication campaigns . Lack ofOur study aimed to understand NCD surveillance at all levels of the health system, including technical support from regional PHI, technical management and direction from CDC, and implementation at primary healthcare levels (district and CHS). All surveyed CHS are in or adjacent to provinces where PHI are located and are likely to receive more technical support and monitoring compared to CHS located in provinces without such PHI. In addition, information bias could have occurred, as the study’s quantitative data on reporting accuracy was self-reported. To mitigate such bias, researchers explored NCD data and indicators collected from CHS in detail. Logbooks used at CHS were also reviewed during qualitative data collection visits.Study results indicate that although Vietnam has a NCD surveillance system integrated into health system management from community to central levels, many data quality issues persist. To improve NCD surveillance quality in Vietnam, the Ministry of Health should develop policies, guidelines, and standardised tools to guide data collection systems for integrated NCD surveillance, develop training packages and manuals, and conduct utilisation-focused training programs using face-to-face and online training. Additionally, the Ministry of Health should strengthen policy advocacy activities for funding for NCD surveillance activities by regularly disseminating NCD information to the government and other stakeholders and mobilising communities, businesses, and social organisations to prioritise NCD prevention.Additional file 1: Supplementary Table 1. Data collection tools and methods. Supplementary Table 2. Planning and funding for NCD surveillance activities. Supplementary Table 3. Questionnaire sections for the self-administered survey. Supplementary Table 4. The specialized documents for NCD surveillance. Supplementary Table 5. Source of information for identifying the number of death and cause of death in CHSs. Supplementary Figure 1. Self-assessment of data quality, timeliness, and completeness.


What tangible and accessible resources, such as scholarships and mentorship, are offered by national medical societies in the support of underrepresented minority and female trainees?In this cross-sectional study of all 45 medical and surgical societies recognized by the Council of Medical Specialty Societies, less than half of these societies offered readily accessible scholarships or mentorship opportunities to minority and female trainees despite 84.4% of societies declaring public support of this initiative.The accessibility of resources related to increasing representation in medical societies appears to be lagging behind published statements of support. This cross-sectional study examines resources for underrepresented minority and female trainees made available by nationally recognized medical and surgical societies. The lack of racial, ethnic, and gender diversity in medicine has been recognized as problematic, but the question of what medical educators and societies are doing to rectify and promote representation of historically marginalized groups persists.To examine what easily accessible resources are offered by medical and surgical societies to support women and individuals in minority groups that are underrepresented in medicine (URiM).This cross-sectional study evaluated transparent and accessible resources on the webpages of societies recognized by the Council of Medical Specialty Societies. Data collection and analysis were performed from September 1, 2021, to November 1, 2021.The society websites were searched for official diversity statements, diversity and women task forces or committees, and mentorship and scholarship opportunities for URiM and female trainees. The primary outcome was accessible resources in the form of financial support (scholarships) and mentorship for URiM and female trainees.Of the 45 societies included in the analysis, 38 (84.4%) have published diversity statements. All but 6 societies (86.7%) have a dedicated diversity task force, committee, or work group. Twenty societies (44.4%) have a committee specifically for women or include women in diversity task force initiatives. Seventeen societies (37.8%) offer minority-specific mentorship, 15 (33.3%) offer scholarships targeted toward URiM trainees, 10 (22.2%) provide gender-specific mentorship, and 8 (17.8%) offer scholarship opportunities for female trainees.Although most of the societies included in this study acknowledge the importance of diversity in medicine, less than half of these societies offer readily accessible scholarships or mentorship opportunities to URiM and female applicants. Indeed, surgical subspecialties continue to lag nonsurgical programs with regard to representation of women,11 but ongoing research continues as to why this remains the case despite endeavors to recruit more women.Another topic frequently covered under the umbrella of diversity in medicine is gender equity. In recent years, recognition of the disparate gender gap pervasive throughout medicine has driven increased efforts throughout all levels of training—from medical schools to residency and faculty positions—to promote greater gender inclusion.Journal of Racial and Ethnic Health Disparities, dedicated to these matters. The lack of racial, ethnic, and gender diversity in medicine has been recognized as problematic, but the question of what medical educators and societies are doing to rectify and promote representation of historically marginalized groups persists. To that end, the purpose of this study was to examine what, if any, easily accessible resources are offered to URiM and female trainees by Council of Medical Specialty Societies (CMSS)–recognized medical and surgical societies. We hypothesized that most CMSS-recognized societies (>75%) would offer tangible resources to URiM and female trainees.Change begins first with identification of the issue, thereby allowing an open discussion of potential solutions. However, this lack of diversity in gender as well as ethnic and racial realms has been a reoccurring concern at the national level, with conferences hosted by national organizations, such as the Association of Women Surgeons, and academic journals, such as the URiM will be used throughout this manuscript and is defined per the Association of American Medical Colleges (AAMC) as persons of racial and/or ethnic backgrounds who identify as Black, Mexican American, Native American , and/or mainland Puerto Rican.12 The terms female and women are used interchangeably throughout this article, and they are meant to describe both cisgender and transgender women. Resources are henceforth defined as tangible scholarships, mentorship, funding, and networking opportunities. Links to articles on the topic of diversity were not classified as resources. Easily accessible is defined as information readily available on websites that did not require email requests for information or membership to access.The term STROBE) reporting guideline.This cross-sectional study evaluated transparent and accessible resources on CMSS-recognized medical and surgical societies’ webpages. Data collection and analysis were performed from September 1, 2021, to November 1, 2021. No follow-up was necessary because this study was performed with a cross-sectional design. Institutional review board approval was not required because no patient data were included in this study. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology  medical and surgical societies were included in the analysis . Of the Box. American Academy of Allergy, Asthma and ImmunologyAmerican Academy of DermatologyAmerican Academy of Family PhysiciansAmerican Academy of Hospice and Palliative MedicineAmerican Academy of NeurologyAmerican Academy of OphthalmologyAmerican Academy of Orthopaedic SurgeonsAmerican Academy of PediatricsAmerican Academy of Physical Medicine and RehabilitationAmerican Association of Clinical EndocrinologyAmerican College of CardiologyAmerican College of Emergency PhysiciansAmerican College of Medical Genetics and GenomicsAmerican College of Obstetricians and GynecologistsAmerican College of Occupational and Environmental MedicineAmerican College of PhysiciansAmerican College of Preventive MedicineAmerican College of RadiologyAmerican College of RheumatologyAmerican College of SurgeonsAmerican Epilepsy SocietyAmerican Gastroenterological AssociationAmerican Geriatrics SocietyAmerican Medical Informatics AssociationAmerican Psychiatric AssociationAmerican Society of AnesthesiologistsAmerican Society of Clinical OncologyAmerican Society for Clinical PathologyAmerican Society of Colon and Rectal SurgeonsAmerican Society of HematologyAmerican Society of NephrologyAmerican Society of Plastic SurgeonsAmerican Society for Radiation OncologyAmerican Society for Reproductive MedicineAmerican Thoracic SocietyAmerican Urological AssociationInfectious Diseases Society of AmericaNorth American Spine SocietySociety of Critical Care MedicineSociety of Gynecologic OncologySociety of Hospital MedicineSociety of Interventional RadiologyThe Society of Nuclear Medicine and Molecular ImagingSociety of Thoracic SurgeonsSociety for Vascular Surgery13List as of September 2021.Thirty-nine societies (86.7%) had a dedicated diversity task force, committee, or interest group . Twenty 14 A large and increasing body of evidence suggests that diverse teams consistently outperform homogeneous groups in problem solving, innovation, and the successful completion of other complex tasks.16 Furthermore, as we learn more about the underpinnings of health disparities across different groups of people, the improvement of diversity in the medical community has become a major topic of discussion.17 In light of this growing awareness, we have seen moderate improvement in undergraduate medical education,18 but structural racism continues to contribute to differences in achievement of and opportunities for minority students.19 Progress in representation of Black20 and American Indian and Alaska Native21 matriculants have halted if not declined, with the current quota insufficient to serve the representative populations within society.2 With a growing, racially diverse population and a lagging relative proportion of minority physicians, there is a dire need to develop sustainable initiatives to increase representation. Although undergraduate medical education institutions for URiM students, such as Howard University, exist, improvement in representation of minority students has been driven by only a handful of schools.26 Moreover, a bottleneck persists in the pipeline of URiM residents in certain specialties,26 largely seen at educational transition points, such as those from medical school graduation to residency.27During the last 10 years, issues of diversity and inclusion in medicine and surgery have been brought to the forefront of popular discourse throughout the community. Globally, medical schools have been prioritizing the improvement of gender, racial, and ethnic diversity in medical education.28 Many URiM students struggle to obtain these relationships. Proposed reasons include the lack of social capital and financial barriers that come with being a first-generation college graduate29 as well as the lack of culturally concordant mentors.28 Furthermore, URiM students of low socioeconomic status may face financial obstacles in participation in networking events, such as national conferences and meetings. In 2020, the mean number of presentations, abstracts, and publications of seniors at US medical schools who matched to plastic surgery was 19.1.30 Often, these works are presented at conferences and meetings, which offer medical students the opportunity to build relationships with potential mentors in the field. With the lack of accessible mentors and the observed proliferation of community-based medical schools focusing on primary and ambulatory care in the last 15 years,33 many URiM students may have limited to no access to a department in their specialty of choice and thus struggle with obtaining the often required letter of recommendation from a department chair. Moreover, many residency programs unofficially require students to rotate at outside institutions during their fourth year for 1-month audition rotations, which are traditionally funded solely by the student. Competitive specialties, such as integrated plastic surgery and orthopedics, often require multiple audition rotations at different institutions to establish ties to particular geographic regions or receive letters of recommendation, enhancing the likelihood of residency interview invitations. The inability to fund these activities can be a significant impediment for URiM students of low socioeconomic status interested in applying for residency training in similarly competitive fields.Overwhelming evidence suggests that high-quality mentorship is key in the pursuit of a career in academic medicine and surgery.34 In addition, the Women of Color in Plastic and Reconstructive Surgery group has been making rounds on social media as a mentorship opportunity with the aim to “engage, connect, and empower plastic surgeons and plastic surgery trainees who identify as women of color.”35 Furthermore, integrated plastic surgery residency programs—often in association with their respective surgery departments—at various institutions, including our own, offer stipends to offset the cost of travel, housing, and fees for visiting fourth-year medical students from diverse backgrounds.Despite the current study demonstrating that less than half of CMSS-recognized medical and surgical societies provide resources for URiM and female trainees, there are several niche societies created to fill this void. In particular, the field of plastic surgery has various institution-specific initiatives and national groups to support the recruitment of these cohorts. An example of this is the Arthur L. Garnes Society, an organization dedicated to “fostering mentorship, collaboration, and fellowship among Black, African-American, and other underrepresented groups in medicine and in plastic and reconstructive surgery.”36 A multifaceted approach devised and implemented at the University of Pennsylvania Health System also increased representation of African American and Latino plastic surgery residents. This monetary travel scholarship and mentorship for URiM students who are pursuing an elective rotation at their institution deemphasizes board scores during residency application review and partners with a group able to perform effective outreach to URiM candidates.37 In addition, although the workshop is just beginning, the Plastic Surgery Research, Education, and Preparation Promoting Equity and Diversity Program, funded by the Plastic Surgery Foundation Diversity and Inclusion Grant, aims to prepare medical students from disadvantaged backgrounds for subinternships with the goal of enhancing their success at residency match.38 Critics of these initiatives iterate that the data are limited by inclusion bias because students seeking these opportunities may ultimately be in a position of success with or without these programs.Several studies from various surgical specialties demonstrate the influence of initiatives on career development and recruitment of URiM and female trainees. Specific to orthopedic surgery, the Perry Initiative and Nth Dimensions programs have successful track records in increasing female and URiM representation by offering guidance on career development, clinical exposure, networking opportunities, and research experiences to applicants.This study has several limitations. Specifically, a formal survey was not used to assess medical societies’ commitment to diversity initiatives. Administering a formal survey might have allowed for more inclusive results, given that some societal websites require membership to access areas of the sites, which entails submission of an application, letter of sponsorship, and fee in most cases. These societies were thereby reported as not readily accessible, although they may have offered scholarships and mentorship to members only; thus, we recognize that these results may not be complete. In the future, a more formal survey of medical societies is warranted to fairly assess meaningful financial outreach and mentorship opportunities. Furthermore, although we focused solely on CMSS-recognized societies, component institutions (societies or programs in association with CMSS) may offer supplemental opportunities. However, we were unsure how to identify component institutions or access potential resources.This cross-sectional study found that although most CMSS-recognized medical and surgical societies publish official statements on the importance of diversity and inclusion with respect to recruitment of trainees, fewer than half of these organizations appear to offer scholarships, funding, or mentorship opportunities to support URiM and female applicants. Featuring publicly available resources and initiatives on the CMSS society’s website that display its commitment to equitable racial and gender representation may help to attract a diverse candidate pool. This study serves to highlight the opportunities CMSS societies may offer to demonstrate their commitment to diversity and inclusion.


Nature-based solutions (NBS) were introduced as integrated, multifunctional and multi-beneficial solutions to a wide array of socio-ecological challenges. Although principles for a common understanding and implementation of NBS were already developed on a landscape scale, specific principles are needed with regard to an application in urban areas. Urban areas come with particular challenges including (i) spatial conflicts with urban system nestedness, (ii) specific urban biodiversity, fragmentation and altered environments, (iii) value plurality, multi-actor interdependencies and environmental injustices, (iv) path-dependencies with cultural and planning legacies and (v) a potential misconception of cities as being artificial landscapes disconnected from nature. Given these challenges, in this perspective paper, we build upon and integrate knowledge from the most recent academic work on NBS in urban areas and introduce five distinct, integrated principles for urban NBS design, planning and implementation. Our five principles should help to transcend governance gaps and advance the scientific discourse of urban NBS towards a more effective and sustainable urban development. To contribute to resilient urban futures, the design, planning, policy and governance of NBS should (1) consider the need for a systemic understanding, (2) contribute to benefiting people and biodiversity, (3) contribute to inclusive solutions for the long-term, (4) consider context conditions and (5) foster communication and learning. Global responses to societal challenges in terms of sustainability are called for by the 2030 Agenda for Sustainable Development and the New Urban Agenda adopted at the United Nations’ HABITAT III conference  potential development conflicts with urban systems nestedness; ii) specific urban biodiversity and related environmental conditions; iii) value plurality, multi-actor interdependencies and environmental injustices; iv) path-dependencies with cultural and planning legacies; and finally v) a potential misconception of cities as being artificial landscapes disconnected from natures.Given the five challenges NBS strategies should consider in the urban context, the aim of this perspective paper is to complement earlier considerations about NBS principles .Our proposed five distinct principles should be regarded as a suite of guiding tenets but not in isolation. They are interlinked, show clear overlaps and integrate knowledge from academic scholarship and build on lessons learnt about planning NBS in cities  knowledge, experience and learning during their implementation and environmental management establish connections of people with nature and in this way may also contribute to pro-environmental behaviour and increased awareness of the significance of sustainability in everyday urban life (Soga and Gaston Research in selected European cities has shown that near-natural greening is considered as attractive for humans and may provide similar opportunities for recreational activities compared to a conventional park or square (Fischer et al. In terms of making urban NBS part of sustainability transitions, they should be part of transdisciplinary and citizen-based environmental learning as well as awareness strategies and campaigns. Creating knowledge and increasing awareness about the benefits of nature in cities as a response to pressing global challenges, not only with the general public but also local decision-makers, may help creating an argument in local planning budget deliberations and increases support of implementing NBS compared to pure technical solutions (Davies and Lafortezza Planning and implementation of NBS should be informed by citizens’ concerns and preferences to support positive relations with urban nature. In this context, learning should be mutual, also aiming at expanding awareness for citizens’ needs. In addition to this, NBS efforts should be culturally sensitive and allow citizens to express their ideas of aesthetic appeal and functioning, balancing between subjective values, preferences, uses, conflicts and beliefs on the one side and goals of NBS planners for services delivery on the other side (Beumer and Martens Hundreds of scientific papers are now out all using and referring to the term, concept or framework of NBS. In 2016, we were among the first discussing perspectives on indicators, knowledge gaps, barriers and opportunities for action for NBS (Kabisch et al. Acknowledging existing principles being important for a broader landscape scale, with this perspectives paper, we aim to stimulate discussions on the planning and governance of NBS in urban areas. We introduced five principles for urban NBS because cities come with specific challenges. We conceptualised our principles against five major challenges and used recent research and urban applications for illustration. Our five principles for urban NBS offer an extended, interlinked perspective when NBS are to be implemented in urban areas but may also guide future research on urban NBS and sustainability transitions.With the consideration of our five principles for urban NBS, we hope to contribute to an increased appreciation of nature in cities in which the beneficial contribution of nature is considered, given a proper weight in collaborative decisions and becomes a core solution, while still considering that NBS build on living organisms and ecological processes that require context-adaptation, specific conditions, appreciation of citizens and long-term care.For some principles, we mentioned potential trade-offs related to NBS. More discussion is needed in the context of emerging contestations and conflicts that may arise when NBS are being implemented, even with best intentions. Future research may help to assess whether it is possible to avoid or partially or fully prevent trade-offs, and if not, how schemes to prioritise and decide between different actors, functions and beneficiaries could look like.With the Nature Editorial , now nea


Further investigations using larger groups are necessary to confirm our data and to verify in more depth the potential correlation between these biomarkers and ASD clinical features, such as the severity of the core symptoms, the presence of associated symptoms, and/or the evaluation of a therapeutic intervention. However, these data not only might shed a light on the neurobiology of ASD, supporting the neuroinflammation and neurodegeneration hypothesis, but they also might support the use of these biomarkers in the early diagnosis of ASD, to longitudinally monitor the disease activity, and even more as future prognostic biomarkers.Autism spectrum disorder (ASD) is one of the most common neurodevelopment disorders, characterized by a multifactorial etiology based on the interaction of genetic and environmental factors. Recent evidence supports the neurobiological hypothesis based on neuroinflammation theory. To date, there are no sufficiently validated diagnostic and prognostic biomarkers for ASD. Therefore, we decided to investigate the potential diagnostic role for ASD of two biomarkers well known for other neurological inflammatory conditions: the glial fibrillary acidic protein (GFAP) and the neurofilament (Nfl). Nfl and GFAP serum levels were analyzed using SiMoA technology in a group of ASD patients and in a healthy control group (CTRS), age- and gender-matched. Then we investigated the distribution, frequency, and correlation between serum Nfl and GFAP levels and clinical data among the ASD group. The comparison of Nfl and GFAP serum levels between ASD children and the control group showed a mean value of these two markers significantly higher in the ASD group . Interestingly, we also found a statistically significant positive correlation between GFAP levels and hyperactivity symptoms ( Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairment in different brain functional areas such as communication, social interaction, and restricted behaviors . The diaThe prevalence of ASD is highly variable across the world: it is estimated to be 2.5% in USA, 1.5 % in Denmark, Finland, and Sweden, and 1.7% in Great Britain . Autism Usually, environmental factors associated with ASD occur early in gestation, during the first or second trimester ,15. For In addition to these findings, other studies reported an association between ASD and the impairment in specific brain regions’ development, such as the amygdala, the cerebellum, and other regions of the brain ,21,22,23Nevertheless, although extensive studies have been carried out on autism, there are still several controversies about its neurobiological mechanisms. Evidence of neurodegeneration and neuroinflammation has been found in cases of children with ASD who experienced progressive loss of neurological function; these findings were associated with abnormal microglial cells and astrocyte activation, evidence of oxidative stress, and with the presence of proinflammatory cytokines and neuronal cell loss ,26,27,28More recently it has been shown that serum GFAP levels may be associated with the severity of ASD . InteresEarly diagnosis of autism leads to targeted rehabilitation interventions that can improve the natural history of the disease. Identifying diagnostic and possibly prognostic biomarkers at an early stage will help the clinician in choosing a targeted intervention for that type of patient.The novelty of our study lies in the simultaneous analysis of two serum biomarkers indicating processes of neuroinflammation and neurodegeneration using the SiMoA technology.Thus, the main objective of this study was the evaluation of these biomarkers to find possible diagnostic value and correlation with disease severity. The first aim was to assess Nfl and GFAP serum levels in a population of pediatric patients divided into two groups: the first group diagnosed with ASD and the second with neurotypical development (control group). The second aim was to investigate, among ASD, the relationship between serum NfL and GFAP levels and the clinical features obtained by neuropsychiatric assessment.A total of 71 children were recruited: 42 patients with ASD diagnosis were included in the clinical sample and 29 age- and gender-matched neurotypical development subjects (CTRS) were selected for the control group among patients admitted to the pediatric department for minor issues.Sociodemographic and clinical data of ASD patients are shown in Moreover, the following comorbidities were identified: 7 patients (16.67%) had a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), 17 patients (40.48%) manifested hyperactivity/impulsivity symptoms under the threshold for ADHD, and 1 patient (2.38%) had a diagnosis of a learning disorder. The instrumental diagnostic assessment evidenced the presence of nonspecific electroencephalogram (EEG) alterations in 4 patients (9.52%), and only 2 patients (4.76%) presented Magnetic Resonance Imaging (MRI) alterations; both findings were without clinical significance.p < 0.0001) in the ASD sample compared to controls .The comparison of Nfl and GFAP serum levels between ASD children and control group is shown in p value < 0.001). The matrix Spearman’s correlation test is shown in Then, in the ASD sample, Nfl and GFAP serum levels were compared between patients characterized by different neuropsychiatric and medical features. Although these results did not show statistical significance, Nfl and GFAP serum levels were higher in ASD subjects showing EEG and MRI abnormalities, speech impairment, intellectual disability, and higher ADOS-2 scores. Interestingly, GFAP serum levels were significantly higher in patients with hyperactivity  a mean value of Nfl and GFAP serum levels that is significantly higher in the ASD sample compared to controls; 2) a significant positive correlation between GFAP serum levels and hyperactivity. The Simoa technique allows one to measure very low concentrations of sNFl and sGFAP; it has previously been used by Wei-chao-He , but to Serum levels of Nfl and GFAP have been mostly investigated in some neurological conditions rather than in ASD or other neurodevelopmental disorders. Firstly, serum GFAP levels were studied as potentially informative for the prognostic and diagnostic evaluation of some neoplastic forms, such as gliomas . Foerch As for GFAP, the prognostic and diagnostic role of serum Nfl has been investigated: elevated levels were identified in many pathologies such as Huntington’s chorea, spinal cord lesions, neurodegenerative diseases such as multiple sclerosis, Parkinson’s and Alzheimer’s, and various forms of dementia .p < 0.0001). To assess the correlation between serum Nfl and the severity of ASD symptoms, serum values were compared to the patient score obtained through the structured CARS interview (which explores the severity of ASD symptoms), highlighting a positive correlation between the increase in serum NFl values and high CARS scores. Moreover, through an analysis of postmortem histological samples, several studies have revealed an aberrant astrocytic activity in different regions of the brain, highlighting a high astrocytic infiltration by immunohistochemical assays with an intense detection of GFAP. In 2015, Crawford et al. compared the levels of astrocyte activation markers in postmortem histological specimens between ASD patients and normal development subjects [In ASD, the data about these biomarkers’ diagnostic and prognostic value are very limited. However, our findings are coherent with previous studies. Some authors investigated the correlation of high serum Nfl values and severity of ASD symptoms, comparing serum Nfl levels in a group of ASD patients (age 3–8 years) to a control group of peers . Samplessubjects . The ressubjects . In a vesubjects . They fosubjects . In 2016subjects . Measuresubjects . The resA recent review reported evidence that supports the alteration of innate immunity in ASD, collecting data about aberrant immunity cell function and evidence of neuroinflammation and microglia activation . AnotherTaken together, these data strongly support the current hypothesis that neuroinflammation might play a potential role in the neurobiology of autism, mostly through the activation of glial cells such as astrocytes and microglia ,56,57,58The participants were recruited at the Child Neuropsychiatric Unit, University/Hospital Policlinico of Bari, between July 2021 and April 2022. The sample selection was based on patients, who referred to our unit as a first evaluation or for follow-up, diagnosed with ASD, according to the Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition [A sex and age-matched control group was recruited between typical neurodevelopment patients referred to General Pediatric Unit for minor illnesses, excluding autoimmune, inflammatory, infective, and major neurological diseases.All the participants underwent blood sampling, and sera were tested for Nfl and GFAP serum levels. Demographic (age and gender), clinical, brain magnetic resonance imaging (MRI), electroencephalogram (EEG), and neuropsychiatric data were recorded for all the patients. For all the participants, written informed consent was collected by the caregivers and the study was approved by the Local Ethics Committee of the University Hospital—Policlinico of Bari .Nfl and GFAP serum levels were analyzed by SiMoA technology using the Quanterix-SRX instrument. Nfl concentrations were measured via the commercially available SiMoA NF-light Advantage Kit . Serum GFAP levels were measured via the SiMoA GFAP Discovery kit  following the manufacturer’s instructions. Briefly, samples were tested blindly and in duplicate, and two quality controls  were run, in duplicate as well, on each plate for each run necessary to complete the study. Samples were run with a 4-fold dilution and results were compensated for this dilution. Nfl and GFAP concentrations (pg/mL) were calculated using a standard curve made from a sample of known concentrations in triplicate, as recommended by the manufacturer. For each protein, intra-assay coefficient of variation (CV) values were calculated by the SRX-analyzer software from technical replicate measures of specimens assayed within a single run. CV for these samples was <1%.All the ASD participants underwent the following neuropsychiatric evaluation: Intelligence quotient (IQ) was evaluated for all ASD patients. Patients with speech impairment underwent a non-verbal IQ evaluation using the Leiter-R Visual and Reasoning battery . This teAutism Diagnostic Observation Schedule-2 (ADOS-2)  is a semThe language skills evaluation was conducted using the Language Evaluation Test  , a standFor ASD patients who had IQ >70 and who already started primary school, writing, reading, and maths abilities were evaluated using the following standardized protocols: MT-3 test  for reading skills , AC-MT 3Sociodemographic data, including age and sex; clinical data, including IQ, language impairment, the severity of ASD symptoms, and total ADOS-2 score; and medical data, including EEG abnormalities, MRI abnormalities, and blood serum levels of Nfl and GFAP, were collected in structured databases exclusive for this research. Qualitative data were expressed in frequencies and quantitative data in means and medians. Statistical analysis was performed using IBM SPSS. Initially, we compared serum Nfl and GFAP levels of ASD patients and the neurotypical control group using the Mann–Whitney test. Then, we evaluated the distribution, frequency, and correlation between serum Nfl and GFAP levels and clinical data among the ASD group patients using the Mann–Whitney test and nonparametric Spearman correlation test.In conclusion, to our knowledge, the present study is the first one investigating both serum GFAP and Nfl in autistic children as potential diagnostic biomarkers. Indeed, we found that both of these markers are significantly higher in ASD patients when compared to healthy controls. Moreover, we found a positive significant correlation between sGFAP and the hyperactivity symptom. These preliminary data require further investigations to verify their potential diagnostic and prognostic purposes. Future studies might support the use of these biomarkers in the early diagnosis of ASD or in monitoring the progress of the disease, and eventually the treatment response.The main weakness of this preliminary study is the small size of the ASD group. Further investigations using larger groups are necessary to confirm our data and to verify in more depth the potential correlation between these biomarkers and ASD clinical features, such as the severity of the core symptoms, the presence of associated symptoms, and/or the evaluation of a therapeutic intervention. Nevertheless, even if this study is a preliminary investigation, the presence of significantly high levels of both serum biomarker values in the ASD group might support the hypothesis of mechanisms of neuroinflammation and neurodegeneration in the neurobiology of autism, and this evidence might have a higher impact on further studies.


The impact of the COVID-19 pandemic has prompted governments internationally to consider reform and strengthening of their Public Health systems. To support this work in Ireland, we undertook a review Public Health systems internationally (research question [RQ] 1), and identified lessons learned from the COVID-19 pandemic (RQ2).Data relating to Public Health systems (RQ1), and lessons learned (RQ2) for a select group of 12 countries were identified from organisations’ websites, an electronic database and grey literature search and representatives from key national-level organisations. Data for RQ1 were extracted, mapped to the 12 Essential Public Health functions (EPHFs) at national, regional and local levels, and verified by participating representatives. For RQ2, thematic analysis of semi-structured interviews with participating representatives was undertaken and.Typically, across all included countries, there is national strategic oversight of all EPHFs and, for certain functions, there is regional and local level implementation. Lessons learned from the COVID-19 pandemic broadly related to the themes of legislation and decision making; data collection, surveillance, evidence synthesis and collaboration; public health interventions; public participation, public messaging and communication; continuation of healthcare services; and workforce capacity and resilience.When structuring Public Health systems, there is a need to identify which functions, and or which elements of a function, should be delivered at a national, regional or local level to ensure a sustainable and comprehensive Public Health system. Appropriate IT infrastructure, strong communication and an established evidence synthesis function are key to timely and informed decision making. Ideally, these functions should be established during periods of relative stability to permit a faster response during a pandemic or emergency situation.


Research that demonstrates high quality reporting is important to improve clinical nursing practice and facilitate follow-up studies in various disciplines. Poor reporting is unethical ,2, and shttps://www.equator-network.org/). EQUATOR is an acronym for Enhancing the QUAlity and Transparency Of health Research. As the name suggests, the EQUATOR Network, an international organization, is a new initiative to persuade clear and transparent health research reporting [The most frequently recommended and well-known reporting guidelines were developed by the EQUATOR Network , as the official journal of the Korean Society of Women Health Nursing, is constantly striving to improve the journal quality by publishing quality research reports. Not only is this beneficial for our readership, but this would also be one of the strategies for the journal to be indexed in international journal databases, such as the Social Science Citation Index (SSCI). As one of the efforts to improve the quality of reporting of published research, while adopting a double-blind peer review system comprising a professional reviewer pool, KJWHN also recommends using the reporting guidelines of the EQUATOR Network in its author guidelines [The idelines . In addiidelines -11. KJWHDespite the concerns regarding the strict use of reporting guidelines inhibiting the creativity of researchers , the perThe EQUATOR Network was officially launched in 2008 as a result of the EQUATOR project, which was funded by the United Kingdom in 2006 and intended to make a map for preparing and disseminating health research reporting guidelines and establish a global collaborative relationship among key persons [As a simple structured tool, reporting guidelines are used by researchers while writing manuscripts and they comprise a basic list of information required to enable reviewers and readers to make accurate appraisal of the research quality . As suchIn addition to many biomedical journals, nursing journals also emphasize the use of reporting guidelines while preparing manuscripts, but there are no previous studies on how much the reporting guidelines are specifically recommended in nursing journal guidelines. Therefore, for this editorial, 122 journals listed in the nursing category of SSCI as of June 1, 2022 , were anAmong the 122 SSCI nursing journals, 94 journals (77.0%) specified adopting the EQUATOR Network’s guidelines in their author guidelines, whereas 28 journals 23.0%) did not mention reporting guidelines at all. This rate is quite high compared to a 2012 study of journals in other disciplines, in which 46% of journals mentioned reporting guidelines in their journal instruction [.0% did nAmong the 94 journals that mentioned reporting guidelines use, 85 (90.4%) provided information about representative reporting guidelines according to the research design, such as CONSORT  guidelines along with the EQUATOR Network link URL, whereas 9 journals (9.6%) simply mentioned the use of the reporting guidelines of the EQUATOR Network without listing reporting guidelines specifically.The reporting guidelines that were frequently mentioned more than 10 times in nursing journals are PRISMA  for systematic review (n=71), CONSORT for randomized trials (n=64), SQUIRE  for quality improvement studies (n=42), STROBE  for observational studies (n=41), COREQ  for qualitative research (n=37), TREND  for nonrandomized trials (n=27), STARD (STAndards for the Reporting of Diagnostic accuracy) for diagnostic/prognostic studies (n=19), CARE (CAse REport) for case report (n=14), SRQR  for qualitative research (n=14), and MOOSE  for systematic review of observational studies (n=12), as arranged based on their frequency. Details, including the meaning of acronyms for reporting guidelines, version information, and the direct link URL of either the EQUATOR website or individual guideline website; are presented in If readers click the suggested link URL in In addition, the level of recommendation regarding reporting guidelines also varied. Some nursing journals required authors to complete and attach reporting guideline checklists while submitting the manuscript, whereas other journals only encouraged authors or reviewers to refer to reporting guidelines when writing or reviewing a manuscript, and as stated above, some journals did not mention reporting guidelines at all. Given that this is a phenomenon also frequently seen in other disciplines , althougNumerous guidelines have been presented on the homepage of the EQUATOR Network , but it https://www.equator-network.org/wp-content/uploads/2013/11/20160301-RG-Decision-Tree-used-for-EQUATOR-wizard-vn-1.pdf), which is an algorithm that helps in the selection of reporting guidelines [https://www.penelope.ai/equator-wizard), a new tool to help authors find the right reporting guideline or different checklists for different types of study design [Recently, algorithms and websites have been developed to help authors find reporting guidelines that fit their research design effectively. The EQUATOR Network developed the EQUATOR Reporting Guidelines Decision Tree (idelines , and theAs the positive influence of adhering to reporting guidelines enhancing the quality of published research is evident, I suggest strategies for the effective use of reporting guidelines by authors, reviewers, and journal editors, based on the EQUATOR Network’s suggestions and previous studies.Firstly, for authors, try to find out the reporting guidelines when planning the study and drafting the manuscript, rather than at the stage of submitting the manuscript . AuthorsSecondly, reviewers should understand the reporting guidelines correctly and verify the proper reporting of each item in the manuscript. To improve their detailed understanding of the frequently used reporting guidelines in nursing, and to increase general awareness about reporting guidelines, reviewers should acquire updated information. Opportunities in academic communities to actively share the experience of using reporting guidelines would be a practical measure to this aim, through events such as conferences and workshops.Finally, the editorial board of journals should include the link to the EQUATOR Network website as well as frequently used reporting guidelines in the ‘Instructions for Authors’ to find the available reporting guidelines easily. In addition, the editorial board should attempt to provide clear instructions on the appropriate use of the guidelines so that authors and reviewers can easily assess the quality of the manuscript based on reporting guidelines. Journal editors and reviewers should also review the manuscript carefully, verifying the adherence to recognized reporting guidelines pertinent to the research design in the manuscript. Similar to the previous research conducted by the editorial board of KJWHN to evaluate reporting guideline use, further evaluation studies must be conducted regularly to identify reporting areas for improvement and weakness. These efforts should be actively shared with authors and reviewers to promote their understanding and motivation for using reporting guidelines. As noted above, continuous education for guideline use in the academic conference or workshop should be provided to authors and reviewers to improve research quality in the journals.


Adding health interventions to women's groups primarily formed for financial purposes, such as self-help groups, is a widely used strategy to reach low-income women. An analysis of implementation intensity highlights the importance of ensuring that women's groups have sufficient time and population coverage to address health issues. Women's self-help groups in 2 Indian states discussed health issues for approximately 30 minutes per month in group meetings, with wide variation in member participation across interventions.Home visits that aimed to reach women with health information outside of group meetings reached between 30%–40% of households with a group member. Women's participation in community events was low.Group-based interventions commonly employed a range of social and behavior change techniques that aimed to increase women's individual knowledge and build social networks.Approaches to layering health activities onto existing women's groups should carefully consider the time available in group meetings to discuss health and calibrate intervention goals accordingly.Implementers and researchers should monitor, evaluate, and report implementation intensity of layered interventions, including group meetings, individual visits, and community-based events.Policy makers can explore a range of approaches to address health through working with groups, ranging from information dissemination to community mobilization. They should consider women's health priorities, time availability to participate in intervention activities, and the intensity required to improve health outcomes. In India, a large network of self-help groups (SHGs) implements interventions to improve women's and children's health and nutrition. There is growing evidence on the effectiveness of women's group interventions to improve health but limited information on implementation intensity, including how often groups meet, for how long, and with whom, despite this often being cited as a key factor for success. We aimed to assess the implementation intensity of large SHG-based health and nutrition interventions with rural, low-income women, to inform program design, delivery, and measurement.We synthesized process data from surveys, meeting observations, and process evaluations across 8 maternal and child health and nutrition interventions in India. We examined the implementation intensity of 3 common intervention delivery channels: group meetings, home visits, and community-level activities.SHG members spent approximately 30 minutes in monthly meetings discussing health or nutrition. SHG dissolution or limited participation in meetings was a common challenge. Beyond group meetings, home visits reached approximately 1 in 3 households with an SHG member. Pregnant and breastfeeding women's participation in community events varied across interventions.Interventions that aim to capitalize on existing networks of financial women's groups not specifically formed for health and nutrition objectives, such as SHGs, will need to have an implementation intensity that matches the ambition of their health objectives: substantial changes in behavioral or mortality outcomes are unlikely to be achieved with relatively light intensity. Interventions that require sustained interactions with members to achieve health outcomes need to ensure adequate community and individual outreach to supplement group meetings, as well as improved participation through more intensive community mobilization approaches. Evaluations of group-based interventions should report on implementation intensity to support the interpretation of evaluation evidence and to inform further scale-up. The National Health Mission supports government community health workers such as accredited social health activists (ASHAs) to engage women's groups in participatory learning and action to improve maternal and newborn health.–In another approach, the National Rural Livelihood Mission supports the formation of women's self-help groups (SHGs), voluntary groups of 10–12 adult women who engage in joint savings, credit, and livelihoods activities. SHGs reached 50 million households by 2020, with the goal of reaching 70 million in the next 4 years.,Coverage: SHGs are widespread in many states, and their members are largely from low-income and vulnerable households that are also a focus of health interventions. For example, approximately half of rural households in Bihar and Jharkhand are covered by SHGs, and a population survey reported that nearly 30% of pregnant women/mothers with children aged 2 years and younger were SHG members in 3 additional states.Organizing structure: SHGs function according to established guidelines, which include weekly meetings and regular financial transactions, providing a ready forum to conduct additional discussions on health and nutrition. Groups are also federated at the village and cluster level, which supports collective activities and information dissemination beyond individual groups.–Due to their structure and functioning, SHGs may address underlying determinants of health by design, including financial security, decision making, and political participation.There are 3 potential advantages of integrating health interventions into existing microfinance-based SHGs —commonly known as “layering”—in India.,,,how these interventions work—who participates, for how long, what do they do, and how often.Taken together, these 3 features suggest that add-on interventions could result in a multiplier effect on health, nutrition, and well-being. Impact evaluations and observational studies indicate some improvements in health behaviors among SHG members through layered interventions.Global evidence syntheses on women's groups have identified significant gaps in our understanding of how these interventions work.,quantitative measure of the amount of inputs into, or activity to support, program implementation.Understanding the implementation intensity of these interventions is critical to identifying implementation features specific to women's groups that influence effectiveness, along with transferability and scalability in different settings.Measures of intensity  vary based on an intervention's theory of change and envisaged processes. Interventions with SHGs to improve health and nutrition have several advantages but also specific challenges. The intensity of additional interventions with SHGs largely depends on the strength of the preexisting groups established to meet financial objectives; this objective defines the demographic profile of members and how frequently they meet.,,Despite the widescale interest in improving health and nutrition outcomes using women's groups, including beyond India, evidence syntheses consistently highlight that relatively little is known about the intensity achieved in practice through add-on or layered health interventions.SHG-based health and nutrition interventions center on the presence of a preexisting group—a consistent, captive audience—and are premised on women learning new information and skills related to health and nutrition. The population coverage and active functioning of groups influence the overall community-level intensity of the intervention, supplemented by activities that extend beyond group meetings to reach individuals and community members. These typically include home visits, community-level meetings and events, and less commonly, supply-side interventions.We drew from the literature on health and nutrition interventions with SHGs to identify 3 intervention channels relevant to implementation intensity: group meetings with SHG members; individual outreach; and community health activities. We first identified studies from a 2020 published mixed-methods systematic review of studies on women's groups and health outcomes conducted in India.,–From the systematic review, we included 5 studies that met 2 inclusion criteria: (1) evaluated maternal and child health and nutrition interventions implemented with SHGs, and (2) reported indicators of implementation intensity, at minimum the meeting frequency and intervention coverage. The 5 studies that met these inclusion criteria reported on layered health interventions with 2 large SHG programs: (1) JEEViKA, a state-level government livelihoods program in Bihar under the National Rural Livelihood Mission, and (2) Uttar Pradesh Community Mobilization Program (UPCMP), led by a nongovernmental organization.The interventions had similar implementation approaches—health and nutrition discussions by trained facilitators in SHG meetings, home visits, and additional community-level events. The interventions included pilots in limited geographies to test the layering approach and subsequent implementation in larger geographies. The interventions we included in our analysis had similar implementation approaches—health and nutrition discussions by trained facilitators in SHG meetings, home visits, and additional community-level events.We synthesized available data in 3 ways. First, we examined group and community-level intensity by compiling data on the frequency and length of SHG meetings on health, intervention duration, and group dissolution. Length of health discussion in meetings was based on direct observations, where reported. These meetings included scheduled health and nutrition meetings  as well as regular SHG meetings. Next, we compiled data on women's exposure to health messages outside of SHG meetings. Finally, we drew on Kok et al.'s taxonomy to identify the number and types of social and behavior change techniques employed in interventions.Our findings present a largely consistent picture of intensity achieved by health interventions with SHGs in Uttar Pradesh and Bihar, India. The programs studied had similar implementation models in which trained facilitators added health and nutrition interventions into large-scale SHG programs. Most interventions were implemented for at least 1 year, suggesting an intent to achieve health and nutrition outcomes through sustained contact with members, but available data from 2 studies indicated that between a quarter and a third of groups dissolved over the intervention period. In addition, SHG members spent approximately 30 minutes per month discussing health and nutrition. Interventions employed a similar number and range of social and behavior change techniques, consistent with the intent to reach women beyond the group meetings, along with family members and the wider community. Targeted activities, such as home visits, reached more than a third of households with an SHG member. As reported by women, community meetings and events were not well attended by the focus population of pregnant and breastfeeding women. Behavior change techniques varied according to the intervention's intended outcomes. For example, interventions that aimed to improve child dietary diversity placed greater emphasis on individual-level techniques, whereas maternal health interventions used more social and environmental techniques. No studies described the specific behaviors targeted by each technique.,,Members' participation in health and nutrition meetings varied widely across interventions. Participation was higher in pilots of the layering approachParticipation in meetings was higher in pilots of the layering approach compared to fully scaled-up programs, which may reflect less intensive program inputs when programs operate on a wider scale.,Our findings are consistent with a recent synthesis of enablers and barriers to implementing women's group interventions to improve health and nutrition.Our findings point to 3 priority areas to strengthen the delivery of health and nutrition interventions through microfinance-based women's groups.First, programs will require a realistic assessment of time spent on health and nutrition in SHG meetings. The members spent 30 minutes per month discussing health, potentially because the group has limited time beyond primary objectives of savings and credit or health/nutrition topics were not of member's interest.Second, the strength of the underlying group – regular meetings and sustainability over time– is likely a prerequisite before considering layering on additional interventions at scale. If groups are not meeting weekly as per their core principles, or groups are likely to dissolve, the platform itself may not be ready to absorb an additional load on women's time. While including nonfinancial topics may attract women to attend meetings, there is no evidence that groups with additional agendas have lower dissolution rates. Accordingly, add-on interventions should assess the readiness of the underlying group, as well as consider processes that support integration of new activities over time into the group's overall approach. The sustainability of SHGs poses another complexity to program implementation: older groups tend to conduct less regular group meetings, while newer groups meet more regularly but may require time to accept and adopt additional interventions.Strength of the underlying group is likely a prerequisite before considering layering on additional interventions at scale.,Third, where SHGs are not primarily composed of concerned women , home visits or community events are the primary modes for reaching these women. Interventions may place a greater emphasis on community events and home visits, aligned with evidence on community interventions that have improved maternal health and nutrition in similar settings.,Further, the evidence base offers alternative approaches to engaging with groups to improve population health and nutrition. For example, an ongoing nutrition pilot in 3 states of India engages with SHG federations through participatory, community-based mapping of nutrition needs and active convergence across government departments to extend intervention reach. Lastly, we have identified several areas for continued research on how women's groups improve health. Impact evaluations will benefit from describing and tracking implementation processes specific to women's groups, such as intensity and population coverage. While the studies in this synthesis reported on intensity to some extent, none captured population-level estimates of participation in the interventions. Research and analysis of why groups dissolve and the factors that influence member participation and retention will provide important insights. In addition, evaluations of behavior change interventions will benefit from analyses not just of the intensity of different techniques, but also whether the techniques were suited to the target behaviors.Our analysis has some limitations. We did not link levels of, or variations in, program intensity to outcomes achieved since the required intensity of social and behavior change interventions depends on the intended outcome as well as specific behaviors. For example, a simple information dissemination campaign may be sufficient to improve awareness of schemes for institutional delivery, while reducing neonatal mortality requires extensive contact within and beyond the group to address individual beliefs and capabilities as well as social norms.While SHGs or other women's group networks may provide a ready-made channel for health interventions, our findings indicate that interventions must reconsider how to improve the intensity with which concerned women can be reached. Low implementation intensity also suggests that observational evidence of improved maternal and child health behaviors among SHG households may depend on mechanisms outside of layering health and nutrition messages and activities onto group meetings, such as self-selection of members into groups.


Frontiers in Genetics and Frontiers in Nutrition – Nutrigenomics, forward-thinking reviews and original research manuscripts provided by experts in the field promote cutting edge computational and statistical approaches, discover novel nutrigenetic relationships, and provide critical guidance on evaluating and implementing nutrigenetic findings in a clinical setting to improve human health.Precision medicine brings hope and draws attention towards advances in nutrigenomics research which elucidates the synergistic roles nutrition and genetics play in human health. In this Research Topic of Doherty et al. outline the enormous potential for artificial intelligence-led functional food ingredient discovery, validation, and characterization to address these challenges in a high-throughput manner. The authors argue for an artificial intelligence integrated workflow that complements traditional approaches from the start, highlighting its power in two case studies: the discovery of Asian rice as a potential anti-inflammatory food based on predicted immunomodulatory peptides and the characterization of peptide function in a hydrolysate derived from Vicia faba  previously shown to prevent muscle atrophy. These approaches pave the way for future work integrating naturally occurring genetic variation in both the food compound and the human host to understand how these genetic effects may modify efficacy and implementation in precision health.Functional food ingredients that have a scientifically backed impact on human health and disease are in high demand with consumers looking for both more products and more information on their source, activity, and safety. Identifying and characterizing impactful bioactives is a tedious process, typically done in a wet-lab, using specialized and expensive instruments. N = 1,573), Lee et al. combined a genome-wide and epigenome-wide scan for body mass index with 397 dietary and lifestyle factors and their interactions using the generalized multifactor dimensionality reduction method to identify significant predictors of obesity , and then compared machine learning algorithms to identify the model with the best prediction accuracy in an independent sample (N = 394) from the same cohort. The stochastic gradient boosting model achieved an ROC = 0.72 and its top predictors included 21 SNPs and 230 DMs in genes such as CPT1A, ABCG1, SLC7A11, RNF145, and SREBF1 and 26 dietary factors with processed meat, calcium intake, and diet soda at the top.Obesity is one of the main risk factors associated with the development of non-communicable diseases , worldwide. To create preventive strategies against obesity and its sequelae, there is a need to develop approaches that integrate genetics, epigenetics, environmental factors, and their complex interactions. Using data from the Framingham Heart Study  genetic instrumental variable analysis, Taba et al. apply a novel method in refining genetic instruments for MR by selecting SNPs which do not demonstrate mediation by common factors such as body mass index, educational attainment, and many others. They apply this approach to assess the causal effects between 40 foods and dietary patterns and 123 blood metabolites, representing some of the most likely intermediates on the path from diet to human disease. Together with their more recently published work  low 31-SNP nutrigenetic risk score in overweight and obese adults – both in the context of triglyceride changes in response to omega 3 fatty acids eicosapentaenoic acid (EPA) and/or docosahexaenoic acid (DHA). In the current perspective article Keathley et al., the authors apply the AGREE II approach to consider desirable and undesirable impacts, values and preferences, and resource use to develop clinical practice guidelines. The first recommendation of which is that triglyceride responsiveness to EPA/DHA omega-3 fatty acids in males can be based on APOE SNPs , however, given the link between this locus and Alzheimer’s Disease, care-providers need to comply with local regulations and patient consent while also considering ethical and legal implications of this test. The second recommendation confirms the use of previously published 31-SNP nutrigenetic risk score to evaluate TG responsive to EPA/DHA supplementation in both male and female overweight or obese adults. Their final recommendation is to not use these nutrigenetic findings for plasma lipids, lipoproteins and apolipoproteins given the current available evidence.Though clinical practice guidelines in nutrigenetics do not yet exist, they could be an effective tool for clinical care providers and policy makers to translate scientifically valid findings to healthcare. In a previously published article by Within this Special Section in Nutrigenomics, we offer but a glimpse on many aspects of diet and nutrition, nutrition’s role in health and disease, and the practical implementation of bringing precision nutrition to the public.