The SARS-CoV-2 pandemic disrupted the delivery of education in our school systems and exacerbated pre-existing health and educational disparities. School administrators and staff from underserved communities struggled with continuously changing medical guidance, ensuring equitable education by virtual platforms, and re-opening schools safely. The Hackensack Meridian School of Medicine (HMSOM) partnered with statewide resource-limited school districts to create the COVID Support Our Schools (SOS) initiative. This consisted of a physician advisory board, medical student task forces, and community leaders. Numerous sessions were hosted by the COVID SOS team to answer questions, address community needs, and carry out initiatives to meet identified needs. Surveys, including Likert scale questions and open-ended feedback, were administered to all participating school districts. In total, 100% of respondents strongly agreed or agreed that the COVID SOS program was dedicated to community needs and provided timely support with necessary resources. Open-ended feedback described that the K-12 school districts valued our partnership as well as found the opportunity to engage with other districts informative and rewarding. The partnership between our academic medical institution and community school districts is mutually beneficial, providing an opportunity for medical student service learning as well as imparting medical expertise in times of need. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has not only been challenging for the medical community but has caused chaos and disruptions in our kindergarten through 12th grade (K-12) school systems . This drAcademic health departments or community institutional partnerships refers to the collaboration between academic medical institutions and public/community departments ,6. CommuAt the Hackensack Meridian School of Medicine (HMSOM), we collaborated with our local K-12 school districts and implemented the COVID Support Our Schools (SOS) initiative. Pre-existing well-established community partnerships were essential for rapidly identifying and responding to the needs of the community during this health crisis. This highlights the value for medical schools to develop strong community partnerships, which proved to be instrumental in a healthcare crisis.The objectives of this report are to illustrate our mutually beneficial community–academic partnership and review quantitative and qualitative feedback about the program from our community partners.The COVID SOS initiative was developed as part of the Human Dimension Course at HMSOM. This curriculum was built upon prior established philosophies of community-engaged medical education (CEME) which “underscores a relationship between the community served and medical school that is both interdependent and reciprocal” ,13. FundK-12 school districts were invited to join the program based on their preexisting relationship with HMSOM and the Human Dimension Course. In total, 11 school districts and one Boys and Girls Club representing 138 individual schools across a broad geographic region in New Jersey, from historically underserved areas with students from marginalized populations, were enrolled in the program. Community needs were identified during town hall, recurring meetings, individual conversations, and correspondence.The COVID SOS Advisory Board consisted of an interprofessional committee of clinical physician faculty and a community engagement team. Twelve faculty members representing diverse specialties including pediatrics, internal medicine, family medicine, infectious disease, library sciences, and emergency medicine worked alongside a team of two social workers, one community engagement specialist, and four community liaisons.Since the spring of 2020, the COVID SOS Advisory Board has hosted regular Question and Answer (Q&A) sessions for school leaders at various intervals ranging from weekly to every 3 months based on local COVID-19 trends. A total of 24 sessions, each 60–90 minutes long, were conducted via video conferencing. Each session had a topic of focus which was pre-determined by community member vote during the previous session. During the virtual sessions, community partners and faculty were placed into breakout groups to allow for individualized support; groups would then report back to share challenges and solutions in a discussion with the full group. Session topics included: COVID Guidelines, Staffing and Operational Challenges, Child Abuse and Neglect during COVID-19, Masking, Planning for Vaccinations, Education Disparities, Unique Challenges of Remote Learning, and the Mental Health impact of COVID-19 on Communities. In between Q&A sessions, school districts had direct access to faculty to answer questions specific to their school in a timely manner.The COVID SOS Student Task Force component of the initiative matched groups of eight preclinical medical students supervised by one clinical faculty with school districts and specific schools to support leadership on any COVID-19-related challenges the school(s) elected. The task forces met with their school partners approximately every 4–6 weeks via video conferencing for approximately 60 min, during which the schools outlined challenges and tasks for which the students could help research and create solutions. Examples of task force areas of focus included: Translating and Operationalizing COVID-19 Guidelines, Virtual Interactive COVID-19 Educational Series for Elementary Students, COVID-19 Vaccine Q&A for Students, Parents and School Staff, Developing and Hosting Mental Health and Wellness Programs for Middle School Students, and Programming to Improve Digital Literacy. Both the COVID SOS Advisory Board and the Student Task Forces were supported by the HMHSOM Community Programs Team.The study survey was approved by the Institutional Review Board (IRB) committee at Hackensack Meridian Health and designed to evaluate the success of the program as well as identify ongoing needs. Questions were structured to provide both quantitative and qualitative feedback. The survey was administered to all school personnel who participated in the program. The school district and job category were collected and this information was then de-identified, with limited staff having access to the identifiable data.Qualitative response themes from the survey included:Informative: Obtaining real-time interpretation of COVID-19 guidelines from experts as well as information sharing among school districts and their challenges and responses.Relationship Building: Ability to develop long-lasting relationships with both the medical community and other school districts.Medical Student Involvement: Contributions from medical students to individualized needs of the schools.All of the schools who were invited to participate in the program accepted. There was an 83% response rate to the survey sent to the participating school districts to evaluate our COVID SOS initiative. The survey questions explored the impact, effectiveness, and timely support of the COVID SOS initiative as well as addressing community needs and providing resources. The responses were scored on a 5-point Likert scale from ‘strongly agree’ to ‘strongly disagree’ as well as open-ended questions for comments regarding the initiative. ‘Strongly agree’ and ‘agree’ responses were grouped as favorable as shown in Open-ended feedback regarding the most helpful aspects of the initiative revealed that the discussions were very informative and that having medical expertise outside the districts’ resources was incredibly valuable. The opportunity to connect with other school districts and to build relationships was also a prominent theme. Lastly, comments pointed to the valuable contributions that the medical students made for the districts’ work around COVID-19. In total, 100% of respondents reported that they would recommend partnering with a local medical school on a program like this to other school districts.This program highlights the critical importance of established community partnerships between academic medical institutions and community stakeholders to provide invaluable assistance during a time of need, such as a global pandemic.Community stakeholders can often provide deep insight and background, thereby increasing research relevance and feasibility . It is cIn addition, involving community stakeholders such as school districts can decrease the marginalization of communities that have historically not been involved in research settings. The approach of treating the community stakeholder as an equal partner engenders trust and an optimal collaboration.These partnerships are mutually beneficial by providing medical students important real-life experiences to develop advocacy and social determinants knowledge and skills, while also providing the community with guidance based on medical expertise. Medical students are in a unique position to mobilize effectively and quickly during a healthcare crisis.The unique characteristics of this partnership facilitated the collaborative process and promoted engagement amongst all parties. The medical students, physicians, and school leaders rated this initiative highly. Together, the teams were able to display an agile response to a rapidly changing environment.Limitations: Our sample may not be representative of the state of New Jersey or the entire United States. Although the school staff found the information presented in our sessions useful, we were not able to measure outcomes such as vaccination rates of school personnel and students, effectiveness of school policies in infection prevention and control, and student performance during the pandemic.Our initiative can serve as a framework for other institutions to establish a community–academic partnership. Such initiatives and community involvement can continue beyond the pandemic to address ongoing healthcare concerns and challenges such as vaccine hesitancy, health curriculum, and sports safety.


Vaccinia virus vaccine, as an alternative to ACAM2000. In November 2021, ACIP unanimously voted in favor of JYNNEOS as an alternative to ACAM2000 for primary vaccination and booster doses. With these recommendations for use of JYNNEOS, two vaccines (ACAM2000 and JYNNEOS) are now available and recommended for preexposure prophylaxis against orthopoxvirus infection among persons at risk for such exposures.Certain laboratorians and health care personnel can be exposed to orthopoxviruses through occupational activities. Because orthopoxvirus infections resulting from occupational exposures can be serious, the Advisory Committee on Immunization Practices (ACIP) has continued to recommend preexposure vaccination for these persons since 1980  that comprise multiple species, including Variola virus, Vaccinia virus, Monkeypox virus, Cowpox virus, and newly discovered species  (Variola virus) in 1980  and Monkeypox virus. ACIP has historically recommended more frequent booster vaccination doses for persons working with more virulent orthopoxviruses than for those working with less virulent orthopoxviruses  with it; myopericarditis also occurs with ACAM2000 , but the underlying mechanism is unknown , following vaccination with JYNNEOS and consequently no risk for inadvertent inoculation or autoinoculation. The effectiveness of JYNNEOS was inferred from the immunogenicity of JYNNEOS in clinical studies and from efficacy data from animal challenge studies. Occurrences of serious adverse events are expected to be minimal because JYNNEOS is a replication-deficient virus vaccine. However, because the mechanism for myopericarditis following receipt of ACAM2000 is thought to be an immune-mediated phenomenon, it is not known whether the antigen or antigens that precipitate autoantibodies are present in JYNNEOS as well. ACIP began considering discussing the data for JYNNEOS in February 2020. This report describes the ACIP recommendations for the use of JYNNEOS for preexposure prophylaxis in persons at occupational risk for exposure to orthopoxviruses.Variola virus or Monkeypox virus receive a booster dose of JYNNEOS every 2 years after the primary JYNNEOS series; 4) should persons who are at ongoing risk for occupational exposure to less virulent replication-competent orthopoxviruses such as Vaccinia virus or Cowpox virus receive a booster dose of JYNNEOS at least every 10 years after the primary JYNNEOS series; and 5) should persons who are at ongoing risk for occupational exposure to orthopoxviruses and who received an ACAM2000 primary vaccination have the option to receive a booster dose of JYNNEOS as an alternative to a booster dose of ACAM2000. The Work Group comprised experts in diverse disciplines, including laboratory, public health, infection control, preparedness, and various clinical specialties . Federal partners represented on the Work Group included FDA, the National Institutes of Health, the U.S. Department of Defense, and the U.S. Department of Health and Human Services-Biomedical Advanced Research and Development Authority. CDC contributors also joined Work Group meetings with subject matter expertise in orthopoxviruses, regulatory affairs, laboratory diagnostic testing, vaccine adverse events, and drug services. Data collected, analyzed, and prepared by the Work Group were deliberated by ACIP during four public meetings.During January 2020–November 2021, the ACIP Orthopoxvirus Work Group participated in monthly or bimonthly teleconferences to consider the evidence for five questions: 1) should JYNNEOS be recommended for research laboratory personnel, clinical laboratory personnel performing diagnostic testing for orthopoxviruses, and designated response team members at risk for occupational exposure to orthopoxviruses; 2) should JYNNEOS be recommended for health care personnel who administer ACAM2000 or care for patients infected with replication-competent orthopoxviruses; 3) should persons who are at ongoing risk for occupational exposure to more virulent orthopoxviruses such as Subject matter experts performed a systematic review and metaanalysis of the published literature on August 12, 2020, to inform the recommendations; the review was not limited by date or language. The Work Group used a modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to determine the certainty of evidence rated on a scale of 1 (high certainty) to 4 (very low certainty) for the following desirable and undesirable outcomes deemed critical for decision-making: prevention of disease, incidence of serious adverse events, and incidence of myopericarditis; prevention of disease was defined as prevention of an orthopoxvirus infection. Although no level of antibody protection for orthopoxviruses has been established, the detection of neutralizing antibodies after JYNNEOS is an indirect measure of protection . Immunogenicity that peaks 2 weeks after completion of the 2-dose series  is called primary immunogenicity. Within the evidence to recommendations (EtR) framework, ACIP considered the importance of orthopoxvirus infection as a public health problem; the benefits and harms (including the graded evidence); the target populations’ values and preferences; and issues of resource use, acceptability to stakeholders, feasibility of implementation, and anticipated impact on health equity.For the first and second questions, regarding recommendation for JYNNEOS as an alternative to ACAM2000 for primary vaccination, the systematic review identified three randomized controlled studies and 15 observational studies including a total of 5,775 subjects. After considering geometric mean titers and seroconversion data together, the Work Group had moderate (level 2) certainty that JYNNEOS provides a small increase in disease prevention compared with that provided by ACAM2000.To address the third and fourth questions, regarding booster doses, the systematic review identified one randomized controlled trial and 17 observational studies that included a total of 6,417 subjects. After considering geometric mean titer and seroconversion rate together, the Work Group estimated with very low (level 4) certainty that a small increase in disease prevention occurs after JYNNEOS booster versus the JYNNEOS primary series only.For the fifth question, regarding providing the option of transitioning to JYNNEOS for a booster dose in persons who had received primary vaccination with ACAM2000, the systematic review identified one randomized controlled trial and five observational studies that included a total of 435 subjects. A total of 82% of subjects seroconverted when given JYNNEOS booster, with very low (level 4) certainty in that estimate. The Work Group estimated, with low (level 3) certainty, fewer serious adverse events occurred after the JYNNEOS booster than after the ACAM2000 booster in persons previously vaccinated with ACAM2000Variola virus and Monkeypox virus), should receive a booster dose of JYNNEOS every 2 years after the primary JYNNEOS series; persons who receive the 2-dose JYNNEOS primary series and who are at ongoing risk for occupational exposure to less virulent orthopoxviruses, , should receive booster doses of JYNNEOS at least every 10 years after the primary JYNNEOS series. ACIP also recommends that persons who received an ACAM2000 primary vaccination and who are at ongoing risk for occupational exposure to orthopoxviruses may receive a booster dose of JYNNEOS as an alternative to a booster dose of ACAM2000.Research laboratory personnel,JYNNEOS involves a replication-deficient virus and has fewer contraindications, no risk for inadvertent inoculation and autoinoculation, and is associated with fewer serious adverse events compared with ACAM2000 . In addiFor those working with more virulent orthopoxviruses, the frequency of booster doses also differs: ACAM2000 boosters are recommended every 3 years, whereas JYNNEOS boosters are recommended every 2 years. After successful administration of vaccine, ACAM2000 produces a take containing infectious vaccinia virus capable of transmission through autoinoculation and inadvertent inoculation of close contacts of vaccinees; JYNNEOS does not produce a take. Some persons might prefer receiving ACAM2000 because the vaccine is a derivative of Dryvax, which was used successfully in eradicating smallpox, a clear demonstration of its effectiveness in preventing disease.A robust antibody response following a single dose of JYNNEOS has been observed in clinical trials . Reporting is encouraged for any clinically significant adverse event, even if it is uncertain whether the vaccine caused the event. Information on how to submit a report to VAERS is available at Variola virus and Monkeypox virus).Peak antibody response is achieved 2 weeks after receipt of the second dose of the 2-dose JYNNEOS vaccination series  may receive vaccination with JYNNEOS. However, because the number of immunocompromised persons is increasing in the United States (Monkeypox virus); identifying the specific reservoir might facilitate the identification of high-risk activities for acquiring orthopoxvirus infections that are not already recognized.Additional data on JYNNEOS vaccine are needed. Further studies are needed to determine the duration of protection after the 2-dose JYNNEOS vaccination series; recommendations regarding the frequency of booster doses can be modified accordingly. The effectiveness of a single dose JYNNEOS series should be evaluated if orthopoxvirus exposures occur before peak immunogenicity is achieved. Clinical trials evaluating the risk for myopericarditis and serious adverse events are needed to ensure that the risks are characterized and guidance about co-administration of JYNNEOS with mRNA COVID-19 vaccines can be elucidated. Establishing a correlate of protection after vaccination with JYNNEOS might facilitate confirmation of effective vaccination in certain populations and might also shed light on the effectiveness of a single dose of JYNNEOS vaccine. In addition, extensive studies to date have not identified the specific small mammal reservoir for some orthopoxviruses  recommended preexposure prophylaxis with ACAM2000, a replication-competent live virus Vaccinia virus vaccine was licensed in the United States. On November 3, 2021, ACIP voted to recommend JYNNEOS preexposure prophylaxis as an alternative to ACAM2000 for certain persons at risk for exposure to orthopoxviruses.In 2019, JYNNEOS, a replication-deficient live A second vaccine is now available for persons for whom vaccination against orthopoxvirus infections is recommended. Potential vaccinees should weigh the risks and benefits of each vaccine when deciding which to receive.


Malnutrition is a frequent problem in cancer patients, which leads to prolonged and repeated hospitalizations, increased treatment-related toxicity, reduced response to cancer treatment, impaired quality of life, a worse overall prognosis and the avoidable waste of health care resources.Despite being perceived as a limiting factor in oncologic treatments by both oncologists and patients, there is still a considerable gap between need and actual delivery of nutrition care, and attitudes still vary considerably among health care professionals.In the last 5 years, the Italian Intersociety Working Group for Nutritional Support in Cancer Patients (WG), has repeatedly revisited this issue and has concluded that some improvement in nutritional care in Italy has occurred, at least with regard to awareness and institutional activities. In the same period, new international guidelines for the management of malnutrition and cachexia have been released.Despite these valuable initiatives, effective structural strategies and concrete actions aimed at facing the challenging issues of nutritional care in oncology are still needed, requiring the active participation of scientific societies and health authorities.As a continuation of the WG's work, we have reviewed available data present in the literature from January 2016 to September 2021, together with the most recent guidelines issued by scientific societies and health authorities, thus providing an update of the 2016 WG practical recommendations, with suggestions for new areas/issues for possible improvement and implementation. Although malnutrition is recognized by both oncologists and patients as a limiting factor in oncologic treatments, it remains poorly managed Despite the abundance of scientific literature highlighting the problem, and the availability of international guidelines for managing nutritional care in cancer patients, many patients do not receive adequate nutritional support The Italian Association of Medical Oncology, the Italian Society of Artificial Nutrition and Metabolism and the Italian Federation of Volunteer-based Cancer Organizations implemented in 2016 a collaborative Working Group (WG) and initiated a structured project named “Integrating Nutritional Therapy in Oncology”, with the aim to increase the awareness of nutritional issues among oncologists and, consequently, to improve the nutritional care of cancer patients in Italy Among its activities, in 2016 the WG issued the first inter-society consensus document in order to provide suitable, concise and practical recommendations for appropriate nutrition in cancer patients In the last 5 years, several further initiatives have been undertaken by the WG While this represents progress, nutritional care in oncology is still inadequate and needs the involvement and cooperation of scientific societies, the Ministry of Health and the Ministry of Education. Consequently, the WG decided to update the 2016 recommendations, which are presented here. The aim of this document is to: 1) stimulate the national and international Oncology Scientific and Clinical Community; 2) to increase the awareness on nutritional care; 3) to improve the clinical nutrition management of patients with cancer through the provision of simple but mandatory nutrition protocols for daily oncological practice.The WG included physicians , dietitians and patient representatives. We reviewed available data on the nutritional management of patients with cancer, which appeared in the literature from January 2016 to September 2021, including the evidence-based recommendations released in the guidelines issued by scientific societies and health authorities. Authors were also asked to identify further references from their personal collection of literature or other sources and to choose the most relevant ones to be included in the manuscript. After critical evaluation of literature, the original 2016 WG recommendations have been implemented along with accompanying commentaries. Compared to the 2016 paper, we chose to modify the structure, focusing still on nutritional risk and malnutrition recognition, nutritional counseling and oral supplementation, but then, also, on the different phases of the disease, together with current critical issues and future perspectives.The drafting process was based on a consensus discussion followed by Delphi rounds and votes until agreement was reached. A final version of the paper was circulated and approved by the scientific board of the endorsing scientific societies, which exclusively funded the present project.Screening is key to identifying the risk of malnutrition A number of techniques have been used to assess nutrition status in cancer patients although no 'gold standard' has emerged as superior for sensitivity or specificity. The most frequently employed tools are: the Nutritional Risk Screening 2002 (NRS 2002), the Malnutrition Universal Screening Tool (MUST), the Malnutrition Screening Tool (MST), the patient-generated subjective global assessment (PG-SGA), and the Mini Nutritional Assessment (MNA) They all showed a moderate to substantial agreement with one another and should be employed as tools to guide corrective measures. There is no comprehensive evaluation of their comparative predictive and/or prognostic value on patient outcomes More recently, the Global Leadership Initiative on Malnutrition (GLIM) criteria, based on a consensus of experts, provides a diagnostic and operational tool to identify and treat malnutrition in several settings Independently of the selected criteria/parameters, nutritional status should be considered a dynamic concept, particularly in oncology; therefore, nutritional screening tests should be administered early and periodically repeated, preferably by nurses, during the whole of the patient's journey - at each outpatient visit and within 48 hours of hospital admission.As stated by all the available guidelines and recommendations, patients at risk of malnutrition should be referred to a clinical nutrition service/unit/professional for nutritional assessment and treatment. However, due to the foreseeable clinical course, it is reasonable to suggest that patients with certain cancer type , advanced disease stage or undergoing more aggressive treatments , all of which are expected to affect nutritional status, should be immediately referred to clinical nutrition specialists for early comprehensive nutritional assessment, counseling/support and a strict monitoring program, independently of risk evaluation.The assessment of nutritional status should preferably include tools to identify both malnutrition and to measure body composition, with particular reference to sarcopenia and muscle mass determination The nutritional evaluation should include the combination of different parameters Scientific literature suggests that the exclusive use of anthropometric measures is not sufficient to identify body composition alterations, particularly with respect to muscle mass loss Computed Tomography and Magnetic Resonance Imaging are the gold standard techniques to assess body composition and their imaging of lumbar vertebra L3 correlates well with whole-body skeletal muscle mass Table 1, this process includes a few steps Nutritional support should be provided to malnourished patients and those at nutritional risk, in particular when oral energy intake is already insufficient or expected to be inadequate  for more than 7 days Practical suggestions for managing common symptoms related to cancer treatment, leading to impaired food intake or malabsorption, should be foreseen to optimize patients' diets, in order to cope with nutritional deficiencies and possible swallowing difficulties.Nutritional interventions should compensate for inadequate energy intake with the objective of improving clinical outcomes. So far, numerous reviews have been published Multiple nutrition interventions have been proposed, including dietary counseling or advice, oral nutritional supplements (ONS) and enteral nutrition (EN). The evidence for nutritional counseling to improve clinical outcomes is heterogeneous. According to the most recent review, nutrition interventions were found able to improve body weight and BMI, nutritional status, protein and energy intake, QoL and response to cancer treatments When dietary measures fail to meet patients' protein-calorie requirements as detected by nutritional monitoring, the prescription of energy-dense ONS should be considered, due to their proven efficacy in increasing protein-calorie intake and to fill nutritional gaps In patients with cancer, systemic inflammation inhibits nutrient utilization and promotes catabolism, thus leading to muscle breakdown. Calorie and protein fortification of regular foods, even with standard ONS, does not reduce systemic inflammation. Updated nutritional strategies now suggest considering nutrition with anti-catabolic and inflammation-suppressing ingredients. Studies have indicated that ONS with addition of essential amino acids or high-dose leucine may improve muscle protein synthesis even in the presence of inflammation, although results have not been fully consistent Fish oil, a source of long chain omega-3 fatty acids, is currently suggested to improve appetite, oral intake, lean body mass, and body weight in patients with advanced cancer and at risk of malnutrition The European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines on nutrition in cancer patients recommend supplementation with fish oil, a source of long chain omega-3 fatty acids, to stabilize or improve appetite, food intake, lean body mass, and body weight for patients with advanced cancer undergoing CT, but the level of evidence is still low Studies included in the previously mentioned review, evaluated a sole nutrition intervention of ONS enriched in omega-3 fatty acids (ONS-ω3) vs. placebo, an isocaloric diet, or an isocaloric ONS: they found significantly reduced weight loss and loss of fat free mass, and significantly increased skeletal muscle mass and lean body mass, QoL, and treatment tolerance in the groups receiving ONS-ω3.In a recent pragmatic randomized controlled-trial conducted in 159 H&N cancer patients undergoing RT and CT + RT and receiving nutritional counseling, the use systematic use of ONS-ω3 resulted in better weight maintenance, increased protein-calorie intake, improved QoL and was associated with better anti-cancer treatment tolerance One limitation of most of the available studies on nutritional counseling and oral supplementation is their reliance on small sample size, different outcome measures, variable nutrition interventions, different timings and follow-up.Of note, however, is a recent well-conducted multicenter study on 506 hospitalized cancer patients at nutritional risk, which showed that individualized nutritional support reduced the risk of mortality and improved functional and quality of life outcomes The optimal duration and timing of nutrition interventions should also be explored further, but the general impression that the early approach may be the most effective is gaining support The often underdiagnosed unintentional weight loss and progressive skeletal muscle depletion are frequently present and worsen during CT and targeted therapies Regardless of cancer type, frailty level or age, patients may be similarly affected by malnutrition, Overall, the management of weight-losing cancer patients during active oncologic treatment relies on nutritional counseling, non-pharmacological  interventions and pharmacological support, including artificial nutrition (AN) A proactive assessment of nutritional status is essential for selecting the most cost-effective intervention to apply: for example, oral nutritional support might reduce weight loss and hospitalization, and dronabinol may help to counteract nausea and vomiting or increase food intake. Ongoing randomized trials will make clear if treatment-naïve cancer patients at risk for malnutrition might also profit from an early, short-term, supplemental parenteral nutrition Novel preclinical data have suggested that a relationship between cell metabolism and susceptibility to immunotherapy may exist and uncontrolled studies have reported a correlation between BMI and efficacy of immunotherapeutic agents in several cancers Nevertheless, since conflicting data regarding any benefit from immunomodulators according to baseline BMI have been reported in different cancer types, this issue remains unresolved and the study of a more comprehensive or dynamic nutritional pattern has been suggested A secondary analysis of the data from the Swiss prospective, randomized-controlled, multicenter trial EFFORT compared the outcomes of a protocol-guided individualized nutritional support regime (intervention group) to standard hospital food (control group) in 506 patients with a main admission diagnosis of cancer and characterized by a broad spectrum of cancer sites, treatment types and disease severities. Individualized nutritional support reduced the risk of mortality and improved functional and QoL outcomes in cancer patients with increased nutritional risk, further supporting the inclusion of nutritional care in cancer management guidelines (47).The efficacy of an early nutritional intervention was also highlighted in the study of Lu et al. (67), in which patients with metastatic esophagogastric cancer, who received an early interdisciplinary supportive care, provided by a team of gastrointestinal oncologists, nurse specialists, dietitians, and psychologists, integrated into standard oncologic care, was associated with an improved overall survival, compared with patients in the standard oncologic care-alone group (14.8 vs 11.9 months).Overall, even if the above mentioned and other issues require further research-based evidence, we can affirm with confidence that prompt and strictly monitored nutritional support during oncologic active treatment is essential, in order to improve clinical outcomes and provide patients with the most innovative and effective therapeutic options.Although activating a formal nutritional team in every hospital setting may be difficult, many successful examples may contribute in shaping a shared, cooperative awareness between patient communities and healthcare professionals The adoption of validated care pathways can ensure compliance with updated scientific recommendations, guarantee access to treatments backed by clinical evidence, contain clinical risks, rationalize expenditures, and increase equity.Nutritional care is a keystone for clinical outcomes in oncologic surgery.For now, early oral feeding should always be the preferred nutrition mode after oncologic surgery, and this includes gastro-intestinal procedures The surgical operation causes a trauma that produces systemic inflammation, stress response and metabolic negative effects The perioperative management of surgical patients has been studied in depth in recent years and all these measures have been included in the Enhanced Recovery After Surgery (ERAS) programs Every patient undergoing major surgery should follow a personalized perioperative ERAS program, comprising scheduled steps, including nutritional care. Most of them are common to many different surgical specialties and procedures, such as:- Preoperative nutritional screening with validated tools should be always performed before oncologic surgery, because severe under-nutrition has long been known to be detrimental to surgical outcome - Nutritional support should be started if the patient is malnourished or at nutritional risk before surgery. An appropriate nutritional support package should be applied during the hospital stay and following discharge - In patients undergoing gastrointestinal surgery, the use of oral/enteral immunonutrition should be encouraged for a reduction in post-operative infectious complications - Preoperative fasting from midnight should be always avoided. Patients with no specific risk of aspiration can drink clear fluids until 2 hours prior to surgery and eat solid food until 6 hours before surgery - Oral feeding should be started as soon as possible after surgery, adapting oral intake according to type of surgery and individual tolerance. Special caution should be dedicated to elderly patients - Risk of postoperative ileus should be minimized and an opioid-sparing pathway should be applied, especially the use short-acting anesthetics during surgery and applying multimodal analgesia in combination with epidural analgesia post-operatively The role of nutritional support for oncology patients in palliative care is still a controversial issue.However, in advanced cancer patients, preserving nutritional status may be an important goal also during the palliative care phase, because even when the disease can no longer be cured, patients may survive for several months or years. In this context, malnutrition may jeopardize performance status, QoL, tolerance to palliative treatments and survival.AN can be integrated within a palliative care program when the risk of dying from malnutrition is greater than due to cancer progression Nevertheless, there are many factors that may adversely affect the provision of EN in these patients, e.g. high output ileostomy or intestinal fistulas, large bowel resections, and the presence of nutrition impact symptoms . Also, ESPEN guidelines recommend home artificial nutrition (HAN), either EN or PN, in eligible cancer patients with persistent insufficient oral food intake or malabsorption However, in incurable patients nutritional support should be proposed considering the expected benefit on QoL and the potential benefit on survival Finally, an important question is whether there is evidence of a potential survival benefit due to home parenteral nutrition (HPN) in palliative cancer patients. Recently, a prospective study compared the survival of malnourished cancer patients in palliative care, eligible for HPN according to ESPEN recommendations, who received HPN with a homogenous group of patients, equally eligible for HPN, who did not receive HPN but artificial hydration for logistic reasons or because of patient refusal Malnutrition in oncology is still under-diagnosed and untreated in an unacceptable proportion of patients One major issue is that the number of clinical nutrition units/services is inadequate and most oncology units are even devoid of dedicated dieticians. In Italy, according to the available data, there are around 50 clinical nutrition structured hospital units around the country, which is an insufficient number when compared to the number of oncology units (~330) In addition, clinical nutrition is an overlooked topic at every university teaching level, so that even the basic knowledge is lacking in young physicians and health care professionals.Nowadays, the general education and training offered in clinical nutrition, which should be tailored to satisfy specific professional requirements, is qualitatively and quantitatively inappropriate in the majority of Western countries The timing of nutritional intervention is fundamental in order to improve the therapeutic chances, with the “early approach” being the most effective Similarly, nutritional parameters are still not systematically evaluated and considered as potential confounders in outcome assessment and study design in clinical oncology trials.Last but not least, disinformation remains a critical issue with regards to nutrition for cancer patients. Despite the lack of evidence-based data, hundreds of books and web sites still promote anti-cancer diets, fasting, fasting-mimicking diets and nutritional supplements, which are widely used without medical supervision Inadequate nutritional management for cancer patients should be considered ethically unacceptable and the lack of standard “high level” evidence cannot be a justification for overlooking nutritional care Another critical issue is the quality and the clinical relevance of the available nutritional studies in the oncologic field. Unfortunately, many trials report only nutritional outcomes rather than clinical outcomes . Consequently, the effectiveness of nutritional support may result of limited interest for oncologists and the other health care professionals. Hence, the implementation of properly designed nutritional trials focusing on primary relevant clinical endpoints is key for the future development of clinical nutrition in oncology.Among the topics of future studies, calorie and protein needs assessment for cancer patients should be of particular interest in light of the potential parallelism with the intensive care setting debate Preliminary experience adopting indirect calorimetry in the oncologic setting yield promising results From an economic point of view, quality improvement programs (QIP) involving nutrition support, such as the free provision of ONS at home, showed the potential for saving substantial resources The combination of nutritional support with personalized physical activity programs represents another promising and relevant issue, which deserves further exploration and implementation, in order to preserve muscle mass more effectively Finally, in the era of new technologies, telemedicine implementation may be extremely helpful for patient monitoring and support, leaving them safely at home, but its real applicability still requires proper assessment in the oncologic setting.Table 2, and has identified some new areas/issues for possible improvement and implementation.Compared to the 2016 document, the updated Italian Intersociety WG for Nutritional Support in Cancer Patients makes additional practical recommendations, summarized in In order to implement these recommendations across the whole country, the WG will continue its work by establishing stable collaborations with national and international scientific societies/organizations, health authorities and academic institutions.


Epidemiological measures such as incidence, prevalence, or deaths are essential for monitoring population health. However, evaluating them in isolation cannot adequately compare and assess the relative importance of different diseases. Assessments of the burden of disease (BoD) are therefore of growing importance in supporting health policy decisions. Using disability-adjusted life years (DALY) as a summary measure of population health, BoD integrates morbidity and mortality in a transparent approach.Within BoD methodology, deviations in the health of the population from an ‘ideal’ health status is quantified in the unit of life years. DALY are the sum of years of life lost due to death (YLL) and years lived with disability (YLD). While YLL describe the gap between age at death and statistical life expectancy, the indicator YLD quantifies years lived with a disability or disease. Calculations were based on different primary and secondary data sources for Germany, especially cause-of-death statistics, epidemiological survey data, and statutory health insurance data.In Germany, there were about 12 million DALY in 2017, the equivalent of 14,584 DALY per 100,000 population. Coronary heart disease contributes the most to the overall burden of disease, followed by lower back pain and lung cancer. In women, headache disorders and dementias account for more DALY as compared to men. Men have a higher burden of disease from lung cancer or alcohol use disorders. Pain disorders and alcohol use disorders lead the DALY rankings for both sexes in younger adulthood. The burden due to cardiovascular disease, COPD, and diabetes mellitus increases with age and also varies by region.The results suggest age- and gender-specific prevention as well as regional health care needs. BoD studies therefore provide comprehensive data for population health surveillance and can support health policy decisions.• The importance of specific diseases as measured by DALY differs greatly by age and gender, highlighting the need for targeted prevention measures.• Regional patterns emerge for cardiovascular disease, COPD, and depressive disorders, among others, which may indicate health care needs.


The oral microbiota is enormously diverse, with over 700 microbial species identified across individuals that play a vital role in the health of our mouth and our overall well-being. In addition, as oral diseases such as caries (cavities) and periodontitis (gum disease) are mediated through interspecies microbial interactions, this community serves as an important model system to study the complexity and dynamics of polymicrobial interactions. Here, we review historical and recent progress in our understanding of the oral microbiome, highlighting how oral microbiome research has significantly contributed to our understanding of microbial communities, with broad implications in polymicrobial diseases and across microbial community ecology. Further, we explore innovations and challenges associated with analyzing polymicrobial systems and suggest future directions of study. Finally, we provide a conceptual framework to systematically study microbial interactions within complex communities, not limited to the oral microbiota. The oral diseases caries and periodontitis impact the majority of the adult population in the United States and are two of the most prevalent infections worldwide , 2. Thes3–Streptococcus .–19.17–19–crobiome  (19).Together, the ability to bind to the tooth surface and the ability to coaggregate are critical for oral bacterial survival despite constant flow of saliva, regular hygiene practices, variable nutrient supply, and extreme temperature changes. Further, adhesion, coaggregation, and the environmental differences across the surfaces of the mouth result in multiple biogeographical niches in the oral cavity , 22. AltPorphyromonas gingivalis, Treponema denticola, and Tannerella forsythia (formerly Bacteroides forsythus), were strongly associated with each other and strongly correlated with periodontal disease. Among the colored complexes, this red complex has attracted significant interest because all three members are putative periodontal pathogens, while other complexes contain both commensals and pathogens  in 2008  was limited until Socransky and his colleagues performed a comprehensive and impactful study in 1998. These authors studied over 13,000 human subgingival biofilm samples from periodontally healthy and diseased patients using checkerboard DNA-DNA hybridization techniques and then grouped 40 culturable bacterial species into six “colored” complexes using cluster analysis and community ordination techniques  25). Fo. Fo25). athogens . The pro in 2008 . While t in 2008 .in vitro and in vivo provided fundamental knowledge for understanding interspecies interactions and biofilm development of oral microbiota. The Socransky et al. study showed the importance of looking beyond interactions among two or a few species. The development of next-generation sequencing techniques and bioinformatic analytic tools allows researchers to study the complexity of diverse oral communities without cultivation, although these studies are challenging due to limited bacterial genetic material in clinical samples and disagreement on the best analysis approaches. The application of 16S rRNA gene amplicon sequencing and metagenomics allows differentiation of bacteria at the species or even strain level and determination of their functional potential.The initial studies on species associations Saccharibacteria, was discovered 20 years ago using 16S rRNA gene sequence analyses  and global gene expression (the metatranscriptome). Importantly, the accessibility of the human oral cavity allows for the instantaneous preservation of microbial RNA with temporal and spatial control. Studies using metatranscriptomics on oral specimens have comprehensively shaped our understanding of the oral microbiome. These studies found that although the community composition during periodontitis can vary drastically, the community’s functional activities are conserved . This fi species . One str altered .The oral cavity has become one of the best-described microbial sites in the human body due to its accessibility and clinical relevance; sequencing-driven studies of oral health and disease have broadened our understanding of the community composition and functional activities of the oral microbiota. However, these studies are only starting points, and the driving factors that lead to the progression from healthy to diseased states remain unknown ; Table 1Despite their utility, metagenomic and metatranscriptomic approaches destroy micron-scale spatial information by homogenizing samples during nucleic acid extraction. Bacteria are micron-sized, and research on oral microbes was the first to show that micron-scale spatial patterning (microbiogeography) can impact disease progression , 42. Thuin situ hybridization (FISH) and immunofluorescence allowed researchers to distinguish the identities of microbes in complex oral communities . Th. Thin simunities . These s biofilm , 42.Streptococcus mutans by surrounding oral commensals. In another example, to understand how oral microbes disperse and initiate biofilm formation, Simon-Soro et al. combined microscopy with sequencing, showing that most of the microbial biomass in saliva is composed of aggregates containing a mix of both early and late colonizers , and host interactions, the oral cavity is a valuable model system to study biofilm development, ecological succession, and the eco-evolutionary dynamics that shape an organism’s niche. Given the enormous complexity of oral communities, we suggest that both bottom-up and top-down approaches are important for the further investigation of microbial interactions and the dynamics of oral biofilms ; Table 1tterning , 42, 56,Research on oral microbes has been critical for our overall understanding of microbial interactions, biofilm development, and spatial patterning and has driven the advancement of technologies for studying microbial communities. Undoubtedly, the oral microbiome provides an accessible and deeply studied system for further exploration of microbial interactions and the role of our microbiota in human health. The future unraveling of the complex dynamics leading to health and disease in the oral cavity will continue to result in new discoveries at the intersection of microbial ecology and pathogenesis.


With the intensified social competition and increased psychological pressure in modern society, the impact of emotions on people' health has attracted increasing attention from around the world. Major depressive disorder (MDD) and premenstrual dysphoric disorder (PMDD) are the two common types of depressive disorders described in The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) . Depressvia certain antidepressant treatments . Overall, 30–40% of patients with MDD or PMDD are insensitive to drug treatment and experience substantial psychiatric side effects and slow onset of action. This can also produce drug resistance, with obvious time lag and inefficiency . TherefoIn consideration of the aforementioned realization, we organized this special issue to advance our understanding of the pathogenesis of MDD and PMDD, particularly regarding neural circuits and neuroendocrine mechanisms. This information will provide a basis and possible clues for clinical treatments and drug development. For this Research Topic, we invited recent studies that focus on the neural circuits and neuroendocrine mechanisms of PMDD and MDD and received 11 submissions. After a half year of critical peer review, nine papers have been accepted.Decreased Plasma Hydrogen Sulfide Level Is Associated With the Severity of Depression in Patients With Depressive Disorder,” Yang et al. recruited 47 depressed patients and 51 healthy individuals and found that decreased H2S is involved in the pathophysiology of depression as well as that plasma H2S may be a potential indicator for depression severity.In the experimental report titled “Antidepressant Treatment-Induced State-Dependent Reconfiguration of Emotion Regulation Networks in Major Depressive Disorder,” Zhao et al. collected data from 70 MDD patients and 43 sex- and age-matched healthy controls and found that four dFC states were identified in the emotion networks. Their alterations of state-related occurrence proportion were found in MDD and subsequently normalized following 12-week antidepressant treatment. Baseline strong dFC predicted the reduction rate of Hamilton Depression Rating Scale (HAMD) scores.In the paper titled “Yu et al.'s paper, titled “Serum Lipid Concentrations Are Associated With Negative Mental Health Outcomes in Healthy Women Aged 35-49 Years,” the authors recruited 319 healthy participants and found that there was a significant association between K10 scores and metabolic parameters, including Body Mass Index (BMI), total and LDL cholesterol, and triglycerides.In Sleep Disturbances and Depression Are Co-morbid Conditions: Insights From Animal Models, Especially Non-human Primate Model,” Li et al. evaluated the prevalence, clinical features, phenotypic analysis, and pathophysiological brain mechanisms of depression-related sleep disturbances and emphasized the current situation, significance, and insights from animal models of depression.In the paper titled “Chang et al.'s paper “Depression Assessment Method: An EEG Emotion Recognition Framework Based on Spatiotemporal Neural Network,” the authors proposed a novel EEG emotion recognition framework for depression detection, which provides a robust algorithm for real-time clinical depression detection based on EEG.In Gao et al. investigated 13 PMS patients and 15 healthy controls and found that abnormal functional regulation of brain regions such as the occipital lobe and cerebellum leads to abnormal changes in emotional regulation, cognitive ability, and attention distribution in PMS patients, implying significant central pathogenesis.In the paper titled “Brain Activation during Processing of Depression Emotion in College Students with Premenstrual Syndrome in China: Preliminary Findings,” An End-to-End Depression Recognition Method Based on EEGNet,” Liu et al. proposed an end-to-end deep learning framework for MDD diagnosis based on EEG signals and found that the method is highly accurate for the diagnosis of MDD and can be used to develop an automatic plug-and-play EEG-based system for diagnosing depression.In the paper “Does Childhood Adversity Lead to Drug Addiction in Adulthood? A Study of Serial Mediators Based on Resilience and Depression,” He et al. conducted a thorough investigation of the mental status from 937 participants and found that depression led to drug addiction, while resilience weakened the effect of adverse childhood experiences on depression and drug addiction.In another study titled “Gu et al.'s paper, “The Relationship Between 5-Hydroxytryptamine and Its Metabolite Changes With Post-stroke Depression,” the authors reviewed the relationship of post-stroke depression with three monoamines and emotions. Moreover, they summarized the advantages of psychological therapy in recent years and posted some suggestions for the pharmacology and psychotherapy of post-stroke depression.In Collectively, these studies have thoroughly investigated the neural circuits and neuroendocrine mechanisms of MDD and PMDD as well as some diagnostics and interventions for these emotional diseases. Because neural circuits and neuroendocrine mechanisms are heavily involved in the pathogenesis of MDD and PMDD and the mechanism of drug intervention, multi-faceted exploration in this field will further reveal the underlying neurobiological mechanisms, thereby promoting translational medicine and drug development.SW, FW, JL, and YW wrote the paper. All authors contributed to the article and approved the submitted version.The paper was supported by grants from the National Natural Science Foundation of China (Nos. 81974553 and 82004078), the Natural Science Foundation of Shandong Province (Nos. ZR2020ZD17 and ZR2021LZY018), and the Chinese Medicine and Brain Science Youth Scientific Research Innovation Team, Shandong University of Traditional Chinese Medicine (No. 22202101).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Road traffic injuries (RTIs) constitute a significant global health burden responsible for 1.35 million deaths and 50 million disabilities annually [Recognizing that road safety is a complex issue that involves sectors beyond health care such as transport and police, the international community frequently calls for a multidisciplinary perspective, particularly with a focus on social context, to improve the understanding of RTIs and its application in the reduction of associated mortality, and disability . This rePolice represent the major first responder population that provides pre-hospital trauma care for road traffic injury victims in LMICs . Though Understanding the intersection between road safety and police strike is particularly relevant in LMICs like Nigeria, where almost 50% of road traffic injury victims receive pre-hospital trauma care interventions from police . And howCreating a balance between support and prevention of police strike for advocacy implications poses a great challenge. Further, this challenge would certainly require an evidence-based approach and contextual analysis due to differential risk factors and legal framework within and between countries. For example, in Nigeria, where there was a recent report of a nationwide police strike threat , the socConsidering a previous police strike in Nigeria about two decades ago , with anGiven the knowledge gap, we opine that strengthening injury surveillance to understand the magnitude of road traffic deaths during police strikes is needed. Additionally, consistent with the UN Global Road Safety resolution, and a submission made by The Lancet in the light of the second Decade of Action for Road Safety, in which both documents identified police, health and transport sectors as active stakeholders in road safety ,15, it i


Dementia increases the risk of post-hospitalization transfer to residential care facilities (RCF), increasing mortality risk. The risk of falling is significantly higher among people with dementia, leading to more hospital admissions (HA). This study examines the association between HA and transferring to RCF controlling for dementia and falling. This secondary data analysis used nine years of data from the National Health and Aging Trends Study (2011-2019) with 2,548 participants (each wave). Transfer to RCF was measured based on the residency status, HA and history of falling by survey questions, and dementia  by combining Clock Drawing Test, word recall test, and previous dementia diagnosis. Falling increased the risk of transition to RCF by 31%; however, this association was not statistically significant. Dementia was a significant predictor for transition to RCF (Odds Ratio (OR)=3.889). Transferring to RCF was significantly associated with HA (OR=1.835); after including falling, OR increased to 2.067, showing falling moderates this association. Including dementia into the model dropped HA’s OR to 1.620. The interaction between falling and dementia showed that frequent HA could increase the risk of transition to RCF by 61%. Probable dementia plus a history of falling can increase the risk of transition to RCF by 22 times and 14 times for those cases of probable dementia without a history of falling. These results may reflect the necessity of screening for the risk of falling and dementia among community-dwelling older adults to prevent falling, hence, frequent HA and ultimately transition to RCF.


Approximately 70% of wetlands in native grasslands were categorized as good or very good compared to only 12% of those in reseeded grasslands (formerly cropland). In terms of informing restoration and management activities, results indicated that improved restoration practices could include a greater focus on establishing natural vegetation communities, and both restored and native prairie wetlands would benefit from enhanced management of invasive species.Wetlands deliver a suite of ecosystem services to society. Anthropogenic activities, such as wetland drainage, have resulted in considerable wetland loss and degradation, diminishing the intrinsic value of wetland ecosystems worldwide. Protecting remaining wetlands and restoring degraded wetlands are common management practices to preserve and reclaim wetland benefits to society. Accordingly, methods for monitoring and assessing wetlands are required to evaluate their ecologic condition and outcomes of restoration activities. We used an established methodology for conducting vegetation-based assessments and describe a case study consisting of a wetland condition assessment in the Prairie Pothole Region of the North American Great Plains. We provide an overview of an existing method for selecting wetlands to sample across broad geographic distributions using a spatially balanced statistical design. We also describe site assessment protocols, including vegetation survey methods, and how field data were applied to a vegetation index that categorized wetlands according to ecologic condition. Results of the case study indicated that vegetation communities in nearly 50% of the surveyed wetlands were in  The soc1.1Effects of anthropogenic activities on aquatic ecosystems, as well as their overall ecologic condition, are typically assessed based on the composition of biotic communities, water quality, hydrologic functions, or degree of anthropogenic impacts e.g., . ApproacRather than concentrating on specific contaminants or water-quality parameters, many assessments focus on the overall ecologic condition, or “health,” of aquatic systems. This approach often involves the development and application of multi-metric indices , although these lands typically are subjected to grazing and frequently impacted by invasive plants. Thus, the region is well suited for developing and demonstrating methods for assessing the ecologic condition of restored, degraded, and natural  wetlands. We describe a proven methodology for assessing wetland ecological condition  and demo1.2.12 of central North America, including portions of five United States states and three Canadian provinces  and Typha × glauca (hybrid cattail)  . Based oWithin the PPR, the USFWS National Wildlife Refuge System (NWRS) manages thousands of square kilometers consisting of lands such as National Wildlife Refuges (NWRs) and Waterfowl Production Areas (WPAs) . These c1.2.3All manner of biotic communities of wetlands, along with geochemistry and soils, have been widely studied, but plant and invertebrate communities generally have been promoted as potential indicators of wetland ecologic condition . AquaticConversely, vegetation-based assessments have resulted in the development and implementation of biotic indices for assessing wetland condition . DeKeyse22.1The PPR case study focused on temporarily and seasonally ponded wetlands (classification of 2.22) were evenly distributed throughout the low-prairie zone; seven in the wet-meadow zone and five in the shallow-marsh zone. For temporarily ponded wetlands, eight quadrats were distributed throughout the low-prairie zone, and seven quadrats were distributed in the wet-meadow zone. Quadrats were centered in the interior and exterior vegetation zones, and oriented in a spiraled configuration in the central vegetation zone , smooth brome (Bromus inermis), Kentucky bluegrass (Poa pratensis), reed canarygrass, and hybrid cattail  have been developed for numerous aquatic systems e.g., . The plaTo maximize the provisioning of ecosystem services, conservation personnel require methodologies to assess wetland condition with the purpose of supporting wetland conservation and management. We presented a case study from the PPR to demonstrate the utility of using an existing plant-based biotic index applied with a probabilistic sampling design to assess wetland condition over a broad geographic setting and over different management settings. Methods used for the case study, including site selection, field sampling protocols, plant metrics, and scoring criteria, were developed specifically for PPR wetlands; however, they can provide a baseline for subsequent studies and can be adapted for a variety of wetlands. We also used results of the case study to demonstrate how wetland assessments can inform management and discussed considerations for adapting the method for other systems. Results of this and other studies suggest that plant community characteristics can be appropriate surrogates for assessing the ecologic condition of wetlands, but natural variability and unique traits of specific wetland types should be considered.


The development of foreign direct investment conforms to the theoretical principles of green total factor productivity and is key to promoting regional industry upgrading. Using three-stage data envelopment analysis (DEA) based on city-level data, this paper investigates the effect of foreign direct investment on regional green total factor productivity (GTFP) across China. The results show that foreign direct investment affects regional GTFP through technology spillover effect and human capital spillover effect. Under different environmental regulation intensity and marketization, the relationship between FDI and green total factor productivity is non-linear. The phenomena of “pollution paradise” and “bottom line race” survived at low marketization regional and foreign direct investment will inhibit the improvement of regional green total factor productivity in China. The world economy is undergoing regional industry upgrading. As the largest energy consumer country, China’s energy consumption has increased year by year see Fig. , accountFor developing countries, FDI is an important channel for undertaking international technology transfer, cultivating the competitiveness of local industries, and realizing capital accumulation, technology accumulation, and human capital accumulation. China’s rapid economic growth since the 1980s also benefited from the positive role of FDI in local industrial upgrading, technological innovation, and talent training  to calcmentclass2pt{minimd is the movement factor that reflects the dynamic adjustment of the system, where In the second stage, conduct stochastic frontier analysis model (SFA) . We setFor making each DUM in the same natural state, to measure and calculate the efficiency value that purely reflects the management level of each DUM, we adjust the input items of each DUM according to the calculation results n in Eq. , we use In the third stage, run DEA model again. The original inputs are replaced by the adjusted inputs from step 2, and the outputs remain unchanged. The traditional DEA model is run again to get the efficiency without the influence of environmental factors and random errors, which can more accurately reflect China’s regional green total factor productivity. According to the adjusted input value We first use panel regression method to test the total impact of FDI on GTFP.Secondly, the mediating effect test is conducted to examine the channels that FDI affects GTFP.In order to test the nonlinear impact of FDI on GTFP under different levels of marketization and environmental regulation, While further discussing the heterogeneous influence of FDI on GTFP under different levels of innovation, R&D investment, and human capital accumulation, we adopt the panel threshold regression model proposed by Hansen . The advThe explained variable is GTFP, measured by a three-stage DEA. In this paper, we select total energy consumption, material capital stock, and the number of employees as input indicators. We also select GDP as the expected output indicator and carbon dioxide emissions as the undesired output indicator. Considering the second stage, we need to eliminate those facts that affect the efficiency of GTFP and cannot be changed in a short time, including two key factors for full-time equivalent (FTE) of R&D and full-time equivalent (FTE) of R&D personal. GTFP is also affected by the large development gap between provinces in China, particularly the economic gap; we select the secondary industry’s proportion in GDP and the full-time equivalent (FTE) of R&D as environmental factors Table .Table 1DFDI is measured by the ratio of actual utilization of foreign capital to GDP.Economic development level is measured by per capita GDP; (2) energy structure, measured by the proportion of thermal power generation in total power generation; (3) infrastructure construction, measured by per capita urban road area; (4) population quantity, measured by the total population; (5) urbanization rate, measured by the proportion of the urban population in the total population; (6) physical capital accumulation level, measured by the stock of physical capital; and (7) investment level, measured by the fixed assets of the whole society total investment measurement.(1) Innovation level is measured by the number of domestic patent applications granted per capita; (2) R&D investment level is measured by the full-time equivalent of R&D personnel; (3) human capital accumulation level is measured by actual labor human capital. The policy regulatory factors are represented by environmental regulation (ER) and marketization degree (Market); ER is measured by the level of regional environmental regulation by the proportion of emissions tax levied in GDP, while market is measured by the marketization index.(1) Considering available data, we exclude the data from Tibet, Hong Kong, Macau, and Taiwan. The panel datasets were constructed by 30 provinces from 2000 to 2016 year. The primary data is calculated from the China Urban Statistical Yearbook and China’s Energy Statistical Yearbook. The worth mentioning is the energy consumption data from the statistical yearbooks of provinces, the marketization index measured from the Report with China’s Marketization Index by Wang et al. , and theENC) and emission intensity (EI), respectively; the estimation results are shown in columns 2–3. The coefficients of ENC and EI are significantly negative at the 5% level, which once again proves the “pollution halo effect” of FDI in China. The columns 4–6 list the estimation results of the GMM model; we use the FDI term with a lag period as the instrumental variable. Although the regression results were not significant after replacing GTFP with ENC and EI, the direction of the coefficients was consistent , R&D investment level (Rd), and human capital level (Rlab) and FDI, respectively, and test the coefficients. The estimation results are shown in Table In order to investigate the underlying channels through which FDI may affect GTFP, we introduce the cross-terms of innovation level , innovation level (Inn), R&D investment level (Rd), and human capital level (Rlab) pass the double threshold test at the 1% significance level, and environmental regulation level (ER) passes the double threshold test at the 5% significance level. The threshold values obtained after the threshold effect test are , , , , and  respectively.We use the panel threshold regression model to further investigate the nonlinear impact of FDI on GTFP; estimation results are reported in Table The estimation results in columns 1–3 Table  show thaTable Table According to the estimation results in columns 2 and 3 of Table The relationship between environmental protection and economic growth has been a hot topic in the past decades; however, energy consumption has risen with countries’ industrialization since the industrial revolution. As the world’s biggest energy consumer, China should play an important role in fighting global warming and reducing carbon emissions. The community of shared future for mankind proposed by the Chinese government focus on ecological crisis response with mobilizing international support. Especially, China tries to build an environment-friendly society; the clean production is an essential means to achieve this goal. This paper enriches the existing literature by discovering the potential effects of FDI on the green total factor productivity of developing countries  and testing the threshold effects of regional marketization and environment regulation level and the absorptive capacity of local firms to analyze to what extent regional green total factor productivity benefit from foreign investment.First of all, the results show that FDI has a positive impact on regional GTFP in China. Based on these results, we verify the pollution halo effect of FDI and argue that the important role of FDI plays in promoting clean production and environmental protection in China. Second, through the innovation spillover effect, technology spillover effect, and human capital spillover effect, FDI has heterogeneous impacts on GTFP. Considering the absorption capacity of local firms, only when the innovation level, R&D investment level, and human capital level break through the threshold values, the spillover effects of FDI can have a positive impact on regional green total factor productivity. On contrary, the crowing effects of FDI may lead to a pollution paradise phenomenon. There is a nonlinear relationship between FDI and GTFP with different levels of marketization and environmental regulation. With increasing improvement of marketization level, the environmental benefits of FDI decrease first and then increase, indicating that the free flow of factors and regional cooperation is helpful to weaken the crowding effects of FDI. However, results also show that there is a reciprocal U kink of regional environment regulation level. once local governments start environmental regulation, FDI has a positive impact on regional green total factor productivity. However, if the environmental regulation level is close to a turning point, foreign capital will shift to other destinations for lower environmental costs. Generally speaking, environmental regulation is beneficial to regional sustainable development. Last, the impacts of FDI on GTFP represent the characteristics of regional heterogeneity. Western region and northeast region are the “pollution paradise” in China, and the environmental benefits of FDI vary in regions with different economic scales and industrial structure levels.The Chinese government should continue to encourage foreign direct investment, but it is necessary to formulate practical introduction environmental standards and environmental policies to promote cleaner production in China. First, local governments should formulate formal environmental regulatory policies that meet the local human capital level and technological level considering local characteristics. Second, local governments should actively undertake international high-tech enterprises with low emissions, promote the development of green industry, and continuously improve the level of green economy development. Third, local governments need to reasonably subsidize the green technology upgrades of companies, establish emission trading systems to achieve effective resource allocation, and improve the efficiency of green innovation factor allocation.t and raise the skilled workers’ social position. Second, establish a guarantee mechanism for the free flow of human capital. The government should actively promote the reform of the household registration system and eliminate the institutional obstacles in labor allocation. For example, local governments can provide the free service of releasing labor market information to match supply and demand in the labor market. Local governments also should support the market intermediary’s development of human resource services and labor, encouraging the market power to play a decisive role in personnel allocation.The government needs to improve various supporting systems for the promotion of human capital. First, considering labor market demand, the government needs to pay more attention to vocational education Based on the research results, this paper gives the following policy recommendations.The government should pay attention to intellectual property protection and focus on cultivating the independent innovation capacity of local enterprises. In the past, the poor protection of intellectual property rights led to serious piracy, and it has greatly damaged original enterprises that have invested much money in research and development. It is necessary to protect the researchers’ intellectual property rights and originators’ economic rights to stimulate innovation enthusiasm. For example, in 2019, Shanghai pledged to improve its business environment. Apart from improving government efficiency, one of the essential points is forming a standardized market environment and protecting intellectual property rights. The continuous recognition of technological innovation achievements by the market can increase the investment in scientific research and guide scientific research institutions to meet the market demand to transform technological achievements actively.


A Strengths, weaknesses, opportunities and threats analysis was performed to understand the status quo of education and training in radiation protection (RP) and to develop a coordinated European approach to RP training needs based on stakeholder consensus and existing activities in the field. Fourteen team members represented six European professional societies, one European voluntary organisation, two international healthcare organisations and five professions, namely: Medical Physicists; Nuclear Medicine Physicians; Radiologists; Radiation Oncologists and Radiographers. Four subgroups analysed the “Strengths”, “Weaknesses”, “Opportunities” and “Threats” related to E&T in RP developed under previous European Union (EU) programmes and on the Guidelines on Radiation Protection Education and Training of Medical Professionals in the EU.Consensus agreement identified four themes for strengths and opportunities, namely: (1) existing structures and training recommendations; (2) RP training needs assessment and education & training (E&T) model(s) development; (3) E&T dissemination, harmonisation, and accreditation; (4) financial supports. Weaknesses and Threats analysis identified two themes: (1) awareness and prioritisation at a national/global level and (2) awareness and prioritisation by healthcare professional groups and researchers.A lack of effective implementation of RP principles in daily practice was identified. EuRnR strategic planning needs to consider processes at European, national and local levels. Success is dependent upon efficient governance structures and expert leadership. Financial support is required to allow the stakeholder professional agencies to have sufficient resources to achieve a pan European radiation protection training network which is sustainable and accredited across multiple national domains. Clinical, research and industry professionals administering ionising radiation must prioritise training.Employers and regulators must ensure radiation protection training is mandatory.Expert radiation protection trainers are needed for the European training network.Appropriate resourcing is required for radiation protection training development and implementation.The application of ionising radiation and nuclear technologies play a crucial role in healthcare through the three main medical specialties radiology, radiotherapy and nuclear medicine. These three specialties are among the most innovative of all medical disciplines and early adopters of new technologies. The technological advances in these specialties have enabled significant progress in early detection and diagnosis, treatment selection and monitoring, image-guided intervention. Precise and normal tissue sparing curative treatment of oncological and non-oncological diseases have contributed significantly to developments in personalised medicine. This significant technological progress brings however new challenges, that society must be aware of, in particular the increased exposure of patients and staff to ionising radiation.To find solutions for these challenges, the European Commission (EU) funded a project   supports that professionals involved directly in the use of ionising radiation should receive E&T in RP at the start of their career, and the education process should continue throughout their professional life as the collective knowledge of the subject develops . Howevertection” .To understand the status quo of E&T in RP in Europe, the EuRnR project performed a SWOT  and TOWS analysis of the results/impact of E&T RP outputs developed under previous EU framework programmes –8.To perform the SWOT analysis, the project team working on this task was split into four groups to analyse the “strengths” (group 1), “weaknesses” (group 2), “opportunities” (group 3) and the “threats” (group 4) of each document related to E&T in RP developed under previous EU programmes –11 and oFollowing the first analysis by the four groups, that resulted from a brainstorming amongst the group members, the draft SWOT matrix (planning tool) was sent out for review and comments to a dedicated cross disciplinary expert panel, composed of members of the project advisory board and external experts. This expert panel, composed of 14 members, integrated representatives from five European Professional Societies , one European Voluntary Organisation (HERCA), two International Organisations  and five clinical experts .After incorporating the comments from the panel, the final version of the SWOT matrix was approved, and a TOWS  analysis (an action tool) was performed as a strategy to address the results of the initial SWOT investigation and to define future strategies. The TOWS analysis was carried out by the aforementioned four groups to define how to minimise the threats and weaknesses by maximising the opportunities and strengths , thus ovMultidisciplinary European Low Dose Initiative; EURADOS—European Radiation Dosimetry Group; and more recently EURAMED—European Alliance for Medical Radiation Protection Research) and research projects and partnerships .Ten-year history of collaboration across Europe via various radiation protection research platforms .Strategic research agendas of radiation protection platforms have been produced and disseminated and include E&T elements.Existing guidelines for E&T in RP for health professionals (MEDRAPET).Euratom regulation and National Competent Authorities in existence for many years.Some continued financial support for E&T, even in initiatives not specifically targeting the medical field (e.g. ENEN +—European Nuclear Education Network).Established Network and experience of organising European common training and initiatives on Education and Training in Radiological Protection in Europe (e.g. ENETRAP).E&T initiatives support/encourage European mobility among students/trainees in the field of RP.Ten principal strengths were identified the following SWOT analysis, and the agreed text summarising the findings is as follows:A series of perceived deficiencies were identified and are summarised in Table Many recommendations have been made in the course of previous programmes, however, much of this work is between 10 and 15 years old. Opportunity to systematically review all recommendations and to propose up-to-date recommendations based on the findings of the review.To focus E&T in RP on the needs of the current, and future, clinical workforce .To focus E&T in RP on the needs of the current, and future, medical radiation protection researchers .To propose a sustainable and harmonised model for E&T in RP (many past programmes have not succeeded in producing sustainable outcomes).European-level accreditation or endorsement of a recommended, gold standard model of E&T in RP by EURAMED and/or the professional societies EANM, EFOMP, EFRS, ESR, ESTRO.To identify differences in contents and regulations of E&T in RP in EU member states and to propose a European standard for mandatory E&T course contents and certification based on consensus.To stress the importance of well-trained future generations of RP experts with sufficient knowledge, skills, and competences, to cover future needs of E&T.To develop and deliver European-level online training programmes targeting all relevant professional groups to increase accessibility.To develop E&T in RP during the undergraduate course programmesNine principal opportunities were derived from the text comments and responses received during the SWOT analysis, the agreed opportunities are namely:Threats evidenced from responses during SWOT analysis are summarised in Table From the TOWS analysis a list of actions to be developed have been defined and are summarised in Tables To our knowledge this is the first TOWS analysis on the SWOT results/impact of E&T in RP aspects developed under previous EU framework programmes and EU-funded projects. Despite the success of the EuroSafe Imaging initiative, which is now in its sixth year of active engagement of its’ call for action to achieve international radiation protection goals this study has identified that there is a significant path ahead to achieve delivery, harmonisation and accreditation of radiation protection training across all stakeholders –16. ExteThe development of training material and trainers in a manner which is sustainable and facilitates continual refreshing to match technology advances is identified as core consideration for strategic framework planning . Whilst In recent years our access to digital education technologies, has substantially increased, particularly so during the COVID-19 pandemic . EducatoTo achieve successful radiation protection training goals, it is essential that those administering ionising radiation in the clinical, research or industry environments see the benefit of training and possess a desire to train. Our findings highlight the importance of meeting profession-specific needs and a current lack of priority placed upon the importance of radiation protection training across professional disciplines, researchers, education institutions, national and European bodies Table . In the The challenges ahead should not be underestimated, the impact of the COVID-19 pandemic has further impacted staff resources in both clinical and academic environments, in addition to the increased volume of articles related to professional burnout and the lack of funding for strategic staff contingency planning across healthcare disciplines published pre-COVID-19 –37. In oIn addition to the development of training material, we must also consider training the trainers. Higher education institutions are well placed to assist with, considering their experience in teaching and learning pedagogies and access to a broad array of teaching technologies, experienced teachers and education technologists and their incorporation in the EuRnR Framework documentation is essential. To ensure trainers themselves are effective in the clinical, research, industry, and academic environments, it is essential that they themselves are “trained” to a high standard. This is reiterated across several sections of this study aligned to appropriate financial and staff resourcing.Our findings also identify the need to improve the importance upon which professionals, managers and national agencies place on radiation protection training. The critical role that regulators have in ensuring training programmes are completed is clearly identified in the TOWS analysis Table . EuRnR fOnce training materials and networks are developed our study has identified the importance of determining how a radiation protection network on a European scale, which has national and local on-site activity, could be embedded as mandatory practice by employers and regulators and potentially also have employment incentives potentially attached Table . FurtherAs stated within the discussion at different junctures as with any training programme, the cost of development and implementation requires consideration: from the funding of time and expertise to develop teaching material, hosting virtual/online learning environments, teaching material delivery, trainer costs, academic and clinical site costs, accreditation costs and resourcing of quality review processes. All these items are significant and will differ across nations and locally across clinical, academic and industrial sites and how this can be managed requires intensive discussion and must be clearly and realistically addressed in the proposed EuRnR strategic framework documentation to be completed by this project.In the past, most EU-funded programmes and projects were profession specific or not directly related to medical procedures. Nevertheless, considering the composition of the EuRnR consortium, the group brings together experts in RP from the most relevant health professions and researchers involved in the clinical use of ionising radiation , it was possible to minimise the described limitation, through several multi-professional group meetings, as a strategy to obtain consensus regarding the SWOT analysis and the respective TOWS actions. Future consideration does need to incorporate the expertise of E&T scientists as the EuRnR framework documentation is progressed.E&T in RP is of paramount importance for health professionals and researchers to acquire and develop knowledge, skills and competences in the field of RP to protect patients and staff from the dangers arising from the exposure to ionising radiation. Although several projects have been developed in the past years related to E&T in RP, the SWOT analysis showed a clear lack of real and effective implementation of RP principles in daily practice and therefore there is a critical opportunity under EuRnR to define and set a new momentum, through an objective and dedicated action plan for E&T in RP in Europe. EuRnR Strategic planning documentation needs to consider processes at European, national and local levels and incorporate the multiple factors identified in this SWOT investigation and TOWS analysis. To achieve success, governance structures and strong leadership are key as is the full exploitation of existing resources however equally, appropriate financial support is essential to permit our professions to work collaboratively to achieve a pan European radiation protection training network which is sustainable and accredited across multiple national domains.