Deep learning of artificial neural networks has become the de facto standard approach to solving data analysis problems in virtually all fields of science and engineering. Also in biology and medicine, deep learning technologies are fundamentally transforming how we acquire, process, analyze, and interpret data, with potentially far-reaching consequences for healthcare. In this mini-review, we take a bird’s-eye view at the past, present, and future developments of deep learning, starting from science at large, to biomedical imaging, and bioimage analysis in particular. Rather than providing a technical introduction or an exhaustive review, we briefly discuss major trends in the past, present, and future of deep learning and their implications for bioimage analysis. Along the way, we mainly cite other reviews and surveys for further reading on specific subtopics.2Deep learning popularly refers to the use of artificial neural networks (ANNs) with multiple (ultimately many) layers of elementary computational cells  to progressively extract higher-level representations of given input data in order to perform data analysis tasks 2.1The idea of using ANNs for data analysis dates back to the dawn of digital computing After the ensuing first “AI winter”, from the late 1960s throughout the 1970s and some time beyond, interest in ANNs resurged in the mid-1980s with the (re)invention of the back-propagation algorithm Until the mid-2000s it was generally believed that deep ANNs are very hard to train. This perception started to change when it was shown that a particular type of multilayer ANN called a deep belief network (DBN), where each layer is a restricted Boltzmann machine (RBM), can be efficiently trained by greedy layer-wise unsupervised learning 2.2In recent years, deep learning has been well recognized as a breakthrough technology. So much so that in 2018, the Turing Award, given annually since 1966 by the Association for Computing Machinery (ACM) and generally considered to be the “Nobel Prize of Computing”, was awarded to three highly influential researchers “for conceptual and engineering breakthroughs that have made deep neural networks a critical component of computing”: Yoshua Bengio , Geoffrey Hinton (University of Toronto & Google), and Yann LeCun (New York University & Facebook) Apart from groundbreaking research, two other factors have played an important role in the relatively recent rapid rise of deep learning Together, these advances have enabled the development of ever deeper neural networks, reaching ever higher accuracies and beating the state of the art in an ever growing number of applications. The widespread usage of deep learning has been further accelerated by the development of open-access software libraries and frameworks 2.3The extraordinary power of deep learning in addressing intractable challenges has led to a competitive race for leadership among research groups, universities, companies, and even nations By now, deep learning has become the go-to data analysis technology in domains as diverse as agriculture 3A domain we focus on more specifically in this article is biomedical imaging . Here we3.1In clinical practice, the screening, diagnosis, prognosis, and treatment of disease in the human body, all rely increasingly on advanced medical imaging technologies such as X-ray computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), single-photon emission computed tomography (SPECT), and ultrasound (US) imaging. Successful application of imaging technologies involves not only high-fidelity image acquisition but also reliable image interpretation The impact of deep learning has been reviewed more specifically in a wide range of medical imaging areas, including abdominal imaging 3.2Disease diagnosis and prognosis cannot always be performed solely using structural or functional in-vivo medical imaging, but often also require complementary ex-vivo pathological imaging of tissue, cell, and body fluid samples extracted from the body. Perhaps even more than in medical imaging, visual image interpretation in pathology has traditionally been the task of human experts. However, the increasing adoption of digital whole-slide imaging (WSI) into routine clinical practice in recent years has created unprecedented opportunities for computer-aided diagnosis (CAD) in pathology Pathological imaging plays a prominent role especially in cancer diagnosis and prognosis, and the impact of deep learning has been reviewed in various areas of oncological pathology, including in histopathology 3.3Innovative clinical medical imaging technologies and procedures are usually the fruit of preclinical imaging research with animal models representing humans in studying responses to physiological and environmental changes. Modern small-animal based anatomical, functional, and molecular imaging research involves a wide range of well-established as well as more experimental imaging modalities, including micro versions of clinical scanners , optical coherence tomography (OCT), fluorescence molecular tomography (FMT), bioluminescence imaging (BLI), photoacoustic (PA) and thermoacoustic (TA) imaging, multispectral imaging (MSI), and others 3.4Even more fundamental to our understanding of disease processes and the homeostatic mechanisms maintaining life down to the cellular and molecular levels, is biological microscopy imaging, more succinctly also referred to as bioimaging. Revolutionary scientific discoveries and technological innovations in the past decades have spurred the development of a vast array of advanced light microscopy (LM), notably fluorescence microscopy (FM), as well as electron microscopy (EM) and scanning probe microscopy (SPM) imaging modalities that have proven key to much of the progress in modern biological research Of all biomedical imaging fields, bioimaging arguably faces the biggest challenges in automating visual image interpretation tasks, due to the lack of standard imaging protocols, the high variability of experimental conditions, and the sheer volume of the data produced. Whereas (pre)clinical medical imaging systems typically generate data sets of dozens of megabytes (MB), and digital pathology scanners yield data sets of tens to hundreds of gigabytes (GB), automated microscopes may easily produce on the order of terabytes (TB) of image data in a single experiment 4First studies using ANNs for bioimage analysis date back to the late 1980s 4.1Many bioimage analysis tasks are greatly facilitated if the raw microscopy images are first enhanced by removing artifacts and restoring essential information as much as possible. Generally, a high signal-to-noise ratio (SNR) and spatial resolution are beneficial, but may not be achievable in a given experiment due to the required imaging speed and maximum allowable light exposure to avoid damaging the sample. Depending on the type of microscope used and the imaging conditions, different kinds of image enhancement operations may be applied, and deep learning has proven to be a powerful methodology for these. For instance, using well-registered pairs of low-quality and high-quality images, a CNN can be trained to perform denoising and recover resolution 4.2Another challenge central to many bioimage analysis tasks is to determine whether certain objects of interest are present in given microscopy images. Object detection often goes hand in hand with object localization and has been the subject of intense research for more than half a century 4.3One of the most ubiquitous tasks in bioimage analysis is the partitioning of images into meaningful segments for downstream quantification and statistical evaluation 4.4Characterizing real-life objects requires quantifying not only their spatial properties but also their temporal behavior. As advanced microscopes nowadays enable fully automated acquisition of time-lapse images of living cells and intracellular particles, this calls for robust computational methods capable of not only detecting and segmenting objects, but also tracking them over time in these images. Object tracking is generally considered to be “one of the most challenging computer vision problems” 4.5The task of identifying images or objects therein as belonging to one of multiple predefined classes is a fundamental problem of computer vision in general 5Deep learning has had a long history of discoveries, inventions, expectations, disappointments, rejections, revivals, successes, declines, recoveries, and breakthroughs, but is now widely accepted as the most powerful computing paradigm for big data analysis. The impact of deep learning on our daily lives is already unlike any other technology in the history of computer science, yet it seems we have seen only the proverbial tip of the iceberg. In biomedical imaging, DNNs are beginning to outperform human experts in a growing number of visual interpretation tasks, which is fueling fierce debates among professionals on the future ramifications for the field. Zeroing in on biological imaging, we have reviewed the use of deep learning approaches for common tasks in bioimage analysis, where they are now increasingly favored over traditional computer vision methods. Notwithstanding impressive achievements reported to date, many scientific and engineering challenges remain to further improve deep learning. In closing this mini-review, we touch on several important developments addressing these challenges that are relevant to bioimage analysis , which enable single-machine parallelization. But more efficiency is often needed to finish network training within a desired time frame. Codesigning architectural, algorithmic, software, and hardware solutions to allow multi-machine parallelism and scalable distributed deep learning for this purpose is an ongoing engineering challenge 5.7A major point of criticism for which even the pioneers of deep learning had their early papers rejected by peers in computer science, is that the use of neural networks for any given perceptual task provides “no insight into how to design a vision system” 5.8Ultimately, the goal of developing computational image analysis methods for the biomedical domain, from fundamental biological imaging to clinical medical imaging, is to improve the efficacy of healthcare. But in order for biomedical professionals to be willing to transfer their responsibilities to machines, and for those whose health depends on their care to accept such transition, these methods need to be trustworthy enough. In this regard it seems we have not quite reached the tipping point. In the past few years, the question whether or when AI will replace human experts has been pondered in many areas of biomedical imaging Erik Meijering: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Resources, Visualization.The author declares he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


The coronavirus (COVID-19) pandemic has resulted in changes to the working arrangements of millions of employees who are now based at home and may continue to work at home, in some capacity, for the foreseeable future. Decisions on how to promote employees’ health whilst working at home (WAH) need to be based on the best available evidence to optimise worker outcomes. The aim of this rapid review was to review the impact of WAH on individual workers’ mental and physical health, and determine any gender difference, to develop recommendations for employers and employees to optimise workers’ health.A search was undertaken in three databases, PsychInfo, ProQuest, and Web of Science, from 2007 to May 2020. Selection criteria included studies which involved employees who regularly worked at home, and specifically reported on physical or mental health-related outcomes. Two review authors independently screened studies for inclusion, one author extracted data and conducted risk of bias assessments with review by a second author.Twenty-three papers meet the selection criteria for this review. Ten health outcomes were reported: pain, self-reported health, safety, well-being, stress, depression, fatigue, quality of life, strain and happiness. The impact on health outcomes was strongly influenced by the degree of organisational support available to employees, colleague support, social connectedness (outside of work), and levels of work to family conflict. Overall, women were less likely to experience improved health outcomes when WAH.This review identified several health outcomes affected by WAH. The health/work relationship is complex and requires consideration of broader system factors to optimise the effects of WAH on workers’ health. It is likely mandated WAH will continue to some degree for the foreseeable future; organisations will need to implement formalised WAH policies that consider work-home boundary management support, role clarity, workload, performance indicators, technical support, facilitation of co-worker networking, and training for managers. The current global pandemic caused by coronavirus disease 2019 (COVID-19) has resulted in an unprecedented situation with wide ranging health and economic impacts , 4. For The emergence of new technologies has revolutionised working patterns, enabling work from anywhere for many employees , 8. The The ongoing need for containment of COVID 19 and continued need to undertake WAH requires evidence synthesis to develop policies and guidelines to protect employees’ health and well-being. We undertook a rapid review of the evidence on the impact of WAH on individual workers’ mental and physical health. In addition, we examined any gender differences of these impacts. We considered the body of evidence to develop recommendations for employers to optimise the health of their employees.This rapid review was undertaken using principles recommended by the WHO . PRISMA For inclusion in the current rapid review, studies were required to focus on adult white collar/professional employees WAH during business hours, and to include mental or physical health related outcomes of workers. Studies were excluded if they focused on domestic workers, self-employed workers, informal working from home (working from home after hours to catch up on work), productivity outcomes, chronic illness/disability, or pregnancy/breast feeding. The rationale of the search strategy was to capture studies which included participants who undertook working from home on a regular basis, but these arrangements did not necessarily have to be mandated or formalised by the organisation.Titles, abstracts and full texts were screened by two authors using Covidence . DisagreData extraction was undertaken using a standardised form and included setting, study design, method used, details of participants, industry setting, measures used, and the health outcomes. The risk of bias assessment was used as a proxy for the quality of the study and undertaken for both qualitative and quantitative studies using separate forms. The risk of bias domains were derived from the RTI research bank, Cochrane Collaboration tool quality assessment, and the Johanna Briggs appraisal tool for qualitative research –16. EachAn overall quality assessment of each study was determined using a previously published rating system . StudiesQualitative data were organised using narrative synthesis to identify how WAH influenced employees physical and mental health. Studies were grouped by broad health outcomes and then a separate analysis by gender undertaken.The database search identified 1557 papers of which 21 met the inclusion criteria. Two additional studies were included following a reference list search of the articles which met the inclusion criteria, making a total of 23 studies. The primary reason for exclusion was the study did not include a health outcome. The PRISMA diagram outlines the screening process , financial services (three), technology (two), academia (one), telecommunications (one), logistics (one). Ten studies used data from surveys of the general public or did not focus on a particular industry sector. The number of hours and nature of WAH arrangements varied between studies; participants WAH either full time  identified in the studies included: pain, self-reported health and perceived safety. Mental health related outcomes (n = 7) identified included: well-being, stress, depression, fatigue, quality of life, strain and happiness. Seven studies undertook separate gender analysis  the overall risk of bias for all studies was assessed as moderate. The four studies with high risk of bias included cross sectional surveys [Following assessment of risk of bias, quantitative studies were rated as: four high risk, three moderate risk, and 13 low risk. For the qualitative studies  explored the effect of working at home on mental health. Fourteen are explored in this section and seven studies that included a gender analysis are presented separately.The impacts of WAH on mental health were complex. Nine studies considered environmental, organisational, physical, or psychosocial factors in the relationship between WAH and mental health , 35, 38.Five studies , 35, 38 Anderson  measuredTwo studies explored the home environment as a mediator for the relationship between WAH and health related outcomes. Work-family conflict (WFC) occurs when the demands of work impinge on domestic and family commitments. Golden’s  study ofRelationships between WAH and the following mental health-related outcomes were examined: stress , 37, 38,Bosua et al.  studied Henke et al.  conducteFour studies examined the direct relationship impact of WAH on fatigue  with mixed results , 32, 37.Seven studies examined outcomes by gender , 34, 39.(p < 0.05) compared to non-teleworkers; no differences were found between female teleworkers and non-teleworkers. Song & Gao [The remaining four studies examined the direct relationship between WAH and health outcomes. Two studies, both using data from the American Time Use Survey, examined physical and mental health outcomes by gender. Gimenez-Nadal et al.  identifing & Gao  comparedKim et al.  and KazeDue to the current COVID-19 situation, WAH has been implemented as part of a broad public health measure to prevent the spread of an infectious disease. Although this measure was introduced rapidly, it is likely WAH will remain in place for some time and organisations will utilise this as a strategy to manage the necessary physical distancing requirements to prevent further outbreaks of COVID-19. This rapid review explored the impact of WAH on physical and mental health outcomes to inform the development of guidelines to support employers in creating optimal working conditions. In addition, included studies were examined to explore any gender differences in the relationship between WAH and health.The majority of studies in the rapid review employed cross-sectional designs and were of variable quality. The definition of WAH and the number of days per week employees were working at home were often unclear. Of the 23 studies identified as relevant to this review, only one investigated the condition of mandatory WAH , the remPhysical health and WAH was only examined in three studies. The very low number of studies identified could suggest the search strategy was not adequately targeted to capture studies assessing the physical health outcomes of WAH; however, a range of terms associated with musculoskeletal health were included. Grey literature may have offered further insights but was not included in this rapid review. An alternative explanation may be that in cases where employees are working at home for limited time periods, the use of standard guidelines for workstation arrangements have been considered sufficient and deployed to manage the physical health of workers. The limited coverage of physical health outcomes of WAH was not expected. Previous research, in relation to the occupational health of employees, suggests the focus is more typically on the physical aspects of health .n = 21). Three of the studies employed longitudinal approaches [In contrast, the impact of WAH on mental health outcomes was covered by the majority of included studies proaches . An exteproaches . The tran = 7) undertook separate analysis by gender on the impacts of WAH on health. The differences in health impacts may reflect traditional gender roles where males are perceived as ideal citizen workers whose primary focus is work, whilst for women dual roles exist in the work and domestic sphere which remains pervasive in many cultures [Only one third of the studies  is required. Some financial compensation may be appropriate for employees to reduce this fiscal burden, although some of these costs may be offset by reduced costs associated with commuting.Longitudinal research is required, which systematically considers all factors in the relationship between employees and their organisations whilst WAH; this can inform the development of guidelines to facilitate the creation of optimal WAH conditions to reduce any negative impacts of employees’ health and well-being.


Due to improved efficacy of antitumour treatment in the general population, there are increasingly more childhood cancer survivors. However, some of these survivors are at risk of distant complications including cardiovascular disease. We aimed to examine the risk of overweight/obesity and abnormal body composition in a large group of patients from our paediatric oncology centre. We used anthropometric methods and electrical bioimpedance to assess these features, and then determined their association with disease and treatment. We found patients treated for leukaemia/lymphoma  had significantly higher rates of overweight/obesity compared to the other patient groups. On the contrary, overweight/obesity was more common in girls among patients treated for solid tumours. Patients treated for leukaemia/lymphoma were characterised by a higher body fat content compared to those treated for solid tumours and controls. During treatment for cancer, patients had a higher percentage of muscle mass deficiency compared to those in the control group. Our regression analysis showed time from completion of treatment, gender and type of therapy  were associated with body weight and body composition including fat and muscle content. We recommend paediatricians and general practitioners should actively try to detect and prevent cardiovascular disease among childhood cancer survivors. The efficacy of comprehensive antitumour treatment has improved over the years, leading to an increase in the number of childhood cancer survivors. Nonetheless, cancer survivors should be monitored for relapse of underlying disease, secondary tumours, and late complications of therapy, including endocrine complications such as obesity and diabetes , 2. IndeTo identify these complications diverse measures are used. The most universal marker for the diagnosis of overweight and obesity is the body mass index and standardised deviation score (BMI-SDS); its calculations should be based on updated country norms . For assThe studies carried out so far concerning cardiovascular disease risk factors in childhood cancer survivors have typically involved small groups of patients, or patients with one diagnosis, and typically use only BMI or BIA/DXA for assessment of obesity and excessive body fat. With this in mind, in our cross-sectional study, we aimed to identify clinical factors that affect body weight and body fat and muscle content in people who are currently treated or have had cancer in childhood. We examined body weight and body fat and muscle content in a large group of patients from our paediatric oncology centre using anthropometric methods and electrical bioimpedance. We then examined the relationship(s) of these factors with features associated with the disease and/or its treatment. The data obtained may be used in the future to assess the health condition of childhood cancer survivors.This study was carried out at the Department of Paediatric Oncology and Haematology at the Medical University of Bialystok, Poland from 2014 to 2017 . It was designed as a cross-sectional study evaluating body mass and bioimpedance during and after cancer treatment in childhood. The tests were performed during regular follow-up visits in all patients who met the inclusion criteria. The study inclusion criteria were: diagnosis and treatment of cancer according to the Polish Group for the treatment of leukaemia/lymphomas and solid tumours criteria; Polish nationality; aged 2–22 years; good general condition at the time of the study ; consent of the parents/guardians and/or the patient themselves for inclusion in the study; and in post-treatment patients, remission of the underlying disease. Study exclusion criteria were: relapse or progression of the disease, chromosomal disorders, mental disorders , hormonal and autoimmune disorders including thyroid and adrenal gland disorders, celiac disease, and diabetes. The control group  was composed of siblings/families of patients with cancer, volunteers, and children admitted to the clinic for reasons other than cancer. The control group included patients in whom cancer, chromosomal, autoimmune, hormonal, and psychiatric disorders were ruled out. Parents/guardians and/or subject themselves provided consent for inclusion in the study.2 daily of prednisone or equivalent for a minimum of 30 days. Radiation therapy involved a minimum dose of 12 Gy and may have been applied to the following regions: CNS, neck, mediastinum, abdominal cavity and/or total body.The study group was divided into the following four subgroups, according to the type of cancer and whether they were undergoing active treatment or not: 1) patients currently undergoing intensive/maintenance treatment for leukaemia or Hodgkin’s/non-Hodgkin’s lymphoma, 2) patients after completion of treatment for leukaemia/lymphoma (>1 year after therapy termination), 3) patients currently undergoing treatment for solid tumours and 4) patients after completion of treatment for solid tumours (>1 year after therapy termination). Solid tumours group included patients with rhabdomyosarcoma, Langerhans cell histiocytosis, neuroblastoma, osteosarcoma, germ cell tumours, Wilms tumour and Ewing Sarcoma. Patients treated with steroids were considered those who were receiving a dose of 60 mg/mAnthropometric parameters including age, sex, height, weight, and BMI-SDS were evaluated in all subjects. The disease-associated parameters evaluated in the group of cancer patients/survivors were: type of cancer, treatment regimen used, elapsed time since therapy termination, use of radiotherapy, history of steroid treatment and history of allogeneic hematopoietic stem cell transplantation (HSCT).2) and BMI-SDS values were calculated and coded as follows: underweight = BMI-SDS < −1; normal weight = −1 ≤ BMI-SDS < +1; overweight = +1 ≤ BMI-SDS < +2; obesity = +2 ≥ BMI-SDS .The effects of irradiation and megachemotherapy with allogeneic HSCT on body fat and muscle content were also analysed. After treatment for leukaemia/lymphoma, the fat mass was higher in patients treated with any type of radiotherapy compared to those treated without radiotherapy : excess of FAT was observed in 40 (64.5%) patients irradiated and 47 (38.8%) patients without irradiation (p < 0.01). In patients after treatment with megachemotherapy for leukaemia/lymphomas, higher rates of muscle mass deficiency was observed compared to patients treated without this method, but these differences were not statistically significant.Megachemotherapy with allogeneic HSCT resulted in a greater fat mass in patients after treatment for leukaemia/lymphoma than those without HSCT . Interestingly, the correlation was stronger after the grouping of patients according to gender . However, taking into account the patient’s age at the time of the study, the correlation remained positive only in the group after treatment for leukaemia/lymphoma (r = 0.21): the correlation became negative in those after treatment for solid tumours . Thus, muscle mass increases over time after treatment for leukaemia/lymphoma and decreases after treatment for solid tumours.There was a positive correlation between SMM and time from treatment completion both after treatment for leukaemia/lymphoma and for solid tumours . The time from treatment completion, irradiation, gender and age of diagnosis of cancer explained 29% of the variability in PBF after treatment for leukaemia/lymphoma . A similar model with time from completion of therapy and gender explained 63% of the variability in PBF after treatment for solid tumours ; meanwhile, gender and the use of any type of irradiation explained 49% of the variability in FAT in this group of patients .We then developed regression models to explain the variation in body weight, as well as fat and muscle mass. The time from treatment completion and gender explained 46% of the variability in BMI-SDS after solid tumour treatment . The time from the treatment completion and gender explained the variability in PBF . Finally, the time from the end of treatment, gender, the use of HSCT, the irradiation and the age of cancer diagnosis explained muscle content after treatment for leukaemia/lymphoma or solid tumours .We also performed a regression analysis in a combined group of patients after treatment for both leukaemia/lymphoma and solid tumours . Only the time elapsed from the end of treatment explained the variability in the BMI-SDS in this group . In addThe strength of our analysis is the creation of a regression model that explains which factors affect body mass, fat and muscle after treatment of childhood cancer. This model shows the factors that determine the occurrence of overweight/obesity and abnormal body composition in cancer survivors. The limitations of our study are the significant difference in time from the end of anticancer treatment between leukaemia/lymphoma and solid tumours groups, the small number of children included who were currently undergoing treatment of solid tumours, the difficulties with stratification according to glucocorticoid therapy, and a lack of prospective studies.The occurrence of excessive body weight and body fat after cancer can and must be prevented. An early intervention based on family participation in patient lifestyle intervention has been proposed previously . We recoThe authors declare that they have no conflict of interest.Małgorzata Sawicka-Żukowska and Włodzimierz Łuczyński equally contributed to this work. Małgorzata Sawicka-Żukowska and Maryna Krawczuk-Ryba designed the study, Małgorzata Sawicka-Żukowska and Włodzimierz Łuczyński were major contributors in writing the manuscript, Małgorzata Sawicka-Żukowska and Jakub Dobroch collected and analysed the patient’s data. All authors read and approved the final manuscript.The study design was approved by the Ethics Committee at the Medical University of Bialystok in accordance with the Declaration of Helsinki (No 153-798883L). Signed informed consent was obtained from patients and their parents/guardians.The study was funded by the Medical University of Bialystok, Poland.


In Norway, interest in hand surgery and introduction of new methods developed from reconstructive surgery in patients who had rheumatoid arthritis or polio. After the second world war, surgeons from Norway with special interest in hand surgery, primarily the pioneers Halfdan Schjeldrup  and Henrich Steffens Nissen-Lie , received their hand surgery training mainly in Great Britain and the US . They apCooperation within the Nordic countries was encouraged, and Nissen-Lie was co-founder of the Nordic Hand Club in 1951. Halfdan Schjeldrup and Henrich Steffens Nissen-Lie published numerous articles, gave lectures at the Universities of Oslo and Bergen, and received international recognition for their work, including honorary membership in the British Society for Plastic Surgery and the British Orthopaedic Association. Then and now, the common non-complicated hand operations were performed by general or orthopaedic surgeons at local hospitals throughout the country. The teaching and practice of the pioneers inspired the establishment of hand surgery units at all university clinics and at regional hospitals for the treatment of the more complex cases.With the advancement of loupes, operating microscopes, and fine suture materials, advanced nerve surgery, including nerve grafting, was introduced and established in the 1960s and 1970s. The first replantation surgery was performed in 1983 by Astor Reigstad and colleagues, who later also introduced advanced reconstructive microsurgery, including toe transfer and free flap surgery . During The Norwegian Society for Surgery of the Hand (Norsk forening for Håndkirurgi) was founded in 1979  . The Nor in 1979 . Arne Ru in 1979 . Today, Every year the Society arranges a winter meeting close to the Olympic city of Lillehammer. A renowned international guest speaker is usually invited, together with Norwegian experts on special-focus subjects. The meeting is attended by around 40 surgeons and has become an important venue for professional and social exchange. The Society also awards two scholarships and encourages research and training among its members. The members are active in the SSSH, European, and international federations for hand surgery societies as congress presenters or course faculties, and the delegates serve in the different committees and councils.Norway is a relatively large, but scarcely populated country (5 million people) with 55 hospitals spanning more than 2000 km, from the southernmost to the northern-most hospital, and 550 km from east to west. There are a large number of hand surgery patients; Norway has a high incidence of injuries (where hand injuries account for around 50%) and disorders like Dupuytren contracture, carpal tunnel syndrome, and tenosynovitis is common. Hand surgical services are available in most hospitals and are directed by trained (minimum 6 years of training) orthopaedic specialists, while more complex hand surgery is performed at special hand units (in orthopaedic or plastic surgery departments) at the university clinics and regional centres. Hand surgery training is obligatory for orthopaedic and plastic surgery specialities, but there is no formal speciality in hand surgery in Norway. An annual 5-day postgraduate instructional course in hand surgery is organized with a mixture of lectures, case discussions, and two full afternoons of upper extremity dissection. The course is compulsory for all residents in orthopaedic surgery. In 2009, a Norwegian textbook in hand surgery (revised in 2019) was authored by the members of the Society. It is the obligatory textbook for the course in hand surgery and is used by departments performing hand surgery.Several Norwegian surgeons have obtained speciality training in hand surgery in Sweden . A Norwegian Diploma in Hand Surgery, based on the FESSH (Federation of European Societies for Surgery of the Hand) Diploma, has been created. The candidates are fully trained in either orthopaedic surgery or plastic surgery (6 years) and have at least two more years of training in hand surgery, preferably at one of the university hospitals. The applicants for the diploma must display a logbook, similar to that used for the FESSH examination. Twenty-one hand surgeons have obtained the Norwegian Diploma. Eight Norwegian hand surgeons have also successfully achieved the European Diploma in Hand Surgery (EBHS).Hand surgery in Norway is organized as a regional sub-speciality. The largest Norwegian university hospitals have separate hand divisions as part of their orthopaedic or plastic surgery departments, and these are all certified as hand trauma centres by FESSH . Modern principles for most wrist and hand procedures have been implemented. Arthroscopic surgery has replaced open procedures, needle fasciotomy is the main procedure for primary uncomplicated Dupuytren contracture, and displaced distal radius fractures are treated operatively, usually with anterior locking plates. Flexor tendons are sutured using multiple strands and strong suture materials allowing early active motion. Arthroplasties are offered for arthrosis of the wrist, thumb basal joint, and metacarpophalangeal and proximal interphalangeal joints as an alternative to arthrodesis or interposition. Nerve and tendon transposition and transplantation are commonplace for management of sequelae of injuries or disease.The most advanced reconstructive surgeries have been centralized to single national centres. Replantation surgery and brachial plexus surgery (obstetric/traumatic) is available at the Hand and Microsurgery Department, Division of Orthopedic Surgery, Oslo University Hospital, and the operative treatment for restoration of hand and arm function in tetraplegic patients is available at the Department of Orthopedic Surgery, Haukeland University Hospital in Bergen. Yearly between 60–80 replantations, 40–50 plexus/sequela plexus surgeries, and 15–20 tetraplegic surgeries (in 5–10 patients) are performed for our population of 5 million inhabitants.Research in hand surgery has been dominated by the university departments in the largest cities. There is a professor of hand surgery at the University of Oslo and a professor of orthopaedic surgery with special interest in hand surgery in Tromsø. Annually between five and 10 peer-reviewed hand surgery articles are published. During the last 10 years six PhD candidates in hand surgery have defended their theses on radius and metacarpal fractures, flexor tendon injuries, wrist and trapeziometacarpal joint arthrosis/replacements, and cold intolerance. Ongoing research and doctoral projects include distal radius fractures, replantation surgery, brachial plexus treatment, dysmelia, and wrist replacements.


China has the highest number of hepatitis B and C cases globally. Despite remarkable achievements, China faces daunting challenges in achieving international targets for hepatitis elimination. As part of a large-scale project assessing China’s progress in achieving health-related Sustainable Development Goals using quantitative, qualitative data and mathematical modelling, this paper summarises the achievements, gaps and challenges, and proposes options for actions for hepatitis B and C control. China has made substantial progress in controlling chronic viral hepatitis. The four most successful strategies have been: (1) hepatitis B virus childhood immunisation; (2) prevention of mother-to-child transmission; (3) full coverage of nucleic acid amplification testing in blood stations and (4) effective financing strategies to support treatment. However, the total number of deaths due to hepatitis B and C is estimated to increase from 434 724 in 2017 to 527 829 in 2030 if there is no implementation of tailored interventions. Many health system barriers, including a fragmented governance system, insufficient funding, inadequate service coverage, unstandardised treatment and flawed information systems, have compromised the effective control of hepatitis B and C in China. We suggest five strategic priority actions to help eliminate hepatitis B and C in China: (1) restructure the viral hepatitis control governance system; (2) optimise health resource allocation and improve funding efficiency; (3) improve access to and the quality of the health benefits package, especially for high-risk groups; (4) strengthen information systems to obtain high-quality hepatitis epidemiological data; (5) increase investment in viral hepatitis research and development. China has made considerable achievements in controlling hepatitis B and C through multiple strategies with efforts focused on prevention and increased treatment financing.Formidable challenges remain in combating hepatitis by 2030. Key health system barriers, including a fragmented governance system, insufficient funding, inadequate service coverage and unstandardised treatment, and flawed information systems, have compromised the effective control of viral hepatitis.To tackle these challenges, China must take five immediate actions: restructuring the governance system of viral hepatitis, optimising resource allocation and increasing the efficiency of funding, improving access to and the quality of the health benefits package, strengthening information systems and boosting investment on hepatitis research and development.Infection with chronic viral hepatitis can be caused by exposure to five different types of viruses . Hepatitis B virus (HBV) and hepatitis C virus (HCV) account for 96% of all deaths related to viral hepatitis.7Viral hepatitis control in China is governed by the Bureau of Disease Prevention and Control, National Health Commission (NHC) and overseen by health commissions at the provincial, prefecture and county levels across the country. Under the regulatory supervision of NHC, the Chinese Center for Disease Control and Prevention (China CDC) is responsible for disease prevention and management, while hospitals provide clinical diagnosis and treatment. The Division of Immunization Planning Management and Division of HIV/AIDS Prevention and Control within NHC is responsible for hepatitis B and C control, respectively. The same governance structure for hepatitis B and C control has been put in place at the China CDC system nationwide.Viral hepatitis is increasingly garnering global attention and is included in the United Nations’ 2030 Agenda for Sustainable Development Goals (SDGs) where SDG 3.3 calls for ‘combat viral hepatitis’.This article collected quantitative and qualitative data for analysis. Quantitative data were collected from published literature in Chinese and English, GBD 2017 Study estimates,14China has made substantial progress in controlling HBV and HCV infections over the past few decades. Based on the national seroepidemiology surveys conducted by China CDC since the 1990s, the seroprevalence of HBV surface antigen (HBsAg) among children <15 years old has declined from 10.5% in 1992 to 0.8% in 2014, and reached 0.3% among children under age 5 in 2014.First, China’s HBV childhood immunisation programme has been recognised by WHO for its remarkable success.23Second, comprehensive programmes to prevent mother-to-child transmission boosted HBV transmission control. Mother-to-child transmission is estimated to be responsible for 40%–50% of new HBV infections in China.25 26Third, full coverage of nucleic acid amplification testing (NAT) in all blood stations substantially improved blood safety and prevented transfusion-transmitted infections, including HBV and HCV. The probability of transmitting via blood is especially high for HCV, and NAT can detect low levels of virus during a window period. NAT was included in routine donor screenings and piloted in 14 selected blood stations of 11 provinces since 2010.28Lastly, China has made remarkable progress in implementing effective financing policies to make HBV and HCV drugs affordable over the past few years. Entecavir and tenofovir, two WHO-recommended first-line HBV drugs, were included in the updated National List of Reimbursable Medicines (NLRM) in February 2017.33 34China has almost reached WHO’s targets for HBsAg prevalence (0.3% in 2014 among children under 5), HBV vaccination (99.6% in 2015), PMTCT (95.6% in 2015) and blood safety , and the gap is even more massive for hepatitis C control with little support to implement effective prevention strategies. Although recommended HBV drugs have been included in the NLRM for over 3 years, the actual reimbursement rates vary greatly across China due to the decentralised management and risk pooling across Chinese health insurance schemes. This policy poses formidable challenges in achieving universal hepatitis treatment. It will be the same case for the HCV drugs recently added into the NLRM if no effective actions are taken.The delivery of comprehensive health services for hepatitis B and C, including prevention, testing, diagnosis and treatment, has not achieved its ideal coverage and standardisation. Hospital-acquired infections have not been prevented in low-tiered hospitals or hospitals in remote areas, which may follow less strict sterilisation procedures and skip testing HCV before surgical operations. The coverage of harm reduction practices to prevent HCV infection among drug users is low given stigma, discrimination and legality of using drugs.The information system of viral hepatitis is unable to provide adequate data on the hepatitis epidemic for strategic planning. The current information system, IDSRS, primarily captures HBV and HCV new infections and deaths while providing little information on critical indicators such as service coverage, diagnosis and treatment. Duplication of data undermines its quality and accuracy.In light of the above challenges and taking into account recommendations from literature and key stakeholder interviews, we propose five strategic priority actions to help achieve the international and domestic targets and eliminate viral hepatitis in China.First, restructure the governance system for viral hepatitis control within NHC and the China CDC to change the current fragmented management situation. It is suggested that the NHC establish a separate and independent division for viral hepatitis under the Disease Control Bureau to lead the national viral hepatitis control effort, with the Health Commission and CDC at different administrative levels making similar structural changes. The department should have its own team, budget and work plan with performance indicators to ensure successful operation.Second, optimise resource allocation and increase the efficiency of funding to ensure sufficient and sustainable health financing for hepatitis elimination. It is essential that the NHC identify the funding required to achieve targets, and develop a comprehensive and feasible hepatitis control budget to cover the continuum of health services. The NHC worked with WHO to develop an investment plan for hepatitis in 2016, though it remains unclear if and how this plan will be used for strategic planning. Meanwhile, the NHC can work with the Ministry of Finance and the National Healthcare Security Administration on funding resource mobilisation and reallocation for sustained viral hepatitis health financing, ideally under the designated leadership of the State Council. It is essential to standardise treatment and reduce drug prices to increase funding efficiency. Regional disparities in health insurance coverage need to be assessed and addressed through central budgeting compensations.Third, improve access to and quality of the health benefits package for patients with viral hepatitis, especially for high-risk groups. The five core interventions proposed by WHO  to be inBox 1HBV vaccination;Injection, blood and surgical safety and universal precautions;Prevention of mother-to-child transmission of hepatitis B virus;Harm reduction services for people who inject drugs;Treatment of chronic hepatitis B virus and hepatitis C virus infection.Source: Global Health Sector Strategy on Viral Hepatitis, 2016–2021, WHOBox 2Effective prevention interventions have reduced new hepatitis B virus (HBV) infections and put new hepatitis C virus (HCV) infections under control in China. Treating the large number of people with HBV and HCV needs to be prioritised to meet viral hepatitis elimination targets.Addressing low hepatitis B and C treatment rates largely due to inadequate case identification and high patient financial burden face formidable challenges with respect to service coverage, service quality and financial protection. The treatment success rate is an issue for people infected with hepatitis B, who have to receive lifelong treatment despite the asymptotic nature and side effects. The quality of service provided varies by hospital, and there are no standardised treatment packages. Overprescription of medicines is prevalent, especially auxiliary medicines, as a way to generate revenues. Effective financing strategies have improved the financial protections for patients with hepatitis, especially for patients with hepatitis B in the ‘4+7 Cities’.Looking ahead, China must take urgent actions to improve the treatment service coverage, quality and affordability for people infected with HBV and HCV. Key recommendations are:Increase identification of infected individuals through a better surveillance system and improved testing and diagnosis accuracy. Resource-rich provinces and cities can implement active patient identification strategies, while working on removing stigma and discrimination through population-wide health education programs.Develop a standardised treatment package and ensure it is well implemented at different levels of clinical institutions. Considering the root cause of overprescription, strategies to rationalise physicians’ salary and apply the diagnosis-related groups or capitation payment need to be in place. Capacity training for physicians and carefully designed performance evaluation indicators are also essential to ensure the successful implementation.Strengthen patient management to improve medication adherence. This is especially important for patients with hepatitis B. Hospitals should apply individual patient management to them, similar to the treatment and management of patients with HIV/AIDs.Decrease patient financial burden due to treatment, especially for low-income groups. Economic analysis has demonstrated high cost effectiveness of investing HBV and HCV treatment drugs in many countries. Despite the huge progress, continuing investment needs to be made on reducing drug price and increasing reimbursement rate especially for the low-income patients to increase equity.Fourth, strengthen information systems to obtain high-quality hepatitis epidemiological data. A well-designed quality control system needs to be established and implemented to avoid inaccurate and duplicate cases of hepatitis infection and hepatitis-related death. The system should also integrate process indicators for service coverage to capture data throughout the continuum of care, making it possible to assess the national hepatitis burden and monitor access to, uptake of and quality of services delivered.Lastly, boost investment for hepatitis research and development (R&D) innovations. It is unlikely for either the world or China to eliminate the viral hepatitis burden unless significant progress is made to develop new medicines, technologies and innovative service delivery approaches. Continuing and increasing investment is necessary to improve the prevention, testing, diagnostics, treatment and patient management of chronic viral hepatitis. Particularly, priority should be placed on R&D in effective HCV vaccination and short-course HBV curative treatments.This article highlights recent improvements in the control of hepatitis B and C in China and how they can be furthered. Given projections for increased deaths due to hepatitis B and C in China and the large numbers of individuals infected with hepatitis B and C, it is critical to urgently develop and implement a set of concerted actions, as proposed above, with adequate resources put in place to support the effective implementation of these actions. Inaction, or delay in taking these actions, would have to make a negative impact on a large number of Chinese households and society.


This paper presents data and analysis from survey research conducted by the Rehabilitation Engineering Research Center on Information and Communications Technology Access for Information and Communications Technology (ICT) Access for Community Living, Health and Function (LiveWell RERC) on the perceptions and attitudes of clinical professionals in rehabilitation medicine regarding mobile health  and mobile rehabilitation (mRehab) practices, techniques and technology in the United States. The analytical focus of this paper is on two key survey questions related to specific barriers and opportunities  for adopting mHealth/mRehab interventions. We present response data to these two questions segmented by clinical specialty – physical, occupational, speech and recreation therapy – to identify possible variation between and among these rehabilitation professions. This analysis provides a detailed map of the terrain of clinician expectations and experiences for the adoption and implementation of mHealth/mRehab interventions in the United States, and possibly other countries. Results show substantial support for mRehab interventions and technologies across all four clinical specialties. The most frequently identified barriers to effective use of mobile and internet technologies to support patients remotely focused on patients , not clinicians. The was more variability among clinical specializations regarding best use-cases. Tracking patient adherence to prescribed activities and supporting patients in the home and community were the most frequently cited best use cases across the whole sample. What barriers might limit or detract from mobile and internet technology’s effectiveness in supporting post-acute and between-visits therapy interventions?What do you believe are the most critical use cases for mobile or internet technology support in post-acute or between-visits therapy interventions?This paper presents data and analysis from survey research conducted by the Rehabilitation Engineering Research Center on Information and Communications Technology Access for Information and Communications Technology (ICT) Access for Community Living, Health and Function (LiveWell RERC) on the perceptions and attitudes of clinical professionals in rehabilitation medicine regarding mobile health  and mobile rehabilitation (mRehab) interventions and technology in the United States. We focus on two key survey questions related to specific barriers and best use-cases for mRehab interventions identified by clinicians:We provide summary results from all respondents and analysis of responses by four core clinical specializations: physical, occupational, speech and recreation therapy to identify possible variation between clinical professions. This analysis provides a detailed map of the terrain across multiple dimensions for the adoption and implementation of mRehab interventions in the United States, and possibly other countries.Mobile health and mobile rehabilitation  services and technologies have attracted considerable interest from healthcare providers, technology vendors, rehabilitation engineers, investors and policy makers in recent years –3. SucceMobile healthcare and mobile rehabilitation offer the potential to dramatically expand services to patients in need. Indeed, the World Health Organization (WHO) views “digital health” solutions as a key tool to support the goal of Universal Health Coverage (UHC). According to the WHO: “Digital technologies provide concrete opportunities to tackle health system challenges, and thereby offer the potential to enhance the coverage and quality of health practices and services” .This view is reflected in the World Federation of Occupational Therapists (WFTO), whose Statement of Position states: “Telehealth is an appropriate delivery model for occupational therapy services when in-person services are not possible, practical, or optimal for delivering care and/or when service delivery via telehealth is mutually acceptable to the client and provider” . In the Perceived need for mRehab interventions based on patients’ therapy needs post-discharge from inpatient rehabilitation or between outpatient clinic visitsPerceived barriers to use of mRehab, including personal interest or reservations about mRehab interventionsPerceptions regarding the potential utility of mRehab interventions including the most important use cases for the technologyCurrent interest in, knowledge about, or actual experience using mRehab strategiesWith input from our clinical advisors and informed by a review of the available literature on barriers to adoption of digital health interventions, we developed the “Clinician perspectives on mRehab interventions and technologies” survey questionnaire consisting of 22 questions to address four broad topics:Data were collected from January 22 to March 10, 2019. Participants were recruited through the researchers’ personal networks at Shepherd Center, Duke University Medical Center, the American Congress of Rehabilitation Medicine, American Physical Therapy Association, American Occupational Therapy Association, American Speech-Hearing Association, and others. Data were collected using convenience sampling methods and online data collection on the Survey Monkey web-based platform. Although no protected health information (PHI) was collected in this survey, the Survey Monkey platform does meet the privacy and security requirements of the United States Health Insurance Portability and Accountability Act of 1996 (HIPAA), which establishes essential policies and practices for protecting patient health information from unnecessary and unauthorized access.Efforts were made to ensure that relative balance in the number of respondents among the 4 core clinical therapy professions  by creating unique “collectors” in Survey Monkey and setting limits on the number of respondents to each. A small incentive—a $5.00 Starbucks gift card sent electronically—was offered to respondents to encourage higher levels of completeness in survey responses. The Research Review Committee at Shepherd Center reviewed and approved this research to ensure protection of participants.Response data were analyzed using SPSS version 22. A total of 505 rehabilitation clinicians across multiple rehabilitation specialties completed the questionnaire. About half of respondents reported between 5 and 19 years of experience in their profession, and slightly more than half (55%) personally owned a wearable fitness tracker, smart watch, or other wearable device with sensors. Table Many respondents reported treating multiple patient populations including those with acquired brain injury (ABI), neurodegenerative diseases (NDD), musculoskeletal injury or disorder, cardiovascular disease (CVD), cancer, spinal cord injury (SCI) and other conditions Table .Table 2.Similarly, many respondents reported working in multiple clinical environments, including inpatient and outpatient environments, as well as skilled nursing facilities, home health and other environments Table .Table 3.To map the challenges and opportunities for implementing new mHealth and mRehab interventions for people with disabilities and chronic conditions, respondents were asked to: 1) select the 3 most likely barriers or concerns that might limit or detract from the effectiveness of mobile and internet technology to support post-acute and between-visits therapy interventions; and 2) to identify the 3 most critical use cases for technology-based remote interventions.For each question, respondents were provided a list of barriers and use cases, respectively, with the option to specify additional barriers and use cases in an open-ended comment field. Tables Respondents in all four professions identified concerns over the ability of patients to learn and use the mRehab technology correctly  and access to internet services (65.7%) as the top 2 potential barriers to the effectiveness of mobile and internet technology to support their patients. Physical therapists were notably less concerned with internet access compared to the other four professions.There was some variation in the secondary barriers identified among the four professions. Physical therapists were more concerned with the hassle and time commitment required of clinicians for set-up (36.1%), and the accuracy and reliability of the technology (31.9%). Occupational and speech therapists were more concerned with the cost of the solutions and reimbursement by insurance providers . Recreation therapists identified security and privacy of the technology as their leading secondary concern (33.3%).There was greater variation in the most critical use cases identified by respondents in each of the four therapy professions. Almost three-fourths (73.9%) of physical therapists identified supporting patient adherence to prescribed exercises and activities. Notably, a similar percentage of speech therapists (72.9%) also identified this as a critical use case. But, speech therapists’ most frequently cited use case was supporting patient functioning at home and in the community (78.9%). This was also the most frequently cited use cases for occupational and recreation therapists .Approximately half of the respondents in each profession cited real-time, direct observation and communication with patients as a critical use-case, making this the third most cited use-case. Also noteworthy, almost half of the physical therapists (48.6%) cited remote biometric monitoring as a critical use case. Patient self-reporting of outcomes and remote environmental monitoring using sensors in the home were least frequently cited overall.Clinical professionals often serve as “gatekeepers” for new healthcare technologies . They arThe survey data presented here on the perceptions of rehabilitation clinicians indicates broad acceptance of mHealth technologies and interventions for specific use-cases. There was consensus among respondents in the four rehabilitation therapy professions analyzed here in favor of using of mHealth technologies to support patient adherence to prescribed exercises and activities and to support patient functioning in the home and community. There was much less support for use-cases involving wearable or environmental sensors and patient self-reporting.the patients, not the clinicians. Patients’ ability to learn and use the technology correctly and patient access to the internet were the top perceived barriers. Other potential barriers such as reimbursement from insurance providers, hassle and time commitment on the part of clinicians, security and privacy, accuracy and reliability of data collected, and improvement in health outcomes were much less frequently identified as barriers.There was strong consensus that the main barriers to adoption related to The low levels of concern for these other potential barriers is noteworthy, as these have been identified as concerns in earlier studies of physician perspectives on digital health. In a 2016 survey of physicians in the U.S., most respondents reported being concerned about potential liability, reimbursement, technical problems, and patient privacy . SimilarIt is possible that rehabilitation therapists are more likely to utilize a wider range of technologies, especially mobile and internet technologies, than physicians. Also, rehabilitation therapy usually involves more frequent and longer-duration interactions with patients. That degree of engagement with patients may motivate rehabilitation clinicians to be more concerned about patient access than they might be regarding reimbursement, time commitment on the part of the clinician, privacy, etc.The survey of clinician perspectives on mRehab interventions and technologies serves as the cornerstone for our long-term commitment to engage clinicians regularly regarding their experiences using new methods and modalities of interacting with their patients and using newly emerging technologies. We plan to update and refine this cornerstone survey with the goal of tracking clinician perceptions and experiences over time. Additionally, we plan to conduct more targeted research on topics such as experiences implementing a cloud-based digital therapeutics system for prescribing home exercise programs (HEPs) and tracking progress; and using specific consumer platforms to track patient activity such as smartwatches, fitness trackers, camera-based systems, smart speakers and other smart home devices.


Though clinical practice guidelines are available, the diagnosis of pediatric hypertension (HTN) is often missed. Management may not follow guidelines due to the measurement challenges in children, complexity of interpreting youth blood pressure standards that are dependent on height, age, and sex, familiarity with diagnostic criteria, and variable comfort with management of pediatric HTN among providers. Evidence suggests that wide adoption and adherence to pediatric HTN guidelines would result in lower cardiovascular disease and kidney damage in adulthood. The proposed project will develop an implementation strategy package to increase adherence to clinical practice guidelines for pediatric HTN within safety-net community health centers (CHCs). The centerpiece of which is a provider-facing population panel management (PPM) tool and point-of-care clinical decision support (CDS). Prior research indicates that multiple discrete implementation strategies  are needed to institute practice- and provider-level adoption of such tools.Using participatory research methods involving stakeholders from a practice-based research network of CHCs, with input from scientific advisors, the project aims to (1) employ user-centered design methods to tailor an existing CDS tool for use at the point of care and optimize cohort management with a PPM tool to support adherence to the latest pediatric HTN guidelines, and (2) use a stakeholder-driven method for selecting implementation strategies that support tool adoption and increase guideline-adherent physician behaviors. Multilevel process evaluation using surveys and key informant interview data will assess the acceptability, adoption, appropriateness, cost, and feasibility of the PPM tool and its multicomponent implementation strategy package. Usability testing will be conducted with the PPM tool to iteratively refine features and ensure proper functionality.The proposed research has the potential to improve identification, diagnosis, and management of HTN in primary care settings for high-risk youth by assisting healthcare providers in implementing the American Academy of Pediatrics’ 2017 guidelines using an EHR-integrated PPM tool with CDS. Should the strategy package for PPM tool adoption be successful for pediatric HTN, findings will be translatable to other settings and PPM of other chronic cardiovascular conditions affecting overall population health. Contributions to the literatureThe OpTIMISe–Pediatric Hypertension Study protocol involves a stakeholder-driven approach for the design of health information technology tools to support guideline-adherent care of pediatric hypertension, an underdiagnosed condition with significant health disparities, as well as the development of a multicomponent implementation strategy to support uptake by pediatric providers.This protocol is unique in its use of user-centered design and stakeholder-engaged methods in the implementation preparation phase and its focus on both population-based and point-of-care health information technology strategies to support implementation.This study is conducted in safety-net community health centers serving socioeconomically disadvantaged children who are at high risk for cardiovascular disease.Target organ damage, especially left ventricular hypertrophy associated with heightened risk for cardiovascular events in adults, is detectable in youth with primary hypertension (HTN) , 2. RiskA recent study in community health centers in the Chicago area found only 6.1% among 1478 children (age ≥ 3 and < 18 years) who met criteria for abnormal BP—based on BP values from clinical encounters recorded in the electronic health record (EHR)—were correctly diagnosed . EvidencIn the USA, nearly 1 in 9 children exhibit serious cardiometabolic symptoms, including HTN, type 2 diabetes, insulin resistance, non-alcoholic fatty liver disease, asthma, and obstructive sleep apnea, all of which accelerate the risk for cardiovascular disease and mortality . Additioth%) have HTN [n = 12,169, 8 studies) in overweight children, and by 7.49 mmHg  in children with obesity [About 3% of the general population has HTN, while about 25% of youth with obesity  than those with normal BP ($736) or pre-HTN ($945), after adjusting for body mass index .According to the most recent estimates from the 2015–2016 National Health and Nutrition Examination Survey, 18.5% of all 2- to 19-year-old youth are obese and that a disproportionate number are disadvantaged economically and socially . ObesityUnlike the definition of adult HTN, which is linked to a single BP level, pediatric HTN until age 13 is dependent upon multiple factors, including age, gender, and stature . KnowledThe ideal methods of BP recording require having the patient in a quiet room, sitting, and without verbal interactions . The majThe newest guidelines for clinical care of pediatric HTN  (referreThis project focuses on optimizing cohort management with a population panel management (PPM) tool and tailoring an existing clinical decision support (CDS) tool for use at the point of care. PPM tools consist of a primary care practitioner or staff identifying patients who have unmet preventive and chronic care needs using panel-based health information technology tools . At the p < .001) higher rate of correct identification of patients with HTN (54.9%) among clinics with CDS compared to clinics with none (21.3%) [In the scope of single encounter, it is challenging for providers to review all historical data to make an accurate diagnosis. One of the values of a PPM tool is the ability to visualize data for a panel. As such, PPM tools could remind clinicians to schedule visits  and help (21.3%) . Despite (21.3%) . AddressAdoption of and adherence to the guidelines for pediatric HTN would improve all aspects of underrecognized and inconsistently managed condition that continues to rise amidst the childhood obesity epidemic. The complexity and variation in practice of these guidelines implies that their adoption hinges on effective implementation. PPM tools are a promising strategy that has yet to be evaluated in this context. To speed discovery of an effective practice, data- and stakeholder-driven development of new tools and multicomponent implementation strategies is needed.The overarching aim of the proposed project is to develop and then optimize an effective and feasible implementation strategy package to increase adherence to clinical practice guidelines for pediatric HTN diagnosis and management and to understand contextual barriers and facilitators. We will target children beginning at age 3, when the AAP guidelines indicate onset of universal screening . Prior rWith a stakeholder panel , led by the project team and with input from an external scientific advisory board, we will employ a user-centered design (UCD) approach , 54 to tUsing the adapted ERIC process, a community stakeholder panel, again with input from our scientific advisory board, will develop the initial implementation strategy package to address known and probable barriers to adoption of the tool and its effectiveness in changing guideline-relevant physician behavior related to identification and diagnosis of HTN. Health economic methods  will be The proposed project involves three primary entities: Northwestern University Feinberg School of Medicine, Lurie Children’s Hospital of Chicago, and AllianceChicago Community Health Services. Within AllianceChicago are four CHC organizations in the Chicago area that have a long history of involvement in research and practice change initiatives using the AllianceChicago’s shared health information technology infrastructure. These organizations have more than 40 total clinics (range: 9 to 17 clinic locations per organization) and serve predominantly racial/ethnic minority patients  with 83% of patients below 100% of the poverty line and 25% uninsured. The demographics of these patients align with the health disparities in HTN per epidemiologic data .process is guided by the adapted ERIC protocol [determinants (barriers and facilitators) is guided by the Consolidated Framework for Implementation Research (CFIR) [outcomes is guided by the Proctor et al. [The proposed study uses a community-engaged implementation research approach with a user-centered, stakeholder-driven approach when developing the PPM and CDS tools for pediatric HTN and the implementation strategy package. We focus on the impact of specific implementation strategies on provider behaviors as this is consistent with the purpose and targets of the AAP guidelines for pediatric HTN. The link between these provider practices in the guidelines and the clinical benefit to children was determined by the AAP when specifying the guidelines, based on the best available evidence . The impprotocol  and the protocol ; assessmh (CFIR) ; and evar et al.  taxonomyout-reach step begins by connecting the research team with the members of the stakeholder panel to respectfully and actively promote communication and engagement. The research team will elicit information regarding the needs and knowledge gaps from these diverse stakeholder advisors, which in-turn forms the in-reach. In particular, the team will lead in-translation of stakeholder needs and implementation gaps into scientific research/scientific concepts, which then guides the research team in framing out-translation. The research team shares quantitative and qualitative findings with the stakeholder panel via out-reach—bringing together academic-stakeholder knowledge as recursive OIIO cycles iterate over the project period.Drawing on principles of community-based participatory research  and NHLBThe current project consists of the development and planning activities prior to testing the implementation strategy and the PPM tool with pediatric patients in a subsequent study.The stakeholder panel, comprising 6 to 10 members from four CHC organizations, will be recruited in M1 in collaboration with the leadership of each participating organization and through presentations and individual contacts by research staff. Members will be primarily practitioners who see pediatric patients, including physicians, advanced practice providers, and nurse practitioners; those with clinical leadership roles  will also be eligible.This phase will utilize UCD procedures tailoring an existing CDS tool for use at the point of care and optimize cohort management with a PPM tool  already in use within AllianceChicago for adults with diabetes, HTN, HIV, and Medicare chronic care management. UCD is an iterative development process involving multiple cycles of evaluation and refinement of prototypes through deep engagement with relevant stakeholders . AlliancAs features and functions are identified by the stakeholder panel, AllianceChicago will begin to build the tools (M3–M7). This is followed by two phases of usability testing, performed following the same procedures. In M7–M8, 10 participants from participating CHCs will evaluate the tools for 30 min in lab-based usability testing. Ten participants are typically required to identify 95% of usability problems . Participackage of implementation strategies (often referred to as a toolkit) to support uptake of the tools and use with fidelity.The standard practice when AllianceChicago implements a new health information technology feature is to activate the associated EHR tools, provide written instructions and webinars that explain the tool to its members, and email members to alert them that new tools are in place. A large body of research suggests that such strategies alone without commensurate site-level training are unlikely to result in efficient and complete adoption of the PPM and CDS tools , and eveWe propose to follow the protocol of Go et al. , a pragmTo begin the modified ERIC process from an evidence-based foundation, we plan to use the results and recommendations from a recent systematic synthesis of 44 published reviews on eHealth implementation , focusedBeyond Ross et al.’s summary, we anticipate using strategies unique to a PPM tool. The primary functionality of a PPM tool that distinguishes it from CDS and other eHealth interventions is the ability to examine cohorts of the clinic population for “missed opportunities” in guideline adherence. This population-based snapshot, as opposed to a single patient  perspective, allows clinic staff to examine recent and upcoming patient visits, as well as patients inactive in care, for indicators of need for outreach to re-engage in care for attention to HTN-related concerns. The precise manner in which these unique aspects of the PPM tool will be used in this study are unknown given the dearth of such tools for children.The adapted ERIC process of barrier assessment, strategy selection, and optimization will be further organized through the use of the Implementation Research Logic Model , 73 as aThe proposed study incorporates surveys and stakeholder interviews/meetings with multiple respondents . Mixed methods approaches for implementation research –77 are cn = 2) and stakeholder panel meetings (n = 2 meetings), and the “think aloud” portion of usability testing sessions , will be evaluated through a sequential mixed methods approach involving rapid qualitative analysis of video recordings alongside quantitative results of the System Usability Scale [The co-design workshops ty Scale . These qty Scale , and somty Scale . Use of All qualitative data processing and analysis will be done by a trained Research Associate and a Research Assistant, overseen by JS. For reliability, 20% of panel meetings and “think aloud” tasks will be double-coded in order to calculate reliability . DisagreEvaluation of the strategy development will be mixed methods involving qualitative data analysis from key informant interviews and the stakeholder panel meetings and the results of quantitative surveys.Procedures for the collection, rapid analysis, and reliability of qualitative data are described in Aim 1. To ensure detailed reporting of the implementation strategy package, we will follow published guidelines  and use Surveys administered during development activities of this project focus on usability of the tool (see Aim 1) and the feasibility, appropriateness, and acceptability of the tool and its implementation strategy package assessed via brief, validated surveys developed by Weiner et al.  after toThe mixed methods analytic approach is sequential (“Connect the dots”) , 77 for Economic analyses are central to the implementation evaluation and for providing data of use to potential adopters . Our cost evaluation within this project will focus on estimating the costs associated with implementing each discrete strategy and the package of strategies developed by the stakeholder panel. This cost analysis will be conducted from the perspective of a provider organization that may wish to adopt the multicomponent strategy developed in this study. An ingredient-based cost analysis procedure, including costs for tool refinement and optimization and integrating it with the EHR, training providers and other stakeholders, time of provider usage, and other personnel time to support implementation, will be employed to estimate costs associated with each discrete strategy. Strategy costs will be aggregated to estimate total package costs. Consistent with the aims of this project, we will estimate total cost of implementation preparation activities  as has been done in prior implementation studies led by NJ and JS , 88. Usipotential standardization of the PPM and CDS tools, normalization will be assessed using the NoMAD instrument [implementation (bringing a practice or practices into action), embedding (when a practice or practices may be routinely incorporated into everyday work), and integration  [Defined as the perception of strument , 90. Thestrument , the 23-ization) . The NoMization) –94. It wBased on feedback from our scientific advisory board, we have made three modifications to the protocol. First, to provide contemporary baseline adherence rates to the guidelines prior to implementation, we will perform two secondary data analyses of EHR data from the AllianceChicago network of CHCs to characterize the prevalence of correct diagnosis of pediatric HTN and elevated BP. These analyses will be conducted on two time periods. The first will be 1 year prior to the guideline changes (visits occurring between December 2016 and December 2017), and the second period will be the 2 years after the guidelines changed and minimal EHR capacities were added . Second, consistent with the goal of Aim 1 (to refine a PPM tool that addresses multilevel implementation barriers), we will invite pediatric patients at risk for HTN and their caregiver(s) to participate in a brief interview to better understand their needs and perspectives around the assessment, diagnosis, and management of pediatric HTN to inform implementation strategies concerning raising awareness and motivating adherence with guideline-based care, such as returning for a repeat BP measurement after a first elevated BP. Third, also aligned with Aim 1, pediatric primary care providers will be invited to complete an online survey to better understand their perspectives around identifying and managing pediatric HTN. Feedback from the patient-caregiver interviews and provider surveys will help us better design and implement the PPM tool and associated implementation strategies to support guideline-adherent care for HTN.At submission of this protocol, the project is well underway. Specifically, we have recruited the stakeholder panel and the meeting dates have been scheduled; developed and pilot-tested the provider survey; and convened a meeting of the Scientific Advisory Board. Further, the first set of secondary data analyses of EHR data have been conducted and a manuscript is currently being prepared for submission.It is worth mentioning that we are currently in the middle of the COVID-19 pandemic in the state of Illinois, which includes a stay-at-home order. AllianceChicago CHCs, like most healthcare systems across the nation, are shifting their focus to managing the pandemic. Accordingly, we have temporarily suspended administration of the provider survey and will hold meetings of the stakeholder panels virtually. Our team will continue to modify the protocol as required to meet the shifting needs of our stakeholders and collaborators in the healthcare system during this pandemic, while also adhering to public health guidelines, guidance from Northwestern University, and recommendations from the Center for Disease Control and Prevention and the Illinois and Chicago Departments of Public Health.The ultimate goal of the proposed project is to develop a feasible implementation strategy package to increase adherence to clinical practice guidelines for pediatric HTN diagnosis and management. We will accomplish this aim using a PPM tool and CDS at the point of care. This will broaden the reach of HTN diagnosis and management by providing a tool that assists providers and benefits an entire patient population.The protocol will extend the existing literature in two novel ways. First, we will design and implement a PPM tool to support the adoption of AAP guidelines for the diagnosis and treatment of pediatric HTN. No such sophisticated, EHR-integrated tool currently exists for pediatric HTN, despite evidence that PPM tools are effective at improving diagnosis and management of multiple chronic health conditions (including HTN in adults), and PPM tools are unique and underutilized tools for guideline implementation in pediatrics. Additionally, while the majority of existing PPM tools are for adults, this innovation will focus on children and adolescents. Second, we will leverage an innovative stakeholder-driven process for tool development using UCD methods and development of an implementation strategy package based on best available evidence from the field of implementation science and a low-cost adaptation of the ERIC process. Third, we will conduct a prospective implementation cost evaluation informed by stakeholders to ensure that critical questions informing economic sustainability and incremental cost-benefits are answered. Inadequate cost evaluation is a top reason for failure to implement , and an We anticipate two specific challenges while conducting this study. First, the HTN guidelines currently require repeated measurement of pediatric patients 'BP. As discussed, this guideline receives low adherence among pediatric healthcare professionals who are managing large workloads and competing priorities. Further, it places a large burden on families to attend multiple medical appointments. The activities in Aim 2 will actively address this challenge through understanding the barriers specific to providers and families around this aspect of the AAP pediatric HTN guidelines. Second, accurate assessment of BP in pediatric patients is critical. This speaks to the need of accessible training for pediatric healthcare providers and availability of correct BP assessment tools. Incorporating training in simply measuring BP accurately for younger children (ages 2 to 5 years) and helping pediatric clinics obtain arm cuffs that are properly sized for youth with obesity might become necessary.Identifying youth with HTN is the gateway to getting them into effective treatments that can prevent the deleterious progression of cardiovascular disease risk. Should the implementation strategy package for PPM tool adoption and guideline adherence be successful for pediatric HTN, findings will be translatable to other settings and for PPM of other chronic heart, lung, blood, and sleep conditions among children and adults, thereby decreasing the health care burden of target organ damage in the cardiovascular system, and other complications, in the adult years and improving overall population health.Additional file 1.Additional file 2. Notice of Award. Notice of award from NHLBI – Revision # 1 – Removal of Human Subjects Restrictions.Additional file 3. IRB Approval. Notice of IRB approval from Northwestern University.Additional file 4. Informed Consent. Informed consent documents for study components involving human subjects.