Interprofessional communication (IPC) is integral to interprofessional teams working in the emergency medicine (EM) setting. Yet, the coronavirus disease 2019 pandemic has laid bare gaps in IPC knowledge, skills and attitudes. These experiences underscore the need to review how IPC is taught in EM.A systematic scoping review is proposed to scrutinize accounts of IPC programs in EM.Krishna's Systematic Evidence-Based Approach (SEBA) is adopted to guide this systematic scoping review. Independent searches of ninedatabases  and “negotiated consensual validation” were used to identify articles published between January 1, 2000 and December 31, 2020. Three research teams reviewed the data using concurrent content and thematic analysis and independently summarized the included articles. The findings were scrutinized using SEBA's jigsaw perspective and funneling approach to provide a more holistic picture of the data.18,809 titles and abstracts were identified after removal of duplicates, 76 full-text articles reviewed, and 19 full-text articles were analyzed. In total, four themes and categories were identified, namely: (a) indications and outcomes, (2) curriculum and assessment methods, (3) barriers, and (4) enablers.IPC training in EM should be longitudinal, competency- and stage-based, underlining the need for effective oversight by the host organization. It also suggests a role for portfolios and the importance of continuing support for physicians in EM as they hone their IPC skills.• IPC training in EM is competency-based and organized around stages.• IPC competencies build on prevailing knowledge and skills.• Longitudinal support and holistic oversight necessitates a central role for the host organization.• Longitudinal, robust, and adaptable assessment tools in the EM setting are necessary and may be supplemented by portfolio use. IPC enhances empathetic, sensitive and appropriate communications2 and facilitates history taking, team working,7 patient compliance, and clinical outcomes.13 Effective IPC also improves patient satisfaction,18 professional accountability and responsibility, better-informed consent and reduced medical errors and harm.2028Interprofessional communication (IPC) is defined as the “sharing of information among members of different health care professionals to influence patient care positively” - highlighting the role of effective communication and collaboration within teams of health care professionals including physicians, nurses, technicians, administrative staff, and community service providers. Up to 2012, two-fifths of EU countries did not recognize EM as a specialty.30 The impact of this delay has limited IPC training for staff working in EM's fast-paced,37 stressful, high stakes,25 overcrowded, and often disruptive setting.32 The impact of these gaps in training are further underscored amidst growing public attention on bed crises, overcrowding, and mounting waiting times.42Perhaps nowhere is the value of IPC more evident than in emergency medicine (EM). An academic speciality since the 1960s, IPC training is now an integral aspect of many EM training curricula. Yet, such development has not been consistent globally.46 and guided by the importance placed upon it by the Accreditation Council for Graduate Medical Education (ACGME)23 and the Institute of Medicine,50 we seek to evaluate regnant accounts of IPC training in EM to attend to this gap in understanding51 and guide efforts to design a setting specific training approach.5255With a consistent approach to IPC training in EM continuing to elude practice, while a relativist lens helps account for the context-specific, sociocultural sensitive and user-dependent nature of IPC training.60To overcome concerns as to the transparency and reproducibility of systematic scoping reviews (SSR)s, Krishna's Systematic Evidence-Based Approach (SEBA) is adopted. SSRs in SEBA adopt a constructivist perspective enabling them to map a complex topic from multiple angles62To provide a balanced review and enhance accountability, SSRs in SEBA undergo a 6-staged process. Each stage involves input from an expert team consisting of a medical librarian from the Yong Loo Lin School of Medicine (YLLSoM) at the National University of Singapore (NUS), clinicians specialized in EM at the National University Hospital and Singapore General Hospital, and local education experts and clinicians at the National Cancer Centre Singapore (NCCS), Palliative Care Institute Liverpool, YLLSoM, and Duke-NUS Medical School. The expert team fulfills several roles, such as reviewing, questioning, and challenging the findings of the research team to ensure a robust and evidence-based driven position as well as aiding with reflexivity and trustworthiness.60  format  format . recommendations on ensuring a viable and sustainable research process, the research team confined the searches to articles published between January 1, 2000 to December 31, 2019 to account for prevailing manpower and time constraints. Additionally, another search was conducted on June 26, 2021 to update articles that were published from January 21, 2020 to December 31, 2020. The PubMed search strategy can be found in Supplemental Material A.Six members of the research team carried out independent searches of eight bibliographic databases , Scopus, Psychological Information Database (PsycINFO), Education Resources Information Center (ERIC), Journal Storage (JSTOR), Google Scholar) and one gray literature database (OpenGrey). In keeping with Pham et al's  “negotiated consensual validation” approach which sees “research team members articulate, defend, and persuade others of the 'cogency' or 'incisiveness' of their points of view or show their willingness to abandon views that are no longer tenable". Eight members of the research team independently reviewed all the full-text articles featured on the final lists, discussed their individual lists at online meetings and reached an agreement once more. The research team independently screened the title and abstracts identified and created individual lists of titles to be included. These were discussed at online meetings. Consensus was achieved on the final articles to be included using Sandelowski, Barroso'sIn keeping with the SEBA methodology, the research team then evaluated the references of the included articles. This “snowballing” of references was carried out to ensure a more comprehensive review. while detailing the analytical process improved audits and enhanced the authenticity of the research.Three teams of researchers simultaneously and independently reviewed the included full-text articles. Here, the combination of independent reviews by various members of the research teams using different methods of analyses provided triangulation “RAMESES publication standards: meta-narrative reviews” and Popay et al's “Guidance on the conduct of narrative synthesis in systematic reviews.” The tabulated summaries ensured that key aspects of the included articles were not lost. These tabulated summaries also included quality appraisals using the Medical Education Research Study Quality Instrument and the consolidated criteria for reporting qualitative (COREQ) studies .The first team summarized and tabulated the included full-text articles in keeping with recommendations drawn from Wong et al's approach to thematic analysis. In Phase 1, the research team carried out independent reviews, actively reading the included articles to find meaning and patterns in the data.76 In Phase 2, “codes” were constructed from the “surface” meaning and collated into a codebook to code and analyze the rest of the articles using an iterative step-by-step process. As new codes emerged, these were associated with previous codes and concepts. In Phase 3, the categories were organized into themes that best depict the data. An inductive approach allowed themes to be “defined from the raw data without any predetermined classification”. In Phase 4, the themes were refined to best represent the whole data set. In Phase 5, the research team discussed the results of their independent analyses online and at reviewer meetings. “Negotiated consensual validation” was used to determine if saturation was achieved and establish the final themes. These involved members articulating and defending their analyses where discrepancies arose until consensus was reached.Concurrently, the second team analyzed the included articles using Braun and Clarke's approach to directed content analysis which involved “identifying and operationalizing a priori coding categories.”The third team of researchers employed Hsieh and Shannon's treatise entitled “The assessment of clinical skills/competence/performance” to guide the coding of the articles. Any data not captured by these codes were assigned a new code. In keeping with deductive category application, coding categories were reviewed and revised as required.The research team drew codes from Miller'sFindings were then discussed online until consensus was reached. The final codes were compared and discussed with the final author who checked the primary data sources to ensure that the codes made sense and were consistently employed. Any differences in coding were resolved between the research team and the final author. “Negotiated consensual validation” was used as a means of peer debrief in allthree teams to further enhance the validity of the findings. and the Structured approach to the Reporting In health care education of Evidence Synthesis statement.The narrative produced was guided by the Best Evidence Medical Education Collaboration guideAs part of SEBA's reiterative process, the themes and categories identified were discussed with the expert team. Here, the themes and categories are viewed as pieces of a jigsaw puzzle and areas of overlap allow these pieces to be combined to create a wider andholistic view of the overlying data. The combined themes and categories are referred to as themes/categories.88,89 adaptation of Noblit and Hare's seven phases of meta-ethnography.92 Themes and categories were contextualized by reviewing them against primary codes and subcategories and/or subthemes they were drawn from.88 Reciprocal translation was used to determine if the themes and categoriescould be used interchangeably.Creating themes/categories relied on the use of Phases 4 to 6 of France et al's The funneling process sees the themes/categories identified compared with the tabulated summaries.To provide structure to the funneling process, we employed Phases 3 to 5 of France et al'sadaptation and described the nature, main findings and conclusions of the articles. “the line of argument” in the discussion synthesis, in Stage 6 of the SSR in SEBA.Adapting Phase 5, reciprocal translation was used to juxtapose the themes/categories with key messages identified in the tabulated summaries. The verified themes/categories from the Funnelling Process then formed In total, 18,809 titles and abstracts were identified after the removal of duplicates, 98 full-text articles reviewed, and 19 full-text articles analyzed (Indications for IPC programs.Curriculum and assessment.Outcomes of IPC programs.Barriers to IPC programs in ED.Enablers for successful IPC programs.The final themes/categories identified were:Given that these themes/categories were not discussed and often merely listed in the included articles, they are summarized in 105 This new-found knowledge is then applied in high fidelity simulations with mannikins,97 virtual patients, and/or simulations in-situ.103 Simulations improve team dynamics by providing a “controlled, adaptable environment,” that facilitates mutual understandingand changes in attitude, instils respect and overcomes “social constructs of hierarchy” and “silo mentality.”IPC training often begins with didactic teaching that serve to introduce foundational knowledge in both core or elective-based curriculum content., as well as the TeamSTEPPS Teamwork Attitude Questionnaire and other behaviorally anchored rating scales to assess teamwork.A gradation in training knowledge, skills and attitudes is summarized in Supplemental Material C.Each stage of the learning process is accompanied by outcome measures and assessment tools which are also summarized in The outcome measures for effective IPC also take a long-term perspective as summarized in 93 These include frequent turnover of staff, staff of various backgrounds, skills, experience and clinical specialities, shift work, high patient load, rapid and complex decision-making and past negative interactions with other health care professionals.92 In turn, these barriers hinder culture change, shifts in institutionalized power dynamics and flattening of the hierarchical nature within ED.The long-term nature of the goals of IPC programs in EM is reflected in the obstacles to achieving them. the provision of tutor training and compensation, mandating attendance, ensuring effective assessments of learning outcomes and effective provision of feedback.Enablers to a successful IPC program similarly reflect its long term goals and include the sustained support of the host organization,With concerns over the potential impact of unevidenced, often opinion-led data from gray literature, the research team undertook a comparison of themes identified from gray literature and those from research-driven articles to enhance the accountability and the reproducibility of Stage 6 of SEBA. The results from the gray literature were found to be congruent with those from peer-reviewed research-based articles.“what is known about IPC training for physicians in EM?” ,this SSR in SEBA of IPC training in EM suggests that IPC training occurs in stages. This begins with the use of didactic training that then progresses to the application of the physician’s new knowledge. Practice in the clinical situation follows, culminating in the formation of attitudes and behaviors that value IPC communications. Supporting this premise that IPC competencies develop on prevailing knowledge and skills is the presence of a variety of assessment tools aimed at assessing IPC skills and attitudes along with this longitudinal development.In answering its primary research question on 23 and the Institute of Medicine. Such developments are also consistent with the stated outcomes of these programs and may also be inferred from the enablers and barriers to IPC programs.Having established the presence of a longitudinal training and assessment process that corresponds with Miller’s Pyramid of Clinical Competence as shown in  This also underlines the need for training and assessments to be carried out at appropriate junctures in the development of EM trainees to ensure they achieve requisite competencies in core topics before venturing to secondary content.Here, the presence of stages underscores the importance of the host organization in ensuring an effective assessment of the various stages, curricula topics and providing assiduous program oversight and support.109 To this end, portfolios may be suitable learning and evaluation tools for IPC in EM due to their flexible and holistic nature—allowing for multisource feedback, documentation and reflection of learning activities and assessment scores in one convenient central location. This would offer a comprehensive overview of the learners’ progress, enabling easy identification of areas for improvement.110112This further highlights the need for the IPC training program specific assessment process to account for the personalized needs of varied learners.Overall, this SSR in SEBA highlights the need for greater awareness of the competency-based stages in the development of IPC skills and urges more holistic and longitudinal consideration of its effects upon the physician.Despite efforts to enhance the reproducibility and transparency of the SSR through SEBA, we still face gaps in our methodology and analysis. While we have conducted a two-tiered searching strategy, through both independent searching of selected databases by our expert team and repeated sieving of reference lists of publications, there maybe important papers that have been omitted. Similarly, while use of the split approach and tabulated summaries in SEBA allowed for triangulation and ensured that a holistic picture was constructed from different and diverse perspectives, inherent biases among the reviewers may still have impacted the analysis of the data and construction of themes. Lastly, drawing conclusions from a limited pool of largely North American and European-centric accounts, further narrowed by focusing upon publications in English, may limit the applicability of the findings to other cultural and geographical contexts.Data on the stages of training forwarded by this SSR will be of interest to educationalists and program designers involved in IPC training in EM, where teamwork and communication are instrumental in the provision of safe and effective care for patients, especially in global health emergencies such as the coronavirus disease 2019 pandemic. A stage-based curriculum suggests that trainers need to be aware of the level of experience and abilities of physicians in training and cater their training approach and assessments to meet these personalized needs. Development of skills and abilities needed for effective IPC should begin in medical school and junior residency programs, underlining the role of portfolios to capture their competencies and reflections on their training thus far. Gaps in understanding and supporting trainers, guiding the host organization, and the lack of effective oversight of the stage-wise development of IPC competencies underline areas for further study if IPC training is to achieve its goals of improving safety and patient experience in EM.


Bifidobacterium, Lactobacillus, and Faecalibacterium prausnitzii. Beneficial health effects reported following ITF intake include improved intestinal barrier function, improved laxation, increased insulin sensitivity, decreased triglycerides and an improved lipid profile, increased absorption of calcium and magnesium, and increased satiety. Although there is some evidence for differing effects of ITF based on chain length, the lack of direct comparisons and detailed descriptions of physicochemical properties limits the ability to draw conclusions from human clinical studies. Future research should focus on elucidating the mechanisms by which the intestinal microbiota mediates or modifies the effects of ITF on human health and the contribution of individual factors such as age and metabolic health to the movement toward personalization of prebiotic applications.Inulin-type fructans (ITF), including short-chain fructooligosaccharides (scFOS), oligofructose, and inulin, are commonly used fibers that are widely regarded as prebiotic for their ability to be selectively utilized by the intestinal microbiota to confer a health benefit. However, to our knowledge the literature thus far lacks a thorough discussion of the evidence from human clinical trials for the prebiotic effect of ITF, including beneficial effects on intestinal microbiota composition and intestinal and extraintestinal processes . Additionally, there has been a lack of discussion regarding aspects such as the effect of ITF chain length on its intestinal and extraintestinal effects. The overall objective of this systematic review was to summarize the prebiotic potential of ITF based on the results of human clinical trials in healthy adult populations. Evidence from studies included in the current review suggest that ITF have a prebiotic effect on the intestinal microbiota, promoting the abundances of  Statement of Significance: The current review provides a comprehensive synthesis of results from clinical studies in healthy human adults on the prebiotic effects of ITF on the intestinal microbiota and health, with consideration for effects of ITF chain length and individual factors such as baseline intestinal microbiota composition. Diet-related chronic diseases such as obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease (CVD) are becoming increasingly prevalent and are related to insufficient fiber intake . Less thPrebiotics are defined by the International Scientific Association for Probiotics and Prebiotics (ISAPP) as “a substrate that is selectively utilized by host microorganisms conferring a health benefit” . The criSome, though not all, dietary fibers may be classified as prebiotics, though most prebiotics can be classified as dietary fibers , 6. CurrN) of ‘new’ colony-forming units/g of feces divided by the daily dose (in g) of ITF ingested”  ITF  AND 2) microbiota OR health outcomes . Eligibility criteria were similar to those used by the FDA to determine the physiological effects of inulin (1) the use of an appropriate control group , 2) the use of appropriate statistical methods, 3) the use of ITF in isolation , 4) studies conducted in healthy human populations, and 5) the intervention being of sufficient length of time to capture the gastrointestinal component (≥1 wk)  in February 2021 for full-length English articles published in peer-reviewed journals with no date restriction. Briefly, we divided search terms into 2 categories: f inulin . These c (≥1 wk) . This la2), population characteristics], intervention , the ITF supplement , and effects on the intestinal microbiota and health outcomes compared with the control group.The title and abstract of nonduplicate articles were screened based on the above criteria. The remaining publications were reviewed in full by RLH and DAA, and reference lists of eligible articles were screened for additional publications not identified in the initial searches. HDH and KSS resolved any discrepancies in study inclusion or exclusion. RLH and DAA extracted the data from studies meeting the selection criteria, including information on the study population , apoB, and apoA-I may also modulate disease risk . No effeBifidobacterium and triglycerides (negative) as well as HDL cholesterol (positive), total anaerobes with triglycerides (negative), total facultative anaerobes with total cholesterol (negative), and secondary bile acids with total cholesterol and triglycerides (positive)  . Additioositive) .ITF may also impact mineral absorption . Animal When mineral absorption and bone health were the focus, studies most commonly investigated the effects of ITF on calcium absorption , 102–106There were no reported effects of ITF consumption on PTH or vitamin D concentrations in the studies included , 107, thIn addition to effects on micronutrients related to bone health, a few studies have investigated the effects of ITF intake on iron and zinc absorption , 106. HoFactors that may influence the prebiotic effect of ITF on mineral absorption include age, baseline mineral status, and ITF chain length. For instance, responders—showing an increase in calcium and/or magnesium absorption—were reported to have a lower baseline lumbar spine bone mineral density and higher baseline bone turnover than nonresponders . AdditioBifidobacterium and Lactobacillus  . AdditioThese physiological mechanisms are only a part of the satiety story, which may be influenced by other behavioral, social, and other external factors that affect an individual's desire to eat . TherefoObesity and body fat distribution, particularly visceral fat, increase risk of metabolic disease and CVD . Animal Propionibacterium and Bacteroides, which were decreased following intake of an inulin–oligofructose blend (16 g/d), were positively associated with fat mass percentage and the fat mass to lean mass ratio  and individuals . Though some evidence from studies in the current review suggests differential effects of ITF on Bifidobacterium, may modify the effects of ITF on the microbiota. However, the lack of studies investigating the correlations between baseline fecal microbiota composition and health outcomes following ITF consumption make it difficult to draw conclusions. Although correlations between the fecal microbiota and other individual factors, metabolite production, and subsequent health effects may suggest plausible relationships, establishing causality and mechanisms of action remain challenges within the field of human microbiota research. Multitiered approaches that use a combination of human, animal, and in vitro models, as well as the continuing development of methods of noninvasive sampling and biomarker discovery, will improve our ability to establish causal relationships between ITF intake, the intestinal microbiota, and health outcomes. This research will facilitate the formulation of personalized dietary recommendations and strategies to improve human health using prebiotics such as ITF.Individual factors such as baseline intestinal microbiota composition, habitual fiber intake, and age or health status  may also contribute to interindividual variability in the effects of ITF intake on health outcomes , 87, 88.


To investigate factors predicting hospital mortality and hospital length of stay (LOS) in traumatized adults and older adults, we conducted a three-year retrospective study at an academic hospital, Bangkok, Thailand. We reviewed medical records of 627 trauma patients admitted to the ED. Subjects were classified into 2 groups: adults (□55y), and older adults (□55y). Data were collected for demographic and clinical characteristics, physiologic deterioration using the Modified Early Warning Score (MEWS), severity of injury using the Circulation Respiration Abdomen Motor and Speech Score (CRAMS), and outcomes of hospital mortality and LOS. Multivariable logistic and linear regression models were performed. For hospital mortality, an elevated MEWS  and CRAMS  were strongly predictive, adjusted for demographic and clinical data. For LOS, road traffic accident (RTA)  and falls  were associated with LOS, adjusted for demographic and clinical data. MEWS and CRAMS predicted hospital mortality, and RTA and falls predicted LOS in both age groups. Results support the need for interventions for close monitoring and medical management for older traumatized patients based on CRAMS and MEWS assessment to decrease the risk of death, and targeting those sustaining falls and RTA to reduce prolonged LOS.


Conclusion: Hair mineral and trace elements evaluation may contribute to a proper evaluation of their status in IBD patients and improving the management of nutritional status of IBD patients.Micronutrient deficiencies can arise in various conditions, including inflammatory bowel diseases (IBD), and diagnosing these deficiencies can be challenging in the absence of specific clinical signs. The aim of this study was to evaluate the status of various trace elements hair concentration in IBD patients compared to a healthy control group and to identify potential correlations between the micronutrient status and relevant parameters related to disease activity. The concentrations of iron, magnesium, calcium, zinc, copper, manganese, selenium and sulfur in the hair of 37 IBD patients with prior diagnosed IBD (12 Crohn’s disease and 25 ulcerative colitis) and 31 healthy controls were evaluated by Energy Dispersive X-Ray spectroscopy (EDX). Significant differences in hair concentration profile of studied trace elements were identified for IBD patients compared to healthy controls. A significantly decreased hair concentration of iron, magnesium, calcium and selenium and a significantly increased sulfur hair concentration were observed in IBD patients at the time of evaluation. A decreased hair calcium concentration ( Inflammatory bowel disease (IBD) represents chronic inflammatory conditions of the gastrointestinal tract, characterized by periods of disease flares alternating with remission. Genetic predisposition, environmental factors and dysbiosis are significant factors involved in IBD pathogenesis ,2,3.Malnutrition, including protein-calorie malnutrition or micronutrient deficiency, is common among IBD patients and may persist throughout the course of the disease because of altered intake, impaired absorption, direct gastrointestinal loss or hypercatabolic state . Addition = 25) and Crohn’s disease (CD) (n = 17). The inclusion criteria for the study group were: confirmed diagnosis of IBD based on the clinical presentation as well as endoscopic and histopathological findings, age between 18 and 70 years and written consent of the patients. Patients with overlapping infections, using micronutrients supplements, with a history of neoplasia or metabolic disorders  were excluded. Disease activity was evaluated by calculating the Crohn’s disease activity index (CDAI) for CD patients and a Mayo score for UC. The control group consisted of healthy subjects (n = 37), namely without history of chronic diseases, gastrointestinal disorders and autoimmune diseases. The use of hair therapeutic agents or cosmetics  and restrictive diets in the past 6 months represented exclusion criteria for both the study and the control group. Hair trace elements concentrations for iron (Fe%), magnesium (Mg%), calcium (Ca%), zinc (Zn%), copper (Cu%), manganese (Mn%), selenium (Se%) and sulfur (S%), serum albumin concentration, inflammatory markers, such as C reactive protein (CRP), and complete blood count, including calculating the neutrophil-to-lymphocyte ratio (NLR), were evaluated both for the study and control group. A colonoscopy was performed for all IBD patients and CT scans were also added when needed to assess disease extension.We performed an observational study, including patients diagnosed with ulcerative colitis (UC)  at 30 kV in high vacuum mode. The EDX system mounted on the Quanta 200 SEM was used for element identification and performing the quantitative analysis. The elemental analysis was performed both on the surface and the cross section of the hair specimens. No secondary treatment or processing was necessary.The processing of hair samples was in accordance with the European Directive EC No 206 and the protocol used for processing hair samples undergoing EDX analysis was approved by the Scientific Council of Petru Poni Institute of Macromolecular Chemistry. The study protocol and all procedures included in the study were in accordance with the ethical standards within the Declaration of Helsinki and approved by the Ethical Committee of Grigore T Popa University of Medicine and Pharmacy (25 November 2018), Sf Spiridon County Clinical Emergency Hospital (No 45/04.09/2019). Upon inclusion in the study, written informed consent was obtained from all patients enrolled.t-test, Kruskal–Wallis test or Chi-square test, depending on the homogeneity of the data series. For comparisons among three groups, a one-way ANOVA analysis was used. For evaluating various correlations of the studied parameters, a Pearson correlation or Spearman correlation test was performed, depending on the distribution of the data.The statistical analysis was performed using SPSS v25.0 . Continuous variables were reported as mean values and standard deviation, or as median with 25th–75th percentiles. Qualitative variables were reported as absolute frequencies and relative frequencies (%). The comparisons between the analyzed groups were performed using a Student’s Our study included 37 patients with IBD (25 patients with ulcerative colitis and 12 patients with Crohn’s disease) and 31 control subjects. Baseline demographic and clinical data were collected and are synthesized in p < 0.001 and p = 0.005, respectively), with no significant differences between UC and CD patients (p = 0.548)  .p < 0.001), without significant differences between IBD subtypes (p = 0.967)  .p < 0.001). There were no significant differences for hair calcium concentration between UC and CD patients , and between the UC and CD group (p = 0.009), but without statistical significance when comparing CD patients and the control group (p = 0.81)  .p < 0.001). However, no statistically significant difference between UC and CD patients regarding hair iron concentration was identified (p = 0.716)  .p = 0.015). There was no statistically significant difference between UC and CD patients regarding hair copper concentration (p = 0.462)  .p = 0.697 and p = 0.832), although a slightly lower median hair zinc concentration was identified for UC and CD patients compared to the control group . However, there was no statistically significant difference between selenium hair concentration between UC and CD patients (p = 0.952) (Hair selenium concentration was decreased both among UC and CD patients compared to the control group (= 0.952) .We evaluated the correlation between the hair concentration of the studied minerals and trace elements and disease activity reflected through the Mayo score for UC patients and the CDAI score for CD patients. We identified a statistically significant negative correlation between hair calcium concentration and disease activity for CD patients, but without reaching the level of statistical significance for UC patients. Moreover, there was a strong positive correlation between hair sulfur concentration and disease activity among CD patients, but not for UC patients .The correlations evaluated between the markers of systemic inflammation and active disease  and mineral and trace elements concentration in hair did not reach the level of statistical significance .When studying the correlation between each type of micronutrients and BMI, we did not find any statistically significant correlation between the hair concentration of any of the studied micronutrients and BMI in the study group nor in the control group .The alteration of nutritional factors among IBD patients might be perceived at a first glance as related to a macronutrient deficit, considering the importance of the altered protein status, especially hypoalbuminemia on IBD evolution and complications ,11. BeyoThe most frequently used method for evaluating trace elements is measuring serum concentration, as it is an accessible method ,14. SincOne patient characteristic which might influence the hair concentration of various elements is age. Among the IBD patients included in our study, the UC patients had a higher age , compared to the control group and CD patients, although the statistical significance of this difference reached borderline significance. The absence of a significant age difference between CD patients and the control group, together with registering significantly lower hair calcium concentration among CD patients compared to the control group, might be an indicator of calcium reduction in young CD patients. Regarding both calcium and magnesium concentrations, one study analyzing the age dependence of various elements concentrations highlighted higher calcium and magnesium concentrations in younger subjects (those under 25 years old). Consequently, the authors stated that there may be an age dependence of the concentration of these trace elements, but this is difficult to demonstrate regarding scalp hair concentration if the number of samples collected per age group is not large enough . As far We identified lower hair concentrations for several minerals and trace elements between IBD patients and healthy controls, namely lower iron, magnesium, calcium and selenium, with statistically significant differences between patients and the control group. Our results are consistent with a previous study that included pediatric IBD patients and measured both serum and hair concentration of trace elements . In thisThe magnesium deficit is of importance in clinical practice and requires prompt diagnosis and management, considering its pivotal role in cell signaling, genomic stability and DNA repair processes ,25,26, bAnother mineral which was deficient among the studied IBD group was calcium, which was also negatively correlated with disease activity for CD patients. These findings suggest the presence of a calcium deficit in CD patients, especially during disease flares. Calcium deficiency is pathophysiologically well-founded, considering that calcium is mainly absorbed in the ileum  and thatSelenium represents an important trace element in modulating the anti-inflammatory and antioxidant response, considering that it is part of glutathione-peroxidase and thioredoxin reductase. Moreover, the selenium deficiency can negatively influence DNA repair and cell cycle regulation ,32,33. WThe common encounter of zinc deficiency reported in patients with IBD (15 to 40% of the patient population)  is not sHowever, in our study, we did not identify statistically significant differences between hair zinc concentration between IBD patients and the control group. This particular finding, in spite of the important involvement of zinc deficiency in oxidative stress and intestinal permeability, might partly be related to the low number of patients included in the study. Our results are consistent with the ones reported by Cho JM and Yang HR, who did not identify significant differences between hair zinc concentration between IBD and controls, although when evaluating serum concentrations of this trace elements, the differences were significant and pointed towards a zinc deficit among IBD patients . CorroboHair copper concentration was lower for IBD patients compared to healthy controls in our study, but the difference reached the level of statistical significance only for CD patients, compared to the control group. This finding might be explained by the impaired copper absorption among CD patients with ileal involvement. Moreover, taking into account previous research highlighting that copper incorporated from endogenous sources is securely bound within the hair, without being lost upon exposure to the environment , we can With regard to manganese status, we identified a statistically significant higher concentration of this trace element among UC patients, but not in CD patients, compared to the control group. There was no statistically significant correlation between hair manganese concentration and parameters reflecting inflammation and disease activity scores, neither for UC nor for CD patients in the study group. These findings might be due to the low number of patients included and further studies involving larger patient group could offer better insight regarding the status of manganese among IBD patients. More data on manganese status among IBD patients could be useful, considering that currently, manganese is a less studied trace element for this patient category, although it has an important antioxidant role, as part of manganese-superoxide dismutase and also as a cofactor of xantinoxidase, arginase, pyruvate decarboxylase and glutaminsynthetase . A studyAnother chemical element for which we found increased hair concentration in IBD patients compared to healthy control is sulfur. Since the main hair structural component is keratin, which includes disulfide bonds , we can The oxidative stress in the context of IBD might be related to the deficit of copper we identified among IBD patients compared to the control group, considering that copper is part of the copper-zinc superoxide-dismutase. This activity of this enzyme has been previously reported to be reduced in IBD patients, although the mechanism of this decreased activity is very intricate and involves both chronic inflammation and zinc deficit ,49. As fThe investigation we performed on mineral and trace elements concentration in the hair of IBD patients is among the few currently available and might bring valuable data, especially considering the extended panel of elements evaluated through EDX, including data on copper and manganese, which have been less investigated among IBD patients. The hair evaluation of micronutrient status has become of increasing interest, especially for chronic, inflammatory diseases, since the measurement is not directly influenced by the value of serum inflammatory markers or by recently ingested food and is completely non-invasive to sample. Moreover, hair concentration of various micronutrients could better reflect their status for a longer period than the serum evaluation, which offers information about the recent status of the elements from the moment of sampling. However, there are several factors which might be incriminated in influencing the micronutrient status and hair composition, such as diet, nutritional status or the time of disease evolution. To avoid a significant influence of the general nutritional status on micronutrient concentration, we have studied the correlation between BMI and the concentration of the studied micronutrients and found no statistically significant correlation in the control group nor in the study group. Since the groups did not differ with a statistical significance with regard to BMI and this parameter was within comparable ranges among the studied groups, it is difficult to shape further conclusions with regard to the influence of BMI on the status of hair micronutrients.Furthermore, our patient group was very heterogeneous regarding time from disease diagnosis, ranging from patients just recently diagnosed to patients with long standing disease; additionally, considering the low number of patients included, we did not analyze the correlation between the time of disease course and micronutrient status. This lack of analysis represents a limitation of our study and it would be of interest for future studies involving a higher number of patients, since persistent inflammation, longer disease course and presence of ileal involvement reduce the absorption of various nutrients, which could negatively influence the micronutrient status. There are also some other limitations to the study performed, related to the unavailability of concomitantly measuring the serum concentration of micronutrients. The corroboration of data from more patients, together with concomitant evaluation of hair and serum concentration, would bring a better reflection of the status of these minerals and trace elements and could contribute to optimally assessing their concentration, and therefore, enable shaping clear recommendations for specific supplementation where applicable. Furthermore, adding a systematic approach of the patients’ diet could offer insight into identifying which deficits are also influenced by dietary restrictions and concomitantly assessing fecal calprotectin could contribute to better understanding the involvement of the intestinal inflammation in the micronutrient deficiency. To a certain extent, the concomitant evaluation of vitamin D status could also be of use, especially considering its prevalent deficit among IBD patients, even for quiescent disease and its influence on the phosphocalcic metabolism .In the performed study, we identified significantly lower hair concentrations for iron, magnesium, calcium and selenium among IBD patients (both for UC and CD) compared to healthy controls, without significant differences between UC and CD patients. The presence of some of these deficits was correlated with disease activity and inflammatory markers. Sulfur hair concentration was significantly higher among both UC and CD patients compared to healthy controls. Measuring the hair concentration of various minerals and trace elements might represent a reliable method for evaluating their status among IBD patients and contribute to a better integration of micronutrient supplementation in the disease management.


The postoperative period represents a time where patients are at a high-risk of morbidity, which warrants effective surveillance. While digital health interventions (DHIs) for postoperative monitoring are promising, a coordinated, standardized and evidence-based approach regarding their implementation and evaluation is currently lacking. This study aimed to identify DHIs implemented and evaluated in postoperative care to highlight research gaps and assess the readiness for routine implementation.A systematic review will be conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify studies describing the implementation and evaluation of DHIs for postoperative monitoring published since 2000 (PROSPERO ID: CRD42021264289). This will encompass the Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Web of Science and ClinicalTrials.gov databases, and manual search of bibliographies for relevant studies and gray literature. Methodological reporting quality will be evaluated using the Idea, Development, Exploration, Assessment and Long-term Follow-up (IDEAL) reporting guideline relevant to the IDEAL stage of the study, and risk of bias will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework. Data will be extracted according to the WHO framework for monitoring and evaluating DHIs, and a narrative synthesis will be performed.This review will assess the readiness for implementation of DHIs for routine postoperative monitoring and will include studies describing best practice from service changes already being piloted out of necessity during the COVID-19 pandemic. This will identify interventions with sufficient evidence to progress to the next IDEAL stage, and promote standardized and comprehensive evaluation of future implementational studies. As the capability and accessibility of mobile and wireless technologies continue to advance globally, digital health interventions (DHIs) to support delivery of healthcare have been widely regarded as essential for addressing current and future healthcare needs in both high-income countries and low-income and middle-income countries.1The monitoring of patients after surgery represents a promising target for these interventions, representing a limited period of high morbidity which warrants increased attention.7Prior to the pandemic, there was widespread acknowledgement that the potential of DHIs had yet to be realized in healthcare.The study protocol has been preregistered at the PROSPERO registry (CRD42021264289), and has been written according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines.A systematic literature search will be performed of key medical databases  in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search strategy was developed to identify all studies describing the implementation and evaluation of DHIs for postoperative monitoring . This wi12–1710.1136/bmjsit-2021-000104.supp1Supplementary dataThe results of these searches, which will be uploaded onto the Covidence online systematic review tool,Studies excluded from the review will be (1) patients not undergoing surgery; (2) all reviews, commentaries/editorials, letters and conference abstracts; (3) all studies describing only the design requirements or protocol of a DHI; (4) interventions solely targeted at the anesthetic recovery period or DHIs which are already in routine use in healthcare ; (5) all studies not meeting digital health criteria: (i) telehealth with stationary devices  unless the use of mobile devices or sensors are reported; (ii) telehealth which is web-based only; (iii) devices which are implanted; (iv) devices or interventions which are therapeutic; (v) devices for clinical diagnosis  that did not report on a health outcome.Following the removal of duplicate publications, initial screening of studies will be performed based on titles and abstracts by two independent investigators. In the event of disagreement between the two initial reviewers, studies will be evaluated by a third reviewer to establish a consensus. The same process will be adopted for full-paper screening.Once the studies for inclusion have been determined, data will be extracted from each across four domains using a standardized data extraction instrument: (1) metadata and context of the study ; (2) characteristics of the DHI  assessed); (3) methodology of evaluation ); and (4) results of the evaluation in regard to the WHO evaluation framework for monitoring and evaluating DHIs21Furthermore, studies that do not already report their stage under the IDEAL framework for surgical innovationThe quality of reporting for included studies will be performed using the IDEAL collaboration guideline relevant for the IDEAL classification assigned to the study.Narrative (descriptive) synthesis of results will be performed, with the data extracted to be summarized using the appropriate descriptive statistics: frequencies and percentages for dichotomous variables, and mean (SD) or median (IQR) for continuous variables. Furthermore, the DHIs will be classified into subgroups based on the outcome under investigation: (1) general postoperative recovery and/or rehabilitation, (2) surgical wound care and (3) other specified postoperative complications. The results of the evaluation of each intervention will be explored within these subgroups. Further subgroup analysis by country income level (high income vs low income and middle income) are also planned, if a sufficient number are included in each group.Digital postoperative monitoring poses an immense opportunity to understand and improve postoperative community care and reduce the burden of disease for both patients and healthcare services. However, these benefits have yet to be realized and still face major challenges in how these can be effectively and safely implemented in routine clinical practice. In addition to demonstrating the clinical efficacy and safety of these interventions, there must be consideration of how to ensure appropriate stewardship of data collected,25To our knowledge, this is the first systematic review to examine the implementation and evaluation of all DHIs for postoperative monitoring, and to apply the IDEAL reporting guidelines to assess the literature.There are also several key challenges anticipated. First, while there may be common outcomes for postoperative monitoring of DHIs, there is expected to be significant heterogeneity in the literature in terms of the interventions developed, and the quality of studies and their reporting in publications. Therefore, this may limit definitive conclusions if results present a high risk of bias or are not applicable outside their local context, limiting the wider clinical relevance. Second, there is currently no ‘gold-standard’ framework to evaluate the implementation of DHIs,


This research analyzed the impact of environmental regulations and their power in suppressing tourism carbon emissions. The results showed that: (1) four types of environmental regulations had significant inhibiting effects on tourism carbon emissions, but different types of regulations had varying effects; and (2) environmental regulations had a significant time lag effect on tourism carbon emissions. The decay rates of the environmental regulation effects were dissimilar for supervisory management, market incentives, command and control, and public participation; and (3) environmental regulations had dissimilar influences on tourism carbon emissions at the regional level. Government agencies should choose differentiated environmental regulation tools, attach great importance to the time-lag effect of environmental regulations on tourism carbon emissions, and establish systems and mechanisms of public participation in environmental matters. Over the past 40 years of reform and opening-up, China’s tourism economy has maintained rapid growth with an annual average rate of over 15%. However, in contrast to the common perception that tourism is a smokeless green industry, it has become a significant carbon emitter. In 2005, China’s tourism carbon emissions were 132.74 million tons, accounting for 2.41% of China’s total carbon emissions. In 2020, China’s tourism carbon emissions were 4738.64 million tons, accounting for 4.93% of China’s total carbon emissions. During 2005–2020, the tourism industry’s carbon emissions of China increased at an average annual rate of 2.31% [Several scholars have studied the impacts of environmental regulations on carbon emissions. However, differing views on the effects of environmental regulations on carbon emissions have emerged, and these can be divided into three categories. The first notion is that environmental regulations promote carbon emissions, which Sinn 2008) termed the concept of the “green paradox.” With increasingly strict environmental regulations, he believed that energy developers accelerate the exploitation of fossil energy, leading to an increase in carbon emissions, and this is not conducive to improving carbon emission efficiency . Governm termed tThe second school of thought is that environmental regulations curb carbon emissions. Some scholars believe that environmental regulations have a “forced effect” on carbon emissions. Agriculture is an important industry of the national economy, through measures such as banning straw burning, environmental regulations have had a significant moderating effect on the impact of agricultural carbon emissions. Still, this effect existed only in the eastern region . HoweverThe third proposition is that there is no linear relationship between environmental regulations and carbon emissions, and an increase in environmental regulation intensity does not reduce the carbon emissions of tourism . These sIn summary, environmental regulations have been analyzed from multiple perspectives in terms of their influence on carbon emissions. However, there are still some gaps in tourism-related research: several scholars have conducted studies on environmental regulation and industrial carbon emissions, but there are few studies on impacts on tourism carbon emissions. However, the contribution of tourism to carbon emissions must not be ignored. It is imperative to measure the effect intensity of environmental regulations on tourism carbon emissions. Such measurement research will contribute to the realization of global tourism carbon emission reduction as expressed in the United Nations Sustainable Development Goal 13 (Climate Action). The current description of environmental regulation indicators is not comprehensive enough. The selection of environmental regulation indicators remains relatively simple and the resulting research conclusion may be too one-sided . There iThis study not only theoretically clarifies the impact of environmental regulations on tourism carbon emissions; it will be helpful in improving the implementation of environmental regulations. It is of practical value in promoting environmental improvements and the high-quality development of the tourism economy. The potential contributions of the research findings are as follows. First, a new four-dimensional environmental regulation index system was developed to evaluate the inhibitory effects of environmental regulations on tourism carbon emissions. Second, the lag effects of four types of environmental regulations on tourism carbon emissions were examined, as was the duration of the impacts of environmental regulations. Third, a spatial dimension analysis demonstrated the differing effects of the four types of environmental regulations on regions.Scholars have done substantial research on the impacts of environmental regulations on selected industries. However, there is scant empirical evidence on the influence of environmental regulations on tourism carbon emissions. The effects of environmental regulations on tourism carbon emissions can be categorized into four types.First, command control environmental regulation restricts tourism carbon emissions by governmental agencies legislating and formulating rules and regulations, requiring enterprises to comply with them by administrative orders, and punishing those that violate relevant standards. Command and control environmental regulation forces companies to comply with the relevant environmental regulations ,28. SourMarket incentive environmental regulation to reduce emissions encourages or penalizes actions through subsidies or penalties. This is accomplished through fiscal tax measures, financial, and other economic measures ,32. SubsThe restraining effects of supervisory management environmental regulations are through organizing and formulating environmental protection plans, coordinating environmental protection work for tourism and its policies and legislation, and inspecting, supervising and guiding the implementation of environmental protection laws  by relevThe effects of public participation environmental regulation is through publicity and changing public opinion that promotes participation in the formulation of environmental regulations and guides individuals or companies to save energy and reduce emissions. People are increasingly expressing environmental demands to relevant administrative organizations to safeguard their rights and interests when environmental pollution damages their interests . CitizenReferring to Chen et al. (2019)  and Yangj energy consumed by industry i; Tourism carbon emission (missions . Based omissions  and Huanmissions . The spe to 2.45 .Referring to Wei and Liu (2014) , Wang et(1) Command control environmental regulations  Market incentives environmental regulations (ischarge . In this(3) Supervisory management environmental regulations  Public participation environmental regulations . Command control environmental regulations come from PKULAW (Peking University Fabao Database) database . Market incentives environmental regulations came from the EPS database. Data on supervisory management environmental regulations were obtained from Provincial Statistical yearbooks. Data on public participation environmental regulations were obtained from the China Environmental Statistics Yearbook , while public participation environmental regulation had the lowest impact coefficient (−0.07). Environmental regulations based on market incentives are the most direct carbon emission reduction measure. They increase investment in carbon emission controls and purchases of more advanced emission control equipment, and improve tourism pollution control capacity to meet government carbon emission reduction standards. Market incentive environmental regulations  as independent variables. The time lag effects of environmental regulations on tourism carbon emissions were further analyzed. The regression results are shown in (2) For market incentives environmental regulation, different lag periods had varying effects on tourism carbon emissions. The impacts of market incentives lag periods on tourism carbon emissions were in the shape of “(3) The impact of supervisory management environmental regulations on tourism carbon emissions presented an “S” shape. When the third period was lagged, these regulations did not significantly impact tourism carbon emissions. The impact was mainly concentrated in the first two periods and was significant at the 5% level. Notably, the supervisory management type had long-term characteristics. Its mode is mainly incentive-based, combined with the coordination of personnel and administrative regulations, producing a long-term inhibition effect on tourism carbon emissions. Especially when policies and regulations are first promulgated, all government departments and enterprises will strictly abide by them. However, as time goes by and new policies are issued, the effectiveness of older policies and regulations will gradually weaken.(4) For the public participation environmental regulations, the impacts for the first, second and third lag periods on tourism carbon emissions were −0.04, −0.04, −0.03 at the 5%, 1%, and 10% significance levels, respectively. However, in the fourth phase and beyond, they did not significantly inhibit tourism carbon emissions. The effect intensity on tourism carbon emissions was far lower than the other three types of environmental regulations. The possible reason is that public participation in environmental regulation guides behavior in general behavior and is not compulsory . The pubThere were differences in the decay rates of various environmental regulations on tourism carbon emissions. As shown in Based on a nationwide research sample, the foregoing results indicate that different types of environmental regulations significantly differ in impacts on tourism carbon emissions. However, are there spatial differences in the effects of environmental regulations on tourism carbon emissions for the eastern, central, and western regions of China? This research investigated the variations in the impacts of environmental regulations on tourism carbon emissions by region .As shown in The carbon emissions of tourism in central China were affected by three environmental regulations: command and control, supervisory management, and market incentives. Unlike in eastern China, the impact of public participation environmental regulations on tourism carbon emissions was not significant. In addition, public participation environmental regulation had no significant effect on tourism carbon emission reduction in western China. This may be due to the weak awareness of carbon emission reduction, environmental protection , and insOnly two types of environmental regulations in western China  had significant inhibitory effects on tourism carbon emissions. Their coefficients were significantly larger than those in eastern and central China. The impacts of supervisory management and public participation on tourism carbon emissions were not significant, although the western region has made remarkable progress in building environmental infrastructure. However, tourism enterprises in western China are relatively scattered due to the large area and sparse population. In addition, there is still a substantial effectiveness gap between government environmental supervision departments and those in the central and eastern regions. Therefore, the influence coefficient of environmental regulation on tourism carbon emission was not significant. In conclusion, there were significant differences in the impacts of environmental regulations on tourism carbon emissions in the three regions of China.Based on panel data from 31 provinces in China from 1999 to 2018, this research divided environmental regulations into four types: command and control, supervisory management, economic incentives, and public participation, and empirically examined the intensity, time-lag effects, and regional differences of the four types of environmental regulations on tourism carbon emissions. The findings result in three major conclusions being drawn.Environmental regulations had significant inhibitory effects on tourism carbon emissions, but different environmental regulations had significantly dissimilar influences. The carbon emission reduction of the tourism sector in China is dominated by government regulations. Environmental regulation based on supervisory management had the most significant impact on tourism carbon emissions, followed by market incentives and command and control. Public participation had the least influence on tourism carbon emissions. A comparison of multiple balanced short panel data models showed that the baseline regression results were robust and reliable.Environmental regulations had significant time lag effects on tourism carbon emissions. Command and control environmental regulations significantly impacted tourism carbon emissions in the first, second, third, and fourth periods in terms of lag effect strength. However, in the fifth period, they did not have a positive and significant effect. The lag of market incentives from periods one to five significantly impacted tourism carbon emissions. From the third stage, the supervisory management environmental regulation did not have significant impacts on tourism carbon emissions. The lags of environmental regulation based on public participation significantly impacted the carbon emissions of tourism in the first, second, and third phases. However, they did not play a positive and significant role in the fourth stage and beyond. Therefore, the impact on tourism carbon emission intensity was much lower than the other three types of regulations. From the decay rate of different lag periods on tourism carbon emissions, the order for the four environmental regulations was market incentives, supervisory management, command and control, and public participation. Environmental regulations strongly affected tourism carbon emissions for relatively long durations.Environmental regulations demonstrated significantly different regional effects on tourism carbon emissions. The carbon emissions of tourism in eastern China were affected by the four environmental regulation types . In contrast to the eastern region, the central region’s tourism carbon emissions were only affected by three types of environmental regulations , while public participation environmental regulations had no significant impact on tourism carbon emissions. Only command control and market incentives regulations had significant effects on tourism carbon emissions in western China. Their coefficients were more significant than those in eastern and central China. The impact of supervisory management and public participation on tourism carbon emissions in western China was not substantial, but the coefficients were negative.Based on these conclusions, the following three implications were derived. First, regional development levels must be considered to rationally formulate and select the most appropriate environmental regulation tools. All four environmental regulations in eastern China have significant inhibitory effects on tourism carbon emissions. However, only three environmental regulations in central China and only two in western China were effective. In the process of introducing environmental regulation in various regions, a blanket generalization should be avoided and close attention should be paid to optimizing the combination of environmental regulation tools. For example, tourism enterprises are widely distributed in the central and western regions where the economic foundation is not as strong. Therefore, market incentives regulation tools should be the main strategy, with command and control type regulations in an auxiliary role. Additionally, public participation regulations should be strengthened . The cenGreater importance must be accorded to the time-lag effects of environmental regulations on tourism carbon emissions with more focus on the long-term impacts of policy implementation. To strengthen the restraining effects of environmental regulations on tourism carbon emissions, attention needs to be given to the current effects of environmental regulations and the time-delay effects. We should actively promote long-term and larger space dimension environmental regulations to reduce carbon emissions in the tourism industry.Finally, the inhibitory effect of public participation in environmental regulation requires greater attention. When implementing carbon emission reduction policies, we should give full play to the role of public participation and make the public actively participate in the supervision of tourism carbon emission reduction. Governments should publicize environmental protection, improve public and enterprise awareness, give full play to the role of the public in the supervision of tourism carbon emissions, and encourage the public to actively participate in the process of environmental protection. Governments must establish and improve environmental information disclosure systems, broaden the channels for the public to disclose and report environmental problems, reduce the costs of public participation, and make environmental regulations based on public participation an important tool for lowering tourism carbon emissions. Additionally, governments should enrich the means of environmental regulation and gradually realize their transformation from command and control to public participation to maximize the incentive effect on tourism carbon emission reduction.It should be noted that this research examined the impact of four types of environmental regulations on tourism carbon emissions from the perspective of institutional effectiveness, and drew meaningful conclusions and policy implications. However, there were some research limitations: (1) Considering the availability of data, this investigation examined 31 provinces of China and the results are at the provincial level; municipalities were not included and are still lacking in such analysis; (2) the impact of environmental regulations on tourism carbon emissions may have a spatial effect, but this research did not account for this spatial perspective. These problems are further discussed as directions for future research.


To present guidelines on sensory motor stimulation for newborns and infants in the intensive care unit.We employed a mixed methods design with a systematic review of the literature and recommendations based on scientific evidence and the opinions of physiotherapists with neonatal expertise. The research included studies published between 2010 and 2018 in the MEDLINE® and Cochrane databases that included newborns (preterm and term) and infants (between 28 days and 6 months of age) hospitalized in the intensive care unit and submitted to sensory motor stimulation methods. The studies found were classified according to the GRADE score by five physiotherapists in different regions of Brazil and presented at eight Scientific Congresses held to discuss the clinical practice guidelines.We included 89 articles to construct the clinical practice guidelines. Auditory, gustatory and skin-to-skin stimulation stand out for enhancing vital signs, and tactile-kinesthetic massage and multisensory stimulation stand out for improving weight or sucking.Although all modalities have good ratings for pain or stress control, it is recommended that sensory motor stimulation procedures be tailored to the infant’s specific needs and that interventions and be carried out by expert professionals. Sensory motor stimulation (SMS) for newborns (preterm or term) and infants in the intensive care unit (ICU) is an early intervention that includes a series of strategies aimed at optimizing neuropsychomotor development (NPMD) by promoting sensory stimuli based on the level of functional development, gestational age (GA) at birth, and weight of this population. In the ICU, newborns and infants are often in moderately to highly complex clinical situations that may lead to unstable neurological, hemodynamic and cardiorespiratory systems, requiring technical and scientific knowledge when conducting overall assessments of SMS candidates.,3The primary aim of SMS is to organize human body systems. i.e., tactile, kinesthetic, vestibular, olfactory, taste, auditory, visual and/or a combination of these.Despite technological advances and multiprofessional efforts, extremely premature (GA < 28 weeks) and extremely low weight  newborns remain at high risk of death and functional disability . Approximately 20% to 50% of survivors are at risk of morbidity, including changes in weight-height growth and NPMD.-6Sensory motor stimulation facilitates typical NPMD and prevents or minimizes the harmful effects of the ICU environment and interventions on weight-height growth. As such, it can be applied to treat NPMD changes resulting from prematurity, diseases and/or alterations/complications in the prenatal, perinatal or intranatal period and postdelivery.The aim of the present study is to present clinical practice guidelines on SMS for newborns and infants in the ICU.We employed a mixed method design and the following four stages to create this document.Stage 1 - subject approval for the creation of this document and classification of SMS into the following:Recommendation: the main findings are based on at least one clinical trial, considering scientific evidence on the benefits versus risks to newborns and infants hospitalized in the ICU, viability of comparisons with other intervention options, and confirmation of the reliability of the evidence presented to support the use or rejection of SMS in the clinical practice of physiotherapists.Guiding question: the PICO domains are considered: P, Patient (newborn or infant); I, Intervention (any SMS intervention); C, Comparison  and O- Outcome .Stage 2 - a systematic search was conducted of the Medline and Cochrane databases for studies on SMS published between 2010 and 2018. The keywords used included controlled indexers contained in Health Sciences Descriptors  and/or in Medical Subject Headings ; a number of free terms related to each SMS modality were also used (see below each subitem of the Recommendations in “descriptors”). The search terms were combined using the Boolean operators “OR” and “AND” and their corresponding Portuguese words. Five specialists conducted the systematic search and assessed the studies independently according to each SMS modality. Disagreements were resolved by common consent of all those present during the discussions and/or via Skype. The specialists were subdivided into pairs to write a report on the SMS interventions. All specialists were physiotherapists with neonatal expertise (experience ≥ 12 years) in SMS for newborns and infants (up to six months of age) in the ICU.Stage 3 - the partial data were presented to the public at different pediatric and neonatology congresses, where participants could give their opinions and offer suggestions and comments. The five specialists analyzed the suggestions and comments provided by the public at the aforementioned events and made pertinent changes to the document.Stage 4 - creation and writing of the document, in line with the three SMS modalities  and the types of interventions found in the literature  clinical study, controlled or not, comparative or not, randomized or not, or crossover; (2) the study included some type of SMS intervention; (3) study population consisting of newborns and/or infants and (4) neonatal ICU as the study site. Duplicate articles and review studies, case reports, editorials and letters to the editor were excluded. When deemed relevant, these were included in the introduction and/or comments of the document. GRADE is the evidence rating system endorsed by the World Health Organization. It rates the quality of evidence on a 4-point scale . Randomized trials start at a score of 4/4 (high) and can be downgraded based on methodological flaws. If no published literature was available, expert physiotherapists’ opinions were used. The GRADE ratings are shown in The studies found were classified according to the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) score.Congresso Brasileiro de Medicina Intensiva - CBMI-AMIB), Florianópolis (SC), 2014; the International Symposium of Cardiorespiratory Physiotherapy , Salvador (BA), 2014; CBMI-AMIB, Goiânia (GO), 2014; CBMI-AMIB Costa do Sauípe (BA), 2015; CBMI-AMIB Porto Alegre (RS), 2016; CBMI-AMIB Natal (RN), 2017; Pan-American Congress of Intensive Therapy Rio de Janeiro (RJ), 2017; CBMI-AMIB São Paulo (SP), 2018 and CBMI-AMIB Fortaleza (CE), 2018, with the participation of approximately 600 physiotherapists in the area of neonatal and pediatric intensive therapy from different regions of Brazil.A total of 89 articles were included. The partial data were presented at different pediatric and neonatology congresses: The Brazilian Congress of Intensive Therapy  intervention; reduce pain intensity, as assessed by the Neonatal Infant Pain Scale (NIPS) and changes in heart rate (HR) and respiratory rate (RR) associated with pain stimuli, using the therapeutic touch (TT) intervention; and improve sleep state, as assessed by the Anderson Behavioral State Scale (ABSS) after the GHT intervention and the Yakson protocol. The clinical indicators classified by GRADE are shown in Vestibular stimulationRecommendation: some functional positioning methods, which can also be used for vestibular stimulation , did not exhibit the degree of scientific evidence required for inclusion in unimodal stimulation and were therefore included in multimodal SMS.Recommendation: auditory stimulation is recommended to increase peripheral capillary oxygen saturation (SpO2) and to reduce HR through exposure to male-sung lullabies; increase SpO2 through exposure to a Brahms’ lullaby or one sung/recorded by the mother; decrease physiological (HR) and behavioral responses  during and after pain stimuli;,14 decrease resting energy expenditure through exposure to Mozart’s music (Mozart effect); lower HR and RR through exposure to lullabies and reduce HR during exposure to Mozart’s music; lower HR and RR using three types of interventions , better sucking behavior with heartbeat-like sounds and a rise in caloric intake and improved feeding behavior (sucking rate per minute) using lullabies; reduce the frequencies of adverse cardiorespiratory events , poor sleep-wake cycle, and crying; lower peak HR while feeding, improve sucking, promote faster transition to oral feeding and shorten hospitalization time. One study did not reinforce the beneficial physiological and behavioral effects of lullabies for premature infants. The authors found no significant differences among the intervention (lullaby), placebo and control groups in terms of physiological and behavioral responses. The clinical indicators classified by GRADE are shown in Recommendation: olfactory stimulation is recommended to prevent apnea using stimulation with vanilla fragrance and to reduce pain using odor stimulation with maternal milk. Olfactory stimulation is not recommended to decrease resting energy using vanilla fragrance, and an unfamiliar odor (vanilla) had no noticeable calming effect on healthy full-term newborns subjected to a painful procedure. The clinical indicators classified by GRADE are shown in Recommendation: gustatory stimulation using sensorial saturation, maternal milk, assisted suction,,30 and sweetened solutions  is recommended to reduce pain.-35 When sweetened solutions  and placebo stimulations-45 were compared, the former decreased pain; only one study compared oral sucrose and EMLA® cream, and the combination of sucrose with EMLA® cream had the greatest analgesic effect. The clinical indicators classified by GRADE are shown in Recommendation: visual stimulation was included in multimodal SMS rather than unimodal stimulation due to the absence of scientific evidence that met the inclusion criteria of these recommendations.Multimodal stimulationMultimodal stimulation includes SMS interventions that combine two or more types of sensory stimuli, as follows: tactile-kinesthetic stimulation, therapeutic massage, skin-to-skin control and multisensory stimulation .Recommendation: kinesthetic tactile multimodal stimulation is recommended to improve weight gain and reduce hospitalization time, increase parasympathetic activity during sleep,,48 improve muscle strength and bone mineralization, improve motor behavior performance, lower bilirubin levels, favor brain electrical activity maturation, favor more mature motor patterns and more regulated and organized behaviors, improve the motor component and shorten hospitalization time, improve fat deposition in preterm newborns; and contribute to strengthening the immunological system and weight gain.,57The clinical indicators classified by GRADE are shown in Recommendation: multimodal SMS using massage therapy is recommended to increase weight gain,-60 increase the frequency of defecation episodes,,62 decrease transcutaneous bilirubin levels,-63 reduce pain scores, and raise the state of alertness after massage. The clinical indicators classified by GRADE are shown in Recommendation: SMS using multimodal stimulation with skin-to-skin contact is recommended for newborns on mechanical ventilation,-70 reduces pain during painful procedures,-77 alleviates stress,,79 controls body temperature, is associated with lower newborn salivary cortisol levels, improves the effectiveness of breastfeeding or weight gain,-85 and decreases cost of hospitalization. did not demonstrate a decline in the salivary cortisol levels of preterm newborns; other investigations,86 produced no significant evidence in terms of average daily weight gain. The clinical indicators classified by GRADE are shown in One study,87,88The multisensory stimulation combines different types of stimuli without being necessarily offered simultaneously. Its benefits depend on the maturity of the central nervous system and the sensory subsystems of newborns.Recommendation: multisensory stimulation is recommended to improve the neuromotor score and muscle tone maturation of preterm newborns by applying the “auditory, tactile, visual and vestibular stimulus - ATVV” protocol, improve behavioral organization, raise the frequency of oral behaviors, extend the time spent in the alertness state,,90 improve mother-baby interaction with ATVV and increase weight-height growth. The clinical indicators classified by GRADE are shown in ,94 The Moyer-Mileur protocol was used in all the studies that met the inclusion criteria of these recommendations.Exercises/mobilization (passive or active-assistive) can be initiated for clinically stable preterm newborns with high risk for bone metabolic disease and GA < 32 weeks and/or birthweight < 1000g.Recommendation: SMS using mobilizations performed by physiotherapists is recommended to increase weight, height and tibial length; raise the speed of tibial ultrasound propagation;,96 increase arm circumference, increase bone formation markers and decrease bone resorption markers.,99 The clinical indicators classified by GRADE are shown in The only sensory motor stimulation modality that has a high degree of scientific certainty was multimodal skin-to-skin stimulation, followed by multisensory stimulation. All modalities have good ratings for pain or stress control. Auditory stimulation stands out for enhancing vital signs, and tactile-kinesthetic massage and multisensory multimodal stimulation stand out for improving weight or sucking. It is recommended that sensory motor stimulation procedures be tailored to the infant’s specific needs and that interventions and be performed by expert professionals.


Sustainability of reusing Li-ion batteries is hindered by high nickel content and is susceptible to use and recycling choices. Second life and recycling of retired automotive lithium-ion batteries (LIBs) have drawn growing attention, as large volumes of LIBs will retire in the coming decade. Here, we illustrate how battery chemistry, use, and recycling can influence the energy and environmental sustainability of LIBs. We find that LIBs with higher specific energy show better life cycle environmental performances, but their environmental benefits from second life application are less pronounced. Direct cathode recycling is found to be the most effective in reducing life cycle environmental impacts, while hydrometallurgical recycling provides limited sustainability benefits for high-performance LIBs. Battery design with less aluminum and alternative anode materials, such as silicon-based anode, could enable more sustainable LIB recycling. Compared to directly recycling LIBs after their electric vehicle use, carbon footprint and energy use of LIBs recycled after their second life can be reduced by 8 to 17% and 2 to 6%, respectively. Owing to the rapid growth of the electric vehicle (EV) market since 2010 and the increasing need for massive electrochemical energy storage, the demand for lithium-ion batteries (LIBs) is expected to double by 2025 and quadruple by 2030  The maximized material and energy recovery can hardly offset the carbon footprint and CED from the intensive use of energy and chemicals during recycling processes, whereas it can largely eliminate by up to 68% of life cycle environmental impacts from other impact categories.2) LIBs with higher specific energy density show better environmental performances, but their environmental benefits from second life application are less pronounced.3) Compared to directly recycling LIBs after their EV use, life cycle carbon footprint and CED of LIBs recycled after their second life can be reduced by 8 to 17% and 2 to 6%, respectively, varying across battery chemistries and recycling methods.4) Recycling methods and use scenarios are more impactful on the energy and environmental sustainability of LIBs, compared to the battery technologies.5) The effects of battery chemistry and recycling methods on the life cycle carbon footprint and CED are negligible compared to the penetration of renewables in the power grid, with a reduction in carbon footprint in China (28.5%) twice as large as that in the United States (20%), although the absolute life cycle carbon footprint of LIBs in China is also twice of that in the United States.6) Direct cathode recycling is the most environmentally favorable technology of LIB recycling, in concordance with previous findings (N-methyl-2-pyrrolidone (NMP) production and recovery are highly detrimental to the environment, greener aqueous binders should be further researched and developed for additional environmental benefits of both producing and recycling LIBs.7) Because the 8) Carbon-intensive graphite and carbon black should be separated and recycled from the spent LIBs instead of being combusted to alleviate climate change.9) Energy-intensive processes such as relithiation should be coupled with other exothermic processes to reduce energy demand.10) Industrial recycling processes should be optimized to avoid the excessive use of environmentally expensive chemicals.11) Battery design with less aluminum and alternative anode materials, such as silicon-based anode, could enable more sustainable pyrometallurgical recycling of LIBs.12) Waste LIB sorting would become critical in improving the environmental sustainability of LIB recycling.The importance of LIB design for recycling has been highlighted by previous literature , generates a large quantity of nonrecyclable aluminum and lithium in slag from the smelting process, and uses large doses of environmentally expensive reductants. Moreover, other volatile LIB components, including the separator, electrolyte, binder, graphite, and carbon black, are combusted and evaporated in the furnace. Third, the absence of cobalt and nickel in LMO suggests no recovery of valuable metals, and much fewer reductants are needed accordingly. However, the use of citric acid (leachate) and Mn2O3 (manganese source) causes notably higher environmental impacts in several impact categories than the LMO avoided from material recovery in hydrometallurgical recycling of LMO/NMC532.All recycling methods are beneficial in most impact categories, namely, avoids more environmental burdens from material and energy recovery than causing environmental impacts from the intensive consumption of energy and chemicals. An exception to all types of LIBs is the net environmental burdens in ozone depletion of hydrometallurgical and pyrometallurgical recycling, which can be mostly explained by the direct and indirect methane emission from reagent production. Because of the recovery of less environmentally expensive cathode active materials and usages of reagents, such as citric acid and Mn2CO3; (iii) the increasing nickel content does not only replace cobalt content, which is relatively more carbon and energy intensive, but also replaces the relatively abundant and environmentally benign manganese content. The carbon footprint and CED of NMC811 with pyrometallurgical and direct cathode recycling are slightly higher than that of NMC622, mainly because of the employment of around twice the amount of PVDF used in other LIBs. NCA has the highest nickel content, but the usage of carbon- and energy-intensive HCl in hydrometallurgical and pyrometallurgical recycling of NCA, instead of H2SO4 for other types of LIBs, leads to increases in both carbon footprint and CED. This result suggests that the most environmentally friendly recycling option for the cathode active materials is not only to pursue the least cobalt content, and careful life cycle environmental evaluation in production and recycling processes is needed before any generous incentive or subsidies are given.Carbon footprint and CED are two important metrics to evaluate the climate change mitigation potential and energy performance of introducing second life and recycling into batteries’ life cycle. Adding second life reduces the carbon footprint by 8 to 17% and the CED by 2 to 6%, depending on the specific battery chemistry and recycling method. Keeping the recycling method and use scenario fixed, increased nickel content and decreased cobalt content of LIBs tend to shift their life cycle carbon footprint and CED downward  policy-makers aim to regulate the LIBs traded on the EU market  during the NMC and NCA production.For the cell material production and assembly stage, cathode active material is the predominant factor of the carbon footprint for LMO/NMC532 (60%), NMC622 (65%), and NCA (67%) LIBs. On the contrary, LFP production accounts for only 41% of the carbon footprint associated with this stage. This contrast can be attributed to the high carbon footprint associated with NiSOThe battery management system (BMS) is the main contributor to the carbon footprint of LIB pack accessory production. Production of BMS and other pack accessories, including compression plates and straps, module interconnects, and a trilayer jacket, together is responsible for nearly all the carbon footprint associated with this stage. The dominant role of BMS and other pack accessories can be attributed to the production of printed wiring boards and aluminum-made outer and inner layers of the battery jackets, respectively.2 and recovers cobalt in the form of ionic solutions. Moreover, it only recovers aluminum during the dismantling of the LIB pack but does not recover lithium and aluminum from the subsequent smelting step. This may present a challenge as the EU proposed to mandate the recycling of valuable metals 2 recovery of pyrometallurgical recycling is the major source to reduce carbon footprint. Second, other than direct cathode recycling, hydrometallurgical recycling of NMC622 and NCA generates less greenhouse gas emissions than avoided from their material and energy recovery. Among these greenhouse gas–emitting steps, waste sludge treatment is the most influential one for both hydrometallurgical and pyrometallurgical recycling. This is because they both adopt hydrometallurgical steps, such as leaching, solvent extraction, and precipitation, that eventually discharge a large amount of waste solvent sludge. Instead, liquid CO2, which consumes plenty of electricity, is much more energy intensive than other energy-consuming EOL steps for direct cathode recycling. Moreover, graphite combustion remains one of the most influential steps for all three recycling methods, which suggests a need to suppress graphite combustion to further mitigate carbon footprint. Soaking and recovery of the binder solvent NMP are also a major carbon footprint and CED contributor for both hydrometallurgical and direct cathode recycling. This can be mainly attributed to the need for steam and wastewater treatment for NMP recovery. To further reduce the carbon footprint and CED of battery recycling, especially for hydrometallurgical and direct cathode recycling, research and development on replacing or avoiding the step of binder solvent recovery are highly recommended. Last, according to the battery chemistry, different leaching agents and precipitants with a variety of reaction conditions are selected to recover the cathode active materials for hydrometallurgical and pyrometallurgical recycling, resulting in multiple levels of carbon burden. It is worth mentioning that these EOL steps’ contributions to the carbon footprint and CED are relatively comparable, and none of them are dominant.The roles of EOL steps in carbon footprint depend on the battery chemistry and the specificities of EOL scenarios. First, material and energy recovery during hydrometallurgical and direct cathode recycling reduces slightly less carbon footprint than the amount added by the cell material production and assembly stage. On the contrary, pyrometallurgical recycling is deficient in material recovery because it retrieves nickel as Ni(OH)2, and metals are major contributors to alleviate environmental impacts. Notably, LFP, LMO/NMC532, and Ni(OH)2 recovery is not as environmentally valuable as NMC and NCA recovery in all environmental impact categories, suggesting the necessity of waste LIB sorting by battery chemistry before the recycling. In addition, disassembling LIBs into constituents of cathode, anode, and casing for the hydrometallurgical and direct cathode recycling approaches prevents the subsequent anode-cathode separation and diminishes cathode active material loss and contamination. On the other hand, manual disassembly is labor intensive and could potentially cause hazards through thermal runaways and toxic chemicals , fossil depletion (38 to 50%), ionizing radiation (89 to 92%), ozone depletion (39 to 55%), and urban land occupation (59 to 81%) associated with the EOL steps causing environmental damages.Environmental hotspots are specific to recycling methods. For both hydrometallurgical and pyrometallurgical recycling of LMO/NMC532, NMC, and NCA, the production of leaching agent and precipitant is more impactful in contributing to ozone depletion, terrestrial ecotoxicity, and water depletion than to other impact categories. However, for hydrometallurgical recycling of LFP, the production of HNotably, environmental hotspots are not always extensively distributed across the impact categories. For example, copper recovery is not comparable with aluminum recovery in terms of climate change and fossil depletion. However, copper recovery can largely reduce environmental impacts through the categories of freshwater ecotoxicity, freshwater eutrophication, human toxicity, marine ecotoxicity, metal depletion, and terrestrial ecotoxicity; in addition to fossil depletion, aluminum recovery leads to much environmental burden on freshwater and marine ecotoxicity; NMP soaking and recovery contribute to a large portion of the marine eutrophication, although it only makes a minor contribution to most of the impact categories.Previous results show that environmental impacts associated with the use phase are overwhelming and unavoidable. Because electricity consumption is the only process in the use phase that causes damages to the environment, an effective approach to minimizing the environmental impacts of the use phase is to make the electricity production less carbon intensive. To test the sensitivity of second life LIB’s environmental performance to the temporal and spatial variability of electricity production, we establish a prospective LCA model by integrating the projected electricity production for 2020–2050 from the U.S. Energy Information Administration (EIA) on the basis of the reference static LCA  have the properties of being fluorine-free, ease of disposal, and availability from renewable resources . Thus, waste LIBs should be carefully sorted. Waste LIB sorting by battery chemistry can also benefit the environmental sustainability of pyrometallurgical and hydrometallurgical recycling by avoiding excessive use of environmentally expensive chemicals  Cell material production and assembly2) Module accessory production and assembly3) Pack accessory production and assembly4) Use phase (EV use or EV + ESS use)5) Repurpose (accompanied with the cascaded use scenario)6) EOL phase 7) TransportationThe functional unit of 1-kWh life cycle electricity delivery is used to quantify the environmental impact based on the life cycle energy provision of LIBs. Working parameters of LIBs for both EV and stationary ESS use are provided in table S1. Other than transportation, the whole life cycle of the LIBs, including production, EV use, repurpose, stationary ESS use, and recycling, is assumed to be located in the NYS in 2018 under the baseline case, without considering the temporal and spatial variations in the power grid. For this reason, the environmental impacts associated with electricity consumption remain constant in the baseline case, and the environmental profile of electricity production is determined by the energy sources of the NPCC in 2018. The carbon footprint and CED of electricity generation in other areas of the United States can be found in 2 and cobalt as a salt, both for reentering in the battery supply chain 2, which are raw materials of cathode active materials , do not have readily available LCI data either. Then, we need to construct the LCI from the upstream processes .In this study, carbon footprint, CED, and ReCiPe impact categories are selected to demonstrate and compare the life cycle greenhouse gas emissions, energy consumption, and full-spectrum environmental impacts, respectively. In the life cycle impact assessment stage of LCA, LCIs are computed on the basis of the functional unit through characterization factors to quantify their environmental impacts for each impact category. We collect most of the characterization factors from Ecoinvent, and lists of these characterization factors can be found in table S25 2 is investigated for pyrometallurgical recycling; and the recovery rate of Mn2O3 and citric acid is evaluated exclusively for hydrometallurgical recycling of LMO/NMC532. Ranges of parameters are presented in tables S19 to S22, and impacts of these parameters are shown in figs. S21 to S23. The results of sensitivity analyses are discussed in the Supplementary Materials.The investigated parameters regarding EOL scenarios are considered according to the carbon and energy hotspots identified in X1, X2, …, nX , this normalization method linearly maps each data point to the range of 0 to 1 according to X′, Xa, Xmax, and Xmin represent each data point after normalization, each data point before normalization, the minimum of the dataset, and the maximum of the dataset, separatelyTo intuitively present the life cycle environmental impacts across each impact category, we adopt the min-max normalization method to process data. For a set of data points Nevertheless, the environmental impacts associated with the avoided environmental burden in the EOL phase are negatively signed. Hence, the magnitude of both negative and positive values should be shown on the same basis, while the orientation of environmental favorability  for each process is preserved. However,