State cancer prevention and control programs rely on public health surveillance data to set objectives to improve cancer prevention and control, plan interventions, and evaluate state-level progress towards achieving those objectives. The goal of this project was to evaluate the validity of using electronic health records (EHRs) based on common data model variables to generate indicators for surveillance of cancer prevention and control for these public health programs.Following the methodological guidance from the PRISMA Extension for Scoping Reviews, we conducted a literature scoping review to assess how EHRs are used to inform cancer surveillance. We then developed 26 indicators along the continuum of the cascade of care, including cancer risk factors, immunizations to prevent cancer, cancer screenings, quality of initial care after abnormal screening results, and cancer burden. Indicators were calculated within a sample of patients from the New York City (NYC) INSIGHT Clinical Research Network using common data model EHR data and were weighted to the NYC population using post-stratification. We used prevalence ratios to compare these estimates to estimates from the raw EHR of NYU Langone Health to assess quality of information within INSIGHT, and we compared estimates to results from existing surveillance sources to assess validity.Of the 401 identified articles, 15% had a study purpose related to surveillance. Our indicator comparisons found that INSIGHT EHR-based measures for risk factor indicators were similar to estimates from external sources. In contrast, cancer screening and vaccination indicators were substantially underestimated as compared to estimates from external sources. Cancer screenings and vaccinations were often recorded in sections of the EHR that were not captured by the common data model. INSIGHT estimates for many quality-of-care indicators were higher than those calculated using a raw EHR.Common data model EHR data can provide rich information for certain indicators related to the cascade of care but may have substantial biases for others that limit their use in informing surveillance efforts for cancer prevention and control programs.The online version contains supplementary material available at 10.1186/s12911-022-01831-8. Timely and reliable surveillance data is critical to guide efforts to reduce cancer morbidity and mortality, particularly among underserved populations that experience disparities in cancer risk factors, health care services, and outcomes –3. StateWidespread adoption of electronic health records (EHRs) poses a strategic opportunity to improve upon these limitations in cancer surveillance. EHR data contain a wealth of clinical information, including diagnoses, procedures, lab results, medications, and vitals, which can be accessed in real-time on large convenience samples of in-care patients. In addition, the expansion of health information exchanges or research networks allows for the linkage of EHR data across contributing healthcare institutions. These data systems, which often use common data models to create a standard data format and link patient records across disparate institutions, can provide a more complete representation of care received and a wider geographic coverage than EHR data from a single healthcare institution. These EHR-based systems therefore have potential to produce timely estimates of cancer surveillance indicators along the continuum of the cascade of care. Yet the extent to which EHR networks can be used to generate accurate cancer surveillance metrics remains unknown.EHR data are currently routinely used to explore and explain patterns in cancer care among patient populations. This includes reporting on clinical quality measures for health systems, such as adherence to cancer-related preventative and screening services , as wellTo fill these gaps, our study aimed to (1) review the current state of the literature on how EHRs have been used to inform cancer surveillance to date; (2) propose potential surveillance indicators that can be constructed using common data model EHR variables along the spectrum of cancer surveillance: risk factors, screening and immunization, quality of care, and incidence or prevalence; and (3) perform an initial validity test of these proposed indicators. The overall goal of the project was to identify EHR-based cancer surveillance indicators that could be used by state public health programs to set objectives to improve cancer prevention and control, plan public health interventions, and evaluate state-level progress towards achieving those objectives. Here, we define cancer surveillance indicators as measures related to primary (i.e. reducing the incidence of cancer) or secondary prevention .An academic-government investigative team led by the New York University and City University of New York (NYU-CUNY) Prevention Research Center (PRC) undertook this investigation. The investigation team included researchers from NYU Grossman School of Medicine, as well as epidemiology and cancer control experts from the New York City (NYC) Department of Health and Mental Hygiene (DOHMH), the New York State (NYS) Department of Health (DOH), and the Centers for Disease Control and Prevention (CDC). The goal of the investigation was to evaluate the feasibility of a model cancer surveillance report on EHR-based performance measures that state/territorial/tribal and CDC cancer prevention and control programs could use to plan interventions to improve cancer prevention and control. The start date was September 30, 2019, and the end date was December 31, 2020.The goal of our initial scoping review was to understand the gaps and potential opportunities of using EHRs for cancer surveillance. Our review was informed by methodological guidance from the PRISMA Extension for Scoping Reviews . In DeceBased on these criteria, publications were screened for eligibility during a two-stage process. First, all identified titles and abstracts underwent independent dual screening to exclude any non-relevant publications. Second, all remaining full-text publications underwent independent dual review for eligibility. Reviewers were comprised of a group of seven total reviewers  who were trained on the review protocol. Disagreements were resolved by consensus or by whichever lead author (SC or SB) was not part of the initial review of the article in conflict. Citations were imported to Covidence software to assist with this eligibility screening review . Resultihttps://www.qualtrics.com) to (1) rate potential surveillance indicators for feasibility , actionability , and priority ; (2) prioritize cancer sites; and (3) suggest additional metrics if necessary.Concurrently with the scoping review, we selected and tested potential surveillance indicators that could be constructed using common data model EHR variables along the spectrum of cancer surveillance. Proposed surveillance indicators were selected through the review of the literature and a two-round modified Delphi process. The Delphi process is a method in which anonymous responses or opinions are reduced to rapidly reach consensus and to maximize shared decision-making among stakeholder partners , 37. In We selected 26 surveillance indicators deemed to be feasible, actionable, and a priority for public health agencies Table . We consIn addition to producing crude indicators within the full NYC-resident INSIGHT patient population, we also produced estimates that were weighted to reflect the total NYC population, including those who have not visited a healthcare facility, to account for demographic differences between our sample and the larger target population of NYC residents. These data were weighted using post-stratification to the general NYC population, as derived from the 2018 Integrated Public Use Microdata Series (IPUMS) USA data . Post-stWe conducted two initial validity checks of the proposed indicators. First, we compared the crude indicator common data model estimates obtained through INSIGHT data to estimates obtained using the NYU Langone Epic EHR in order to assess potential data loss in the translation of raw EHR data to the PCORnet common data model. Data loss could occur in this translation since not all elements of the EHR are included or conform to this common data model and would therefore not be represented in these data. All indicator SQL queries were developed and tested on NYC-resident patients within the NYU Langone Clarity database, which allows full access to the raw data for the NYU Langone Epic EHR. Prevalence estimates obtained using INSIGHT data were assessed for comparability to those obtained using NYU Langone data using the two one-sided t-tests of equivalence (TOST) and using a prevalence ratio range of 0.85 to 1.50, allowing for this larger upper bound to accommodate the increased capture in INSIGHT as a result of linking patient care across institutions , 42.We then compared weighted prevalence estimates obtained from INSIGHT data to analogous surveillance indicators from external data sources traditionally used for cancer surveillance, with the goal of assessing the general plausibility of the magnitude of the EHR-generated estimate and hypothesizing any significant sources of information or selection bias that may limit the use of the PCORnet common data model for cancer surveillance purposes. External data sources for these analyses included the NYC Health and Nutrition Examination Survey   were deemed eligible for full-text review  and cancer screening or immunization surveillance domains (N = 146). Over half of the articles with a surveillance, epidemiologic, or methodological study purpose measured a cancer risk factor while less than one-third of quality improvement articles included the risk factors of interest Table . A greatThrough the two-stage modified Delphi process, the stakeholders ultimately selected three cancer risk factor indicators  and eight screening and immunization indicators . In addition, three quality of care indicators , as well as incidence and prevalence indicators, were selected for the cancer sites of the breast, cervix, and colon/rectum , 32.0% had a missing or unknown race, and 29.3% had a missing or unknown ethnicity. The median patient age was 44 years (IQR: 26–62 years). A total of 604,699 NYC resident NYU Langone patients had an ambulatory care encounter in 2018 and were included in the comparison sample. Similar to the INSIGHT patient population, more than half of these patients were women (58.9%) and a sizable proportion had a missing or unknown race (14.4%) or ethnicity (22.1%). The median patient age of the NYU Langone sample was 48 years (IQR: 29–64 years). These patient populations were older and were over-representative of women as compared to the general NYC population .Adult Obesity = 1.11, PRChildhood Obesity = 1.18). The prevalence of adults aged 18 + years who are smokers within the INSIGHT patient population was 10.9%, which was moderately higher than the prevalence of adults aged 18 + years who are smokers within the NYU Langone patient population (PR = 1.67). Weighting through post-stratification to the NYC population led to a slight decrease in obesity prevalence estimates and a slight increase in the smoking prevalence estimate. The weighted prevalence estimates were highly comparable to estimates from external physical exam- or survey-based data sources .When applying these indicators to the INSIGHT patient population, approximately one-third of adults and one-quarter of children were classified as obese Table . These pBreast = 0.54, PRCervical = 0.23, PRColorectal = 0.42) . Similarly, the prevalence estimates for Hepatitis C testing, HBV vaccination initiation and completion, and HPV vaccination initiation and completion were significantly lower than estimates defined within the NYU Langone patient population and remained substantially lower than estimates from external data sources after weighting to the demographic distribution of the NYC population . A sizable proportion of NYU Langone patients who initiated the HBV or HPV vaccination series had their vaccine recorded within the immunizations module of the EHR but not within standardized procedure codes .Less than one-quarter of INSIGHT common data model patients met the breast, cervical, and colorectal cancer screening recommendations Table . The comAny Diagnostic = 0.77, PRTimely Diagnostic = 0.67; Colorectal: PRTimely Diagnosis = 0.91). Weighting to the demographic distribution of the NYC population had a minor impact on the prevalence estimates for these indicators. There was no NYC based data source by which to externally validate these estimates.Within the INSIGHT common data model, prevalence estimates for the quality of care indicators were generally higher than estimates produced within the NYU Langone patient population using the raw EHR Table . HoweverIncidence = 0.66, PRPrevalence = 0.91). Weighting to the demographic distribution of the NYC population led to a slight decrease in the INSIGHT breast, cervical, and colorectal cancer incidence and prevalence estimates, but they remained substantially overestimated as compared to reported rates from the NYS Cancer Registry.Cervical and colorectal cancer incidence and prevalence estimates in the INSIGHT common data model were generally higher than estimates within the NYU Langone patient population, while breast cancer incidence and prevalence were lower (PROur scoping review provided a robust number of studies that explored a diversity of topics along the cancer cascade of care. To our knowledge, this is the first scoping review to provide a comprehensive overview of the EHR-based cancer literature starting from the recent maturation of EHR networks. Importantly, this literature base was critical for informing our indicator development work by providing our stakeholders with an understanding of the feasibility and acceptability of using EHRs to measure these types of indicators and by providing variable definitions that we could attempt to replicate or improve upon in this work.However, we identified a number of gaps in the current literature regarding the use of EHRs to inform cancer prevention and control programs. Although we identified many articles that measured variables related to the cancer cascade of care using EHRs, few had an explicit purpose of informing cancer surveillance efforts. Articles that focused on quality improvement or epidemiologic research generally did not address issues related to selection biases or the representativeness of patient samples, a key challenge for using these data for surveillance efforts. Those that did examine EHR-based measures from the lens of public health surveillance were more likely to incorporate methods or validation approaches to address issues of population representativeness in their samples, but these studies were predominantly focused on cancer risk factors , 68–70. In our development of the proposed indicators for public health surveillance of cancer prevention and control, we attempted to fill these gaps by assessing measures along the cascade of care, from cancer risk factors to cancer incidence and prevalence, and by providing clear definitions that are directly transportable to PCORnet research networks and adaptable to other EHR data sources (Additional file In contrast to cancer risk factors, the unweighted and weighted estimates generated for the screening and immunization indicators demonstrated poor performance, with substantial underestimation as compared to estimates generated using a raw EHR. Within the NYU Langone sample, we saw that many patients had documentation of their screenings and vaccinations within the health maintenance or immunization modules but not within standardized diagnosis or procedure codes. This lower prevalence within the common data model estimates may be largely attributable to the exclusion of certain components of the EHR from the PCORnet common data model, which largely relies on structured variables and standardized codes . FurtherWe found that common data model estimates were actually higher than those calculated using a raw EHR for many of the quality of care indicators. These results demonstrate the potential benefits of using health information exchanges or research networks, which can increase capture if patients receive care across multiple institutions. This benefit may be more apparent for quality of care indicators than preventative care indicators since these services may be more likely to occur in hospital-based settings. We were unable to externally validate these indicators, as there is no established NYC-based surveillance system that tracks timely diagnostic testing and diagnosis after abnormal cancer screenings. Using EHRs to monitor quality of cancer care represents a unique opportunity to fill this gap, and the few studies that we identified as related to this goal demonstrated that EHR data could provide valuable insights into trends and patterns in cancer care –74.Cancer incidence and prevalence within the INSIGHT population was variably higher or lower than incidence and prevalence within the NYU Langone population. This may reflect underlying differences in patterns of care, where NYU Langone may provide care for a disproportionate share of breast cancer patients while other organizations within the INSIGHT network may provide care for a disproportionate share of cervical cancer patients in NYC. In our external validation of these indicators, the weighted estimates for the incidence and prevalence indicators were substantially overestimated as compared to rates reported in the NYS Cancer Registry. However, prior studies that validated EHR-based cancer cases by directly linking these data to cancer registries demonstrated reduced sensitivity of EHRs as compared to registries , 57–59. Limitations to our scoping review include the use of a single reviewer during the data extraction portion of this study, which limited our ability to assess potential inconsistencies in how the reviewers extracted the data. However, an 87% agreement between two reviewers on a large sample of articles mitigated this concern. We also did not publish the scoping review protocol and excluded articles published from 2009 to 2011 during data extraction based on the decreased relevancy and utility of articles as we went further back in time. Limitations to the indicator development include our inability to use race/ethnicity in our weighting approach due to the high proportion of INSIGHT patients who had an unknown or other race/ethnicity. Numerous articles identified through the scoping review demonstrated patterns in these cancer indicators by race/ethnicity , 75–77, In conclusion, a review of the current literature suggests that future research on the use of EHRs for cancer surveillance will benefit from careful reporting of key information such as provision of EHR definitions, standardized codes and common data model correlates, as well as descriptions of data quality and bias correction measures taken. Effort could be made to improve the PCORnet common data model for surveillance purposes, such as through improved reporting of race/ethnicity and through the inclusion of additional sources of preventative health services information from raw EHRs. Future studies could also consider limiting patient cohorts to those seen by primary care providers and incorporating additional variables, like insurance status, into weighting or adjustment strategies to better address the biases we observed in this study. Local, state, territorial, and national public health agencies have a strategic opportunity to use timely and geographically granular EHR data for select indicators for public health surveillance of cancer prevention and control, such as cancer risk factors, to assist in planning interventions to improve cancer prevention and control. These data can also potentially provide more accessible and richer information on the cascade of cancer care than routine surveillance data systems. However, these data currently cannot be used to monitor screening and immunization or cancer incidence and prevalence due to the biases we observed for these indicators. Further research is needed to address issues related to population representativeness of these convenience samples.Additional file 1. Ovid MEDLINE search Run December, 5, 2019Additional file 2. Indicator definitions


A growing body of research highlights that adults with autism spectrum disorder (ASD) have poor health outcomes, yet effective health interventions are lacking for this population. While mobile health applications demonstrate potential for promoting physical activity (PA) in adults with ASD, scientific evidence for supporting this tool’s long-term effectiveness on PA behavior change remains inconclusive. This study aimed to provide the latest information on PA research and the prospective role of mobile health applications for promoting PA in adults with ASD. A literature review demonstrated that a few available studies show contradictory results regarding PA levels in adults with ASD, and behavior change techniques and gamification-guided mobile health applications can be promising tactics to leverage autism’s strengths and increase PA in these individuals. Optimizing design decisions based on needs analysis and user feedback is crucial to identifying and developing a sustainable mobile health intervention for PA promotion in adults with ASD. Autism spectrum disorder (ASD) is a pervasive neurodevelopmental condition characterized by social interaction and communication deficits, as well as restricted or repetitive behavior patterns and interests . Accordin = 1,507) in the United States and highlighted that these individuals are at a higher risk for nearly all mental and physical health conditions  compared to adults without any ASD diagnoses. Furthermore, adults with ASD are more than twice as likely as their neurotypical counterparts to die prematurely  and varying methodological quality in existing studies make it difficult to draw a solid conclusion about the effects of PA on behavioral outcomes in this population.There is little information on PA as a preventive health behavior in adults with ASD . Most reNational and international health organizations recommend that adults should participate in at least 150 min of moderate-intensity PA or 75 min of vigorous-intensity PA throughout a week, or an equivalent combination of MVPA, to see health benefits . While tMobile application is an attractive modality for behavioral intervention in people with ASD because human-technology interaction enables visuospatial learning, which is often noted as a particular strength in those with ASD . It alsopost hoc investigation on the functional outcomes in relation to actual motor skill acquisition/improvement after the intervention and any consequent impact on PA or other daily living activities in real-world settings. In addition, the system focused on children with limited cognitive function and required substantial assistance for proper execution; thus, it cannot be applicable to adults with ASD who live independently and make their own choices in their health behaviors.However, there exist almost no similar attempts to use mobile applications to address PA disparities in individuals with ASD. The only related effort has been a video modeling mobile application, Exercise Buddy, that was developed to help children with ASD acquire and improve fundamental motor skills consisting of locomotor , balance, and object control skills . With suAlthough the evidence supporting their long-term effectiveness on health behavior change is unclear, mobile health applications can have small to moderate effects in the short term  on self-monitoring or changing PA and sedentary behavior in overweight and sedentary neurotypical adults . PA in aBCTs are a systematic, evidence-based health behavior change strategy for altering or redirecting causal processes that regulate healthy behaviors . For exaEffective behavior change interventions generally leverage multiple BCTs to implement health behavior change, and a mobile application enables researchers to deliver diverse BCTs in a time‐ and cost-effective way in real-world settings . Currentn = 24). Findings indicated that PuzzleWalk users spent significantly larger amounts of time on application use compared to Google Fit users throughout a 5-week intervention period. Even though statistical significance was not reached, PuzzleWalk also demonstrated the potential for increasing MVPA in the short term and reducing sedentary time in adults with high-functioning ASD (Despite the limitations, gamified behavior change interventions in particular have presented promising results to promote PA in adults with and without ASD. Gamified interventions leverage game-like elements such as leaderboards, animated avatars, problem-solving, and attractive storylines to elevate the level of motivation and user engagement . Chen anning ASD .Taken together, a growing body of research supports the potential of gamification and BCTs-guided mobile applications for promoting PA in diverse population groups, including adults with ASD. However, despite the increasing popularity of using these promising tactics in commercial PA applications, evidence-based mobile health interventions are lacking, and only a few attempts have been made to address the unique characteristics and health needs in adults with ASD. Furthermore, more research is warranted to better understand the impact of varying degrees of cognitive abilities and sociability on health behaviors in adults with ASD.This brief review has revealed that there is a critical need for interventional studies that leverage autism’s strengths to address preventive health and reduce health disparities in adults with ASD. Despite the seemingly successful expansion of mobile health applications for promoting PA in both adults with and without ASD, most of the existing health and PA applications on the commercial market are not designed using scientific evidence or health behavior theories such as BCTs . It is aThe author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In this perspective article, we provide recommendations for strengthening the policy framework for protecting the Baltic Sea from agricultural nutrient pollution. The most striking weakness is the lax implementation of prescribed abatement measures, particularly concerning manure management, in most countries. Institutions of the EU should also be leveraged for achieving Baltic Sea Action Plan (BSAP) goals. In contrast to the Helsinki Convention, the European Union has economic, political and legal mandates to further implementation and compliance. Equally important is the need for strengthening of local institutions, particularly Water Boards and independent agricultural advisory services in the eastern Baltic Sea Region countries. There is also an urgent need for implementation of voluntary land-use measures where EU funding available to farmers is more broadly and effectively used by providing it on the basis of estimated abatement performance, which can be realized through modelling. The enormous potential for funding performance-based schemes, manure management infrastructure and advisory services through the EU’s Common Agricultural Policy are currently underutilized.he online version contains supplementary material available at 10.1007/s13280-021-01573-3. Agricultural nutrient pollution of the Baltic Sea has been reduced over recent decades, but remains too high for achieving mutually agreed upon water quality and ecological goals HELCOM . NitrogeConvention on the Protection of the Marine Environment of the Baltic Sea Area. On account of the EU acceding to the Convention in 1994, there is substantial overlap between the EU’s Nitrates Directive and the measures prescribed to control nutrients from agriculture in Annex III, Part 2 of the Convention. To attain good ecological status in the open Sea, the 2013 Baltic Sea Action Plan (BSAP) aims to reduce the annual inputs of N by 13%  and P by 41%  compared to the reference period, 1997–2003.S1); however, unlike the prescribed measures of the Convention Annex these are not legally binding.Following HELCOM’s 1990 Rønneby declaration, abatement efforts focussed on identifying and cleaning up pollution ‘hot-spots’ through treatment of wastewater discharges from industry and conurbations. From 1998, agriculture became subject to concerted efforts to reduce nutrient emissions, as specified in amendments to the Three recent synthesis articles on governance structures and policy performance in the Baltic Sea region identify fundamental weaknesses in the current policy framework for controlling agricultural nutrient emissions to the Sea. Thorsøe et al.  find thaThe aim of this perspective article is to recommend actions for strengthening the policy framework for protecting the Baltic Sea from agricultural nutrient emissions. Our arguments are based on the weaknesses identified in the current framework in the three synthesis articles cited above and complemented by additional policy-relevant research literature, thereby helping to bridge the gap between Baltic Sea policy research and its implementation.In their recent perspective article, Ollikainen et al.  argue thWe structure this article around what we consider to be the three pillars of the policy framework for guiding farmers’ nutrient management in the Baltic Sea Region (BSR): (i) minimum nutrient management standards or measures; (ii) voluntary payment schemes for additional abatement measures; and (iii) the institutional framework characterizing each country, particularly the interdependent roles of the EU and local institutions to empower stakeholders.There exists substantial spatial variability in rates of nutrient emissions from agricultural land in the BSR as well as the preconditions for farming, and hence for controlling these emissions HELCOM . ApplyinThat manure-nutrient surpluses accumulate in extremes in some areas, despite their potential for replacing costly mineral fertilizers and improving soil fertility, is explained by the high cost (given current market conditions) of transporting manure more than a few kilometres or processing it to reduce water content. In fact it is economically rational for farmers to generously or “over” apply manure to fields close to livestock facilities, and to only apply mineral fertilizers on fields distant from facilities . Farmers in Poland, Lithuania and Latvia are numerous and receive less average support, which is unfortunate considering the investment needs in, e.g. manure management. Farmers in the Baltic states receive far less support per ha agricultural land than farmers in Finland, Denmark and Germany, however, if financial support is considered per capita of population, the reverse is true. Polish farmers are in any case better off than Swedish farmers in terms of support per ha. These figures suggest that further financial support is not necessarily needed, but what is required seems rather to be fair, stringent and targeted support for nutrient management measures.The public support offered to farmers under the CAP, including national co-financing, differs among old and new Member States  the continuing concentration of livestock resulting in extreme nutrient surpluses; ii) economic inequalities among farmers within and among BSR countries, particularly in Poland and the Baltic states; iii) gaps in nutrient management skills, iv) effective financing of abatement schemes; and v) the capacity for rolling out independent advisory services where they are currently lacking.S1). Different measures are required for reducing nutrient losses during the various stages of the nutrient cycle, which we overview in Fig. In view of the extreme emissions risks associated with the concentration of livestock and resultant nutrient surpluses, BSR countries have agreed to basic nutrient abatement measures , but the conventional broadcast spreading technique is characterized by high nutrient losses. Trail hoses or injection into the soil ensure much higher utilization rates  could be used to concentrate nutrients in less bulky form, lower transportation costs and promote broader utilization in crop production. Still, Tybirk et al.  indicateIt seems therefore necessary that livestock density regulations be strengthened to achieve acceptable nutrient utilization rates. Alternatively, a systematic penalty on nutrient surpluses (Stage 1) beyond a benchmark is a sure-fire way of creating economic incentives to reduce hot-spot surpluses, and promoting wider improvement and innovations in manure management NIER . OtherwiReducing nutrient losses from fields in the BSR is additionally challenging, because the area of agricultural land is large and is heterogeneous in terms of societal, geographical and agricultural conditions  payments are too low to motivate many farmers to apply them, particularly on the most intensively farmed fields. Indeed, the potential for greater differentiation of payments has been found to improve the likelihood of uptake among farmers in Baltic Sea catchments . Initially, one could focus on controlling farms’ nutrient surpluses. Eurostat routinely estimates surpluses by considering the aggregate nutrient outputs in farm products compared to inputs from fertilizers, biological fixation and atmospheric deposition (Eurostat 2013), which Blicher-Mathiesen et al.  show canIn a second more advanced step it would be possible to use modelled predictions of annual emissions abatement and fully implement a PAMR scheme. Although a model might initially only be expected to identify the most desirable locations for payments and exclude the most undesirable, the approach has the potential to improve over time through validation and learning, particularly if perceived as a knowledge transfer system between scientists, farmers and society . However, the EU is underutilized in pursuit of BSAP goals, in particular because HELCOM lacks the competence to act if a signatory is not in compliance , which include agri-environmental and agri-climate measures, account for only 23% of CAP spending, while (ineffective) income support accounts for 73%. The European Court of Auditors also observes that water-quality-related measures have not been a priority for BSR countries’ RDPs, despite a total budget of 10 billion euro . Further, they observe a low level of interest among farmers for nutrient abatement, which is explained by the complexity of measures and, as also discussed above, the poor design and lack of payments for land-use measures. Somewhat timely, the post-2020 CAP reform is introducing the obligation for member states to direct substantial funding from income support to dedicated environmental payments in the form of In terms of institutions, legal requirements for improving cross-sectoral coordination by involving environmental authorities in the disbursement schemes of RDPs should be obligatory, and a specific mechanism for linking to BSAP objectives established. This could be achieved by instituting formal coordination of RDPs with the river basin management planning cycle in BSR countries.Despite the Nitrates Directive constituting a ‘statutory management requirement’ for receiving CAP support, the penalties for non-compliance are modest and not in proportion to the damages incurred , while the sheer complexity of penalty schemes causes considerable frustration among farmers. Introducing performance-oriented penalties (see above) would ensure that any imbalances between crop needs and nutrient surpluses would lead to commensurate reductions in support.The EU’s Recommendation 2001/331/EC on environmental inspections is presently a non-binding act that applies to facilities that are subject to authorization under European law, whereby most farming activities are outside its scope. It seems timely to extend it to cover agricultural activities, particularly large livestock facilities, so that plans for inspections and the frequency of site visits are reported to the European Commission . In addiAlthough the requirements of the EU’s Water Framework Directive (WFD) apply only to the coastal waters of the Baltic Sea, its preamble highlights the need for an effective and coherent water policy to take into account the vulnerability of ‘relatively closed seas’. By building on the EU’s legal framework and adapting it to better reflect the circumstances of the Baltic Sea, there exist opportunities for strengthening implementation of water policy. For example under the Marine Strategy Framework Directive, member states can request EU action when good environmental status cannot be achieved through domestic measures alone.Inclusive forms of planning and stakeholder involvement are recognized as being crucial for successful design and implementation of water policy, because it ensures broad representation of local stakeholders, and allows for trust-building and collaboration  should therefore also be eligible for CAP funding and not just farmers. Therefore, a formal coordination mechanism for Rural Development Programmes with river basin planning is recommended.Over and above these top-down recommendations, complementary grass-roots institutions are needed for building trust with the farming community, and allowing for the integration of practice-based knowledge for improving the quality of nutrient management in the Baltic Sea catchment. In particular, we suggest instituting Water Boards, particularly in the eastern BSR countries, with own revenue sources as known elsewhere in Europe. Water Boards can provide multi-actor fora for building acceptance through consultation and decision-making involving the various stakeholders, particularly farmers.Finally, a burgeoning governance challenge is climate change, which is expected to exacerbate nutrient emissions in coming decades Below is the link to the electronic supplementary material.


Patients undergoing haemodialysis report elevated symptoms and reduced health-related quality of life, and often prioritise improvements in psychosocial well-being over long-term survival. Systematic collection and use of patient-reported outcomes (PROs) may help support tailored healthcare and improve outcomes. This study investigates the methodological basis for routine PRO assessment, particularly using electronic formats (ePROs), to maximise the potential of PRO use, through exploration of the experiences, views and perceptions of patients and healthcare professionals (HCPs) on implementation and use of PROs in haemodialysis settings.Qualitative study.Semistructured interviews with 22 patients undergoing haemodialysis, and 17 HCPs in the UK.Transcripts were analysed deductively using the Consolidated Framework for Implementation Research (CFIR) and inductively using thematic analysis.For effective implementation, the potential value of PROs needs to be demonstrated empirically to stakeholders. Any intervention must remain flexible enough for individual and aggregate use, measuring outcomes that matter to patients and clinicians, while maintaining operational simplicity. Any implementation must sit within a wider framework of education and support for both patients and clinicians who demonstrate varying previous experience of using PROs and often confuse related concepts. Implementation plans must recognise the multidimensionality of end-stage kidney disease and treatment by haemodialysis, while acknowledging the associated challenges of delivering care in a highly specialised environment. To support implementation, careful consideration needs to be given to barriers and facilitators including effective leadership, the role of champions, effective launch and ongoing evaluation.Using the CFIR to explore the experiences, views and perceptions of key stakeholders, this study identified key factors at organisational and individual levels which could assist effective implementation of ePROs in haemodialysis settings. Further research will be required to evaluate subsequent ePRO interventions to demonstrate the impact and benefit to the dialysis community. Qualitative methods yield rich data with face-to-face semistructured interviews allowing the interviewer to monitor non-verbal communications and clarify ambiguous responses.This study involved explorations of a prospective intervention, meaning some participants were unfamiliar with key concepts. Preinterview materials were shared to support and inform discussion and participation.The role of the researchers was carefully considered to acknowledge and minimise bias associated with beliefs and values. Steps were taken to mitigate risks, including use of reflective diaries, participant checking and multiple researchers involved in the coding process.While purposive sampling methods led to a diverse sample of participants, it is acknowledged that the sample did not include non-English speakers or carers. Further research is required.Data were collected before the coronavirus pandemic. The healthcare delivery landscape in the UK has changed, and it is possible that some attitudes and beliefs particularly around digital data capture may have evolved.The prevalence of end-stage kidney disease (ESKD) requiring treatment with renal replacement therapies such as haemodialysis (HD) continues to rise worldwide.However, while patient-reported experience measures (PREMs), which allow patients to self-report their experience of receiving healthcare, have been collected since 2017,Yet the international body of evidence exploring the use of PROs in nephrology settings is growing,30In November 2020, an online UK Summit led by the UK Renal Association, entitled ‘ePROs for the Kidney Patient Community’, was held to create a comprehensive, UK-wide roadmap to facilitate and optimise the collection and use of ePROs for the benefit of people with chronic kidney disease (CKD). This summit highlighted the importance of key stakeholder engagement, including patients and front-line clinicians, early and at all stages of design and implementation.31To inform and direct future research plans, this study aimed to investigate the methodological basis for routine PRO assessment through exploration of the experiences, views and perceptions of patients and healthcare professionals (HCPs) on implementation and use of PROs, particularly ePROs, in HD settings.The qualitative research question: ‘What are the experiences, views and perceptions of patients undergoing HD on the implementation and use of ePROs in routine care and research settings?’et alEpistemologically, pragmatism, which is set within a paradigm of enquiry processes and research practicality,Participants included adults (≥18 years), receiving HD (in centre or at home), able to provide valid informed consent and converse in everyday English. Patients were excluded if they were not deemed established on HD or had been undergoing HD <3 months, or if they had an active intercurrent medical problem requiring enhanced routine clinical care.40Data were collected from 22 patients undergoing HD and 17 HCPs in the UK see . All parAll consenting participants took part in an audio-recorded semistructured interview with the lead author, either face to face or by telephone. Ethical approval was gained for follow-up interviews, but none were required. Patient interviews were conducted at the dialysis unit for those dialysing in centre (n=15) and at home for the HHD group (n=7). Since these interviews were conducted in patient homes, family members were sometimes present at the request of the patient, but did not take an active role in the interview. HCPs were interviewed in a private room at their workplace. Topic guides were used to steer and support the interview process see . These g10.1136/bmjopen-2021-052629.supp1Supplementary data10.1136/bmjopen-2021-052629.supp2Supplementary dataUsing codebook thematic analysis,The CFIR is a widely used conceptual framework developed to guide systematic assessment of factors that might influence implementation and effectiveness, including assessing potential barriers and facilitators in preparation for implementing an innovation see .35 47 Pr4910.1136/bmjopen-2021-052629.supp3Supplementary data10.1136/bmjopen-2021-052629.supp4Supplementary dataResearch on the use and implementation of PROs in nephrology settings was prioritised by the local kidney patients charity. An existing patient and public involvement (PPI) group was used and a study-specific PPI group was convened to help develop the research question, design this study and the associated fellowship application. Patients were consulted on the study documentation, including topic guides and example materials see . A summaParticipant characteristics are summarised in The patient sample was broadly representative of prevalent HD population in the UK.50Data saturation was deemed achieved after interviewing 16 HCPs and 15 patients , optimal timing , preferred setting (home or in centre), favoured mode of administration (electronic or paper versions) and interpretation and feedback of the responses.It was clear from the patients that a fixed means of implementing PROs would not meet the requirements of this heterogeneous group. Any system would need to be flexible while maintaining maximum simplicity. Most patients felt they could complete electronic measures if required, but some strongly favoured paper options. Most interviewees stated that self-completion was possible but felt some would need physical or emotional support from carers. A few patients indicated a desire for assistance with information technology (IT) aspects until they became familiar. Several patients alluded to the need to ‘compartmentalise’ their dialysis by conducting all dialysis-related activity in centre or by having discrete facilities and times for dialysis if being treated at home; suggesting that PRO completion would need to be undertaken at defined times/settings within their schedule. Others were less concerned about daily reminders of their disease and management, so were open to completion timings/settings that were more variable.HCPs discussed the promise of electronic capture to support enhanced management of chronic symptoms, but some expressed concerns about potentially missing acute signs and effectiveness of associated safety reporting and actions. Two HHD patients foresaw the potential benefits of automated safety alerts associated with electronic capture. However, one patient noted that it was important that any automated information or self-help advice should not conflict with information given face to face by the doctor.Participants were asked for their perspectives on computer adaptive technology, a type of assessment in which questions are generated specifically for each individual, using item response theory. This was a new concept to nearly all participants, but most quickly grasped the underlying theory after a short explanation and were supportive of the idea, recognising the potential to stop redundant questions and save time. (See There was a general agreement among all participants that it was important to ensure measurement of ‘what outcomes matter most’ to patients.Several patients highlighted problems with continuity of care and lack of cohesion between primary care and their dialysis provision. One HHD patient felt the use of PROs could assist uptake of home therapies by demonstrating better overall outcomes/HRQoL for patients managing their own dialysis. Participants in both groups reflected that PROs could help support shared decision-making by targeting and prioritising discussions according to the patient’s agenda.Discussing potential implementation and how participants perceive the current situation as needing change, patients and staff alike discussed the approaches to care within dialysis settings. Patients clearly described a ‘task orientated’ style of care in centre, with a focus on practically administering HD, versus a more patient-centred model discussed by those dialysing at home. HHD patients dialysing themselves felt they had developed a level of expertise and the increased ‘control’ had improved their HRQoL. They indicated current communication pathways were effective and that the HHD team was responsive and holistic in their approach to care. Analysis of patient and HCP data suggested that time constraints were the major reason for a task-based approach in centre with both patients and staff exhibiting a desire to complete dialysis sessions with as little impediment as possible. Correspondingly, most in-centre patients did not feel staff had time to have long discussions and some suggested PROs might help rectify this. There was no discernible variation in the views of the HHD cohort on the practicalities of PRO collection.HCP data analysis highlighted the importance of education, training and support for successful implementation. It was indicated that while medical staff needed training in PRO interpretation, such as rating scales, nurses might need a broader programme on use of PROs as well as associated chronic disease management. There was disparity indicated in the health literacy of the patient group; some HHD patients appeared expert in their illness and treatment, while some in-centre patients appeared less confident in their knowledge.Patients expressed an overall lack of awareness and experience of PROs. Many had completed annual PREMs but highlighted a lack of feedback or action. Some patients expressed general anxiety about questionnaire completion, linked to their experience of externally administered questionnaires for other agencies: for example, Personal Independence Payment surveys assessing entitlement to extra costs associated with long-term ill health or disability. When reviewing the example PROs, it was noted that some patients, particularly those from minority ethnic backgrounds, flagged the potential difficulty around asking about sensitive issues such as sexual function. While the participants themselves were happy to discuss such issues, they recognised that not all patients might be.All nephrologists interviewed had experience of using PROs in research settings, but none had regularly and systematically collected PROs in routine care. PRO use in any setting was largely a new concept for nursing staff.There was a confusion around the concepts of PROs versus PREMs, expressed by both patients and HCPs. Participants found it hard to distinguish experience of care from outcomes and used terms interchangeably.Many of the patients in the study had multiple comorbidities and associated symptoms, reflective of the wider HD population. Patients indicated that it was often hard to know which symptoms related to their ESKD and/or treatment, and which were associated with other diseases or advancing age; leading to anxiety about what to raise during a consultation. It was suggested that PRO data review and feedback gave a chance to discuss symptoms and potential causes, thereby potentially providing reassurance. However, some clinicians thought it was outside their role to manage non-nephrology-related outcomes presented by PROs and that it would be difficult to disentangle several, possibly unrelated, symptoms. They feared focusing on symptoms that were not currently being experienced or intractable could cause frustration or anxiety for themselves and the patients. Some patients gave a contrasting opinion, revealing the chance to be heard, even without a solution, was often sufficient to maintain the patient–clinician relationship. There was also concern that an over-reliance on PROs could result in a distraction from other important clinical issues.The experience of life on dialysis was highly varied, with some participants exhibiting signs of depression, anger or acceptance, as well as reporting multiple symptoms.The analysis identified leadership, the identification of champions and a ‘bottom up’ approach to communication and shared solutions among both patients and clinicians as key factors supporting implementation. All participants emphasised the importance of support during completion; however, patients highlighted this need not always be delivered by healthcare staff. Peer-to-peer support and non-clinical champions, that is, administrative staff, might assist. HCPs felt a comprehensive launch was important and that individual roles should be clear. They reflected that senior members of the clinical team would be opinion leaders, and any change agents would need to understand the dialysis setting. Evaluation and reflection were important process components to recognise and deal with any unintended consequences.Across all CFIR constructs, analysis identified potential barriers and facilitators to the introduction of PROs.Nephrologists cited a lack of evidence base supporting the use of PROs in routine kidney care and were concerned regarding the risk of overmedicalising the patient experience. There were perceived time barriers for staff, that is, workflow interruptions, additional obligations caused by PROs; with nurses perceiving quality time with patients in centre as limited. HCP participants argued that nursing documentation had lessened available time, as it often required recording on digital devices away from the bedside. They feared patients were being overburdened by questionnaires, particularly the less health literate.In contrast, patients were often already aware of the complications associated with ESKD and HD. Many had achieved a degree of acceptance and some were reassured that the symptoms were expected and not something new to deal with. Frustration would only arise if, having taken time to complete the questionnaires, no action was taken. Both groups agreed that IT issues, that is, inability to log in, no Wi-Fi, could be a barrier.Several HCPs considered how PROs might work to deliver a relative advantage over current systems to support more patient-centred care. Participants felt PROs could be a communication tool—acting like a ‘tin opener’; but requiring that responses be carefully probed, highlighting that this required appropriate skills and training. Others saw the measures as an aide-mémoire which could help target the consultation and even save time; as could the possibility of remote management of care using ePROs. Perhaps, most importantly, PROs were seen by both patients and HCPs as a way to get to know the patients and hence deliver more meaningful care.There is a growing body of published, peer-reviewed literature exploring the experiences of both kidney patients and multidisciplinary kidney HCPs with ePROs.The key findings of this study are that while patients and HCPs support the concept of PROs, further evidence of their potential benefit is required for effective implementation. It emphasises that any system should be flexible and measure what matters most to patients. Most importantly, the data collected should be acted on. There was a general lack of awareness and experience of PROs particularly among patients and nurses, with concern among the HCPs that PRO capture may highlight issues they might have neither the experience nor resources to manage. Therefore, a comprehensive implementation strategy is required to support any delivery, which involves strong leadership, patient and clinician involvement and ongoing training.This study highlighted the importance of getting ‘buy in’, that is, gaining acceptability, from these stakeholders. This could be achieved by demonstrating evidence on their potential benefits thereby increasing trust to warrant practice change. Clinicians particularly questioned whether positive effects on survival, reported QoL, patient–clinician communications and cost efficiencies demonstrated in oncologyet alThe body of evidence around ePROs in nephrology is emerging. Studies from North America demonstrate the feasibility of electronic capture of PROs in HDA review and synthesis of evidence is currently being undertaken to investigate how PROs might work to enhance patient-centred care in renal settings, to offer strategy and guidance at individual and aggregate levels of decision-making.20 22 58However, the purpose of data collection must be clear. Participants in this study confused the concepts of PROs versus PREMs, understandable given that experience of undertaking HD is intricately linked to both HRQoL and symptoms. The integrated use of both measures, side by side, warrants further investigation. Anxieties about purpose and data sharing could affect patient engagement; clear communication of roles and expectations should be undertaken.While guidance exists on what outcomes to measure in researchThe general lack of awareness and experience of PROs and concern that PRO capture may highlight issues that HCPs should not or cannot deal with, leads to a significant finding that PRO implementation must sit within a broader educational framework. PROs could be used to support wider initiatives and training, especially in the nursing group, who can then cascade information and self-management skills to patients, thereby increasing overall patient health literacy. This could be considered as closing an ‘information loop’. There is already evidence that patient education is associated with better patient outcomeset alet alThis study identified time and workflow interruptions as key barriers to implementation. Rotenstein During the SARS-CoV-2 pandemic, data from the UK Renal Registry showed that patients undergoing HD experience a relative risk of mortality of 45.5% compared with the general population.There are limitations to this study. Participants needed to be English speakers; this could affect transferability of findings. Views of carers were not specifically sought but their influence and importance were clearly identified by patients, suggesting further research targeting this group is warranted. Critically, data collection took place before SARS-COV-2 pandemic and experiences and perceptions around digital data capture and new approaches to healthcare delivery may well have shifted.To conclude, the SARs-COV-19 pandemic has caused an irreversible shift in healthcare delivery, with increased use of digital communication and assessment. While the nephrology community, both patients and HCPs, are largely supportive of the concept of ePROs, there remain caveats to their routine and systematic use. Stakeholders need to be convinced by empirical evidence, considering the best available measures and methodological considerations. By exploring the experiences, views and perceptions of major stakeholders, this study identified key factors at organisational and individual levels which would assist effective implementation of ePROs. Further research will then be required to evaluate any subsequent ePRO interventions to empirically demonstrate the impact and benefit of their use to the dialysis community.


Peripheral nerve injuries are a common clinical problem. They not only affect the physical capabilities of the injured person due to loss of motor or sensory function but also have a significant impact on psychosocial aspects of life. The aim of this work is to review the interplay of psychosocial factors and peripheral nerve lesions. By reviewing the published literature, we identified several factors to be heavily influenced by peripheral nerve lesions. In addition to psychological factors like pain, depression, catastrophizing and stress, social factors like employment status and worker’s compensation status could be identified to be influenced by peripheral nerve lesions as well as serving as predictors of functional outcome themselves, respectively. This work sheds a light not only on the impact of peripheral nerve lesions on psychosocial aspects of life, but also on the prognostic values of these factors of functional outcome. Interdisciplinary, individualized treatment of patients is required to identify patient at risk for adverse outcomes and provide them with emotional support when adapting to their new life situation. Peripheral nerve injuries (PNIs) have annual incidence rates in the USA of 43.8/1,000,000 for PNIs of the upper extremities . PNIs ofThe severity of PNIs and postoperative functional outcomes are usually assessed by quantitative biomedical measures and postoperative evaluations of strength, sensory function, and range of motion ,16. HoweTo gather eligible studies, a literature search on PubMed was performed using the search terms “peripheral nerve”; “peripheral nerve injuries”; “psychosocial “and “psychological”. This yielded 95 results. After removal of duplicates, 90 papers remained for eligibility screening. Both original work and review papers were deemed fitting for discussion in this work. After removal of studies and reviews which addressed topics not related to our research questions and further reference screening of eligible work, 30 papers remained to be included in this review. Uvarov was among the first to publish his hypothesis that negative emotions are involved in the pathogenesis of peripheral nervous system disorders in Russian in the year 1971 . Howevern = 25), the other suffering from traumatic PNI of the upper extremity (n = 24). The authors observed that their study cohort of 49 individuals have given up about a fifth of their daily activities prior to their initial surgeon consultation and a significantly greater activity loss was observable in the group with traumatic PNI. Especially high-demand leisure activity such as physical exercise was reduced by almost 50% in the nerve injury group while social activities were reduced to 82%. In the group with compression neuropathies, leisure activities decreased by 30% and social activities were reduced to 87%, respectively. Pain intensity was reported as moderate among the studied patient sample with no significant differences between groups. The overall ratings for physical and psychological qualities of life were under average and almost 40% of the studied patients suffered from signs of depression secondary to the nerve damage. Interestingly, the cut-off for clinical depression was transgressed in the group with traumatic nerve injury only, but this difference was not statistically significant. Correlation analysis revealed a strong association between activity loss on the one hand and higher levels of depression as well lower perceived QoL on the other hand. Higher level of depression did also strongly correlate with lower perceived QoL. More severe pain was moderately associated with higher depression scores but only a weak correlation was found between the former and QoL. Interestingly, no correlation was observable between pain severity and physical QoL following peripheral nerve damage. In summary, more than 60% of the observed variance could be predicted by means of the two factors depression and activity participation, indicating that these two factors could be addressed as potential targets to improve the QoL in patients with upper extremity nerve damage, regardless of its genesis. However, it must be noted that the authors did not assess the manifestation of depression or other psychosocial factors prior to nerve damage, a potential confounder for the observed results [Besides the number of injured nerves, another point to consider in regard to the psychosocial impact is the severity of the respective lesion. In 2009, Bailey et al. aimed to evaluate the relationship between the degree of nerve damage in the upper extremity and psychosocial parameters such as activity participation, perceived quality of life (QoL), pain, and depression. Two individual groups were analyzed, one with compression neuropathies , ulnar nerve (n = 27) or combined lesions (n = 6) at forearm level. The majority of patients (85%) were blue-collar workers and the median educational score equaled a high-school degree. One year after injury, 84.6% of patients had returned to work. Besides the identification of the DASH score, power grip and sensibility of the hand as best prognostic factors, the aforementioned authors found gender, level of education as well as posttraumatic levels of stress at one- and three months post-injury as highly predictive in regard to functional recovery [Hundepool et al. conducted a prospective multicenter study in 61 patients, aiming to identify prognostic factors for functional recovery in the first postoperative year following injuries of the median nerve . The level of anxiety was also correlated with the objective carpal tunnel syndrome severity as assessed by electrophysiological evaluations, but there was no correlation of electrophysiological findings and depression . Straub’Ehretsman and colleagues evaluated subjective healing of nerve donor site morbidity following nerve graft harvest by means of a telephone survey. The authors evaluated possible correlations between satisfaction with donor site morbidity, both in regard to functional and cosmetic factors, and patient factors such as age, gender, involvement of worker’s compensation and/or ongoing litigation. However, no statistically significant correlation with patient factors was observable . AnotherStokvis et al. conducted a literature review aiming to identify possible prognostics factors for insufficient pain relief following neuroma treatment in 2009 . They exIn addition to clinical studies, psychosocial aspects of peripheral nerve injuries have also been studied in preclinical models, e.g., rodents. Using a spared nerve injury (SNI) model Norman et al. tested the hypotheses that peripheral nerve injury is causative for depression by induction of inflammatory processes in the brain and these neuroinflammatory changes are further exacerbated in case of stress exposure prior to nerve injury. The authors found their presumptions to be confirmed as they observed that injury of the common peroneal and tibial nerve caused mechanical allodynia and depressive behavior in mice, as well as an increased expression of interleukin-1b (IL-1b) and glial fibrillary acidic protein (GFAP). The mechanical allodynia was more severe in mice which were exposed to increased stress by chronic physical constraint two weeks prior to the experimental surgery. Treatment of these animals with a corticosteroid synthesis inhibitor prior to physical constraint eliminated the aforementioned effects, proving that psychosocial factors, e.g., the experience of increased stress directly influences the severity of symptoms following peripheral nerve injury . Besides individual psychological factors like depression, social factors have also been identified to play an important role in symptom severity in rats with peripheral nerve injury. Raber and Devor used a neuroma model of neuropathic pain caused by sciatic nerve injury to investigate pain phenotype in two distinct rat strains. When rats with high (HA) and low (LA) pain phenotype and autotomy-behavior, e.g., gnawing of the toes or entire paws in consequence to nerve injury, were housed together, LA rats showed high levels of autotomy even when they were familiar with the HA preoperatively. The observed autotomy in LA rats was also independent of the performance of autotomy by the HA rats. Interestingly, even the contact with cage bedding soiled by HA rats was sufficient to induce moderate levels of autotomy in LA rats even in the absence of HA rats . AnotherIn this work we reviewed the current body of knowledge in regard to the interplay of psychosocial factors and peripheral nerve lesions as well as these factors’ predictive value of functional outcome following peripheral nerve injury. Our work emphasizes that psychological factors like depression, pain-catastrophizing and anxiety are both influenced by peripheral nerve lesions and also significant predictors of functional recovery and QoL after peripheral nerve surgery in patients suffering from PNI. The same applies to social factors, e.g., employment status or worker’s compensation. These findings underpin the need for personalized treatment concepts involving not only surgeons but also psychologists, occupational therapists, and others. As was pointed out by Kaltenbrunner and other authors ,66 therePatients with depression, pain catastrophizing and anxiety are usually at risk to experience poor outcomes following PNI, reporting higher levels of pain and disability as well as lower satisfaction . Vice veIn our opinion, the findings reported by Ehretsman  and MiloAnother interesting finding was the correlation between picking “no comment” when asked about a possible childhood trauma and pain reported at the current and next visit. The same applies to the predictive value of a positive history childhood trauma for next-visit sadness and depression. It has been suggested that this correlation is caused by trauma-induced changes to the brain of abused or traumatized children ,79,80. IAs several studies reviewed in this work have pointed out there are distinct variations regarding the impact of PNIs on psychosocial factors depending on their severity. Patients with distal, single-site compression neuropathies will likely experience fewer negative psychosocial effects that patients with distal traumatic injuries of both the median and ulnar nerve, dual compression neuropathies or TOS. As was emphasized by Wojtkiewicz these findings bear several implications for clinical practice, as patients suffering from the aforementioned conditions should be counseled regarding the impact of such PNIs on their psychosocial and occupational status prior to surgical treatment . The abiWojtkiewicz summarized the evidence gathered in the literature regarding the influence of pain caused by PNIs on patient-reported disability ,88,89,90To summarize our findings, coaching, and providing emotional support to patients suffering from PNI can be effective to help them adapting a positive mindset, overcome severe psychological distress, and eventually adapting to their new situation, even if the functional outcome following surgical treatment is not more than mediocre. It must be emphasized that objective impairment, e.g., severe paresis, or diminished sensibility does not inevitably result in the same level of subjective disability. This observation has been beautifully condensed by Ring who had reconstructed the median nerve in a female nurse following complete iatrogenic laceration: “Credit goes to her (the patient’s) spirit, adaptation and resiliency; not my knife or suture” . Psychosocial factors play an important role in case of PNI. They are not only directly affected by PNI but also have significant predictive value of functional outcome following surgical treatment. Careful psychological assessment can help to identify patients at risk for unsatisfactory functional recovery and persistent disability following surgical treatment. The interplay of psychosocial factors and PNIs should be kept in mind in regard to personalized treatment concepts for these patients.


According to the World Health Organization , 264 milResearchers seeking to understand this prevalence of depression in modern society have identified social media use as a key risk factor , 9. UndeHowever, there are good reasons to suspect that these conclusions are premature or incorrect. For instance, the haste to pass social media a guilty verdict might stem from moral panic brought about by the fear of contemporary technology , where tSeveral lines of reasoning also suggest that the direction of social media causing depression might instead be reversed. The heavy reliance on correlational data severely limits our ability to infer directionality and argue that exposure to social media causes depression , 22. SomConsidering that increased social media use may be an outcome of depressiveness rather than an antecedent, what does the available data show? Here, we critically examine the literature and consider the evidence from longitudinal and experimental studies.reduced psychological distress due to the social opportunities afforded by social networking sites.While longitudinal designs alone do not provide grounds for causal conclusions, they at least allow the temporal ordering of key variables to be determined . SeveralSome recent longitudinal studies have also shown that depressive symptoms may precede escalated social media use. For instance, Heffer et al.  followedA bidirectional relationship may also exist due to a cascading feedback loop whereby depression engenders compensatory social media use, which in turn aggravates depressive symptoms due to unhealthy social comparisons and other detrimental forms of social interaction , 38. RauAlthough longitudinal designs can ascertain temporal ordering, they do not rule out confounding or third variables that may influence or obscure the relationship between depressive symptoms and social media engagement. Meta-analyses of cross-sectional studies on social media use and depression also report small pooled effect sizes , 11, 12,Most if not all experimental studies of this relationship have manipulated social media use to isolate their effects on depression-related outcomes, probably because (1) this is easier to do than the reverse—manipulating participants' depressiveness and observing their social media behavior, and (2) the approach of blaming social media dominates over other theoretical approaches. However, experimental results do not support the view that social media use increases depression-related outcomes. For instance, Hall et al.  manipulaOther experiments suggest that regulated usage rather than complete abstinence may be key to managing the psychological effects of social media. For example, Hunt et al.  demonstrThe modern pervasiveness of social media use has prompted considerable research effort to understand its psychological repercussions. Much of this work is lamentably correlational, but despite the inability to deduce causality from such data, many researchers have proceeded to point at social media for today's increased rates of depression while ignoring the reverse possibility that depressiveness may, in fact, explain increased social media use. As we described, longitudinal and experimental methods that allow us to probe temporality and causality reveal not so much that social media triggers depressive symptoms, but more so that (1) initial levels of depression-related symptoms predict prospective social media use, and (2) social media engagement that is already problematic  exacerbates depression-related outcomes.To achieve a fuller picture of the social media-depression link as well as a better understanding of how to combat depression, research needs to move toward a deeper analysis of the factors underlying problematic social media activity, such as risk factors for depression that lead to unhealthy social media use. Some considerations include the tendency for individuals with certain predispositions  to view social media as a means to reaffirm their self-worth through social comparisons and seeking social validation . More seAlthough emerging research hints at the role of depression in maladaptive social media use, the available data is meager given the lack of studies guided by the reverse causal direction. Aside from broadly calling for more tests of the effects of depressive symptoms on social media use, we also offer several specific suggestions for further research. First, longitudinal studies should go beyond general measures of social media use  and examine more fine-grained, qualitative features of social media participation, such as purposes of use, active vs. passive engagement, and degree of addiction or problematic use, which have exhibited asynchronous associations with depressive symptoms . For insIn conclusion, the current paper argued that the reverse causal view that depressiveness drives social media use has been neglected in current research. By emphasizing the need for longitudinal and experimental approaches to ascertain directionality, a better grasp of the dynamics that govern depressive symptoms and maladaptive social media use can be attained.AH conceptualized the manuscript. AH, FQ, GT, and JY wrote the manuscript and contributed to critical revision of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.