Dental fear is a prevalent problem that can lead to poor dental health. The Kleinknecht’s Dental Fear Survey (DFS) is one of the used scales to assess dental fear. The present study aims to evaluate the psychometric properties of the Lebanese Arabic version of the DFS (DFS-A) and to determine the optimal cut-off to identify dental fear as well as the correlates of dental fear in a group of Lebanese adults dental patients.A cross-sectional study was conducted among a group of 442 dental patients (18–65 years) recruited at 29 dental clinics from March to June 2019. Patients completed a questionnaire including questions about demographic characteristics, previous bad dental experience, trauma’s experience period, the sensation of nausea during dental treatment, the DFS-A scale, the Lebanese Arabic version of the Modified Dental Anxiety Scale (MDAS-A), and a general question about dental fear..DFS-A revealed evidence of adequate psychometric properties. DFS-A scale demonstrated high internal consistency . Test–retest reliability assessment demonstrated strong reproducibility of the DFS-A scale score (ICC = 0.92 with 95% CI (0.83–0.96), p value < 0.0001 (N = 30). Confirmatory factor analysis revealed a three-factor structure of the DFS-A reflecting fear associated with specific dental stimuli and procedures, patterns of dental avoidance and anticipatory anxiety, and physiologic arousal during dental treatment. A significant correlation was found between DFS-A and the MDAS-A indicating a good convergent validity. The optimal cut-off point to identify patients with and without dental fear is 41. Considering this cut-off score, the prevalence of dental fear in our sample was reported at 33.8%. Multivariable analysis showed that having previous scary and painful dental experiences, a sensation of nausea during treatment, and having dental anxiety were identified as predictors of dental fear.The adapted Arabic version of the DFS (DFS-A) is a valid tool to evaluate dental fear among Lebanese adult patients Dental fear is a prevalent condition that affects all populations worldwide . It is dTo diagnose dental fear in clinical settings, it is important to have a valid and reliable diagnostic tool. In response to this need, researchers have developed various specific instruments to evaluate dental fear. One of the most used tool is the Kleinknecht’s Dental Fear Survey (DFS) . DFS wasDFS was initially established in the English language and authors have revealed good psychometric properties supporting its validity and reliability among adults in the USA , 5. Due Cross cultural adaptation through testing Arabic translations of the measuring system in different countries can assign more information about its validity and reliability. So far, no studies have assessed the feasibility of the DFS in the cultural context of the Lebanese population. Thus, the current study aims to test the properties of the DFS Lebanese Arabic version and to identify the optimal cut-off to detect dental fear. In addition we sought to evaluate the factors associated with dental fear in a group of Lebanese adult dental patients.A cross-sectional study was conducted over 4 months extending from March until June 2019 in different dental clinics from all Lebanese districts. Patients aged between 18 and 65 years who were able to read the Arabic language were included in our study. Pregnant women as well as patients with malignant diseases and mental disabilities were excluded. In addition, patients with missing information about DFS-A were excluded from the analysis (9 of 451 eligible patients). Thus, a total sample of 442 adult patients was collected. The study was approved by the Neuroscience Research committee at the medical Lebanese University (Reference number 12/2/2019). The guideline for Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) was followed when reporting this study.Information about the demographic characteristics , previous bad dental experience, trauma’s experience period, perception of a periodontal problem, the sensation of nausea during dental treatment, the Arabic version of the Dental Fear Scale (DFS-A), the Arabic version of the Modified Dental Anxiety Scale (MDAS-A) were collected from the participants. To determine the test–retest reliability of the DFS-A scale, 30 patients were recruited to complete the DFS-A scale twice within 2 weeks. The methodology used in this study is described elsewhere. The questionnaires were distributed to 500 patients, 442 were completed which corresponded to an overall effective response rate of 88.4%.This scale consists of 20 items divided into three components: Avoidance of dental treatment, physiologic reactions to the dental treatment, and fear aroused by different dental procedures . Each quThe translation and Cross-cultural adaptation of the DFS-A, into the Arabic language, was performed according to the five steps proposed by Beaton et al. , after oThe MDAS consists of 5 questions to measure the degree of dental anxiety in 5 situations: preparing for a dental visit, waiting in the dentist’s office for treatment, sitting in the dental chair for drilling, getting ready in the dental chair for scaling, and preparing for local anesthetic injection. Evaluations range from “non-anxious”  to “extrData entry and analyses were performed using the statistical software SPSS version 21.0. Descriptive statistics were reported using means and standard deviations (SD) for continuous variables and frequency with percentages for categorical variables. Floor and ceiling effects were evaluated for the DFS-A total score. These effects were considered to be present if they exceeded 15–20% of patients receiving the minimum or maximum scores . The Cro2) and degrees of freedom (df), Root Mean Square Error of Approximation (RMSEA), and Comparative Fit Index (CFI).The total group was randomly divided into two groups using the randomization function on SPSS 22.0. In the first random-half sub-sample (n = 221), exploratory factor analysis was conducted using the principal components analysis with Varimax rotation. Sampling adequacy was assessed by the Kaiser–Meyer–Olkin (KMO) measure and Bartlett’s test of sphericity. The number of factors retained in the scale was determined based on Eigenvalues greater than 1, and visual inspection of the scree plot. Confirmatory factor analysis (CFA) was performed in the second random-half sub-sample (n = 221) using the Amos software version 22.0. The goodness-of-fit of the models were evaluated using Chi-square  analysis. The best cut-off point was identified by calculating the Youden index (Youden index = sensitivity + specificity − 1). The score at which the Youden index is maximal was considered the best cut-off point. The Pearson chi-square (χ2) test was used for statistical bivariate analysis. Multivariable logistic regression analyses were performed to identify associated factors of dental fear. Adjusted odds ratio and their 95% confidence intervals were reported. The final logistic regression model was reached after ensuring the adequacy of our data using the Hosmer and Lemeshow test. All statistical tests were two-sided, and the significance level was set at 0.05.Convergent validity using Spearman correlation was assessed to evaluate whether the total DFS-A scale was associated with MDAS-A. The discriminant validity of the scale was also assessed by comparing the means of the anxiety group and non-anxiety group using an independent-samples Table The internal consistency of the DFS-A was assessed using Cronbach’s alpha coefficients and composite reliability (CR) coefficients. The DFS-A scale showed high internal consistency with a Cronbach's alpha = 0.93 and a composite reliability of 0.94. The Corrected–item to total correlation coefficients varied from 0.45 to 0.82. Removing an item from the construct did not significantly affect the Cronbach's alpha which ranged between 0.93 and 0.94 . The scree plot of the Eigen values revealed a three-factor structure of the DFS-A scale: the first factor was related to fear of specific stimuli/procedures (item 14–20) and accounted for 25.56% of the scale’s total variance, the second factor was associated with patterns of dental avoidance and anticipatory anxiety and accounted for 22.65% of the scale’s total variance , and the third factor concerned physiological arousal during dental treatment and accounted for 16.22% of the scale’s total variance (items 3–7). The factor loadings for each item are presented in Table The exploratory factor analysis of the DFS-A scale showed a KMO measure of 0.92 indicating adequate sampling adequacy and a highly significant Bartlett’s Test of sphericity  using the Mann–Whitney test. A statistically significant mean rank difference was found between the two groups with higher scores for fearful compared to the non-fearful group  indicating that DFS-A has good discriminant validity. The receiver operating curve (ROC) analysis was also conducted to evaluate the diagnostic validity of the DFS-A scale. The area under the curve (AUC) was 0.9  indicating a good diagnostic accuracy of the DFS-A Fig. . A cut-oOf the total, 33.8% of the participants have reported having dental fear. Overall, previous scary and painful dental experience, a sensation of nausea during dental treatment, and dental anxiety were identified as predictors of dental fear Table .Table 5F.The present study was conducted to evaluate the psychometric properties of the Lebanese Arabic version of the DFS and to identify the factors associated with dental fear. Results showed evidence of good validity and reliability of the scale that can be used to assess dental fear in Arab-speaking individuals. Having previous scary and painful dental experiences, a sensation of nausea during dental treatment, and having dental anxiety were identified as predictors of dental fearThe results showed an adequate level of internal consistency with a Cronbach’s alpha of 0.93 for DFS-A, indicating the homogeneity of the scale items. The internal consistency of the translated versions of the DFS was 0.95 for the Brazilian version , ranged Test–retest reliability of the DFS-A, as assessed by the ICC (0.92) was high reflecting stability over time. This is also concordant with the results of the Oliviera study where the ICC results were 0.882 (95% CI 0.793–0.930) for avoidance, 0.874 (95% CI 0.810–0.917) for physiological arousal, and 0.897 (95% CI 0.829–0.937) for fears of specific stimuli/situations . This vaThe exploratory factor analysis revealed three factor structure of the DFS-A three constructs underlying dental fear namely “fear of specific stimuli/procedures”, “patterns of dental avoidance and anticipatory anxiety” and “physiological arousal during dental treatment” together explaining about 64% of the variance. Studies that inspected the factor structure of the DFS have shown inconclusive results, with some showing best fit for a three-factor structure , 15, 27,The discriminant validity of the DFS-A scale was confirmed using the ROC curve. The cut-off score of > 41 was identified as the best score to differentiate between patients with and without dental fear with a sensitivity of 90% and a specificity of 76%. The Brazilian DFS reported a different cut-off of 53 that met a sensitivity of 88.9% and a specificity of 92.5% . This coHaving previous scary and painful dental experiences, reporting having a sensation of nausea during dental treatment, and having dental anxiety were found to be risk factors for having dental fear. The previous scary and bad dental experiences can not be erased from the memories of a young brain, so attention should be made when treating young patients, since this will influence their behavior in all the upcoming dental appointments. Usually pedodontic dental practitioners are trained to deal with young dental patients and especially difficult patients by prescribing some antihistaminic drugs that alleviate the patient, using nitrous oxide, benzodiazepines and sometimes treating the patient under general anesthesia. Furthermore, nauseated patients have been proved to suffer from dental fear. This could be related to the difficulty in accepting some dental treatments, in the worst cases, all dental treatments, taking intra-oral radiographs and sometimes brushing their teeth. This disturbance while treating their teeth could lead to dental fear and consequently avoiding dental treatment which will worsen their dental health. Anti-emetic drugs can be prescribed to alleviate their nausea, one hour before the appointment. Finally, being anxious about dental treatment can lead to being afraid of dental treatment. In the literature, these two expressions were used interchangeably  althoughGiven that dental fear is an international problem that may lead to avoiding dental treatment, it is important to have a valid and reliable scale to identify patients with dental fear. The DFS-A scale could act as a screening tool to identify these patients thus appropriate strategies could be applied to alleviate their fears. Several methodological limitations can impact the results of this study such as the possibility of selection bias due to the convenience sampling strategy that was applied to recruit patients. It is worth noting that this translated Arabic-language form may not be suitable for other Arabic-speaking communities. The linguistic characteristics of other Arabic-speaking societies may impose some adjustments to the scale.This study was the first to explore the psychometric properties of the Arabic version of the DFS in Lebanon. Results revealed that the DFS-A has good validity and reliability. Therefore, it is considered a useful screening way for assessing dental fear among Lebanese adult patients in clinical settings. For this population, having previous bad scary and painful dental experience, reporting having a sensation of nausea during dental treatment, and diagnosed as having dental anxiety are risk factors for having dental fear.


Extracellular matrix (ECM) synthesis and metabolism abnormalities may influence the pelvic supporting system and lead to the occurrence and development of pelvic organ prolapse (POP). Genetic polymorphisms of such related genes have been increasingly studied. This study aims to explore the association between the single-nucleotide polymorphisms (SNPs) of genes encoding ECM processing enzymes , ECM degrading enzymes  and their tissue inhibitors of metalloproteinase (TIMPs), and POP.We conducted an association study including 48 women with POP at stages III and IV and 48 women without prolapse in Chinese groups. SNPs were identified using the target region sequencing technique. We performed Fisher’s exact tests to assess the association between SNPs and POP in the unadjusted model and logistic regression analysis in the adjusted model, adjusting for delivery and pregnancy.TIMP2 SNP rs2277698 , ADAMTS13 SNP rs149586801 , and ADAMTS1 SNPs rs370850 and rs422803 , rs402007, rs428785, rs434857, and rs445784 , and POP in the adjusted model.There was a significant association between TIMP2, ADAMTS13, and ADAMTS1 might be candidate genes for POP. Our results provide preliminarily new evidence for future investigation of these genes in the pathophysiology of POP.The online version contains supplementary material available at 10.1007/s00192-021-04917-5. Pelvic organ prolapse (POP) is a common pelvic disorder among older women. It is characterized as the downward bulging of uterus, bladder, rectum, etc., urinary and fecal inconvenience, and sexual dysfunction, which negatively affect women’s quality of life and social activities . The preCOL1A1) [COL3A1) [LAMC1) [MMPs) [The etiology of POP is complicated. Race/ethnicity, advancing age, obesity, higher parity, and menopause are known risk factors for POP. In addition, it is well demonstrated that POP has the characteristics of familial aggregation, as the risk of POP in women increases if their mothers or sisters have suffered from the disease, indicating a genetic contribution to POP . PreviouCOL1A1) , 5, coll[COL3A1) , laminin [LAMC1) , and mat) [MMPs) , which aMMP1, 3, and 9 genes, which could alter the expression of these genes and increase the risk of POP [MMP9 SNPs  and found rs17576 to be associated with POP. Wu et al. [MMP9 SNPs in an association study and found two SNPs, rs3918253 and rs3918256, associated with prolapse. Wang et al. [MMP10 SNP rs17435959 was associated with POP in a Chinese group of 91 cases and 172 controls. Besides these limited studies, other MMP members have not been studied in POP.MMPs are a family of multiple catabolic proteases involved in the degradation of collagen fibers and other components of ECM. Several previous studies have identified the existence of polymorphisms in the promoter regions of k of POP –11. Chenk of POP  detectedu et al.  further g et al.  demonstrTIMP2, which has been considered to be involved in connective tissue disorders and vascular diseases.The bioactivity of MMPs is regulated by tissue inhibitors of metalloproteinase (TIMPs), which are also crucial factors of ECM remodeling. Allen-Brady et al.  carried ADAMTSs, known as a disintegrin and metalloproteinase with thrombospondin motif, are a family of proteinases involved in procollagen processing. They can cleave the N-terminal of the peptide chains of procollagen molecules, which are the precursors of mature collagen . Thus, AMMP1, 3, 9, and 10, SNPs from other MMP members, TIMPs, and ADAMTSs would be associated with POP. Using a target region sequencing technique, we (1) confirmed the previous findings on MMPs and (2) investigated the susceptible loci of some of the other MMP, ADAMTS, and TIMP family genes for POP. We believe that these results might offer novel insights into the molecular mechanisms of POP development in Chinese women.As the fine balance between the synthesis and degradation of ECM components is essential to the integrity of the pelvic floor supportive structures, and given the previous limited findings on some of the MMP studies, and also given the fact that there has been no research on the association between the single-nucleotide polymorphisms (SNPs) of TIMPs/ADAMTSs and risks of POP, we have carried out a case-control association study in a group of Chinese women. We supposed that besides This was part of a case-control association study in which we recruited women from Peking Union Medical College Hospital (PUMCH) in Beijing from October 2016 to May 2017. Cases were POP patients diagnosed at Pelvic Organ Prolapse Quantification (POP-Q) stages III and IV from the Department of Gynecology and Obstetrics, and control women were diagnosed with no prolapse and have not suffered from prolapse surgery from the Physical Examination Center. All the participants signed the informed consents, and the study was approved by the Ethics Committee of PUMCH.We excluded women with the well-known connective tissue diseases, including Marfan syndromes, Ehlers-Danlos syndromes, rheumatoid arthritis or scleroderma, and women with neurological diseases including sclerosis or stroke. As the genetic variants vary between different race/ethnic groups, all the samples were limited to Chinese ancestry. Finally, we recruited 48 cases and 48 controls subjected to the next genotyping. Sociodemographic data and physical information were collected as summarized in our previous study .Genome DNA was extracted from the peripheral venous whole-blood samples using a Puregene Blood Kit . The target region sequencing approach was used to achieve a comprehensive assessment of the specific genes; 1–2 μg DNA of each blood sample was sequenced by Agilent Liquid Capture System  at Novogene  based on the Illumina HiSeq 4000 platform to provide a more than 200× deep of sequencing.http://broadinstitute.github.io/picard) were used to sort the files and mark the duplicated reads. Samtools mpileup and bcftools were used to call variants, insertions, and deletions. The SNP quality control included SNPs with read depth > 4, mapping quality > 30, and the variant quality > 20. Variants with a minor allele frequency (MAF) > 5% remained. SNPs were assessed by PolyPhen-2, SIFT, MutationTaster, and CADD software, respectively, for the prediction of their functional effects. ANNOVAR was applied to provide the annotations of the position, type, and conservative prediction of the altered alleles and other information.The valid sequencing data landed in a BAM file by Burrows-Wheeler Aligner (BWA) software based on the reference genome (UCSC hg19). Samtools and Picard . The linkage disequilibrium (LD) graphs indicating r2 between SNPs were drawn by Haploview .Odds ratio (OR) and 95% confidence interval (CI) were shown for each of the variants with OR < 1 indicating a protective effect and OR > 1 indicating a risk effect . P < 0.0P = 0.663) and body mass index (BMI)  between case and control groups. However, the case group had approximately ≥ 1 delivery  and pregnancy  in contrast to the control group. In the case group, 41 women (85.42%) were diagnosed at POP-Q stage III and 7 women (14.58%) were at stage IV as previously described [We have described sample characteristics in our previous study. Briefly, we matched age  and degradation  in Chinese women. These genes are listed in Table P values < 0.1 in the unadjusted model and 16 SNPs with P values < 0.1 in the adjusted model that were considered to be significant or suggestively significant  after the adjustment, which was an intronic SNP. For other MMP members, we have identified two new MMP13 SNPs, rs3758853 and rs78356340, which were intronic SNPs, which showed a suggestively significant association with POP in the adjusted model   and a suggestively significant association with POP in the unadjusted model . TIMP3 SNP rs9862 showed a suggestively significant association with POP in the adjusted model . rs2277698 and rs9862 were synonymous SNPs that did not result in amino acid changes. TIMP4 SNP rs10433537 showed a suggestively significant association with POP in both the unadjusted and adjusted model , which was an intronic SNP . There was also a suggestively significant association between rs1055432 and POP in the adjusted model . rs1055432 was a synonymous SNP that did not lead to the amino acid alteration  in the adjusted model, which was an intronic SNP . They also showed a trend toward significance with POP in the unadjusted model . rs402007, rs428785, rs434857, and rs445784 were respectively significantly associated with POP in the adjusted model . rs402007 was in the 5’UTR region of the ADAMTS1 gene. rs428785 was a missense SNP. rs434857 and rs445784 were synonymous SNPs that did not lead to amino acid changes. There was also a trend toward significance for the SNP rs436525 and POP in the adjusted model . rs436525 was also a synonymous SNPs without amino acid changes (Table ADAMTS1 gene were described. rs436525 was in good LD with six other SNPs (r2 > 0.8), and rs370850, rs422803, rs402007, rs428785, rs434857, and rs445784 were in perfect LD between each other (r2 = 1)  Fig. . The misMMP9 and 10 polymorphisms and further analyzed the association of some other MMP genes, TIMPs, and some ADAMTS genes with risks of POP for the first time. Besides MMP9 and 10, our study provided novel evidence that MMP13, TIMP2, 3, 4, and ADAMTS1, 13, 14 might be possible candidate genes for POP.POP is a common female pelvic disorder due to the decline of the pelvic floor supportive tissues. The imbalance of synthesis and degradation of collagen and other ECM components plays a role in the pathogenesis of POP. Such regulation of ECM stability mainly relied on MMPs, which can cleave collagen, elastin, and proteoglycans, etc., and their inhibitors TIMPs . ADAMTSsMMPs act on ECM breakdown in multiple physiological and pathological processes, including embryonic development, tissue remodeling, wound repair, angiogenesis, inflammatory processes, and tumor progression . AccordiMMP1, 3, and 9 in our target region sequencing approach, we did not verify our data in relation to the previous polymorphisms in the promoter regions of MMP1, 3, and 9. However, we compared our results to the previous MMP9 and 10 studies [MMP9 SNPs, rs3918242, rs17576, and rs2250889, and found that rs17576 G allele was a risk site for POP. The authors recruited 92 POP patients at POP-Q stage ≥ II and 152 control women at stage 0–I of Taiwanese women. Wu et al. [MMP9 SNPs and found rs3918253 and rs3918256 associated with POP in non-Hispanic white women in 239 cases with stages III and IV and 197 controls with stages 0–I. In our study, we did not find the previously reported MMP9 SNPs rs3918253 and rs3918256 by Wu et al. [MMP9 SNPs rs3918242, rs2250889, rs3918278, rs2274755, rs17577, rs2236416, and rs3787268 by Wu et al. and Chen et al., we confirmed that these SNPs also showed no association with POP in our study. Besides validating the previous study, we additionally identified a MMP9 SNP rs3918254 that had a suggestively significant association with POP, which was an intronic SNP. Wang et al. [MMP10 SNP rs17435959 genotype G/C was distributed differentially between 91 women with POP at stage ≥ II and 172 control women at stage 0-I of Chinese ancestry. However, we did not find a significant association in the MMP10 gene in our study. The inconsistency of these studies may partially be attributed to the differences in the recruitment criteria and the characteristics of the women, for example, the race, age, BMI, parity, etc., which were key influencing factors for POP, or in the detection methods.The role of MMPs in the development of POP has been primarily explored in their expression changes as well as their susceptible loci for POP. Previous analysis demonstrated that women with POP showed higher expression levels of MMP1 and MMP8 compared with the control women . The exp studies –14. Chen studies  conducteu et al.  additionu et al.  in signiu et al.  reportedu et al.  and our MMP9 and MMP10, we have sequenced multiple MMP genes and aimed to find the association between these genes and POP. However, we did not observe any positive associations among MMP1, 2, 3, 8, 10, and POP, respectively. Additionally, we have found two new MMP13 SNPs, rs3758853 and rs78356340, which showed borderline significant associations with POP and may have a risk effect for POP.Studies on other MMP polymorphisms have not been conducted in POP. In this study, besides TIMP1, 2, 3, and 4 genes for the first time. We found a significant association between a TIMP2 SNP rs2277698 and POP. Our data suggested that it may show a protective effect for POP development. We also reported a TIMP3 SNP rs9862 and a TIMP4 SNP rs10433537 that had a borderline association with POP, which should be further investigated in future research.There were few studies focusing on TIMP family genes and POP. TIMP2 expression level in the POP group was lower than that in the control group . TIMP3 aADAMTS1 SNPs rs370850, rs422803, rs402007, rs428785, rs434857, and rs445784 and POP, which may be risk factors related to POP, and a significant association between ADAMTS13 SNP rs149586801 and POP, which showed potential protective effects for this disease. We also found three additional SNPs, ADAMTS1 SNP rs436525, ADAMTS13 SNP rs1055432, and ADAMTS14 SNP rs4747097, which have suggestively significant associations with POP. Additionally, ADAMTS1 SNP rs428785 is a missense SNP and can lead to a substitution of alanine to proline, which might exhibit a benign and tolerant effect predicted by PolyPhen-2 and SIFT. Therefore, ADAMTS1, ADAMTS13, and ADAMTS14 could be novel candidate genes for POP, and this needs further validation.The ADAMTS protease family plays crucial roles in ECM remodeling and tissue morphogenesis as well as in inflammation and other physiological and pathological processes . This faMMP9 and 10, but also analyzed the association between MMP1, 2, 3, 8, and 13 and POP for the first time. Additionally, the polymorphisms of TIMP and some ADAMTS family genes have been first studied in POP, suggesting new susceptible SNPs. Third, we focused on unrelated Chinese women from mainland China in this candidate gene association study, choosing extreme symptoms of severe POP with POP-Q stages III and IV, tying to improve the detection of the potential variants.Our study had several strengths. As previous studies were few and focused on certain limited SNPs of a gene, we sequenced several MMP, TIMP, and ADAMTS family genes by target region sequencing technique to assess the entire genes with their coding regions. Second, we not only validated the data of the previously identified SNPs in MMP, TIMP, and ADAMTS polymorphisms for future investigation of the involvement of these candidate genes in the etiology of POP. The genetic contributions to POP remain poorly understood. Additional work needs to be done to provide further validation of POP predisposition variants in a variety of different populations to establish the role of these genes in the pathogenesis of prolapse [However, the main limitation of our study was the small sample size. Since our nationwide epidemiological survey in mainland China found that the prevalence of POP at stages III and IV was 2.04% , this maprolapse .MMP9 and 13, TIMP2, 3, and 4 and ADAMTS1, 13, and 14 genes in Chinese groups, preliminarily revealing the underlying mechanisms for the pathophysiology of this common disease.MMP, TIMP and ADAMTS family genes are crucial for ECM synthesis, modification, and metabolism. In this study, we provide initial evidence that the genetic variants in these genes may have an association with POP. We identified several susceptible SNPs in the Table S1All of the variants with a minor allele frequency of 5% (XLS 66 kb)


NCDN gene encoding Neurochondrin (NCDN), NM_014284.3:c.1206G > A, p.(Trp402*). The variant was associated with a ~ 31% reduction in full-length protein levels in the patient’s brain, suggesting that this mutation leads to NCDN haploinsufficiency. We examined the effects of NCDN haploinsufficiency on FUS and found that depleting primary cortical neurons of NCDN causes a reduction in the total number of FUS-positive cytoplasmic granules. Moreover, we found that these granules were significantly larger and more highly enriched with FUS. We then examined the effects of a loss of FUS function on NCDN in neurons and found that depleting cells of FUS leads to a decrease in NCDN protein and mRNA levels. Our study identifies the NCDN protein as a likely contributor of FTLD-FET pathophysiology. Moreover, we provide evidence for a negative feedback loop of toxicity between NCDN and FUS, where loss of NCDN alters FUS cytoplasmic dynamics, which in turn has an impact on NCDN expression.Frontotemporal dementia (FTD) is a heterogeneous clinical disorder characterized by progressive abnormalities in behavior, executive functions, personality, language and/or motricity. A neuropathological subtype of FTD, frontotemporal lobar degeneration (FTLD)-FET, is characterized by protein aggregates consisting of the RNA-binding protein fused in sarcoma (FUS). The cause of FTLD-FET is not well understood and there is a lack of genetic evidence to aid in the investigation of mechanisms of the disease. The goal of this study was to identify genetic variants contributing to FTLD-FET and to investigate their effects on FUS pathology. We performed whole-exome sequencing on a 50-year-old FTLD patient with ubiquitin and FUS-positive neuronal inclusions and unaffected parents, and identified a de novo postzygotic nonsense variant in the The online version contains supplementary material available at 10.1186/s40478-022-01314-x. Frontotemporal dementia (FTD) is a common form of dementia characterized by a progressive neuronal loss, primarily across the frontal and temporal lobes, leading to changes in executive functions, personality, abnormal behaviors and language impairments , 54. FTDFUS mutations have been identified in FTLD-FET patients or even in cases of ALS-FTLD .FTD shares clinical, genetic and pathogenic features with ALS , 52. ALS–10% ALS , 44, 82.–10% ALS , 44, 82,–10% ALS , 51, 66.nowledge , 80. In NCDN was not associated with any Mendelian disorder. Missense variants were however reported in patients with a neurodevelopmental phenotype with epilepsy. One family exhibited a missense homozygous variant, with unaffected heterozygous parents, while 3 unrelated patients showed missense de novo variants with a more severe phenotype [NCDN function. In addition, although there are no truncating NCDN variant predicted to trigger NMD in variant databases or deletions in controls, a few patients with a developmental disorder were reported with deletions encompassing NCDN and multiple other genes. However, it is unclear (i) whether NCDN plays a role in the developmental phenotype of the latter patients and (ii) whether the same patients as well as recently described patients with missense variants will eventually develop FTLD-FET. Here, the nonsense mutation was detected as a mosaic. We hypothesize that such an NMD-triggering variant, if carried in the germ line, might be lethal during in-utero development, which could explain absence from control databases and absence of association with developmental disorders.Until very recently, henotype . FunctioIn a non-Mendelian manner, NCDN has been implicated in several neurological disorders including epilepsy, depression, schizophrenia and spinal muscular atrophy (SMA) –85, 87. NCDN translation and whether NCDN:FUS:SMN are part of a converging pathway involved in maintaining synaptic homeostasis.NCDN is also linked with SMA, a degenerative muscular disease caused by a reduction in the survival motor neuron (SMN) full-length protein , 76. ThemGluR5−/− neurons [A previous study showed that NCDN interacts with a subset of group 1 mGluRs, including mGluR5, where NCDN has been shown to promote mGluR5 cell surface expression and activation of mGluR5 through a direct interaction with this receptor . mGluR5  neurons . In resp neurons . Under c neurons . In our  neurons , 68, 77, neurons . NCDN variant in a FTLD-FET patient that results in haploinsufficiency of NCDN. We conclude that NCDN has an important function in regulating FUS granule dynamics, and that these changes cause a misregulation of NCDN expression. Based on the common biological functions of both NCDN and FUS, as well as their link with FTLD-FUS and ALS-FUS, there is an intriguing possibility that these proteins are part of a common regulatory pathway for the maintenance of synaptic homeostasis. Taken together, our findings suggest that disruption of this pathway would lead to neuronal defects and neurodegeneration.In summary, we have identified a rare de novoAdditional File 1: Supplementary tables and figures:Table S1. Exome sequencing data or DNA samples from multiple international cases with FTLD-FET. Fig. S1. Validation of secondary antibody specificity for immunocytochemistry studies. Fig. S2. Immunocytochemistry validation of NCDN knock-down in neurons. Fig. S3. Knock-down of FUS in N2a affects NCDN protein and mRNA levels. Fig. S4. Model for NCDN haploinsufficiency and FTD-FET. Supplementary References. Citations for Table S1.


Musculoskeletal ailments affect millions of people around the world and place a high burden on healthcare. Traditional treatment modalities are limited and do not address underlying pathologies. Mesenchymal stem cells (MSCs) have emerged as an exciting therapeutic alternative and Wharton’s jelly-derived mesenchymal stem cells (WJSCs) are some of these. This review reports the clinical and functional outcomes of the applications of WJSCs in orthopedic surgery. A systematic review was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The studies that used culture-expanded, mesenchymal stem or stromal cells, MSCs and/or connective tissues procured from Wharton’s jelly (WJ), from January 2010 to October 2021, were included. Conventional non-operative therapies and placebos were used as comparisons. Six studies that directly discussed WJSCs use in an animal model or the basic scientific testing using an injury model were identified. Five publications studied cartilage injury, three studied degenerative disc disease, one was related to osteoarthritis, and one was related to osteochondral defects. The results of these studies suggested the benefits of WJSCs in the management of these orthopedic pathologies. To adequately assess the safety and efficacy of WJSCs in orthopedic surgery, further randomized controlled clinical studies are necessary. Orthopedic musculoskeletal ailments involve inflammatory and/or degenerative conditions in muscles, tendons, ligaments, nerves, and bones. These conditions are estimated to affect one in four people in developed countries, thus representing a significant burden on healthcare . TraditiThe field of regenerative medicine has undergone a tremendous growth as of late, especially the field of orthopedic surgery . MesenchBMC and adipose-derived stem cells (ADSCs) are clinically available and have a long history of being used with robust clinical data, in comparison to other sources . HoweverWJ is an allogenic tissue comprised of connective tissue located within the umbilical cord. Wharton’s jelly resists torsional and compressive stresses during fetal development levied upon the umbilical vessels. The primitive mesenchymal stem cells reside within the UC-derived WJ . These pWharton’s jelly is easily accessible and available in comparison to autogenic tissues. The UC, and the Wharton’s jelly within it, is an after-birth tissue, and is normally discarded after every birth, presenting ample opportunity for harvest . The easGiven the possible advantages of Wharton’s jelly, the present systematic review evaluated the quality of the published evidence related to the safety and efficacy of WJSCs for orthopedic regenerative applications. The primary goal of this review is to document the clinical and functional outcomes of WJSCs for orthopedic, regenerative medicine applications. The secondary goal of this review is to identify the methodological characteristics associated with the application outcomes.Of the 20 publications describing the use of Wharton’s jelly in regenerative medicine application for orthopedic surgery, only seven directly discussed human WJSCs are undergoing human or animal model testing, or basic scientific testing using an injury model. Five of the publications studied cartilage injury: three related to degenerative disc disease, one related to osteoporotic vertebral compression fractures, one related to osteoarthritis, and one related to osteochondral defect. Han et al. analyzed the effect of Wharton’s jelly cells on degenerative nucleus pulposus cells isolated from a degenerative intervertebral disc. Wharton’s jelly cells were co-cultured in vitro with nucleus pulposus cells for seven days with and without direct cell-to-cell contact. Gene expression was quantified using a polymerase chain reaction (PCR) analysis. Compared to a Wharton’s jelly cell control and a degenerative nucleus pulposus cell control, the expression of type II collagen, aggrecan, and SOX-9 were significantly elevated for Wharton’s jelly and the nucleus pulposus co-culture. The gene expression was at its highest with direct cell-to-cell contact using a ratio of 75:25 Wharton’s jelly cells to nucleus pulposus cells. The polymerase chain reaction gene expression of the co-cultured Wharton’s jelly cells and degenerative nucleus pulposus cells differed from each individual control. Human Wharton’s jelly cells could be induced to differentiate toward nucleus pulposus-like cells when co-cultured with degenerative nucleus pulposus cells .Cheng et al. analyzed the effects of a single injection of Wharton’s jelly-derived cells on acute spinal cord injury in a rat model. At day 28, the L3 transected rats that received the Wharton’s jelly injection exhibited a statistically significant increase in motor function versus the rats that did not receive Wharton’s jelly. The use of transmission electron microscopy in the Wharton’s jelly group demonstrated considerably increased neurofilaments and microtubules at the injury site compared to the rats that did not receive Wharton’s jelly. Additionally, the authors demonstrated an increase in the neural differentiation factor (NGF) expression and a decrease in the inflammatory marker interleukin-1β. Wharton’s jelly cells injected after spinal cord injury in a rat model produced better functional clinical results .6 Wharton’s jelly cells labeled with a viral vector were injected into L6-7. L5-6 was injected with saline, L4-5 served as the injured control, and L3-4 served as the uninjured control. Throughout the experiment, the disc height index and relative gray index were measured via a radiograph and magnetic resonance imaging (MRI), respectively. At 24 weeks, the intervertebral disc injected with Wharton’s jelly cells exhibited a statistically significant slower progression of disc height loss than the injured control and saline injected control. The intervertebral disc injected with Wharton’s jelly cells also exhibited a statistically significant and higher relative gray index than the injured control and saline injected control. At 20 weeks after injection, the discs were removed. Immunohistochemistry confirmed the presence of Wharton’s jelly cells at 20 weeks [Yan Zhang et al. studied the effects of Wharton’s jelly on degenerated nucleus pulposus in a canine model. The degeneration of L4-5, L5-6, and L6-7 were induced. Intervertebral discs were exposed through an anterolateral approach, and 14.5 ± 2.7 mg of nucleus pulposus was aspirated from each disc. Four weeks after the procedure, 10Shim et al. presented the results of a randomized, open-label, phase I/IIa study examining the safety and effectiveness of managing osteoporotic vertebral compression fractures with WJSCs and teriparatide. Twenty subjects were followed for 12 months. All subjects received a daily subcutaneous injection of 20 mg teriparatide and 20 mg oral bazedoxifene daily for 6 months. The subjects in the experimental group underwent an injection of WJSCs intramedullarily on day 0 and intraveniously on day 7. Three subjects from the control group dropped out because of an adverse reaction to teriparatide. Four subjects in the experimental group experienced an adverse event. Three patients chose to drop out of the study: one secondary to a urinary tract infection shortly after WJSC injection, another secondary to a pulmonary embolus discovered 30 days after WJSC injection on chest CT, and the third secondary to a diagnosis of pancreatic cancer discovered on CT. The clinical outcome scores exhibited statistically significant improvements in VAS, ODI, and SF-36 after 12 months versus the baseline. The pain score in the VAS, as well as the ODI and SF-36 scores, for the experimental group were statistically significant when compared to the control group at 12 months. Bone turnover markers measured did not demonstrate a statistical significance between the control and experimental groups. Bone mineral density improved significantly for both the control and experimental groups, but there was no statistically significant difference between the two groups. CT analysis demonstrated an improved microarchitecture for the experimental group compared to the control group at 12 months .Shalaby et al. examined the effect of Wharton’s jelly cells added to a nerve conduit on the functional recovery of a 10 mm sciatic nerve deficit. At 12 weeks, the Functional Recovery Index was −5.2 ± 2.1 in the uninjured control group, −55.3 ± 12.3 in the injured control group, −23.8 ± 5.6 in the injured group treated with nerve conduit alone, and −9.8 ± 2.5 in the injured group treated with nerve conduit and Wharton’s jelly cells. There was a greater significant improvement in the Wharton’s jelly group. For the pin prick-functional analysis, there was a statistically significant improvement in the treated groups, but no significance for the nerve conduit group and the group treated with Wharton’s jelly. Histologic analysis of the surgically treated nerve exhibited more normally appearing nerve fibers and axons with thin a myelin sheath than nerve conduit and control groups. The real-time PCR showed a significant increase in innetrin-1, ninjurin, the glial cell-line-derived neurotrophic factor (GDNF), the brain-derived neurotrophic factor (BDNF), the vascular endothelin growth factor (VEGF), and angiopoitin-1 gene expression versus the other three groups .Sofia et al. conducted a basic science study observing the matrix metalloproteinase-13 (MMP-13) gene expression of synoviocytes isolated prior to a total knee arthroplasty versus those cells combined with Wharton’s jelly cells. This study analyzed the gene expression of two pro-inflammatory markers: MMP-13 and RELA. The addition of Wharton’s jelly to synoviocytes isolated from human knees with grade IV osteoarthritis reduced the expression of MMP-13 and RELA. The findings were statistically significant compared to the synoviocyte control .Zhang and colleagues seeded Wharton’s jelly cells to an acellular cartilage extracellular matrix scaffold. The seeded scaffold was then tested against a microfracture for the restoration of a 6.5 mm diameter, femoral condyle osteochondral defect in a caprine model. At nine months, the Wharton’s jelly group demonstrated more abundant glycosaminoglycans and type II collagen with highly organized fibers compared to that of the microfracture group. The modulus of elasticity was 2.9 ± 9 MPa for the Wharton’s jelly group compared to 2.2 ± 5 MPa for the microfracture group. An MRI analysis of the treated osteochondral defect demonstrated an appearance that was similar to the native articular cartilage than the microfracture group. Of note, two knees of goats from the microfracture group were deemed to have a meniscus tear at the time of euthanasia .The Wharton’s jelly extracellular matrix is partly comprised of glycosaminoglycans and collagen, similar to cartilage ,30,31. TThe present study evaluated the quality of published evidence regarding the safety and efficacy of WJSCs for orthopedic regenerative medicine applications. To date, there is only one scientific publication in the literature using culture-expanded WJSCs for orthopedic applications in clinical practice. Shim et al. presented the results from a randomized, open-label, phase I/IIa study examining the safety and effectiveness of managing osteoporotic vertebral compression fractures with WJSCs and teriparatide. The study reported a statistically significant improvement in the pain and functional scores for the experimental group compared to the control. The bone mineral density and bone turnover markers did not significantly differ from the control and experimental subjects. Of note, that study included a large percentage of participants who did not complete the 12-month trial. More clinical research must be completed to determine the safety and efficacy of WJSCs in a human compression fracture model.7 WJSCs for moderate hip, knee or glenohumeral osteoarthritis. One hundred subjects will receive an injection of WJSCs every three months for one year. The subjects will be followed throughout the study and 24 months post-administration of last injection, studying clinical responses, inflammatory markers, and magnetic resonance imaging. The clinical trial is still in the recruitment phase [There is another current phase I/II clinical trial at the Medical University of Warsaw evaluating the efficacy of an intra-articular injection of 10nt phase .Aging negatively affects stem cells. This makes stem cells cultured from the umbilical cord or placenta advantageous over stem cells cultured from adipose tissue, bone marrow, or other autogenic adult cell sources. Birth-derived products have shown potential for use in the orthopedic sector. Multiple companies now have a flowable placental allograft formulation that is under consideration for approval by the US FDA as Human Cells, Tissues, and Cellular and Tissue-Based Products (HCT/P’s) for eventual clinical use. While there is growing interest from companies, consumers, and healthcare providers, a lack of insurance reimbursement and limited safety and efficacy studies limit the development and use of these products. Additionally, to our knowledge the current commercial products on the market do not offer living cells .Similar to placental tissue, Wharton’s jelly is obtained after birth. This alleviates the controversial aspects of harvesting embryonic cells. Unique to WJSCs, the process used to extract WJSCs can be performed without the use of digestive enzymes, cryoprotectants, or the in vitro expansion of cells . All revIn the study by Yan Zhang et al., human Wharton’s jelly-derived cells were injected into the intervertebral disc in a canine model. Immunohistochemistry confirmed the presence of Wharton’s jelly cells at 20 weeks . SimilarThe methodology of this systematic review followed the protocol that was previously published and registered on the international prospective register of systematic reviews (PROSPERO), registration number CRD42020182487 . The varThe literature describing the use of WJSCs for musculoskeletal regenerative medicine is limited. However, the safety profile and the effectiveness in managing musculoskeletal ailments described in this review are encouraging. The benefits of WJSCs for cartilage restoration seem to be the most promising, given the similarities between chondrocytes and Wharton’s jelly cells and the cellular matrix of cartilage and Wharton’s jelly. Further well-designed and appropriately powered, prospective, non-randomized and randomized studies evaluating the safety and efficacy of WJSCs in a human model are warranted to justify their clinical use.


Patients’ spontaneous speech can act as a biomarker for identifying pathological entities, such as mental illness. Despite this potential, audio recording patients’ spontaneous speech is not part of clinical workflows, and health care organizations often do not have dedicated policies regarding the audio recording of clinical encounters. No previous studies have investigated the best practical approach for integrating audio recording of patient-clinician encounters into clinical workflows, particularly in the home health care (HHC) setting.This study aimed to evaluate the functionality and usability of several audio-recording devices for the audio recording of patient-nurse verbal communications in the HHC settings and elicit HHC stakeholder (patients and nurses) perspectives about the facilitators of and barriers to integrating audio recordings into clinical workflows.This study was conducted at a large urban HHC agency located in New York, United States. We evaluated the usability and functionality of 7 audio-recording devices in a laboratory (controlled) setting. A total of 3 devices—Saramonic Blink500, Sony ICD-TX6, and Black Vox 365—were further evaluated in a clinical setting (patients’ homes) by HHC nurses who completed the System Usability Scale questionnaire and participated in a short, structured interview to elicit feedback about each device. We also evaluated the accuracy of the automatic transcription of audio-recorded encounters for the 3 devices using the Amazon Web Service Transcribe. Word error rate was used to measure the accuracy of automated speech transcription. To understand the facilitators of and barriers to integrating audio recording of encounters into clinical workflows, we conducted semistructured interviews with 3 HHC nurses and 10 HHC patients. Thematic analysis was used to analyze the transcribed interviews.Saramonic Blink500 received the best overall evaluation score. The System Usability Scale score and word error rate for Saramonic Blink500 were 65% and 26%, respectively, and nurses found it easier to approach patients using this device than with the other 2 devices. Overall, patients found the process of audio recording to be satisfactory and convenient, with minimal impact on their communication with nurses. Although, in general, nurses also found the process easy to learn and satisfactory, they suggested that the audio recording of HHC encounters can affect their communication patterns. In addition, nurses were not aware of the potential to use audio-recorded encounters to improve health care services. Nurses also indicated that they would need to involve their managers to determine how audio recordings could be integrated into their clinical workflows and for any ongoing use of audio recordings during patient care management.This study established the feasibility of audio recording HHC patient-nurse encounters. Training HHC nurses about the importance of the audio-recording process and the support of clinical managers are essential factors for successful implementation. Patients’ spoken language provides a window into a wide range of pathological entities, including pulmonary hypertension , respiraDespite the promising findings of these studies, the audio recording of patients’ spontaneous speech is not a part of routine clinical workflows. Most studies on patients’ speech were cross-sectional and conducted in laboratory (controlled) settings, where patients were instructed to follow specific diagnostic and screening tests  without having any interaction with clinicians -8. TheseHealth care stakeholders’ perspectives toward audio recording patient-clinician verbal communication have been discussed in previous studies. A recent study that investigated policies for audio recording patient-clinician encounters in the 49 largest health care systems in the United States found that despite physicians’ willingness to audio record patient-clinician encounters, none of the health care systems had a dedicated policy or guidance for integrating audio recordings of patient-clinician encounters into clinical workflow  exploredThere is a growing consensus on the usability of home health care (HHC) technology as a significant factor affecting the use of technology in the HHC settings. HHC is a health care setting where services are provided by skilled practitioners (often registered nurses) to patients in their homes . HHC patAlthough some studies have reported on audio recording of clinical encounters mainly for patients’ personal use  ,18, few To address the gaps in the literature, this study aimed to (1) evaluate the functionality and usability of several audio-recording devices for audio recording patient-nurse verbal communication in the HHC setting and (2) elicit the perspectives of HHC stakeholders (patients and nurses) about the facilitators of and barriers to integrating audio recording into clinical workflows.This descriptive feasibility study was conducted at the largest not-for-profit home health agency in the United States. The agency has approximately 10,600 staff, including 1470 nurses and >6500 home health aides. In 2019, the agency served >106,000 unique patients across >1.08 million clinical visits. A summary of patients’ demographic information in 2019 showed that most of the Visiting Nurse Service of New York (VNSNY) patients were aged >65 years, predominantly women , and almost half were African American or Hispanic . This study was approved by the Visiting Nurse Service of New York Institutional Review Board (reference #E20-003).In the first phase of the study, we created a list of criteria for selecting the audio-recording devices. The criteria included the portability of the device, wearable features, functionality of the device (memory size and battery life), and voice activation features. We reviewed the features of >50 audio-recording devices from different web-based sellers, such as Amazon, BestBuy, and SpyCenter. We selected 7 devices that met the criteria for the audio-recording device for the study. We evaluated the 7 devices for audio recording HHC patient-nurse verbal communication. All the devices were portable, with relatively simple operation, and could be used easily for recording verbal communication without disrupting the participants’ movements during communication. The devices used were Black Vox 365, SOTA Surveillance-USR500, INSTAMIC PRO, Sony ICD-TX6, Mini Wristband Voice Activated Recorder, Apple Watch, and Saramonic Blink500 Pro B2. Transcription Accuracy section for evaluation metrics of automated voice activation features). The SOTA Surveillance-USR500, INSTAMIC PRO, Mini Wristband Voice Activated Recorder, and Apple Watch were excluded from further evaluation in the clinical settings because of their low battery life; low memory capacity; no indicators for recording (on or off), battery, and memory status; and low accuracy of automatic transcription of recorded communications. A total of 3 recorders, Black Vox 365 (further referred to as Vox), Sony ICD-TX6 (further referred to as Sony), and Saramonic Blink500 Pro B2 Pro (further referred to as Saramonic), were included for further exploration in HHC because of the relatively high accuracy of automatic transcription, easy operation, good battery life, and memory capacity.In the first phase of evaluation, 2 study investigators (MZ and SV) used the 7 devices to audio record verbal communications between themselves in a controlled environment, which resembled the verbal communication between patients and nurses in HHC settings. The investigators evaluated the devices using 8 criteria: memory size; battery life; indicators for memory size, battery life, or recording status; automated voice activation feature; ease of device attachment to clothing; and accuracy of automatic transcription of recorded verbal communications as an indicator of voice quality , which can facilitate the process of separating the patient’s voice from the nurse’s voice for analysis purposes. By contrast, Sony and Vox embedded microphones with single-channel features. In contrast with Vox, Sony and Saramonic could be easily attached to the patients’ and nurses’ clothes and included indicators for recording status (on or off). Vox had a voice activation feature that was not available in Saramonic and Sony.Next, we collaborated with 2 HHC nurses who used the 3 selected devices to audio record their verbal communication with patients during HHC encounters. With HHC organizational support of the study and after institutional review board approval, we approached nurses through email and advertising at the VNSNY site. Interested nurses provided written consent. The consent form included information about the aim of the study and its potential risks and benefits. A research assistant (RA) trained the nurses to use the audio-recording devices.Several different strategies were used to engage patient participants. The first strategy involved nurses providing flyers to patients with a brief description of the study. Nurses provided the RA with the name and contact information of patients who expressed interest. The second strategy was that after a waiver of authorization was granted, the RA reviewed the nurse’s schedule in the EHR to identify patients on the nurse’s caseload. The RA contacted the potential patient participants by phone and described the study’s aim, potential risks, and benefits. For those who provided verbal consent, the RA mailed the consent form to the patients for their reference. Both nurse and patient participants received a gift card as a token of appreciation.The participating nurses audio recorded their routine HHC encounters with consented patients. Audio-recorded encounters were uploaded to a secure server. Nurses also completed the System Usability Scale (SUS) questionnaires  for eachThe quality of audio-recorded communications affects the transcription accuracy of a specific automatic speech recognition system such as the Amazon Web Service General Transcribe System (AWS-GTS) . For exaWe evaluated 2 components of transcription quality, word error rate (WER) and speaker identification accuracy, using the steps described in Step 1For each device , we randomly selected 3 audio-recorded home health care encounters.Step 2One of the investigators transcribed the audio files manually and assigned each utterance  to an appropriate speaker (patient or nurse). Manual transcription was reviewed by a second investigator to ensure the quality of the transcription.Step 3All audio files were transcribed using the Amazon Web Service General Transcribe System application programming interface. The application programming interface returns the transcriptions as JSON files, including the start and end times of each transcribed word and the assigned speaker  to each word. The transcribed words were joined to form an utterance using the type of speaker and converted to a Microsoft Excel sheet. We define an “utterance” as a continuous block of the uninterrupted speech of a single speaker.Step 4The quality of automatic transcriptions at the utterance level was compared with manual transcription and measured using the word error rate (WER). WER is a common metric for measuring the performance of speech recognition systems. It is computed based on the number of substitutions, insertions, and deletions that occur in a sequence of recognized words using a speech recognition system. The WER score starts from 0 (indicating no error in transcription) and can reach any score >1 depending on the length (number of words) in the utterance or document. For comparison, the average WER for human transcriptions is 0.04 (4%). Our earlier preliminary study for measuring the quality of transcription of an open-source automatic speech recognition system, Wav2Vec, on a subset of audio-recorded patient-nurse encounters provided a WER of 0.98 (98%). Wav2Vec is an unsupervised pretraining for speech recognition that learns representations of raw audio and was developed by the Facebook Company .Second, we used the speaker identification feature of AWS-GTS to measure the accuracy of the automatic transcription of audio-recorded patient-nurse verbal communication by the devices. We expected that multiple-channel audio-recording devices  would provide higher accuracy for speaker identification than that provided by single-channel devices . To measure the accuracy of speaker identification, we used the following steps:Step 1: All manually transcribed audio files with assigned speakers at the utterance level (patient or nurse) were tokenized into words, and each word was linked to the assigned speaker.Step 2: The words of each manually transcribed utterance were mapped to the corresponding utterances and words provided by AWS-GTS.Step 3: We computed the percentage of words with accurate speaker identification with references to the total number of transcribed words in each audio file.To understand the facilitators and barriers to the integration of audio recording of patient-nurse encounters into the clinical workflow, we conducted semistructured interviews with patients and nurses. The questions for nurses mainly covered their experience, concerns , potential benefits of recording (for both patients and clinicians), and their overall attitude toward the integration of audio-recording processing into HHC clinical workflows. The questions for patients covered their motivation to participate in the study, their concerns, and their attitudes toward audio recording their conversations with nurses. All the research questions were reviewed and discussed by the research team, 2 nurses with expertise in HHC services, a patient representative , and 2 health informaticians. The study team ensured that the topics of the semistructured interviews would lead to the discovery of major facilitators and barriers to the development of a practical approach for audio recording patient-nurse encounters in a clinical setting. The questions for the semistructured interviews are presented in A total of 5 nurses audio recorded their communication with patients. However, during the study period, 40% (2/5) of nurses left the participating agency and were therefore not available to participate in the interviews. The nurses participated in audio-recorded encounters with 45 patients in this ongoing study. After securing additional consent, we conducted interviews with the remaining 60% (3/5) of nurses.To reduce the likelihood of selection bias in creating a sample of HHC patients for the interviews, we used a stratified sampling technique. Using this technique, we stratified the pool of patients who participated in the audio recording of patient-nurse verbal communication (45 patients) based on the study nurse who recorded the encounter. Next, from each group of patients, the RA randomly contacted 2 patients for interviews. If the patient agreed to participate, the RA consented the patient for the study. This process was repeated until data saturation was achieved by interviewing a sample of 22% (10/45) of HHC patients.To address the patient’s potential concern about privacy and confidentiality of the information collected during the interviews and ensure that the patient expressed their unbiased perspectives, our RA consented the patients by explaining our commitment and strategies to protect the patients’ privacy and confidentiality. In addition, patients were informed that they could withdraw from the study  without any consequences and had the freedom not to answer any questions.In addition, our RA, who conducted the interviews, was well trained for effective communication  with VNSNY’s patient population and had extensive experience in interviewing HHC patients for different qualitative studies. Gift cards were offered to both nurses and patients for participating in the qualitative interviews.The team created an initial codebook to summarize the open-ended interviews. Next, we used a thematic analysis approach for the systematic coding of the interviews. Thematic analysis is a qualitative descriptive approach for identifying, analyzing, and reporting themes within data -25. The Sony had the highest SUS score compared with Vox and Saramonic. Although the Saramonic device had a slightly lower SUS score than the SUS score of the Sony device, nurses found Saramonic easier in terms of approaching HHC patients for permission to audio record the verbal communication because of the appearance of the device and flexibility in attaching the microphone to the patient’s clothes. In addition, the quality of audio-recorded communication using Saramonic was higher than that of the other 2 devices when measured using the WER of automatic transcription and accuracy of speaker identification provided by AWS-GTS. As expected, the desirable usability feature of Vox was automatic voice-activated recording. However, this feature might compromise the patient’s or nurse’s privacy if the nurse forgets to pick up the device from the patient’s home or if the nurse forgets to turn off the device, which in turn would start recording unrelated conversations. This feature was not available for Sony or Saramonic. Overall, we found that Saramonic is the most appropriate device for recording patient-nurse encounters with the highest SUS score and accuracy of speaker identification, as shown in We investigated the perspectives of HHC stakeholders (patients and nurses) toward integrating the audio-recording of patient-nurse verbal communications into the clinical workflow. This study is the first to develop a practical approach for audio recording HHC patient-nurse verbal communication and evaluate the feasibility of integrating this approach into the clinical workflow. We showed that the type of recording device can have a differential effect on the accuracy of downstream tasks built on audio-recorded patient-nurse encounters, such as automatic transcription and provided speaker identification. In addition, our results suggest that HHC stakeholders’ attitudes toward the recording process are a crucial factor affecting the successful integration of the audio recording of patient-nurse verbal communications into the clinical workflow.Selecting an appropriate recording device is of great importance to designing and implementing an effective approach for audio recording clinical encounters in HHC settings. Some devices are lightweight, can be easily attached to the participants’ clothes, and have a very simple operation mechanism with one on or off button. However, these devices often have functionality issues, such as short battery life or limited memory size, which reduce their usability by increasing the number of clinicians or administrative staff. The INSTAMIC PRO device is an example of such a device with high ease of use but low functionality because of its small memory capacity. In contrast, some devices are easy to use with good functionality; however, because of their size or weight, they cannot be easily attached to a patient’s or clinician’s clothes. Vox is an example of a device that needs to be set on a flat surface  during the process of recording. Although this solution is practical for recording patient-clinician encounters where no movement is required during communication, it is not an appropriate solution in HHC settings where there is a constant required movement of the patient or nurse for physical examination or treatment. The patient’s or nurse’s movement will change their position with reference to the device location and, therefore, would affect the quality of audio-recorded communication, in turn affecting downstream tasks built on the audio data .In addition, the quality of the audio-recorded communication by devices substantially affects the quality of automatic transcription and speaker identification provided by an automatic speech recognition system. This is particularly important when the goal of the study is to develop an automatic analytic pipeline for processing and modeling patient-nurse verbal communication to develop a risk identification or diagnostic algorithm . Regarding the possibility of background noise in HHC settings, which comes from different sources such as television, air conditioner, or a caregiver’s speaking, it is important to set the microphone as close to the patient’s and nurse’s mouths to reduce the possibility of background noise captured by the device’s microphone. An option for reducing background noise is to use a unidirectional (cardioid) overhead microphone; however, as this study was conducted during the COVID-19 pandemic and the study participants were recognized as being at high risk for COVID-19, we avoided any devices that touched the patient’s face. Unidirectional microphones pick up audio  from only the front compared with omnidirectional microphones that pick up audio from all directions. Another reason that convinced us not to use overhead microphones was the risk of patient discomfort during the recording procedure when the microphone touches the patient’s face.Another important feature of audio-recording devices is the number of channels with the ability to separate audio tracks for each individual participating in the communication. Devices with this type of feature usually have multiple microphones that are used by several individual speakers. The voice captured by each microphone is transmitted to an individual channel. This feature is important for downstream tasks, especially the differentiation of the patient’s voice from the nurse’s voice. Among all the devices evaluated in this study, the Saramonic device was the only device that included this feature; consequently, it had a higher score for speaker identification when it was measured using AWS-GTS. Overall, because of the better quality of automatic transcription and speaker identification (measured using AWS-GTS) of verbal communications recorded by this device and the high score for usability, we selected this device for audio recording further encounters beyond the pilot assessment.Understanding HHC patients’ and nurses’ perspectives toward audio recording is a key determinant of the successful integration of the audio recording of patient-nurse verbal communication into the HHC clinical workflow. Overall, patients found the process of audio recording to be satisfactory and convenient, with minimal impact on their communication with nurses. Patients expressed that they were able to freely share their concerns and health care issues with nurses, and they even forgot about the presence of audio devices soon after the visit started. This expression implies that the Hawthorne effect on patients’ communication patterns with nurses was minimal. It also shows the practicality of the recording procedure designed for this study.The Hawthorne effect refers to a study participant’s reactivity, in which the participant changes an aspect of their behavior in response to their awareness of being observed by the study’s investigator . At the formal rather than personal. Therefore, we may conclude that the presence of a recording device can introduce a Hawthorne effect on nurses’ communication with patients. Nurses expressed concern about sharing audio-recorded encounters with supervisors for evaluation purposes. Owing to this concern, we experienced difficulties in recruiting nurses to audio record their communication with patients; however, after educating nurses about protecting their privacy and confidentiality, 5 nurses agreed to participate in the study. Nurses were not very optimistic about the usability of integrating audio recording in clinical workflows as they perceived limited benefits in audio recording the HHC encounters. This is contrary to the findings of numerous studies [Similar to patients, nurses found the audio-recording procedure satisfactory and easy to learn. However, in contrast to patients, nurses expressed that audio recording of HHC encounters can affect their practice and communication patterns in the HHC settings. Some nurses suggested that their communication with patients might become more  studies -8 showinThe findings of this study should be considered in light of several limitations. First, although the audio-recording devices selected for this study included a wide range of useful and convenient features for audio recording HHC patient-nurse encounters, they may not represent all features of existing devices in the market. For example, future studies may investigate the usability and functionality of Amazon Alexa (a device that was developed by the Amazon company) for audio recording patient-nurse encounters, the possibility of connecting to a secure server for storing the audio-recorded data, and the potential risks to patient privacy and confidentiality. Second, we quantified the quality of audio-recorded communication by measuring the accuracy of the automated transcription provided by AWS-GTS. Although the quality of audio-recorded data is correlated with the accuracy of automated transcription, it may not provide comprehensive insights into the quality of audio recorded by a device. Future studies may investigate other measures such as the sensitivity of the device for filtering background noise in noisy clinical settings to better evaluate the quality of the audio-recorded voice by the device. Third, as this study was conducted during the COVID-19 pandemic, recruitment and retention of HHC nurses were challenging. This was mostly because of nurses’ heavy workload, and precautions needed to be taken to reduce the risk of COVID-19 transmission in the HHC setting. In addition, because of the COVID-19 pandemic, it was challenging for the research team to reach out to all nurses with a potential interest in participating in this study. Overall, we were able to recruit 5 nurses for the study of audio recording patient-nurse verbal communication conducted at VNSNY. Of the 5 nurses, 2 (40%) nurses left the VNSNY during the study. Hence, unfortunately, we could not reach the 2 nurses to solicit their perspectives. Although a sample size of 3 nurses may not provide sufficient data to achieve data saturation, the 3 nurses who participated in the interviews had extensive experience in HHC services, HHC workflow, and working with a racially diverse patient population in VNSNY. Therefore, they were able to provide a valuable evaluation of the facilitators and barriers to the pipeline designed for audio recording and its integration into the HHC workflow. Aggregation of the 3 nurses’ perspectives sheds light on the facilitators and barriers to a large extent and was very informative for HHC managers and policy makers. For example, the manager of the VNSNY research center informed us that they were willing to address some of the barriers  to encourage more HHC nurses to participate in similar studies in the future. Currently, we are actively recruiting more nurses for this study, which will enable us to provide a better picture of nurses’ opinions toward this process in our future report. Fourth, the racially diverse sample size of patients  who participated in this study was achieved through an iterative process and data saturation of thematic analysis of interview findings, which represents the patient population at the study agency to a large extent. However, the findings regarding patients’ opinions may not provide a deep insight into the attitudes of ethnic minority patients or those with complex clinical conditions. Finally, this study was conducted at one agency, the largest HHC organization in the United States. However, there might be differences in the types of health care services, communication, and practice patterns across HHC. Therefore, the overall findings of this study may not be representative of all HHC settings.To develop an effective practical approach for integrating audio recording of patient-nurse verbal communication in HHC settings, it is essential to select an audio-recording device with high functionality and usability. Training nurses and clinical managers on the importance of audio-recorded verbal communication can encourage them to support the process of integration.In addition, training can reduce the potential concerns of nurses about protecting their privacy and confidentiality during the recording process.


The simulation results revealed that 59% of the catchment does not contain or benefit from flood-mitigating land cover features. Adding 0.6 km2 (4% of the catchment) of green roofs alongside major stormwater flow paths resulted in a nearly three-fold decrease (11%) in the unmitigated flooding area. These results suggest that green roofs could help manage stormwater and mitigate flooding in the densely built areas of the catchment. Using ecosystem service assessment tools, like Nature Braid, can inform the design of more regenerative and resilient urban green infrastructure networks that help mitigate climate change impacts on urban residents.Many cities are vulnerable to flooding due to their high proportion of impervious surfaces and lack of vegetated land cover. This vulnerability will often be exacerbated by changing rainfall and storm patterns due to climate change. Using the principles of urban biomimicry, this study aims to show an ecosystem service-based approach to designing an urban green infrastructure network for stormwater management in densely built areas that more closely emulates natural hydrology processes. Nature Braid (next-generation LUCI) is an ecosystem services assessment tool that was used to simulate flood mitigation ecosystem services in a 13.7 km As population growth and urbanisation drive the expansion of urban environments ,2, the pHabitat provides the foundational abiotic and biotic resources, such as soil and plants, that support flood mitigation ecosystem services, such as rainfall absorption, evapotranspiration, and disturbance prevention . TypicalSpatial multi-criteria analyses, such as the ones conducted by Venter et al.  and LangPredicting and managing flooding risk will be critical to the well-being and resilience of urban residents as climate change progresses. Despite a large field of literature on the benefits of green infrastructures, like green roofs, there remains a reliance on grey stormwater management infrastructure to manage flooding in urban environments. Better design and simulation tools that help optimize the design of urban green infrastructure networks and quantify their benefits could help increase the uptake and implementation of green infrastructures by local governments and landowners, thereby helping cities emulate ecosystem processes and functions more effectively. Using Wellington, New Zealand, as a case study, this research aims to show how an ecosystem service assessment tool, Nature Braid, can be used to guide the design of an urban green roof network to increase flood mitigation ecosystem services across a city. Nature Braid is one of the ecosystem service tools most suitable to Oceanic sites  and is c2 of green space per capita in central Wellington, which is higher than the minimum 9 m2 recommended by the World Health Organization [Located in the South Pacific on the North Island of Aotearoa New Zealand, Wellington is a temperate coastal city with a population of approximately 203,000 . Wellingnization . Howevernization .2)  , particuNature Braid, the next generation of the Land Utilisation and Capability Indicator (LUCI), is a GIS-based framework and accompanying embedded tools that simulate the impacts of land cover and management on different ecosystem services and allows the user to compare where synergies and trade-offs occur . Nature Nature Braid requires a set of input data, including digital elevation, land cover, soil, and climate data . The WelThe outputs generated from pre-processing were then used in the flood mitigation ecosystem service tool. This tool uses soil permeability and land cover to generate maps of features that help mitigate flooding and high stream flow and where overland stormwater flow accumulates . Feature2 (4% of the catchment) of green roof area was added to the base land cover file . Nature Braid is able to represent overland and subsurface flow based on topography, land cover, and soil, but does not yet include subsurface flow due to grey infrastructures, such as sewers and stormwater drains. However, its output remains useful  as it identifies where stormwater flows and flooding most need to be managed, whether that be through green, grey, or hybrid infrastructures. The average water flow paths highlight areas where overland flows are most significant and where more mitigation is needed to slow their flow. These flow paths were used to guide the design of a green roof network that could help manage stormwater in the catchment . The buiver file . The lan2 or 4% of mitigating features area (green roofs) resulted in a nearly three-fold decrease (1.49 km2 or 11%) in the non-mitigated flood area  in non-mitigated flood areas in the catchment, demonstrating the positive impacts they can have for flood mitigation beyond their individual sites. While these are promising results, there is still room to improve the design of the green roof network. As highlighted by area A in The results of the Nature Braid simulation demonstrate that the proposed green roof network can aid in stormwater management in a densely built urban catchment. Though previous research has evidenced the stormwater management benefits of green roofs on a single building ,21,22, tWhile the Nature Braid tool can estimate the supply and spatial extent of ecosystem services in a given area, some important limitations must be mentioned. Gaps or inaccuracies in the base or input data can result in potential errors while running the tools or in the outputs produced. The LiDAR information for buildings was unavailable, and though a workaround was achieved using building footprints and heights, the DEM input could be improved by filling these gaps. This will be particularly important for refining the building selection for green roof networks, as roof shape and slope will determine their suitability for green roofs. Many other factors will also impact buildings’ suitability for green roofs, such as structural capacity, building code restrictions, and costs. These are beyond the scope of this analysis but could be done in future research to enhance the feasibility of the proposed green roof network. The information to supplement or amend gaps in the soil data was limited. The majority of the catchment was classified as the soil type ‘town’ with no differentiation between the soil classification of densely built areas and significant green spaces . More data on the soil types and permeabilities of the green spaces in the study area, as well as determining an appropriate soil classification for green roofs, would help improve the accuracy of the Nature Braid results and other similar biophysical and geospatial analyses. Though the primary focus of this study was to determine the amount and location of green roofs needed to reduce flooding in the study area, green roof type  impacts how they manage stormwater ,54. The Though this is the first study using the Nature Braid tool to design and simulate an urban green roof network, similar stormwater management benefits of widespread urban green roofs have been found using other modelling and simulation tools. Mora-Melià et al.  used theThis paper focused on the flood mitigation ecosystem service tool of Nature Braid; however, there are several other ecosystem service tools  that could be used in future research to develop an urban green infrastructure design that optimises the outputs for multiple ecosystem services, responds to additional climate change impacts, or addresses other societal challenges. The applications of Nature Braid and other ecosystem system service assessment tools are relevant to many disciplines. As has been demonstrated in this paper, they can help urban designers and planners map risk areas and design urban green/grey infrastructures to mitigate them. The tools can also help policymakers identify and draft suitable regulations and incentives to support urban-scale biomimicry projects. However, the successful implementation of these projects will depend upon knowledge from other fields. Architects and engineers can help determine the suitability and capacity of buildings and existing grey infrastructure to support green infrastructures, like green roofs. Local ecologists will also need to be consulted regarding the target species and habitats that green infrastructures should emulate, conserve, restore, or regenerate. Interdisciplinary collaborations are essential to creating buildings and urban green infrastructures that contribute to the regeneration of urban ecosystem services and help cities adapt to climate change.As cities expand and increase in density, and climate change drives more frequent and severe rainfall events, the need for urban ecosystem services increases in quantity and urgency. This research found that large-scale implementation of green roofs (4% of the catchment area) resulted in a three-fold decrease (11% of the catchment area) in the unmitigated flood risk area. Urban biomimicry strategies and tools, like Nature Braid, can help planners, designers, policymakers, and stakeholders create more resilient urban green infrastructure networks that mimic natural hydrological processes and increase flood mitigation. Robust urban green infrastructure networks that increase flood mitigation and other ecosystem services, like habitat provision, air purification, and evaporative cooling, will be critical to the health, well-being, and resilience of urban residents as climate change progresses.