Environmental Heath. In this Comment, I point out that, also warranting being called out, are the arguments/assertions of Cléro et al. who, in their recent response to an article by Tsuda et al., reiterated the conclusions and recommendations derived from their European project, which were published in Environment International in 2021.The need to call out and expose authors for their persistence in improperly using epidemiology has been previously noted. Tsuda et al. have done well to expose Schüz et al.’s arguments/assertions in their recent publication in Tsuda et al. had critiqued the Cléro et al. 2021 publication in their 2022 review article. However, in their response to it, Cléro et al. deflected by not addressing any of the key points that Tsuda et al. had made in their review regarding the aftermath of the Chernobyl and Fukushima nuclear accidents. In this Comment, I critique Cléro et al.’s inadequate response.Publication of this Comment will help in routing out the improper use of epidemiology in the formulation of public health policy and thereby reduce the influence of misinformation on both science and public policy. My critique of Cléro et al. is not dissimilar from Tsuda et al.’s critique of Schüz et al.: in as much as Schüz et al. should withdraw their work, so should Cléro et al.’s article be retracted.The response by Cléro et al. consists of four paragraphs. First was their assertion that the purpose of the SHAMISEN project was to make recommendations based on scientific evidence and that it was not a systematic review of all related articles. I point out that the Cléro et al. recommendations were not based on objective scientific evidence, but on biased studies.In the second paragraph, Cléro et al. reaffirmed the SHAMISEN Consortium report, which claimed that the overdiagnosis observed in non-exposed adults was applicable to children because children are mirrors of adults. However, the authors of that report withheld statements about secondary examinations in Fukushima that provided evidence against overdiagnosis.In the third paragraph, Cléro et al. provided an explanation regarding their disclosure of conflicting interests, which was contrary to professional norms for transparency and thus was unacceptable.Finally, their insistence that the Tsuda et al. study was an ecological study susceptible to “the ecological fallacy” indicated their lack of epidemiological knowledge about ecological studies. Ironically, many of the papers cited by Cléro et al. regarding overdiagnosis were, in fact, ecological studies.Cléro et al. and the SHAMISEN Consortium should withdraw their recommendation “not to launch a mass thyroid cancer screening after a nuclear accident, but rather to make it available (with appropriate information counselling) to those who request it.” Their recommendation is based on biased evidence and would cause confusion regarding public health measures following a nuclear accident. Those authors should, in my assessment, acquaint themselves with modern epidemiology and evidence-based public health. Like Tsuda et al. recommended of Schüz et al., Cléro et al. ought also to retract their article. From the SHAMISEN  international experts’ consortium, Cléro et al. published a review article entitled, “Lessons learned from Chernobyl and Fukushima on thyroid cancer screening and recommendations in the case of a future nuclear accident” . Their rTheir review, however, misrepresented the Fukushima empirical findings and the Chernobyl experience by including citations of biased literature and by emphasizing overdiagnosis in thyroid screening using ultrasound echo, but with no specific verification/validation. Tsuda et al. communicated the current situation in Fukushima and Japan, pointed out errors in Cléro et al.'s claims, and evaluated those claims using the “Toolkit for detecting misused epidemiologic methods” , 3. ClérCléro et al. responded that the SHAMISEN paper was not a systematic review of all papers published on the Chernobyl and Fukushima accidents , 4. HoweCléro et al. stressed that the evidence suggests that overdiagnosis is similar in children and adults . HoweverCléro et al. emphasized "small thyroid nodules" in cases of overdiagnosis , but, beEnvironment International [Environment International, and the public at large, will carefully assess whether the claims of Cléro et al. are valid. Furthermore, conflicting interests should be disclosed that involve IARC Expert Group chairs and the Japanese government, whose evident bias is to obscure the large excess incidence of thyroid cancer in Fukushima.Cléro et al. described the way that Dr. Dominique Laurier declared her conflict-of-interest , 3, 4. Tnational , 3, 4. CFirst, if the epidemiological study on historical air pollution in six cities in the United States by Dockery et al. were considered to have a semi-ecological rather than a cohort study design , then coSecond, if the design of Snow's foundational epidemiological investigation regarding the outbreak of cholera  were deeIn the final paragraph before their conclusion, Cléro et al. , using JThe main role of epidemiologists is not to classify study designs; nor is the role of epidemiologists to continue to insist on things for which there is no evidence. The role of epidemiologists is to collect and analyze data, draw conclusions based on the results of analyses that take the study design employed into account, and make valid causal inferences based on the body of evidence. Then, the role of epidemiologists in public health is to propose and implement necessary and feasible intervention measures in a timely manner, based on these results and conclusions. Cléro et al. , 4, the In their conclusion, Cléro et al. claimed, without evidence, that the large number of excess thyroid cancers in Fukushima was caused by overdiagnosis , 4. AlthWithout sufficient discussion and evidence on the already disproven claim regarding overdiagnosis and the effects of screening, the above authors and the SHAMISEN Consortium have caused distress and confusion and have delayed scientifically justifiable interventions in Japan , 6, 9. TFinally, members of the SHAMISEN Consortium appear to me to have a deep understanding of the Japanese language in which the phrase "playing shamisen" is Japanese slang; it means "to mislead" or "to lie” . Again,


The rapid development of smart devices and electronic products puts forward higher requirements for power supply components. As a promising solution, hybrid energy harvesters that are based on a triboelectric nanogenerator (HEHTNG) show advantages of both high energy harvesting efficiency and multifunctionality. Aiming to systematically elaborate the latest research progress of a HEHTNG, this review starts by introducing its working principle with a focus on the combination of triboelectric nanogenerators with various other energy harvesters, such as piezoelectric nanogenerators, thermoelectric/pyroelectric nanogenerators, solar cells, and electromagnetic nanogenerators. While the performance improvement and integration strategies of HEHTNG toward environmental energy harvesting are emphasized, the latest applications of HEHTNGs as multifunctional sensors in human health detection are also illustrated. Finally, we discuss the main challenges and prospects of HEHTNGs, hoping that this work can provide a clear direction for the future development of intelligent energy harvesting systems for the Internet of Things. With the rapid development of the Internet of Things and artificial intelligence, various portable and wireless electronic products and their derived intelligent sensor systems are widely present in our life ,2,3,4,5.Nowadays, various energy harvesting technologies have been developed, such as triboelectric nanogenerators (TENGs) ,15,16, pHowever, to meet the increasing power consumption requirement of more powerful electronics, it is anticipated that TENGs will be integrated with other energy harvesting devices to build hybrid energy harvesters so that multiple energy sources can be simultaneously collected efficiently from the surrounding environment ,25,26,27In this article, the latest research progress of HEHTNGs and the working principles of different devices are systematically reviewed . Key strTENGs can effectively convert mechanical energy into electrical energy based on Maxwell’s displacement current theory . NowadayThe basic principle of PENGs is to use the positive piezoelectric effect of the piezoelectric material a. The po3 are often used to make pyroelectric generators. By harvesting waste heat energy, pyroelectric nanogenerators can be used in applications such as temperature monitoring and healthcare [In general, the harvesting of thermal energy relies mainly on the Seebeck effect b, but ifalthcare ,54.2Te3 materials with high conductivity and low thermal conductivity after doping are widely used. In addition, some materials such as PbTe, CoSb3, and Mg2Si have also been reported for the production of TEGs [Waste thermal energy is one of the most easily overlooked energy sources. With the deepening of research, thermal energy harvesting can be applied to various aspects, among which not only can PyENGs collect thermal energy but TEGs can also convert thermal energy into electrical energy under very small temperature differences. The working principle of TEGs is the thermoelectric effect c, which  of TEGs ,58,59,60Solar energy is the most important renewable energy source, and is now applied to solar heating, photosynthesis, the PV effect, and other aspects. Solar cells are a device that uses chemical and physical phenomena to convert light energy into electricity ,62. The The basic working principle of EMGs is based on Faraday’s law of electromagnetic induction e, consisFrom TENGs to hybrid energy harvesters, the high efficiency and versatility of devices are closely related to structural design, material selection, and surface modification . A reasoThis section focuses on the flexible structure of the hybrid energy harvesting device, and the reasonable structural design enhances the device’s consistency and greatly improves the operating stability and output performance of the device. A hybrid nanogenerator with triangular cylindrical origami was prepared based on ancient origami a–c. The Increasing the contact area is a commonly used method in structural design, in addition to forming fast charge transfer channels to achieve changes in the internal structure of the thin film. Zhu et al. drilled a hole in the friction layer to serve as a conductive channel d–f, alloLee et al. proposed a TENG-EMG hybrid generator (S-TEHG) with elasticity g–i, wherChanging the operating mode of devices through external components can also improve device performance. Wang et al. used lateral connectors to connect a TENG, EMG, and SC to collect wind and solar energy j–l, convDue to the flexible structure design of the device, the output performance and stability are improved, but it is easier to neglect other characteristics such as flexibility and biocompatibility .3 nanorods to form hybrid films (2) groups in chitosan readily release electrons, thus generating positive zeta potential and enhancing matrix cation capture. The tested power output is more than four times higher than the power enhancement of pristine chitosan TENGs, achieving an ultra-high effective charge density [It is well known that the selection of a suitable functional layer material is one of the important factors for improving the high-performance output of hybrid energy harvesting . The funid films a–c. The  density .3Bi2Br9 increases the electron capture ability and polar crystalline phase. Forming a good energy level matching with PVDF-HFP improves the electron transfer efficiency and reduces charge loss. The experiment proved that the device can operate for a long time, and it set a record regarding the the output voltage of a halide perovskite-based nanogenerator [Meanwhile, perovskite materials have excellent electrical properties, making them a hot research topic nowadays. Jiang et al. prepared a multifunctional nanofiber composite material (LPPS NFC) by electrospinning lead-free perovskite/polyvinylidene fluoride co hexafluoropropylene (PVDF HFP) d–f. As aenerator .In recent years, fabrics have been used as carriers to provide high friction properties through various technologies. Kim et al. reported a Fab-EH-based energy collector (Fab-EH) g–i. The The functional layer prepared by Nawaz et al. consists of cubic zinc ferrite nanoparticles (CZF NPs) and a polymer matrix, realizing a multifunctional hybrid multimodal nanogenerator (HNG) j–l. The In the past, it was common to choose environmentally friendly or toxic high-performance materials. With the development of flexible and biocompatible wearables, it is a trend to gradually choose natural cellulose or plant extracts for device preparation .In addition to material selection, the surface modification of hybrid energy harvesting devices is very important. Surface modification technology can change the physical morphology and electrical properties of the functional layer surface, enabling the energy harvesting device to have high-performance output. Yu et al. reported that the use of liquid-nitrogen-induced phase transition and in situ doping methods resulted in a piezoelectric polymer containing 71% β after quenching a–c. Dopi2) nanoparticles  and titanium dioxide  composed of an EMG and TENG, g–i. Usinl device .Some inorganic materials are expensive and contain substances that are toxic to the human body. It is a trend to look for low-cost natural modifiers. Mariello et al. prepared a metal-free hybrid piezoelectric nanogenerator (HPENG) based on soft biocompatible materials j–l. CardSurface modification technology plays an important role in improving device output. By changing the degree of interfacial friction and dielectric properties of thin films through physical or chemical methods, the device output can be further improved.The integration strategy of hybrid energy harvesting systems is crucial. Through reasonable integration, energy harvesting systems can have the characteristics of efficient harvesting and a wide application range in different environments.The hybrid energy harvesting system, due to its characteristic of collecting multiple energy sources, can operate alternately to compensate for the limitations of single energy harvesting, thereby increasing the harvesting efficiency of the system. For example, Liu et al. used polysilicon solar cells and an interdigitated electrode structure triboelectric nanogenerator (IDE-TENG) to form an umbrella-shaped energy harvesting system a–c. The Ye et al. designed an efficient R-TENG array d–f. The Due to the applicability of EMGs and TENGs in high-frequency and low-frequency applications, Dan et al. adopted a segmented alternating working strategy to expand the energy harvesting range of hybrid devices g–i. The Liu et al. integrated a TEG and TENG using a converter j–l. ThisThe advantage of a hybrid energy harvesting system is that it can adjust the working mode according to needs. The strategy of running the system simultaneously can maximize system output, but it will limit its application scenarios. Yuan et al. prepared a multifunctional DC-TENG that can harvest both mechanical energy and solar energy by constructing a dynamic Al/CsPbBr3 Schottky junction a–c. The The simultaneous operation strategy adopts a multi-part simultaneous triggering mode, and each part can not only be assembled horizontally but also designed vertically. Lee et al. vertically stacked TENG components on PENG components to prepare a mixed foot mechanical energy harvesting device d–f. WhenParanjape et al. made a multi-stage continuously connected hybrid nanogenerator (HNG) using composite films g–i and oWen et al. proposed a flexible hybrid photothermal generator (PTEG) j–l. The The overall output of the energy harvesting system not only relies on the output performance of hybrid devices but also requires external circuit assistance. Since the output form of a TENG is AC, a rectification circuit is required to convert it into DC to supply power for electronic components. Moreover, with the help of an external circuit, the charging speed can be accelerated and the charge density of the TENG can be improved. For example, the hybrid nanogenerator prepared by Pongampai et al. is combined with the designed self-charge pump (SCP) module to improve the charge density of the friction layer a–c. The The external circuit design generates DC pulses that are conducive to energy transmission. Shi et al. set up specialized mechanical switches to connect the TENG with photovoltaic cells in series d–f. By gBy changing connections and adding external components to optimize the charging speed, Kim et al. developed an energy collection system based on a TENG and TEG g–i and uWang et al. developed a high-performance ocean energy harvesting device to ensure the continuous operation of wireless sensor nodes. A power management system (PMS) was designed to improve the charging efficiency of the TENG j–l. The Hybrid energy harvesting systems are widely combined with various sensors to form intelligent systems due to their efficient energy harvesting and sensing performance. Feng et al. integrated a hybrid energy harvesting device, power management circuit, sensor, microcontroller, and wireless communication module to create an intelligent ocean buoy a–c. UndeBy customizing and developing smartphone applications, better control will be achieved based on hybrid energy harvesting systems. Rana et al. developed an energy harvesting device driven by biomechanics as a continuous power source d–f. BaseIn addition, in order to increase the energy conversion efficiency of TENGs, Zhao et al. reported a self-powered wireless marine environment monitoring system g–i, desiXue et al. developed a self-powered wireless temperature and vibration monitoring system based on LTC3331 as the core of an energy harvesting controller j–l. The HEHTNGs are widely used as multifunctional sensors due to their multi-energy harvesting characteristics, good adaptability to different environments, and efficient energy conversion efficiency.In wind power generation, traditional turbine design and installation have drawbacks such as a high cost and complex equipment, which are not suitable for large-scale applications. However, TENGs can overcome these drawbacks. Many researchers shifted their research direction to TENG-based energy harvesting systems. Wang et al. designed a hybrid nanogenerator a–c. BecaIn another work, wind energy harvesting devices are combined with other sensors to form an intelligent agriculture self-powered distributed meteorological sensing system. Zhang et al. proposed this system d–f, whic−1 to 15 ms−1) and can effectively collect various levels of wind energy through an optimized structural design. Experiments have shown that the FTEHG has proven to be a wind speed sensor that can successfully charge a 47 μF capacitor to 1.5 V in 4 s, and is thus a system with great potential for wind energy harvesting and sensing [EMGs and TENGs have good harvesting efficiency in high and low frequencies, respectively. Ye et al. reported a triboelectric–electromagnetic hybrid nanogenerator (FTEHG) g–i. The  sensing .−3) at wind speeds of 2–16 ms−1. In addition, a dual-channel power management topology (DcPMT) has been established to control the outputs of two modules in the TEHG. This system has the advantages of broadband and efficient wind energy harvesting and can provide 3.3 V voltage to power electronic products, playing an important role in improving the environmental adaptability of the Internet of Things [Hybrid wind energy harvesting devices of EMGs and TENGs are being developed. Yong et al. designed a dual-rotor triboelectric–electromagnetic hybrid nanogenerator (TEHG) through the synergy between TENGs and EMGs j–l, resuf Things . A summaMany regions have rainy conditions, and the harvesting of raindrop energy is easily overlooked. However, with the development of TENGs, raindrop energy can compensate for SCs’ shortcomings on rainy days, forming a complementary solution. Ye et al. prepared a hybrid nanogenerator array a–c. By sThe main research on raindrop energy harvesting focuses on two types of energy: raindrop impact energy and electrostatic transfer generated by solid–liquid contact. Mariello et al. designed a multifunctional, flexible, and conformal hybrid nanogenerator (HNG) to collect energy from different water transfer sources  d–f, grea2 [Chen et al. prepared a fully encapsulated piezoelectric–triboelectric hybrid nanogenerator (PTHG) g–i. On t2 .Inspired by solid–liquid contact, Liu et al. designed an interdigital electrode structure to integrate solar panels with a TENG (IDE-TENG) j–l. TheySound energy can widely exist in the surrounding environment but, due to the low power density of sound waves and the lack of effective sound harvesting technology, it is not systematically researched and developed like other energy sources. The working principle of converting sound energy into electrical energy is the triboelectric effect and electrostatic induction effect of acoustic vibration, so sound energy harvesting devices based on TENGs have been widely studied. Zhao et al. prepared a novel triboelectric nanogenerator (HR-TENG) based on a dual-tube Helmholtz resonator a–c. The In addition, some researchers have efficiently utilized wind and sound energy. Wang et al. have implemented a hybrid triboelectric nanogenerator (TENG) inspired by windmills to simultaneously capture wind and sound energy d–f. One In order to improve the efficiency of harvesting sound energy, a porous three-dimensional structure is designed to increase the triboelectric effect. Yu et al. used nanoporous PVDF hollow fibers and PDMS valves to simulate the tympanic membrane (PHVAH) g–i. The On the basis of previous studies, Yu et al. designed a unique beam-like structure from a structural design perspective, promoting the diffraction and scattering of sound waves inside the hole wall, enhancing its vibration and friction j–l. In aOcean energy is one of the most abundant sources of energy, and the development of ocean energy is challenging due to the corrosion of electronic devices caused by seawater and the susceptibility to adverse weather conditions on the sea surface. Wang et al. made a hybrid nanogenerator system with an internal topology a–c. UsinCurrently, the research direction of TENG-based ocean energy harvesting mainly includes system design, structural design, and external incentives. Hao et al. designed a box-type energy harvesting device d–f. The Encapsulated devices have better corrosion resistance. Pang et al. used silicon shells to prepare soft spherical devices (TEHG) g–i and s−3. This work provides conditions for the application of high-power self-powered systems [However, inspired by the pendulum, Zhang et al. coupled the dual-pendulum hybrid nanogenerator (BCHNG) module j–l, incl systems . A summaWith the rapid demand for sports and fitness, wearable sensors have an important role in the process of the real-time monitoring of human movement status in different ways due to their flexibility, high sensitivity in detecting tiny signals, and so on . Zhu et In addition, wearable sensors can not only monitor human motion status but also serve as self-powered devices to power other intelligent sensors, achieving an intelligent integration of IoT devices. Jiang et al. reported a wearable non-contact free-rotating hybrid nanogenerator d–f that With the deepening of research on wearable devices, electronic skins that focus on comfort and practicality have become a research focus. Although devices integrated into clothing can detect human motion status, they still have certain errors and discomfort, and electronic skins can solve such problems. Gogurla et al. have prepared a biocompatible electronic skin g–i. ThisMariello et al. reported a hybrid nanogenerator with high sensitivity and super flexibility j–l. The Nowadays, some diseases such as the heart and brain require implantable devices to provide treatment . ImplantAs devices implanted in the human body require better safety, Gogurla et al. used proteins to create an electronic skin d–f. By dThe recovery process of nerve injury repair is slow due to its complex and individual differences. Jin et al. developed an implantable system with a physiological adaptation function g–i. The Li et al. prepared a TENG-based hybrid energy harvesting system j–l, whicThe TENG-based hybrid energy harvesting system, which couples multiple working mechanisms, can harvest energy in the environment to achieve higher efficiency, multifunctionality and self-sustainability. Combining these characteristics, the integration of TENGs with various energy harvesters in current self-sustaining systems is increasingly attractive, especially in this era of the Internet of Things. It can be seen that HEHTNGs are undergoing fast progress, and current research is mainly focused on the technological improvement process of HEHTNGs from the aspects of device operating principles, performance improvement, and integration concepts. Secondly, HEHTNGs can operate alternately or simultaneously under one or more energy conditions, efficiently collecting energy from different environments, such as wind energy, raindrop energy, ocean energy, and wave energy. And, it can even be used as multifunctional sensors in human health and other environmental stimuli detection while fulfilling the energy needs of electronic devices and self-powered systems. A high power density and sustainability are always the ultimate development trends; in fact, they are also the most active direction of HEHTNGs.Nowadays, most devices are simply stacked and connected, which limits their range of use. Optimized structural designs should be developed to achieve a high power density and sustainability while maintaining device integration and miniaturization to meet various application needs.The durability and stability of devices are easily overlooked, and materials can cause damage in long-term use. Therefore, it is urgent to study materials with self-healing functions.In terms of enhancing performance output, doping and surface modification can increase the output performance of devices, but they can cause material preparation complexity and high costs. Therefore, external excitation methods are sought to promote the generation of functional layer charges to meet the requirements.With the rapid development of the Internet of Things and artificial intelligence, while pursuing a high power density, exploring multifunctionality such as synergistic sensing by integrating devices with each other may achieve novel intelligent features for wearable devices, medical devices, and other environmental monitoring systems.However, there are still some key issues and challenges that need to be addressed, which not only limit the output performance but also limit their potential future applications:


Myofunctional orofacial examination (MOE) is an important tool for the assessment of the stomatognathic system and orofacial functions, and the early diagnosis of orofacial myofunctional disorders. Therefore, the purpose of the study is to scan the literature and determine the most preferred test for myofunctional orofacial examination.A literature review was conducted to collect information. Pubmed and ScienceDirect database was explored by using keywords gained by MeSH .Fifty-six studies were retrived from the search and all of the studies were screened and evaluated regarding the subject, aim, conclusions and the orofacial myofunctional examination test they used. It has been observed that traditional evaluation and inspection methods have been replaced by newer and methodological approaches in recent years.Although the few tests used differ, 'Orofacial Examination Test With Scores’ (OMES) was found to be the most preferred myofunctional orofacial evaluation method from ENT to cardiology. Myofunctional orofacial anomalies refer to abnormal orofacial functions that can lead to changes in the function, structure and formation of the stomatognathic system. These disorders can cause malocclusions of the jaws, temporomandibular joint disorders, and other problems involving the orofacial region. Factors triggrering malocclusions may include myofunctional anomalies characterized by disturbances in chewing, swallowing and breathing patterns. Infantile swallowing, mouth breathing and tongue thrust, which are clinically common, and can be caused by genetic and/or environmental factors could be counted as examples –3. The pOrthodontic and dentofacial orthopedic treatment is often used to correct malocclusions and other orofacial abnormalities –7. But tThe diagnosis of myofunctional orofacial disorders requires a comprehensive myofunctional orofacial examination (MOE) of the orofacial musculature and function. This examination is commonly performed by speech-language pathologists, dentists, and orthodontists. The MOE has been described in several studies as a comprehensive tool for assessing the orofacial region by various examination protocols. However, there is no global consensus on a standardized orofacial myofucntional examination form. Various examination forms and methods have been presented for the evaluation of orofacial anomalies and functions which includes the examination of stomagnatic region: orofacial muscles, lips, tongue, breathing, swallowing patterns, cranio-oro-facial posture and speech. The purpose of the myofunctional orofacial examination is to evaluate the function and structure of the orofacial complex statically and dynamically and, to detect any dysfunction that may be present. The information obtained from the examination is aimed to be used for developing an individualized treatment plan to address any orofacial dysfunction that is detected –22.Myofunctional examination may include the following stages: reviewing the patient's both current health and medical/dental history; statically and dynamically examining and both photographing and video recording of facial/mouth structures, oral functions, and general face and body posture; things to be evaluated sequentially and individually: Respiration and Respiratory tract; Oral Habits; Craniofacial/orofacial appearance  and function of involved muscles and TMJ; Evaluation of tongue ; hard and soft tissues of the mouth; occlusion; speaking function, appearance and resting position; chewing; liquid and solid swallowing; review of examination findings; consulting if necessary; establishing a treatment strategy and plan –22. In rIn addition to the examination, studies are also carried out on the treatment of these anomalies. Rehabilitation of the tongue , examinaNevertheless, the need for a standard and valid myofunctional orofacial assessment test has become more evident for dentists, all specialist dentists and especially orthodontists. That is why, the research question of this study is 'Which is the most preferred and presented myofascial orofacial examination test in the literature?' And thus, the aim of the study is to scan the literature with this point of view and to identify the most valid and used test.Pubmed and ScienceDirect database was searched by one researcher of the present study on April 2, 2023 by using keywords: “myofunctional[Title] AND orofacial[Title] AND examination[Title] AND orofacial[Title] AND myofunctional[Title] AND examination[Title]”, “myofunctional[Title] AND orofacial[Title] AND assessment[Title] AND orofacial[Title] AND myofunctional[Title] AND assessment[Title]”, “ OR ” for PubMed and, "myofunctional orofacial assessment”,”myofunctional orofacial evaluation”, "myofunctional orofacial examination”,”orofacial myofunctional examination”,”orofacial myofunctional assessment”,”orofacial myofunctional evaluation” for ScienceDirect. Medical Subject Headings (MeSH) terms was used in creating the search keywords.Fifty-six studies reached by screening both databases. 5 studies were duplicates, 2 were review articles, 3 were conference abstracts, 1 was an erratum, 1 was a case report. After excluding those 12 studies, 44 studies remained for evaluation. All of 44 remaining studies were included in screening (Fig. The following data were recorded: database, name of publication, study type, name of the examination form used in the study. In addition all studies were screened regarding subject, aim, conclusions in the discussion of the present study Table .Table 1DAmong all studies, OMES and OMES-E tests were the most preferred myofunctional anamnesis protocols. MGBR was following them. A few studies were based on conventional conventional OMD examination rules. It was observed that some studies examining myofunctional anomalies and temporomandibular disorders together used DC/TMD or RDC/TMD and, EMG tests. Some studies were specifically aimed at measuring the functions and working force of the tongue. Two researchers have published publications promoting their personal measurement protocols. One study used a protocol to evaluate facial muscular mimic-specific measurements. A nutrition scale was used in one study. Nasal obstruction was separately evaluated in one study.In some studies, specialized tests were used to evaluate specific functions, such as the ability to produce speech sounds. It was observed that studies examining OMD and TMD together also used RDC/TMD and EMG tests. Some studies were specifically aimed at measuring the functions and functional strength of the tongue. Some researchers have published publications promoting their own personal measurement protocols. One study used a protocol that made mimic-specific measurements. A nutrition scale was used with MOE in one study. Effects of nasal obstruction was evaluated by using a MOE in one study.The MOE examination forms used in the screened studies included observation of the patient's orofacial posture at rest, assessment of swallowing patterns, assessment of speech production, and a comprehensive oral-motor examination. Those included assessments of various aspects of orofacial function, such as lip and tongue resting posture, swallowing patterns, and speech production. In OMES protocol each assessment is given a score to define the severity of orofacial dysfunctions which are observed and detected. It is observed that orofacial myofunctional examinations for the studies screened were performed in a clinical setting such as language-speech pathology clinic or dental clinic or ENT clinics or pediatric clinics, which shows that the subject is definitely multi and interdisciplinary.This literature review has shown us that the MOE protocol is used in many different disciplines of medicine and dentistry and in the diagnosis and treatment of many different orofacial anomalies. The aims and results of all the publications scanned in the study are given below in the form of a short review. In addition, which MOE test was used in each study is indicated in Table De Araújo SRS et al.  investigBueno et al.  conducteIn their study, Magnani et al.  used OMEGraziani et al. , 32 studPaskay LC . in her In his study, Hanson ML . drew a Medeiros et al.  studied Rohrbach et al.  examinedMacedo et al.  conducteLima et al.  evaluatePimenta et al.  presenteBarbosa et al.  investigSantos et al.  studied In their study, Arias Gullien et al.  assessedDe Castro Correa et al.  investigIn their case report, Carvalho Lima et al.  studied In their systematic review study, Palomares-Aguilera M et al.  investigIn their study, in which they compared orofacial myofunctional evaluation with scores protocol with traditional orofacial myofunctional evaluation, Felicio and Ferreira  proved tIn an other study, de Felicio CM et al. , 46 expaFolha et al.  in theirFolha et al.  in theirDe Felicio CM et al.  investigIbrahim AF et al.  examinedDe Felicio et al.  conducteFerreira et al.  assessedMarim et al.  in theirPedroni-Pereira A et al.  evaluateScudine KGO et al.  examinedBueno Dde A et al.  evaluateSantos REA et al.  analyzedCorrea CC et al.  examinedMuñoz-Vigueras N et al.  examinedHansen D et al.  mentioneMagnani DM et al.  aimed toDa silva AP et al.  comparedMagnani DM et al.  assessedBraga et al.  aimed toTrawitzki LV et al.  evaluateFasscollo CE et al.  using elRenom-Guiteras M Et al.  aimed toMapelli A et al.  aimed thTrawitzki LV et al.  aimed toFinger LS et al.  aimed toLodetti et al.  aimed toTartaglia GM et al.  comparedDe Felicio CM et al.  examinedGubani MB et al. –76 in thMapelli A et al.  aimed toMilanesi JM et al.  comparedAnother problem that can be caused by myofunctional orofacial anomalies is orofacial pain. In the modern world, myofascial pain is one of the most common problems related to the orofacial region, both due to our head and body postural disorders, due to stress and myofunctional orofacial anomalies. Orzeszek et al.  In theirSince this study was conducted to determine which OMES test is the most known and preferred in the literature, the quality of the methodologies of the studies was not examined one by one. This was a limitation of the study. Studies in the field about orofacial disorders, which is a highly multidisciplinary medical problem, are relatively insufficient. Myofunctional orofacial dysfunction is a complex condition that requires careful examination and appropriate multidiscipliner treatment to achieve optimal outcomes. Anomalies that occur in a region that we call the stomatognathic system and where vital and important functions such as speech, swallowing, feeding, breathing, chewing, facial appearance and posture are performed, cause many other medical problems and even anomalies of other systems. Furthermore studies with future studies could develop the evaluation and rehabilitation processes.The MOE is a valuable tool in many disciplines of dentistry and medicine to assess the orofacial region and to identify orofacial myofunctional disorders both statically and dynamically. In general, across all disciplines, OMES was found to be the most preferred test. In addition, it has taken its place in the literature that the OMES test makes consistent and reliable measurements in many different conditions.


I argue that the electrophysiological phenomenon, the visual mismatch negativity (vMMN), considered to be the signature of automatic visual change detection is post-perceptual.Presenting stimulus sequences with frequent physically or categorically identical visual stimuli (standards) and rare stimuli (deviant) that violate the regularity of standards, an ERP component, the vMMN emerges, even if these stimuli are unrelated to the ongoing task . VMMN is observed in the ERP when stimulus sequences with frequent physically or categorically identical visual stimuli (standards) and rare stimuli that violate the regularity of the standards (deviants) are presented. It is considered the counterpart of the auditory mismatch negativity  MMN and vMMN is the predictive coding theory. In summary, the mechanism underlying (auditory) MMN), and o et al.  clearly o et al. . In the VMMN is usually measured on the difference potentials, where ERPs to the standard are subtracted from the ERPs to deviant.At the later time range, deviant minus standard ERP differences appear after 250 ms, e.g., for dot motion  is later than the time needed to identify images depicting single objects, objects within contexts, and scenes.The most direct method to measure the time needed to identify (plus decide and respond) visual events is a “go/no-go categorization task,” first introduced by Thorpe et al. . ParticiPotter and her colleagues introduced a series of studies presenting pictures using the rapid serial visual presentation (RSVP) method. In her now-classic study Potter,  she presIn a passive paradigm (participants reacted to the color change of the fixation dot) Stothart et al.  presenteidentified events. These events have potential importance, even in a passive oddball paradigm. This suggestion is not new; it fits the early interpretation of (auditory) MMN by Risto Näätänen. “The mismatch negativity was interpreted by Näätänen et al.  component, the visual mismatch negativity (vMMN) in the 120–350 ms latency range. Data from visual discrimination, identification, and steady-state evoked potential studies show that its latency is longer than the time needed to identify even complex visual events. Therefore, it is improbable that vMMN is a signature of the processes of early phases of stimulus identification. In the paradigms investigating vMMN , events appear in the context of other ones. The context is the set of standard stimuli. Due to the regular appearance of standards, the system is capable of developing predictions about forthcoming events. I agree that the processes underlying vMMN are error signals, but signals of mismatch between expected and unexpected  n et al.  as reflen et al.  lead to n et al. , p. 523.n et al. .IC: Conceptualization, Writing—original draft.


Multiple studies have connected parenting styles to children's internalising and externalising mental health symptoms (MHS). However, it is not clear how different parenting styles are jointly influencing the development of children's MHS over the course of childhood. Hence, the differential effects of parenting style on population heterogeneity in the joint developmental trajectories of children's internalising and externalising MHS were examined.Growing Up in Ireland cohort study was derived for further analyses. Parallel-process linear growth curve and latent growth mixture modelling were deployed.A community sample of 7507 young children  from the p < 0.01; LMR = 682.19, p < 0.01; E = 0.86). The majority of the children (83.49%) belonged to a low-risk class best described by a decreasing trajectory of externalising symptoms and a flat low trajectory of internalising MHS. In total, 10.07% of the children belonged to a high-risk class described by high internalising and externalising MHS trajectories, whereas 6.43% of the children were probable members of a mild-risk class with slightly improving yet still elevated trajectories of MHS. Adjusting for socio-demographics, child and parental health, multinomial logistic regressions indicated that hostile parenting was a risk factor for membership in the high-risk  and mild-risk  classes. Consistent  parenting style was a protective factor only against membership in the mild-risk class.The results indicated that the linear growth model was a good approximation of children's MHS development . The growth mixture modelling revealed three classes of joint internalising and externalising MHS trajectories . Furthermore, hostile parenting style is a substantial risk factor for increments in child MHS, whereas consistent parenting can serve as a protective factor in cases of mild-risk. Evidence-based parent training/management programmes may be needed to reduce the risk of developing MHS. As can be seen in As a reference only, the sample was distributed into the age-appropriate cut-off centiles based on the new fourfold classification of the scores on the SDQ scales in the UK (χ2(9) = 926.16, p < 0.001. The linear parallel-process LGM (intercept-slope) exhibited great fit to the data, i.e. scaled χ2(4) = 30.22, p < 0.001, CFI = 0.996, TLI = 0.98, RMSEA = 0.03, SRMR = 0.013. Thus, we could be confident that a linear model of change could be a good approximation for the MHS trajectories. The LGM parameters are presented in the Supplementary materials. Next, we estimated the GMM to identify possible heterogeneity in the trajectories of MHS. The model with three classes of MHS trajectories exhibited significant improvement compared to the two-class model. Moreover, the likelihood ratio tests revealed that the addition of a fourth class did not result in improved model-data fit (p > 0.05). The ‘elbow’ plot of the BIC values showed that adding more than three classes did not improve fit substantially . Additionally, we estimated further models where the variances of the intercept and slope parameters were freely varying between classes. However, the variance–covariance matrices were not positive definite, and thus, the variances were held equal across classes. Keeping in mind that this was a general population sample, we did not expect extreme variation in mental health symptomatology, and thus, the three-class model was retained. Fit indices for the models are presented in An intercept-only model was found to be degraded compared to the intercept-slope model, Satorra–Bentler N = 6268) of the children belonged to class 1 (low risk) that was characterised by a flat low trajectory of internalising MHS, and a declining trajectory of externalising MHS. In contrast, 10.07% (N = 756) of the children were members of a high-risk class 2 that was characterised by an accelerating high trajectory of internalising and externalising MHS. Finally, 6.43% (N = 483) of the children belonged to class 3 with MHS trajectories that were slightly improving but still elevated (mild-risk). The estimated trajectories are shown in The model revealed that 83.49%  were inspected and found to be less than 6 (mean VIF = 1.84). Thus, no extreme collinearity was diagnosed for the model. The results of the multinomial logistic regressions are presented in Hostile parenting style was a substantial predictor of membership in the high-risk class  and the mild-risk class . Warm parenting style did not predict membership in the high-risk  or the mild-risk  classes. Although consistent parenting style did not predict membership in the high-risk class , it was a protective factor against membership in the mild-risk class . The results for the covariates are discussed in the Supplementary materials.et al., et al., et al., et al., et al., et al., The person-centred approach revealed some extent of heterogeneity in children's MHS trajectories. Contrary to most preceding evidence (Patalay et al., et al., et al., et al., As mentioned, most of the preceding evidence did not examine (Miner and Clarke-Stewart, et al., et al., et al., et al., et al., et al., et al., et al., Last but not least, the present study sought to evaluate the impact of parenting styles on the heterogeneity in children's MHS developmental trajectories. Using a developmental and psychopathology multisystem resilience approach (Masten et al., et al., et al., et al., et al., et al., et al., Overall, the present study is distinct from preceding works (Fernandez Castelao and Kröner-Herwig, et al., Nevertheless, the present work also had some limitations. Specifically, it should be underscored that SDQ is a broad screening tool of children and adolescents’ MHS and does not necessarily target specific symptoms of the most common mental disorders. Moreover, evidence suggests that SDQ may not have high criterion validity in predicting emotional and behavioural disorders (Aydin The present findings may have significant implications for policy and practice. For instance, the correlated nature of the developmental trajectories of internalising and externalising MHS indicates that mental health professionals should always screen for both types of MHS. Furthermore, the person-centred modelling indicated that only a small proportion of the general population of young children may be at-risk for increased MHS. However, mental health practitioners should be vigilant to identify those children. Thus, more robust extensive screening may be needed. Most importantly, the present study's results underscored the importance of parenting styles for the identification of children at-risk for developing high/mild MHS. Therefore, we suggest that routine background checks of parenting behaviours should be applied while screening children for possible MHS. Given that hostile parenting style was associated with children's membership in the high- and mild-risk classes with high MHS trajectories, we recommend evidence-based parent training/management programmes to improve positive interactions between parent and child.


Hsp90 is known for its role in the activation of an eclectic set of regulatory and signal transduction proteins. As such, Hsp90 plays a central role in oncogenic processes ,2. AlthoThe review by Bjorklund and Prodromou , an ‘EdiThe article by Wengert et al. , also seThe review of Joshi et al. , anotherThe article by Jay et al.  looks atThe ‘Editor Choice’ review by Backe et al.  looks atThe article by Ziaka and van der Spuy  extensivPlasmodium falciparum (PfHsp90), and its associated co-chaperone complexes, display key structural and functional differences compared to the human Hsp90 system. While the core co-chaperones regulating client entry, ATPase activity and Hsp90 conformation are broadly conserved in P. falciparum, there are some major differences, such as the expression of two p23 isoforms, and the apparent absence of a canonical Cdc37. Overall, these differences in the co-chaperone network of PfHsp90 suggest that the elucidation of Hsp90–co-chaperone interactions can greatly extend our understanding of proteostasis and lead to the identification of novel inhibitors and drug candidates.The review by Dutta et al.  highlighPiper et al.  bring toIn addition to assisting protein homeostasis, Hsp90 has been shown to be involved in the promotion and maintenance of proper protein complex assembly either alone or in association with other chaperones, such as the R2TP complex. The review by Lynham and Walid  looks atThe review by Mankovich and Freeman  shows thThe review by Maiti and Picard , an ‘EdiThe review by van Oosten-Hawle  looks atThe ‘Editor’s Choice’ article by Haufeng  discusseThe study by Omkar et al.  exploredA second contribution by Bjorklund et al.  looks atIn conclusion, the ‘Special Issue’ brings together a series of review and research papers that concentrate on past and recent advances on Hsp90. It highlights its diverse role form the cytoplasm to the extracellular environment and even at the organismal level, and concentrates on the structure, mechanism and its pivotal position in disease. The articles bring together a diverse array of research findings into specific articles that will help drive research effectively towards making further progress in this fascinating research field that is Hsp90.


Dear Editor:1. From the OCT images presented, the case in the inverted ILM flap group had MTM with lamellar macular hole (LMH); after surgery, the OCT images shows a flap closure configuration, instead of a true MH. This pattern is precisely what we would like to achieve with the addition of inverted ILM flap. Bonińska et al. [We read with interest the article “Anatomical and visual outcomes of fovea‑sparing internal limiting membrane (ILM) peeling with or without inverted flap technique for myopic foveoschisis” by Zheng et al. . In thisa et al.  has repoa et al. . This po


The purpose of this review was to identify the effectiveness of environmental control (EC) non-pharmaceutical interventions (NPIs) in reducing transmission of SARS-CoV-2 through conducting a systematic review. EC NPIs considered in this review are room ventilation, air filtration/cleaning, room occupancy, surface disinfection, barrier devices, This article is part of the theme issue ‘The effectiveness of non-pharmaceutical interventions on the COVID-19 pandemic: the evidence’. The rapid spread of SARS-CoV-2 worldwide presented a unique challenge ,2. For iMany countries implemented isolation of imported cases of COVID-19 and their contacts, but by late February 2020 cases of community transmission with no links to travel were identified in the UK and many other countries . The rapAlthough highly effective in reducing transmission, the adverse social and economic consequences associated with lockdown  meant thThis review of the impact of environmental controls (ECs) covers ventilation, occupancy, disinfection and air filtration. ECs are defined as measures which were intended to alter the potential contamination level of surfaces, imposed barriers to person-to-person contact, and modified the air within buildings. By focusing on transmission rather than surrogate markers such as virus detection in the environment, the review seeks to identify the effectiveness of measures in terms of reduction of transmission in real-life situations. While modelling and experimental studies help inform our understanding about the role of various ECs, direct extrapolation of their findings for humans in real-life situations is limited.. 2 (a)Systematic searches of databases from Web of Science, Medline, EMBASE, preprint servers MedRxiv and BioRxiv were conducted in order to identify studies reported between 1 January 2020 and 1 December 2022. All articles reporting on the effectiveness of ventilation, air filtration/cleaning, room occupancy, surface disinfection, barrier devices,  (b) 1.did not consider the transmission of SARS-CoV-2 between humans or animals 2.did not include a comparison between groups that implemented the NPI and groups that did not 3.were modelling studies with no original data 4.were experimental studies that used model aerosols with no SARS-CoV-2 virus 5.were studies on environmental sampling alone 6.did not include original research such as review papers etc. 7.were not published in English.Studies were included in the review if they (i) reported on the transmission of SARS-CoV-2 in humans or animals and (ii) reported how transmission is impacted by the implementation of the following EC NPIs: ventilation, air cleaning devices, surface disinfection, room occupancy modification, barrier devices,  (c)Three authors  screened the retrieved articles based on the title and abstract of the references. The obtained references were screened a second time by one reviewer (A.M.) to further exclude references based on criteria 3–6 listed above in §2b. A second reviewer (C.I.) reviewed 5% of the exclusions. Four reviewers  then performed a full text review in order to select the final papers based on the inclusion/exclusion criteria in §2b. Each paper selected for full text review was reviewed first by one reviewer (A.M.) and inclusion/exclusion decisions that were not straightforward were reviewed by a second reviewer . Disagreements were then subsequently resolved by a third reviewer. The following variables were noted in the final papers: country, setting, environmental NPI implemented, sample size, SARS-CoV-2 transmission results and other factors associated with transmission. Where available the following data were also summarized: measurements related to the environmental NPI considered (air changes per hour (ACH) or  (d)Three authors  made an assessment of methodological study quality using a Cochrane ‘risk of bias’ tool for non-randomized studies. Risk of bias assessment for each study using ROBINS-I is included in . 3n=3) [In total, 13 971 unique articles were identified in the systematic search. A total of 3217 of these were retrieved based on initial title and abstract screening. Further screening of the titles and abstracts based on the inclusion/exclusion criteria in §2b reduced the number of articles for full-text review to 1328. Only 19 of these studies met the inclusion criteria for the review; those which had been initially identified through pre-print servers were subsequently published following peer review, and it was the peer reviewed version which was included. For a detailed description of the number of references at each stage, see the Prisma flowchart in n=12) –21; air 2) [n=4) –28; surf4) [n=5) –24; room5) [n=6) ,24–26; aes (n=6) ,22–24; r6) [n=3) ,11,21; m3) [n=2) ; school 2) [n=2) ,17; an o2) [n=1) ; a bus (1) [n=1) . Two stu1) [n=2) ,28. TablAll of the included studies were found to have critical or serious risk of bias in at least one domain, see §4. (a)Among the 12 studies that considered the effectiveness of ventilation on the transmission of SARS-CoV-2: (i) six studies provided evidence suggesting improved ventilation decreases SARS-CoV-2 transmission, (ii) three studies found no association between improved ventilation and transmission and (iii) three studies considered the impact of a combination of NPIs that included ventilation, therefore making it difficult to determine the effect on transmission of ventilation alone.Positive association: Six (of 12) studies provided evidence suggesting improved ventilation decreases SARS-CoV-2 transmission. Only two of these studies directly measured ventilation rates, either experimentally . These : Six of  studies  [et al. . Walshe : Six of  studies u et al.  measured: Six of  studies et al. [Additionally, the viral load present in the boning hall (where the outbreak originated) may have been different from that in the abattoir, which could have impacted the differences in secondary infection rates. In the study of the two buses , the exet al. [et al. [et al. [et al. [In two of the other studies which showed decreased transmission with increased ventilation , ventil [et al.  consider [et al.  reportedet al. [et al. [et al. [et al. [The presence/absence of a ventilation system was assessed through questionnaires in the studies by Gettings et al.  and Poko [et al. . Getting [et al.  studied a et al.  analysedNo association: Three (of 12) studies showed no significant association between the presence of a ventilation system and SARS-CoV-2 transmission. In all three studies, data were collected through questionnaires or interviews. Wang et al. [et al. [et al. [et al. [et al. [g et al.  studied  [et al.  consider [et al.  consider [et al. , there w [et al. , there whree of 1 studies Unclear association: Three (of 12) studies considered ventilation in combination with a range of other NPIs  and do  [et al.  found thet al. [et al. [et al. [Feathers et al.  and Danc [et al.  studied  [et al.  changed  (i)et al. [All of the four studies that considered the effectiveness of air cleaning devices reported evidence for reduced viral transmission ,26–28. HPositive association: The only controlled laboratory experiments identified in this review were undertaken by Fischer et al. [et al. [et al. [et al. [r et al.  and Zhan [et al. , and the [et al.  separate [et al.  showed t [et al. . Howeveret al. [Gettings et al.  Among the six studies that considered the impact of room occupancy on SARS-CoV-2 transmission, (i) four studies provided evidence suggesting that decreasing room occupancy leads to a reduction in SARS-CoV-2 transmission, (ii) one study concluded that there is no association between room occupancy and transmission and (iii) one study showed unclear association.Positive association: Walshe et al. [et al. [et al. [et al. [et al. [e et al.   was one of a number of different factors considered and using statistical analysis they concluded that this factor did not have a significant impact on transmission.g et al. ) reporteUnclear association: Oginawati et al. [per capita) was associated with increased transmission in a residential setting. However, the authors attributed this result to the likelihood (based on trends in the area studied) that larger houses generally contained more family members (i.e. more people in the same house), and therefore a larger susceptible population for each index case. The significance for the association between lower occupancy rates with higher transmission in this study was therefore confounded by the measure of occupancy used.i et al.  conclude (c)Five studies were identified that considered the effectiveness of surface disinfection on transmission of SARS-CoV-2: (i) three showed a positive association, i.e. enhanced disinfection was associated with reduced transmission and (ii) two studies showed no association between disinfection and transmission. These studies relied on data collected through questionnaires, interviews or site visits.Positive association: Atnafie et al. [et al. [et al. [et al. [et al. [e et al.  and Kera [et al.  consider [et al.  used dati et al.  compared [et al.  consideret al. [et al. [et al. [Both of the studies on healthcare settings  were ba [et al. , it was No association: Guedes et al. [et al. [s et al.  studied  [et al.  studied  (d)et al. [Only one of the identified studies considered the impact of barrier devices on transmission. Gettings et al.  No evidence was found for the effectiveness (or ineffectiveness) of the EC NPIs of . 4The risk of bias assessment for each domain across all included studies is given in . 5For all but one of the NPIs considered there were studies that reported a positive association (i.e. that the NPI reduced transmission), no association (i.e. that the NPI was ineffective for reducing transmission) and unclear association. Most of the studies were based on retrospective analyses of real-world settings with many factors either left uncontrolled or not measured including; the viral load of the infectors, the number of infectors, the size of the susceptible population, infection risk of the host outside the investigated setting, and the influence of other NPIs etc. . These factivity –36.Due to such confounding factors, many of the studies reported in §3 have a high risk of bias.Additionally, in most real-world settings, a combination of NPIs was generally employed together to reduce transmission, thereby making it difficult to determine the effect of a single NPI from observations of these settings. Many of the studies reported in §3 used questionnaires, interviews or surveys to collect data, thereby introducing potential bias in the data. For the few studies that measured the impact of the different NPIs in settings where there were recorded transmission events, the exact conditions  that were present during the transmission event were not fully documented, thereby weakening the confidence in the conclusions. Two laboratory animal studies were identified in this review. However, transmission between segregated infected and naive hamsters in controlled environments is not directly comparable to socially mixing humans. Furthermore, the sample size of these animal studies (of infectors and infectees) was very small, and there was a lack of measurement of factors such as the amount of virus present in the environment. The combination of these factors reduces the confidence of findings from these studies in terms of how they may relate to human transmission of SARS-CoV-2. (a)Studies that were published outside of the date range for the review or did not directly provide evidence for the effectiveness of the NPIs, but instead just suggested an association between the NPI and transmission, were excluded from the results section of this review. However, some of these studies do provide insights into the NPIs and are therefore briefly discussed here. The choice of which ‘excluded’ studies to discuss is not exhaustive, but chosen to represent the breadth of the material discovered in the literature.Ventilation and air filtration: There are studies that report on outbreaks where, in the absence of adequate ventilation, the authors attributed long-range airborne transmission as the dominant transmission route [et al. [et al. [on route –50. They [et al.  and Vern [et al. ) showed  [et al. –57. From [et al. . The autSome studies found a correlation between the probability of getting infected and the location of people relative to the air handling units in the setting ,59. Theset al. [et al. [The analysis of air samples for SARS-CoV-2 genomic material (SARS-CoV-2 RNA by RT-PCR) is a method widely used for assessing the impact of ventilation and air cleaning devices. A number of studies have shown some reduction in SARS-CoV-2 genomic material in the air samples collected from hospitals with COVID-19 patients and enhanced ventilation ,62. HEPAet al. , it was  [et al.  showed t [et al. ,66. Howeet al. [Buonanno et al.  consideron rates ,69. FurtSurface disinfection: Contamination of surfaces in houses or hospital wards housing individuals with COVID-19 suggests that fomite transmission may be possible [et al. studied secondary transmission to HCWs that performed gastrointestinal endoscopy in 11 COVID-19 patients at a hospital in China, where enhanced disinfection strategies were in place both during and after the procedures. No SARS-CoV-2 transmission to HCWs was reported in the study [possible –72. Lin he study . Howeverin vitro disinfection of non-porous surfaces inoculated with inactivated SARS-CoV-2 demonstrated a reduction in detectable genomic material after disinfection [A number of studies involved the swabbing of surfaces in hospitals housing COVID-19 patients and were able to demonstrate reduction in the detection of SARS-CoV-2 genomic material after disinfection –79. Howenfection .Barrier devices: A type of barrier device  was used during aerosol generating procedures on COVID-19 positive patients in healthcare settings. There are studies that report zero or reduced transmission to HCWs during procedures where such barrier devices were employed [e.g. yed e.g. , 82. Howyed e.g. . This suyed e.g. . They us. 6Evidence from the literature suggests that EC NPIs of ventilation, air cleaning devices and limiting room-occupancy may have a role in reducing transmission in specified settings. However, it is important to recognize that this conclusion is based on evidence which was usually of low or very low quality and hence the level of confidence ascribed to it is low. There were two significant challenges that limited the confidence in evidence for the effectiveness of many NPIs examined: (a) the low number of studies and (b) the low-quality assessment of the identified studies. What does this mean for the future? It is recommended that future studies on NPIs should be prioritized where there is a current lack of evidence on the effectiveness on transmission and where they have significant implementation cost including: (i) enhanced surface disinfection, (ii) use of barrier-devices, (iii) Many of the studies identified herein had a critical risk of bias mainly due to confounding factors. It is suggested that international level checklists/guidelines/protocols for both field and laboratory studies on pathogen transmission are established in order to ensure optimum utilization of available research resources. A more standardized approach focused on reducing confounding factors would equip future researchers with the tools that would enable a higher degree of confidence to be associated with their conclusions.Only 19 studies from the initial dataset of 13 971 references addressed the issue of the effectiveness of EC NPIs on the transmission of SARS-CoV-2 in humans or animals . The paucity and low quality of evidence makes it challenging to draw firm conclusions regarding the effectiveness of implementing these NPIs in the future to control the spread of SARS-CoV-2. This is exacerbated by apparently contradictory findings for almost all NPIs investigated (in that at least one study reported the opposite conclusion to the others). The review did not involve simply counting the number of studies for and against; the robustness of each study and findings were assessed and the extent to which confounding factors played a role was also considered. A majority of the studies were found to provide only low-quality evidence mainly due to the presence of many confounding factors in the study design.The evidence identified for surface disinfection and barrier devices (screens) does not permit conclusions to be drawn regarding their effectiveness against SARS-CoV-2 transmission. While this does not mean that they are ineffective, their effect on SARS-CoV-2 transmission is not yet known. No studies were found that discussed the effect of Evidence, although of low quality, was found which showed increased ventilation and use of air cleaning devices reduced the transmission of SARS-CoV-2 in some situations. There was evidence, also of low quality, that decreasing the occupancy levels within some settings was found to be effective in reducing the transmission of SARS-CoV-2. An important caveat is that the evidence for these measures is limited to the settings that were studied and cannot necessarily be extrapolated beyond these. There is no evidence on the implementation of EC NPIs that provides any information on their effectiveness in altering transmission of SARS-CoV-2 at a community or population level.In summary, this review has highlighted that there are significant knowledge gaps regarding the effectiveness of ECs in limiting transmission of SARS-CoV-2. It is extremely challenging to conduct controlled studies in the midst of a pandemic. However, it is important that lessons can be learned in these circumstances and protocols should be established to study the effectiveness of ECs using observational approaches during a pandemic. It is equally important that rigorous controlled studies are undertaken to study the effectiveness of ECs in experimental studies before another pandemic strikes.


Elective surgery can be overwhelming for children, leading to pre-operative anxiety, which is associated with adverse clinical and behavioural outcomes. Evidence shows that paediatric preparation digital health interventions (DHIs) can contribute to reduced pre-operative anxiety and negative behavioural changes. However, this evidence does not consider their design and development in the context of behavioural science. This systematic review used the Theoretical Domains Framework (TDF) to evaluate the design and development of DHIs used to support children up to 14 years of age and their parents, prepare for hospital procedures, and determine any correlation to health outcomes. It also considered whether any behavioural frameworks and co-production were utilised in their design.A search of the MEDLINE, EMBASE, PsycINFO, and HMIC databases was carried out, looking for original, empirical research using digital paediatric preparation technologies to reduce pre-operative anxiety and behavioural changes. Limitations for the period (2000–2022), English language, and age applied.Seventeen studies were included, sixteen randomised control trials and one before and after evaluation study. The results suggest that paediatric preparation DHIs that score highly against the TDF are (1) associated with improved health outcomes, (2) incorporate the use of co-production and behavioural science in their design, (3) are interactive, and (4) are used at home in advance of the planned procedure.Paediatric preparation DHIs that are co-produced and designed in the context of behavioural science are associated with reduced pre-operative anxiety and improved health outcomes and may be more cost-effective than other interventions.https://www.crd.york.ac.uk/prospero/, identifier: CRD42022274182. AnaesthHeightened pre-operative anxiety can lead to poor anaesthesia induction, an increased risk of emergence delirium, pain, inconsolable crying, irritation, incoherency, and uncooperativeness . These fVarious pharmacological and non-pharmacological interventions have been used to reduce pre-operative anxiety in children and improve post-operative psychological and physiological outcomes. Pharmacological interventions include anti-anxiety and sedative drugs, but these commonly cause adverse effects such as drowsiness and can interfere with anaesthesia medication . Non-phaThe use of pre-operative preparation interventions indicates that well-prepared children have reduced pre-operative anxiety and negative responses to surgery or medical procedures –16. Pre-Behavioural science is interested in aspects such as behavioural change, in this case, the design and development of paediatric preparation DHIs and their impact on children's emotional, behavioural, and clinical outcomes. Due to the lack of understanding between the preparation DHIs and behavioural change, this systematic review builds upon this research. It looks specifically at the design and development of paediatric preparation DHIs through the application of the Theoretical Domains Framework (TDF). It applies the 14 domains of the TDF to assess the components of DHIs and examines whether there is a correlation to improved outcomes. The TDF was developed from the synthesis of 33 behaviour change theories into a framework comprising 14 domains and 84 behaviour constructs, founded on the Behaviour Change Wheel . The Beh1.1.Children undergoing medical procedures, anaesthesia, and surgery experience significant psychological and physiological reactions. The unfamiliar environment, the equipment and routines, fear of separation, needles, and the medical procedure are well documented as sources of these negative reactions –29. Thes1.1.1.Pharmacological interventions include anti-anxiety and sedation medications, such as Midazolam, Fentanyl, Ketamine, and Clonidine. These are used as effective pre-operative anxiolytic and sedation medications in children, which reduce pre-operative nausea and vomiting, enable satisfactory separation from parents and anaesthesia induction, and reduced the need for post-operative analgesics –35. HoweDue to these adverse side-effects, non-pharmacological interventions have increasingly been used to manage pre-operative anxiety. Research on the use of parental presence is mixed. Some papers suggest it has been used to provide reassurance and comfort, eliminate separation anxiety and reduce the need for medications, while other papers suggest it can increase anxiety if parents themselves are anxious –39. DistWithin the last 20 years, there has been increased research into the use of digital technologies such as DHIs to manage pre-operative anxiety either through distraction , 48, 49 1.1.2.The TDF provides a validated framework, developed to provide a more accessible and usable tool to support improving the implementation of evidence-based practice. By bringing together a range of behaviour theories and key theoretical constructs, a simple and integrated framework is provided to inform and assess intervention design and implementation . The TDFThis study aimed to evaluate the design and development of paediatric preparation DHIs used to support children up to 14 years of age, and their parents, to prepare for hospital procedures, and to understand their impact on their health outcomes. The primary objective was to evaluate the design and development of paediatric preparation DHIs against the TDF and ascertain whether any behavioural frameworks and co-production were used. A secondary objective, and in the context of the previous systematic reviews , 20, 53,2.The study protocol is publicly available under registration number CRD42022274182 on the International Prospective Register of Systematic Reviews (PROSPERO). The inclusion and exclusion criteria  were bui2.1.The OVID databases that were selected were MEDLINE, EMBASE, PsycINFO, and HMIC. A mix of keywords and Medical Subject Headings (MESHs) was used to search for themes. The search was carried out in February 2022 using the complete syntax with truncation for each database as outlined in 2.2.The preliminary search returned 931 records; 363 duplicate records were identified, and 176 records were removed. A total of 730 records remained, and these progressed to the stage of title and abstract screening . Two revData relevant for extraction were considered against the aims and objectives of the review . SupplemThe synthesis and analysis were first assessed, on the basis of the degree of homogeneity , 81, in 1.input from one or more healthcare professionals, children, and parents, and2.use of any behavioural frameworks.During pilot testing of the modified TDF against a few studies, it was decided that the TDF’s “social/ professional role and identity” domain was not applicable. This was attributed to its focus on the behaviours and displayed personal qualities in a social or work setting, whereas the TDF domains were being used to assess the design of digital intervention in respect of use by children and their parents. It was subsequently removed and the scoring for the evaluation of the DHIs was adjusted to be out of 15 domains.The digital health interventions in the studies are aimed at changing behaviour to reduce pre-operative anxiety through education, information, and coping strategies. The TDF was chosen to evaluate the design and development of the digital health interventions within the context of behavioural science, as it is a validated tool for assessing implementation issues, supporting intervention design, and analysing interventions , 26, 82.For each domain in the modified TDF, the domain descriptions were used to develop a criteria checklist to guide the evaluation of the DHIs. The criteria checklist considered what information, activities, techniques, or actions the DHIs should incorporate to meet the domain descriptions. This was tested against a sample of the DHIs to refine the criteria checklist. Each DHI was then assessed against each domain criteria checklist and a score applied depending on whether the DHI fully met, partially met, or did not meet the requirements in the criteria checklist. To determine any correlation between the evaluation of the development of the DHIs and the reported outcomes, quantitative data was converted into a summary statistic. Specifically, this examined what outcomes were measured and how, whether there was a noticeable measure of effect, and how it correlated to the scoring from the DHI evaluation. To ensure that the data analysis met the requirement of systematic review transparency, established reporting guidelines were followed .d, Glass's delta, and Hedges’ g  or the state  anxiety between groups. State anxiety on arrival at the hospital was significantly lower in the DHIG with a negative medium effect  compared with that in the control group. Similarly, Wantanakorn et al. (p = 0.82) to after its application (p = 0.012) within the DHIG, with a negative medium effect (d = 0.6). This suggests that the DHIs positively impacted levels of anxiety in these two studies. It is noted that both DHIs included interactive elements and scored fully in the domains for behavioural regulation, beliefs about capabilities, and reinforcement. However, Wantanakorn et al. (d = 0 and d = 0.03). Parental self-reported state anxiety (STAI-S) increased pre-procedure and decreased post-procedure but with a notable increase in anxiety in the DHIG compared with that in the two control groups. A medium positive effect occurred between the DHIG and control group 1 (d = 0.58) and a small positive effect between the DHIG and control group 2 (d = 0.48) pre-procedure, changing to a small positive effect compared with control group 1 (d = 0.43) and no effect compared with control group 2 (d = 0.15) post-procedure. Fernandes et al. (p < 0.001). This translated into a large negative effect between the DHIG and each of the controls. In addition, the video game control group had lower levels of worries compared with the no intervention control group. SAM results showed no significant differences in valence  or arousal (happiness) between the groups before and after the interventions. Despite this, a small effect (d = 0.25) was calculated between the DHIG and control group 1 for valence post-intervention. For arousal in the DHIG compared with the control groups, a small effect occurred pre-intervention (d = 0.20 and d = 0.4) and a medium effect post-intervention . Parental anxiety in the DHIG was significantly lower with a negative medium effect compared with that in control group 1  but comparable with no effect compared with that in control group 2 (d = 0.08). This DHI was developed using a behavioural framework and co-production with children and healthcare professionals. It also met the modified TDF domains for emotion and reinforcement, scoring fully across seven domains. Fortier et al. (p = 004) in the DHIG than in the control group pre-procedure and post-intervention, with a medium negative effect (d = 0.65). Anxiety remained lower in the DHIG at separation but was not statistically significant and had a small negative effect (d = 0.25). Wakimizu et al. (d = 0.45) and 1 month after the procedure (d = 0.27), and a partial small effect occurred at 1 week after the procedure (d = 0.2). Wakimizu et al. (d = 0.60) effect post-operatively and a negative small effect (d = 0.23) at 1 week after the procedure, and all other time points showed no effect. Campbell et al. (p = 0.790) before the intervention across all three groups . However, during induction and recovery, the observer-rated child VAS to determine anxiety levels shows a decrease in anxiety across all groups over time. A significant change was noted between the DHIG and control group 1 at induction (p = 0.014) and between the DHIG and control group 2 at recovery (0.016). The effect could not be calculated because of a non-normal distribution of data. While the results of these two studies suggest that the DHI had some impact, albeit a small effect for Wakimizu et al. (p = 0.009) in the DHIG post-intervention and with a negative medium effect (0.67).Bray et al.  revealedn et al.  revealedn et al.  only parn et al.  scored fn et al.  showed ts et al.  assessedr et al.  parentalu et al.  showed cu et al.  also foul et al.  found seu et al. , it is n3.5.1.2.p = 0.407) and after . Likewise, self-reported STAI and observed VAS parental anxiety were comparable between the control group and the DHIG immediately after child induction with no effect observed in the STAI results (d = 0.01). Campbell et al.  between the I-PPP and the usual care groups in the holding area and to a medium negative effect (d = 0.53) and small negative effect (d = 0.34) between the DHIG and the usual care and I-PPP + parent groups, respectively. The lower anxiety levels in both the I-PPP and the I-PPP + parent groups to the usual care group suggest that the DHI positively impacted anxiety levels. When considered against the higher parental anxiety STAI-S scores in the control groups, it was possible that parental anxiety may have impacted child anxiety. Fortier et al.  and again considerably during induction . Parental STAI anxiety scores followed a similar trend to that of the children. The DHI used by Hatipoglu et al. (p < 0.001). A large negative effect was calculated between the DHIG and the control groups, respectively . The DHIs used by Wantanakorn et al.  in observer-rated m-YPAS child anxiety after the use of the DHI in the DHIG compared with the control group. A medium negative effect (d = 0.6) and large negative effect (d = 0.9) were calculated. Ryu et al.  between the DHIG and the control group after the use of the DHI 1 h before the procedure, with negative effects of small (d = 0.47) and large (d = 0.80) in the first two. The effect could not be calculated for Ryu et al. (p = 0.01). Ryu et al. . Fortier et al. (p = 0.04), with a small negative effect (d = 0.45). Post-operative behaviour was measured by Hatipoglu et al. (p < 0.001) between control group 1  and both control group 2 (voice recording) and the DHIG. The effect size between the DHIG was large to control group 1 (d = 2.049) and small to control group 2 (d = 0.31). In addition, they showed that anxious children had a 1.03 times greater risk of adopting negative post-operative behaviours.The DHIs used by Wright et al.  and Fortr et al.  found a u et al.  was a vin et al.  and Ligun et al.  were useu et al. , 61, 70 u et al.  reportedu et al.  measuredr et al.  measuredu et al.  using th3.5.2.2.d = 0.02 at admission before intervention and d = 0.01 in the holding area after the intervention. Although the intervention was used a week before the procedure, Huntington et al. (d = 0.21) was calculated between the DHIG and control group 2 (handwashing game) both pre- and at induction. For induction behaviour and compliance, Ryu et al. (p = 0.92). Huntington et al. . Park et al. (d = 0.07). Ryu et al. . For behaviour, Ryu et al.  among children in the two groups. Eijlers et al. (p = 0.251).Eijlers et al.  found non et al.  found nou et al.  found PBn et al.  found nok et al.  ICC resuu et al.  and Eijlu et al.  also meau et al.  used thes et al.  used the3.5.3.d = 0.45, d = 0.36) increasing to a medium negative effect post-intervention  in the DHIG compared with the control groups.The study by Fernandes et al.  was the 3.5.4.p = 0.410, p = 0.454, and p = 0.30, respectively. For patient flow, Huntington et al. (d = 0.31) and spent less time on the ward compared with control group 1  with a small negative effect (d = 0.28). Fortier et al. (p = 0.708) or recovery (p = 0.26) time. Medication usage for analgesic consumption was recorded by Fortier et al. , and overall, a small effect (d = 0.22) was calculated between the need for rescue analgesia in the DHIG compared with the control group. Stunden et al. (p = 0.07) nor among the three groups (p = 0.27). The chi-square p-value effect calculated a small effect (d = 0.43) in average successful MRI and a small negative effect (d = 0.26) between the groups, with the DHIG (VR-MRI) being on average less successful at 30% compared with control group 1 (SPM) at 47% and control group 2 (CLP) at 50%. Preparation time and assessment time were measured in minutes. Preparation time between the groups was significantly different (p < 0.001) and had a medium effect size (η2 = 0.57), with the DHIG preparing the longest on average at 22.05 min. However, assessment time was comparable across the groups with no significant difference (p = 0.13).Clinical status was assessed in five studies , 68, 71 n et al.  measuredr et al. , with aln et al.  used hea3.5.5.p < 0.001) and parents or caregivers (p = 0.01) in the DHIG compared with the control group. The calculated effect was positively large for children (d = 1.11) and positively medium (d = 0.59) for parents and caregivers. Procedural satisfaction in children and parents was not statistically significant (p = 0.10 and p = 0.72) but was higher in the DHIG than in the control group, with a small positive effect in children (d = 0.37). Stunden et al.  and whether it improved their child's ability to cope . Ryu et al. . Park et al. (p = 0.008). Wright et al. (d = 0.20) was calculated against control group 1 and a medium negative effect (d = 0.50) was calculated against control group 2. Stunden et al. (p = 0.03), and of the 20 children who completed the form, they liked the different components. Wakimizu et al.  were satisfied.DHI usability, satisfaction, and/or knowledge and understanding were assessed using seven different measures across eight studies , 70, 73.um d = 0. for paren et al.  measuredn et al.  evaluateu et al. , 70 usedk et al.  did findt et al.  measuredum d = 0. for paren et al.  used a 53.6.The risk of bias across the 16 randomised control trials was generally concerning, with 68.8% having an overall result of some concern –70, 73 aAll studies used a random group allocation sequence, with this being computerised in eight studies , 70–72. Bias due to deviations from intended interventions (D2) was low across 50% of studies. Of the five studies considered to have some concern of bias in this domain, three , 62, 63 Bias due to missing outcome data (D3) was low across 88% of the studies and considered high for two studies. Ryu et al.  excludedBias for measurement of outcome (D4) was deemed low in 50% of studies , 70, 71 Most studies 68.8%) had some concern for bias in D5 “selection of the reported results”. This was due to an inability to confirm whether the outcome data were analysed following a finalised pre-specified analysis plan before unblinded outcome data were made available for analysis. This according to Cochrane RoB2 guidelines  means th.8% had sMedical trials entail a comprehensive understanding of clinical ethics, with those involving children complicated by stricter standards than those involving adults . In addi4.1.health outcomes observed,2.co-production and use of behaviour frameworks,3.type of DHIs, and4.timing and location of the DHIs used.DHIs are increasingly being used to prepare children and their parents for hospital procedures, aiming to reduce pre-operative anxiety and improve health outcomes. It is evidenced that well-prepared children are associated with reduced pre-operative anxiety and that DHIs can be an effective preparation method –16. This4.1.All studies included in this review assessed child anxiety either as an emotion or as a feeling or behavioural response. Compared with children in the control group(s), 14 studies (82%) showed that children using the DHIs were associated with lower anxiety levels and the DHI had a positive impact, with this corresponding to the result of the effect size calculations where they could be calculated. This differed for three studies (17%), which showed anxiety levels were similar and the DHIs had no or little impact and effect. Given that higher pre-operative anxiety is a predictor of negative behavioural changes, the results for measures such as emergence delirium, induction behaviour, and induction compliance were mixed, although they were considered only in a small number of the included studies. For the three studies , 68, 71 The first finding is that paediatric preparation DHIs scoring higher against the modified TDF are more likely to be associated with reduced anxiety and reduced negative behavioural changes, as they will provide detailed information on the planned procedure and encompass information on coping with emotions, feelings, and anxiety , 13. Bra4.2.The second finding is that preparation DHIs scoring higher against the modified TDF are more likely to have used co-production and a behavioural framework in their design and development. Aufegger et al.  stated tThe three higher scoring studies , 62, 71 4.3.The third finding is that the type of preparation DHI plays an important role in achieving a higher score against the modified TDF, with this being intrinsically linked to interactivity and rewards or achievements. In a previous qualitative study , childre4.4.The fourth finding is that the timing and location of the preparation DHI lends itself to a higher score against the modified TDF. Three of the highest scoring DHIs, by Bray et al. , Wright 4.5.This study's strength is that it evaluates the design and development of DHIs used in preparing children for hospital procedures, correlating this against effectiveness in improving outcomes. Previous systematic reviews , 98–100 There are limitations to this study. The first and second limitations relate to the search strategy and data extraction. While the search strategy was considered comprehensive, it was limited to papers in English published within the last 22 years, with the period being to ensure the relevance of the studies. When snowballing references of included papers and previous systematic reviews, a few papers published before the year 2000 may have been relevant for inclusion.The third was the inability to conduct a meta-analysis because of the presence of heterogeneity across the included studies. Consequently, effect sizes were calculated, but not all studies reported the mean and standard deviation. It was, therefore, necessary to convert the median and interquartile ranges into a mean and standard deviation to then calculate the effect size. However, due to insufficient information to determine proximity to a normal distribution, the results may potentially be skewed. Some data reported in the studies were not amendable to calculating the effect size, and for these studies, the results were only narratively synthesised.Finally, the level of information contained within some of the study papers to describe the DHIs was minimal, with supporting resources not found. This was a factor in the inability to draw meaningful conclusions against many of the modified TDF domains.4.6.The quality of the studies was predominately moderate, with five studies having an overall high risk of bias. However, when considering the individual risk of bias in each of the five domains, it generally ranged from low to some concern, with most of the concerns linked either to an uncertainty of, or to a confirmed lack of, blinding of participants or those assessing the data, or to a lack of information in the papers to make a judgement. This was within the domains for “randomisation process” and “selection of reported results”, with the latter predominately linked to uncertainty on whether the analysis plan was finalised before results were assessed and the trial protocol not being readily available to verify, rather than the results being biased.4.7.It is considered that this study is the first to use an adapted version of the TDF to assess the design and development of DHIs used to prepare children for hospital procedures. The four key findings from this study suggest that the TDF can be used to analyse the effects of preparation DHIs, and by using theory-driven behavioural science, their design can be redressed accordingly to improve health outcomes. While these findings contribute to this field of study, further research is required to validate the findings. Furthermore, research is required to understand the developmental costs of these preparation DHIs and whether they are cost-effective against the traditional form of pre-operative preparation.5.The Theoretical Domains Framework is a validated tool designed to enable the evaluation of behaviour change and can be used to assess implementation issues, support intervention design, and analyse interventions. This study applied an adapted version of the Theoretical Domains Framework to assess the design and development of DHIs used to prepare children for hospital procedures.1.associated with positive health outcomes,2.influenced by the use of co-production and behavioural science in their design and development,3.interactive,4.used a few days to a week in advance of the planned procedure within the comfort of the child's own home.These four findings together are associated with reduced anxiety and reduced negative behavioural changes in the DHIs that scored the highest against the modified TDF. Furthermore, well-designed and developed DHIs that can be used in the child's own home and in advance of the planned procedure may be more cost-effective. This is in respect of the reduced staff time for on-the-day preparation and the potential longer-term reduced healthcare utilisation.The main findings from this assessment are that DHIs scoring highly against the modified TDF arePaediatric preparation DHIs that are designed in the context of behavioural science and with co-development from healthcare professionals, children, and their parents are more likely to be associated with reduced pre-operative anxiety and have the potential for improving health outcomes. Furthermore, the use of paediatric preparation DHIs well in advance of planned invasive and non-invasive procedures may be more cost-effective than traditional preparation programmes such as Child Life Specialists or hospital tours that require staff time, resourcing, and planning around the child's procedure. By enabling pre-operative information to be provided digitally in the child's own home, these costs could be reduced. However, further research is required into the cost–benefit of this weighed against the developmental costs associated with the DHIs, particularly those that have shown to be more effective in reducing pre-operative anxiety.