Artificial and biological supports are different for pea plants.

Previous studies on the kinematics of pea plants' ascent and attach behavior have demonstrated that the signature of their movement varies depending on the kind of support. So far, these studies have been confined to artificial supports (e.g. wooden sticks). Little is known regarding the conditions under which pea plants could rely on biological supports (e.g. neighboring plants) for climbing toward the light. In this study, we capitalize on the 3D kinematic analysis of movement to ascertain whether pea plants scale their kinematics differently depending on whether they aim for artificial or biological support. Results suggest that biological support determines a smoother and more accurate behavior than that elicited by the artificial one. These results shed light on pea plants' ability to detect and classify the properties of objects and implement a movement plan attuned to the very nature of the support. We contend that such differences depend on the augmented multisensory experience elicited by the biological support.

Ascent and Attachment in Pea Plants: A Matter of Iteration.

Pea plants (Pisum sativum L.) can perceive the presence of potential supports in the environment and flexibly adapt their behavior to clasp them. How pea plants control and perfect this behavior during growth remains unexplored. Here, we attempt to fill this gap by studying the movement of the apex and the tendrils at different leaves using three-dimensional (3D) kinematical analysis. We hypothesized that plants accumulate information and resources through the circumnutation movements of each leaf. Information generates the kinematical coordinates for the final launch towards the potential support. Results suggest that developing a functional approach to grasp movement may involve an interactive trial and error process based on continuous cross-talk across leaves. This internal communication provides evidence that plants adopt plastic responses in a way that optimally corresponds to support search scenarios.

A system for the study of roots 3D kinematics in hydroponic culture: a study on the oscillatory features of root tip.

BACKGROUND: The root of a plant is a fundamental organ for the multisensory perception of the environment. Investigating root growth dynamics as a mean of their interaction with the environment is of key importance for improving knowledge in plant behaviour, plant biology and agriculture. To date, it is difficult to study roots movements from a dynamic perspective given that available technologies for root imaging focus mostly on static characterizations, lacking temporal and three-dimensional (3D) spatial information. This paper describes a new system based on time-lapse for the 3D reconstruction and analysis of roots growing in hydroponics. RESULTS: The system is based on infrared stereo-cameras acquiring time-lapse images of the roots for 3D reconstruction. The acquisition protocol guarantees the root growth in complete dark while the upper part of the plant grows in normal light conditions. The system extracts the 3D trajectory of the root tip and a set of descriptive features in both the temporal and frequency domains. The system has been used on Zea mays L. (B73) during the first week of growth and shows good inter-reliability between operators with an Intra Class Correlation Coefficient (ICC) > 0.9 for all features extracted. It also showed measurement accuracy with a median difference of < 1 mm between computed and manually measured root length. CONCLUSIONS: The system and the protocol presented in this study enable accurate 3D analysis of primary root growth in hydroponics. It can serve as a valuable tool for analysing real-time root responses to environmental stimuli thus improving knowledge on the processes contributing to roots physiological and phenotypic plasticity.

Exploring the impact of socially assistive robots on health and wellbeing across the lifespan: An umbrella review and meta-analysis.

BACKGROUND: Socially assistive robots offer an alternate source of connection for interventions within health and social care amidst a landscape of technological advancement and reduced staff capacity. There is a need to summarise the available systematic reviews on the health and wellbeing impacts to evaluate effectiveness, explore potential moderators and mediators, and identify recommendations for future research and practice. OBJECTIVE: To explore the effect of socially assistive robots within health and social care on psychosocial, behavioural, and physiological health and wellbeing outcomes across the lifespan (PROSPERO registration number: CRD42023423862). DESIGN: An umbrella review utilising meta-analysis, narrative synthesis, and vote counting by direction of effect. METHODS: 14 databases were searched (ProQuest Health Research Premium collection, Scopus, PubMed, Web of Science, ASM Digital Library, IEEE Xplore, Cochrane Reviews, and EPISTEMONIKOS) from 2005 to May 4, 2023. Systematic reviews including the effects of socially assistive robots on health outcomes were included and a pooled meta-analysis, vote counting by direction of effect, and narrative synthesis were applied. The second version of A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) was applied to assess quality of included reviews. RESULTS: 35 reviews were identified, most focusing on older adults with or without dementia (n = 24). Pooled meta-analysis indicated no effect of socially assistive robots on quality of life (standard mean difference (SMD) = 0.43), anxiety (SMD = -0.02), or depression (SMD = 0.21), although vote counting identified significant improvements in social interaction, mood, positive affect, loneliness, stress, and pain across the lifespan, and narrative synthesis identified an improvement in anxiety in children. However, some reviews reported no significant difference between the effects of socially assistive robots and a plush toy, and there was no effect of socially assistive robots on psychiatric outcomes including agitation, neuropsychiatric symptoms, and medication use. DISCUSSION: Socially assistive robots show promise for improving non-psychiatric outcomes such as loneliness, positive affect, stress, and pain, but exert no effect on psychiatric outcomes such as depression and agitation. The main mechanism of effect within group settings appeared to be the stimulation of social interaction with other humans. Limitations include the low quality and high amount of overlap between included reviews. CONCLUSION: Socially assistive robots may help to improve loneliness, social interaction, and positive affect in older adults, decrease anxiety and distress in children, and improve mood, stress, and reduce pain across the lifespan. However, before recommendations for socially assistive robots can be made, a cost-effectiveness analysis of socially assistive robots to improve mood across the lifespan, and a quantitative analysis of the effects on pain, anxiety, and distress in children are required.

The community nurse's role on the promotion of papillomavirus vaccination among young students: A study protocol.

Vaccination is the principal strategy for primary prevention of infection by Human Papilloma Virus (HPV), which causes different pathological conditions, up to cancer, in both males and females. However, to date, knowledge among adolescents and their parents about the HPV vaccine is still low. The aim of this quasi-experimental, multicenter study is to assess the effectiveness of a digital educational intervention, conducted by a multidisciplinary health-care team including a Community Nurse, to increase adolescents' HPV vaccination uptake, their knowledge, self-efficacy, feelings and involvement in HPV vaccine decision-making, and parents' vaccination hesitancy. The study will be carried out among a population of students (and their parents), aged between 11 and 13, at secondary schools in Italy. Validated questionnaires will be administered to both students and parents at baseline (T0) and 3 months after a digital educational intervention (T1). The findings may be useful in evaluating and deepening a methodology for designing and implementing educational interventions, embedded in the school setting, that could promote the achievement of outcomes within the broader process of youth's health promotion.

'United we stand, divided we fall': intertwining as evidence of joint actions in pea plants.

In life, it is common for almost every kind of organism to interact with one another. In the human realm, such interactions are at the basis of joint actions, when two or more agents syntonize their actions to achieve a common goal. Shared intentionality is the theoretical construct referring to the suite of abilities that enable such coordinated and collaborative interactions. While shared intentionality has become an important concept in research on social cognition, there is controversy surrounding its evolutionary origins. An aspect still unexplored but promising to bring new insights into this open debate is the study of aneural organisms. To fill this gap, here we investigate whether climbing plants can act jointly to achieve a common goal, i.e. reaching the light. We examined Pisum Sativum plants growing intertwined when there is a need to climb but a potential support is not present in the environment. Three-dimensional kinematic analysis of their movement revealed a coordinated and complementary behaviour. They tend to coordinate their movement in time and space to achieve a joint climbing. By deliberately extending the context in which a joint action takes place, we pay tribute to the complex nature of this social phenomenon. The next challenge for the field of joint action is to generate a perspective that links coordination mechanisms to an evolutionary framework across taxa.

Cardiometabolic risk estimation using exposome data and machine learning.

BACKGROUND: The human exposome encompasses all exposures that individuals encounter throughout their lifetime. It is now widely acknowledged that health outcomes are influenced not only by genetic factors but also by the interactions between these factors and various exposures. Consequently, the exposome has emerged as a significant contributor to the overall risk of developing major diseases, such as cardiovascular disease (CVD) and diabetes. Therefore, personalized early risk assessment based on exposome attributes might be a promising tool for identifying high-risk individuals and improving disease prevention. OBJECTIVE: Develop and evaluate a novel and fair machine learning (ML) model for CVD and type 2 diabetes (T2D) risk prediction based on a set of readily available exposome factors. We evaluated our model using internal and external validation groups from a multi-center cohort. To be considered fair, the model was required to demonstrate consistent performance across different sub-groups of the cohort. METHODS: From the UK Biobank, we identified 5,348 and 1,534 participants who within 13 years from the baseline visit were diagnosed with CVD and T2D, respectively. An equal number of participants who did not develop these pathologies were randomly selected as the control group. 109 readily available exposure variables from six different categories (physical measures, environmental, lifestyle, mental health events, sociodemographics, and early-life factors) from the participant's baseline visit were considered. We adopted the XGBoost ensemble model to predict individuals at risk of developing the diseases. The model's performance was compared to that of an integrative ML model which is based on a set of biological, clinical, physical, and sociodemographic variables, and, additionally for CVD, to the Framingham risk score. Moreover, we assessed the proposed model for potential bias related to sex, ethnicity, and age. Lastly, we interpreted the model's results using SHAP, a state-of-the-art explainability method. RESULTS: The proposed ML model presents a comparable performance to the integrative ML model despite using solely exposome information, achieving a ROC-AUC of 0.78±0.01 and 0.77±0.01 for CVD and T2D, respectively. Additionally, for CVD risk prediction, the exposome-based model presents an improved performance over the traditional Framingham risk score. No bias in terms of key sensitive variables was identified. CONCLUSIONS: We identified exposome factors that play an important role in identifying patients at risk of CVD and T2D, such as naps during the day, age completed full-time education, past tobacco smoking, frequency of tiredness/unenthusiasm, and current work status. Overall, this work demonstrates the potential of exposome-based machine learning as a fair CVD and T2D risk assessment tool.

Nurses' knowledge and self-assessment of their clinical experiences of intraosseous access: A multicentre cross-sectional study.

BACKGROUND: Intraosseous access is an effective and safe option when difficult vascular access occurs. The knowledge, competence, and clinical experience of nurses are collectively essential for the successful implementation of this approach in clinical practice. Education and clinical learning are the main pillars supporting this new practice to ensure patient safety. The aim of this study was to identify the nurses' knowledge and clinical experience of intraosseous access and the factors associated with the adoption of this procedure. METHODS: A cross-sectional study was carried out from October to December 2020. A convenience sample of 432 nurses from four Italian hospitals were involved. A structured questionnaire was used to assess the nurses' knowledge of the intraosseous access guidelines and their clinical experience. RESULTS: Most participants were female (71.5%) with more than 10 years of experience (63.7%) working in an emergency (38.9%) and medical (37.7%) setting. Most of the participants demonstrated their knowledge of the use of a device e.g., it is used if vascular access is not rapidly achieved in a child (83.1%) and the boluses of liquids required in the intraosseous procedure (72.7%). A few participants reported having placed intraosseous access (3.5%). A higher level of educational preparation and working in emergency and paediatric settings were associated with increased knowledge. CONCLUSIONS: Our findings highlighted a sub-optimal level of knowledge of the IO procedure, little experience of this practice in clinical contexts, also associated with a lack of adequate protocols and devices available to nurses. Nurses need to develop their knowledge and practice the skill clinically to embed this practice. University and nurse educators should emphasise the relevance of this practice in nursing education and training, so as to improve the nursing care practice and level of patient safety.

Evidence of motor intentions in plants: A kinematical study.

"How" an action is performed is not solely determined by biomechanical constraints, but it depends on the agent's intention, that is, "why" the action is performed. Recent findings suggest that intentions can be specified at a tangible and quantifiable level in the kinematics of movements; that is, different motor intentions translate into different kinematic patterns. In the present study, we used 3D kinematical analysis to investigate whether the organization of climbing plants' approach-to-grasp action is sensitive to the kind of intention driving their movement toward potential support, namely individual or social. For the individual condition, a plant in isolation acted upon the support. For the social condition, two plants were located in the same pot opposite to each other with a support in the middle. Results indicate differences in kinematics depending on the context within which the plant is acting. In the presence of neighbors, climbing plants are able to modify their behaviors to maximize their long-term gains, including the grasping of a potential support. Overall, these data suggest that the organization of climbing plants' kinematics is sensitive to the "intention" driving their movement toward a potential support. To discuss this phenomenon, we capitalize on the concept of motor intentionality in plants and on available theories concerned to motor cognition. We suggest how they could be revisited to explain the intentionality component inherent in plant life and other brainless organisms. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Decision-Making Underlying Support-Searching in Pea Plants.

Finding a suitable support is a key process in the life history of climbing plants. Those that find a suitable support have greater performance and fitness than those that remain prostrate. Numerous studies on climbing plant behavior have elucidated the mechanistic details of support-searching and attachment. Far fewer studies have addressed the ecological significance of support-searching behavior and the factors that affect it. Among these, the diameter of supports influences their suitability. When the support diameter increases beyond some point, climbing plants are unable to maintain tensional forces and therefore lose attachment to the trellis. Here, we further investigate this issue by placing pea plants (Pisum sativum L.) in the situation of choosing between supports of different diameters while their movement was recorded by means of a three-dimensional motion analysis system. The results indicate that the way pea plants move can vary depending on whether they are presented with one or two potential supports. Furthermore, when presented with a choice between thin and thick supports, the plants showed a distinct preference for the former than the latter. The present findings shed further light on how climbing plants make decisions regarding support-searching and provide evidence that plants adopt one of several alternative plastic responses in a way that optimally corresponds to environmental scenarios.

Barriers and facilitators of vaccine hesitancy for COVID-19, influenza, and pertussis during pregnancy and in mothers of infants under two years: An umbrella review.

BACKGROUND: Vaccination during pregnancy has been repeatedly demonstrated to be safe and effective in protecting against infection and associated harms for the mother, developing baby, and subsequent infant. However, maternal vaccination uptake remains low compared to the general population. OBJECTIVES: An umbrella review to explore the barriers and facilitators to Influenza, Pertussis and COVID-19 vaccination during pregnancy and within 2 years after childbirth, and to inform interventions to encourage uptake (PROSPERO registration number: CRD42022327624). METHODS: Ten databases were searched for systematic reviews published between 2009 and April 2022 exploring the predictors of vaccination or effectiveness of interventions to improve vaccination for Pertussis, Influenza, or COVD-19. Both pregnant women and mothers of infants under two years were included. Barriers and facilitators were organised using the WHO model of determinants of vaccine hesitancy through narrative synthesis, the Joanna Briggs Institute checklist assessed review quality, and the degree of overlap of primary studies was calculated. RESULTS: 19 reviews were included. Considerable overlap was found especially for intervention reviews, and the quality of the included reviews and their primary studies varied. Sociodemographic factors were specifically researched in the context of COVID-19, exerting a small but consistent effect on vaccination. Concerns around the safety of vaccination particularly for the developing baby were a main barrier. While key facilitators included recommendation from a healthcare professional, previous vaccination, knowledge around vaccination, and communication with and support from social groups. Intervention reviews indicated multi-component interventions involving human interaction to be most effective. CONCLUSION: The main barriers and facilitators for Influenza, Pertussis and COVID-19 vaccination have been identified and constitute the foundation for policy development at the international level. Ethnicity, socioeconomic status, concerns about vaccine safety and side effects, and lack of healthcare professionals' recommendations, are the most relevant factors of vaccine hesitancy. Adapting educational interventions to specific populations, person-to-person interaction, healthcare professionals' involvement, and interpersonal support are important strategies to improve uptake.

Nurses' Knowledge, Attitudes and Practices on the Management of Clostridioides difficile Infection: A Cross-Sectional Study.

Clostridioides difficile is, worldwide, the leading cause of hospital-acquired infection. Outbreaks are largely related to antibiotic exposure and contact contamination, but little is known about C. difficle infection (CDI) awareness in the nurse population. We conducted a cross-sectional survey to study Italian nurses, based on CDI guidelines. We recruited 200 nurses working in 14 Italian hospitals. Using a one-way analysis of variance of knowledge scores, female nurses (mean 9.67 (standard deviation ± 1.63), p = 0.03), and nurses with a higher level of university education (mean 9.79 (SD ± 1.67), p = 0.04) were demonstrated to have better knowledge about CDI. In addition, 92.5% (n = 184) of the sample declared that they did not have specific postgraduate training about CDI. Seventy-four percent (n = 149) of the respondents declared that they used procedures, protocols and guidelines about CDI in their workplace, but only 46.5% (n = 93) reported using C. difficile-specific bundles during their daily practice. In conclusion, our study highlights a lack of knowledge concerning CDI clinical guidelines among Italian nurses.

Immersive and Non-Immersive Virtual Reality for Pain and Anxiety Management in Pediatric Patients with Hematological or Solid Cancer: A Systematic Review.

Invasive and painful procedures, which often induce feelings of anxiety, are necessary components of pediatric cancer treatment, and adequate pain and anxiety management during these treatments is of pivotal importance. In this context, it is widely recognized that a holistic approach, including pharmacological and non-pharmacological modalities, such as distraction techniques, should be the standard of care. Recent evidence suggested the use of virtual reality (VR) as an effective non-pharmacological intervention in pediatrics. Therefore, this systematic review aims to analyze previously published studies on the effectiveness of VR for the management of pain and/or anxiety in children and adolescents with hematological or solid cancer. Medline, SCOPUS, Web of Science, ProQuest, CINAHL, and The Cochrane Central Register of Controlled Trials were used to search for relevant studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Randomized controlled trial, crossover trial, cluster randomized trial, and quasi-experimental studies were included. Thirteen studies, published between 1999 and 2022, that fulfilled the inclusion criteria were included. Regarding the primary outcomes measured, pain was considered in five studies, anxiety in three studies, and the remaining five studies analyzed the effectiveness of VR for both pain and anxiety reduction. Our findings suggested a beneficial effect of VR during painful vascular access procedures. Limited data are available on the reduction of anxiety in children with cancer.

Pre-registration nursing students' anxiety and academic concerns after the second wave of COVID-19 pandemic in Italy: A cross-sectional study.

BACKGROUND: The pandemic and its related social restrictions have led to many uncertainties in nurse education, including the fear of infection in clinical learning settings and the challenge of remote learning. The modification of clinical and academic environments generated anxiety and academic concerns among nursing students. OBJECTIVES: To explore the main determinants of anxiety related to the clinical and classroom environments in nurse education after the second wave of the COVID-19 Pandemic. DESIGN: Multicentre cross-sectional study. SETTINGS: Ten universities offering nursing bachelor programs in central and southern Italy. PARTICIPANTS: A convenience sample of 842 nursing students. METHODS: From April to July 2021, the Self-Rating Anxiety Scale and the Altered Student Study Environment Tool were administered to assess, respectively, students' anxiety and their concerns about the study environment. A regression model was tested. RESULTS: Most of the nursing students were female (76.6 %), living with family (70.9 %), and full-time students (85.7 %); 44.6 % were third-year of Bachelor in Nursing students. The majority of the participants (88.5 %) showed a level of anxiety. The statistically significant predictors of anxiety levels were concerns about grade attainment (ß=0.42, p < 0.001) in the total sample, and, among the first-year students, the completion of clinical placement (ß=0.14, p = 0.047). CONCLUSIONS: Results suggest a need for the redesign of teaching activities and clinical learning experiences to ensure academic outcomes and to preserve students' psychological well-being. Models of learning environments' dynamic adaptation and ongoing psychological support should be implemented to develop tailored interventions.

Barriers and facilitators to vaccination for COVID-19, pertussis, and influenza during pregnancy: Protocol for an umbrella review.

Pregnant women are particularly vulnerable to infection. Furthermore, infection from pertussis, influenza and COVID-19 increases the likelihood of adverse consequences to the mother and developing baby such as stillbirth, ICU admission, and pre-term caesarean birth. Increased rates of transmission and risk of adverse consequences from infection justifies the provision of national maternal vaccination programmes. Additionally, maternal vaccination helps protect the infant until they are able to receive their own vaccinations; a time when they are most at risk of mortality from influenza and pertussis. Vaccination during pregnancy has been repeatedly demonstrated as safe and effective in reducing harm, although rates of uptake remain low compared to the general population. The current protocol describes the methodology for an umbrella review aiming to explore the barriers and facilitators of vaccination during pregnancy for pertussis, influenza, and COVID-19. Systematic reviews that investigate the barriers and facilitators of at least one of either pertussis, influenza, or COVID-19 will be included in this review. Multiple databases will be searched, and included reviews assessed for quality (using the Joanna Briggs Institute (JBI) quality assessment for systematic reviews) and degree of overlap of included primary studies. Included reviews will be analysed according to the WHO SAGE model of determinants of vaccine hesitancy and separated by whether these explore influenza and pertussis, or COVID-19. The outcomes of this review will help inform the development of interventions to increase uptake of vaccination during pregnancy, and on whether interventions need to be tailored depending on the infectious disease. The key findings will identify the specific barriers and facilitators of vaccination hesitancy by considering contextual influences (e.g. sociodemographic variables), individual/social group influences (e.g. trust in the institutions), and vaccine-specific issues (e.g. safety and recommendations).

SPEAKapp: Language as Digital Biomarker for Mental Health.

Language has always been a rich source of amnestic information in the context of cognitive and affective disorders. Many of the language tests and metrics that are employed today have been designed when the only available technology was paper and pencil. Here we present a novel digital tool to administer and score a set of tests based on language.

A large cross-sectional survey of COVID-19 vaccination willingness amongst healthcare students and professionals: Reveals generational patterns.

AIMS: To determine coronavirus disease 2019 (COVID-19) vaccination hesitancy in healthcare professionals and healthcare students in Italy across four generations (baby boomers, generations X, Y and Z). DESIGN: A cross-sectional descriptive study was performed through an online survey conducted from May to June 2021. The STROBE guidelines were adopted for reporting. METHODS: Data were collected by initially sending a survey link to a convenience sample of healthcare professionals and students, which was followed by snowball sampling. The VAX scale was validated and adopted. An ANOVA was performed to detect differences in vaccine-hesitancy beliefs between the four generational groups. RESULTS: The survey was completed by 1226 healthcare professionals and students. Worries about unforeseen future effects accounted for the higher vaccination hesitancy factor across generations. More positive attitudes towards COVID-19 vaccination were expressed by members of generation Z than by members of generation Y and baby boomers. Members of generation X had the highest vaccination hesitancy scores in the overall scale. CONCLUSION: The results suggest that public health campaigns should take into account the generational differences in COVID-19 vaccination hesitancy to achieve higher levels of vaccine acceptance, including amongst healthcare professionals and students. IMPACT: Vaccination is the most effective strategy to tackle the COVID-19 pandemic. The advice of health professionals strongly influences vaccination willingness in the general population. A consideration of the generational patterns in the COVID-19 vaccination hesitancy of healthcare workers and students may increase vaccination uptake in these populations, which in turn may lead to greater public acceptance of the vaccine.

LongITools: Dynamic longitudinal exposome trajectories in cardiovascular and metabolic noncommunicable diseases.

The current epidemics of cardiovascular and metabolic noncommunicable diseases have emerged alongside dramatic modifications in lifestyle and living environments. These correspond to changes in our "modern" postwar societies globally characterized by rural-to-urban migration, modernization of agricultural practices, and transportation, climate change, and aging. Evidence suggests that these changes are related to each other, although the social and biological mechanisms as well as their interactions have yet to be uncovered. LongITools, as one of the 9 projects included in the European Human Exposome Network, will tackle this environmental health equation linking multidimensional environmental exposures to the occurrence of cardiovascular and metabolic noncommunicable diseases.

Lived experiences of frontline nurses and physicians infected by COVID-19 during their activities: A phenomenological study.

We analyzed the lived experiences of frontline nurses and physicians who were affected by COVID-19 through a phenomenological approach, using Cohen's methodology with interview data. The participants were enrolled in the study in May 2020 during the COVID-19 pandemic in Italy. The inclusion criteria were (i) being a nurse or physician employed full time caring for COVID-19 patients before falling ill; (ii) contracting SARS-CoV-2 between February 2020 to May 2020; (iii) having recovered before enrollment; and (iv) providing informed consent to participate. Sixteen participants (60% nurses) with an average age of 45 years were included. The following main themes were extrapolated from our data analysis: "fear of diagnosis," "loneliness (as isolation)," "touch of nurses," and "feeling guilty of abandonment." Several aspects emerging from our study highlight the strong emotional impact of COVID on nurses and physicians infected during their activities, such as feelings of fear and loneliness on the one hand, and of impotence and guilt for not being able to help on the other.

Effectiveness of virtual reality in the management of paediatric anxiety during the peri­operative period: A systematic review and meta-analysis.

BACKGROUND: Children undergoing surgery generally experience anxiety during the perioperative period, which could impact the surgical outcome, cause long-term psychological consequences and result in later healthcare avoidance. Preoperative anxiety in children is managed using both pharmacological and non-pharmacological therapies. The latter include distraction, a tour of the operating room and parental presence until the induction of anaesthesia. A novel and effective non-pharmacological therapies is the use of virtual reality to reduce anxiety and pain in children scheduled for medical procedures. However, the effectiveness of virtual reality in paediatric surgery has yet to be evaluated in a systematic review. OBJECTIVE: To evaluate the effectiveness of virtual reality in the management of anxiety in paediatric patients during the perioperative period. DESIGN: Both a systematic review and a meta-analysis of randomised controlled trials were performed according to the methods outlined in the Cochrane Handbook for Systematic Reviews of Interventions Section 8.5 and in accordance with the Cochrane Effective Practice and Organisation of Care. The results are reported as prescribed by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. DATA SOURCES: A systematic search of randomised controlled trials was conducted using Medline, SCOPUS, Web of Science, Ovid MEDLINE and CINAHL. REVIEW METHODS: Two researchers screened potentially eligible articles and then assessed the quality of the reported studies using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions Section 8.5 and according to Cochrane Effective Practice and Organisation of Care. The data were synthesised using the random-effects models to incorporate the estimated heterogeneity in the weighting. Heterogeneity was tested using the Q and I2 statistics. The τ2 statistic, an estimate of the amount of variation between the included studies, was also determined. Studies whose heterogeneity with respect to primary outcome measurements hindered pooling of the results for meta-analysis were summarised narratively. RESULTS: Seven studies were eligible for inclusion in this systematic review. An effect size for anxiety could be determined in six. The results support the effectiveness of virtual reality in reducing anxiety in paediatric patients undergoing elective surgery. The overall effect was supported by a confidence interval < 0 (PL = -0.341, 95% confidence interval: -0.620 to -0.107) and by heterogenity indexes that were non significant (Q = 9.49, p = 0.091) or not important (I2 = 38.64%). CONCLUSIONS: Paediatric patients undergoing elective surgery may benefit from virtual reality as a distraction method that can reduce anxiety. PROSPERO register, number: (blinded for Referee).