Temperament and mental illness are considered to be variations along the same continuum of imbalance in the neurophysiological regulation of behaviour.This presentation presents the benefits of constructivism approach to psychiatric taxonomies.The presentation reviews findings in neurochemistry that link temperament traits in healthy individuals and symptoms of psychiatric disorders to complex relationships between neurotransmitter systems.Specialization between neurotransmitter systems underlying temperament traits is analyzed here from a functional ecology perspective that considers the structure of adult temperament corresponding to the functional structure of human activities. In contrast to a more popular search for neuroanatomic biomarkers of psychopathology and temperament traits in healthy individuals, this presentation focuses on neurochemistry-based biomarkers. The roles of monoamine neurotransmitters , as well as the roles of acetylcholine, neuropeptides and opioid receptor systems in the regulation of specific dynamical properties of behaviour are summarized within the neurochemical Functional Ensemble of Temperament (FET) model (Table 1) , 101-133).Image 2:The FET framework allows having a neurochemistry-based structure of a taxonomy that can classify both, healthy bio-psychological traits and symptoms of psychopathology. The presentation will give examples of how the FET framework can be used in psychiatry and clinical psychology.None Declared


Colorectal cancer (CRC) is a significant global health concern, due to its increasing incidence worldwide. Recent research has proven that the gut microbiota plays a crucial role in the development and progression of CRC. Numerous studies have explored the relationship between gut microbiota and CRC, shedding light on potential diagnostic, mechanistic, and therapeutic applications. This special Research Topic aims to gather recent insights into influences of gut microbiota on CRC, which includes epidemiological investigation, diagnosis, pathological mechanism and therapeutic interventions.Xiong et al. focused on the differences in gut microbiota profiles between patients with early-onset colorectal cancer (EOCRC) and late-onset colorectal cancer (LOCRC). The results demonstrated that patients with EOCRC exhibited a distinct gut microbiota composition compared to those with LOCRC. This dysbiosis was reflected in the species diversity, abundance of bacteria, and abnormal functional predictions. This study adds to the growing body of work on role of gut microbiota as a potential diagnostic tool for distinguishing between different types of CRC.The first article by Chen et al. aimed to identify the gut microbiota associated with lymph-vascular invasion (LVI) in CRC patients and construct predictive labels for accurate assessment of LVI. The results revealed significant differences in the composition, abundance, and biological function of the intestinal microbiome between patients with and without LVI. The study also successfully constructed predictive models based on microbial markers, which could aid in predicting LVI in CRC patients. These findings have important implications for improving the diagnosis and prognosis of CRC.Yang et al. examined the global research output and trends in the crosstalk between gut microbiota and CRC. The analysis revealed a rapid increase in publications on CRC research involving in gut microbiota, with China and the United States leading in terms of scientific contributions. The study identified hotspots in the field, including the effect of gut microbiota on tumorigenesis, CRC treatment, screening, and the underlying mechanisms. These findings highlight the importance of ongoing research in understanding the relationship between gut microbiota and CRC.The contribution by Zheng et al. focused on the implication of gut microbiota in recovery from gastrointestinal surgery. The disruption of gut microbiota during the perioperative period can contribute to postoperative complications. Understanding how to balance gut microbiota is crucial for enhancing recovery from gastrointestinal surgery. This study emphasized the importance of preserving the beneficial functions of gut microbiota in the recovery from gastrointestinal surgery.Gu et al. reviewed the role of gut microbiota and bacterial metabolites in mucins of CRC. The crosstalk between host mucins and gut microbiota was found to be associated with the occurrence and development of CRC. Dysbiosis of gut microbiota can lead to dysfunction of mucins, potentially triggering host responses and the progression of CRC. These conclusions further highlight novel treatment strategies targeting gut microbiota and bacterial metabolites as new avenues for CRC therapy.In the paper of this Research Topic, Fan et al. explored the potential of Traditional Chinese medicine (TCM) in targeting gut microbiota for the treatment of CRC. TCM was highlighted as a promising source of natural medicines and herbal products with anti-CRC properties. The application of TCM to modulate gut microbiota represents an exciting area of investigation for CRC management. This article emphasizes the potential of TCM as a promising approach for targeting gut microbes in the treatment of CRC, inspiring future research in this field.The final research by In conclusion, this diverse Research Topic of primary research papers provide valuable insights into the role of gut microbiota in CRC. The long-term goal of these research efforts are to further elucidate the crucial role of potential probiotics and pathogenic bacteria in the development and progression of CRC. Additionally, the investigation of specific protein components or metabolites derived from microbiota, as well as the interaction between gut microbiota and TCM, holds great potential as a promising direction for in-depth research on the intricate relationship between gut microbiota and CRC. Exploring these factors can provide valuable insights into the mechanisms and diagnosis underlying CRC pathogenesis and potentially contribute to the development of novel therapeutic strategies targeting the gut microbiota.The author confirms being the sole contributor of this work and has approved it for publication.


Despite great progress in uncovering the complex connectivity patterns of the human brain over the last two decades, the field of connectomics still experiences a bias in its viewpoint of the cerebral cortex. Due to a lack of information regarding exact end points of fiber tracts inside cortical gray matter, the cortex is commonly reduced to a single homogenous unit. Concurrently, substantial developments have been made over the past decade in the use of relaxometry and particularly inversion recovery imaging for exploring the laminar microstructure of cortical gray matter. In recent years, these developments have culminated in an automated framework for cortical laminar composition analysis and visualization, followed by studies of cortical dyslamination in epilepsy patients and age-related differences in laminar composition in healthy subjects. This perspective summarizes the developments and remaining challenges of multi-T1 weighted imaging of cortical laminar substructure, the current limitations in structural connectomics, and the recent progress in integrating these fields into a new model-based subfield termed ‘laminar connectomics’. In the coming years, we predict an increased use of similar generalizable, data-driven models in connectomics with the purpose of integrating multimodal MRI datasets and providing a more nuanced and detailed characterization of brain connectivity. Over the last two decades, the field of neuroimaging has made great strides in its exploration of the intricate patterns of interconnectivity of the human brain, led in part by the The field of structural connectomics still experiences conceptual and methodological drawbacks related to diffusion MRI techniques. Some of the main drawbacks on the conceptual side involve the fact that the dMRI measures displacement of water molecules, and not their diffusion directly. Furthermore, the measured displacement of water molecules does not always follow a Gaussian law, as previously assumed, since it is sometimes restricted in biological tissues.Strong effect of methodology: choice of methodology, including tractography algorithm, had a strong effect on resulting accuracy levels, revealing a tradeoff between sensitivity and specificity.High false positive rates: even the use of high-resolution images in FT still resulted in tractograms containing more invalid than valid  fiber bundles.Errors in reconstructing strong tracts: many algorithms experienced high false positive rates when reconstructing strong tracts, due to increasingly high certainty assigned to strong local field potentials.Difficulty reconstructing small tracts: many FT algorithms also experienced high false negative rates for small tract with diameters of 2 mm or less, such as the anterior commissure (CA).Difficulty reconstructing complex geometry: the intricate geometry of many fiber junctions posed a source of many artifacts and miscalculations in FT (If we focus on fiber tractography (FT), many methodological and technical pitfalls appear. Deterministic streamline tractography, the most widespread method for tractography, uses dMRI to compute the Lastly, one of the biggest methodological limitations in tractography and structural connectomics in general is the difficulty in estimating the exact terminations of fiber tracts inside cortical gray matter. The cortical termination bias involves difficulties in estimating tract terminations not only laterally across the cortical folding , but also radially across the cortical layers. The main causes for this significant limitation are the partial volume effect associated with voxel-wise FT approaches, coupled with the difficulties in estimating small and complex fiber tracts.Over the years many advanced techniques for tractography have been proposed for tackling these limitations in structural connectomics. Some of these advancements include techniques for resolving high false positive connections using filtering, replacing manual filtering based on prior knowledge with thresholding of connectivity matrices or with automated knowledge and data-driven algorithms . Other aIt should be noted that despite the many technical developments in the field, there still lacks a single ‘gold standard’ tractography methodology. Furthermore, the estimation of exact terminations of fiber tracts in cortical gray matter remains a significant difficulty that has resulted in a biased representation of the cerebral cortex. This representation falsely considers the cortex a single homogenous unit and ignores its microstructural laminar composition.Following the partitioning of the cortex into cortical layers at the beginning of the 20th century, the cortical column was introduced as a single unit that spans across all six layers and repeats across the brain . The conSince then, a variety of methods have been applied outside the field of neuroimaging in the exploration of connectivity patterns of the brain on the cortical layer level, including histological staining, tract tracing (retrograde and anterograde), electrical recordings, and others. Most of these explorations used animal models, ranging from cats  to nonhuThis approach to cortical layer connectivity has since been reexamined and the inherently interlinked concepts of the cortical column and the cortical microcircuit have been questioned . What foSince its discovery at the beginning of the 20th century , the geoPrior to this progress, it was already established that myelination causes shortening of T1 values. In 1992, a study of both in vivo and postmortem human brains used high-resolution T1-weighted images to identify the striate cortex and revealed six laminar clusters within it, with decreasing T1 values from the outermost to the innermost parts of the cortex . ConsequSince then, studies have offered a variety of MRI approaches for exploring cortical gray matter on the laminar level, including The T1-weighted approach has proved most suitable so far, thanks to findings from a series of follow-up studies over the past decade. In 2012, a study used T1-weighted imaging to characterize the cortical layers in vivo across the entire brains of both human subjects and rat models . The stuIn 2021, a study used the same low-resolution multi-T1 weighted protocol to explore patterns of cortical dyslamination in epilepsy patients . The stuIt should be noted that despite the significant progress and success of the low-resolution multi-T1 approach for laminar composition analysis, it does have certain limitations. The first and most notable limitation is that T1 relaxation is still not considered a direct measure of Nevertheless, it is our assertion that the T1 layer methodology can be solidified as a framework for direct measurement of cortical cytoarchitecture if a specific algorithmic challenge is overcome. This challenge involves spatial clustering of the resulting multidimensional, surface based T1 layer composition on a whole-brain scale and across a group of subjects. If successful, the T1 clusters will show both visual and quantitative correspondence with established cytoarchitectonic atlases and highlight the role of T1 imaging as a direct probe of tissue microstructure.As the field of connectomics  advanced, the need grew for a unified view of connectivity from the macroscale to the microscale . SeveralIn 2021, a study addressed this subject by presenting an MRI-based, data-derived model of cortical laminar connectivity that offers a way to overcome the biased representation of the cerebral cortex as a single homogenous unit . The stuA follow-up validation study was then performed, implementing the same model on In 2022, following the formation and corroboration of this model of laminar connectivity, a study modeled the laminar connectome of 30 healthy human subjects . Unlike It should be noted that the model of cortical laminar connectivity presented in these studies  has certTaking these limitations into account, alongside the sanity checks found in the visual, motor, and auditory cortices, the model offers a more nuanced whole-brain look at patterns of connectivity on the laminar level. This characterization of the healthy human laminar connectome could provide a new level of detail in the examination of different groups of interest that are presumed to involve distinct features of layer-dependent connectivity.Over the past 20 years, the field of neuroimaging has experienced great advancements in imaging both white matter connectomics and more recently also in imaging the laminar composition of gray matter. The progress in imaging gray matter has amplified the demand for a less biased representation of the cerebral cortex in connectomics that addresses the lack of information regarding the exact terminations of fiber tracks inside the cortical foldings.To address this issue and overcome this bias, knowledge-based models must be used. The MRI-based, data-driven model discussed here  offers oWhile the model discussed here has its own set of drawbacks and limitations, it offers a straightforward approach to integrating multimodal MRI datasets into a whole-brain view of connectivity on the laminar level. Moreover, this model showcases the benefits of using data-driven models to explore structural connectomics in a more unbiased and nuanced approach, which considers the laminar structure of the cortex. We believe that the use of such novel models will play an important role in structural connectomics even if higher resolution imaging of connectivity is achieved, on the condition that the models are knowledge-based, applicable, and generalizable to any existing or future structural connectivity methodology. The resulting modeled multilayered connectomes will necessitate the use and development of advanced network analysis tools that can visualize and explore multidimensional networks  or schizophrenia. This framework can also be used to enhance the exploration of the mechanisms behind different motor, auditory, or visual skills. The use of multidimensional complex network analysis tools could shed new light on the connectivity patterns and mechanisms that make these groups distinct on the laminar level.Ittai Shamir: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing. Yaniv Assaf: Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Resources; Supervision; Validation; Writing – review & editing.


Orally Inhaled and Nasal Drug Products (OINDPs) are of growing importance in the pharmaceutical domain, owing to their intrinsic benefits over the traditional dosage forms, such as low first pass effect by hepatic metabolization, fast onset action, and high drug levels in brain tissue  and lung . Moreover, OINDPs can treat both local  and systemic  diseases. One of the efficient delivery mechanisms for the substances, such as synthetic drugs, phytoconstituents, genes, proteins, and peptides is by inhalation through the pulmonary airways. Therefore, OINDPs present potential approaches to expand pharmaceutical commercialization opportunities. In this thematic issue, we have judiciously selected original research and review articles that build a strong foundation for understanding the myriad of applications of the OINDPs. The thematic issue contains one review article and three research articles on OINDPs. The thematic issue begins with a comprehensive review of the recent advancements in nasal formulations. The review article by Dhapte-Pawar and co-workers summarizes the key developments in nano-carrier-based nasal drug delivery systems for effective neurotherapeutic molecule delivery . The artin situ thermal responsive nasal gel, containing rufinamide (an anticonvulsant medication) in epilepsy treatment (Punna Rao Ravi and team present the physicochemical characterization and animal testing data of an reatment . The nanin-vitro by administering it to Lewis lung carcinoma cells and in vivo by using this technique on subcutaneously implanted Lewis lung carcinoma cells in C57BL/6J mice. They observed decreased viability and apoptosis induction in the cellular studies and decreased tumor size and an increased number of apoptotic cells in vivo. Briefly, this proof-of-concept study showed that targeted drug delivery by electrospray is efficient in lung cancer management and presents a potential clinical application.David and co-workers proposed a local treatment regimen for bronchial carcinoma by cisplatin electro-spraying . The autKaneko and team highlight the negative impact of administering higher doses of a pulmonary drug, by focusing on drug-induced interstitial lung disease . This paThe manuscripts in this research topic describe some of the possibilities for pulmonary and intranasal administration. Other promising applications for pulmonary and intranasal delivery include pain treatment and mucosal vaccination. The ease-of-production of the nasal formulations and their unique access to the brain make intranasal administration more attractive than oral inhalation in systemic delivery. The major limitations of the nasal route are the smaller absorption area, the minimal volume of the administered formulation, the dilution of the drug by mucosal secretions, the potential mucosal irritation upon chronic use, and the shorter retention. Methods to increase drug concentrations of intranasal formulations are likely to help in overcoming some of these limitations . This thWe would like to thank all the contributors to this thematic issue for their valuable time and contributions. We hope that these review and research articles offer a valuable reference for the researchers to probe the role of OINDPs to persist in the important battle against life-threatening pulmonary diseases.


Electron microscopy has welcomed many important advancements in the last decade. The availability of direct electron detectors and new image processing algorithms led to a breakthrough in protein structure resolution, which had historically been limited by radiation damage in protein molecules . Since tThis Research Topic presents two reviews and three original research articles addressing the Research Topic of electron microscopy on radiation sensitive samples from diverse aspects.Xue et al. summarizes the different mechanisms of radiation damage by high-energy electrons and discusses the experimental parameters to consider for limiting radiation damage in cryo-electron tomography. Tomography reconstructs the 3-dimensional (3D) structure of an individual object (non-averaging) using a set of its projections from different angles. As such, the technique is highly dose-intensive as the sample is subjected to many exposures to the electron beam as projections at different angles are acquired. The reward is that 3D structures of unique objects can be reconstructed. Indeed, with the data Research Topic strategies and image analysis algorithms developed in the Ren group and described in the review, 3D structures of individual particles of radiation-sensitive biomaterials have been reconstructed with sub-nanometer resolution . Recent advances in electron microscopy will surely accelerate the understanding of carbohydrate nanoparticle structure and the development of their applications.The mini-review by Duong et al. examines the practice of high-resolution electron microscopy on CsPbBr3 nanoparticles. These perovskite nanocrystals are inorganic but their highly ionic nature renders them radiation sensitive. They have exceptional optical and electronic properties and have great potential in many applications, including light-emitting devices and photoreduction. Their structural studies had been controversial due to their susceptibility to radiation damage. Duong et al. demonstrate that the native structure of these nanocrystals can be revealed by direct imaging or diffraction by combining the use of a hybrid-pixel detector, low-temperature imaging, low-dose image acquisition, and graphene sample support film. Lessons learned from these studies can evidently be applied to electron microscopy studies of other radiation-sensitive materials.The research article by Kouchi et al. investigate a rare phase of ice important to planetary science. The formation of this ice phase is sensitive to the type as well as the intensity of the radiation. To investigate the transition to this ice phase, Kouchi and others describe the instrumentation necessary for the studies, including an ultrahigh vacuum microscope and ports for the deposition of ice as well as for the controlled ultraviolet irradiation. A special liquid-He cooled holder was also used. Besides using techniques to ensure that the imaging electron beam does not interfere with the experiment of the radiation-sensitive ice-phase transition, the article also describes techniques for measuring the ice thickness. Readers will find rich information on how an electron microscope can be tailored for the studies of special samples.Diverging from the above works, which orient towards materials with technological applications, Katsuno et al. use machine learning to detect nucleation events. Nucleation is stochastic and determines the crystallinity and thus the physical properties of the resulting crystal. Nucleation is important in all branches of science and technological developments. The classical nucleation theory has been the general understanding but has been challenged in recent years (From space science, we get to the most futuristic article in this Research Topic, which describes AI-assisted experiment monitoring and data Research Topic. nt years . To studnt years . AlthougThough our Research Topic comprises a small number of articles, these articles span a wide range of samples and perspectives on electron microscopy and radiation sensitive materials. The nice assortment testifies to the interdisciplinarity of the Research Topic. As technology involves more and more organic and biomaterials, we hope that the information in this Research Topic can be applied to diverse disciplines and contribute to the advancement of various fields of science.


The United States is experiencing the most profound and devastating opioid crisis in history, with the number of deaths involving opioids, including prescription and illegal opioids, continuing to climb over the past two decades. This severe public health issue is difficult to combat as opioids remain a crucial treatment for pain, and at the same time, they are also highly addictive. Opioids act on the opioid receptor, which in turn activates its downstream signaling pathway that eventually leads to an analgesic effect. Among the four types of opioid receptors, the µ subtype is primarily responsible for the analgesic cascade. This review describes available 3D structures of the µ opioid receptor in the protein data bank and provides structural insights for the binding of agonists and antagonists to the receptor. Comparative analysis on the atomic details of the binding site in these structures was conducted and distinct binding interactions for agonists, partial agonists, and antagonists were observed. The findings in this article deepen our understanding of the ligand binding activity and shed some light on the development of novel opioid analgesics which may improve the risk benefit balance of existing opioids. In 1999, there were 6984 opioid-related deaths, while in 2020, the number of fatalities significantly increased by approximately 14-fold to 94,371. Opioid-related deaths have been separated by the CDC Wonder database  into four specific categories: natural or semisynthetic opioids, synthetic opioids, heroin, and mental and behavioral disorders. Natural opioids such as morphine and codeine and semisynthetic opioids such as oxycodone and hydrocodone are frequently prescribed for pain reduction. Synthetic opioids such as fentanyl are often prescribed for treating severe pain, typically advanced cancer pain, although the most recent cases of harm are linked to illicitly manufactured synthetic products. Since 2013, synthetic opioids have contributed the most to the rapidly increasing trend of all opioid-related deaths and are responsible for 42% of all mortalities. The opioid crisis has not only resulted in increasing fatalities throughout the years but also financially impacts society. In November 2017, the White House suggested that previous estimations of the economic impact of the opioid crisis had been extremely underestimated in the Council of Economic Advisers’ report .Although medicinal chemists spent almost two centuries developing drugs targeting the MOR, many of the compounds still share the same scaffold as morphine or have similar synthetic scaffolds, which in turn limits the diversity of the active compounds. Moreover, this scaffold was reported to induce undesirable adverse effects, including respiratory depression and constipation. More recent approaches to developing new drugs targeting the MOR involve high-throughput screening and defined signaling assays in stable MOR transfected cell lines. However, these approaches are time-consuming and expensive. The advancement of X-ray crystallography and cryo-EM helped to solve more opioid receptor structures in recent years, which provided an unprecedented opportunity in computer-aided drug design. High-resolution structures of the MOR in complex with agonists or antagonists can confirm the binding site of the ligands and provide insights into the chemical recognition of the ligands. The molecular details of the binding site itself provide valuable information for structure-based drug design. Furthermore, some of the MOR structures have been crystallized with G proteins, which not only provides hints regarding the conformational changes that drive the downstream signaling pathway, but also in terms of the atomic details of the protein–protein interaction interface, which can potentially serve as a binding site for protein–protein interaction disruptors or molecular glues that stabilize the interface. Finally, these high-resolution structures have enabled researchers to explore novel allosteric binding sites. Recent improvements in computational chemistry have increased the accuracy of docking calculations, and with rapidly increasing computational power, researchers can explore the infinite chemical space and screen hundreds of millions of compounds. Structurally divergent compounds are likely to have unique biological properties that may potentially act as safer analgesics. Overall, the availability of high-resolution structures and a better understanding of the MOR structures may hold the key to successful opioid analogue discovery.


Traditionally, doctoral student education in the biomedical sciences relies on didactic coursework to build a foundation of scientific knowledge and an apprenticeship model of training in the laboratory of an established investigator. Recent recommendations for revision of graduate training include the utilization of graduate student competencies to assess progress and the introduction of novel curricula focused on development of skills, rather than accumulation of facts. Evidence demonstrates that active learning approaches are effective. Several facets of active learning are components of problem-based learning (PBL), which is a teaching modality where student learning is self-directed toward solving problems in a relevant context. These concepts were combined and incorporated in creating a new introductory graduate course designed to develop scientific skills (student competencies) in matriculating doctoral students using a PBL format.Evaluation of course effectiveness was measured using the principals of the Kirkpatrick Four Level Model of Evaluation. At the end of each course offering, students completed evaluation surveys on the course and instructors to assess their perceptions of training effectiveness. Pre- and post-tests assessing students’ proficiency in experimental design were used to measure student learning.The analysis of the outcomes of the course suggests the training is effective in improving experimental design. The course was well received by the students as measured by student evaluations (Kirkpatrick Model Level 1). Improved scores on post-tests indicate that the students learned from the experience (Kirkpatrick Model Level 2). A template is provided for the implementation of similar courses at other institutions.This problem-based learning course appears effective in training newly matriculated graduate students in the required skills for designing experiments to test specific hypotheses, enhancing student preparation prior to initiation of their dissertation research.The online version contains supplementary material available at 10.1186/s12909-023-04569-7. For over a decade there have been calls to reform biomedical graduate education. There are two main problems that led to these recommendations and therefore two different prescriptions to solve these problems. The first major issue is the pursuit of non-traditional (non-academic) careers by doctorates and concerns of adequate training , 2. The One approach that prioritizes the aggregate scientific skill set required for adept biomedical doctorates is the development of core competencies for doctoral students , 14, 15,Analyses of how doctoral students learn scientific skills suggest a threshold model, where different skillsets are mastered (a threshold reached), before subsequent skillsets can be mastered , 18. SkiIt is notable that the changes these examples incorporate into the curriculum are accompanied with a shift from didactic teaching to active learning. Many studies have demonstrated that active learning is more effective than a conventional didactic curriculum in STEM education . ProblemThe premise for PBL is that actively engaging in problem solving enhances learning in several ways , 30. FirA comprehensive review of PBL outcomes from K-12 through medical school indicated that PBL students perform better in the application of knowledge and reasoning, but not in other areas like basic knowledge . Other rAt our institution, biomedical doctoral students enter an umbrella program and take a core curriculum in the first semester prior to matriculating into one of seven biomedical sciences doctoral programs across a wide range of scientific disciplines in the second semester. Such program diversity created difficulty in achieving consensus on the necessary scientific foundational knowledge for a core curriculum. Common ground was achieved during a recent curriculum revision through the development of required core competencies for all students, regardless of field of study. These competencies and milestones for biomedical science students at other institutions , 14, 15,A course was created to develop competencies required by all biomedical sciences doctoral students regardless of their program of interest . As an iDevelop broad, general scientific knowledge (core competency 1 ).Develop familiarity with technical approaches specific to each problem.Practice critical thinking/experimental design incorporating rigor and reproducibility,including: formulation of hypotheses, detailed experimental design, interpretation of data, statistical analysis (core competencies 3 and 4 ).Practice communication skills: written and verbal communication skills (core competency 8 ).Develop collaboration and team skills (core competency 6 ).Practice using the literature.Students were organized into groups of four or five based on their scientific background. Student expertise in each group was deliberately mixed to provide different viewpoints during discussion. A single faculty facilitator was assigned to each student group, which met formally in 13 separate sessions (Appendix II). In preparation for each session, the students independently researched topics using the literature  and met informally without facilitator oversight to coordinate their findings and organize the discussion for each class session. During the formal one-hour session, one student served as the group leader to manage the discussion. The faculty facilitator guided the discussion to ensure coverage of necessary topics and helped the students identify learning issues, i.e. areas that required additional development, for the students to research and address for the subsequent session. At the end of each session, teams previewed the leading questions for the following class and organized their approach to address these questions prior to the next session. The whole process provided experiences related to goal 5.As the course was developed during the COVID-19 pandemic, topics related to SARS-CoV2 and COVID-19 were selected as currently relevant problems in society. Session 1 prepared the students to work in teams by discussing about how to work in teams and manage conflict . In session 2, the students met in their assigned groups to get to know each other, discuss problem-based learning and establish ground rules for the group. Sessions 3 and 4 laid the course background by focusing on the SARS-CoV2 virus and COVID-19-associated pathologies . The subsequent nine sessions were organized into three separate but interrelated three-session blocks: one on COVID-19 and blood clotting, one on COVID-19 and loss of taste, and one on SARS-CoV2 and therapeutics. The first session in each of these blocks was devoted to covering background information . The second session of each block discussed hypothesis development . In the second sessions the students also began to design experiments to test the hypothesis. The final session of each block fleshed out the details of the experimental design .The process was iterative, where the students had three opportunities to discuss hypothesis development, experimental design and analysis during sessions with their facilitators. Written and oral presentation assignments (Appendix V) provided additional opportunities to articulate a hypothesis, describe experimental approaches to test the hypotheses, propose analysis of experimental results and develop communication skills .Are the methods and experimental approaches rigorous? How could they be made more rigorous?” “Discuss how your controls validate the outcome of the experiment. What additional controls could increase confidence in your result?” The facilitators were instructed to direct discussion to topics related to the rigor of the experimental design. The students were asked about numbers of replicates, number of animals, additional methods that could be applied to support the experiment, and other measurements to address the hypothesis in a complementary fashion. In the second iteration of the course, we introduced an exercise on rigor and reproducibility for the students using the NIH Rigor and Reproducibility Training Modules (see Appendix III). In this exercise, the students read a short introduction to rigor and reproducibility and viewed a number of short video modules to introduce lessons on rigor. The students were also provided the link to the National Institute of General Medical Sciences clearinghouse of training modules on rigor and reproducibility as reference for experimental design in their future (see Appendix III).Rigor and reproducibility was incorporated into the course. This was an important component given the emphasis recently placed on rigor and reproducibility by federal agencies. As the students built the experimental design to address the hypothesis, recurring questions were posed to encourage them to consider rigor. Examples include: “The first delivery of the course was during the COVID-19 pandemic and sessions were conducted on the Zoom platform. The thirteen PBL sessions, and two additional sessions dedicated to oral presentations, were spaced over the course of the first semester of the biomedical sciences doctoral curriculum. The second iteration of the course followed the restructuring of the graduate first year curriculum and the thirteen PBL sessions, plus one additional session devoted to oral presentations, were held during the first three and a half weeks of the first-year curriculum. During this period in the semester, this was the only course commitment for the graduate students. Due to this compressed format, only one written assignment and a single oral presentation were assigned. As the small group format worked well via Zoom in the first iteration of the course, the small groups continued to meet using this virtual platform.IRB Approval. The West Virginia University Institutional Review Board approved the study (WVU IRB Protocol#: 2008081739). Informed consent was provided by the participants in writing and all information was collected anonymously.Surveys. Evaluation of training effectiveness was measured in two ways corresponding to the first two levels of the Kirkpatrick Model of Evaluation [aluation . First, not accountable, e.g. always late (score = 1), accountable, e.g. punctual, well prepared, follows up (score = 4) and controlling, e.g. finds fault in others (score = 7). Each student provided a peer-to-peer evaluation for each student in their group. (see Appendix VII). In the second course iteration, Goldilocks surveys were collected three times over the three-week course period due to the compressed time frame. This was necessary to provide rapid feedback to the students about their performance during the course in order to provide opportunities to address and rectify any deficits before making final performance assessments.Peer-to-peer evaluations were collected to provide feedback on professionalism and teamwork. This survey utilized a Goldilocks scale ranging from 1 to 7, with 4 being the desired score. An example peer question asked about accountability, where responses included Evaluating Pre- and Post-Tests. All pre- and post-test answers were evaluated by three graders in a blind fashion, where the graders were unaware if an answer came from a pre- or post-test. Prior to grading, each grader made up individual answer keys based upon the question(s) on the tests. The graders then met to compare and deliberate these preliminary keys, incorporating changes and edits to produce a single combined key to use for rating answers. While the students were asked to answer one question, some students chose to answer several questions. Superfluous answers were used as a training dataset for the graders. The graders independently scored each answer, then met to review the results and discuss modification of the grading key. The established final grading key, with a perfect score of 16, was utilized by the graders in independently evaluating the complete experimental dataset consisting of all pre- and post-test answers (Appendix IX). To assess the ability of student cohorts to design experiments before and after the course, three of the authors graded all of the pre- and post-test answers. Grading was performed in a blind fashion and the scores of the three raters were averaged for each answer.Statistical analysis. To measure the interrater reliability of the graders, the intraclass correlation coefficient (ICC) was calculated. A two-way mixed effects model was utilized to evaluate consistency between multiple raters/measurements. The ICC for grading the training dataset was 0.82, indicating a good inter-rater agreement. The ICC for grading the experimental dataset was also 0.82. For comparison of pre-test vs. post-test performance, the scores of the three raters were averaged for each answer. Since answers were anonymous, the analyses compared responses between individuals. Most, but not all scores, exhibited a Gaussian distribution and therefore a nonparametric statistic, a one-tailed Mann Whitney U test, was used for comparison. The pre-test and post-test scores for 2020 and 2021 could not be compared due to the different format used for the course in each year.Thirty students participated in the course in the first offering, while 27 students were enrolled in the second year. The students took pre- and post-tests to measure their ability to design an experiment before and after training (Appendix VIII). As the course progressed, students were surveyed on their views of the professionalism of other students in their group (Appendix VII). At the end of the course, students were asked to respond to surveys evaluating the course and their facilitator (see Appendix VII).Student reception of the course (Kirkpatrick Level 1). In the first year, 23 students responded to the course evaluation (77% response rate) and 26 students submitted facilitator evaluations (87% response rate), whereas in the second year there were 25 responses to the course evaluation (93% response rate) and 26 for facilitators (96% response rate). Likert scores for the 2020 and 2021 course evaluations are presented in Fig. Student learning (Kirkpatrick Level 2). Twenty-six students completed the pre-test in each year and consented to participate in this study (87% response in the first year and 96% response in the second year). Eighteen students completed the post-test at the end of the first year (60%) and 26 students completed the test at the end of the second year (96%). Question selection  is shown in Table Average scores on pre-tests and post-tests were compared using a one-tailed Mann Whitney U test. Since the format of the course was different in the two iterations, comparison of test results between the two years could not be made. The average scores of the pre- and post-test in 2020 were not statistically different (p = 0.0673), although the post-test scores trended higher. In contrast, the difference between the pre- and post-test in 2021 did reach statistical significance (p = 0.0329). The results collectively indicate an overall improvement in student ability in experimental design Fig. .This course was created in response to biomedical workforce training reports recommending increased training in general professional skills and scientific skills, e.g. critical thinking and experimental design. The course utilizes a PBL format, which is not extensively utilized in graduate education, to incorporate active learning throughout the experience. It was well received by students and analysis suggests that major goals of the course were met. This provides a template for other administrators and educators seeking to modify curricula in response to calls to modify training programs for doctoral students.Student evaluations indicated the course was effective at motivating active learning and that students became more active learners. The evaluation survey questions were directly related to three specific course goals: (1) Students reported developing skills in problem solving, hypothesis testing and experimental design. (2) The course helped develop oral presentation skills and written communication skills (in one iteration of the course) and (3) students developed collaboration and team skills. Thus, from the students’ perspective, these three course goals were met. Student perceptions of peer professionalism was measured using peer-to-peer surveys. The wide range of Goldilocks scores in the first student cohort was unexpected. In the second student cohort changes in professional behavior were measured over time and the score ranges were narrower. The reasons for the difference between cohorts is unclear. One possibility for this discrepancy is that the first iteration of the course extended over one semester and was during the first full semester of the pandemic, impacting professional behavior and perceptions of professionalism. The second cohort completed a professionalism survey three times during the course. The narrow range of scores from this cohort in the initial survey made detection of improved professionalism over the course difficult. Results do indicate that professionalism improved in terms of respect and compassion between the first and last surveys. Finally, the results of the pre-test and post-test analysis demonstrated a trend of improved performance on the post-test relative to the pre-test for students in each year of the course and a statistical difference between the pre- and post-test scores in the second year.Areas for improvement. The course was initially offered as a one-credit course. Student comments on course evaluations and comments in debriefing sessions with facilitators at the end of the course concurred that the work load exceeded that of a one credit course. As a result, the year two version was offered as a two-credit course to better align course credits with workload.There were student misperceptions about the goals of the course in the first year. Some students equated experimental design with research methods and expressed disappointment that this was not a methods course. While learning appropriate methods is a goal of the course, the main emphasis is developing hypotheses and designing experiments to test the hypotheses. As such, the choice of methods was driven by the hypotheses and experimental design. This misperception was addressed in the second year by clearly elaborating on the course goals in an introductory class session.The original course offering contained limited statistical exercises to simulate experimental planning and data analysis, e.g. students were required to conduct a power analysis. Between the first and second years of the course, the entire first semester biomedical sciences curriculum was overhauled with several new course offerings. This new curriculum contained an independent biostatistics workshop that students completed prior to the beginning of this course. Additional statistics exercises were incorporated into the PBL course to provide the students with more experience in the analysis of experimental results. Student evaluations indicated that the introduction of these additional exercises was not effective. Improved coordination between the biostatistics workshop and the PBL course is required to align expectations, better equipping students for the statistical analysis of experimental results encountered later in this course.An important aspect that was evident from student surveys, facilitator discussions and debrief sessions was that improved coordination between the individual facilitators of the different groups is required to reduce intergroup variability. Due to class size, the students were divided into six groups, with each facilitator assigned to the same group for the duration of the course to maintain continuity. The facilitators met independent of the students throughout the course to discuss upcoming sessions and to share their experiences with their respective groups. This allowed the different facilitators to compare approaches and discuss emerging or perceived concerns/issues. In the second year, one facilitator rotated between different groups during each session to observe how the different student groups functioned. Such a real time faculty peer-evaluation process has the potential to reduce variability between groups, but was challenging to implement within the short three-week time period. Comprehensive training where all facilitators become well versed in PBL strategies and adhere to an established set of guidelines/script for each session is one mechanism that may reduce variability across different facilitator-group pairings.Limitations. The current study has a number of limitations. The sample size for each class was small, with 30 students enrolled in the first year of the course and 27 students enrolled in the second. The response rates for the pre-tests were high (> 87%) but the response rate for the post-test varied between the first year (60%) and second year (96%) of the course. The higher response rate in the second year might be due to fewer end of semester surveys since this was the only course that the students took in that time period. Additionally, the post-test in the second year was conducted at a scheduled time, rather than on the student’s own time as was the case in year one. Due to restructuring of the graduate curriculum and the pandemic, the two iterations of the course were formatted differently. This precluded pooling the data from the two offerings and makes comparison between the outcomes difficult.Presentation of the course was similar, but not identical, to all of the students. Six different PBL groups were required to accommodate the number of matriculating students in each year. Despite efforts to provide a consistent experience, there was variability between the different facilitators in running their respective groups. Further, the development of each session in each group was different, since discussion was driven by the students and their collective interests. These variables could be responsible for increasing the spread of scores on the post-tests and decreasing the value of the course for a subset of students.The pre- and post-tests were conducted anonymously to encourage student participation. This prevented correlating the differential between pre- and post-test scores for each student and in comparing learning between different groups. The pre-test and post-test were identical, and provided the students with five options to design experiments  in response to a different biomedical science problem. An alternative approach could have used isomorphic questions for the pre- and post-tests. It is clear that some students answered the same question on the pre- and post-test, and may benefit from answering the same question twice . Some students clearly answered different questions on the pre- and post-test and the outcomes might be skewed if the two questions challenged the student differently.While the course analysis captured the first two levels of the Kirkpatrick model of evaluation (reaction and learning), it did not attempt to measure the third level (behavior) or fourth level (results) . Future Implementation. This curriculum is readily scalable and can be modified for graduate programs of any size, with the caveat that larger programs will require more facilitators. At Van Andel, the doctoral cohorts are three to five new students per year and all are accommodated in one PBL group [BL group . At our Consistency between groups is important so each group of students has a similar experience and reaps the full benefit of this experience. Regular meetings between the course coordinator and facilitators to discuss the content of upcoming sessions and define rubrics to guide student feedback and evaluation were mechanisms used to standardize between the different groups in this course (Appendix VI). In hindsight, the course would benefit from more rigorous facilitator training prior to participation in the course. While a number of our facilitators were veterans of a medical school PBL course, the necessary skillset required to effectively manage a graduate level PBL course that is centered on developing critical thinking and experimental design are different. Such training requires an extensive time commitment by the course coordinators and participating facilitators.de novo development of all course material. This entailed collecting and compiling information about the virus and the disease to provide quick reference for facilitators to guide discussion in their groups, all in the face of constantly shifting scientific and medical knowledge, along with the complete lack of traditional peer-based academic social engagement due to the pandemic. In development of this course, three different COVID-based problems were identified, with appropriate general background material for each problem requiring extensive research and development. Background material on cell and animal models, general strategies for experimental manipulation and methods to measure specific outcomes were collected in each case. Student copies for each session were designed to contain a series of questions as a guide to identifying important background concepts. Facilitator copies for each session were prepared with the goal of efficiently and effectively guiding each class meeting. These guidelines contained ideas for discussion points, areas of elaboration and a truncated key of necessary information to guide the group (Appendix IV). Several PBL repositories exist  and MedEdPORTAL  publishes medical-specific cases. These provide valuable resources for case-based ideas, but few are specifically geared for research-focused biomedical graduate students. As such, modification of cases germane to first year biomedical graduate students with a research-centered focus is required prior to implementation. Finally, appropriate support materials for surveys and evaluation rubrics requires additional development and refinement of current or existing templates to permit improved evaluation of learning outcomes (Appendix VI).The most difficult task in developing this course involved the course conception and development of the problem-based assignments. Designing a COVID-19 based PBL course in 2020 required Development of an effective PBL course takes considerable time and effort to conceive and construct. Successful implementation requires the requisite higher administrative support to identify and devote the necessary and appropriate faculty needed for course creation, the assignment of skilled faculty to serve as facilitators and staff support to coordinate the logistics for the course. It is critical that there is strong faculty commitment amongst the facilitators to devote the time and energy necessary to prepare and to successfully facilitate a group of students. Strong institutional support is linked to facilitator satisfaction and commitment to the PBL-based programs . InstituKey Takeaways. The creation and implementation of this course was intellectually stimulating and facilitators found their interactions with students gratifying. From student survey responses and test results the course was at least modestly successful at achieving its goals. Based upon our experience, important issues to consider when deciding to implement such a curriculum include: (1) support of the administration for developing the curriculum, (2) facilitator buy-in to the approach, (3) continuity (not uniformity) between PBL groups, (4) other components of the curriculum and how they might be leveraged to enhance the effectiveness of PBL and (5) effort required to develop and deliver the course, which must be recognized by the administration.Future Directions. Novel curriculum development is an often overlooked but important component to contemporary graduate student education in the biomedical sciences. It is critical that modifications incorporated in graduate education are evidence based. We report the implementation of a novel PBL course for training in the scientific skill sets required for developing and testing hypotheses, and demonstrate its effectiveness. Additional measures to assess the course goals in improving critical thinking, experimental design and self-efficacy in experimental design will be implemented using validated tests [ed tests , 43–45. ed tests , 46–48.Incorporation of courses emphasizing development of skills can be done in conjunction with traditional didactic instruction to build the necessary knowledge base for modern biomedical research. Our PBL course was stand-alone, requiring the students to research background material prior to hypothesis development and experimental design. Coordination between the two modalities would obviate the need for background research in the PBL component, reinforce the basic knowledge presented didactically through application, and prepare students for higher order thinking about the application of the concepts learned in the traditional classroom. Maintaining a balance between problem-based and traditional instruction may also be key in improving faculty engagement into such new and future initiatives. Continued investments in the creation and improvement of innovative components of graduate curricula centered around developing scientific skills of doctoral students can be intellectually stimulating for faculty and provide a better training environment for students. The effort may be rewarded by streamlining training and strengthening the biomedical workforce of the future.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2Supplementary Material 3Supplementary Material 4Supplementary Material 5


The overall clinical burden of non-alcoholic fatty liver disease (NAFLD) has increased steadily since the 1980′s affecting 25% of individuals with around three times higher prevalence within population affected by type 2 diabetes mellitus (T2DM) . Additiogold standard” in preventive medicine, mainly due to the harmonic combination of many foods with antioxidant and anti-inflammatory properties .Currently, there are no medical treatment available for the management of NASH with the lifestyle changes remaining the first-line treatment strategy. Emphasis is focused on the weight loss  but sustoperties . Althougoperties , no dietoperties . In a stFu et al.); more studies are needed to confirm these observations in larger global populations.Questions are raised about which specific macronutrients may mediate the beneficial effects elicited by the Mediterranean diet on NAFLD and cardiometabolic health and the putative molecular mechanisms underpinning these effects . In thisLuo et al.). A retrospective study in Chinese adults with visceral adiposity investigated the gender- and age-specific association between low muscle mass and the presence of NAFLD . In this study, SMI was significantly lower in men and middle-aged women with NAFLD than in those without NAFLD. An inverse relationship with the presence of NAFLD in both men and women was also observed; muscle mass was associated with a higher likelihood of NAFLD in middle-aged females and males of any age.Sarcopenia is the involuntary reduction of muscle mass and decline in strength. It is also a combination of quantitative (reduction in motor unit number) and qualitative (muscle fiber atrophy) characteristics . SimilarPrevention and management of NAFLD still remains an active scientific field. The recommendations such as adhering to healthier dietary patterns (Mediterranean diet) may provide beneficial health outcomes and should be still considered as the promising management of the NASH. This approach should also include adequate strategies for the prevention of the loss of the muscle mass and decline in strength. More research should be orientated toward determining the paths that result in impaired liver health to drive effective and management solutions in terms of dietary and overall lifestyle interventions.MK, DS, MZ, and NN were editors of this Research Topic. MK has produced a first draft. DS, MZ, and NN have provided the input, review, and editing. All authors have read and approved the final version of this Editorial.


The need for emergency medical services increased drastically during disaster relief. Poor location selection of emergency medical facilities may harm the interests of healthcare workers and patients, leading to unnecessary waste of costs. It involves multiple stakeholders' interests, a typical multi-criteria decision-making problem. Based on multiple-criteria decision-making technology, most current location selection decisions methods comprehensively consider the evaluation criteria of "issue" and "problem" simultaneously and establish mathematical models to achieve the results. Such methods are difficult to take into account the influence of different attribute factors on the final location selection results in practice. Therefore, in this study, we used the WSR methodology as a guide to divide the factors of location selection into "Wuli", "Shili" and "Renli", and proposed the WSR methodology-based multi-criteria decision‐making (MCDM) framework for selecting the appropriate location for emergency medical facilities. The integrated framework consists of the Entropy Weight Method, Best–Worst Method, and interval type‐2 fuzzy Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) methodologies. Combined with the comparative analysis of actual cases, the results under the guidance of this framework were consistent with practicalities. Also, the sensitivity analysis showed that the location selection ranking fluctuations were not apparent with the fluctuation of criteria weights. Wherefore, the validation of the proposed method's effectiveness, feasibility, and robustness was proved, which provided a valuable reference for the location selection of emergency medical facilities. From the perspective of the relationship between the supply and demand of medical resources, one solution is to build "medical evacuation points" to evacuate the wounded and reduce the medical demand in emergencies. For example, emergency medical evacuation points were built in public spaces such as the stadium and the racetrack to meet the transfer and evacuation needs of the seriously injured during the earthquake in Yushu, China5. Another solution is to improve the medical supplies in emergency areas to conduct "on-site treatment" by increasing temporary emergency medical facilities. For example, the United Kingdom transformed large-space public buildings such as gymnasiums and convention and exhibition centres into NHS Nightingale Hospitals in the early stage of the COVID-19 epidemic, adding additional intensive care capacity and providing vaccination services in late period7. On the whole, facing the impact of major emergencies on the traditional medical system, it is necessary to establish temporary emergency medical facilities to meet the space requirements in different rescue processes regardless of the above mitigation solutions.Major emergencies, especially public health events, will have a collective health impact on large-scale populations. Also, cities often experience a surge in medical demand in a short period, leading to a shortage or even a run on regional medical resources8. The location selection of temporary emergency facilities in various regions is usually affected by specific evaluation criteria and distinct decision-making methods9. There are many multi-attribute decision-making methods for ranking alternative solutions, such as Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS)10 , Multi-Attributive Border Approximation Area Comparison (MABAC)11, Ranking of Alternatives through Functional Single Interval (RAFSI)12 , Multi-Attributive Ideal-Real Comparative Assessment (MAIRCA)13, and Combinative Distance-based Assessment (CODAS)14. In specific applications, these methods possess their advantages and disadvantages. For instance, the MABAC method offers benefits such as not requiring prior weights and being intuitive and simple to comprehend. However, it may become complex when selecting sensitive data standardization and boundary construction methods. In addition, the RAFSI method can focus on the weights and relative importance between multiple attributes. However, it may have subjectivity in selecting segmentation and mapping and lacks flexibility for specific complex decision-making scenarios. Besides, the MAIRCA method can comprehensively consider the performance of multiple attributes, and its calculation is intuitive and straightforward. However, the complex weight assignment is required about the relative importance of the attributes because of the assumption that each attribute has equal weight. Moreover, although the CODAS method does not require decision-makers to assign weights, it can become computationally complex when dealing with numerous standards and alternative solutions. In public health emergencies, the site selection of temporary emergency medical facilities is often constrained by objective conditions and indirectly influenced by subjective judgments. Therefore, the decision-making process for site selection often needs to consider both "problem" and "issue" factors simultaneously. These criteria are heterogeneous and require an optimization method to assess them and their mutual influences. Considering that TOPSIS is an intuitive method for meeting the urgent needs of emergency location selection without pre-allocating weights to multiple attributes or standards and complex model construction, this paper chose the TOPSIS method for evaluation. However, its limitations lie in its dependence on weights and subjectivity in data standardization and ideal solution selection. To address the limitations, we used the WSR methodology as a guide to divide the factors of location selection into "Wuli", "Shili" and "Renli" and proposed the Multi-criteria Decision Making (MCDM) framework based on the WSR methodology. Similarly, different weight determination methods also possess their advantages and disadvantages. For example, the Ordinal Priority Approach (OPA) 15 allows decision-makers to allocate weights based on their preferences, meaning that weight allocation is subjective and personal bias, which may lead to inconsistent decision-making results. In addition, although the Full Consistency Method (FUCOM)16 can reduce the subjective influence and inconsistency of expert preferences on the final value of standard weights, its operation process is not concise because of the two sets of constraint definitions implication. Besides, The Level Based Weight Assessment (LBWA) 17model can eliminate inconsistencies in expert preferences with simple calculations. Still, the setting of the elasticity coefficient may affect the robustness of the final results. This article mainly adopted the Entropy Weight Method (EWM) and Best Worst Method (BWM) methods to allocate weights. EWM can make weight determination more objective and fairer without relying on the subjective preferences or weights of decision-makers; therefore, it is used as a weight determination method for "problem" factors. Besides, the BWM method is suitable for decision-making problems in various backgrounds without highly specialized mathematical or statistical knowledge and can avoid subjective bias because its weight determination is based on the relative performance of alternative solutions on various standards. Therefore, we chose the BWM method as a weight determination method for "issue" factors, though it cannot effectively handle decision-makers handling uncertainty or variability in weights. Meanwhile, this study introduced Interval Type-2 Fuzzy Sets (IT2FS) to solve weight determination's subjectivity and uncertainty problems. In emergencies, it is difficult for decision-makers to quantify their subjective cognition with crisp values in a short period, while IT2FS helps decision-makers express their preferences in a vague way, which is more closely related to the decision-making process under crises. Furthermore, facing situations of inaccurate data acquisition and incomplete understanding by decision-makers, IT2FS can represent the uncertainty range of weights through interval values. Moreover, IT2FS can make decisions more adaptable to different situations and information in emergencies to improve the robustness of decisions.Currently, the most common emergency location decision-making method is constructing a single-objective, multi-objective, or hierarchical model to perform objective calculations to get the optimal function value Therefore, we proposed a BWM- TOPSIS and interval type‐2 fuzzy as an integrated MCDM framework for the location selection of emergency medical facilities. The location selection decision-making framework can effectively divide different factors based on practical needs, and the primary advantage of the proposed approach is that it has simplified calculations and provides reasonable and practical solutions due to good computational efficiency compared to other methods. For validation, a case study is accompanied by Shanghai.18. MCDM methods have found diverse applications across various domains, providing valuable support to decision-makers in complex decision problems19. Typically, since the location selection of traditional hospitals includes issues belonging to different fields and there are several and sometimes conflicting stakeholders to take into account, it chiefly uses MCDM techniques 20. Researchers have put forward different decision-making frameworks for hospital location selection by combining various methodologies, such as Analytical Hierarchy Process21, the Technique for Order Preference by Similarity to Ideal Solution, and Analytical Network Process22,et al. In addition, some researchers have proposed fuzzy versions of MCDM techniques based on a fuzzy mathematical calculation to consider the uncertainty and vagueness regarding the hospital location selection process. In emergency decision-making problems, especially in the COVID-19 pandemic, MCDM methods have been extensively used in taking decisions26. However, there are few studies on the location decision of emergency medical facilities in major emergencies, they follow the same technical route, mainly based on MCDM technology. For example, Nazanin Vafaei et al. proposed a combination of MCDM and GIS to meet the location selection requirements of field hospitals after the earthquake to determine their optimum location. At this stage, especially during the COVID-19 pandemic, fuzzy versions of MCDM techniques are primarily available. For example, Nezir Aydin and other researchers proposed the MCDM framework based on Delphi for selecting the most suitable location of emergency medical facilities during a pandemic, which consists of the Delphi, Best–Worst Method (BWM), and interval type‐2 fuzzy TOPSIS methodologies which is an objective DMs subjective scoring-based computational evaluation method; Muhammet and others proposed the Fuzzy Choquet integral multi criteria decision making technique for linguistic evaluation to determine the location of field hospitals during an epidemic, which eliminates subjective decision errors by using interval values for decision makers to evaluate each criterion 27; Chia-Nan Wang and other scholars proposed the MCDM model for the location of a temporary hospital in a fuzzy environment during the epidemic based on the fuzzy analytic hierarchy process (FAHP) and weighted aggregated sum product assessment model28; Ze-hui Che and others investigates an efficiency-based multi-criteria group decision-making (MCGDM) method by combining BWM and data envelopment analysis (DEA) in trapezoidal interval type-2 fuzzy (TrIT2F) environment to rank alternatives by measuring their overall efficiency29 .Evaluations of location selection are a challenging and complex task due to several variables which relate to specific decisions in many decision-making problems, such as environmental, social, physical, organizational, and social criteria 32. TOPSIS‐based location selection applications include fuzzy TOPSIS to select most effective location based on interval type‐2 fuzzy TOPSIS methodologies and so on33. Furthermore, BWM and TOPSIS have already been applied to several MCDM problems owing to its simple and clear procedure. Hoseini used BWM and TOPSIS methods to prioritize suppliers, and they also implemented the proposed approach in type 2 fuzzy environment to deal with the uncertainty in experts' opinions34. Haeri developed an integrated BMW and TOPSIS approach in a fuzzy environment to prioritize suppliers35.Recently published study, some applications of BWM include identification of the best configuration of key performance indicators; fuzzy extension of the BWM and so on Overall, the decision-making process of the location selection methods at this stage few combine BWM with TOPSIS. And the research also rarely considers the objective evaluation criteria of "problem" and the subjective evaluation criteria of "issue" separately. However, the actual location selection decision often involves factors of different attributes in different periods, resulting in solving it difficultly in one step. The final result of the location selection decision is a staged and constantly revised process. Therefore, facing major emergencies, we need to find a new decision-making method for the location selection of emergency facilities which should be consistent with the engineering practice process. Through continuous screening and correction, the final location selection results can be achieved.36. However, the reality later indicated that excessive quantification and mathematical modelling could not wholly solve specific practical issues. Faced with this problem, the International Institute for Applied Systems Analysis (IIASA) organized a seminar on the theme " Rethinking the Process of Systems Analysis". Participants concluded that quantitative methods could not be applied well to some problems, mainly due to incorrect methodologies, such as over-reliance on the establishment of mathematical models and ignoring or no explicit human factors37.In the 1950s, the systems engineering methodology and other similar methodologies were formed to solve the organization and management of large and complex projects. Based on established work steps and thinking methods, this methodology emphasizes establishing mathematical models and quantitative analysis methods38. As a systematic tool for solving complex problems, the methodology decomposes the complexities into three interconnected dimensions: Wuli, Shili, and Renli. Wuli refers to the objective of the existence of things and laws, including the physical environment and structural organization, etc., as principles and rules for dealing with specific affairs in the real world. "Shili" emphasizes the mode of interaction between people and the "world", which is an intervention or processing mechanism. "Renli" emphasizes the subjective relationship between all parties involved in systems engineering, especially the subjective role of people.Based on this background, Gu Jifa and Zhu Zhichang proposed the Wuli-Shili-Renli (WSR) methodology based on engineering experience combined with traditional oriental philosophical thoughts39and the comprehensive index system of sustainability evaluation of the shale gas industry40. In addition, some researchers also use the WSR method to build theoretical models. For example, Abdelbasset W K and others proposed a service model based on WSR theory and contributed to the theoretical research of delivery services . Lin and others analyzed the complexity of knowledge management and established a general knowledge management model for the Knowledge Management System41 . Furthermore, other researchers combined the WSR method with other models or theories and conducted quantitative calculations and demonstrations. For example, Gen Li and others determined the energy intensity factor system of the manufacturing industry based on the WSR method. They used the VAR model to analyze various factors influencing the energy intensity of the manufacturing industry 42. Based on the WSR methodology, Jinxian Zhao and others introduced the fuzzy theory to develop a comprehensive subway shield construction evaluation model based on combined weighting by the multiplicative synthesis method 43.Since the WSR methodology is appropriate for dealing with complex issues in a hierarchical and organized manner by reasonably coordinating the complex connections between various factors, scholars in different fields have begun to use this methodology to research complex issues. Some researchers use the WSR method to construct evaluation systems, such as the government credit evaluation index system The above analysis shows that the WSR method is appropriate for dealing with complex systems and things. Through dividing various factors into “Wuli”, “Shili” and “Renli” according to their attributes, WSR method provides different solutions under the constraints of various factors. The location selection of emergency medical facilities is a complex problem of multi-factor interaction and influence, so the WSR method derived from engineering practice experience can be used to decompose this complex problem. By dismantling complex problems into different solution stages according to the different attributes of the influencing factors, each stage can meet specific needs to obtain the optional result. Compared with the previous simple application of multi-objective optimization model or MCDM method for one-shot modeling solution, this hierarchical location decision-making idea is more in line with the operation process of engineering practice, and it can also more conveniently consider the effects of different attribute factors on the location decision-making.The WSR methodology recommends six elements of action: understanding desires, investigating conditions, formulating objectives, creating models, coordinating relations and implementing proposals. This study develops an MCDM method based on the WSR methodology Fig. . The speStep 1: Understanding desires: A DMs expert group is developed and the actual situation in the current region and basic information such as the type and level of emergencies are obtained;C is identified that affect the location selection under such emergencies, and the relevant factors are divided into "Wuli" factors Step 2: Investigating conditions: According to the specific situation of the current area and emergency, the set of factors Step 3: Formulating objectives: Potential alternative facility set Step 4: Creating models: A screening model for alternative facilities is developed, and the order of action of the "Wuli" factor, "Shili" factor and "Renli" factor is clarified. The alternative locations that do not meet objectivity requirements from the "Wuli" factor should be directly excluded. The "Shili" factor is an artificially formulated and quantifiable evaluation standard based on the actual situation, whose weight can be given by the entropy weight method objectively, and then the factors would be sorted by the TOPSIS method. The "Renli" factors refer to the evaluation criteria for subjective judgments based on decision-makers experience. The BWM method calculates subjective weights to the "Renli" factors, and the remaining alternative facilities screened by the "Shili" factors are ranked by applying the interval type-2 fuzzy TOPSIS method;Step 5: Coordinating relations: According to the actual situation of the city, which alternative facilities can be used to build emergency medical facilities can be finalized after the screening of the fourth step model;Step 6: Implementing proposals: Construction can begin according to the location decided by the city's final decision maker.Step 4, "Creating models", is the core link in the above workflow framework, which is one of the crucial innovations of this study. The screening models of alternative facilities would directly influence the final decision result. The specific steps and mathematical models are as follows:Step 4.1: According to the actual situation, the DMs expert group need to decide the order of action of "Wuli", "Shili" and "Renli" factors. The following will explain the selection process of alternative facilities in the order of "Wuli"-"Shili"-"Renli".Step 4.2: The "Wuli" factor is an objective requirement. Compared the obtained actual data of the evaluation index with the required numerical value of the index according to the "Wuli" factor Step 4.3: The "Shili" factor is human intervention. At this time, the "Shili" factor should be objectively weighted by the entropy weight method, and the TOPSIS method should be used for sorting and screening. The specific process is as follows:Step 4.3.1: Constructing the initial matrix. Firstly, the mathematical model of each factor is established according to the "Shili" factor Step 4.3.2: Normalizing the initial matrix. The dimensions of each index factor are different in the "Shili" evaluation index, which lead to the impossibility of direct comparison and comprehensive evaluation. In order to eliminate the influence of the dimension on the evaluation results, it is necessary to perform dimensionless processing on the index by establishing a standardized decision matrix Step 4.3.3: Determining the weight of each evaluation index by entropy weight method. The index weight Step 4.3.4: Weighting the normalized matrix. The normalized decision matrix F is weighted to form the matrix Step 4.3.5: Determining the positive ideal solution Step 4.3.6: Calculating the closeness Step 4.3.7: According to the closeness 46. The Mathematical calculation rules of the type‐2 fuzzy set have also been sufficient in the relevant literatures which is beneficial to facilitate calculations 49.Step 4.4: The "Renli" factor Step 4.4.1: Determining the criteria 50to form an initialization evaluation matrix Step 4.4.2: Constructing the initial matrix. According to the "Renli" factor mentclass2pt{minimStep 4.4.3: Constructing the normalized Initial matrix. In the "Renli" evaluation factor, the normalization process is performed to convert multiple criteria measures into similar measures to establish a standardized decision matrix For positive indicators:For negative indicators:Step 4.4.4: Weighting the normalized matrix. The normalized decision matrix 51and Step 4.4.5: Determining the positive ideal solution Among Step 4.4.6: Calculating the closeness of the alternative location Step 4.4.7: Ranking the alternative facilities 52. They have served as separate emergency medical facilities in various types of disaster relief operations in different countries, such as the Fangcang shelter hospital 53, the NHS Nightingale Hospital in public health emergencies and the alternative care facility 56 and the medical evacuation point during natural disasters. Previous cases have fully demonstrated that large-space public buildings represented by gymnasiums can supplement the need for beds in the healthcare system and decompose the system pressure quickly when the urban medical system is facing collapse. In addition, emergency medical facilities transformed from large-space public buildings are easy to construct and will not cause too much social and economic burden. However, one of the most critical problems is how to screen the optimal from numerous large public buildings which are the potential alternative locations.Facing excessive medical demand load caused by major emergencies, it is difficult for the government to guarantee to host and treat their patients in fully equipped hospitals. In emergency rescue, public buildings such as gymnasiums and convention and exhibition centres have the strengths of large spatial scale, high security and so onAs emergency medical facilities, the Fangcang shelter hospitals' location are selected from the large-space public buildings such as gymnasiums and convention and exhibition centres to serve patients who are infected with COVID‐19. Therefore, this paper applies the proposed emergency location decision method to the selection of the location of the Fangcang shelter hospitals during public health emergencies.As an international metropolis and one of the largest commercial centers in the world, Shanghai has the high human circulation and is vulnerable to the impact of the epidemic. In March 2022, the COVID-19 epidemic in Shanghai had a major impact on the medical system. Shanghai launched the construction of Fangcang shelter hospitals to treat patients with mild symptoms to ensure the safety of medical supplies and the health of urban residents. In response to this public health emergency, we selected the available within the city as alternative facility points set entclass1pt{minimaThe selected locations of the Fangcang shelter hospitals must keep a safe distance from the surrounding environment, for avoiding potential impact on the surroundings.Large‐scale areas being evaluated should be close to an infectious disease hospital or third-grade class-A hospital so that the patients whose illness worsen from mild to severe can be rapidly transferred for further treatment Fig. .Figure 3In case of emergency, Fangcang shelter hospitals should choose Large‐scale buildings with sufficient indoor space for construction which can be expanded with additional bed capacity in a short time.The location selection of Fangcang shelter hospitals not only needs to take into account the surrounding road conditions, but also the connection with the transportation hub. Because it is necessary to facilitate the arrival of surrounding patients, as well as the arrival of external aid materials and personnel Figs. , 5.FigurConsideration should be given to the difficulty of restoring the original function. Because expropriated buildings need to restore their original functions after the epidemic.The degree of matching between the requisitioned building space and the function of the Fangcang shelter hospitals affects the difficulty of construction.Consideration should be given to the time cost of completing the reconstruction of the requisitioned building, because the construction of the Fangcang shelter hospitals should be completed in a short time.Since Fangcang shelter hospitals separate patients from their relatives and society, enough space should be available to socialize and receive various types of services,such as medical care, monitoring, nutrition, accommodation.The DMs expert group divided the eight impact criteria into the factors of "Wuli", "Shili" and "Renli" Table , and decThe evaluation index of the "Wuli" factor often has precise objective requirements. The construction guidelines of the Fangcang shelter hospital require that a greening distance of at least 20 m be reserved between it and the surrounding areas to avoid causing cross-infection to the other areas, which belongs to the objective and unmodifiable requirements in epidemic prevention and control. Through the data collection of the surrounding greening distance of 39 locations in set The "Shili" factor evaluation criteria can be considered non-absolute indicators within a reasonable range. It is a roughly understanding that the larger or smaller the numerical value of certain criteria would be more conducive to the construction of makeshift hospitals. First and foremost, objective quantification methods for each criterion need to be defined.Rescue efficiency will be affected by road, rail and air transportation, so for location accessibility, we specifically use road accessibility, air accessibility and rail accessibility to express alternative location accessibility. First, urban roads are the most critical transportation facilities in the city, and their accessibility index can reflect the convenience of the target facilities. In this paper, each candidate facility in set The distance from the location to the designated hospital: the actual distance from the candidate location to its nearest infectious disease hospital or third-grade class-A hospital. The formula is:The scale of the site space: the available indoor area of the candidate point is divided by the specified per capita area. The number of temporary beds available of alternative locations can be equivalent to the size of the location.According to the above evaluation criteria, the evaluation results of the "shili" factor are shown in Suppl Appendix The evaluation criteria for "Renli" factors are difficult to express clearly with specific mathematical formulas and mainly rely on the experience of decision-makers to make subjective judgments. The DMs first determined the weight of the evaluation index of the "renli" criteria according to the BWM method, as shown in Table mentclass2pt{minim57.After screening through the location selection decision-making framework, the National Convention and Exhibition Center has the advantage of being located at a central point that can be reached by air or roadways, with many indoor and outdoor empty areas, far from residential areas, extensive infrastructure, and so on. Therefore, transforming the National Convention and Exhibition Center into a Fangcang shelter hospital by equipping it with the necessary tools and health professionals to receive patients also meets the expectations of government administrators and DMs. Relevant studies have shown that the Fangcang shelter hospitals built during the epidemic in Shanghai, especially the transformation of the National Convention and Exhibition Center, played an essential role in curbing the epidemicFollowing National Convention and Exhibition Center, many exhibition halls and gyms with large areas, accessible transportation, and being away from crowded districts have also been selected as the appropriate location for Fangcang shelter hospitals. During the Shanghai epidemic, they were successfully converted into Fangcang shelter hospitals to receive patients. Overall, after the three-level screening of "Wuli'"–"Shili"–"Renli", the final ranking order of the alternative locations suitable for the establishment of Fangcang shelter hospitals was obtained in this case. Compared with the actual construction and use during the epidemic, the top seven in the final ranking have experience being used as emergency medical facilities, of which the top six are used as the Fangcang shelter hospitals. In particular, the ranking 1 National Convention and Exhibition Center (Shanghai) was transformed into the largest Fangcang shelter hospital in Shanghai, which played an essential role in stabilizing the epidemic in Shanghai. Since then, with the decline of the ranking, the seventh-ranked Yuanshen Sports Center was used as a transfer station for recovered patients to return to the community during the epidemic. Besides, the last four alternative facilities were not used due to their location, area, and other deficiencies.To validate the effectiveness and feasibility of the proposed method for evaluating alternative locations to set up Fangcang Shelter hospitals, sensitivity analysis was directed to check the robustness of the results. We manipulated the criteria weights and created ten cases consisting of extreme cases. The weights of the criteria in the "Wuli" factor were not adjusted because of their absoluteness. Ten groups of weight combinations Tables  and 8 weThe sensitivity analysis results in the "Shili" stage Fig.  showed tOn the other hand, the changes in rankings showed the sensitivity of the ranking procedure of the framework considering the criteria weights. In particular, the ranking was changed significantly when the weight of operability was the highest, which meant the results were sensitive to operability. Overall, as seen in case 1, 2, and 10, when the weight of the operational effect is the lowest, the final ranking fluctuation is relatively stable. Moreover, as seen in case 4, 5, and 7, the ranking fluctuation is significant when the weight of post-pandemic building recovery is low.In a word, sensitivity analysis showed that the framework produced robust and valid results. Consequently, the comparative analysis showed that the WSR methodology-based MCDM framework that integrates EWB, BWM, and interval type‐2 fuzzy TOPSIS method is efficient and consistent with actual usage.Emergency medical facilities are essential to alleviate local excessive medical demand load after major emergencies. To reduce medical evacuation time and improve the possibility of survival, efficient and scientific planning of the location of emergency medical facilities is a significant way to improve the efficiency of first aid, especially for urban areas with high-density populations. However, previous studies I have not fully considered the difference between "issue" and "problem" factors in the influencing factors of location selection. It often comprehensively considers all the factors affecting the location selection at one time by using one method to solve all factors, which challenging in taking into account the impact of factors with different attributes in different stages on the final location selection results.Guided by the WSR methodology, this study constructed a three-level screening method for emergency facility location selection by distinguishing between "issue" and "problem" factors. Specifically, this study used different methods to screen and judge each "Wuli", "Shili" and "Renli" factor. The first step is to directly screen out the candidate points that do not meet the objective requirements of "Wuli" factors. For example, we can use GIS to analyze the location of emergency medical facilities because of the spatial nature of the potential criteria. The second step is to assign values to determine the index weight of the "Shili" factor index composed of objective data with the entropy weight method to secondary screen the alternative facilities with the TOPSIS method. The third step is to determine the "Renli" factor index weights constituted by the subjective evaluation with the BWM method to finalize the selection of alternative facilities with the TOPSIS method. Finally, a case study was presented in detail to indicate the application of the proposed location selection framework, and the final screening results can prove that it can well serve the actual location selection needs. The sensitivity analysis validated the robustness of the method. To sum up, the validation of the effectiveness, feasibility, and robustness of the proposed method is proved. This framework can be easily applied to other cities to meet the location needs of emergency medical facilities.The current study can be extended in several directions. First, WSR methodology-based multi-criteria decision‐making framework can be employed to determine the most suitable locations for emergency facilities. Second, the suitable criteria to be used can be evaluated by using the interval type‐2 fuzzy technique. Finally, the interrelationships among the factors that affect the location selection can be analyzed using EWM-TOPSIS or BWM-TOPSIS.Even though this study provides a decision-making framework for emergency facility location selection in response to major emergencies through the proposal of the scientific three-level screening method of "Wuli'"–"Shili"–"Renli" and the verification of practical application cases, certain limitations should be considered in evaluating the conclusions of this research. Based on the "hypothesis of rational man", the established location selection framework assumes that the members of DMs can make rational decisions in line with the actual situation under the control of relatively complete information. However, decision-makers often lack relevant practical experience and relatively limited information obtained in a short time, which may deviate the decision-making process and result. Therefore, it is not only necessary to strengthen the relevant training of professionals in the future to enhance the understanding of various emergencies and the information of the city but also to establish an information management platform for large urban public buildings and to enter relevant data information in advance to shorten the acquisition time of information in emergencies. Apart from these, it is better to optimize further the decision-making process of the "Shili" factor and "Renli" factor and seek a more simplified and efficient calculation and screening method.Supplementary Information 1.Supplementary Information 2.