Industry is an important pillar of the national economy. Industrial projects are the most complex and difficult projects to control in the construction industry, and major industrial projects are even more complex and difficult to control. Multi-agent coordination is one of the core issues of industrial projects. Based on an analysis of the engineering and construction chains and agent relationships and agent networks of industrial projects, a complex network of the engineering and construction agents of industrial projects is established, and the complex network structural holes theory is applied to study the nonrepeated relationships among agents in industrial projects. Assuming agents are linked through contract relations and the most critical contract index between the agents in the contract amount, through structural hole analysis considering the EPC and PMC model, the aggregate constraint list is obtained, 2D network diagram and 3D network diagram are shown. According to the aggregate constraint value, the EPC contractor with the minimum aggregate constraint value and the project management company with the minimum aggregate constraint value are the critical agent in EPC and PMC model. By analyzing the complex network comprising different models of industrial projects, it is concluded that the characteristics of the agent maintain an advantage in competition, the coordination mechanism of the integration of agent interests, and multi-agent relations are considered to solve the multi-agent coordination problem in major industrial projects. Major projects include infrastructure or plant projects with a large investment scale, high technical complexity and difficult control process, such as transportation, energy, chemical industry, communications, municipal administration and aerospace projects, which exert an important influence on political, economic, social, science and technology, engineering development, environmental protection, public health, national security and strategic planning aspects.With the development of science and technology, industrial projects tend to be increasingly large-scale and intensive projects. Industrial projects are characterized by a large scale, high investment, complex process system, intensive layout, open-air features, automatic control, high construction technology requirements, numerous design institutes, several suppliers, many construction units, various cooperation units, countless work interface relations, and long construction cycles, and the agent coordination problem of industrial engineering and construction projects is difficult to solve, which requires a new analysis method of the essential characteristics.Complex networks have been widely applied in many fields, including social, technical, information, biological and economic networks. From the Internet to the Worldwide Web, from the structural network of organisms to the food chain among animals, from the neural network of the human body to the social relationship network, and from the construction chain of engineering to the relationship network of engineering agents, complex networks occur everywhere. The research of complex networks permeates various fields, such as physics, biology, social science and engineering, and the qualitative and quantitative research of complex networks has become a major research topic.In 1977, Freeman , 3 studiSince the 21st century, scholars have carried out extensive empirical studies on complex systems in different fields, such as criminal networks, Twitter, community networks, and interpersonal communication, in terms of the complex network centrality and cluster coefficient theory.Structural holes are the nonrepeated relationships between two agents. The benefits contributed by the two agents associated with the structural holes to the network are accumulative but not overlapping. There are two indexes to measure structural holes: cohesion and structural allelism. If strong ties occur between two agents, repeated agent relations exist that lack structural holes, and cohesion redundancy follows. A structural hole exists if two of neighbours are not linked to each other. Through these two neighbours, they are connected to different parts of the larger network, and thus have access to different sources of dispersed information. Thus if a firm is to form a new link, closing a structural hole is less valuable than finding a partner to whom none of the current partners is currently connected . The argThe advantages of structural holes are that it emphasizes that structural holes in interpersonal networks can bring advantages in information and other resources to organizations and individuals in that position. If there is no direct connection between the two, and the connection must be formed through the third party, then the third party acting occupies a structural hole in the network of the relationship. Obviously, the structural hole is for the third party.ijp, which is the ratio of the probability value of the relation between nodes i and j to the probability value of all relations of i, and ija is the value of the edge attribute between nodes i and j.A structural hole is considered to measure the constraint index of networks ijc denote the missing constraints of node j around the initial hole of node i.Aggregate constraints K is the set of all nodes connected to node i, for k∈K.ijc coefficient, the fewer structural holes there are and the higher the network closure is.The higher the i is ic, corresponding to independent nodes ic = 1.The aggregate constraint of node The industrial project construction stage includes the decision-making, implementation and commercial operation stages, among which the implementation stage includes the engineering, procurement, construction and commissioning stages. The whole construction stage of industrial projects involves the participation of multiple agents who undertake different management tasks and exhibit different interests. Therefore, project management representing agents of different interests is established at the different stages of the project. The engineering and construction chains of industrial projects include the large, complex and systematic industrial projects surrounding the industrial engineering and construction process, from the feasibility study of preparation, process design package, general design, front end engineering design (FEED)/basic design, detailed design, procurement, construction, precommissioning, commissioning, start-up, performance testing, final acceptance, and the whole engineering and construction process until the final engineering products are delivered, which includes licensers, design companies, engineering companies, suppliers, and construction subcontractors, to the owner or end user comprise the chain structure as a whole. The engineering and construction chains describe the integration of the interests of multiple agents in the process of industrial project construction, unified allocation of resources between the engineering and construction chains and coordination of the relations among agents to achieve the common interests of all agents. The agents of the industrial project engineering and construction chains include owners, supervising companies, project management companies, contractors, licensers, design companies, suppliers, construction subcontractors and commissioning companies.The multi-agent relationships of the industrial project engineering and construction chains are linked by contracts, and the connecting agents of contracts differ under the various construction models. Under normal circumstances, the principal relationships involving the core or key technology, core or key resources, general supervision and production supervision are contracted by the owner or investor to ensure the overall technology, quality and control of the project. For example, the contract relationship between the licenser, catalyst company, core or key equipment company and supervision company is signed by the owner.Under the engineering, procurement and construction (EPC) model, the owner establishes a contract with the contractor. All decisions within the work scope of the contract belong to the contractor, while the contractor also assumes all responsibilities within the work scope of the contract, and the contractor establishes contracts with the design company, supplier, construction subcontractor, etc.Under the project management contractor (PMC) model, the owner establishes a contract with the project management company. The work scope of the project management company is to cooperate with the owner to carry out work without any decision-making power or responsibility. All decision-making power belongs to the owner, who establishes contracts with the design company, supplier, construction subcontractor, etc.The engineering and construction agent networks of industrial projects are the relationship networks of all agents in the overall process of the engineering and construction chains. Figs In the Figures above, the arrows of the engineering and construction agent networks of industrial projects only represent the initiator of the subordinate relation, contract or entrusted originator, and the relationship between agents is an equal contractual relationship. The flow of information and data is a two-way flow process.Industrial projects are characterized by many design companies, several suppliers, numerous construction companies, countless cooperative companies, various work interface relations, and long construction periods, which generally involves hundreds or thousands of agents. They comprise a network of agents through the contract relations and complete the engineering and construction of industrial projects through interaction.A large number of agents occurs in industrial projects, which constitute a complex agent network that cannot be analyzed with conventional methods. Therefore, it is necessary to analyze the characteristics of the topological structure of the complex network of the agents occurring in industrial projects through software suitable for the analysis and visualization of large networks with thousands or millions of nodes.Selecting a coal chemical project as an example, the agent network of the industrial project is established, and the network under the different construction models is analyzed.Overview of the coal chemical project: The project construction scale is the production of 1 million tons/year glycol and 2 million tons/year methanol. The project content mainly includes coal storage and transportation, boiler operation, air separation, gasification, conversion, purification, methanol and ethylene glycol production, tank area maintenance and provision of auxiliary facilities.The agent relationship of industrial projects is determined by the construction model, and the agent relationship is different under the various construction models. The following analysis of the engineering and construction process includes the agents from the beginning of the project to the final acceptance of the project. The characteristics of the above two construction models, i.e., the EPC and PMC models, are compared through complex network analysis.O(n2), namely, O(n), O(nlogn). This characteristic of the Pajek algorithm is different from that of other algorithms, and large complex networks are quickly processed, which is also the advantage of Pajek , but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section.”If your commercial affiliation did play a role in your study, please state and explain this role within your updated Funding Statement.2.2. Please also provide an updated Competing Interests Statement declaring this commercial affiliation along with any other relevant declarations relating to employment, consultancy, patents, products in development, or marketed products, etc.  http://journals.plos.org/plosone/s/competing-interests) . If this adherence statement is not accurate and  there are restrictions on sharing of data and/or materials, please state these. 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Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: YesReviewer #3: No**********5. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Dear authors,Thank you for submitting your paper to the PLOS ONE Journal. I believe your paper is an informative paper that can be published after a major revision. Please address my comments in the attached document.Reviewer #2: Title: Research on the coordination mechanism of major industrial project engineering and construction multi-agents based on structural holesThis topic seems to be interesting and practical. The manuscript cannot be considered as a potential publication in its current form. However, there are some concerns to be resolved carefully.1- The English and writing of the manuscript should improve. I found several errors.2- Abstract should contain the main contributions and achievements of the study, particularly in a numerical way.3- You should provide a useful survey on the related work addressing the main challenges, limitations, etc.4- The information of all indices should be given in each mathematical equation.5- What are the pros and cons of your proposed methodology?6- Figures cannot be read and understood.7- More comparisons should be made against the rival methods.8- The outlook of the research is missed.Reviewer #3: 1. Research keywords are not carefully selected. It is also necessary to give the reader an adequate explanation after choosing a keyword.2. What was the lack of available knowledge that led to this research? Research novelty should be clearly stated in the abstract and introduction.3. It is better to compare the results of this study with other similar studies. Also, the benefits of research are described.4. In conclusion, the direction of research by other researchers in the future is not specified.**********what does this mean?). If published, this will include your full peer review and any attached files.6. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool, Attachmentmyreview.docxSubmitted filename: Click here for additional data file. 23 Jun 2021See the attachment for Response to Reviewers.Below are the responses to the comments:Reviewer #1: Thank you for submitting your paper to the Journal of PLOS ONE. I believe your paper is an informative paper which can be published after a major revision.Comments:1. It is not clear what the research gap that the paper is addressing. What is the objective of this paper? Please clarify somewhere clearly all your contributions. Reply:The agent coordination problem of industrial engineering and construction projects is difficult to solve, which requires a new analysis method of the essential characteristics. This paper attempts to solve the multi-agent coordination problem in major industrial projects.This study contributes to the literature by exploratively examining the coordination mechanism of the major industrial project engineering and construction multi-agents. There has been limited research into multi-agents relationship. The influence of organizational characteristics on agent and project performance is a direction of the multi-agents relationship, and how to establish an effective multi-agents social networks is another direction of multi-agents relationship.2. The literature review is not goal oriented. The process should be as follows:i) Critical evaluation of the literature; ii) identifying the gap based on this critical evaluation of the literature; iii) proposing your hypothesis to address the identified gap; iv) posing the appropriate and relevant research question based on your proposed hypothesis; and finally explaining your proposed method to answer this research question. Therefore, you will have a systematic way of conducting your research. Right now, the literature review section has no clear objective. Reply: It has been revised.3. An adequate literature review and a clear gap identification have been tried to be conducted. However, authors have ignored some research which has been done in the area. I strongly recommend the authors to provide a more comprehensive literature review in the introduction section. The following papers are recommended:• Social cohesion, structural holes, and a tale of two measures. Journal of Statistical Physics, 151(3), 745-764.• Knowledge, networks, and knowledge networks: A review and research agenda. Journal of management, 38(4), 1115-1166.• Performance evaluation of complex electricity generation systems: A dynamic network-based data envelopment analysis approach. Energy Economics, 104894.• Complementary or contradictory? The effects of structural holes and status on innovation. Innovation, 20(4), 393-406.Reply: The references have been added.In 2012, Phelps et al.[9] developed a comprehensive framework that organizes the knowledge networks literature, which was used to review extant empirical research within and across multiple disciplines and levels of analysis, and identified points of coherence and conflict in theoretical arguments and empirical results within and across levels and identified emerging themes and promising areas for future research. In 2015, Burt [10] studied the strengthening of structural holes and proposed a reinforcement measure. In 2018, Tohyun et al. [11] studied focuses on the joint effects of the firms’ access to structural holes within social networks and their status within social hierarchy on their innovation performance, argued that the effects of structural holes and status contradict, rather than complement, each other because one tends to interfere with the other, and found that the positive effects of structural holes tend to be relatively stronger among lower-status firms, whereas the negative effects become stronger as the firms’ status increases. In 2019, Deng et al. [12] proposed a new measurement model for critical nodes based on global features and local features, which considers the edge betweenness and edge clustering coefficients and combines the mutual influence between nodes and edges in a network, and proposed an algorithm based on the aforementioned model Subsequently. In 2020, Alizadeh et al. [13] proposed a dynamic DEA (DDEA) model with time-based dependencies between the successive periods for assessing the performance over successive periods, and found that the efficiencies of power generation and transmission sectors are decreasing while the distribution performance is increasing.4. A thorough editorial check and English improvement are needed. Please kindly proofread the entire manuscript.Reply: It has been revised.5. The conclusion part is also needed to be revised; which questions are answered, what is the value/originality/contribution of the paper, how the proposed method answers the research questions that previous methods are not able to answer? Reply: It has been revised.Industry is an important pillar of the national economy, and industrial projects are the most complex and difficult to manage and control in the construction industry; thus, the multi-agents coordination of industrial projects is one of the core issues for industrial construction projects.A large number of agents occurs in industrial projects, which constitute a complex agent network that cannot be analyzed with conventional methods. Therefore, it is necessary to analyze the characteristics of the topological structure of the complex network of the agents occurring in industrial projects through software suitable for the analysis and visualization of large networks with thousands or millions of nodes.In this paper, the agent network of industrial projects is constructed by analyzing the relationship of the engineering and construction multi-agent chains of industrial projects. On the basis of the agent network structure of industrial projects, the nonrepeated relationships between the network agents under the different models are analyzed via the structural holes theory. It is concluded that the characteristics of the agent maintain an advantage in competition, the coordination mechanism of the integration of agent interests, and multi-agent relations are considered to solve the multi-agent coordination problem in major industrial projects.6. It feels you need a king of aggregating results somewhere clearer. Reply: It has been revised.According to the above analysis of the complex network, it is concluded that under the different models, the engineering and construction agents compete for the dominant position among the structural holes because that position attains the dominant advantage. Therefore, to achieve the integration of multi-agent interests and coordination of multi-agent relationships, it is necessary to reduce the structural holes, whereas the aggregation coefficient of each agent tends to remain the same.According to the conducted structural hole analysis of the EPC and PMC models, it is concluded that when the aggregation coefficient of each agent tends to remain the same, the relationships among all agents and between the agent location in the network and that in the engineering and construction network tend to be more similar, which is conducive to the integration of multi-agent interests and coordination of multi-agent relationships, in addition to the stable development of the construction market.7. Please propose and suggest more possible future studies related to the current study. Reply: Discussion has been added.This study contributes to the literature by exploratively examining the coordination mechanism of the major industrial project engineering and construction multi-agents. There has been limited research into multi-agents relationship. The influence of organizational characteristics on agent and project performance is a direction of the multi-agents relationship, and how to establish an effective multi-agents social networks is another direction of multi-agents relationship.8. If you can, please make a small comparison between what did you do and what others did before; as a conclusion.Reply: The research on the coordination mechanism of the major industrial project engineering and construction multi-agents is sparse.9. The abstract is not deep enough and Is not well prepared. Please try to re-write it better. The problem should be clearly stated and the gap which you are going to address need to be clarified. Simply explain your contributions and key findings.Reply: The abstract has been revised.Industry is an important pillar of the national economy. Industrial projects are the most complex and difficult projects to control in the construction industry, and major industrial projects are even more complex and difficult to control. Multi-agent coordination is one of the core issues of industrial projects. Based on an analysis of the engineering and construction chains and agent relationships and agent networks of industrial projects, a complex network of the engineering and construction agents of industrial projects is established, and the complex network structural holes theory is applied to study the nonrepeated relationships among agents in industrial projects. Assuming agents are linked through contract relations and the most critical contract index between the agents in the contract amount, through structural hole analysis considering the EPC and PMC model, the aggregate constraint list is obtained, 2D network diagram and 3D network diagram are shown. According to the aggregate constraint value, the EPC contractor with the minimum aggregate constraint value and the project management company with the minimum aggregate constraint value are the critical agent in EPC and PMC model. By analyzing the complex network comprising different models of industrial projects, it is concluded that the characteristics of the agent maintain an advantage in competition, the coordination mechanism of the integration of agent interests, and multi-agent relations are considered to solve the multi-agent coordination problem in major industrial projects.10. There are some errors in your reference list. Please check and fix the errors.Reply: It has been modified.Reviewer #2:Title: Research on the coordination mechanism of major industrial project engineering and construction multi-agents based on structural holesThis topic seems to be interesting and practical. The manuscript cannot be considered as a potential publication in its current form. However, there are some concerns to be resolved carefully.1. The English and writing of the manuscript should improve. I found several errors.Reply: It has been modified.2. Abstract should contain the main contributions and achievements of the study, particularly in a numerical way.Reply: The abstract has been revised.Industry is an important pillar of the national economy. Industrial projects are the most complex and difficult projects to control in the construction industry, and major industrial projects are even more complex and difficult to control. Multi-agent coordination is one of the core issues of industrial projects. Based on an analysis of the engineering and construction chains and agent relationships and agent networks of industrial projects, a complex network of the engineering and construction agents of industrial projects is established, and the complex network structural holes theory is applied to study the nonrepeated relationships among agents in industrial projects. Assuming agents are linked through contract relations and the most critical contract index between the agents in the contract amount, through structural hole analysis considering the EPC and PMC model, the aggregate constraint list is obtained, 2D network diagram and 3D network diagram are shown. According to the aggregate constraint value, the EPC contractor with the minimum aggregate constraint value and the project management company with the minimum aggregate constraint value are the critical agent in EPC and PMC model. By analyzing the complex network comprising different models of industrial projects, it is concluded that the characteristics of the agent maintain an advantage in competition, the coordination mechanism of the integration of agent interests, and multi-agent relations are considered to solve the multi-agent coordination problem in major industrial projects.3. You should provide a useful survey on the related work addressing the main challenges, limitations, etc.Reply: Discussion has been added.This study contributes to the literature by exploratively examining the coordination mechanism of the major industrial project engineering and construction multi-agents. There has been limited research into multi-agents relationship. The influence of organizational characteristics on agent and project performance is a direction of the multi-agents relationship, and how to establish an effective multi-agents social networks is another direction of multi-agents relationship.4. The information of all indices should be given in each mathematical equation.Reply: The information of all indices is as follows:A structural hole is considered to measure the constraint index of networks , which is the ratio of the probability value of the relation between nodes i and j to the probability value of all relations of i, and is the value of the edge attribute between nodes i and j. (1)Aggregate constraints denote the missing constraints of node j around the initial hole of node i. (2)K is the set of all nodes connected to node i, for .The higher the coefficient, the fewer structural holes there are and the higher the network closure is.The aggregate constraint of node i is , corresponding to independent nodes =1. (3)5. What are the pros and cons of your proposed methodology?Reply: The pros is that it emphasizes that structural holes in interpersonal networks can bring advantages in information and other resources to organizations and individuals in that position. If there is no direct connection between the two, and the connection must be formed through the third party, then the third party acting occupies a structural hole in the network of the relationship. Obviously, the structural hole is for the third party.The cons is that if there is no third party, or the network structure is not complex, it is difficult to reflect the advantages of structural hole theory.6. Figures cannot be read and understood.Reply: The figures are the visualization of 547 agents under the EPC model and 541 agents under the PMC model by Pajek software, so they look complex.7. More comparisons should be made against the rival methods.Reply: The related references have been added.8. The outlook of the research is missed.Reply: Discussion has been added.The prospect of this research is that it can be applied to large, complex and systematic industrial project management, and can be used as a guide for selecting project management model.Reviewer #3: 1. Research keywords are not carefully selected. It is also necessary to give the reader an adequate explanation after choosing a keyword.Reply: The key words have been revised; the key words are industrial project; major industrial project; multi-agents; coordination mechanism; complex network; structural holes. Because this paper is to study the multi-agents relationship of major industrial projects, and apply the structural hole theory.2. What was the lack of available knowledge that led to this research? Research novelty should be clearly stated in the abstract and introduction.Reply: With the development of science and technology, industrial projects tend to be increasingly large-scale and intensive projects. Industrial projects are characterized by a large scale, high investment, complex process system, intensive layout, open-air features, automatic control, high construction technology requirements, numerous design institutes, several suppliers, many construction units, various cooperation units, countless work interface relations, and long construction cycles, and the agent coordination problem of industrial engineering and construction projects is difficult to solve, which requires a new analysis method of the essential characteristics.The abstract and introduction have been revised.3. It is better to compare the results of this study with other similar studies. Also, the benefits of research are described.Reply: The research on the coordination mechanism of the major industrial project engineering and construction multi-agents is sparse.The advantages are that it emphasizes that structural holes in interpersonal networks can bring advantages in information and other resources to organizations and individuals in that position. If there is no direct connection between the two, and the connection must be formed through the third party, then the third party acting occupies a structural hole in the network of the relationship. Obviously, the structural hole is for the third party.4. In conclusion, the direction of research by other researchers in the future is not specified.Reply: Discussion has been added.This study contributes to the literature by exploratively examining the coordination mechanism of the major industrial project engineering and construction multi-agents. There has been limited research into multi-agents relationship. The influence of organizational characteristics on agent and project performance is a direction of the multi-agents relationship, and how to establish an effective multi-agents social networks is another direction of multi-agents relationship. The prospect of this research is that it can be applied to large, complex and systematic industrial project management, and can be used as a guide for selecting project management model.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 7 Jul 2021PONE-D-21-16612R1Research on the coordination mechanism of major industrial project engineering and construction multi-agents based on structural holesPLOS ONEDear Dr. Han,Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.Please consider the comments of reviewer 3plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.Please submit your revised manuscript by 17 July 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at Please include the following items when submitting your revised manuscript:A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.A marked-up copy of your manuscript that highlights changes made to the original version. 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Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: We look forward to receiving your revised manuscript.Kind regards,Ahmed Mancy Mosa, Ph.D.Academic EditorPLOS ONEJournal Requirements:Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.[Note: HTML markup is below. Please do not edit.]Reviewers' comments:Reviewer's Responses to QuestionsComments to the Author1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.Reviewer #1: All comments have been addressedReviewer #2: All comments have been addressedReviewer #3: (No Response)**********2. Is the manuscript technically sound, and do the data support the conclusions?The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: YesReviewer #3: No**********3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: YesReviewer #2: YesReviewer #3: No**********4. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.The Reviewer #1: YesReviewer #2: YesReviewer #3: No**********5. Is the manuscript presented in an intelligible fashion and written in standard English?PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********6. Review Comments to the AuthorPlease use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: Dear authors,Thank you for your efforts in revising the manuscript. I believe you did a great job in the revision and the changes alleviated my concerns regarding the manuscript. Therefore, I recommend its publication.Looking forward to seeing the published version of your paper.Good luckReviewer #2: The authors could address all the comments and improve the quality of the manuscript. It can be now accepted.Reviewer #3: Unfortunately, this study does not have sufficient conditions for confirmation. This study still does not have sufficient conditions for confirmation. These confusing images, inadequate descriptions, inefficient sources, and unsystematic writing can lead to disapproval of the article.**********what does this mean?). If published, this will include your full peer review and any attached files.7. PLOS authors have the option to publish the peer review history of their article  digital diagnostic tool,  14 Jul 2021Here are the responses to the comments:Reviewer #3:1. Research keywords are not carefully selected. It is also necessary to give the reader an adequate explanation after choosing a keyword.Reply: The key words have been revised. The key words are industrial project; major industrial project; multi-agents; coordination mechanism; complex network; structural holes theory. Because the paper is to study the mechanism of the multi-agents relationship of major industrial projects based on the structural holes theory, so the above keywords are selected.2. What was the lack of available knowledge that led to this research? Research novelty should be clearly stated in the abstract and introduction.Reply: With the development of science and technology, industrial projects tend to be increasingly large-scale and intensive projects. Industrial projects are characterized by a large scale, high investment, complex process system, intensive layout, open-air features, automatic control, high construction technology requirements, numerous design institutes, several suppliers, many construction units, various cooperation units, countless work interface relations, and long construction cycles, and the agent coordination problem of industrial engineering and construction projects is difficult to solve, which requires a new analysis method of the essential characteristics.The abstract and introduction have been revised, as following:AbstractIndustry is an important pillar of the national economy. Industrial projects are the most complex and difficult projects to control in the construction industry, and major industrial projects are even more complex and difficult to control. Multi-agent coordination is one of the core issues of industrial projects. Based on an analysis of the engineering and construction chains and agent relationships and agent networks of industrial projects, a complex network of the engineering and construction agents of industrial projects is established, and the complex network structural holes theory is applied to study the nonrepeated relationships among agents in industrial projects. Assuming agents are linked through contract relations and the most critical contract index between the agents in the contract amount, through structural hole analysis considering the EPC and PMC model, the aggregate constraint list is obtained, 2D network diagram and 3D network diagram are shown. According to the aggregate constraint value, the EPC contractor with the minimum aggregate constraint value and the project management company with the minimum aggregate constraint value are the critical agent in EPC and PMC model. By analyzing the complex network comprising different models of industrial projects, it is concluded that the characteristics of the agent maintain an advantage in competition, the coordination mechanism of the integration of agent interests, and multi-agent relations are considered to solve the multi-agent coordination problem in major industrial projects.1 IntroductionMajor projects include infrastructure or plant projects with a large investment scale, high technical complexity and difficult control process, such as transportation, energy, chemical industry, communications, municipal administration and aerospace projects, which exert an important influence on political, economic, social, science and technology, engineering development, environmental protection, public health, national security and strategic planning aspects.With the development of science and technology, industrial projects tend to be increasingly large-scale and intensive projects. Industrial projects are characterized by a large scale, high investment, complex process system, intensive layout, open-air features, automatic control, high construction technology requirements, numerous design institutes, several suppliers, many construction units, various cooperation units, countless work interface relations, and long construction cycles, and the agent coordination problem of industrial engineering and construction projects is difficult to solve, which requires a new analysis method of the essential characteristics.3. It is better to compare the results of this study with other similar studies. Also, the benefits of research are described.Reply: The similar studies have been revised.3 Structural holes theoryStructural holes are the nonrepeated relationships between two agents. The benefits contributed by the two agents associated with the structural holes to the network are accumulative but not overlapping. There are two indexes to measure structural holes: cohesion and structural allelism. If strong ties occur between two agents, repeated agent relations exist that lack structural holes, and cohesion redundancy follows. A structural hole exists if two of neighbours are not linked to each other. Through these two neighbours, they are connected to different parts of the larger network, and thus have access to different sources of dispersed information. Thus if a firm is to form a new link, closing a structural hole is less valuable than finding a partner to whom none of the current partners is currently connected [19]. The argument is that agents attempt to increase their betweenness centrality. Rodan empirically tested a mediated moderation model that distinguishes between the five different theoretical mechanisms: autonomy, competition, information brokering, opportunity recognition and innovativeness, and the findings suggested that of these five theoretical causal motors, innovativeness plays a key role in linking network structure and network content to performance [20]. Xing et al. analyzed the spreading effect of industrial sectors with complex network model under perspective of econophysics, and the industrial complex network based on input-output tables from WIOD was proposed to be a bridge connecting accurate static quantitative analysis and comparable dynamic one [21]. Latora et al. attempted to reconcile closed and open structures by proposing a new measure, Simmelian brokerage, that captures opportunities of brokerage between otherwise disconnected cohesive groups of contacts, and the implications of our findings for research on social capital and complex networks were discussed [22].Zhao et al. proposed a novel measure based on Structural Holes and Degree Centrality(SHDC) which combined Structural Hole and Degree Centrality to measure the node influence, and the method used Degree Centrality to make a fast and coarse distinction between the influence of nodes and uses Structure Hole to reflect the impact of topological connections among neighbor nodes, which improved the ability to distinguish the influence of nodes in the low time complexity [23].The advantages of structural holes are that it emphasizes that structural holes in interpersonal networks can bring advantages in information and other resources to organizations and individuals in that position. If there is no direct connection between the two, and the connection must be formed through the third party, then the third party acting occupies a structural hole in the network of the relationship. Obviously, the structural hole is for the third party.Referenceshttps://doi.org/10.2307/30335431. Freeman LC. A Set of Measures of Centrality Based on Betweenness. Sociometry. 1977; 40(1):35-41. https://doi.org/10.1016/0378-8733(78)90021-7#doilink2. Freeman LC. Centrality in social networks : Conceptual clarification. Social Network. 1979; 1(3):215-239. https://doi.org/10.1016/0378-8733(79)90002-93. Freeman LC, Roeder D, Mulholland RR. Centrality in Social Networks: II. Experimental Results. Social Networks. 1980; 2(2):119-141. 4. Burt RS. Structural Holes: The Social Structure of Competition. Cambridge MA: Harvard University Press; 1992.5. Watts DJ, Strogatz SH. Collective dynamics of 'small-world' networks. Nature. 1998; 393(6684):440-440.6. Barabási AL, Albert R.Emergence of scaling in random networks. Science. 1999; 286(5499):509-512.https://doi.org/10.1016/j.socnet.2009.11.0027. Rodan S. Structural holes and managerial performance: Identifying the underlying mechanisms. Social Networks. 2010; 32(3):168-179. https://doi.org/10.1007/s10955-013-0722-z8. Latora V, Nicosia V, Panzarasa P. Social Cohesion, Structural Holes, and a Tale of Two Measures. Journal of Statistical Physics. 2012; 151(3):745-764. https://doi.org/10.1177/01492063114326409. Phelps C, Heidl R, Wadhwa A. Knowledge, Networks, and Knowledge Networks: A Review and Research Agenda. Journal of Management. 2012; 38(4):1115-1166. https://doi.org/10.1016/j.socnet.2015.04.00810. Burt RS. Reinforced structural holes. Social Networks. 2015; 43:149-161. https://doi.org/10.1080/14479338.2018.147873311. Tohyun K, Kisang P, Eunjung K. Complementary or contradictory? The effects of structural holes and status on innovation. Innovation Management Policy & Practice, 2018; 20(4):393-406. https://doi.org/10.1007/s11276-019-02040-412. Deng YJ, Li YQ, Yin RR ,Zhao HY, Liu B. Efficient measurement model for critical nodes based on edge clustering coefficients and edge betweenness. Wireless Networks. 2019; 26(1): 2785-2795. https://doi.org/10.1016/j.eneco.2020.10489413. Alizadeh R, Beiragh RG, Soltanisehat L, Soltanzadeh E， Lund PD. Performance evaluation of complex electricity generation systems: A dynamic network-based data envelopment analysis approach. Energy Economics. 2020; 104894. https://doi.org/10.1155/2021/559535414. Han XK, Yan WZ, Lu M. Research on reasoning concerning emergency measures for industrial project scheduling control. Advances in Civil Engineering. 2021; 5595354. https://doi.org/10.1007/s13198-021-01106-x15. Han XK.WBS-free scheduling method based on database relational model. Int J Syst Assur Eng Manag. 2021; 01106-x. https://doi.org/10.1155/2021/993011316. Han XK, Yan WZ, Lu M. Intelligent Critical Path Computation Algorithm Utilising Ant Colony Optimisation for Complex Project Scheduling. Complexity 2021; 9930113. 17. Nooy WD, Mrvar A, Batagelj V. Exploratory Social Network Analysis with Pajek: Revised and Expanded Edition for Updated Software. Third Edition. New York: Cambridge University Press; 2018.18. Mrvar A, Batagelj V. Program for Analysis and Visualization of Large Networks Reference Manual List of commands with short explanation version 5.10. Slovenia: University of Ljubljana; 2020.https://doi.org/10.1007/s11403-007-0024-019. Cowan R, Jonard N. Structural holes, innovation and the distribution of ideas. J Econ Interac Coord. 2007; 2: 93–110. https://doi.org/10.1016/j.socnet.2009.11.00220. Rodan S. Structural holes and managerial performance: identifying the underlying mechanisms. Social Networks. 2010; 32(3): 168-179. https://doi.org/10.1371/journal.pone.015627021. Xing L, Ye Q, Guan J, Adriana B L. Spreading Effect in Industrial Complex Network Based on Revised Structural Holes Theory. Plos One. 2016, 11(5): e0156270. https://doi.org/10.1007/s10955-013-0722-z22. Latora V, Nicosia V, Panzarasa P. Social Cohesion, Structural Holes, and a Tale of Two Measures. J Stat Phys. 2013, 151: 745–764. https://doi.org/10.1109/CSE-EUC.2017.137.23. Zhao X, Guo S, Wang Y. The Node Influence Analysis in Social Networks Based on Structural Holes and Degree Centrality. 2017 IEEE International Conference on Computational Science and Engineering (CSE) and IEEE International Conference on Embedded and Ubiquitous Computing (EUC). 2017, 708-711. 4. In conclusion, the direction of research by other researchers in the future is not specified.Reply: Discussion has been added.This study contributes to the literature by exploratively examining the coordination mechanism of the major industrial project engineering and construction multi-agents. There has been limited research into multi-agents relationship. The influence of organizational characteristics on agent and project performance is a direction of the multi-agents relationship, and how to establish an effective multi-agents social networks is another direction of multi-agents relationship. The prospect of this research is that it can be applied to large, complex and systematic industrial project management, and can be used as a guide for selecting project management model.AttachmentResponse to Reviewers.docxSubmitted filename: Click here for additional data file. 26 Jul 2021Research on the coordination mechanism of major industrial project engineering and construction multi-agents based on structural holes theoryPONE-D-21-16612R2Dear Dr. Han,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. 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Enterococcus spp, three Streptococcus gallolyticus, and one Escherichia coli), followed by Staphylococci (three cases of S. aureus and S. epidermidis each). Among the risk factors evaluated, age, vascular nephropathy, and elevated calcineurin inhibitor through levels were significantly associated with the occurrence of IE in our study. Patient and death-censored graft survival were greatly diminished five years after IE, compared to controls being 50.3% vs. 80.6% (p < 0.003) and 29.7% vs. 87.5% (p < 0.002), respectively. IE in KTRs is a disease that carries significant risks both for the survival of the patient and the transplant.Kidney transplant recipients (KTRs) tend to develop infections with characteristic epidemiology, presentation, and outcome. While infective endocarditis (IE) is among such complications in KTRs, the literature is scarce. We describe the presentation, epidemiology, and factors associated with IE in KTRs. We performed a retrospective case/control study which included patients from two centers. First episodes of definite or possible IE (Duke criteria) in adult KTRs from January 2010 to December 2018 were included, as well as two controls per case, and followed until 31 December 2019. Clinical, biological, and microbiological data and the outcome were collected. Survival was studied using the Kaplan–Meier method. Finally, we searched for factors associated with the onset of IE in KTRs by the comparison of cases and controls. Seventeen cases and 34 controls were included. IE was diagnosed after a mean delay of 78 months after KT, mostly on native valves of the left heart only. Pathogens of digestive origin were most frequently involved (six  Infective endocarditis (IE) is an invasive infection characterized by high inoculum of a pathogen that has a strong propensity to form biofilms, and that is also capable of systemic dissemination. Worldwide, this severe disease  remains rare. Over the last decades, a trend was observed with an increase in staphylococcal infections and increasing incidence in older patients with more comorbidities [End-stage renal disease (ESRD) is a growing worldwide concern, with almost one million ESRD patients in the United States in 2019 . IE in tWe therefore sought to describe the presentation, epidemiology, risk factors, and outcome of IE in kidney transplant recipients (KTRs) through a case/control study.We performed a retrospective case–control study with patients from two centers: the Pitié-Salpêtrière  and in the Dupuytren  Hospitals. Cases were screened from the databases of the medical-based information systems in the two hospitals. Patients were included according to the following conditions: kidney transplant recipients with a functioning allograft, diagnosed for a first episode of certain or possible IE, on a native heart (exclusion of kidney-heart recipients), between January 2010 and December 2019. Two controls were included with each case; these were the patients who had received a kidney transplant just before and just after the case in the same center, provided that those patients survived at least until the delay of IE in the case. If one of the following exclusion criteria applied to the controls, the next-previous or the next-after transplanted patient was included instead: diagnosis of IE during the study period (included as a case), death before the diagnosis of the IE in the corresponding case, or presence of another organ transplanted with the kidney.The diagnosis of definite or possible IE was made according to the modified DUKE criteria ,4.Medical history: presence of a heart disease at high risk of IE heart , a history intravenous drug use, pre-transplant diabetes or new onset diabetes after transplantation (NODAT).Kidney transplantation (KT) history: the most recent estimated glomerular filtration rate  considered as stable before IE onset, induction and maintenance immunosuppressive treatments before and at the time of the infectious episode, the presence of high levels of calcineurin inhibitors or antimetabolites prior to the infectious episode  > 60 mg.h/L), the treated episodes of rejection and viral infections  between transplantation and the IE episode.The characteristics of the IE with the time to onset after KT, bacteriological documentation, infectious gateway, ultrasonography features, type of valve, vascular  and immunological (glomerulonephritis) complications, and the presence of an indication for surgery according to the European Society of Cardiology ,IE therapeutic management: antibiotic therapy used, treatment duration and surgical managementOutcome: patient and renal graft survival one year after the IE were collected. For controls, the delay between the IE diagnosis in the corresponding case and the event  was considered for the survival analysis. The end of the study was 31 December 2019.The onset date of the episode was defined by the start of antibiotic therapy for IE. The following clinical data were collected from the medical record:The annual incidence was estimated by dividing the annual number of cases of IE by the number of living KTRs in the two centers during the same year.Quantitative variables are presented as mean ± standard deviation . Comparisons were made using a Student’s t-test. Qualitative variables are presented as numbers (percentages). The data were compared using the Fischer or Chi2 test.p < 0.1. A two-sided p value < 0.05 was considered statistically significant in the univariate analysis. We did not perform multivariate analysis, as the validity criterium of at least 10 events per included variable was not met.Risk factors for IE were searched using univariate logistic regression, including all clinical characteristics differently distributed between cases and controls with a p value < 0.05.Survival analyses were performed using the Kaplan–Meier method. A log-rank test was performed for the comparison between the two groups, with a ®  and Stata® .The statistical analyses were performed using GraphPad PRISMAll patients provided consent to be included in the local databases before their transplantation and granted us the authorization to anonymously use their clinical data in the perspective of clinical research. The clinical databases were approved by the French Ethics Committee on the Treatment of Computerized Data in the Field of Medical Research, under the auspices of the French Ministry of Research .Over the study period 17 KTRs were diagnosed with IE, resulting in a mean annual incidence of 1.1%. We identified and included 34 controls. The characteristics of the population are shown in The clinical presentation and management of the cases of IE are summarized in Enterococcus spp (6), Streptococcus gallolyticus (3), coagulase-negative Staphylococci , Staphylococcus aureus (3), Escherichia coli (1), and one undocumented case. Concerning IE on prosthetic valves , Streptococcus gallolyticus, Enterococcus faecalis, and Staphylococcus epidermidis were found (one of each). One patient with a bioprosthetic valve had a definite Staphylococcus epidermidis IE, followed 10 months later by a new episode with Escherichia coli . The microorganisms were considered to be of digestive origin in 10 cases and of cutaneous origin in 6 cases. There was no case of IE with an oral origin.The bacteria causing the infection were: Vascular embolism was observed in six subjects . No immuSeven patients presented with an indication for surgery as recommended by the European Society of Cardiology in 2015 [S. aureus uncomplicated endocarditis of a native valve. Aminoglycosides were used in twelve patients . Vancomycin was used in three patients .The duration of the antibiotic therapy was six weeks, except for one case in which the patient received only four weeks of gentamicin and daptomycin for a methicillin-resistant p = 0.03, p < 0.01 for the global comparison of all nephropathies). In order to identify potential risk factors for IE, the distribution of clinical characteristics, comorbidities, and IS protocols  were comp = 0.08; IS protocols were evenly distributed between cases and controls; only high trough levels of CNI tended to be observed more frequently in cases than in controls (p = 0.04), elevated CNI through levels (OR: 7.22 95% CI (1.19 to 44.0), p = 0.03), and vascular nephropathy (OR: 8.72 95% CI (1.53–49.8)) appeared as risk factors for IE.We then performed a logistic regression including these potential risk factors . In the univariate analysis age (OR: 1.06 per year 95% CI (1.01–1.12), p < 0.003). The median survival was 20 months for cases and was not reached in controls at the end of the study. Eight patients with IE died, including seven within the first year of follow-up, and five within the first six months.Patient survival was greatly diminished after an episode of IE A. One- ap < 0.002). The median graft survival for cases was 49 months and was not reached at the end of follow-up for controls.Death-censored graft survival was also greatly lower in cases than in controls B. The esThe characteristics of the cases complicated by death or allograft loss (without death over the study period) are summarized in the IE is well described in the general population ,6,7, witIn our study, the annual incidence is 1.1‰ and surprisingly high if we consider that none of the patients in our study harbored a central venous device nor underwent repeated vascular puncture as a risk factor. This is probably the consequence of the IS treatment and of the comorbidities of this population.IE in KTRs occurred mostly in younger people than in the general population ,6,7,11, Staphylococci [Enterococci as the most frequent pathogen, as previously described in SOTRs [The microbiology also appears different from what has been described in HD patients, where there is a large predominance of ylococci ,13. In tin SOTRs ,19,20,21in SOTRs ,23,24. Tin SOTRs .In contrast with what has been reported for SOTRs in one study ,26, but The time to onset after transplantation was consistent with other reports for KTRs, with a mean delay of 3 to 5 years ,27.Interestingly, our study identified the combination of immunosuppression and vascular disease as risk factors for IE in KTRs. Age  and chrA history of CMV infection was not found to be associated with IE, as opposed to earlier studies where co-occurring CMV replication was found to be associated with both disease and mortality ,28, suggWe found IE is a frequently deadly disease, with a one-year mortality of 43%, when all the controls survived after the same delay. This mortality appears comparable with what has previously been described in SOTRs ,20 and iMore than 70% of the patients received aminoglycosides. According to the 2015 ESC Guidelines [Finally, death-censored graft survival after IE also appeared unexpectedly low, with half of the grafts lost after four years, versus 13% in the controls after the same delay. Endocarditis is known to result in acute and long-term kidney complications  due to iIE after kidney transplantation is a critical disease, both for the patient and the transplant function. Bacteria from the gut microbiota are overly represented, which underlines the fact that the host–pathogen crosstalk is insufficiently understood and should be further investigated in KTRs.


Patient portals are promising tools to increase patient involvement and allow them to manage their health. To optimally facilitate patients, laboratory test results should be explained in easy language. Patient characteristics affect the usage of portals and the user satisfaction. However, limited research is available, specified for online communicating laboratory test results, on whether portal use and acceptance differ between groups.The aim of this study was to assess the effect of patient characteristics  on the self-efficacy and perceived usability of an online patient portal that communicates diagnostic test results.We used the online-administered eHealth impact questionnaire (eHIQ) to explore patients’ attitudes toward the portal. Patients visiting the portal were asked to complete the questionnaire and to answer questions regarding gender, age, education, and chronic disease. The subscale “information and presentation” of the eHIQ assessed the usability of the patient portal and the subscale “motivation and confidence to act” assessed self-efficacy to determine whether patients were motivated to act on the presented information. Age, gender, education, and chronic disease were the determinants to analyze the effect on usability and self-efficacy. Descriptive analyses were performed to explore patient characteristics, usability, and self-efficacy. Univariable and multivariable regression analyses were performed with age, gender, education, and chronic disease as determinants, and usability and self-efficacy as outcomes.P<.001); b=-2.512, 95% CI -4.791 to -0.232 (P=.03); and b=-3.630, 95% CI -6.545 to -0.715 (P=.02). High education was also a significant determinant for a lower self-efficacy . Other determinants were not significant.The questionnaire was completed by 748 respondents, of which 428 (57.2%) were female, 423 (56.6%) were highly educated, and 509 (68%) had no chronic disease. The mean age was 58.5 years (SD 16.4). Higher age, high education, and asthma or chronic obstructive pulmonary disease were significant determinants for decreased usability; respectively, b=-.094, 95% CI -1147 to 0.042 (This study showed that the higher-educated users of a patient portal scored lower on usability and self-efficacy. Usability was also lower for older people and for patients with asthma or chronic obstructive pulmonary disease. The results portal is not tailored for different groups. Further research should investigate which factors from a patient’s perspective are essential to tailor the portal for different groups and how a result portal can be optimally integrated within the daily practice of a doctor. The involvement of patients is important to allow them to manage their own health. When patients are more engaged, they tend to make better decisions on health behavior . PatientIn 2019, we investigated patients’ attitudes toward the same portal designed to communicate laboratory test results using the eHIQ . The usaThe main aim of this study is to evaluate the effect of gender, age, education, and chronic disease on the usability and self-efficacy of patients using a patient portal designed to communicate laboratory tests.A cross-sectional real-world study was conducted between December 2019 and July 2020 to explore the influence of patient characteristics on the usability of a patient portal and on self-efficacy. Patients who viewed their test results in the portal were automatically approached to complete the eHIQ. Age, gender, education level, and chronic disease were measured as well. There were no further inclusion or exclusion criteria.No personal information was collected, and the data could not be traced back to the individual. Therefore, this study does not fall under the Medical Research Involving Human Subject Act (Wet medisch-wetenschappelijk onderzoek met mensen) and did not require approval from an ethics committee.In 2015, Saltro launched a web-based portal that gives patients access to their own laboratory test results, including understandable explanatory information . The conAfter blood withdrawal, the patients can look up their results by logging into the portal, with a username and password, through the website of the GP. The log-in procedure adheres to Dutch security legislation and guidelines  and the General Data Protection Regulation guidelines. The patients can see an overview of all laboratory tests ordered by date . Each reThis portal can be approached directly for laboratory test results but can also be approached within other portals as a plug-in; for example, a GP portal that functions as medication description.Primary outcomes were “information and presentation” and “motivation and confidence to act” in the Dutch version of the eHIQ, part 2 (eHIQ2) ,13. The The determinants were age, gender, education, and chronic disease , based oP<.10) determinants were included in multivariable models to examine which characteristics were independently related to the outcomes. To be rather inclusive than exclusive regarding the selection of variables for our multivariable model, P=.10 was chosen. A common level of P=.05 might fail to include relevant variables in those models [P<.05 was considered statistically significant. The analyses were performed using the SPSS version 24 (IBM Corp) [Descriptive analyses were performed to explore patient characteristics, usability, and self-efficacy. Univariable regression analyses were performed with age, gender, education, and chronic disease as determinants and usability and self-efficacy as outcomes. Significant  .The questionnaire was completed by 748 respondents. Response rate was 1.9% . The participants had a mean age of 58.5 years (SD 16.4), and they were mostly female  and highly educated  . MoreoveP<.10 for usability in the univariable analysis; they and where subsequently added in the multivariable model ; and b=-2.512, 95% CI -4.791 to -0.232 (P=.03). Chronic disease affected usability, with patients with asthma or COPD scoring significantly lower compared with those without a chronic disease .Age, education level, and chronic disease were relevant determinants with le model . MultivaP<.10   . Other dThis study aimed to evaluate the impact of patient characteristics on the perceived usability and self-efficacy of a patient portal. Higher education was associated with decreased usability and self-efficacy. Furthermore, usability was lower for older patients and for patients with asthma or COPD. The eHIQ is a validated questionnaire, and the results of this study with the eHIQ are in line with our previous study .The finding that highly educated people have a significantly lower perceived usability and self-efficacy after using the portal is not in line with other research projects . Mostly,This study also revealed that older participants scored lower on the usability of the portal. In other studies, the differences between age groups could be explained via the groups' digital skills. Van Deursen et al  and BroeFurthermore, our research demonstrated that patients with asthma or COPD were more negative about usability. Other research projects reported that these patients are often insufficiently capable of understanding health information , which c Moreover, we were not exhaustive with the possible patient characteristics as determinants. We cannot determine other factors that contribute to the patients' perceived usability and self-efficacy after seeing their lab results online. Possible other determinants that may impact usability and self-efficacy are the quality of the portal, the motivation to use the internet for health improvement [A strength of our study was the high sample size and that the patients completed the questionnaire immediately after they viewed their results, thereby limiting recall bias and giving an accurate picture of the patients’ attitudes toward the portal. Nevertheless, those who completed the study questionnaire were a small portion of the total group that used the patient portal. The low response rate precludes generalizing whether the patient portal display and explanation of the results are acceptable and informative for all of the patients. In future research, it is interesting to compare patients that use the portal to those who do not.rovement , and therovement ,33. Regarovement , and tecrovement ,35. PrevHighly educated users of a test results portal scored lower on usability and self-efficacy. The usability was also lower for older people and for patients with asthma or COPD. Result portals must adapt the language and communication used, according to the different target groups of age, education, and chronic illness. Only then can users take full advantage of the online information provision. Further research is necessary to determine promoting factors that users themselves consider important in a results portal, in order to tailor it for different groups. Further research is also needed on ways in which a portal can be optimally implemented and integrated within the daily practice of a doctor.


Objectives: To compare the ability to participate in social activities among rheumatoid arthritis patients with other rheumatic disease patients and identify potentially implicated factors. Patients and methods: Between June and November 2019, we consecutively selected patients aged ≥18 years with RA (defined according to ACR/EULAR 2010), SpA (ASAS/EULAR 2010), and SLE (ACR 1997). Main outcome measures: Ability to participate in social roles and activities evaluated using the PROMIS score v2.0 short-form 8a (PROMIS-APS). Secondary outcomes: Participation in social activities according to a series of variables . We evaluated the association between the ability to participate in social activities and associated variables using multivariable linear regression analysis. Results: The study population comprised 50 patients with RA (33.1%), 51 patients (33.8%) with SpA, and 50 patients (33.1%) with SLE. The mean PROMIS-APS scores were similar in the three groups. The multivariable analysis for the whole sample showed that the ability to participate in social activities was inversely associated with depression and directly with social satisfaction, mobility, company, and age. The stratified analysis revealed an inverse association between inflammatory activity and ability to participate in social activities in patients with RA and SpA, but not in those with SLE. Conclusion: All patients with RA, SpA, and SLE had a similar ability to participate in social activities. This was associated with other psychosocial factors  and clinical factors (age and inflammatory activity). Rheumatic diseases, such as rheumatoid arthritis (RA), spondyloarthritis (SpA), and systemic lupus erythematosus (SLE), are characterized by joint inflammation and other systemic manifestations that lead to functional disability and impaired quality of life . The thePatients with rheumatic disease have a reduced capacity for participating in social activities in various settings . Such soHowever, it is not easy to provide a general measurement of participation in social activities, since this area encompasses a wide variety of domains . One of We performed an observational, cross-sectional study of a series of patients with rheumatic diseases . The study was performed at the Instituto de Investigación Biomédica de Málaga (IBIMA) by the Department of Rheumatology of Hospital Regional Universitario de Málaga (HRUM), Malaga, Spain. The study was approved by the Clinical Research Ethics Committee of HRUM (Code no. 2062-N-19).We consecutively included patients who visited the rheumatology clinic between June and November 2019. The selection criteria were as follows: age ≥ 18 years, RA according to the 2010 ACR/EULAR classification , SpA accWe recruited all patients who fulfilled the inclusion criteria and none of the exclusion criteria. All patients are generally followed prospectively via the rheumatology clinic every 3–6 months according to a pre-established protocol for systematic data collection. The protocol includes variables such as clinical and epidemiological data on disease activity. The reference rheumatologist invited the patients to participate in the study, collected the signed informed consent documents, and recorded the variables in the clinical protocol. The patients then attended the nursing clinic to complete the questionnaires. The nursing department was responsible for explaining the questionnaires to the patients and for resolving any doubts.The main variable was the ability to participate in social activities, evaluated using PROMIS-APS , which cThe secondary variables evaluated were social activities in terms of various factors, such as mobility, depression, satisfaction with social relationships, social isolation, company, ability to participate in social activities, emotional support, instrumental support, and support via information. All the variables were evaluated using the PROMIS questionnaire with quantitative scores. A higher score indicates increased ability to participate in social activities. All the questionnaires are included in the We also recorded demographic, clinical, and treatment-related data. The demographic and clinical data included age (years), sex, race, educational level , and socioeconomic level . In addition, we recorded traditional cardiovascular risk factors  and comorbid conditions included in the Charlson comorbidity index ,22.The protocol date was the date that the patient was included in the study. Cut-off values were recorded for the Disease Activity Score (DAS) 28 with ESR in RA ,24, the 2 and ANOVA or Kruskal–Wallis test  were used to compare the main characteristics between the 3 groups of patients: (1) patients with RA; (2) patients with SpA; and (3) patients with SLE. Several multivariable linear regression models were then run to assess factors that were independently associated with impaired ability to participate in social activities among all patients with rheumatic disease and in each group individually .We performed a descriptive analysis. Qualitative variables were expressed as absolute number and percentage; quantitative variables were expressed as mean (SD) or median and interquartile range (IQR), depending on their distribution. The normality of the continuous variables was confirmed using the Kolmogorov–Smirnov test. The χp < 0.05 for all analyses. All data were analyzed using R 2.4-0.The multicollinearity of the independent variables was verified using the Pearson correlation coefficient (r > 0.4). The sample size was calculated assuming a prevalence of involvement of 39% in the physical function or pain domain in PROMIS for rheumatic diseases. Considering as relevant a mean of 56.4 with respect to the controls, with a 2-sided α error of 0.05 and β of 0.20, the sample size necessary to detect these differences was 50 patients in each group . StatistWe recruited 151 patients between June and November 2019: 50 (33.1%) with RA, 51 (33.8%) with SpA, and 50 (33.1%) with SLE. All the patients completed the questionnaires, and no data were missing.p = 0.010). There were more women in the RA group (90.0%) and SLE group (96.0%) than in the SpA group (50.0%) (p < 0.001). There were no differences in educational level or socioeconomic level between the groups. Most participants had a basic educational level and a socioeconomic level of €1000–1500 per month.The main patient characteristics are shown by group in p = 0.065) and anxiety (p = 0.027) and less frequently with arthritis (p < 0.001).The most frequent comorbid conditions overall were visual impairment , anxiety , and depression . Patients with SLE were more frequently diagnosed with depression  at the time of the evaluation. The mean DAS28 score in patients with RA indicated low disease activity, the mean BASDAI in patients with SpA was 4, and the mean SLEDAI score was around 5 in patients with SLE. No patients with SpA had psoriasis. The main clinical characteristics of patients with SLE are shown in p = 0.017)  .The ability to participate in social activities for all the patients with rheumatic diseases was independently associated with age and the PROMIS items social satisfaction, mobility, depression, and company. Consequently, levels of participation in social activities increased by a mean of 0.07 units per year of age, 0.25 units for each point increase in social satisfaction, 0.15 units for each point increase in mobility, and 0.17 units for each point increase in company; however, the score decreased by 0.17 units for each point increase in depression.We subsequently ran three separate multivariable linear regression models to identify factors associated with the ability to participate in social activities for each of the groups individually.Following this approach, we observed that in patients with RA, the ability to participate in social activities was independently associated with satisfaction with social roles, mobility, less social isolation, instrumental support, and lower inflammatory activity according to DAS28 . FurtherSocial participation is thought to be a major factor in several health domains  and in the maintenance of health in the general population and in patients with rheumatic diseases . In the On the other hand, we found that improved PROMIS scores for social satisfaction, mobility, company, older age, and lower frequency of depression were independently associated with the ability to participate in social activities (PROMIS-APS). While these aspects have not been evaluated in this type of patient, other studies on patients with musculoskeletal and neuromuscular involvement revealed that participation, as assessed using the PROMIS questionnaire, is associated with better quality of life, greater social satisfaction, and less frequent depression ,29. As fOur study also revealed that participation in social activities by patients with RA and SpA was negatively associated with inflammatory activity, as measured using DAS28 and BASDAI, respectively. This finding is consistent with those of other studies of RA, which found an association between increased inflammatory activity and pain, anxiety, depression, and quality of life . In SpA,Our study was subject to a series of limitations. First, its cross-sectional design prevented us from establishing causality. However, it did enable us to fulfill the primary objective. Second, the PROMIS-APS questionnaire has not yet been validated for rheumatic diseases, although it has proven successful in patients with musculoskeletal conditions; in addition, the reference for PROMIS is the US population and, in our study, was the Spanish population ,15. FurtIn conclusion, we observed that patients with RA, SpA, and SLE had the same ability to participate in social activities and the three groups of patients had scores below those of the reference population. In addition, we found that the ability to participate in social activities was affected by psychosocial factors  and clinical factors (age and inflammatory activity). It would be interesting to perform interventional studies on these psychosocial factors and inflammatory activity in order to improve participation in social activities and patient quality of life.