Universities are now becoming more active in the field of Corporate Social Responsibility (CSR). Nevertheless, they do not appear to be granting the same degree of importance to the dissemination of these activities. This article analyses the voluntary corporate social responsibility information disclosed by leading USA universities. We created several indexes of corporate social responsibility information disclosure and examined main universities’ characteristics that affect corporate social responsibility disclosure by these entities. The findings obtained show that the universities are strongly committed to the dissemination of corporate social responsibility information, and that a university’s size, affiliation, public/private status and ranking position are the factors most significantly affecting its online disclosure of general corporate social responsibility information. These findings could be useful for university administrators, especially those in public universities, highlighting the importance of developing and supporting policies and incentives to promote CSR disclosure and thus attract new students and meet social expectations about the ethical behaviour of universities. Corporate social responsibility (CSR) has been defined as “the responsibility of enterprises for their impacts on society […] to integrate social, environmental, ethical, human rights and consumer concerns into their business operations and core strategy in close collaboration with their stakeholders . This isIn response, universities are now becoming more active in the field of corporate social responsibility ,4. UniveAmong the corporate social responsibility strategies commonly adopted by firms, corporate social responsibility disclosure is considered the most important means of communication to stakeholders regarding corporate social responsibility activities . CorporaBy publishing corporate social responsibility information, universities can provide the information demanded by stakeholders, increase transparency, enhance their reputation and legitimacy, facilitate benchmarking with other universities and support corporate information and control processes . This inHowever, despite extensive academic and corporate interest in the subject, a review of the main journals addressing aspects of corporate social responsibility shows that little research has been undertaken to analyse the crucial role of universities’ disclosure of CSR information . MoreoveAccording to stakeholder theory, variables such as size, affiliation, private-public status, age and ranking position can influence the online disclosure of CSR information. The degree of CSR disclosure by universities is positively associated with their age and size. Larger and older universities usually address a wider audience, are subject to the assessment of a greater number of stakeholders and, therefore, have a greater impact on society.In the other hand, universities with some faculty regarding CSR implies that universities that have faculties or departments which address aspects of CSR are usually more committed to the disclosure of this type of information.In the competitive environment, universities increased competition to attract students. We find that private universities are more aware of applying criteria of social responsibility they can obtain a competitive advantage and maintain good relations with stakeholders and satisfying expectations ,6. TheseBy last, the online disclosure of CSR information could represent an element by which universities can be differentiated in terms of the ranking awarded for their quality of education and research.Therefore, the aim of this paper is to examine the voluntary corporate social responsibility information disclosed by leading USA universities and to analyse how the main characteristics of universities—their size, affiliation, private-public status, age and ranking position, among other aspects –can influence the online disclosure of CSR information.The contribution of this study is twofold. On the one hand, we present a new approach to evaluating the voluntary corporate social responsibility information disclosed by universities. A model is proposed with which to measure the degree of disclosure of this type of information and, therefore, each university’s commitment to CSR and its subsequent disclosure to stakeholders. On the other hand, the paper seeks to determine the variables or factors that may influence this information disclosure. Thus, the proposed evaluation model can be used to identify best practices and to reveal which models or types of universities are most strongly committed in this respect. This knowledge will facilitate the adoption of policies to meet social expectations about the ethical behaviour of universities, and at the same time help make them more competitive.Taking into account the above considerations, The present paper is based on the stakeholder theory, which has been applied to the disclosure of CSR information. Stakeholder theory is an important reference in corporate social responsibility disclosure research, and many studies have used it to explain the organisation–society relationship ,13. In fAccording to stakeholder theory, the long-term success and survival of an organisation depends on the support it receives from stakeholders. Accordingly, the disclosure of corporate social responsibility information is considered a vital aspect of managing their needs, expectations and demands, and of balancing potential conflicts among them . Thus, CThe demand for corporate social responsibility disclosure has been driven by the increasing prominence and interventionism of stakeholders . In respThe presentation of corporate social responsibility information is a means of promoting dialogue with stakeholders . This thThis paper focuses on the following university-related variables: size, affiliation, public versus private status, age and ranking position. These specific variables were studied because they have been justified in the theoretical framework analyzed and they are the main ones considered in previous studies of information disclosure, both in general ,23,24 anAlthough some of the variables in our model have been proposed in other research studies concerning universities , we analsize has frequently been used to explain the extent to which corporations are pressured to disclose information [Organisations are subjected to numerous pressures to disclose CSR information ,28,29. Aormation . From anormation ,27.Such disclosure is sometimes costly and so it is larger organisations that usually disclose most information . FurtherThis positive relationship has also been observed in the university sector, by studies such as those by Gordon et al.  and GallHypothesis 1 (H1):There is a positive relationship between a university’s size and the CSR online information disclosed on their website.In the private sector, the delegation of functions and tasks to various departments has produced specialisation, with each one being headed by professionally qualified management experts. Therefore, when reports from different areas are prepared and published, the process is supported by the heads of each section of the organisation and their joint efforts enable a comprehensive overview of the business. Previous research suggests that organisations with CSR-related departments are more likely to disclose information in this respect ,30.According to stakeholder theory, organisations with various CSR-related departments are usually more closely involved with social and environmental issues and publish a greater amount of information, seeking thus to meet the needs of a wide range of stakeholders .A university is composed of various schools and faculties offering many different degrees and curricula. Extrapolating the idea of a business focus in this area, we believe that universities that have faculties associated with CSR will possess qualified personnel who may intervene in decisions and in planning actions that refer to CSR; equally, such personnel may provide a more complete understanding and facilitate the dissemination of CSR information. Accordingly, the following hypothesis is proposed see :Hypothesis 2 (H2):Universities with faculties related to the field of CSR will disclose more CSR online information on their website than those in which no such faculties are present.The university system in many countries, and especially in the USA, is characterised by the coexistence of public and private universities . AlthougFalling student numbers in recent years, and the consequent reduction in State funding , has ledTherefore, apart from universities’ teaching and research quality, which is an essential element in their reputation, socially responsible behaviour by universities and how this behaviour is reflected through informational transparency could produce a competitive advantage in the higher education market, which in turn could provide universities with greater legitimacy in their relationship with stakeholders. The use of new information technology, and specifically, the internet, has proved to be a very important tool in this process ,30.For this reason, it is expected that private universities, in view of the strong competition they face to obtain financial resources and of the competitive advantage that might be gained from the disclosure of CSR information, will present higher levels of disclosure of this information on their official websites. Therefore, the following hypothesis is proposed see :Hypothesis 3 (H3):Private universities disclose a larger volume of CSR online information on their website than public universities.age has been considered an influential factor in information disclosure. In the present study, it is used to refer to the time elapsed since the university was established [In previous research, the variable ablished , in the ablished . TherefoIt has been observed that the degree of CSR disclosure by universities is positively associated with their age , and thuHypothesis 4 (H4):Older universities disclose more CSR online information on their website than younger universities.According to Cooke , when a Extrapolating this variable to consider the field of universities, good corporate results are reflected, in this case, as the achievement of a favourable position in rankings of teaching and research quality. Therefore, according to stakeholder theory, universities, too, will provide more information in order to underpin their position within the market .The introduction of competitive financing mechanisms in higher education has led to the development of new strategies for attracting students. Highly rated universities tend to be characterised by inter-organisational linkages, i.e., voluntary ties with third parties, such as academic spin-offs and other informal mechanisms of technology transfer .Acceptance of the relationship between legitimacy and information disclosure has led to the creation of university classification systems . These cUniversities with greater legitimacy are more closely scrutinised by stakeholders and assign a high priority to the outcome of the evaluation process underlying the rankings system. The lack of such recognition would be detrimental to the legitimacy of the university .Prior research indicates that the universities reputed to provide the highest quality education and research are the most likely to disclose CSR information online . Thus, tHypothesis 5 (H5):The universities offering the highest quality education and research are the strongest proponents of the disclosure CSR online information on their website.Numerous universities have shown an outstanding commitment and pioneering spirit in developing corporate social responsibility policies, especially in European countries , includiIn this analysis of best practices in CSR voluntary communication, our study sample was drawn from USA universities. Although of course many universities worldwide publish CSR reports, those in the USA are the most active in the online disclosure of CSR-related information . The USAOur selection of universities for analysis has some limitations. First, it only includes those which implement corporate social responsibility actions and report their policies online. Therefore, the present study does not address universities that, while committed to corporate social responsibility, do not disclose their commitment or, even if they do, use other means, such as printed materials . Nevertheless, we believe the sample considered is appropriate for the goals of this study, i.e., to analyse the factors influencing online transparency on CSR-related issues.Secondly, the 154 leading USA universities included in our sample were selected according to the Academic Ranking of World Universities (ARWU), more commonly known as the Shanghai ranking. Although this ranking has been questioned and its methodological limitations highlighted , the ARWIn this section, we derive a model to represent the influence of the above factors on CSR information disclosure see . The modi; ESRDi; NSRDi; SSRDi; DSRDi are the dependent variables in every model referring to each USA university;MODEL: the approach adopted in the empirical analysis is summarised by the following general form of the model:i.j are the coefficients of the explanatory variables for each evaluation model proposed  and the variables are defined as in β Many studies have used total assets, sales or market capitalisation to measure firm size. However, as Gordon et al.  observedThe number of students, as a variable reflecting the size of the university, is a significant factor. Students are, in fact, the institution’s main stakeholders and the major consumers of its resources . Thus, pAffiliation is a dummy variable which takes the value 1 if the university has a faculty related to CSR, and 0 otherwise. Public versus private status is a dummy variable which takes the value 1 if the university is a private institution and 0 otherwise. The Age variable is measured by logarithm of the number of years elapsed since the university’s foundation, and the ranking is the university’s position in the Shanghai ranking  Sustainability Guidelines ,56 were Specifically, the index of general CSR information disclosure (GSRD), taking into account the structure of the GRI guidelines, is divided into five sections: 1. Vision and Strategy; 2. Profile; 3. Governance Structure and Management Systems; 4. GRI Content Index; 5. Performance Indicators ,56,57.The GRI guidelines are organised in terms of economic, environmental and social performance. These items configure the sub-indices related to specific CSR information . For the purposes of the present study, these items were adapted according to the specific nature of the information provided by the universities.The GRI guidelines are among the most complete tools available with which to assess CSR information disclosure. Although the guidelines were not intended specifically for this purpose , they prIn their core competences, i.e., education and research, universities differ substantially from corporations. Therefore, for the GRI to be suitable for our field of study, it must include the education dimension. In this respect, various universities and many researchers and educators have been collaborating with the University Leaders for a Sustainable Future (ULSF) team to develop a standardised version of the GRI for universities . Taking In summary, a model was created to evaluate online CSR information disclosure by universities, considering the economic, environmental and social dimensions established in the GRI guidelines report and adding, for the case of universities, the educational dimension proposed by the ULSF. Based on these items, the model was developed to ensure its appropriateness for the specific field of universities.We believe this model extends and enhances the literature on CSR information disclosed by universities. The model we present was created in a multi-stage process. First, various search engines were used to determine the CSR information currently being disclosed online by universities, taking the total population as the study sample. Different types of data were analysed to assess the sustainable practices used, by examining the following sources: (i) university web pages (ii) annual reports; (iii) CSR reports (or sustainability reports as they are termed by some universities in accordance with the GRI guidelines and which include CSR information). Consequently, meetings were held to discuss the results obtained, following which a draft model was proposed, summarising the main aspects of the information disclosed. No restrictions of country or region were imposed regarding the universities considered.This process gave an initial approximation of the model to be analysed. It was then completed in accordance with the guidelines issued by international bodies, such as the GRI, and taking into account previous research in this area , with particular respect to the university context.This evaluation model was then applied to the USA universities selected for analysis. The data required for this were obtained from the universities’ main channels of communication, i.e., their web pages  or CSR reports (in PDF format).Thus, the information on the dependent variables was obtained after a detailed analysis of CSR reports of the universities in the sample, in the view that these reports constitute an effective mechanism of control and communication . We alsoRegarding the score assigned to each of the questions included in our proposal for the assessment of CSR information disclosure, and taking into account previous approaches , we opteDuring April and May 2020, we examined the websites of the universities in our sample to obtain the information required. To ensure objectivity, the process was carried out separately by each of the three authors, who subsequently discussed the results and reached a consensus. If there were any significant discrepancies, the websites were examined again by all three authors. In the following months, we proceeded to the statistical analysis and final writing of the paper.Of the items included in the GRI recommendations, those which are least often disclosed by the universities in our sample are the stakeholders’ profiles and the performance indicators for the different dimensions of CSR . The items most commonly reported  are provided by nearly 50% of the universities.The universities examined are more committed to the provision of specific information, on their websites or in annual reports. In this respect, the highest values recorded were for the disclosure of economic or social information (70.65% and 70.37% respectively). High values were observed for economic information because it is usually published in the institution’s financial reports. Social information, on the other hand, tends to be more dispersed, on the website or within the annual report. Almost all items produced values close to 80% except those regarding equal opportunity (47.40%), the statement of integrity (14.29%) and the university’s code of conduct (57.14%) see .All these universities provide environmental information, but they only achieve just over 50% of the total score possible. The items most commonly disclosed refer to energy, waste management and recycling, while those least often published refer to sustainable food and fair trade. With respect to the educational information contained in these universities’ disclosure of CSR, the disclosure of voluntary service is the most highly valued item (81.82%), and the least, the description of research topics relevant to CSR (63.63%) see . The preWe next consider the influence of certain factors on the universities’ online disclosure of general and specific CSR information. The comparison of typified predicted values versus typified residuals revealed the presence of random features, and therefore there were no problems of heteroscedasticity or non-linearity; consequently, we accept the hypotheses of linearity and of equality of the variances. None of the variance inflation factors not reported exceeded the critical value of 10 and thus multicollinearity is not a serious problem in this study . In view of these considerations, after having confirmed that the above statistical assumptions were met, and the validity of the model thus endorsed, we decided to use the OLS method, given its simplicity and ability to test the hypotheses.size variable, the universities analysed in this study have an average of 4.19 students . 38% have CSR-related faculties or schools, and their average age is 2.09 years (measured through logarithm of number of years since the foundation year).With respect to the p < 0.001) for the general, environmental and social information and with confidence levels of 95% (p < 0.05) and 99% (p < 0.1) for educational and economic information, respectively. These results suggest that future studies should examine other variables that may have a greater influence on the online disclosure of CSR and specific information by universities.According to the results of the empirical analysis of our model see , the modsize, affiliation, public-private status and ranking position.Analysis of the factors that influenced our model, particularly regarding GSRD, the statistically significant variables were the universities’ size and ranking position all have a positive influence on the online disclosure of environmental information by the universities in our sample  at 95% significance.For environmental information (NSRD), the variables age , while for educational information (DSRD), the only significant variable was affiliation . Finally, we recorded an inverse association between the social information disclosed online (SSRD) and the public-private status of the university (β = −0.129) and positive with respect ranking position (β = 0.657).For economic information disclosed online (ESRD), the only significant variable was size and Overall, therefore, the results obtained by the model, for our sample data, support hypotheses H1, H2, H3 and H5, indicative of positive relations between the size, affiliation, private status of universities and ranking position in terms of the online disclosure of general CSR information. Furthermore, our results support H1 and H5 in relation to the disclosure of environmental information; H1 and H5 on economic information; H3 and H5 on social information and H2 on educational information. In every case, the signs obtained were consistent with those expected.The aim of the present study is to advance stakeholder theory  by showiTherefore, the main theoretical implications of this study are related to stakeholder theory. The provision of CSR information by universities contributes to the public good by adding value to the information supplied . UniversHowever, although the research findings presented in this paper show that universities are making use of these channels and are improving their provision of CSR information, the outcome falls short of our expectations. Thus, greater awareness among universities of the importance of communicating CSR information is still necessary. Improving their performance in this regard would contribute to universities’ fulfilling their duty of accountability to stakeholders, and favour the development of benchmarking procedures which, in turn, would help universities gain competitiveness in their market.Our results show that, in general, the universities examined are more inclined to disclose information of an economic and social nature, perhaps because these aspects have a greater trajectory of disclosure through the annual reports.Another aim of our study was to identify the factors that influence CSR information disclosure. With respect to disclosure on CSR in general, numerous factors have a significant positive impact, including university size, affiliation, private-public nature and ranking. According to stakeholder theory, larger universities usually address a wider audience, are subject to the assessment of a greater number of stakeholders and, therefore, have a greater impact on society ,25,26,27Universities that have faculties or departments which address aspects of CSR are usually more committed to the disclosure of this type of information. Highlighting this fact can raise awareness among universities of the importance of having qualified teachers in related subjects, which can subsequently be grouped into units, departments and faculties.Furthermore, the universities in the highest positions in the rankings for quality of education and research disclosure differ significantly and positively, in terms of CSR information provided, from those in low-ranking positions.In line with previous studies, we find that private universities are more aware of these considerations, because by applying criteria of social responsibility they can obtain a competitive advantage and thus improve their financial results , whilst maintaining good relations with stakeholders and satisfying expectations ,32.Similar results were found regarding the factors that significantly influence the disclosure of environmental information, i.e., university size and ranking. However, this is not the case for other areas of information. Private universities are the most committed to the disclosure of social information, reflecting the importance granted by these universities to areas such as student funding, campus safety, diversity, equal opportunity and summer programmes. Private universities pay special attention to these aspects because they are considered of crucial importance in attracting future students. In the highly competitive situation currently facing universities worldwide, CSR disclosure is an intangible asset of considerable interest to universities, especially private ones, as students’ tuition fees constitute their main source of income .The variable affiliation is most strongly associated with the disclosure of information on educational issues related to CSR. Thus, the more faculties, departments and personnel dedicated to the area of CSR, the greater the university’s commitment to social, environmental, economic and educational issues. Moreover, such a university will also present greater interest in education and research in this area and in the disclosure of related information.The variable age has a positive influence on the disclosure of information of an economic nature. The publication of this type of information has a long history in universities, and therefore it is to be expected that older universities will be more committed to the disclosure of such information in the field of CSR.These considerations should be communicated to public managers and university administrators responsible for designing strategies for the online disclosure of CSR information and for increasing awareness of its importance. This information is demanded by society as a whole and by future students in particular, who may rely on it in making their choice of university.In fact, private universities and those ranked highly in terms of quality of education and research are aware of this, and often prioritise the online provision of CSR information in order to attract future students .University managers could enhance their disclosure strategies, for example by creating more faculties and departments related to CSR. This would generate more training and awareness and ultimately promote the implementation of CSR policies and the disclosure of related information.Finally, it should be noted that our research work has highlighted a set of variables that may affect the disclosure of CSR information according to previous literature. However, the values obtained by the R2 in each model have been low. Maybe, these variables may have been justified in the private sphere or in sectors other than higher education. The universities, perhaps because of their nature and connotations, need a more profound study to look for other variables that will have a greater influence on the dissemination of this information.The findings presented in this research paper are of interest from various standpoints. On the one hand, we provide a new understanding of universities’ online disclosure of information on CSR-related topics and propose a model for assessing the disclosure of diverse aspects of CSR. On the other, we analyse the factors that may promote this information disclosure.The CSR information disclosed by the universities in our sample corresponds to the items included in our evaluation model. The results obtained highlight the importance of online CSR information disclosure by universities, in each of the aspects considered: social, environmental and educational.With respect to factors that may promote information disclosure, our findings show that, all of the variables considered are associated with the increased provision of CSR-related information. We find, therefore, that universities respond to the information needs of their stakeholders in their CSR disclosure policies. The findings of this paper could be useful for university administrators, especially those in public universities, highlighting the importance of developing and supporting policies and incentives to promote CSR disclosure and thus attract new students and meet social expectations about the ethical behaviour of universities. In addition, we call upon university policy makers to contribute to the global conversation with regard to CSR reporting and thus meet the information needs of all stakeholders.In practical terms, university managers should take into account the importance of ensuring the presence of university teachers who are well informed of the role of CSR, who address this topic in the classroom, and who subsequently communicate their knowledge to society at large. Legislators and educators, in their respective fields, should take measures to encourage the formation of future human capital through teaching, research and the transfer of knowledge, thus increasing general awareness of social responsibility and its importance. Accordingly, governments should support the education system by allocating resources for CSR training, so that teachers can transmit this awareness to their students, who may subsequently put it into practical effect in the business world.We show that larger universities are more aware of their inter-relationship with their environment and of the need to strengthen departments and faculties related to CSR, in view of the greater impact of these institutions on society. In future research, it would be interesting to examine whether the number of faculties in each university addressing aspects of CSR in their study programmes might be related to the level of CSR disclosure made, and to the strategic planning conducted by the institution or to the CSR-related policies adopted.We believe it would be useful for these rankings to include, in addition, the impact made by CSR disclosure by universities, as an index of their quality.In conclusion, our paper contributes to stakeholder theory by proposing a new model for CSR disclosure quality, which can be used to evaluate the disclosure of this information by universities, based on the need to meet stakeholders’ needs for CSR information. Furthermore, analysis of the factors involved in CSR information disclosure by universities could help and encourage university administrators to implement policies with which to meet stakeholders’ expectations regarding CSR disclosure by universities.Universities are to consider CSR as a strategic and differentiating factor. This question has been shown to be of significant importance in attracting students to the institution. Like that, public managers and university administrators should encourage policies that favour the dissemination of CSR. One way to raise awareness of these issues is through training of their own staff. In this way, specific departments and sections involved in the management and dissemination of CSR can be created. This will lead to a greater awareness of these aspects which in turn will translate into the training of future business leaders.As limitations to our article, we emphasise that it focuses on USA universities. The variables included in our analysis should be examined according to the context in which the study findings are expected to be applied. Obviously, in some ways the context of universities in Europe will be different from that considered in this paper. For example, it would be interesting, in future research, to include variables such as the prevailing culture or the funding system applicable to universities.Another limitation is the way in which the proposed CSR online information disclosure model is evaluated, since this is done in terms of the absence/presence of the parameter in question, without taking into account its quality and quantity. Thus, future research efforts should address the items that obtained the highest scores, in order to obtain a more nuanced view, weighting the evaluation made in terms of the quality and quantity of the parameters considered.As further areas of interest for future research, we recommend the identification and analysis of other variables that may affect universities’ policies on the disclosure of CSR-related information. For example, variables concerning internal management and organisational culture, such as the balanced scorecard system or that of corporate governance, could be added to the analysis. The adoption of such a complementary approach could help us achieve a better understanding of the functioning of universities and of their forms of organisation and management, thus facilitating comparison with other areas of management and with other countries. It would be useful in future research to analyse other measures in order to determine the influence of these variables on CSR reporting . Accordingly, a line of interest for future study would be to analyse the models required to manage and properly channel the university information on CSR that is provided to stakeholders. This question may be of decisive importance in students’ choice of university and in shaping the prestige of the institution. In this respect, an aspect of evident importance is that the online information provided by universities is now a major factor in determining where students choose to study.


What kinds of personalities do humans have? Can these personalities be classified into several discrete types? These issues have been of considerable concern as they could potentially provide deeper understanding of the nature of human individuality and mental disorders. Recently, Gerlach et al.  addressedimensional view and categorical view. The dimensional view supposes that the distribution is unimodal and individuals' personalities are continuously distributed in the 5D space. The categorical view posits that there are multiple clusters (dense regions) in personality space  and each individual can be classified into one of these clusters. In personality theory, such clusters are referred to as personality “types.” While common analytical tools of personality  are constructed based on the dimensional view, some researchers have considered the categorical view and claimed the existence of personality types , which consist of neuroticism, extraversion, openness, agreeableness, and conscientiousness  to the five factor scores that provide the positions of individuals in the 5D space  can be obtained when the distribution has skewness . In the This mechanism could have influenced Gerlach et al.'s results. The distributions of their factor scores were found to be skewed , and to Our discussion is closely related to another commentary on Gerlach et al.  by FreudIn conclusion, we have demonstrated the possibility that the skewness of the distribution can influence the personality types reported by Gerlach et al. , althoughttps://github.com/kkatahira/personality_skewness.The R script used for the simulation is available at: KK, YK, YY, and SS designed the research. KK conducted simulations and analyzed the data. KK and SS drafted the manuscript. YK and YY provided critical revisions.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


In Aug 19, 2018, China celebrated its first national Doctors’ Day, approved and supported by the State Council. The main purpose of setting up the festival is to honor the clinical physicians and to pay tribute to their indispensable contributions in Chinese public health work. This action will encourage our society to pay more respects and attention to physicians and the healthcare sector, which will inspire all the medical staff in this country.http://www.stats.gov.cn/tjsj/ndsj/2017/indexch.htm), China owns nearly one-fifth of world’s population, ranking first worldwide and aging population proportion is estimated to 23.3% in 2050, which will cause great burdens on national and global health care and social economy. China's public health work will continue to face enormous challenges in the future, and among all the causes, the absolute shortage of physicians comes first. The establishment of the Doctors’ Day means that the Chinese government values more on the indispensable role of physicians in public health work. High-quality public health construction is a complex and systematic project, setting up the Doctors’ Day is a good beginning which shows the determination of the Chinese government in the cause. This initiative may be useful for some other countries, especially for those developing countries lacking experience in public health construction.The day means much more than just a common festival for Chinese doctors. It is an official recognition and appreciation of their hard and even sacrificing work at the state level. During the past decade, China’s medical reform has confronted with many though challenges. China now owns a population of more than 1.39 billion people, however, the total number of Chinese registered medical practitioners is only 3.39 million, which brings about a huge gap between medical demand and supply in China. To solve the severe shortage of medical personnel, the Chinese government has made great efforts by taking following measures, such as to increase budget on medical development, improve the income of medical staff, enlarge the enrollment of medical students and implement some other preferential policies. The huge gap between the medical need and supply has also aggravated their working load, putting much extra pressure on Chinese medical workers, and further results in the shortage. According to the latest two studies, the workload of Chinese physicians has been on the increase . Over th


Suboptimal use of antibiotics is a driver of antimicrobial resistance (AMR). Clinical decision support systems (CDSS) can assist prescribers with rapid access to up-to-date information. In low- and middle-income countries (LMIC), the introduction of CDSS for antibiotic prescribing could have a measurable impact. However, interventions to implement them are challenging because of cultural and structural constraints, and their adoption and sustainability in routine clinical care are often limited. Preimplementation research is needed to ensure relevant adaptation and fit within the context of primary care in West Africa.This study examined the requirements for a CDSS adapted to the context of primary care in West Africa, to analyze the barriers and facilitators of its implementation and adaptation, and to ensure co-designed solutions for its adaptation and sustainable use.We organized a workshop in Burkina Faso in June 2019 with 47 health care professionals representing 9 West African countries and 6 medical specialties. The workshop began with a presentation of Antibioclic, a publicly funded CDSS for antibiotic prescribing in primary care that provides personalized antibiotic recommendations for 37 infectious diseases. Antibioclic is freely available on the web and as a smartphone app . The presentation was followed by a roundtable discussion and completion of a questionnaire with open-ended questions by participants. Qualitative data were analyzed using thematic analysis.Most of the participants had access to a smartphone during their clinical consultations , but only 49% (23/47) had access to a computer and none used CDSS for antibiotic prescribing. The participants considered that CDSS could have a number of benefits including updating the knowledge of practitioners on antibiotic prescribing, improving clinical care and reducing AMR, encouraging the establishment of national guidelines, and developing surveillance capabilities in primary care. The most frequently mentioned contextual barrier to implementing a CDSS was the potential risk of increasing self-medication in West Africa, where antibiotics can be bought without a prescription. The need for the CDSS to be tailored to the local epidemiology of infectious diseases and AMR was highlighted along with the availability of diagnostic tests and antibiotics using national guidelines where available. Participants endorsed co-design involving all stakeholders, including nurses, midwives, and pharmacists, as central to any introduction of CDSS. A phased approach was suggested by initiating and evaluating CDSS at a pilot site, followed by dissemination using professional networks and social media. The lack of widespread internet access and computers could be circumvented by a mobile app with an offline mode.Our study provides valuable information for the development and implementation of a CDSS for antibiotic prescribing among primary care prescribers in LMICs and may, in turn, contribute to improving antibiotic use, clinical outcomes and decreasing AMR. Antimicrobial resistance (AMR) is a global threat that affects both high-income countries (HIC) and low- and middle-income countries (LMIC). The drivers of AMR, including antibiotic misuse, lack of infection prevention and control, and poor sanitation, particularly affect LMICs ,2. Data Electronic clinical decision support systems (CDSS) have been devised to provide prescribers with rapid access to updated information, which is required to make appropriate therapeutic decisions . CDSS caConsequently, the development and implementation of CDSS that fit into clinical work might be part of interventions to mitigate against drivers of AMR in LMICs. However, the adaptation of CDSS for antibiotic prescribing in routine clinical care and their sustainability are often limited ,18. As iBefore developing or implementing a CDSS for antibiotic prescribing in West Africa, we need to understand the contextual, structural, and behavioral determinants that will facilitate or prevent the use of CDSS for antibiotic prescribing. Our study aimed to examine the requirements for a CDSS adapted to the context of primary care in West Africa and to analyze the barriers and facilitators of its implementation and adaptation by prescribers using qualitative methods during a preimplementation workshop.Our aims were (1) to understand the potential benefits and risks of a CDSS for antibiotic prescribing in primary care in West Africa, (2) to analyze the barriers and facilitators of its implementation, and (3) to ensure co-designed solutions for its adaptation and sustainable use. To this end, we organized a workshop with West African antibiotic prescribers that began with a presentation of Antibioclic, a CDSS for antibiotic prescribing currently widely used in France and freely available on the web and as a smartphone app (further details below). We chose to begin the workshop with an example of an existing CDSS rather than with a theoretical description of a CDSS for antibiotic prescribing. This strategy was considered by the organizing team as the most promising to elicit reactions among the participants. The main characteristics of a CDSS were presented, and the organizers went through a number of clinical scenarios on infectious diseases using Antibioclic. Then, the organizers moderated a roundtable discussion with all the participants. During this first-of-its-kind workshop, the participants generated barriers and facilitators to the use of a CDSS such as Antibioclic in West Africa and were asked to hypothesize if its use could lead to benefits or risks, including unexpected events. Participants were specifically asked to debate the challenges in the implementation and adaptation of a CDSS for antibiotic prescribing in West Africa and to co-design solutions.Antibioclic is a French CDSS for antibiotic prescribing in primary care,  targetinAntibiologie et Antibiothérapie en Afrique Subsaharienne (Antibiotic therapy in Sub-Saharan Africa) organized in Bobo-Dioulasso, Burkina Faso, on June 2019. This course lasts 5 weeks and is organized every year by the University Nazi Boni of Bobo-Dioulasso and the University of Montpellier. The course is open to West African health professionals working on AMR or antibiotic therapy, whether in primary, secondary, or tertiary care, with no selection among participants. Attendance to the workshop was voluntary for the participants of the course.The 3-hour workshop to discuss the implementation and adaptation of a CDSS for antibiotic prescribing in West Africa was organized in Burkina Faso by 2 professors of infectious diseases, 1 from Burkina Faso (AP) and 1 from France (FL). To maximize participation and cost efficiency, the workshop took place during the French-speaking university course After the roundtable discussion, an electronic questionnaire with closed- and open-ended questions was given to each participant . The queData from the closed-ended questions of the questionnaire were imported into R software version 3.2.4 . Numerical data are presented as absolute numbers, proportions, and median (IQR). The entire roundtable discussion was audio recorded and transcribed verbatim by the AMK France professional company. Data from the roundtable discussion and open-ended questions were analyzed using thematic analysis and were coded to identify key categories, which were developed into themes using NVivo 12 software . The analysis of questionnaires and the roundtable discussion supported cross-validation and triangulation of the findings.Written consent was obtained from each participant. No distinguishable personal information was recorded, and all the data were analyzed anonymously. This survey was approved by the research ethics committee of Centre Muraz  and was compliant with the European General Data Protection Regulation.All 47 participants of the course, 19 women and 38 men with a median (IQR) age of 31 (30-38) years, participated in the workshop and completed the questionnaire . Most ofMost of the participants  had a smartphone with internet access during their clinical consultations, but less than half  of the participants had access to a computer, and 15% (7/47) of the participants had no access to any electronic tools during their consultations. Most of the clinicians did not use an electronic health record system  or CDSS  for any clinical decision making during their clinical consultations. The only CDSS mentioned by the participants was a tool for basic medical calculations and a tool that displays medical cards. No CDSS for antibiotic prescribing  was used by the participants .Most of the participants expected favorable outcomes from the implementation of a CDSS for antibiotic prescribing in primary care in their countries . They thDuring the roundtable discussion and through the open-ended questions, the participants identified a number of consequences of a CDSS on a wider scale. Participants underlined the lack of antimicrobial stewardship teams in West Africa. They hypothesized that a CDSS could help many isolated structures to have access to antibiotic prescribing recommendations and could relieve existing antimicrobial stewardship teams of simple antibiotic prescribing advice and let them focus on complex cases. One participant noted that a CDSS could be used to increase surveillance capability in primary care. Indeed, its use could be monitored and lead to reports on the incidence of infectious diseases and the rate of antibiotic prescriptions. The participants agreed that this is particularly important in West African countries where epidemiological data are scarce. The use of French guidelines was not seen as a barrier to a CDSS. Indeed, most of the participants declared that they did not have national guidelines to prescribe antibiotics in their country. However, the participants pointed out that a successful CDSS could have a positive impact in encouraging national societies to develop guidelines that could then be integrated into the CDSS. More broadly, they agreed that this CDSS could help to increase the awareness of health professionals on the importance of appropriate prescribing and the risks of AMR. The participants also agreed that a CDSS could be used in the initial training and continuous medical education of health professionals by updating antibiotic prescribing knowledge:If you use it continually, you certainly update your knowledge.General practitioner in Burkina FasoRegarding the scope of a CDSS for antibiotic prescribing, the participants stated that it could have a positive impact on the management of urinary tract infections (84%); skin and soft tissue infections (84%); gastrointestinal tract infections (83%); genital infections (80%); pneumonia (77%); meningitis (70%); ear, nose, and throat infections (70%); dental infections (67%); and surgical site infections (61%). The participants identified a wide diversity of potential users of a CDSS for antibiotic prescribing in West Africa, including general practitioners, infectious diseases specialists, physicians in other specialties, pharmacists, nurses, clinical microbiologists, and midwives.The participants identified a number of challenges and proposed a number of solutions for the adaptation of a CDSS for antibiotic prescribing in a West African setting , and theAt the country level, the participants pointed out the scarcity of epidemiological data in West African countries, the difference between epidemiology of diseases in HICs and LMICs, the lack of national guidelines, and the limited availability of diagnostic tests and antibiotics. To produce computer-interpretable clinical guidelines, CDSS developers need to have access to clinical practice guidelines. For countries where national guidelines for infectious diseases management do not exist, the participants first suggested the development of a CDSS based on French or WHO guidelines to encourage the establishment of national guidelines. To address the specific needs of primary care prescribers in West Africa, the CDSS should not only target the management of common bacterial diseases but also the management of parasitic diseases and tuberculosis. Participants stressed the importance of tailoring the CDSS to local capacity and infrastructure, such as resource availability and antibiotics, with the help of national scientific societies.The first challenge at the organization level was the lack of internet access and information technology (IT) infrastructure. Taking into account the wide availability of smartphones with internet access, the participants highlighted major opportunities through the development of mobile phone versions of CDSS (on iOS and Android) with an offline mode. The second challenge was the important number of independently operating and geographically isolated health structures, such as dispensaries, in the West African health system. To reach these structures, participants suggested the involvement of relevant stakeholders, including health authorities, the Ministry of Health, scientific societies, the media, and opinion leaders, using traditional and social media:It is important to use the traditional networks of the Ministry of Health where information goes down hierarchically but also social media that are more and more used.Physician in a university hospital, Burkina FasoThe organization of a phased approach was suggested by initiating and evaluating CDSS in a pilot primary care structure linked to an academic hospital followed by dissemination to other health structures:You have to show people that it's used by people like them starting with a pilot test site.Physician in a general hospital, Burkina FasoThe diversity of primary care prescribers who have different levels of decision support needs was identified as a challenge to developing effective CDSS. A physician working in a general hospital stated that in West Africa “nurses see a lot of patients, certainly more than physicians” highlighting the need to codevelop the CDSS with primary care health care professionals who frequently prescribe antibiotics, such as general practitioners, nurses, midwives, microbiologists, dentists, and pharmacists. The implementation of a CDSS in West Africa should take into account the lack of widespread knowledge on the use of CDSS by organizing training sessions with primary care prescribers. One participant said that some health care professionals or patients could be refractory to new technologies, but this was not considered a major barrier by the other participants. The participants identified a number of facilitators for the adaptation of a CDSS by primary care prescribers and patients, including the independence of the tool from pharmaceutical companies, codevelopment with users, free access to the CDSS, and good usability.The most discussed unexpected consequence was that an open access CDSS such as Antibioclic could amplify self-medication of antibiotics due to availability without prescription:My point of view is really mixed. This represents an undeniable progress for antibiotic prescribing but in the context of our country, there is a non-negligible risk of self-medication by non-healthcare professionals.General practitioner, Burkina FasoA very good tool for the treatment of infections but which could be dangerous in the southern countries because of self-medication and the accessibility of antibiotics without prescription.Physician in a university hospital, Burkina FasoIn this context, the CDSS may be used as a substitute for expert health care opinion. However, some participants highlighted the fact that much information is already available on the web and that Antibioclic is already available, including in Burkina Faso, with no reported use by patients. In fact, there was uncertainty regarding if implementing a CDSS in West Africa would amplify the phenomenon of self-medication or would help by providing a reliable source to patients who would want to self-medicate anyway:Some patients will buy antibiotics without prescription, with or without the tool.General practitioner, Burkina FasoOn the contrary, if patients have access to national recommendations, this reinforces and this even facilitates your message.Professor in a university hospital, Burkina FasoA consensus emerged that the best solution is to increase efforts to limit access to antibiotics without prescription.We conducted a preimplementation workshop with West African health professionals to examine the requirements for a CDSS adapted to the context of primary care in their countries. The use of CDSS for antibiotic prescribing  is currently missing, but the importance and need for such tools to support antibiotic prescribing in primary care were stressed by all participants. Regarding the implementation of a CDSS in primary care, the participants encouraged a procedure of co-designing the tool with health professionals and stakeholders involved in antibiotic prescribing and initiation via a primary care pilot site, which is linked to an academic hospital . The difThe participants pointed out the potential risk of self-medication in countries in which antibiotics can be bought with no prescription. Such a risk should certainly be anticipated and monitored, but most of the participants did not think that the CDSS should have restricted access. On the contrary, some participants thought that a CDSS could provide an opportunity to strengthen the education of the general public about antibiotic prescribing and AMR. Development and implementation of a CDSS was seen to be associated with a number of benefits related to improving clinical care and reducing AMR and also to strengthening and updating practitioners’ knowledge of antibiotic prescribing recommendations, encouraging the development of national guidelines, and developing surveillance capabilities in primary care. Indeed, the implementation of a CDSS for antibiotic prescribing could be coupled with measures that allow an increase in the capability of surveillance of antibiotic use. Examples include real-time monitoring of requests expressed on the platform and extracting reports about antibiotic use ,29. MoreThe lack of preimplementation and co-design work concerning the assessment of CDSS for antibiotic prescribing has been reported in recent reviews ,31. MoreFew studies have focused on CDSS for the management of infectious diseases in LMICs and in particular in West Africa. A recent review identified 6 CDSS for the management of febrile children in primary care in LMICs . In a piThe participants stressed the diversity of prescribers and health structures in West Africa that must be taken into account when codeveloping the CDSS. However, most of the participants in our workshop were physicians specialized in general practice working in Burkina Faso university hospitals. This bias was related to our recruitment of participants via a university degree organized by French and Burkina Faso universities. We, thus, need to involve more primary care prescribers such as nurse prescribers, midwives, and physicians working in dispensaries to allow for a broader view of primary care antibiotic prescribing. Indeed, prescribing habits may vary between professional groups ,48, and To open the discussion, we decided to provide an example of a currently used CDSS. Indeed, as we anticipated that most of the participants had no experience using electronic decision support systems for antibiotic prescribing, we wanted to show them an existing CDSS and collect opinions. This approach was likely to influence the answers of participants and the discussion during the roundtable discussions. However, we think that the barriers and facilitators identified in the study are not limited to Antibioclic. Indeed, the contextual barriers that have been found have been described in other studies. Nonprescription dispensing of antibiotics in the community has been widely described both in LMICs ,50 and iThe governance system and public health priorities could be important additional factors that need to be studied in West Africa before the implementation of a CDSS. Work has been done in European countries about governance to address AMR , and relPreimplementation research is needed to ensure that CDSS are adapted to the context in which they are deployed. Our study provided valuable information to develop and implement a CDSS for antibiotic prescribing among primary care prescribers in LMICs. We plan to organize workshops to co-design a CDSS tailored to the context of primary care in West Africa. Optimizing the use of antibiotics in primary care may have beneficial consequences for the entire health system and can contribute to limiting the spread of AMR. Most of the barriers and facilitators that we identified may easily relate to a broad spectrum of CDSS, including systems for clinical decisions other than antibiotic prescribing.


Information-intensive transformation is vital to realize the Industry 4.0 paradigm, where processes, systems, and people are in a connected environment. Current factories must combine different sources of knowledge with different technological layers. Taking into account data interconnection and information transparency, it is necessary to enhance the existing frameworks. This paper proposes an extension to an existing framework, which enables access to knowledge about the different data sources available, including data from operators. To develop the interoperability principle, a specific proposal to provide a (public and encrypted) data management solution to ensure information transparency is presented, which enables semantic data treatment and provides an appropriate context to allow data fusion. This proposal is designed also considering the Privacy by Design option. As a proof of application case, an implementation was carried out regarding the logistics of the delivery of industrial components in the construction sector, where different stakeholders may benefit from shared knowledge under the proposed architecture. The recent advances in Information Technology, Internet of Things (IoT) and Cyber-Physical Systems (CPS), among other fields, have enabled digitization and automation of production processes and led to the definition of the fourth industrial revolution, also known as Industry 4.0 (I4.0) ,2,3. In Human factors, such as fatigue indicators, have significant effects on product quality and factory productivity in manufacturing activities . It is cReference Architecture Model for Industry 4.0 (RAMI 4.0)  to [DateTime]; andProof of worth for accessing the data.When either people or agents request the web service to access the specific data according to the above structure, when they have the right of access, the web-service will access the DLT repository under the specific criteria provided and verify the ownership of the requested information. This verification will be based on consuming the smart-contract to obtain access to the symmetric encryption key used by the node, thus being able to decrypt it and compare signatures. Then, such data can be aggregated (according to the requested period of time) and be sent to the requester by the web service after encrypting it using the provided public key of the user/agent. The data consumers will receive back the data and handle it by using its private key, in such a way that only they themselves are allowed to consume it.The whole schema can be seen in This type of solution can help companies from at least three different perspectives. They can redesign their adopted business models related to the IIoT and its integration into the management dimension of the organization ,67. HoweIn the case of public messages, there are no requirements for encryption. Under the restricted approach, the encryption certificate can be shared among the interested stakeholders, in such a way they can collect the information on their own.Not only due to the transparency provided, but also because such data streams are delivered automatically by the different digital twins, the trust of shareholders and consumers will increase immediately. In addition, such knowledge will enable the management needs of owners, being more consistent with its potential value when shared.To validate the proposed architecture, a data-handling system based on a DLT (IOTA), and domain ontologies was designed to improve data interoperability, with integrated privacy criteria through message encryption and data sharing under the Industry 4.0 paradigm.The implemented system was adopted in a practical industrial scenario. The aim was to verify that our proposed architecture has practical potential in real-world applications, leveraging the implemented system to demonstrate its feasibility. The approach, which adopted a positivist view of research, relied on the literature and empirical data coming from the case itself, as well as on the insights of the researcher to build incrementally more powerful theories.The application case was conducted in a Spanish factory manufacturing steel rebars to reinforce concrete in the construction sector. The general workflow is as shown in Consider the truck loading process as an example. The requirement is that the right rebar bundles are loaded into the truck in a specific disposal sequence, which needs to be well managed as the bundles are delivered and distributed to different sites. As a lack of specific items could impact the delivery dates, an improper loading disposal sequence may negatively affect the scheduled work in the unloading process. In the present situation, the responsibility for such a decision relies on the crane operators, who take charge of loading the rebar bundles to the truck buffer using a crane machine.To effectively assess this internal logistics, different data sources should be taken into consideration. Such an analysis requires knowledge about the order and manufacturing sequences, which are handled by the ERP system, MES, or PLM. The logistics information is required, such as where and when the items are loaded into the truck, in order to understand whether the items were loaded and well-placed in a proper storage buffer in the truck.Moreover, more details, such as the crane operator profile, their working conditions, and working status  are also relevant. Body-related parameters need to be integrated, mainly as the stress of the crane operators may affect the loading process. The movement trajectory/speed need to be considered, as analysis can be made to understand whether the loading process requires excessive physical efforts.When different stakeholders need to have access to specific process-related information, non-tampered data are required due to certification principles; therefore, an open system is a convenient tool, reducing the IT barriers and which is robust against facility ownership changes.The system prototype will adapt the proposal presented in Production related information from ERP/MES/PLM system;Ultra wide band (UWB) indoor positioning system (IPS) to track crane position and crane operator movements, to better define the location for rebar bundles; andSmart band to monitor crane operator’s heart rate and blood pressure.Different devices, systems, and data sources composed the configured prototype, as indicated below:The MES manages sequence planning and the bottom-up data flow on the shop-floor . It provhttps://tracktio.com/) was used to track the crane hook and crane operators. Rebar bundle locations in different buffer areas of production or positions in the truck for customer delivery were derived from the dynamic behavior of the process. The position of crane operator was tracked as a reference for understanding the movement trajectory and speed. The IPS had its own data repository; the data were acquired from a web service.The UWB indoor positioning system (IPS) from the Tracktio™ company ; then, it was reprocessed and transmitted to a MongoDB database located in the local cloud.For data interoperability, all data sources in this industrial scenario were semantically modeled, fostering their linkage to other domain knowledge. To this end, different existing domain ontologies were reused in this study. The data sources were in the three aforementioned sectors: production system, IPS, and individual wearable devices. The existing and shared/published ontologies for each sector were collected and one was selected to model the data source in this study, according to the mapping of data structure. The details of available ontologies for reusability are listed in To map the generated data sources in this industrial scenario, three ontologies were chosen for data modeling. The selection criteria were chosen on basis of the degree of matching between the ontological schema and data source structure. After deeper analysis of each ontology’s schema, as listed in https://usc-isi-i2.github.io/karma/) provides a graphical user interface which automates the semantic modeling process. Karma learns to recognize the mapping of data to the chosen ontology classes and proposes a model that can generate JavaScript Object Notation for Linked Data (JSON-LD) for large data sets in a batch mode. JSON-LD is a lightweight Linked Data format, which was designed based on the concept of "context", linking object properties in JSON to concepts in an ontology. The JSON-LD data type was selected as it is lightweight and interoperate at Web-scale, but also provides embedded semantics. The data format is based on JSON and ontological schemas, maintaining a common space of understanding and supporting the evolution of schemes over time without requiring data consumers to change format. The data source, applied ontology schema, and the transformed JSON-LD format (containing semantic annotation) are listed in The mapping tool Karma (https://nodes.thetangle.org:443) was selected for data submission to the IOTA Tangle. The message sent to the IOTA Tangle is encrypted. A python script that implements the RSA (Rivest–Shamir–Adleman) public-key cryptosystem was used for encryption and validation of messages. PyOTA , an IOTA python API library, was used to implement data sending and retrieval to and from the IOTA Tangle. The source code can be found at  in IOTA Tangle. Related transactions could be looked up and fetched by tags or bundles. After data retrieval, a data message should be validated and decrypted by stakeholders, where the semantic meaning of the data are encoded in the message itself. This design fosters data reusability by learning processes and growth of models, as they can select the appropriate meaning of data sets or ask for automatic preprocessing before accomplishing further transformations.As shown in The needs of the near-future dimensions of I4.0 require an increasing level of integration of data from different sources, including data from not only workers, but also from different providers and sources. This enforces PbD requirements, due to both company security rules and regulatory requirements. A major aspect of the GDPR are the so-called legal grounds for lawfully processing personal data, one of which is consent. In several IoT applications where consent is used, it may even need to be explicit consent.Data consistency and the use of different sources of information and/or different time periods or geographical positions;Data storage: although properly scrambled, masked, or blurred, the related persons probably are not aware such pieces of information do exist related to them; andProblems related to EU citizens when requesting products or services outside of the EU.There still remain, after the GDPR, some problems with personal data, as follows:Accountability regarding users; but also,Accountability within the organization.The harder problem is the second one, mainly due to the absence of accountability: as a user never knows who is gathering information about them, they cannot ask for access, erasure, or modification. Thus, there are two types of accountability:In our validation case, the delivery process to the customer has limited information from the process itself, as truck loading is mainly a human-driven activity. Therefore, it risks exposure to a significant time variability and existence of errors in missed or items wrongly included inside the truck. From a business perspective, adding transparency by maximization in the amount of automation involved is worthwhile for stakeholders. Furthermore, current private and centralized data management approaches limit the high-level integration of multi-modal data sources, as well as data ownership and re-usability .The deployed architecture, as proof of concept, was able to provide additional information, integrated in a convenient way in order to help to understand the type of items frequently creating problems, configurations of truck layout consistent with specific delivery sequences, the movements used to load particular item shapes, and so on.There exist potential contributions in the direction of empowering operators of I4.0 , includiObviously, to have significance in such an analysis, large periods of data collection and close integration are required. Indeed, path dependency  does exiAnother critical enabling technology for data interoperability adopted in this study is semantic modelling and ontology engineering. Ontologies provide standardized definitions for different data sources and make possible of reasoning and autonomous decision-making, by formalizing the structure of the knowledge. Existing ontologies, i.e., vital sign ontology, positioning ontology, and the MES ontology, are reused in this study to accelerate the development. To obtain a higher level of interoperability, such ontologies can be further exploited and adapted to keep align with widely recognized upper-level ontology such as BFO  and to bAs one of the fundamental enabling technologies of I4.0, the digital twin concept is briefly discussed in this study but not explored with details as it is not the main focus of this paper. Nevertheless, the proposed data integration and handling approaches are important basis for implementation of digital twins. For example, in some existing digital twin studies ,91, simiIn this paper, our main contributions were to extend and complement the I4.0 reference model LASFA, with reference to some more general ones , by adding additional data flows to complete the production process description and including different provider add-ons for digital twin construction. The proposed update enables higher level integration and more efficient process description. By considering the PbD design for exchange of information over public DLT systems, it also accounts for information transparency and data ownership for related stakeholders.The adopted configuration, which enables the semantic enrichment of data, also make it possible to implement rules enforcing interaction mechanisms and to derive new properties related to the employed ontologies. Although such a direction was not implemented in the proof of concept carried out, it may be useful for stakeholders accessing the data.The presented proposal benefits from the integration of semantically annotated data from different sources, including human health-related wearable device data, in an industrial context. When information related to people has been included, a signature layer is used to provide a PbD solution, in full accordance with the GDPR regulations and to enable positive-Sum .The core idea of the proposed architecture is to enable the sharing of different obfuscated data streams over a public immutable network-oriented database with quick-answer capabilities and good scalability characteristics. The proposed architecture enables extensions, in order to facilitate higher levels of control and empowerment of data owners by integrating an explicit delegation of access to specific data sets and time windows through the use of web services.Considering a simple application case, the benefits from a business perspective appear evident, with the integration of different dimensions not previously considered. There also exists additional value with the possibility of further performance analysis of procedures, when the proposed architecture is combined with artificial intelligence (AI) techniques. The theoretical implications of this research allow for a convenient framework providing a high level of control on the data produced by each agent, while also providing a platform to share data coherently with different business models. It also provides a flexible way to interconnect semantically powered data streams, which is a significant contribution for data driven ML/AI applications.This paper also makes a point from a practical application perspective; in particular, by providing an interesting implementation of data handling strategies aligned with Industry 4.0 principles enabling the integration of data coming from workers. Such tools can have a significant impact on advanced lean manufacturing and lean management implementations, as they go a step beyond classical digitization approaches. This could be the case for the standardization of formal communications under Lean Management (CPD)There are several aspects that provide us with further research paths, as we require long data collection approaches and the definition of consistent key performance indicators for individual applications. Furthermore, the definition of related business models for micro (smart contract-based) data monetization and traceability applications also provides avenues for further research.A clear limitation of the existing research is the adoption of a single and specific DLT technology; namely IOTA. The proposal is not conceptually dependent on IOTA; it simply served as a driver to implement our architecture in the proof of concept. However, some other technologies, such as Obyte, may be considered to be potential substitutes.Another limitation is the required digital infrastructure needed in the companies to successfully implement the digital twin concepts, which is capable of managing requirement of both internal and external stakeholders.Future research steps will be to deeply analyze the meaning of the integrated data built, in terms of value for business, looking to identify behavioral patterns or to create forecasting models, and its ability to better adjust operation times and, most importantly, timely delivery.Another interesting perspective to be considered is that wearable devices, such as smart watches  and smar


Frailty is increasingly recognized as an important construct which has health implications for older adults. The Clinical Frailty Scale (CFS) is a judgement-based frailty tool that evaluates specific domains including comorbidity, function, and cognition to generate a frailty score ranging from 1 (very fit) to 9 . The aim of this scoping review is to identify and document the nature and extent of research evidence related to the CFS.We performed a comprehensive literature search to identify original studies that used the Clinical Frailty Scale. Medline OVID, Scopus, Web of Science, CINAHL, PsycINFO, Cochrane Library and Embase were searched from January 2005 to March 2017. Articles were screened by two independent reviewers. Data extracted included publication date, setting, demographics, purpose of CFS assessment, and outcomes associated with CFS score.Our search yielded 1688 articles of which 183 studies were included. Overall, 62% of studies were conducted after 2015 and 63% of the studies measured the CFS in hospitalized patients. The association of the CFS with an outcome was examined 526 times; CFS was predictive in 74% of the cases. Mortality was the most common outcome examined with CFS being predictive 87% of the time. CFS was associated with comorbidity 73% of the time, complications 100%, length of stay 75%, falls 71%, cognition 94%, and function 91%. The CFS was associated with other frailty scores 94% of the time.This scoping review revealed that the CFS has been widely used in multiple settings. The association of CFS score with clinical outcomes highlights its utility in the care of the aging population. Worldwide, the population of older adults is expected to grow from 8.5% of people aged 65 and older to nearly 25% by 2050 . As the Frail individuals experience higher rates of adverse outcomes . As suchThe Clinical Frailty Scale is a clinical judgement-based frailty tool developed for the Canadian Study of Health and Aging . There iCovidence software for screening.The search strategy for this scoping review was developed with assistance from a librarian, with the aim of identifying all original studies that assessed the Clinical Frailty Scale . A varieStudies were only included when 1) they were original research and 2) the CFS was used. Due to the broad nature of this scoping review, we did not limit by language, study design, setting, age of participants or outcome measure. For non-English articles, members of the research team or colleagues with knowledge of the given language screened them and assisted in data extraction. Quality assessment is not a priority in scoping reviews; thus, studies were not excluded based on their quality.Covidence software. The only inclusion criterion for the title and abstract screening was whether the article described an original study. Review articles, conference abstracts, editorials and commentaries were excluded from the review. Screening was completed by two independent reviewers and conflicts were managed and resolved by discussion between the two reviewers, including a third reviewer when necessary.Title and abstract screening was completed in Covidence software. Studies that include the Clinical Frailty Scale in their methods were included for data extraction; protocol papers proposing the use of the CFS in a study were also included. Studies that reference the CFS but did not assess or plan to assess frailty with the CFS in a group of participants were excluded. Full text screening was completed by two independent reviewers, with conflicts managed by discussion to achieve consensus or by a third reviewer when necessary.Full text screening was also completed in A data extraction form on Microsoft Excel was used to guide the collection of information from each article. Data was first extracted from 10 articles, and then this form was modified before the completion of the data extraction. The following descriptive data was extracted from each article that satisfied the inclusion criteria: year of publication, language, country, study design, and study setting. For completed studies (not protocol studies) participant demographics were extracted, including number of participants, and participant age and sex. With respect to the CFS, we extracted information about persons who administered the CFS, cut points for identification of frailty, frailty prevalence, and the purpose of the CFS assessment. All outcomes and variables that studies assessed for a relationship with CFS were recorded. As numerous outcome variables were identified, outcomes were grouped according to overarching themes for the purpose of analysis. Analyses were conducted using IBM SPSS 21.Our database search retrieved 2907 articles and hand-searching identified 5 additional articles for a total of 2912. After duplicates were removed, 1688 articles were included for title and abstract screening. We screened the full text of 1353 articles and 183 articles  were ideThe CFS was assessed by researchers (46% of articles) and by a variety of professionals with physicians being the most common 24%). The CFS was originally developed as a 7-point scale but there is currently an updated 9-point version. Among the included articles, 58% used the 7-point scale and 38% used the 9-point scale (Table 4%. The CThe association of the CFS with outcomes was examined 526 times and was a significant predictor in 390 (74%) (Fig. In this scoping review, we have reviewed the research evidence pertaining to the CFS. The CFS has been used in a variety of contexts around the world. Although most administered in Canada and the United Kingdom use of this tool has reached Asia, South America, and other parts of Europe. The number of publications measuring the CFS has increased in recent years, possibly reflecting the medical community’s interest in the topic of frailty as an important construct. The CFS is most often used in hospital settings, particularly on Geriatric Medicine and Cardiology units, however, has been applied to a range of inpatient and outpatient populations. The increase of its use in a variety of settings shows that researchers and clinicians value the ease and efficiency of using this judgement-based tool. In research, the CFS is commonly used to predict health outcomes. The outcomes with which it most has been reported to be significantly associated are mortality, comorbidity, functional decline, mobility, and cognitive decline.This study was scoping in nature, allowing us to capture a broad range of information about the use of the CFS in research. However, this study is limited by the fact that it is not a meta-analysis and thus does not examine the quality of the evidence presented in each article. It was our aim to provide a high-level overview of this scale and its uses. In addition, the initial search was completed in 2017 and therefore does not incorporate articles published more recently.In recent years, as interest in frailty as a medical construct has increased, so too has the number of publications measuring the CFS. Overall, these studies have assessed the CFS in a range of different populations, which as a whole are representative of the general population of older adults. Preliminary analysis of this data demonstrated that the CFS has been found to be associated with a variety of important patient characteristics and clinical outcomes. Since the CFS combines clinical judgment with objective measurement and can be easily conducted, it has been seen as one of the most promising and practical ways of screening frailty in routine assessment  and espeThis further supports the use of the CFS as a tool in clinical practice, as it provides valuable information to guide patient care and health policy development. Synthesizing the evidence around CFS and gaining a better understanding of its feasibility and psychometric properties, could assist with the development of education materials for clinicians about how the CFS can better inform the care they provide and how it can help them discuss with patients and their families the risks and benefits of potential treatments. This will assist clinicians to provide more informed and rational shared decision making. Most recently, beyond what had been imagined when designed, and not without controversy –16, the The CFS is mostly used within geriatric medicine, cardiology, intensive care, general medicine, emergency medicine, surgery, and dialysis; information for other medical specialties is lacking. The CFS is also not commonly used to predict patient-oriented measures such as quality of life, which should be included in future observation studies using the CFS. Using the CFS to assess the degree of frailty in clinical settings extends beyond evaluating risk to mitigating frailty by understanding disease presentation, acute management, recovery time, and rehabilitation potential.Further research into the potential of this tool is warranted and will likely reveal novel applications to improve medical care of older adults. For example, investigation is warranted into whether implementing CFS in routine practice will improve care. In certain NHS centers in the United Kingdom, the CFS is routinely used to screen all patients over the age of 75 who are admitted to hospital via the Emergency Department . Data frThis scoping review revealed that the CFS has been widely used in multiple settings. Most of the included studies were conducted in hospital settings and most articles that examined the association of the CFS with adverse health outcomes showed that it has good predictive ability. The association of CFS score with clinical outcomes highlights its utility in the care of the aging population.Additional file 1. Supplementary figures & tables.


At the beginning of 2020, the outbreak of COVID-19 in China has brought great impact on the society, economy and life. This article introduces current status of Chinese postgraduate medical students under this epidemic situation in combination with the author’s own experience from four aspects: professional spirit, professional knowledge, learning status and protective measures. Since the outbreak in China, the numbers of confirmed cases and deaths have rapidly increased. COVID-19 has been clarified as a grade B infectious disease, others of which include severe acute respiratory syndrome and highly pathogenic avian influenza, and is treated according to the protocol for grade A infectious diseases. COVID-19 is the seventh known coronavirus-induced disease that involves infection of the respiratory system in human beings. The other two potentially life-threatening coronavirus-induced diseases are severe acute respiratory syndrome and Middle East respiratory syndrome.4 This novel coronavirus-induced pneumonia is transmitted from person to person and is highly infectious, with high susceptibility among the general population. The coronavirus responsible for COVID-19 has a long incubation period and diverse clinical features, seriously impacting normal work and life throughout the country. As of 13 April 2020, COVID-19 had been recognised in over 200 countries, with a total of 1 784 364 laboratory-confirmed cases and 111 832 deaths, and these numbers have since continued to rise.A novel coronavirus has been discovered and confirmed since the first case of unidentified pneumonia was confirmed in Wuhan, China, in December 2019.On 23 January 2020, the Chinese government immediately blocked the city of Wuhan and cut off all outside contact to stop the spread of COVID-19. Other cities successively announced closure of public places and restricted the flow of people. At the time of this writing, the Chinese Ministry of Education had stated that no student was allowed to return to school until further notification. Some postgraduate medical students residing at school were isolated in safe places. Some others who had returned home for holiday were restricted to their local residence and prohibited to return to the hospital or medical school for studies or clinical work. We herein describe the status and situation of postgraduate medical students in China under the influence of COVID-19.At the frontline of the fight against COVID-19, many medical staff members around the country have devoted their full power without hesitation while ignoring their own personal safety. Their teachers, colleagues and friends have also participated in this battle. Such behaviour demonstrates the humanitarian nature of medicine, which involves healing the wounded and rescuing the dying. This vivid lesson helps medical students to internalise medical ethical principles through emotional penetration and thus deepens their understanding and strengthens their beliefs. It benefits society to cultivate a spirit of benevolence among medical students and to train postgraduate medical students to engage in positive behaviour. In recent years, the position of the medical humanities in medical education has gradually improved. The combination of medical humanities and medical knowledge is regarded as a successful medical education, which manifests scientific and human brilliance. Such education could help medical students to realise the transformation from medical ethical cognition to medical ethical behaviour in their future career.Medical students can help their relatives and friends to recognise the symptoms of pneumonia early according to their professional knowledge. The diagnosis of COVID-19 is based on a combination of epidemiological information, clinical symptoms, CT imaging findings and laboratory tests according to the standards of either the WHO or the National Health Commission of China. Although medical students were not in the hospital and had no access to CT or test kits, they generally have a higher level of professional judgement than people in the general population with respect to medical knowledge and patients’ symptoms. For example, if a person within a medical student’s neighbourhood develops a fever and cough and has a travel history from Wuhan, the student can advise him or her to go to the hospital in a timely manner. Postgraduate medical students can also educate the people around them, which helps the public to realise the importance of prevention and comply with regulations formulated by the country. Medical students can also serve as volunteers within the community and use their professional knowledge to make more contributions to community residents.5 Basic medical courses such as physiology, pathology and biology are relatively easy to study by video or electronic books. However, clinical medicine courses such as surgery are not suitable for online study. Because medicine is a practical science, it cannot break away from clinics and patients, and even simulation training cannot achieve a real-world effect. Many universities lack the ability to use the computers or software required to conduct online teaching courses, record teaching videos and prepare teaching documents such as text, picture, audio and animation. Students living in rural areas with underdeveloped networks and poor hardware facilities may find it difficult to meet the requirements of online learning. During this special period in China, self-study has become an important skill for medical students. Students of different majors have different learning styles. Dermatology students can review photographs of lesions to improve their skills in differential diagnosis. Internal medicine students can analyse complex cases to exercise their logical ability. Surgery students can learn more about internal medicine to become more comprehensive surgeons. Additionally, online learning allows students to restart long-forgotten projects, modify research papers and complete unfinished work. They can also review the literature in a field of interest, create an outline of future research and contemplate their career plan. All doctors in China are willing to apply for assistance from the National Natural Science Foundation of China, a famous and widely used research fund. Online application usually starts in March every year, but in 2020, it was postponed until April because of the epidemic. This gave medical students more time to carefully prepare for their application under the guidance of a mentor.The sudden outbreak of this novel coronavirus disrupted normal teaching and studying in the field of medical education. Non-stop learning via online teaching despite suspension of classes was put forward by the ministry of education. During the disease outbreak, online lectures and learning tutorials were adopted to avoid unnecessary aggregation of people and the associated risk of infection.6 Students can also consult psychologists from university-affiliated hospitals who are online 24 hours a day. The Chinese government provides students with a wide coverage of virus protection education that has shown good results to date; the government also provides corresponding psychological counselling services. Specifically, China has1 stopped centralised classroom teaching,2 carried out antiepidemic knowledge training,3 encouraged the wearing of masks and4 paid attention to hand hygiene. These measures are worthy of implementation in foreign countries as well. Conversely, European countries have encouraged medical students to graduate early so that they may work to help fight COVID-19, which is worthy of implementation in China.Although the medical resources of the whole country are devoted to treatment of all patients infected with the novel coronavirus, the schools and government still make special efforts to protect the health of students. Peking Union Medical College has developed an online system called SARISenor, which is used by medical students to report the body temperature and physical condition every day. This system also has a locating function based on the global positioning system, which is convenient for localised management. Our medical school also developed a course to increase knowledge of COVID-19, and all students are required to study this course online. A test is administered after completion of the course, and students must complete the test to obtain a certificate and show the certificate to the school. This compulsory measure improves students’ awareness of the novel coronavirus and strengthens their ability to prevent COVID-19. With respect to psychological health, medical students are easily affected by disease-associated fear and pressure, and schools should be prepared to provide psychological services to those who need them.We cannot neglect the adverse effects of COVID-19 on Chinese scientific research. Fundamental experiments, scientific conferences, funding applications and other activities have been postponed or suspended because of the pandemic situation, which has caused a huge loss in scientific research in China. Specifically, pharmaceutical companies are lacking essential drugs because of shutdowns; scientific researchers are out of work because of the closures of laboratories; and students are unable to attain their academic degrees because of the suspension of research. However, the damage to science is insignificant compared with the level of human suffering. Notably, 5G wireless communication technology, artificial intelligence and cloud computing have played effective roles in prevention and monitoring during this epidemic emergency. Additionally, because of the lack of specific drugs and vaccines, traditional Chinese medicine has been adopted as a part of clinical therapy.Thanks to the leadership of the government and the efforts of many medical workers, the effect of COVID-19 control in China has been remarkable. The Chinese Ministry of Education recently announced that senior medical students can return to universities in advance if circumstances permit. Doctors and postgraduate medical students are also glad to return to their clinical work and make their own contributions to the health of the people. With increased knowledge of the viral features, epidemiological characteristics, clinical symptoms and antivirus theory, efficient strategies have been taken to prevent, control and stop the spread of COVID-19. During the current COVID-19 pandemic, which is a worldwide war, everyone is a fighter. Under the close unity of all countries worldwide and with active participation of the world population, we believe that the prevention and control of COVID-19 will be finally achieved.