Caesarean section (CS) has become an increasingly common method of delivery worldwide, rising in the UK from 9% of deliveries in 1980 to over 21% 2001. This increase, and the question of whether CS should be available to women on request, has been the subject of considerable debate, and national reports and guidelines have specifically highlighted the importance of patient choice in the decision making process. For women who have already experienced CS, the UK National Institute of Clinical Excellence recommends that the decision should consider maternal preferences and priorities in addition to general discussion of the overall risks and benefits of CS. Decision aids for many different medical treatment and screening decisions have been developed and evaluated, but there is relatively little evidence for the use of decision aids for choice of mode of delivery among women with a previous CS. The aim of the study is to evaluate two interventions to assist decision making about mode of delivery among pregnant women with one previous CS.Women with one previous CS are recruited to the trial during their booking visit at approximately 12–20 weeks' gestation in participating maternity units in Bristol, Weston and Dundee. Using central randomisation, women are allocated to one of three arms: information programme and website; decision analysis; usual care. Both interventions are computer-based, and are designed to provide women with detailed information about the potential outcomes for both mother and baby of planned vaginal delivery, planned CS and emergency CS. The decision analysis intervention additionally provides a recommended 'preferred option' based on maximised expected utility. There are two primary outcomes , and five secondary outcomes . Primary follow up for the questionnaire measures is at 36–37 weeks' gestation, and a total of 660 women will be recruited to the study. The primary intention-to-treat analyses will comprise three pair-wise comparisons between decision analysis, information and usual care groups, for each of the two primary outcomes. A qualitative study will investigate women's experiences of the decision making in more depth, and an economic evaluation from the perspective of the NHS will be conducted.Provision of information to women facing this decision appears variable. The DiAMOND study aims to inform best practice in this area by evaluating the effectiveness of two interventions designed to aid decision making. Over the last 20 years caesarean section (CS) has become an increasingly common method of delivery. The CS rate in the United Kingdom rose from 9% of deliveries in 1980 to 21% in 2001 .The Changing Childbirth report has emphasised the importance of patient choice when decisions need to be made in relation to the management of pregnancy and childbirth . HoweverIn an attempt to ensure appropriateness of CS in the UK, a set of evidence-based guidelines on indications for CS have recently been published . The guiIt has been proposed that the way in which clinical decisions are made lies on a continuum, from paternalistic (clinician decides) through partnership (clinician and patient share the decision) to informed (patient decides) . AlthougDecision aids are designed to help people select between various treatment strategies by providing information on the options and outcomes relevant to a person's health. Decision aids for many clinical conditions have been developed , and evaThe specific content of decision aids may vary, but in general they aim to present more than one strategy for clinical management, help people understand the probable outcomes of treatment choices and allow people to consider the personal value they place on benefits versus harms. Decision aids can take several formats, such as leaflets, interactive videodisks, individualised decision analysis, personal counselling sessions and audio workbooks. Interventions to assist patient decision making can improve knowledge about treatment options, make patients more realistic in their expectations, reduce decisional conflict and increase active involvement in decision making .As an intervention to aid patient decision making, individualised decision analysis has so far received limited attention. By explicitly combining patients' values regarding treatment outcomes and individual probability information, decision analysis attempts to provide a rational framework to guide patient decision making. The use of individualised decision analysis has been debated , but empThe aim of this paper is to describe the protocol for a randomised controlled trial of two interventions to aid decision making about mode of delivery among pregnant women with one previous CS. The interventions being assessed are (1) Decision analysis, and (2) Information programme and website. Both decision aids will be compared with usual care given by the obstetric team. The interventions will be assessed in terms of decisional conflict, planned and actual mode of delivery, anxiety, knowledge, perception of shared decision making and satisfaction with the decision making process. Development and piloting of the interventions took place in 2003–2004, and the main phase of the study started in May 2004 and will continue until December 2006. Ethical approval for the study was obtained from the UK South West Multi-Centre Research Ethics Committee.The sample will comprise pregnant women with one previous lower segment CS , no current obstetric problems and delivery expected at ≥ 37 weeks. Women are being recruited to the study by research midwives during their initial booking visit at approximately 12–20 weeks' gestation. Recruitment takes place from maternity units in St Michael's and Southmead Hospitals in Bristol, Weston General Hospital, and Ninewells Hospital in Dundee. The current CS rates for these units range between 18 and 24% and are representative of rates for other units throughout England and Scotland. The women are informed that although both vaginal delivery and repeat CS carry their own benefits and risks, the best method of presenting this information in order to assist women in reaching a decision is not known. Women expressing an interest in participating in the trial at the booking visit are given an information sheet, a written consent form and a baseline questionnaire to take home. Following receipt of the baseline questionnaire and written informed consent to enter the trial, women are randomised to one of three arms as detailed below. Allocation is stratified by maternity unit and preferred mode of delivery and blocked  to ensure reasonable balance between the trial groups through time. The randomisation sequence was generated by a member of the study team (AAM), and allocation of participants is performed by a staff member with no other involvement in the study.Both interventions are computer based. Women allocated to receive an intervention have an appointment with a researcher to allow the decision aid to be delivered using a laptop computer, usually in the woman's own home or workplace.This intervention provides information about the outcomes associated with planned vaginal delivery, planned CS, and emergency CS. This includes descriptions of outcomes for both mother and baby, and the probabilities of these outcomes based on the best available evidence. Both the probabilities of having and not having the event are given, and all probabilities are presented in both numerical and pictorial format . The proThere are generally four main steps involved in a decision analysis. The first is to draw up a decision tree that maps out the likely outcomes of the strategies in question . These oThe decision analysis intervention in the trial proceeds according to the principles described above. First, women are given information about the outcomes associated with planned vaginal delivery, planned CS, and emergency CS. This includes descriptions of outcomes for both mother and baby, but not the probabilities of these events. These are embedded in the decision tree which is not visible to users. Second, women are required to rate  each possible outcome using a visual analogue scale. Finally, the programme combines the elicited utilities and the probabilities of each outcome in a decision tree to produce a recommended 'preferred option' based on maximised expected utility. Each woman is given a computer printout of the outcome of the decision analysis.This comprises care normally given by the obstetric and midwifery team. Women allocated to decision analysis or information programme receive these interventions in addition to usual care.Women in both intervention arms are contacted by letter at 35 weeks' gestation. The purpose is to encourage discussion of the intervention with their obstetrician and/or midwife when they attend the clinic at 36–37 weeks to finalise their planned method of delivery. Participation in the study is recorded in the medical records of all women in the trial.There are two primary outcomes:(1) Decisional Conflict Scale (DCS) ,29. This(2) Actual mode of delivery . Unlike a previous trial , we are There are five secondary outcomes: anxiety;  knowledgThe primary and secondary outcomes are assessed in all three groups at baseline, and approximately two weeks after randomisation. The questionnaire at two weeks will constitute a secondary follow up, and will enable sufficient time for delivery of the appropriate interventions. As part of usual care, women in the trial normally attend the clinic at around 36–37 weeks' gestation to finalise plans for their preferred method of delivery. Questionnaire outcomes are measured again after this visit, and this constitutes the primary follow up for this trial. Actual and attempted mode of delivery  and satisfaction with choice are assessed by a further postal questionnaire at approximately six to eight weeks after giving birth.As noted above, differences in excess of 0.35 standard deviations have been considered as important for the total DCS score, and differences of this magnitude are feasible for interventions of this kind . With reWith two-sided 1% alpha, a total sample size of 600 provides 82–99% power to detect a standardised difference of 0.35–0.5 in total decisional conflict score between the groups, and 84–95% power to detect odds ratios of 2.1–2.4 in women achieving vaginal delivery. A pair-wise alpha of 1%, corrected for multiple comparisons using Tukey's procedure, maintains an overall study-wise alpha of 3.4%. In order to allow for pre-term deliveries, malpresentations, and losses to follow-up, we will therefore recruit 660 women to the trial.Data analysis will proceed according to CONSORT guidelines for randomised controlled trials. The first stage of the analysis will be to use descriptive statistics to describe the group of individuals recruited to the trial in relation to those eligible, and to investigate comparability of the trial arms at baseline. The primary analyses will comprise three pair-wise intention-to-treat comparisons between decision analysis, information and usual care groups, for each of the two primary outcomes. These comparisons will use appropriate  multivariable regression models, adjusting for maternity unit, initial preference regarding mode of delivery, and value of the outcome variable at baseline. Full attention will be paid to the estimates and confidence intervals for these comparisons as well as the p-values, with the latter adjusted for multiple comparisons using Tukey's procedure. Secondary outcomes will then be analysed in the same way, using appropriate multivariable regression models depending on the nature of the outcomes.Other secondary analyses will involve investigation of the short-term effects of the interventions using data from the two week follow up, and the effects at 36–37' weeks gestation adjusted for both baseline and two week follow up. Pre-planned subgroup analyses employing appropriate interaction terms in the regression models will be used to ascertain any differential effects of the interventions on the two primary outcomes across the following categories of women: previous caesarean section occurring before or after labour; previous successful vaginal delivery; stated preferred mode of delivery. Since the trial is powered to detect overall differences between the groups rather than interactions of this kind, the results of these essentially exploratory analyses will be presented using confidence intervals as well as p-values, and interpreted with due caution. Finally, we will investigate the effect of differential use of the information intervention via the internet using descriptive statistics and appropriate comparisons with the other groups.Qualitative research methods will be used in order to explore aspects of the interventions and women's experiences of the decision making in more depth. Specifically, semi-structured interviews will be conducted with a sample of women from each of the intervention arms , across the research sites in Bristol and Dundee. These interviews will explore:(1) Women's views and experiences of the intervention and its delivery – for example, the quality and relevance of the decision aid/information, what they felt about the risk information presented to them, and which particular aspects of each intervention were helpful or unhelpful.(2) Which factors women felt had most influenced their preferences regarding method of delivery.(3) Whether the women had prior preferences about method of delivery, whether/how these changed during their pregnancy and in the case of the decision analysis, what they felt about the method of delivery proposed by the intervention compared to any prior preferences.(4) Any other information sources women sought and used to help them make a decision about method of delivery .(5) Women's views and feelings about their actual method of delivery compared with any prior preferences and the method of delivery suggested by the intervention .A small number of interviews may also be conducted with women in the usual care arm of the trial to explore what support and advice was normally provided during pregnancy to those who did not receive an intervention.A sample of approximately 30 women across the two intervention arms will be interviewed in depth to ensure a thorough exploration of emergent themes and concepts. Within each arm, women will be purposefully chosen to include those with different parities/ages/socio-economic backgrounds, and where possible different methods of delivery/outcomes, following a maximum variation sampling strategy . The intInterviews will be conducted in the womens' homes or other suitable setting chosen by them. A check-list of topics will be used to ensure that the primary issues are covered, whilst allowing flexibility for new issues to emerge from each interview. Interviews will be recorded on mini-disc, fully transcribed and anonymised to protect confidentiality. Transcripts will be studied in detail and a list of common themes and concepts drawn up. Data collection and analysis will run in parallel and the coding index added to or refined and coded material regrouped as new themes and categories emerge from subsequent interviews . FurtherIn addition to the interviews with women, a small number of focus groups with health professionals  in each research site may be conducted near the end of the trial, resources and time permitting. Focus groups are often used in evaluations of new services/interventions and are useful for exploring group views, concerns and preferences (e.g. consensus or disagreement about an issue) . They maThe aim of the economic evaluation is to compare the costs and benefits of the two interventions with usual care. The analysis will be from an NHS perspective and will be based on the costs incurred during pregnancy, delivery and 6–8 weeks following delivery. Incremental cost effectiveness ratios will be formed comparing (i) the cost per point improvement on the Decisional Conflict Scale (DCS) and (ii) the cost per extra patient able to make a decision (represented by a 0.5 standard deviation change on the DCS). We will also compare the average cost of care per patient in each arm of the trial with patient satisfaction. Differences in the cost of care of women receiving the two interventions will be compared with usual care from the point at which patients are randomised. The analysis will include all resources under the control of the NHS that may differ as a result of the interventions and will include resources used by both mother and baby. The costs identified as being of relevance are: antenatal appointments in addition to routine appointments, including both primary and secondary care; mode of delivery and related hospital stay for mother and baby; follow up care for mother and baby, including primary and secondary care appointments, outpatient appointments, inpatient stays, A&E visits, and prescribed medication.Data on resource use will be collected principally by two questionnaires completed by the women. The first questionnaire, completed at 36–37 weeks' gestation, will provide information on all antenatal appointments, and the proportion of these that involved discussion about mode of delivery. Women will be asked how often mode of delivery was addressed at (i) routine appointments, and (ii) appointments initiated by them to discuss mode of delivery. A sample of 10 hand-held records from each arm at each main centre  will be scrutinised to validate the information given in response to the questionnaire. The second questionnaire, completed six to eight weeks after delivery, will provide information on mode of delivery and all non-routine postnatal health service contacts and prescriptions for both mother and baby.The principle of opportunity cost will underlie the valuation of resource use. In many cases, market rates will act as a proxy for opportunity cost. National data sets such as the Unit Costs of Health and Social Care  and the Costs and outcomes will not be discounted, as the economic evaluation will be limited to a period of 12 months. Sensitivity analysis will be conducted in areas where there is uncertainty around assumptions about resource use measurement and/or valuation. Variation in resource use and the effectiveness of the intervention is not captured by a cost-effectiveness/utility ratio. We will use bootstrapping to address this, and construct a cost effectiveness acceptability curve.Women with an uncomplicated pregnancy and expected term delivery who have previously delivered by CS face a choice between repeat elective CS or attempted trial of labour. Guidelines in the UK emphasise the importance of involving women in the decision making process and taking account of maternal preferences and priorities, but the type and amount of information available to women facing this choice appears variable. The DiAMOND study is a randomised trial that aims to inform best practice in this area, by evaluating the effectiveness of two interventions to assist decision making in terms of decision quality and actual mode of delivery.The author(s) declare that they have no competing interests.Alan Montgomery, Deirdre Murphy, Ali Shaw and Sandra Hollinghurst drafted the manuscript, with input from the other members of the DiAMOND Study Group.The Decision Aids for Mode Of Next Delivery (DiAMOND) Study Group comprises the following members: Clare Emmett, Tom Fahey, Peter Gregor, Sandra Hollinghurst, Claire Jones, Beverley Lovering, Alan Montgomery, Irene Munro, Deirdre Murphy, Roshni Patel, Tim Peters, Ian Ricketts, Anne Schlegelmilch, Ali Shaw, Kav Vedhara, Kate Warren.The pre-publication history for this paper can be accessed here:


It is an absolute necessity to continually assess the quality of health information on the Internet. Quality-controlled subject gateways are Internet services which apply a selected set of targeted measures to support systematic resource discovery.The CISMeF health gateway became a contributor to the MedCIRCLE project to evaluate 270 health information providers. The transparency heritage consists of using the evaluation performed on providers that are referenced in the CISMeF catalogue for evaluating the documents they publish, thus passing on the transparency label from the publishers to their documents.Each site rated in CISMeF has a record in the CISMeF database that generates an RDF into HTML file. The search tool Doc'CISMeF displays information originating from every publisher evaluated with a specific MedCIRCLE button, which is linked to the MedCIRCLE central repository. Starting with 270 websites, this trust heritage has led to 6,480 evaluated resources in CISMeF .With the MedCIRCLE project and transparency heritage, CISMeF became an explicit third party. The availability of Internet health tools and services has been increasing at a phenomenal rate in recent years making the Internet a major source of knowledge for healthcare professionals, medical students and also patients and the general public. This increase has made it an absolute necessity to continually assess the quality of health information on the Internet. Indeed, creating a Web site is relatively easy, therefore uncontrolled health information can be launched by virtually anyone with access to the Internet. Peer review is often absent throughout this media as opposed to scientific journals. There have been numerous debates about the variable quality of health information on the Internet and its impact on public health . There iIn the past five years, a lot of authors have scrutinized the quality of the health content available on the Internet. These studies, assessing the quality of health information, have been extensively reviewed by Eysenbach et al. . In the As of today, access to accurate and trustworthy health information on the Internet is not an easy task; there are a great number of directories and search engines available in this new media . But, thThe objective of CISMeF  ,7 is to ) [CISMeF is a quality-controlled subject gateway initiated by the Rouen University Hospital (RUH). Each of the following phases proposed by Koch , which c) , (b) col The CISMeF Web site opened in February 1995. In December 2003, 13,012 resources had been indexed, with an average of 55 new resources indexed each week. CISMeF is considered by most professionals as the reference health institutional Web site in France with as many as 25,000 unique machines visiting this Web site by working day. Doc'CISMeF is the search tool of the CISMeF gateway [CISMeF is manually maintained. In CISMeF, a resource is defined as 1) a Web site or 2) high-quality documents from this Web site. CISMeF describes and indexes the most important sources of institutional health information in French, in order to allow them to be searched quickly and precisely. A great variety of resources are indexed, in terms of resource type , and resource format . Its Universal Resource Locator (URL) is  gateway .In 1997, because the quality of health information became an important issue for the building and maintenance of a trustworthy health gateway, the CISMeF team participated in the development of a user guide named Net Scoring . The goa) [In 2002, CISMeF became a contributor to the MedCIRCLE project (URL: ) . The aim) . MedCIRCThe main deliverable of this project for the CISMeF team was the evaluation and rating of 270 health information providers (or publishers) which who release health resources in French on a regular basis. Because CISMeF catalogues and indexes not only Web sites but also and mainly quality-controlled documents from those health publishers, we introduced the concept of "transparency transitivity" or " transparency heritage". It consists in applying to these documents the evaluation performed for their publishers, thus passing on the transparency label from the publishers to their documents.Health professionals have begun to realize that it is their responsibility to guide consumers and patients to the best available medical information on the web. Many national governments and medical societies have acknowledged that it is their responsibility to help users to identify "good quality" information sources and have begun to develop national health gateways , portal sites and other forms of "infomediaries" such as seals of approval  or certiHowever, current approaches do not harness any of the advantages of the Web as a decentralized, distributed information system. There is a need for "next generation" tools, including intelligent knowledge-based tools, allowing consumers to positively and actively identify reliable health information that suits their needs.) for laypersons, listing consumer health information sites. Before MedCIRCLE, documents had been evaluated using the DISCERN instrument [) represents the medical profession of Barcelona. To this date, in the project "Web Medica Acreditada", COMB has accredited more than 300 Spanish health websites from Spain and Latin America [The three application partners of MedCIRCLE, besides CISMeF in France, were the Agency for Quality in Medicine (AQuMed) in Germany and the Official Medical College of Barcelona (COMB). AQuMed was founded in March 1995 as a joint institution of the German Medical Association and the National Association of Statutory Health Insurance Physicians. AQuMed established a health gateway  thesaurus from the US National Library of Medicine, and several metadata element sets : (a) 11 ) [HIDDEL is a metadata language and an ontology, which enables the expression of descriptive and evaluative annotations in XML/RDF. The first version of HIDDEL was initially developed during the MedCERTAIN project  . HIDDEL ) , a basic) . HIDDEL evaluate health information providers. It presents three levels of evaluation: (a) self-disclosure (b) evaluation by non-medical experts, and (c) evaluation by medical experts. As a quality-controlled subject gateway, CISMeF uses HIDDEL only as a third-party.HIDDEL is based on existing quality criteria such as the Health On the Net (HON) Code of Conduct . It was The HIDDEL vocabulary can be downloaded freely from the MedCIRCLE Web site, as long as the sources are acknowledged and requests for changes or expansions are fed back to the community. At present HIDDEL is available in four languages: English, German, French and Spanish. The use of this controlled vocabulary enables automatic translation (except for free text). The heritage process was made possible because of HIDDEL's dual structure: on the one hand, Infoprovider metadata, describing to the health information provider , and on the other hand, Sitespecific metadata devoted to one Web site evaluation . In CISMeF, we have applied Sitespecific metadata to each resource  from a publisher already included in the CISMeF database. The name of the person responsible for the quality of the Web site, which is one of the Infoprovider metadata, is the same for every document of the Web site. On the contrary, the language of the document, which is one of the Sitespecific metadata, may vary from one document to another. The CISMeF team implemented the whole HIDDEL structure in the CISMeF database, which involved the creation of triggers, thus ensuring automated transfer from CISMeF to HIDDEL metadata, and the creation of new forms (interface recasting) to deal with non-CISMeF metadata. Because the HIDDEL elements are optional and repeatable, CISMeF has selected a number of 70 metadata among the 305. Most of the metadata previously used in CISMeF and in particular the Dublin Core are also included in the HIDDEL language. These metadata were automatically triggered in the HIDDEL language.The interoperability process consists of an exchange of RDF files, containing experts' annotations "written" in HIDDEL. The semantic-based Archer Annotation System deals with RDF annotations reception. Archer is a Web application that allows annotating health information Web sites using the HIDDEL vocabulary. It is a technical platform and an organizational infrastructure that can be used by consumers, health information providers, and third party rating services. The first version of Archer was implemented as a part of MedCERTAIN, and further enhanced in the course of the successor project MedCIRCLE to allow the exchange of metadata between third party rating organizations.) into the generated HTML pages, making them not only machine-readable (as every HTML page is) but also machine-processable. Therefore, one of the main goals of this metadata element set was fulfilled easily: it became interoperable with other Internet services. Moreover, an RDF Scheme describing CISMeF specific metadata was created (URL: ).On another ground, through its search engine Doc'CISMeF, CISMeF provides external links to Archer backend servlets, and internal links to rated sites disclosure  included in the CISMeF database: national agencies, medical societies, universities and hospitals. CISMeF first checks the publishers' information without asking the health information provider to self-declare any metadata as described in the MedCERTAIN quality management process.CISMeF used HIDDEL to select and evaluate the 270 health publishers most represented in CISMeF and made the results of their evaluations explicit and accessible using RDF metadata. These were exported into the searchable MedCIRCLE Open Directory.) displays the information originating from each of the publishers that were evaluated with a specific MedCIRCLE button, which is linked to the MedCIRCLE central repository where HIDDEL metadata elements are displayed  has been previously accredited a third party.Nonetheless, every resource included in CISMeF and those evaluated by the MedCIRCLE process are quality-controlled. The MedCIRCLE consortium takes a very neutral approach and does not impose but strongly recommends certain procedures or minimum metadata, taking into account that collaborating gateways, accreditors, certifiers, raters may approach from very different angles.CISMeF has applied full heritage from the evaluated publishers: each document from a MedCIRCLE rated publisher, indexed in CISMeF, will also receive the MedCIRCLE button of the publisher with the same link to MedCIRCLE central repository. The idea is to keep the common Infoprovider elements for every document, and to use CISMeF metadata to disclose Sitespecific elements specific to each document, in particular the indexing with the MeSH thesaurus. At the end of the project in December 2003, starting from 270 websites, the translation from CISMeF metadata to HIDDEL, led to 6,480 evaluated resources in CISMeF in September 2003 . All CISMeF selected HIDDEL metadata (70 out of 305) are displayed in the Doc'CISMeF record in RDF into HTML. The top five publishers indexed in CISMeF, which produced trustworthy documents in French are: Grenoble Medical School (N = 435), Health Canada (n = 275), Strasbourg Medical School (N = 263), and French Ministry of Health (N = 248).Every new document  included in CISMeF from one of the 270 main publishers evaluated through the MedCIRCLE process inherits automatically: (a) a MedCIRCLE button linking to the repository and (b) HIDDEL metadata included in CISMeF database and displayed in the Doc'CISMeF record in RDF into HTML. On the other hand, a document that comes from one of the 270 publishers evaluated within the MedCIRCLE project but not included in the CISMeF database will not receive a MedCIRCLE button in the CISMeF gateway. However, this more global transitivity could be applied in a more generic search tool such as Google.Since February 2003, when the MedCIRCLE button became operational in the CISMeF gateway, the CISMeF team has decided to go on (keep) applying the MedCIRCLE transparency process after the end of the project with the following rules: (a) check every month if there is a new publisher with five documents already included in CISMeF and (b) if so, begin the MedCIRCLE process for these publishers and apply transparency heritage for their respective documents. We applied these rules after the end of the EU-funding project. In March 2004, the CISMeF database contained a complete evaluation through the MedCIRCLE process for 346 publishers  and 7,053 documents from these publishers .In the MedCIRCLE repository, end-users can access an aggregate view of what people say about a certain Web site by clicking: The CISMeF gateway is one of many possible producers of trustworthy metadata regarding a health information provider. Metadata from the Open Directory can also be fed into search engines and other gateways.) consortium (URL: ): this HON tool bar is indicating if the site is accredited directly by HON or indirectly by one specific accredited Web sites as health gateways such as CISMeF or MedlinePlus. In this context, HON is creating a seal of quality trust heritage where MedCIRCLE is creating a seal of transparency heritage. A formal evaluation of these two examples of heritage  is mandatory to check their respective hypothetical added value.As the number of health related Web sites worldwide has been estimated as being around 100,000, complete coverage by a single third party evaluation body is impossible. Instead, a collaborative approach as shown in this paper has to be promoted, whereby different rating services or organizations use comparable standards and a common metadata language. More recently, the Health on the Net Foundation has developed a HON tool bar in the course of the EU-funded Active Health , which partially granted the MedCIRCLE consortium.One of the main findings of the MedCIRCLE consortium in the course of the project has been that there is no absolute objective quality of a Web site. Quality is to a certain degree subjective, may vary in time and also according to the eye of the beholder. A Web site that a consumer looking for health information finds acceptable one day may be unacceptable another day. For example, a consumer may search general information for one drug (e.g. after a TV show) and finds advice on a patient information Web site. Later, the same consumer searches for the same drug for his/her child. But this time, he/she checks if the respective Web site is sponsored by a pharmaceutical company. He/she comes to the same Web site as before, but this time this Web site will be unacceptable. The context of the search changed, making a general advice acceptable and a specific advice unacceptable. By providing metadata about health related websites, MedCIRCLE allows the health information consumers to decide themselves if a website is of good quality. Trust is improved by enhancing transparency. More globally, the MedCIRCLE consortium will lead to a safer Internet by providing a seal of transparency to over 7,000 resources on the Internet via the CISMeF search engine. The precaution principle is now widely accepted in the European Union, which develops Action Plans, such as the Action Plan for Safer Use of the Internet  by providing a seal of transparency. The Netizen (citizen on the Internet) has the active role to evaluate the reliability when reading the HIDDEL metadata after clicking the MedCIRCLE button. With a seal of trust, the role of the Netizen is more passive but leads to a faster trust information access. Nevertheless, a drawback of the MedCIRCLE button is a possible misunderstanding by end-users, who might confuse it with a quality seal and therefore may forget to actively press the MedCIRCLE button, which may hinder their valid judgement. Here again, a formal evaluation of theses two approaches (transparency vs. trust) is necessary.implicit third party. One of the main results of the MedCIRCLE project, from the CISMeF team's point of view, is that CISMeF proceeded from being an implicit to being an explicit third party thanks to the creation of the MedCIRCLE button now used for 346 publishers (2.6% of the resources included in CISMeF) and 7,053 resources (53.3% of the resources included in CISMeF), which multiplies by 20 the number of resources with a seal of trust.While using Net Scoring, CISMeF was acting as an The HIDDEL language is totally embedded in the CISMeF metadata element sets. This allows a very easy interoperability with MedCIRCLE tools, and more specifically Archer. Semantic Web approaches already used in the MedCIRCLE project could open up new ways for educating health professionals and consumers and reaching less savvy health professionals and consumers, because part of the intelligence and knowledge currently required to critically appraise information on the health professional or consumer Web site could be built into the search tools. The feasibility of this approach has been already demonstrated by CISMeF but also by the German (AQuMed) and Spanish partners (COMB). The impact on health professionals and consumers is subject to ongoing investigation within the MedCIRCLE project. The Semantic Web may provide the health professional or the consumer with a greater capacity to determine the reliability of a given health information provider or service than the Web in its current form.With the MedCIRCLE project and transparency heritage, CISMeF became an explicit third party.None declared.SJD had the original idea of seal transparency and drafted the manuscript. DH and TRRB developed respectively in France and Germany the programs to implement the seal transparency in CISMeF & MedCIRCLE Web sites.The pre-publication history for this paper can be accessed here:


Many patients with several concurrent medical conditions (multimorbidity) are seen in the primary care setting. A thorough understanding of outcomes associated with multimorbidity would benefit primary care workers of all disciplines. The purpose of this systematic review was to clarify the relationship between the presence of multimorbidity and the quality of life (QOL) or health-related quality of life (HRQOL) of patients seen, or likely to be seen, in the primary care setting.Medline and Embase electronic databases were screened using the following search terms for the reference period 1990 to 2003: multimorbidity, comorbidity, chronic disease, and their spelling variations, along with quality of life and health-related quality of life. Only descriptive studies relevant to primary care were selected.Of 753 articles screened, 108 were critically assessed for compliance with study inclusion and exclusion criteria. Thirty of these studies were ultimately selected for this review, including 7 in which the relationship between multimorbidity or comorbidity and QOL or HRQOL was the main outcome measure. Major limitations of these studies include the lack of a uniform definition for multimorbidity or comorbidity and the absence of assessment of disease severity. The use of self-reported diagnoses may also be a weakness. The frequent exclusion of psychiatric diagnoses and presence of potential confounding variables are other limitations. Nonetheless, we did find an inverse relationship between the number of medical conditions and QOL related to physical domains. For social and psychological dimensions of QOL, some studies reveal a similar inverse relationship in patients with 4 or more diagnoses.Our findings confirm the existence of an inverse relationship between multimorbidity or comorbidy and QOL. However, additional studies are needed to clarify this relationship, including the various dimensions of QOL affected. Those studies must employ a clear definition of multimorbidity or comorbidity and valid ways to measure these concepts in a primary care setting. Pursuit of this research will help to better understand the impact of chronic diseases on patients. With technological advances and improvements in medical care and public health policy, an increasingly large number of patients survive medical conditions that used to be fatal. As a result of this phenomenon, and parallel to the aging of the population, a growing proportion of primary care patients presents with multiple coexisting medical conditions. From available data, it was estimated that 57 million Americans had multiple chronic conditions in 2000 and that this number will rise to 81 million by 2020 .chronic conditions; they also proposed some qualifiers to better classify the type of multimorbidity . Unfortunately, much confusion still exists in the literature, where the 2 terms often seem to be used interchangeably. For the purpose of this paper, the term "multimorbidity" will be used according to Van den Akker and colleagues' definition and the focus will be solely on chronic diseases.The terms "comorbidity" and "multimorbidity" have been used to describe this phenomenon. Feinstein  originalPrevious reports on multimorbidity or comorbidity have documented that this phenomenon influences outcomes in many areas of health care -19. OutcQuality of life (QOL) is an outcome measure that is increasingly being used to evaluate outcomes in clinical studies of patients with chronic diseases -26. QOL Little is known about the impact of multimorbidity on QOL of primary care patients , althougFor this review, we consulted Medline and Embase electronic databases for the reference period 1990 to 2003. Figure Quality of Life Research and Health and Quality of Life Outcomes journals. We also screened references from key articles retrieved (hand searching).To identify studies pertinent to the primary care setting, the following search terms were used: general practice, family practice, family medicine, family physician, and primary health care. A parallel strategy was used to identify all descriptive studies, regardless of the context of care, and the results were then combined. For the initial screening, the search was restricted to studies on human subjects, published in French or English. To be complete, we directly searched the One researcher (LL) performed the initial screening. Any ambiguous findings were discussed with the lead investigator (MF) and a consensus was reached.For the purpose of this systematic review, we selected original, cross-sectional, and longitudinal descriptive studies that had evaluated the relationship between multimorbidity or comorbidity and QOL or HRQOL as the main outcome of interest. As stated earlier, we focused on the population of patients seen, or likely to be seen, in the primary care setting including members of the general population and residents of nursing homes and home healthcare facilities. We also selected original descriptive studies that had examined the relationship between multimorbidity or comorbidity and QOL or HRQOL as a secondary outcome.Figure Before being included in the synthesis, the quality of each article selected was critically analyzed. For this assessment, we devised a scale in which points were assigned for study parameters indicative of good quality . Using this scale Table , 2 reseaFigure Of the 7 studies that featured QOL as a primary outcome -42, 5 haAll studies came to the same conclusion, namely that there is an inverse relationship between the number of medical conditions and QOL or HRQOL. This association may be affected by the patient's age or gender. Whereas multimorbidity mostly affects physical dimensions of QOL or HRQOL ,37,41, dIn each study, investigators relied on simple count of chronic diseases from a limited list to measure multimorbidity. The chronic conditions included in this list varied among the studies, and no attempt was ever made to assess or account for the severity of each condition. Furthermore, 5 of the 7 studies did not consider psychiatric comorbidity, either because the illnesses considered did not include psychiatric diagnoses or because patients presenting with psychiatric diagnoses were excluded from the QOL evaluation. In most cases, the diagnostic information was obtained by a questionnaire that was completed by a nurse or a doctor or sometimes self-administered. One study assessed comorbidity via chart review.To measure QOL, a variety of scales were used. Most studies (5/7) used tools from the Medical Outcomes Study i.e., the Short-Form-36 Health Survey (SF-36) and Short-Form-20 Health Survey (SF-20). However, the Nottingham Health Profile (NHP) was used in one study and the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) was used in another. Although the number of domains explored varied from one study to the next, the measuring instruments used have excellent psychometric properties and validity.The 4 studies associated with the highest quality scores explored only a limited number of potential confounders, namely age ,38, gendOf the 23 studies that evaluated the relationship between multimorbidity or comorbidity and QOL as a secondary outcome measure -65, mostAs with the results from the main outcome studies, we found an inverse relationship between the number of medical conditions and the QOL relating to physical domains in all studies. However, the relationship between multimorbidity and QOL relating to psychological or social domains was less clear. Some investigators reported an effect of multimorbidity on these domains in patients with 3 or more diagnoses , while oAs in the main outcome studies, tools from the Medical Outcomes Study, including the SF-36 (17 studies), SF-20 (3 studies), and Short-Form-12 Health Survey (SF-12) (1 study), were used to evaluate QOL in most of these studies. However, the NHP was used in one study and the Quality of Well-Being Scale (QWB), in another. In the majority of studies, all of the QOL domains were explored.Although this systematic review confirms the inverse relationship between multimorbidity and QOL, it also raises some important questions. First, the relative lack of studies in primary care evaluating the association between multimorbidity and QOL or HRQOL is surprising given the number of patients who suffer from multiple concurrent chronic conditions. Although the existence of this association makes logical sense, it still has to be demonstrated and thoroughly studied to find ways of improving care for specially affected patients. Thus, the pressing question may not be whether there is an association but rather how strong is the association and what factors are responsible for it? Identifying these factors may contribute to better care for the affected patients. There is a clear need for further studies to address these issues.Ultimately, multimorbidity has the potential to affect all domains of QOL. However, the influence of multimorbidity on the social and psychological dimensions of QOL is much less clear than its influence on the physical domains. It is noteworthy that several studies showed a significant decline in social and psychological dimensions of QOL in patients with 3, 4, or more concurrent diagnoses. What does this finding mean? Is there any bias that can explain this difference, or is it related to a certain capacity for adaptation? Are there other factors associated with this finding? All of these questions have yet to be answered.All the studies examined were cross-sectional in nature. The effect of multimorbidity may vary over time. Some medical conditions may improve while others worsen resulting in various effects on QOL. Therefore, cross-sectional studies may not capture the real effect of multimobidity on QOL and predict the direction of change over time.The absence of a uniform way of defining and measuring multimorbidity is of special concern and may explain some of the variability in our results. In most of the studies we evaluated, investigators had used only a simple list of diseases to identify concurrent medical conditions in patients, providing very incomplete information. Furthermore, the numbers and types of medical conditions in these lists varied among the studies, precluding comparisons.Given the urgent need for conceptual clarity, Van den Akker and colleagues' definition of multimorbidity should be refined and advanced to achieve a common understanding. A distinction must be made between simple and complex chronic diseases. Treated hypothyroidism (simple) and ischemic heart disease (complex) obviously do not have the same impact on QOL. Moreover, the influence of single-organ versus multi-organ diseases needs to be appropriately weighed. Additional factors to be considered when defining multimorbidity include the severity of the conditions and the presence or absence of associated pain.The use of self-reported diagnoses in many studies is another methodological limitation that may have introduced error. Patients may confuse symptoms and minor ailments with more significant disease states or may forget to report important diagnoses that are still active. Self-reporting may even be completely inaccurate in the presence of psychosomatic disorders. Conducting a chart review, clinical interview or using any specific standardized method may be a better way to obtain data related to diagnoses.Another methodological limitation of most of the studies evaluated was their failure to consider the influence of psychiatric comorbidity. This was either because psychiatric diagnoses were not included in the lists of disease states or because patients presenting with psychiatric diagnoses were excluded from QOL assessment. Given the importance of psychiatric conditions in primary care practice with a prevalence of more than 20% , this liQOL tends to decrease with age , whereasOnly a few of the studies evaluated had explored the effect of gender. Furthermore, their results were contradictory, with gender being more detrimental to the QOL of women in some cases ,58 and mLittle has been reported about the effects of other potential confounding variables , although these factors are recognized as having an impact on QOL -71. A feacute conditions, the time since the diagnosis of important chronic conditions, and the duration and prognosis of health problems are among factors that may explain some of the variability in QOL or HRQOL.Many other factors should be explored in this regard. For example, the presence of coexisting In light of the findings of this systematic review, further research is needed to clarify the relationship between multimorbidity and QOL. The early work will certainly be conceptual and theoretical. The resultant conceptual clarity would benefit both researchers and practitioners. How do we define and how should we measure multimorbidity are among the first questions to be addressed. More descriptive studies, which take into account the influence of multiple potential confounders, can then be conducted. Multivariate analyses will help control for the effects of these confounding variables. The effects of age and gender also need to be further explored, with reference to established norms. Although there is still a need for cross-sectional studies, longitudinal studies are also needed to identify changes in the relationship between multimorbidity and QOL over time.The main limitation of a systematic review is its inability to include all of the relevant literature. We realize that some articles may have been missed during the search stage. However, our review of a huge number of abstracts generated by different strategies improved the sensitivity of the search. Obviously, the absence of a keyword for multimorbidity is a limitation. However, we found that in the majority of cases in which the term "multimorbidity" was used to search, the term "comorbidity" also appeared in the list of keywords. Adding the term "chronic disease" also helped to circumvent the problem. Restricting the search to articles published in French or English is another limitation.This systematic review focused on the relationship between the presence of several chronic coexisting medical conditions and QOL or HRQOL in a primary care setting. However, the studies evaluated had important limitations due to the lack of a uniform definition for multimorbidity or comorbidity, the absence of assessment of disease severity, the use of self-reported diagnoses, and the frequent exclusion of psychiatric diagnoses. The potential impact of important confounding variables was also neglected. In light of these observations, it seems clear that further studies are needed to clarify the impact of multimorbidity on QOL or HRQOL and its various dimensions . A clear understanding of this relationship will ultimately help both researchers and primary health care professionals to deliver more comprehensive care.MF was responsible for the conception and design of this systematic review and was also involved in the literature review. In addition, he was responsible for critically assessing the evaluated articles and drafting this manuscript. He takes responsibility for the integrity of the work as a whole and provided final approval of this version of the manuscript.LL provided a major contribution to the literature review and critical appraisal of the identified articles. She also participated in the drafting of this manuscript and gave final approval of this version.CH participated in both the conception and design of this review. She also contributed by critically revising this manuscript and gave final approval of this version.AV participated in the design of this review. He also made an important contribution in critically revising the manuscript and gave final approval of this version.ALN participated in the drafting of the manuscript and made an important contribution by critically revising it. He also gave final approval of this version.DM participated in the drafting of the manuscript and made an important contribution by critically revising it. She also gave final approval of this version.


Coccidioidomycosis was first recognized as a serious disease over 100 years ago, but the disease remains an enigma and often goes undiagnosed, even in endemic areas It has been more than a century since coccidioidomycosis was first recognized as a serious disease, and its etiology and epidemiology have been well documented. But the disease remains an enigma to many, and it often goes undiagnosed, even in endemic areas. As management of this chronic disease remains problematic, new preventive or therapeutic options are needed.Coccidioides immitis and C. posadasii, generically referred to as the “Californian” and “non-Californian” species respectively Coccidioidomycosis is a fungal disease found only in the Western Hemisphere. It is caused by two nearly identical species, Mycelial phase—The growth form in the soil, composed of filamentous hyphae and reproductive spores called arthroconidia.Arthroconidia—Reproductive spores, highly resistant to dessication, which are the infectious particles inhaled by man and animals.Spherules—The parasitic phase of this dimorphic fungus; spherules are round cells of 30–100 µM or more that reproduce the progeny endospores.Endospores—The progeny units of the parasitic phase, derived from spherules.C. posadasii is thought to be the predominant species in Mexico Endemic regions for coccidioidomycosis have long been identified in semiarid areas in Mexico As the soil dries or nutrients become limiting, the fungus reproduces asexually by disarticulating the hyphae into small, environmentally-resistant arthroconidia (reproductive spores) . These aIt is estimated that upwards of 100,000 primary coccidioidal infections occur in humans each year in the endemic areas of the United States In their pioneering epidemiologic studies, Smith and colleagues found that about 60% of exposures to the fungus result in asymptomatic infection In regions where tuberculosis rates are high, the two diseases may occur together. Tuberculosis and coccidioidomycosis share common epidemiological, clinical, radiographic, and even histopathological features, making a correct diagnosis extremely difficult in cases where both diseases coexist. In areas where both diseases are endemic, the pertinent studies for diagnosing both conditions should be performed in every patient with compatible clinical features. The diagnosis of one of them does not exclude the possible existence of the other Historically, patients with the primary respiratory form of the disease were not treated because the vast majority recovered on their own. Instead, such patients were given supportive care and were monitored, often with radiographs, until the disease resolved. In recent years, however, an increasing number of physicians are prescribing azole antifungals in cases of primary disease, both because drugs like fluconazole have a good safety record, and because there is a perception that treatment may prevent progression to more serious forms of the disease. This latter presumption, however, is not supported by controlled trial data.All cases of chronic or disseminated disease call for antifungal therapy, but the choice of drugs, route, and duration of therapy is highly dependent on the form of the disease, the severity and site(s) of infection, and the immune status of the patient. Galgiani and colleagues have published clinical practice guidelines on the choice of drug and duration of therapy for a given form of the disease There are only two classes of antifungal therapy routinely used for treatment of coccidioidomycosis. The first class is the polyenes, with amphotericin B desoxycholate and the newer lipid formulations used for the more serious forms of disease. The second class is the azoles, with ketoconazole, fluconazole, itraconazole, and the newer analogue voriconazole as available options. Voriconazole, in particular, is being used more and more often in life-threatening mycoses, and was found to be better than amphotericin B in the primary therapy of invasive aspergillosis Treatment of the more serious or aggressive forms of the disease is typically of long duration and often results in less than complete resolution of disease; relapse is common In addition to drugs, surgery is sometimes indicated to remove focalized infections, such as pulmonary cavities, or to debride osseous forms of the disease Acquired resistance to coccidioidomycosis strongly correlates with the development of a delayed-type hypersensitivity skin test response to coccidioidal antigens Although all humans are equally susceptible to initial infection, there is evidence of genetic predisposition to dissemination, independent of socioeconomic or environmental factors, particularly among African-Americans and Filipinos In cases of marked immunosuppression, either in advanced AIDS or other forms of depressed cellular immunity, the management of coccidioidomycosis is particularly challenging and requires aggressive treatment www.valleyfever.com), has identified and cloned immunogenic proteins that have proven effective in the prevention of deaths and fungal burdens in mouse models of coccidioidomycosis. This suggests that a vaccine for use in humans could be created As previously mentioned, recovery from disease confers lifelong immunity to reinfection, and is a rationale for the development and implementation of a vaccine for the prevention of symptomatic or serious forms of the disease. The combination of increasing incidence of disease, a growing population in the endemic area, and the lack of a highly effective drug treatment justifies efforts to prevent (rather than treat) this disease. To that end, a university-based consortium, the Valley Fever Vaccine Project (Although the vast majority of infected individuals emerge from coccidioidomycosis without complications, an unlucky minority are faced with a debilitating disease that lacks adequate drug options for rapid and completely effective treatment. In the absence of newer therapeutics, discoveries that lead to immunologic intervention


Dafin Muresanu invitees:Andriy Huk (Ukraine);Johannes Vester (Germany);Nicole von Steinbüchel (Germany);Stefan Strilciuc (Romania);Razvan Chereches (Romania);Irina Vlad (Romania);Iulia Vadan (Romania);Constantin Radu (Romania).provided insightful and action-oriented analyses offering a glimpse of the future steps to be taken in the field of TBI.PRESENT , designed to bring more clarity to the flow of TBI patients and the data to be collected, as an example of a project developed in a middle-income country like Romania. Furthermore, Johannes Vester called upon condensing the essence of the new scientific research by bringing together all pieces of the puzzle for a deeper understanding of the complex setting of trauma, as well as of the complexity of therapy options at different points in time and different groups of patients, from mild to severe. Thus, a multidisciplinary approach such as the one embraced by AMN also means discussing health care issues.Prof. Dafin Muresanu used i.e.:The entire dialogue of the panelists and invitees was constructed upon the country data sheets presented by some specialists, the first one belonging to the Romanian representative, Felix Brehar. Important data regarding the present status of the Traumatic Brain Injury (TBI) care system were shared, starting with epidemiological references such as incidence, similarity with an average incidence in EU countries, and mortality rates. The etiology of TBI is split between traffic accidents (50.5%), falls (29.7%), aggression 17.7%), loss of consciousness (0.8%), and other unspecified conditions (1.3%). At the same time, the management of TBI, especially mild cases, follows a route that starts from the emergency unit, followed by a CT scan, the neurosurgical department, and followed by actions undertaken either by the neurologist or the family physician, with a 60 days follow-up after discharge at home. A similar route is present in the case of severe TBI, with admission into the Intensive Care Unit (ICU) after the Computerized Tomography (CT) is performed, and a rehabilitation program undertaken after the release from the neurosurgical department. Several weak points of the status of TBI care are also presented, such as the lack of CT scans in all small hospitals in the country, of biomarkers in TBI management  or implementing new programs;By 2023 – Accessing EU grants by submitting more project proposals dedicated to TBI basic and clinical research to the Horizon EU program;By 2024 – Setting up a TBI national registry employing a dedicated server information system that collects all the information regarding hospitalized patients using the diagnosis-relateg group (DRG) system;By 2025 – Setting up 3 rehabilitation centres part of county hospitals using EU funds and 3 rehabilitation centres part of country hospitals using national funds.etc.) to rule out negative CT scans becomes a necessity. Should an S100B analysis be negative, the patient could be discharged with oral and written information to be considered as per the minimal brain injury diagnosed.With respect to future directions in TBI research, special attention was given to the biomarkers approach. More precisely, as CT scans are used excessively in the emergency departments for mild TBIs, the use of S100B protein – blood biomarker screening test , most probably due to the pandemic. As a result, the incidence in the emergency ward and the severity of head injury changed accordingly. For example, there were only 7 cases of severe head injury in 2021, while the assessed mortality following a severe head injury decreased from 35% in 2001 to 25% in 2019 and further down to 23.50% in 2021.The second country sheet, based on data assessed from the central database of Hospital Fernandez in Argentina, was presented by Ignacio Previgliano. He used a timespan of 20 years to analyse his data, Ignacio Previgliano concluded that a possible explanation for the decrease of all the assessed parameters could be the improvement of care processes in the emergency room and intensive care unit (increased use of POCUS – point-of-care ultrasound to diagnose problems and RECUSS protocol – ultrasound guided resuscitation of the patient).Final information was provided regarding the coverage of the National Traumatic Database in Argentina, namely:1 hospital  in Buenos Aires city;22 hospitals in Buenos Aires state;4/5 public hospitals in different states.As a final remark, I. Previgliano added that ICU monitoring devices  are available in all city hospitals and this enhances major advances to be made in managing severe head trauma .etc.). Currently, the program of medical guarantees is declared the ex-territorial principle of delivery and rehabilitation so that everybody can receive this service anywhere. Volodymyr Golyk underlines that, during this period, there is a need for a pathway, with support from the Ministry of Health and international organizations, to help identify non-destroyed facilities that could be used as rehabilitation centres, but also to enhance capacity building with respect to staff, equipment, and overall system rebuilt.Moving on with the presentations, Prof. Dafin Muresanu invited the colleagues from Ukraine to offer their perspectives on the panel topic . VolodymIn addition to what his colleague stated, Andriy Huk points to the need for a good IT infrastructure to work with digitalised applications. Having previously tested the RES-Q  application, where an average of 15 minutes were necessary to work with the patient, Andriy Huk stated that the clear need-to-know data for TBI is an immediate necessity and, without the implementation of registries, the quality of health care could not be influenced in terms of improvements brought in.The problem of documenting official numbers in TBI is also present in Egypt, as the country is divided into high-income and low-income regions. Tarek Lotfy points to the lack of specialised centres for head injuries and treatment of TBI and the scarcity of intradepartmental connectivity and communication where these specialisations exist .As a public health specialist, Razvan Chereches highlights some conclusions from an analysis he undertook in 2019 regarding the number of published articles connected to TBI, namely that high-income countries have the highest number of articles published, with the highest impact . Given tPRESENT, a project of the AMN where the simplicity and brevity of the tool is key to gathering compliance from the physicians, but also RES-Q – a registry for quality of care in stroke that benefited from a lot of support from the industry. In other words, the solution is to come up with something simple but able to bridge the need for information and mirror the clinical process.With Prof. Dafin Muresanu asking what would be the best meeting point between the efforts of AMN and the actions of the governmental structure regarding the issue of registries, Stefan Strilciuc, governmental expert, indicated that, as Romania is shifting from a middle-income to a high-income country (income based on GDP), the level of care is close to that of a low-income country, which also impacts research to a great extent. Concerning national registries, the major problem would be the lack of capacity to implement projects at the central level, so, from his perspective, the solution would come from the academic field/professional societies. To support his statement, Stefan Strilciuc used PRESENT and RES-Q, with the latter being upgraded to close the loop with the rehabilitation part and the former offering a clear, simple, time-saving model for doctors and generating useful information.Prof. Dafin Muresanu emphasised the statements of Stefan Strilciuc, highlighting the good direction of Constantin Radu, also an expert currently training in public health and health economics, underlined the importance of mapping out the patient's pathways and identifying the best interventions, not only in terms of efficiency and safety, but also in terms of cost-effectiveness so that a set of interventions are put together, and offer the best outcome for the patient.Moreover, as PRESENT enables data collection from physicians in a timely and effective manner, it should become the rule for data gathering, optimizing patient pathways, and identifying the most cost-effective interventions.i.e., via means of artificial intelligence (AI), to gather data from existing databases of patients.Moreover, Iulia Vadan highlighted the accessibility of PRESENT to be used by patients and the rapidity in providing status information and tracking patients. Irina Vlad underlined that this registry was tailored to the needs of TBI and, as such, it covers the multidisciplinarity of TBI and the patient's pathway from the ER to discharge (the average time needed for completing the registry is 7.3 minutes). Shortly, it will also function as a tool for hospitals without an electronic database of patients, Considering all of the above, the entire development of the Congress, and in reference to the Neurotrauma Treatment Simulation Center (NTSC) – VIENNA upcoming event that would also provide hard evidence to contribute to a better understanding of the field problems related to TBI, Prof. Dafin Muresanu concluded that the Academy for Multidisciplinary Traumatology is a mature organization, with stable pillars and clear projects and task forces at work for developing future projects. Nicole von Steinbüchel added that the AMN has all the requisites and motivation to move forward, integrate younger people, and also work on ameliorating patient care.i.e., the patient) that counts and this way of thinking should be enhanced across academic borders.The president of AMN, Johannes Vester, closed the panel, the session, and the Congress with his statement that there is only ONE HUMAN BEING (


Mechanical industrial infrastructures in mining sites must be monitored regularly. Conveyor systems are mechanical systems that are commonly used for safe and efficient transportation of bulk goods in mines. Regular inspection of conveyor systems is a challenging task for mining enterprises, as conveyor systems’ lengths can reach tens of kilometers, where several thousand idlers need to be monitored. Considering the harsh environmental conditions that can affect human health, manual inspection of conveyor systems can be extremely difficult. Hence, the authors proposed an automatic robotics-based inspection for condition monitoring of belt conveyor idlers using infrared images, instead of vibrations and acoustic signals that are commonly used for condition monitoring applications. The first step in the whole process is to segment the overheated idlers from the complex background. However, classical image segmentation techniques do not always deliver accurate results in the detection of target in infrared images with complex backgrounds. For improving the quality of captured infrared images, preprocessing stages are introduced. Afterward, an anomaly detection method based on an outlier detection technique is applied to the preprocessed image for the segmentation of hotspots. Due to the presence of different thermal sources in mining sites that can be captured and wrongly identified as overheated idlers, in this research, we address the overheated idler detection process as an image binary classification task. For this reason, a Convolutional Neural Network (CNN) was used for the binary classification of the segmented thermal images. The accuracy of the proposed condition monitoring technique was compared with our previous research. The metrics for the previous methodology reach a precision of 0.4590 and an F1 score of 0.6292. The metrics for the proposed method reach a precision of 0.9740 and an F1 score of 0.9782. The proposed classification method considerably improved our previous results in terms of the true identification of overheated idlers in the presence of complex backgrounds. The automation and robotization of condition monitoring (CM) processes in the mining sector are inevitable steps for increasing the industrial equipment life cycle and improving the safety of operations. Modern automation methods provide solutions to reduce or totally exclude the presence of humans in hazardous environments. Using mobile robots for CM applications can improve the inspection process, as they apply more sophisticated techniques for identification and localization of faults in industrial infrastructures located in mining sites ,3,4,5,6.Conveyor systems have been developed throughout the past decades and used as the most common method for transporting raw materials in mining sites. The idlers are responsible for supporting the loaded bulk materials’ weights that are carried by the belt ,8. FaultThe minimum L10 life requirement (the amount of time in which 10% of the bearings will fail) or, in other words, the lifetime of idler bearing in normal environmental conditions, should be 50,000 h or 5–7 years. However, this time can considerably decrease due to environmental conditions and belt speed ,12.Harsh environmental conditions in mining sites can considerably reduce the life span of the conveyor system idlers. Dust, high temperature, and sunlight can be considered as environmental factors that can affect the life span of idlers. The idler sealings are usually poor; therefore, the accumulation of dust in conveyor systems can increase the rotation resistance of the conveyor idlers. Similarly, high ambient temperatures and sun reflection in hot, dry climates can increase the bearing temperature, which reduces the bearing life span . The idlDifferent fault signatures in rotating machinery can be caused by misalignment, and bearing damage and mass imbalance are recognizable by IRT methods ,19,20,21Two different methods can be used to measure the thermal condition of idlers. In quantitative methods, we need to determine the exact temperature of the idler surfaces. On the other hand, in the qualitative methods, the acquired thermal signatures are analyzed to find the characteristic patterns based on relative temperatures of equipment in a captured scene. In our study, we chose to identify the overheated idlers base on qualitative methods; therefore, the relative temperature values of detected hotspots in IR images were analyzed with respect to other areas ,26,27,28Modern IR image analysis software has the capability to prepare an inspection report. However, despite its ease of use and functionality, the manual evaluation of data is time-consuming for inspectors . FurtherOver-centralized distribution of pixels and their low-intensity contrast are the main features of the IR images that bring difficulties in correct identification of temperature anomalies within the region of interest (ROI). The classical threshold-based segmentation techniques can accurately segment the ROI areas in images that are captured in visual light. However, due to the nature of IR images, the accuracy of final results can be affected by over- and undersegmentation ,31,32. F1.A novel method based on binary classification with CNN was developed for classification of overheated idlers in segmented frames.2.We showed that our proposed CM method can accurately classify the overheated idlers, even in IR images with complex backgrounds.3.Our novel CM method based on the deep learning approach was compared against an IRT method that was specifically developed for identification of the overheated idlers in IR images.In this paper, we developed solutions for improving the proposed CM method in our previous study . TherefoIn this section, we firstly focus on the importance of application of robotic-based IRT for the reliability of conveyor systems in mining environments. The length of a conveyor belt in mining sites can reach several kilometers, while hundreds of idlers that support the belt, and the loads need to be monitored by technicians ,35. The Autonomous or semi-autonomous robotics IRT are categorized as a non-destructive CM method that can be used as a proper solution for automatic detection of faulty idlers in conveyor systems. In IRT-based techniques, the emitted IR radiation from objects’ surfaces is analyzed for identification of temperature anomalies .IRT methods are used in a wide range of fields, including medical imaging, non-destructive testing, defect detection in civil structures, and so on . HoweverMost of the proposed automated diagnostic system for analyzing IR images of industrial infrastructures consist of three steps: estimation of ROI, extraction of relevant features and, finally, classification of extracted features ,47,48. TIn ,20,24,49For the detection of the idlers from their background, different methods based on deep learning are proposed. For instance, a CM method based on object detection, Hough line transform, and template matching algorithms are proposed by . HoweverThe weaknesses of the related works are grouped into three categories: the first category focuses only on the detection of hotspots; the second category uses stationary camera systems for CM of equipment; and the third category handles deep learning techniques but does not propose methods for classification of other thermal sources that can be wrongly identified as thermal defects. Information is presented in more detail in The main idea of the methodology is described in In some frames, due to the existence of different thermal sources that are not related, the segmentation algorithm cannot always precisely exclude hotspots (overheated idlers) due to oversegmentation. For improving the oversegmentation issue, we choose to preprocess the ROIs using different preprocessing techniques. In this study, intensity normalization, Contrast Limited Adaptive Histogram Equalization (CLAHE), and the Fast Non-Local Means Algorithm (FNLM) were used.For segmenting overheated idlers in preprocessed frames, an outlier detection method based on the interquartile range (IQR) technique was used to calculate the optimal threshold value in each frame.Based on the visual analysis of the segmented frames, we noticed that in some frames other thermal sources including sun reflection or other overheated equipment were wrongly segmented and recognized as overheated idlers. This can reduce the accuracy of the CM method. For the identification of hotspots in segmented frames, we proposed a classification method based on binary classification technique using a CNN. The different stages of the proposed methodology were developed in the Python programming language using OpenCV library for image processing and did not have major changes. Furthermore, the Keras and TensorFlow libraries were used for developing the proposed image classifier.Through the conducted experiments, the inspection mobile robot moved alongside the conveyor systems and captured different data, including IR and RGB videos. The mobile robot camera system was installed on a fixed hand above the robot and pointed toward the conveyor system. The mobile robot followed a straight line with constant speed; therefore, we did not have major changes in the camera system POV toward the conveyor system. The captured RGB and IR videos from the conveyor systems contain information on target pixels that are related to idlers and redundant areas. For improving the segmentation accuracy, we excluded the non-ROI areas from the original captured frames.Through analyzing the extracted frames, we understand that idlers that are located on the right side of the conveyor (from mobile robot POV) were not always visible for being analyzed in extracted IR and RGB frames; therefore, for improving idler detection, we chose to define ROI on extracted frames for capturing idlers that were on the left side of the conveyors.By observing neglectable changes in the camera system POV through the sequence of extracted frames, we could accurately predict the location of idlers. Different detection algorithms can be used for following the idlers in the sequence of the frame. In our work, we chose to consider a rectangular ROI with predetermined size: 200 × 200 pixels with a fixed position to extract ROIs from captured IR and RGB frames. The size of the extracted ROIs covers the idler sections, while it is considerably smaller than the originally captured frames The captured IR images are characterized by noise due to illumination and contrast variation; therefore, the use of automatic segmentation methods for detection of overheated idlers can become a challenging task. To address this issue, in this paper, intensity normalization, CLAHE, and FNLM were used for improving the overall quality of extracted IR images.The intensity value of each pixel in an original frame is predefined by the IR camera, considering the hottest and coldest point within the frame borders. For defining statistical parameters that work well for analyzing ROIs, we need to recalculate the pixels’ values with respect to the pixel distribution in defined ROIs. Normalization of the ROIs can reduce the seasonal differences and lets us define statistical parameters that work in ROIs with varying temperature ranges. The normalization was performed using the following equation:i, where i. Furthermore, the maximum and minimum values of pixel intensities within the ROIs are defined as In Equation , Ni can Histogram equalization (HE) is an elementary method to improve the contrast of underexposed and overexposed images. However, in the HE method, changes in natural brightness of the processed images can cause undesirable noise in the results . Adaptivp represents the assigned value to each pixel after applying CLAHE.In Equation , the maxThe Non-Local Means Denoising Algorithm (NLM) is an effective method for reducing the unwanted noise in images Z(m):In Equation , the weiThe calculation of s is defined as In Equation , τ is deBy simplifying the process through one-dimensional computations, the FNLM method can denoise the image four times faster than the NLM method ,58,59,60Image segmentation is a process of dividing images into regions that may be meaningful for extracting the desirable objects or constituent areas. Thresholding techniques are considered as the simplest way of performing image segmentation in IR images. Generally, in IR images, regions with high temperatures are correlated to the foreground; therefore, pixels with high intensity represent the heated objects. In the proposed method, the optimal threshold value for captured IR images can be defined based on analyzing the statistical features that are extracted from the IR images’ histogram.An IR image histogram describes the tonal or color distribution of pixels. The tonal distribution of pixels in grayscaled IR images refers to discrete temperature values; therefore, the analysis of IR images’ histogram from a statistical point of view is a useful approach for detecting temperature anomalies in monitored equipment. Different statistical features such as: mean value, variance, and standard deviation can be extracted to describe the pixel tonal distribution in IR images. For a gray-leveled IR image, the first-order histogram probability  follows :(8)P(g)=g, where the total number of pixels in a processed image is defined by M. In gray-scaled IR images, the total number of available levels for the pixel L span into In Equation , L(g) isFurthermore, the dispersion of a set of data points around their mean can be defined by variance value as follows:The standard deviation or the square root of the variance indicates the image contrast. It can be considered as an important factor for identifying the thermal anomaly, as analyzing temperature distribution in IR images is a key index of detection of possible defects.IQR) can be used to extract histogram features that can help us to define the outliers.In this work, a qualitative-based method is proposed for identification of hotspots in preprocessed frames. In IR images with uniform background, the defected idlers can be recognized as hotspots. For separation of the hotspots from the background, thermal anomalies in idlers’ surfaces are treated as outliers. Outlier detection can be described as a problem of finding data that cannot be defined in the range of normal behavior. The interquartile range The outliers can be extracted and classified in two different groups, namely: mild and extreme outliers. The lower and upper bounds can be calculated as r bounds ,65.T in each frame, while W and H can be considered as the processed ROI height and width, while x and y represent the pixel coordination.The optimal thresholder value can be defined as To separate the hotspots from background in The pixels that are related to overheated idlers cannot always be defined as mild outliers. Furthermore, the definition of overheated idlers based on mild outliers can cause oversegmentation. For addressing the oversegmentation issue, we choose to extract extreme outlier values in extracted IR frames and consider them as the optimal threshold values for segmentation of possible hotspots, as shown in During the visual inspection of the results, we found out that the proposed segmentation method could accurately segment the overheated idlers from the background in the majority of extracted frames. However, due to overestimation in some frames, other thermal sources were wrongly segmented as overheated idlers.The objective of this section is to propose a method to accurately classify the segmentation results in two different classes considering the differences between hotpot shapes in segmented frames. The first class consists of frames where the segmentation method could accurately separate overheated idlers from the background, while the other class consists of hotspots that were not related to idlers.A CNN is an ANN  with different numbers of intermediate layers. The CNN models are able to automatically detect the specific features on each image and then train a classifier model on them ,67. CNNsDeep learning models that use CNN architecture are suitable for image processing classification problems. In CNNs, different layers in a network work as a detection filter for the recognition of specific patterns or features. The first layer of a CNN model can detect major features in an image that can be easily interpreted, while in middle layers, more abstract features can be detected. Finally, in the last layer, the collected details from previous layers are accurately merged and classified .Through the experiments, two conveyor systems that were located in an opencast mining site were inspected. The inspected conveyor systems were used for the continuous transportation of mineral materials from the mine pit to the bunker. The length of the investigated conveyor systems reached one hundred meters and is designed to operate in harsh environmental conditions. The opencast mining site in this study is located in Jaroszów, 50 km to the west of Wrocław. The length of the inspected parts of the conveyor systems were 150 m, where there was a 1.45 m space between each idler. Furthermore, the idlers’ diameter was 1.33 m and the belt length was 0.8 m.A mobile inspection robot was used for data accusation The precision of an IRT method is directly related to environmental parameters and the IR camera specifications In opencast mining sites, solar radiation can warm up the conveyor system surfaces, especially modules that can absorb the considerable amount of sun energy. Our experiment was conducted on a sunny day. As long as we organized the measurement session a few weeks before the experiment, it was almost impossible to predict the weather. However, in the proposed method, we tried to provide a solution that can be applicable in different environmental conditions. Furthermore, in our case, the solar radiation was mostly blocked by ceiling; therefore, their affect on the idler surface temperature was negligible.Examples presented here show the application of IRT in industrial data sets is always challenging. As a result, the classical image segmentation techniques cannot provide accurate detection results due to instances of different thermal sources in mining areas, as shown in In this work, we developed a binary classification model for classification of the segmented hotspots to identify frames where overheated idlers are correctly segmented The proposed classification model includes three blocks, where each block is composed of a convolution layer with a 3 × 3 filter, followed by a maximum grouping layer. The ReLU activation function was used in each conventional layer. The depths of our architecture for the three blocks are 32, 32, and 64 respectively. A value of zero (0) or one (1) should be predicted for each input image, as we used a binary classification. The sigmoid type of activation was used to regularize the deep neural network at the final output layer. Regularization simulates the different possible changes on the structure of the network and increases the strength of the nodes in the developed network. Finally, for compiling the data, the binary cross-entropy method was used as a loss function, and the Adam method was used as the optimizer to form a classifier on the image data sets Three different data sets, which consist of segmented IR images captured from two different conveyor systems, were used for training the CNN model. Through the experiments, the inspection robot moved alongside conveyor system number one (back and forth) and conveyor system number two (forth). As a result, three different data sets, 6275 frames from conveyor one (moving forward), 6135 frames from conveyor 2 (moving backward), and 10896 frames from conveyor two (moving forward), were selected and underwent preprocessing stages and segmentation. Afterward, the segmented frames were filtered based on the size of the segmented hotspots; therefore, in each segmented frame, the number of non-black pixels was calculated, and frames that the number of non-black pixels was above 400 pixels were kept for further analysis.The classifier was trained using images labeled by experts. We labeled each segmented image as “contained an overheated idler” or “other thermal sources”, as shown in For evaluation of the proposed classifier, we computed the following performance metrics: sensitivity, precision, accuracy, and F1-score.TP (true positive), TN (true negative), FP , and FN  factors for scoring the model. The ideal value of these metrics is 1 and is the target for the models in this study.Here, accuracy is the proportion of correctly classified overheated idlers among the whole population. Sensitivity is measured as the proportion of true positive cases that are correctly predicted by the classifier, while specificity is the prediction of true negative cases that are correctly predicted. Precision is the proportion of the correct predictions in the confusion matrix out of all positive predictions. Furthermore, the F1-score is the harmonic mean of precision and sensitivity. The coefficient takes into account the In this section, we evaluate the performance of the proposed method in the detection of overheated idlers. Furthermore, the performance of the proposed method is compared with our previous research using test data randomly chosen from 20% of the whole data set .The confusion matrix is used to display the results of classifications and generate all of the performance metrics. Our binary classification model could accurately classify the segmentation results in over 97% of studied cases, as shown in The training and validation loss graph of the trained model is shown in The training and validation accuracy curves are shown in The receiver operating characteristic curve (ROC) for a binary classification model is shown in In this paper, we solve the problems related to the identification of overheated idlers in IR images with complex backgrounds. We demonstrate that the identification of overheated idlers in IR images captured in real case scenarios is a challenging task. For the proposed methodology, the following points were covered: Firstly, in The value of the accuracy metrics in Future work assumes the improvement of the CM method in terms of adaptability to different conveyor systems that are located in different mining sites. Furthermore, our team is interested in working on methods that can be used for the detection and localization of overheated idlers in global navigation satellite system denied environments, such as deep underground mines, by fusion of LIDAR and IR images captured by an inspection mobile robot.