Background: Biocuration involves a variety of teams and individuals across the globe. However, they may not self-identify as biocurators, as they may be unaware of biocuration as a career path or because biocuration is only part of their role. The lack of a clear, up-to-date profile of biocuration creates challenges for organisations like ELIXIR, the ISB and GOBLET to systematically support biocurators and for biocurators themselves to develop their own careers. Therefore, the ELIXIR Training Platform launched an Implementation Study in order to i) identify communities of biocurators, ii) map the type of curation work being done, iii) assess biocuration training, and iv) draw a picture of biocuration career development.Methods: To achieve the goals of the study, we carried out a global survey on the nature of biocuration work, the tools and resources that are used, training that has been received and additional training needs. To examine these topics in more detail we ran workshop-based discussions at ISB Biocuration Conference 2019 and the ELIXIR All Hands Meeting 2019. We also had guided conversations with selected people from the EMBL-European Bioinformatics Institute.Results: The study illustrates that biocurators have diverse job titles, are highly skilled, perform a variety of activities and use a wide range of tools and resources. The study emphasises the need for training in programming and coding skills, but also highlights the difficulties curators face in terms of career development and community building.Conclusion: Biocurators themselves, as well as organisations like ELIXIR, GOBLET and ISB must work together towards structural change to overcome these difficulties. In this article we discuss recommendations to ensure that biocuration as a role is visible and valued, thereby helping biocurators to proceed with their career. Often, these biological databases are annotated by biocurators whose work, in a simplified explanation, is to i) collect scientific data, ii) verify and validate the information collected, iii) add value by structuring it in a logical, consistent and relevant manner and iv) integrate it into databases. Bourne and McEntyre4, in their homage to the profession, considered biocurators as the “museum cataloguers of the Internet age”. We believe biocurators are more than this, they are integral to the modern life sciences and pivotal to good data management. They are the guardians of the integrity and FAIRness of life sciences data.Together with bioinformatics, curated databases have become an essential part of modern molecular biology. Databases such as Ensembl5; it places data into context, makes it more interoperable, adding unique identifiers, licences, and structured descriptions alongside other appropriate metadata. In this respect, biocuration shares some aspects of data stewardship, but there are also some differences. Data stewardship involves improving the FAIRness of a dataset, but doesn’t include adding value to the data, via curation and integration. In many ways, biocuration begins where data stewardship finishes, with data stewards helping researchers to prepare their data for biocurators to add value through integration into appropriate databases.The art and science of biocuration helps make data Findable, Accessible, Interoperable and Reusable (FAIR)https://elixir-europe.org) is an inter-governmental organisation that brings together bioinformatics resources across Europe and helps researchers to find, analyse, and exchange life science data. In 2016, the ELIXIR Data Platform put in place a process to identify European data resources that are of fundamental importance to research in the life sciences6. Many of these resources are manually curated and ELIXIR recognises the substantial added value that this brings to these resources. Manual biocuration is a highly valued task, and the biocuration efforts of a resource are an important indicator of its quality.The European life sciences infrastructure for biological information  counts over 250 members working in over 82 institutions around the globe. The 27th annual Nucleic Acids Research database issue and molecular biology database collection lists 1613 databases, including 59 new databases7. Biocurators not only work in well-known databases but also inad-hoc, often behind the scenes projects where biocuration is needed, be they in academia, non-governmental organisations or private companies. A large, diverse body of individuals and teams are involved in biocuration across ELIXIR. It is anticipated that a number of these may not identify themselves as biocuratorsper se – this could be due to them being unaware of this as a position or career path, or that biocuration is not the main aspect of their job. In this article, we use a broad definition of ‘biocurator’ to encompass anyone who carries out biocuration tasks as part of their work regardless of whether it is the primary focus of their role. The International Society for Biocuration . A large number of biocurators work within the ELIXIR Nodes, and the ELIXIR TrP requires a clear picture of who they are, their profiles, what resources they work on, the tools that they use and, in particular, their training needs. The last survey of biocurators was conducted several years ago in 2011, and in an international context where ELIXIR and the Global Organization for Bioinformatics Learning, Education and Training  did not yet exist. An up-to-date profile of the landscape of biocuration would allow these organisations and employers to take action to recognise and value biocuration, and to plan future training. The ELIXIR Training Platform (TrP), one of the five infrastructure pillars of ELIXIR, aims to strengthen national bioinformatics programmes, grow bioinformatics capacity and competences across ELIXIR member states and empower researchers to use ELIXIR’s services and tools (In this research article we describe the outcomes of an ELIXIR Biocuration Implementation Study that aims to i) identify communities of biocurators within ELIXIR and worldwide, ii) review and map the kind of biocuration work being done, for which databases and life science/health domains, iii) assess the capacity requirements for new biocurators and training provision available, and iv) draw a picture of the biocuration career development. We outline a set of recommendations to ensure that the biocuration career path can be even more valued. We urge the community to ensure that the knowledge and skills offered by existing biocurators are shared across ELIXIR Nodes and beyond, and to develop training so it is available to those areas and disciplines where biocurators needs are in highest demand.Extended data: Pilot survey questions8) about the nature of the respondents’ work , the tools and resources used in their day-to-day work, training that the respondents have received, and additional training needs. It was sent to all campus staff as we had the specific aim of capturing individuals who may not identify as biocurators but who carry out biocuration-related tasks as a part of their role. The pilot survey was open between 12 December 2018 and 18 January 2019 with reminders sent ten days and one day before the final deadline.In order to map the landscape of biocuration, we first ran a pilot survey with staff at the Wellcome Genome Campus, near Cambridge, UK. The pilot was used to test the survey questions with a smaller audience so that they could be fine-tuned to enable us to undertake the required analysis. This pilot included questions (seeExtended data: Questions to guide conversations with biocurators8) with answers captured and transcribed directly, rather than recording and transcribing later.Additionally, we met with four EMBL-European Bioinformatics Institute (EMBL-EBI) biocurators who had replied to the pilot survey to discuss their responses in more detail. The conversations were carried out in person by Alexandra Holinski and Melissa Burke at EMBL-EBI and took the form of a guided conversation  was a revised version of the pilot. Revisions were made where questions led to overly general and broad answers and to introduce relevant topics raised in the conversations. This survey was disseminated globally by making use of Wellcome Genome Campus, ELIXIR, International Society for Computational Biology (ISCB), ISB, the SIB Swiss Institute of Bioinformatics and GOBLET mailing lists. It was also publicised via Twitter and LinkedIn with reminders and retweets sent at regular intervals. To reach biocurators in industry, the survey was promoted at the EMBL-EBI Industry Programme quarterly meeting and was disseminated through their mailing list. This global survey was open between 4 March 2019 and 1 May 2019. Both the pilot and global survey were conducted online using SurveyMonkey (https://www.surveymonkey.co.uk).The final survey  How did you get into the field? Have you left? What do you do now? ii) How long did it take you to feel “fully” trained as a biocurator? iii) What skill/piece of knowledge was the most difficult to learn when becoming a biocurator? iv) How would you encourage others into the field of biocuration? v) How can we engage with others whose role is partially biocuration; or those sitting outside of traditional academic/research centres? vi) What career support would you like to see for those in biocuration; where would you like your skills to take you?The second workshop was conducted on 19 June 2019 at the ELIXIR All Hands Meeting in Lisbon, Portugal. Twenty-one people attended the workshop in which we presented the full results of the survey. The participants were asked to comment on the following questions: i) How can ELIXIR support biocurators? ii) What are your experiences with/thoughts on community biocuration? iii) Anything else you would like to tell us?https://www.wordclouds.com/). It is worth noting that the outcomes of the pilot survey do not differ greatly from the results of the global survey.In our analysis, we focus on the outcomes of the global survey, the conversations with EMBL-EBI biocurators and the two workshops. Analysis of all data was performed by A.H. and M.B. Where free text answers were provided in the global survey, themes across the answer sets were initially independently identified and categorised by A.H. and M.B. These individual sets were then combined to form the final answer sets provided below. For example, for the question ‘Please provide a short description of your current work.’ the answers were sorted into categories based on the tasks mentioned. A.H and M.B took a similar approach for analysing the guided conversations. Themes across the answers were independently identified and categorised and the individual sets were combined. For the word clouds, responses that make no sense were removed from the word lists, e.g. fff or wsx. The responses were edited for case, e.g. Bionformatician vs. bioinformatician, to ensure that each term is only displayed once in the word cloud. Word clouds were created with WordClouds.com  which were not to be used as part of the reporting set. Given the nature of our study, we therefore deemed it unnecessary to undergo formal ethical review via an ethics committee. For participants, all details relating to the involvement in the study, including how the information they provided would be used and where results would be reported, was provided in both an invitation email and at the start of the survey. Participant consent was presumed based on their completion of the survey.This study was conducted in accordance with GDPR. Directly identifiable data  was not collected from all respondents as this was an optional element of the survey. The nature of a number of the responses provided does however mean that it may be possible to identify individuals in specific positions due to their unique job titles and affiliated institutions. Given this potential for identification we are not providing raw data outputs from the survey and transcripts from the guided conversations.The global survey received 212 responses with most from Europe and the USA .Underlying data: Global_survey_deidentified8). Among the named academic institutes, 25% of respondents belong to international biocuration hubs, including EMBL-EBI, the Wellcome Sanger Institute and SIB. In free text answers, respondents indicated that they work across a wide range of life science domains, with the most commonly mentioned being bioinformatics, genomics, genetics, biology and biochemistry . In addition, many respondents indicated in free text that they also take part in database, pipeline and method development, web-interface design, help-desk and user requests, teaching, outreach, team management, grant writing, and ontology development . This variety of tasks makes it difficult to define a clear biocuration profile.The survey shows that biocurators perform a diverse range of activities and that biocuration tasks are undertaken in a variety of roles. From a list of biocuration activities, the tasks most often selected in the survey were data annotation (69 of 166 respondents - 42%), ontology and controlled vocabulary application (62 of 166 respondents - 37%), data analysis (48 of 166 respondents - 29%), and literature curation (47 of 166 respondents - 28%) (seeUnderlying data: Tools and resources8) as being used in biocuration activities. These resources can be broadly clustered into public databases and tools, literature search tools, ontology services, scripting languages and in-house biocuration tools; many of them are specific to the biocurators’ roles and particular life science domains in which they work. Biocurators that we spoke to and workshop participants emphasised that this makes common biocuration pipelines difficult to identify and implement, and complicates efficient knowledge exchange and community building amongst biocurators.Participant responses to the survey, our conversations with biocurators and the workshops also make it clear that the precise nature of biocuration methods employed depends on the area in which they work. This is reflected in the 400 different tools listed in the survey . Training was mainly received in the form of one-to-one teaching and self-directed training, or via face-to-face courses  respondents said that they have received training in biocuration, while the rest said that they have not received any training (seecourses . RespondUnderlying data: Biocuration training course list8), which may be relevant to biocurators. This course collection is not exhaustive and may again reflect the nature of the informal 1:1 and in-house training many respondents said they had received.From the responses provided, we collated a list of face-to-face and online training courses, materials and providers . Survey respondents and biocurators that we spoke to highlighted that computational skills, such as programming/scripting/coding and extracting relevant data from the literature, are decisive for a successful career development yet are the most difficult to learn. Other skills that were highlighted as being essential for a successful biocuration career include biological knowledge (mentioned in 41 of 124 responses - 33%), attention to detail (mentioned in 23 of 124 responses - 19%), patience (mentioned in 11 of 124 - 9%), communication (mentioned in 8 of 124 responses - 6%) and curiosity (mentioned in 8 of 124 responses - 6%) . These views were reiterated and emphasised by biocurators that we spoke to individually and at the workshops.In the survey, from free-text answers, the most commonly indicated training needs are programming/scripting/coding (mentioned in 18 of 134 responses - 13%), development and use of ontologies (mentioned in 16 of 134 responses - 12%), and database management (mentioned in 10 of 134 responses - 7%)  communities. Nevertheless, we believe that the results are a fair representation of the varied views and experiences of biocurators worldwide. Our study highlights the diversity of roles and experience within the biocuration community but also reinforces the need for improved recognition of this work and career.13, this highlights that biocurators possess many transferable skills in addition to their scientific and biocuration expertise, characteristics that are highly valued by employers. Our survey shows that biocurators in different resources work quite differently, using different tools and following different workflows and pipelines. There are some efforts to encourage biocurators in different resources to streamline their work by following the same biocuration workflows14. Steps have been taken to encourage this streamlining through the addition of biocuration-related databases, curation tools and standard metadata records to FAIRsharing11 (an ELIXIR Recommended Interoperability Resource and the ELIXIR Registry of Standards). However, it is clear from our survey that the diversity of biocuration practices and the data curated mean that a universal biocuration tool or workflow are still some time away.The day-to-day activities of biocurators are amazingly diverse and include both biocuration and non-biocuration tasks such as training, outreach, website design and project management. As noted by Samili and Vita15. Similarly, in response to a 2017 survey of biocuration training needs conducted during the development of the Postgraduate certificate in Biocuration at the University of Cambridge, 32% of respondents rated ‘Application of programming to curation tasks - e.g. scripting in Python as their top training need . From our discussions, it became clear to us that it is essential for biocurators to learn coding skills, not only to be able to wrangle data and perform tasks more efficiently but to facilitate discussion with database developers and gain a greater understanding of how the data they curate is represented in a database.Having said that, some commonalities in the experience of biocurators can be found. For instance, the clear need for more training on programmatic or coding skills, such as Python, and data modelling skills such as the creation, maintenance and use of ontologies. This is in line with a 2011 survey of biocurators carried out by the ISB in which 55% of respondents thought that better training in computer languages would be beneficial for their jobs, and 43% indicated that they would benefit from better training in bioinformaticsIn our survey, 28% of respondents indicated that they had received biocuration training and some training courses were specifically named by respondents. It is possible that this relatively low figure is due to the way in which respondents interpreted the question. For example, respondents might not necessarily equate “training in a programming language”, “1:1 training” or “self-directed training” as “biocuration training”. However, a low level of formal training was also reported in response to the survey of biocuration training needs conducted during the development of the Postgraduate certificate in Biocuration at the University of Cambridge. In that survey, 12% of respondents had received training in the form of formal short courses while 88% had received informal 1:1 training in work . The specific nature of biocuration tasks observed in our survey calls for a shift in the way that we teach biocuration skills. There is a need to develop bioinformatics training that is targeted to biocurators (e.g. programming skills for biocuration related tasks vs programming for research related tasks). Ensuring that all biocurators are up to speed with the latest biocuration and data stewardship best practices should increase the standard and consistency of biocuration while providing transferable skills that improve career mobility.https://tess.elixir-europe.org/)12, and by adopting FAIR principles to ensure that they are appropriately tagged and described16. This would allow democratisation of training efforts such that they expand out from centres of excellence (such as the EMBL-EBI or SIB) to independent biocurators. Some training events and materials listed in the survey have already been indexed in TeSS12, which will allow the identification of gaps in training provision.The lower reported level of formal training suggests that a potential challenge for biocurators is in being able to find available and/or appropriate training courses. An absence of training courses will also affect community building, with fewer opportunities for biocurators to meet, network and share expertise. To facilitate expanded training for biocurators, training providers should make their courses and training materials easier to find, for example by sharing them in portals such as ELIXIR’s TeSS , alongside a lack of recognition of the skills and the role of biocurators both by those performing biocuration activities and in the wider scientific community.Our study also highlights the need for improved career support. This sentiment seems to have changed little from the 2011 ISB survey, in which 82% of respondents felt concerned about future work opportunities17.Biocurators that participated in the workshop discussions indicated that one way to address these challenges is to establish stronger links between academia and industry to create a wider and more diverse biocuration community, facilitate knowledge exchange and enable career planning. Another way biocurators can be helped is through appropriate credit, both in terms of citation of the resources they maintain and personal credit through nanopublications, annotation credits and other attributions displayed and linked via their OrCID19 and Data Stewards20. In these settings, centralised teams of research software engineers or data stewards have been created, and this has led to improved knowledge exchange, peer support and career sustainability20. For example, within a University environment, a pool of dedicated biocurators could be created, ready to be deployed where need and experience allows, and supported with local funding, so the biocurators themselves have job security.Ultimately, we perhaps need a new model of careers in biocuration , such as those being developed for Research Software EngineersWe urge funding agencies to recognise the importance of biocuration and to fund both databases and biocuration training activities appropriately. In addition, we recommend that both academia and industry provide clearer career structures for scientists whom biocuration is their primary activity, given their role and impact will only grow. We call on everyone, from the ISB, ELIXIR, academia, industry, and biocurators themselves, to work together to create a more integrated global community of biocurators, to share expertise, training initiatives and best practices.Biocuration activities have a vital role in the life science data ecosystem, but are often undervalued. These skills, both innate and taught, are highly prized and fundamental not only to the preservation and FAIRness of life science data but are also transferable to other data science and knowledge management roles. The issue we face is one of education. Sometimes scientists performing biocuration activities do not realise the value and rarity of their skills and in many cases researchers and managers do not realise or appreciate the work that biocurators perform. To future-proof this career and the valuable work that biocurators do, organisations, employers and biocurators themselves must act as champions for biocuration and advocate for structural changes. We believe organisations like ELIXIR, ISB and GOBLET have the mandate to actively support the biocurators in their scientific endeavours, work towards raising awareness about the impact that biocuration has within different scientific communities and to convince team leaders of the importance and value of skilled biocuration work. Organisations can also act to facilitate, encourage and support knowledge exchange between biocuration communities. Biocurators themselves have a role to play in championing the work that they do, engaging with the researchers who rely on their expertise and in training the future generation of biocurators. By doing this, organisations and individuals can contribute to the creation of a sustainable and visible biocuration community. We hope the work we have presented here continues this educative process as we continue to define the profession of biocuration.The nature of a number of the responses provided means that it may be possible to identify individuals in specific positions due to their unique job titles and affiliated institutions. Given this potential for identification we are not providing raw data outputs from the survey. Instead we provide the de-identified data on Zenodo from the global survey.The nature of the responses provided in the guided conversations and the fact that all four participants are staff of EMBL-EBI mean that it may be possible to identify the individuals. Given this potential for identification, we do not provide the transcripts but a themed summary of the responses. Information that may lead to the identification of individuals has been redacted.https://doi.org/10.7490/f1000research.1116798.19 andhttps://doi.org/10.7490/f1000research.1117413.110.Data relating to the workshops can be found in the slide sets from these workshops:http://doi.org/10.5281/zenodo.39917378.Zenodo: Biocuration - mapping resources and needs - Underlying data,This project contains the following underlying data:Global_survey_deidentified.xlsx ○ This file includes de-identified responses to the survey questions. Responses that may lead to the identification of respondents have been redacted. Free text responses to questions 6, 14 and 15 have been categorised into tasks, topics and skills, respectively. Bar graphs of global survey.xlsx Tools and resources.xlsx Biocuration training course list.xlsx Themed summary of the responses given in the guided conversations - deidentified.docxUnderlying data,http://doi.org/10.5281/zenodo.39917378.Zenodo: Biocuration - mapping resources and needs -This project contains the following underlying data:Pilot survey questions.docx (questionnaire sent to staff of Wellcome Genome Campus)Questions to guide conversations with biocurators.docx (conversation guide outlines the type of questions to be asked)Global survey questions.docx Creative Commons Attribution 4.0 International (CC-BY 4.0).Data are available under the terms of the The revised version of the article is more comprehensive and useful to clarify the rationale behind the study.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?PartlyIs the study design appropriate and is the work technically sound?PartlyAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Biocuration, Molecular and Causal interactions, Community Standard FormatsI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This work presents the result of an implementation study on biocuration needs. The article describes the results coming from the analysis of an online SurveyMonkey polls, filled out by over 200 curators from 33 countries around the globe and integrated with the results of few interviews with a subset of curators and with the outcomes of two questionnaires performed during two workshops.Identify communities of biocuratorsMap the type of curation work being doneAssess biocuration trainingDraw a picture of biocuration career development. The global survey was useful to identify biocuration communities, the types of curation work and to understand the training needs while the interviews and workshops questionnaires were useful to outline career development and communities need. The implementation study aimed to define four points; In the paper, the study is well explained and the conclusion well described. However, I think the study design miss some aspects that would have make the result more comprehensive and consistent. While the global survey analysis has been performed on a wide and geographically well distributed biocuration community, the interviews analysis not. In my opinion, the guided conversations and the selection of biocurators would have benefited from the involvement of a wider number of curators, such as for example, curators coming from different academia and research institutes where the figure of biocurator is less recognised and supported compared to the EMBL-EBI. The interview of a wider number of curators, it could have highlighted and arisen further needs and pain points. Moreover, the paper described two questionnaires performed during two workshops held during the 11th ISB Biocuration Conference 2019 and the ELIXIR All Hands Meeting 2019 but the results of these surveys are not explained in full detail and are not available in the supplementary data. There is only a link to the slides presented in the workshops. It would be very useful a summary table or a figure on the results of the two workshops. Nevertheless, I think that the conclusions arising from this study are well drawn and pointed out the main needs of the biocuration community. I particularly liked the final recommendation and suggestions. I believe that this article will help to increase the appreciation and understanding of biocuration work by scientific communities and the support by Academia and Research Institutes.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?PartlyIs the study design appropriate and is the work technically sound?PartlyAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:Biocuration, Molecular and Causal interactions, Community Standard FormatsI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Dear Luana Licata, Thank you for taking the time to review our article and for your valuable feedback on our project. We would like to address two of your comments: 1)  “While the global survey analysis has been performed on a wide and geographically well distributed biocuration community, the interviews analysis not. In my opinion, the guided conversations and the selection of biocurators would have benefited from the involvement of a wider number of curators, such as for example, curators coming from different academia and research institutes where the figure of biocurator is less recognised and supported compared to the EMBL-EBI. The interview of a wider number of curators, it could have highlighted and arisen further needs and pain points.” The guided conversations served to explore the questions asked in the pilot survey in more detail and to identify additional relevant topics for inclusion in the global survey. We agree that one-to-one interviews with a wider number of curators would have been useful, however due to time constraints we were unable to do so. To efficiently gather more diverse and detailed insight into the biocuration landscape we made use of group discussions during the workshops held at ISB 2019 and the ELIXIR all hands 2019 meetings as described in the manuscript. These workshops included a global audience of biocurators. By using this approach we were able to gather a broader set of ideas through the workshops than would have been possible through one-to-one interviews. 2)  “Moreover, the paper described two questionnaires performed during two workshops held during the 11th ISB Biocuration Conference 2019 and the ELIXIR All Hands Meeting 2019 but the results of these surveys are not explained in full detail and are not available in the supplementary data.” In both workshops we did not perform questionnaires but held group discussions in which we asked attendees to note down their answers to specific questions on post-it notes which we collected on whiteboards. This is outlined in the “Methods” (paragraph: Workshops at ISB Biocuration Conference 2019 and ELIXIR All Hands Meeting 2019). Photographs and transcripts of the post-it notes are included in the slides from the workshops (referenced in the article). We understand that this is not clearly specified in the “Methods”, and have revised this section accordingly. We hope that our responses help to clarify the rationale behind the study and welcome any further comments. Kind regards, The authors The manuscript details the analysis of a global survey of biocuration work using the results of several in person interviews, online SurveyMonkey polls, and a couple of workshops to identify biocurators and the types of work that they perform.  It is apparent that the community is diverse not just in training, background,and job titles, but also in the skill sets and tools that are employed in day to day tasks. I appreciate the details provided by the study and the emphasis on the need for more broader scientific engagement to understand and appreciate this type of work. I recommend acceptance without revisions and hope that the indexing and broad dissemination of this paper will result in a greater appreciation for and support of the biocuration community.Is the work clearly and accurately presented and does it cite the current literature?YesIf applicable, is the statistical analysis and its interpretation appropriate?Not applicableAre all the source data underlying the results available to ensure full reproducibility?YesIs the study design appropriate and is the work technically sound?YesAre the conclusions drawn adequately supported by the results?YesAre sufficient details of methods and analysis provided to allow replication by others?YesReviewer Expertise:biocuration, community engagement, data resource sustainabilityI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Despite the emergence of app evaluation tools, there remains no well-defined process receptive to diverse local needs, rigorous standards, and current content. The need for such a process to assist in the implementation of app evaluation across all medical fields is evident. Such a process has the potential to increase stakeholder engagement and catalyze interest and engagement with present-day app evaluation models.This study aimed to develop and pilot test the Technology Evaluation and Assessment Criteria for Health apps (TEACH-apps).Tailoring a well-known implementation framework, Replicating Effective Programs, we present a new process to approach the challenges faced in implementing app evaluation tools today. As a culmination of our experience implementing this process and feedback from stakeholders, we present the four-part process to aid the implementation of mobile health technology. This paper outlines the theory, evidence, and initial versions of the process.The TEACH-apps process is designed to be broadly usable and widely applicable across all fields of health. The process comprises four parts: (1) preconditions , (2) preimplementation , (3) implementation , and (4) maintenance and evolution . TEACH-apps has been tested internally at our hospital, and there is growing interest in partnering health care facilities to test the system at their sites.This implementation framework introduces a process that equips stakeholders, clinicians, and users with the foundational tools to make informed decisions around app use and increase app evaluation engagement. The application of this process may lead to the selection of more culturally appropriate and clinically relevant tools in health care. Excitement over the myriad digital health apps available on commercial marketplaces has been tempered by emerging privacy, efficacy, usability, and implementation concerns . AccordiChallenges with current app evaluation tools and websites can be best understood from an implementation science perspective. The Replicating Effective Programs (REP) framework consists of four phases: preconditions, preimplementation, implementation, and maintenance and evolution. In the preconditions phase, needs and implementation barriers are identified. The preimplementation phase includes gathering community opinions and pilot testing the intervention. Implementation requires intervention education and technical assistance, while the maintenance and evolution phase requires the establishment of sustainable practices. Utilizing the REP framework for health care interventions , the neeThe vast number of health apps available offers an opportunity to select unique tools to meet the local needs of consumers and clinics. Considerations of foreign languages that apps need to support, price points, and literacy level are all important factors that impact the adoption  and use Customizing app evaluation to be responsive to preconditions is necessary not only to ensure that local needs are met but also that buy-in and support from clinicians and consumers are obtained. Lower levels of support around the use of apps in care today are due to many factors, but lack of active engagement from end users and clinicians plays a notable role ,9. OfferThe focus of many existing efforts involves the actual rating of apps, as seen in the myriad of scales, scoring systems, and websites that exist for this purpose. A core challenge of these efforts is the lack of validity or reliability in their resulting metrics . This deDisregarding maintenance and evolution in any app evaluation process remains a critical flaw. The first version of the United Kingdom’s National Health Service app evaluation library was suddenly shuttered amid research showing that the app ratings displayed did not account for recent updates to apps. These apps were no longer protecting data nor offering evidence-based care as they did when they were first evaluated . A recenCurrent app evaluation efforts prioritize and concentrate on the hands-on review of apps. In the model shown in The American Psychiatric Association (APA) App Evaluation framework offers a useful tool to guide informed decision making around apps. Supported by evidence ,14, inteTen committee members were recruited from our team’s hospital at Beth Israel Lahey Health. Our committee consisted of a range of stakeholders from undergraduate students to research assistants to clinicians. Input from this diverse pool of stakeholders holds unique potential to yield a comprehensive understanding of the benefits and concerns regarding each app.Asking all stakeholders to submit the names of any apps they may have heard of, used, or have an interest in will create a pool of apps for consideration. To supplement the app list produced by stakeholders, conduct a narrow search on the app store by choosing a specific category of apps such as physical health or mindfulness. Local app needs can be identified by asking participants to name areas in which apps may be of help, even if they do not know of an app that suits, will highlight local needs around apps.In parallel, at this stage, recruitment of a committee interested in app evaluation begins. The committee should be diverse and represent a variety of stakeholders with unique perspectives. Technology expertise is not a requirement for the committee, but interest in the topic and willingness to learn more is encouraged. Committee members are responsible for evaluating a certain number of apps broadly, then making decisions on whether to push the app forward into the next stage of the evaluation process.The preimplementation stage involves an in-person meeting with the app evaluation committee. Although an online, self-directed survey assessment is feasible, it has not yet been tested by our team. The initial task of the committee is to reflect on feedback from the preconditions stage and utilize it to establish what app evaluation criteria should be added or removed from the APA App Evaluation framework. For example, if people are not willing or able to pay for apps, a free criterion feature in the “access” level is necessary. Likewise, if the need for strong evidence is not considered crucial as people will be using these apps under close supervision and as an adjunct to care, related questions may be removed. There is no right or wrong customization of the APA App Evaluation framework, and the goal is to ensure it reflects the priorities and needs of the local users. It is easy to add or remove questions as deemed appropriate and necessary during the preceding stages of the process. As Henson et al demonstrated, the APA framework organizes the primary evaluation considerations into five levels—background information gathering, privacy, evidence, ease of use, and interoperability  14]. Sa. Sa14]. The committee can also add any apps to the list of those submitted they believe to be potentially valuable and may remove any for which they have serious concerns. By personalizing the framework and eliminating apps that fail to meet the consumer’s needs, stakeholders further narrow their list of apps. At this stage, the committee can also reflect on the need for technical assistance and user support in working with apps.The final component of preimplementation may be the most time consuming but can be done outside of the in-person committee meeting. The goal is to evaluate the available apps selected for consideration in the context of the final criteria and note which apps best align with the defined criteria. No scores or points are assigned, as the goal at this stage is to allow a closer inspection of the apps to separate those that have serious flaws from those that may be acceptable.The list of apps deemed acceptable in the preimplementation stage is now brought back to the committee, and members are invited to interact with and test drive the apps. While some apps can likely be tested in a matter of minutes , others such as medication reminders or habit-forming apps may require a more extensive test drive. The goal at this stage is to collect feedback on which apps may be a better fit in terms of usability and offer the most clinical value. See While there is no absolute number of days within which app recommendations must be updated, there is evidence that 180 days may be a good target . DevelopThe TEACH-apps process was pilot tested at our hospital by a team of ten committee members with diverse levels of expertise. During the initial committee meeting, the team discussed and determined the focus of their app evaluation efforts: health-related apps. Although this focus reduced the list of apps significantly from about two million to over three hundred thousand, the team relied on clinician recommendations, personal experiences or familiarity with apps, and popularity on the Apple App Store and the Google Play Store to further narrow their list. This process resulted in the creation of an initial list of 180 apps.We understand that not all committees following the TEACH-apps process will have the opportunity to host an initial meeting to gather relevant apps. Thus, this stage can be conducted through email , or discStage two of TEACH-apps involved an in-person committee meeting where the team was asked to determine what app evaluation criteria should be added or removed from the APA App Evaluation framework. Analysis of the APA App Evaluation framework allowed the committee to develop their top eight general categories of interest in no specific order: (1) privacy, (2) medical evidence, (3) price, (4) ratings, (5) attributes, (6) features, (7) onboarding, and (8) performance.This initial evaluation allowed the committee to narrow the list from 180 to 56 apps. We acknowledge there is no ‘perfect’ app, and those evaluating apps during this stage will have to use some level of discretion informed by the precondition and preimplementation stages. Our team recognized that not everyone interested in conducting the TEACH-apps process would be able to dedicate this much time to the evaluation. Since then, our team has created a database of common and popular apps where we have coded their features, thus creating a resource to help expedite the preimplementation process. The database allows participants to narrow their search by applying filters such as language or disorder. This database is publicly available .The implementation stage of TEACH-apps consisted of a hands-on app evaluation by the committee. The in-depth analysis of each app involved reading the privacy policy of all 56 apps and documenting key aspects from the customized criteria developed in the preimplementation stage . Each coWhile maintenance and evolution will vary by site and need, our solution includes a publicly accessible online database . Unlike Like any process, we will keep updating the app evaluation process based on feedback. To that end, we offer a pre- and postsurvey to both committee members and end users to identify areas for continual improvement , and our newly developed database has not been tested. Although we have provided comprehensive resources to conduct both the preconditions and preimplementation phases digitally, an additional limitation stems from the fact that we were able to hold in-person meetings, and our pilot process was thus informed by in-person discussion and debate that may be lost in online surveys.As digital health apps continue to grow in number and prominence, there is an increasing need for solutions that help consumers and providers find and evaluate relevant apps while taking into account concerns about privacy, efficacy, usability, and implementation.We have proposed an implementation framework that equips clinicians and users with the tools to make informed decisions around app use. The framework may be applied to a wide variety of medical contexts and can be customized to address specific segments of the estimated 300,000 health apps currently on the market. For example, although the preconditions for an assessment of meditation apps versus apps for diabetes management differ, the outline of the process remains intact.The process is comprehensive, with a preconditions stage focused on gathering relevant apps, a preimplementation stage to customize the criteria of evaluation to local needs, and the ultimate implementation comprising a hands-on test run of the apps that met the tailored set of criteria. With this process completed, stakeholders, clinicians, and users can more easily navigate the dynamic digital health space and utilize health apps for the advancement of care and well-being.


Online shopping for customized garments has become the fastest-growing field of the Chinese eBusiness market. Most consumers not only limit themselves to buying standardized garments but also want to buy garments customized to their preferences. This phenomenon has pushed the fashion textile and apparel industry to change its supply chain operations to meet the customization demand. Besides, the fashion textile and apparel industry also want to study how different channel factors will affect consumers' perceived value and further influence consumers' purchasing decisions. We initiated this study and empirically tested more than 200 experienced consumers. This study collaborated with a fashion textile and apparel company that aims to implement customized product lines soon. Based on the perceived value theory and risk management theory, we investigated whether product involvement and channel identification on supply chain design will affects potential customized product consumers' purchasing decisions. The findings reveal that channel recognition affects consumer decisions by having a positive impact on their perceived value. The perceived risk and shopping channel involvement of consumers have a negative impact on their perceived values and channel selections. In addition, product involvement has a moderating effect on the relationship between channel's perceived risk, perceived values, and channel selections as well. The rapid evolution of development plans like Industry 4.0 and Made in China 2025, as well as emerging information technologies, such as Cloud Computing, Big Data, and the Internet of Things, plays an important role in the development of garment production , the MTO (Make to Order), and the C2M (Customer to Manufactory). The last one especially, the C2M (or C2B), is recognized as the best sustainable business model  websites and apps in China . Respondents were selected from experienced customized products buyers, and they were questioned on the social network apps with which they were familiar as well as similar ones. This survey was conducted from January to February 2017, and out of the 346 questionnaires, 158 were usable for our analysis. Our response rate is 45.66% and the respondents were 35.44% male and 64.56% female see .Whether the data are reliable or valid is the premise of the hypothesis testing. In this paper, SPSS is used to analyze the reliability (using Cronbach's α coefficient) and validity of the data. Prior to the consistency check of the questionnaire, the Corrected Item-Total Correlation (CITC) was used to delete the unqualified items   of the latent variable, and then, with the CR, we test whether each observation variable can reflect the latent variables correctly and completely. The reliability coefficient (R2) and the average variance extraction (AVE) of each index are used to measure to what extent these indexes can be explained by the latent variable. The test indicates that the internal quality of the model is sufficient when the R2 value is >0.3 and that the index can reflect the potential traits of common factors validly when the AVE value is >0.5. Moreover, it shows that the internal quality of the model is adequate when the CR value is higher than 0.6 , which means we can reject the null hypothesis and accept the opposite hypothesis: the product involvement has a significant regulating effect.The results of both unrestricted and restricted models were then compared with the all group analysis. We can see in 2 value of test in Similarly, the χGiven the data collected from the questionnaires, the following conclusions are achieved with respect to the analytical results from AMOS:Conclusion 1: Based on the descriptive statistics, nowadays, consumers, when choosing customized fashion garment online shopping channels, have a preference for those official direct ones. Presumably, the phenomenon is due to the fact that the majority of the consumers tend to believe that it is less risky to use an official direct channel for customized products. Moreover, this kind of online shopping pattern conforms the most to the traditional concept of purchasing.Conclusion 2: Consumers' perceived value of online shopping channel has a positive impact on their choice making. The data analysis shows a relatively strong positive correlation between perceived value and channel selection, which means that when a consumer is selecting online shopping channels for customized fashion garments, according to people's usual logical thinking, then almost all the functional, sentimental, and social values are affecting their consideration. Furthermore, the perceived values of direct channels outrange the ones people perceive from the third-party retail channels universally and, thus, help consumers in making their final purchase decisions.Conclusion 3: Consumers' perceived risk and shopping channel involvement in customized fashion garment have both a negative impact on the perceived value and the channel selection. Statistics, together with many other research findings, indicate that both perceived value and channel selection procedure correlate negatively with perceived risk to a large extent. However, the data presented in this study show a rather poor negative correlation coefficient, which may be the result of the online channel customized fashion garment platforms' policy taken to increase the coefficient of safety and to protect consumers' rights. Additionally, the findings show that among most consumers' opinions, those official direct channels for customized products are less risky than their traditional counterparts.Conclusion 4: Product involvement has a moderating effect on the relationship between channel's perceived risk, perceived value, and channel selection process; this shows how fundamental the customized product is to the consumer and how much attention the consumer pays to the customized product influence on consumers' perception. All of this helps to regulate the relationship mentioned above and eventually might have an influence on the channel selection and purchase decision process for the customized products.Based on the related literature of online shopping and channel selection of customized garment products, this paper penetrates the matter focused on how consumers choose their online shopping channels from the perspective of perceived values, constructs a theoretical model composed of perceived values, perceived risk, and channel selection, and brings forth new ideas in the moderating effects of risk attitude and product involvement.The analysis of the sample data with the use of AMOS and SPSS proves the influence posed by both perceived value and risk, as well as product involvement, on the multi-channel online shopping environment. Besides, the research results show that although perceived value and perceived risk affect the choosing procedure, there are still some differences between the new online multi-channel environment and the regular one.Most studies concerning channel choices focus mainly on offline, traditional and online parts while this paper provides an in-depth understanding of the choosing procedures between different online channels and take consumer's personal factors for customized garment products into consideration, which means it fills the existing gap in the problem of online shopping channel selection, offering new ideas for the development of online multi-channel environments. Similarly, the rapid advancement of online shopping for customized garment products will have an impact on the sellers frustrated about choosing the most beneficial channel to sell their customized products.Given the findings, there is no doubt that the key to soaring online shopping sales for customized garment products remains on consumers. And, thus, online sellers ought to further clarify the features and positioning of their customized products due to the impact of several factors like product involvement on consumers' decision-making process and to realize the features and positioning of the channels. They must focus on the importance of perceived value and risk to make optimal use of the channels for customized garment products by lowering the risk and improving the revenue.As for the various online shopping channels for customized garment products, a high-quality, raffinate, cost-effective product can indeed attract consumers and maintain sustainability in the industry.In future studies, we can extend this issue by increasing sample size to re-study and re-verify the related factors. In addition, another future studies path will focus on whether or how purchase decisions for customized garment products are influenced by consumers' strategic behavior, internal mental status, and risk attitude.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants was not required to participate in this study in accordance with the national legislation and the institutional requirements.BD: conceptualization. JH: investigation. ZL, BD, JY, and WY: writing of the original draft preparation. BD and LP: writing, review, and editing. BY: methodology. YZ: funding acquisition. All authors have read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Bovine respiratory disease (BRD) cause important health problems in all cattle husbandry systems. It contributes substantially to the use of antimicrobial substances and compromises animal welfare and the sustainability of the cattle industry. The existing preventive measures of BRD focus at the individual animal or herd level and include vaccination, mass treatment with antimicrobials and improvement of the animal's environment and general health status. Despite progress in our understanding of disease mechanism and technological development, the current preventive measures are not sufficiently effective. Thus, there is a need for alternative, sustainable strategies to combat the disease. Some of the primary infectious agents in the BRD complex are viruses that are easily transmitted between herds such as bovine respiratory syncytial virus (BRSV) and bovine coronavirus (BCoV). This conceptual analysis presents arguments for combatting BRD through improved external biosecurity in the cattle herds. As an example of a population-based approach to the control of BRD, the Norwegian BRSV/BCoV control-program is presented. The program is voluntary and launched by the national cattle industry. The core principle is classification of herds based on antibody testing and subsequent prevention of virus-introduction through improved biosecurity measures. Measures include external herd biosecurity barriers and regulations in the organization of animal trade to reduce direct and indirect transmission of virus. Improved biosecurity in a large proportion of herds will lead to a considerable effect at the population level. Positive herds are believed to gain freedom by time if new introduction is avoided. Vaccination is not used as part of the program. Dissemination of information to producers and veterinarians is essential. We believe that reducing the incidence of BRD in cattle is essential and will lead to reduced antimicrobial usage while at the same time improving animal health, welfare and production. Alternative approaches to the traditional control measures are needed. Bovine respiratory disease (BRD) is a worldwide health concern in cattle and is one of the most common diseases in calves and young stock in all production systems. The disease is multifactorial and develops in complex interaction between factors associated with the host, the pathogens and the environment. The existing preventive measures therefore include a wide range of strategies. Despite advances of newer and better therapeutic and preventive medications, as well as efforts to improve management and optimize the environment to prevent BRD, the morbidity and mortality rates have not declined. A recent review of evolving views on BRD control measures concludes that blanket vaccination and mass treatment provides inconstant control for BRD and highlights the need to reappraise the use of these measures . Our queThis conceptual analysis presents arguments for combatting BRD at the population level through improved external biosecurity in cattle herds. The rationale for such a program will be given by describing the current impact of BRD, the effect of the current preventive measures and the likely effect of additional biosecurity improvements. Bovine respiratory syncytial virus (BRSV) and bovine coronavirus (BCoV) are two important causative agents in BRD. The Norwegian control program for BRSV and BCoV is presented as an example of a novel and alternative strategy to prevent and reduce BRD. Challenges of such a program and relevant differences between Norway and other areas are also discussed.BRD is a common disease in cattle worldwide, both in feedlots and non-feedlot husbandry systems , 3. In UBRD has negative effects on the animals' life and the producers' economy. It is a major cause of morbidity, mortality and economic loss in both the beef and dairy cattle industries , 8. FataAntimicrobial usage in animals may affect both public health and the environment . BRD andLivestock contribute to the total human-induced greenhouse gas emissions, with cattle production accounting for the majority (60%) of the livestock sector's emissions . PracticFor BRD, the severity of clinical signs, the high incidence of chronic cases, and the high mortality and morbidity estimates underscore the importance of limiting BRD to improve animal health and welfare. Freedom from disease is a fundamental aspect of animal welfare.The multifactorial nature of BRD and the global differences in production systems of beef and dairy cattle have led to a variety of prevention strategies. Common for all strategies are attempts to either improve the animal environment, strengthen the general health and host immunity and/or minimize animal exposure to the relevant pathogens. Vaccination and preventive antimicrobial medication are the most common preventive measures, with the aim to keep a low infection pressure and/or helping the host to combat infection. All preventive measures focus on the single animal or herd as the unit of interest.Mannheimia haemolytica has been found in cattle after metaphylaxis and treatment for BRD  is a co-operative owned by the producers and 96% of the dairy herds report to the Norwegian dairy herd recording system, where membership is voluntary . This prTrichophyton verrucosum has nearly been eliminated due to an eradication program that combined vaccination and zoosanitary measures  and feces (BCoV) can be used for antigen detection or for genome detection by RT-PCR . AntibodThe herd-sensitivity and herd-specificity of a diagnostic test is influenced by the basic performance of the test, the within-herd prevalence and the number of animals tested. Misclassification can arise as a result of imperfect test performance or changes in status after testing. Imperfect test performance could also be due to a suboptimal test-regime with regard to which, and how many, animals are tested.The interpretation of testing will depend on the age and number of animals sampled. Bulk tank milk serology can provide an estimate of herd-level seroprevalence of BRSV and BCoV . The metThe recently launched Norwegian BRSV and BCoV control program is presented as an example of a national level control program based on systematic improvement of external biosecurity at the herd level. The program contains no vaccination or mass-treatment. A brief description of cattle production in Norway is included for context, followed by an outline of the chosen method for herd classification and the applied biosecurity measures.Milk production in Norway is extensive and based on small, mostly family run-farms. The number of dairy herds is around 8,300, with an average herd size of 27 cows in 2018. For members of the Norwegian dairy herd recording system, production data is available to advisors and veterinarians. Many producers rear their own heifers and keep bull-calves for slaughter, which means that young stock and adult cows are often kept in the same or nearby facilities. The number of beef herds is 3,600. These are predominantly suckler-cow herds with an average number of 23 cows, which rear their calves until slaughter . There iIn a nationwide study of 134 randomly selected Norwegian dairy herds, Gulliksen et al.  found 31The control program for BRSV and BCoV was initiated by a joint cattle industry and launched in Norway in 2016. The goal of the program is to reduce the occurrence of BRSV and BCoV in the national cattle herd. A key feature is to classify all herds according to BRSV/BCoV antibody status (sero-positive or -negative) and protect animals in both positive and negative herds from infection through herd biosecurity measures. Vaccination or antimicrobial treatment is not included in the implementation plan, and vaccination against BRD is usually not practiced. Knowledge of herd status is assumed to motivate producers to implement the recommended measures for prevention of virus introduction. Furthermore, sero-negative herds who can document specific additional biosecurity measures are eligible for financial incentives.The costs of the Norwegian control program are shared between producers and the industry. The dairy industry financed the initial screening of dairy herds and the meat industry financed testing of beef herds. After that, the cost of one testing per year per herd is covered by the industry. A project leader is employed by the industry partners and responsible for information flow and education of veterinarians, producers and others within and outside the organizations.The principle of herd classification in the control program is illustrated in All samples are tested with a new multiplex immunoassay for BRSV and BCoV antibodies . The sensitivity and specificity for the bulk tank application of the test have been estimated to 94.4 and 90.6 for BRSV and 99.9 and 93.7 for BCoV, respectively  and indirect (people and fomites) routes. All producers are encouraged to avoid live animal contact between negative and positive herds by purchasing animals or sharing pastures with animals only from sero-negative herds. Live-animal trade is organized by the producer organizations, both for replacement animals and for animals shipped to slaughter. Since the launch of the control-program, separate transport vehicles have been used for animals from negative and positive herds. Farmers are encouraged to build suitable loading areas for shipment of live animals. Furthermore, improved external biosecurity is encouraged by implementing restricted human access into herds. There is a legal requirement to provide sluices where veterinarians, AI technicians, advisors, claw trimmers, service people and others can change to protective clothing and footwear provided by each herd. Advisory support from the program is provided to ensure a feasible design of these sluices. In general, the advice is for the herd to provide clothing and footwear for visitors, washing facilities with cold and hot water and suitable storage areas for equipment.To encourage compliance with the control program, herds can acquire a “Healthy herd status” by fulfilling a set of specific criteria. These criteria include having a sero-negative status for both BRSV and BCoV. In addition, the herd needs a veterinary certificate confirming high external biosecurity through the implementation of a physical barrier sluice. A loading-area for shipment of live animals to and from the herd is also required, to enable the truck driver to access the animals without entering the barn. A “Healthy herd” status is rewarded with an increase of approximately 10% in price when selling young-stock and breeding animals.A final measure to be mentioned is the establishment of a “hot-line,” where producers report episodes of diarrhea or respiratory disease by phone. This is done to enable rapid discovery of possible outbreaks, and a notification leads to warning of relevant personnel  such that necessary precautions can be taken to avoid further disease transmission and increase the vigilance in the area.We have presented arguments for biosecurity-based control of BRD and outlined the ongoing Norwegian control program for BRSV and BCoV. We argue that successful population-level disease control is possible through external herd level biosecurity measures but that several conditions must be met.Generally, the requirements for initiating a control program will differ according to biological factors , possible control measures , availability of technical tools  and socioeconomic considerations . LindberThe first element, biosecurity, is the primary focus in the control program. The aim is to reduce risk of introduction of virus both through live animals, people and fomites. A critical point is the efficacy of the recommended protective measures. This may differ according to management system and herd structure. For example, large herds have been shown to have more visitors and thereby more indirect contacts compared to smaller herds . This caM. bovis and IBR, it is probably wise to focus on these pathogens first. However, the preventive measures will generally have positive effect on the transmission of many other infections.The effect of the recommended protective measures also depends upon the compliance to these, where the motivation among stakeholders, veterinarians and producers is crucial. It is also an ongoing measure that needs to be nourished over time. Basic education, as well as a continuous flow of updated information, is necessary. Knowledge about the occurrence of the infections is useful to motivate action. The impact of BRD is well-recognized among farmers and veterinarians in Norway, and they are usually aware that BRSV and BCoV are the primary pathogens, and that BCoV also causes winter dysentery. This probably makes it easier to motivate the producers for control of BRSV and BCoV in Norway compared to countries with other Specters of BRD pathogens. For BRSV and BCoV, the documented varying prevalence, and presence of negative herds in high-prevalence areas , 59, shoThe second element, elimination of virus from infected herds, receives little attention in the program as self-clearance is regarded likely. This is probably more effective in small herds, and the small average herd size in Norway is therefore an advantage. In larger herds, naïve cattle in sufficient numbers might be available all the time, and both acute, subclinical infections and possible persistent infections are more likely. Altogether, control might be more challenging in areas where herds are larger, and more intense monitoring might be necessary. Nevertheless, biosecurity-based control might still succeed if new introduction of virus is avoided, as it will most likely be a question of time before virus cease to circulate also in larger herds.The third element, monitoring of progress, is based on the feasibility of the classification of herds, and the frequency of the testing. There is a need for herd-level diagnostic tools that accurately classify the herds in a cost-efficient manner. Serological investigations will result in an overestimation of prevalence, as earlier discussed. In the Norwegian test-regime the small average herd size might cause few first-parity cows or calves to be available, consequently reducing the herd-sensitivity. The within-herd prevalence is to some degree unknown and probably variable between herds, and within groups in the herds, which further complicates the matter. In the control program, the test-result is valid for a full year. The probability of virus introduction after classification is considerable, particularly in herds that purchase animals. An updated herd-classification based on the combination of bulk milk tank testing, herd size, information on animal movements and geographical location has been shown to provide a more accurate estimate of herd status  and coulAltogether, herd size influences all the three fundamental elements discussed here. It is also where the Norwegian situation differs considerably from most European countries. Our average dairy herd comprises 27 cows and suckler-cow herds 23, and there is an absence of feed-lots as well as few and small fattening herds. In addition, herd size might also influence the time until a new infection is detected. In Norway, the number of animals tested is the same regardless of size. In herds with many animals a control program with a more intense diagnostic test regime regarding both number of animals tested and frequency of testing, might be necessary. Herd sizes are increasing in Norway, which coincides with an increase in the recorded number of infectious diseases . InfectiStakeholders and producers are obviously concerned with the costs related to a control program; is it worth it? The financial losses due to BRSV and BCoV in Norway were analyzed by the industry prior to onset of the program. This included the available knowledge of the viruses' effect on BRD and winter dysentery, and the costs of running a control program were weighted against the impact (not published). It was concluded that controlling BRSV and BCoV would be cost-efficient and should be prioritized. There are several uncertainties in such an analysis. In a study from France, the authors assumed that a reduction of BRD incidence between 20 and 50% was a realistic outcome to expect from improvements in farm biosecurity , but furThe situation in Norway with few transmissible and notifiable diseases highlight the large impact of BRSV and BCoV. Control of these highly contagious viruses require a systematic approach, and a cooperative culture with a common goal. Previous experience from systematic eradication and control of other diseases might have contributed to a culture for disease control through prevention and joint efforts in Norway. Successful control of BRSV and BCoV here could motivate to action also in other countries. Effects on public health is a profound reason for animal disease control. The expected benefits is considerable regarding the usage of antimicrobials and antimicrobial resistance, in agreement with the present OIE strategy (90). Another expected “by-product” of the control program is the likely reduction of infections caused by other pathogens transmitted via the same routes, both endemic and emerging pathogens. The Norwegian BRSV and BCoV control program indicates a way forward in how to achieve improved animal health and welfare.Antimicrobial resistance is a major public health threat. Growing concerns regarding the environmental impacts of livestock calls for new and innovative measures to prevent endemic diseases, and thereby improve the sustainability of the cattle industry. An alternative strategy to combat BRD is urgently needed. We believe it is both desirable and possible to control BRSV and BCoV, and subsequently reduce BRD, through biosecurity measures. The Norwegian initiative represents a new way of thinking that will likely have wider implications. The ultimate goal is improved animal health, welfare and a reduction in antimicrobial usage in the cattle sector as well as a more effective production.Development of concept was done during a walk-shop where all authors contributed ideas and input. Drafting of the manuscript was led by MS, with contributions and critical review from all authors. All authors have read and approved the final product.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Underwater robots emit sound during operations which can deteriorate the quality of acoustic data recorded by on-board sensors or disturb marine fauna during in vivo observations. Notwithstanding this, there have only been a few attempts at characterizing the acoustic emissions of underwater robots in the literature, and the datasheets of commercially available devices do not report information on this topic. This work has a twofold goal. First, we identified a setup consisting of a camera directly mounted on the robot structure to acquire the acoustic data and two indicators  to provide a simple and intuitive characterization of the acoustic emissions of underwater robots carrying out specific maneuvers in specific environments. Second, we performed the proposed analysis on three underwater robots belonging to the classes of remotely operated vehicles and underwater legged robots. Our results showed how the legged device produced a clearly different signature compared to remotely operated vehicles which can be an advantage in operations that require low acoustic disturbance. Finally, we argue that the proposed indicators, obtained through a standardized procedure, may be a useful addition to datasheets of existing underwater robots. The oceans are essential for life on Earth, hosting a remarkable and still poorly known biodiversity, representing an invaluable source of food and energy, and being involved in the balancing of the planet’s climate ,2,3. ThaDepending on the specific task required, different types of underwater vehicles can be currently used. For instance, AUVs are often used for long operations such as monitoring ecological parameters or mapping the seabed over wide areas. Missions are usually pre-programmed with little or no interactions with human operators except for the deployment and recovery phases. Instead, ROVs are used in missions that require the continuous supervision of an external operator, including maintenance interventions on anthropogenic structures, search-and-recovery missions and scientific surveys. All underwater robots are equipped with different sets of sensor-packs, which can be as simple as a single camera used as a feedback for the operator of small commercial ROVs, up to a whole sensory suite including navigation units, sonar-based equipment, and sophisticated devices for ecological and biological investigations in AUVs and larger ROVs.Although appearing silent, the oceans are characterized by a wide spectrum of sounds. Some of them are natural, such as the noise produced by the waves or emitted by animals , and somIn terrestrial robotics, the noise produced by a device represents an issue that has recently gained attention under the name of ego-noise . EssentiIsidella elongata  [Eunicella verrucosa  [Antipathella subpinnata (Ellis and Solander 1786) [The ego-noise of aquatic robots is an essential variable to take into account in studies that target the assessment of vagile fauna presence and composition, considering that it can disturb the organisms, thus limiting the chances to see them. For instance, ROVs can be used to highlight the pivotal role of important habitats, such as coral forests, in enhancing the presence of species of conservation interest as well as of fish and crustaceans of high commercial value. For instance, the forests of the bamboo coral r, 1788)  proved tr, 1788) . A compas, 1766)  or by ther 1786)  in the Mer 1786) ,16,17. Her 1786) ), fish aer 1786) . For exaer 1786) , while fer 1786) ,10,20. Per 1786) , their ner 1786) ) with clIn the literature, there are a few attempts at characterizing the noise generated by an underwater robot, most of them with the goal of achieving stealth in military applications ,24. RegaIn this work, we resorted to cameras directly mounted on three different underwater robots with the aim of providing a simple characterization of the noise they introduce to the environment for different maneuvers in terms of well-known signal processing tools. The methodological choice of using commercial cameras instead of specific sensors, such as hydrophones, was driven by two main motivations. On the one hand, recordings occurred during real operative sessions, i.e., the robots were performing their task in the field and were not operated specifically for the collection of acoustic data. On the other hand, such a simple setup would allow end-users to perform the same analysis and understand how much noise they are introducing into the environment where they are operating. The consequences of this methodological choice are discussed in fRO , and theThe robots used in this study fall into two very different classes. On one hand, the ROVs, Prometeo and Seaeye Falcon DR , are slightly positively buoyant for automatic resurfacing in the case of failure and propel by means of thrusters. On the other hand, the ULR SILVER2, which is negatively buoyant and harnesses the interaction between legs and seabed to move. While there are several commercially available ROVs, ULRs are a novel category of devices mostly used in a research context at the time of writing. An overview of the features of the robots used in this work is presented in Prometeo is propelled by four thrusters actuated by brushless DC motors. The propellers are functionally divided into elevators and thrusters, respectively, responsible for vertical and horizontal motion. In this work Prometeo was operated in manual mode  because it is not equipped with autopilot. This allowed to clearly distinguish phases during which only the elevators or the thrusters were active, phases in which all propellers were active, and phases when all motors were off.Falcon is propelled by five thrusters actuated by brushless DC motors. The thrusters’ configuration is different from the Prometeo, as it presents one vertical thruster responsible for vertical motion plus four horizontal thrusters. In this work the Falcon was operated with the autopilot on, so that it was not possible to isolate sequences when specific thrusters were on or off, but it recorded the effective noise produced by the analyzed maneuvers. This choice was driven by the fact that autopilot is commonly used by pilots to stabilize the vertical position of the ROV, thus measuring the noise produced with autopilot on gave a more reliable idea about the effective noise produced during operations at sea.The SILVER2 is characterized by six legs 63 cm long, actuated by 18 Dynamixel servomotors controlled using user-tunable feed-forward strategies. As thoroughly described in Reference , SILVER2Audio signals were recorded with cameras directly mounted on the structure of the robots as shown in Recordings occurred in independent sessions, during real operations of the devices in different areas of the Italian coast (Mediterranean Sea), all of them with good weather conditions and with supporting vessel engines off. Data from Prometeo were recorded at Tremiti Islands Marine Protected Area  during a scientific study on vulnerable coral forests at a 55–60 m depth . Data frx(t) was obtained by trimming a long mp3 file of the duration of the whole session to extract only the part corresponding to the maneuver of interest. The sampling frequency was sf = 44,100 Hz, and it was assumed that s(t) is the sound emitted by the robot and n(t) is the ambient noise recorded when all actuators are off. The following analysis was performed:N, over N bins, where N is the total number of samples of x(t);Power spectral density computed with a Hanning window of length b1 and b2 are the band edges, ks is the spectral value at bin k and b1, b2) = ;Spectral roll-off point Spectrogram computed on 1024 sample bins with a 768 sample overlap;Autocorrelation coefficient Noise introduced into the environment Each audio signal The raw mp3 signals for the three robots performing the maneuvers described in In the case of the Falcon ROV E,F, the The SILVER2 was operated in two distinct modes, resulting in different acoustic signatures G–I. The The signals presented in The power spectral density plots reported in The power spectral densities of the ANs of the four recording sessions are reported in The spectrograms of all the maneuvers considered in this work are shown in An intuition of the periodicity of the acoustic signature emitted by the robots clearly emerges by the autocorrelation coefficients depicted in As already commented, the absolute acoustic intensities recorded in this work cannot be compared directly because the orientation and distance of the microphone from the actuators can vary from case to case and according to the recording device. For this reason, in order to provide a ground of comparison for the noise emitted by the robots considered, we computed the NE indicator for all the maneuvers and reported it in All robots moving produce a noise that is mostly related to the type, power, and activation pattern of its actuators, and which can be an obstacle to a successful completion of some specific tasks. The ego-noise may limit the ability of a humanoid or service robot to perform speech recognition to assist humans  or it maGiven the very low transmission of electromagnetic waves, underwater systems often rely on sonar technologies for sensing. Although the operating frequencies of such devices are generally in the order of MHz, in some cases, when a longer range is needed ,6, the eIn this work we approached the issue of ego-noise from the perspective of underwater robotics and characterized the acoustic noise emitted by three different robots belonging to the categories of ROV and ULR in terms of power spectral density, spectral roll-off point, spectrogram, autocorrelation and noise emitted to the environment. Similar analyses have been performed in literature, mostly with the aim of achieving stealth in military applications or improve the signal-to-noise ratio in autonomous surveys . In thisx and the noise was the AN recorded when all motors were off n. The NE allows to compare the noise emitted in the environment and recorded with the presented setup in non-controlled conditions by explicitly subtracting the energy related to the ambient noise. Among all the maneuvers considered, the most interesting result concerns the NE of station keeping. For the Prometeo and Falcon ROVs, station keeping consisted of compensating, either manually or through a feedback control, the buoyancy with continuous or intermittent use of vertical thrusters. The SILVER2 instead realizes station keeping by relying on negative buoyancy and just keeping all motors off. For this reason, the recording of SILVER2 during the station keeping maneuvers was the same as the AN and therefore NE = 0.Comparisons among robots based on the absolute intensity of the raw signals or power spectral densities measured in this study would be misleading. In fact, the noise produced by the three robots tested was not recorded in the same location and with the same device, which had distances from the actuators (which are considered the main source of noise) that were not constant. On the other hand, it is possible to understand in which frequency range most of the energy of the signal is concentrated by either looking at the power spectral density plots reported in These evaluations are of critical importance for the use of ROVs and/or ULRs in scientific surveys aiming to observe vagile organisms such as fish, mollusks, and crustaceans, that can be easily disturbed by the ego-noise of the robot. In fact, marine fauna is particularly sensitive to noise pollution, including the one eventually introduced during the surveys ,10,11, dThe possibility to develop a silent tool able to explore the seabed and to perform long station keeping on specific targets would allow a non-invasive assessment of vagile macro- and megafauna, as well as the observation of unknown behaviors, leading to the understanding of species’ roles and interactions in remote environments, such as the mesophotic and aphotic portions of the seabed . CurrentTo conclude, in this work the proposed indicators (i.e., NE and ow 5 kHz .As future works, the performed measurements can be repeated in a standardized recording setup . The seaWithin this acquisition setup, the proposed indicators may extend their utility and be a valuable addition to datasheet of commercially available underwater vehicles and guide end-users in the selection of the most suitable device for their needs.In this work we proposed a simple setup to acquire acoustic data emitted by underwater robots performing different maneuvers with the aim of easily characterize their acoustic signature. We found that the spectral roll-off point,


Palliative care is indicated in patients with heart failure since the early phases of the disease, as suggested by international guidelines. However, patients are referred to palliative care very late. Many barriers could explain the gap between the guidelines’ indications and clinical practice. The term palliative is perceived as a stigma by doctors, patients, and family members because it is charged with negative meanings, a poor prognosis, and no hope for improvement. Many authors prefer the term supportive care, which could facilitate a discussion between doctors, patients, and caregivers. There is substantial variation and overlap in the meanings assigned to these two terms in the literature. Prognosis, as the main indication to palliative care, delays its implementation. It is necessary to modify this paradigm, moving from prognosis to patients’ needs. The lack of access to palliative care programs is often due to a lack of palliative care specialists and this shortage will be greater in the near future. In this study, a new model is proposed to integrate early over the course of the disease the palliative care (PC) specialist in the heart failure team, allowing to overcome the barriers and to achieve truly simultaneous care in the treatment of heart failure (HF) patients. The prevalence of heart failure (HF) in Western countries is 2.2%–2.5%, with 5–10 new cases per 1000 people/year [Patients with HF have the same symptom burden as those with cancer, with the same prevalence of depression and reduced spiritual wellbeing (35%–40% of patients) . Over haThe guidelines of the main international scientific societies ,5,6,7 alThe same recommendations are present in Canadian Cardiovascular Society guidelines on heart failure.However, the number of patients who need PC differs markedly from the number who actually receive it, especially in patients with cardiovascular diseases. Only 4% of HF patients in Great Britain receive PC, and this figure has remained constant over the years . In the What are the reasons for this gap between the practices advocated by the guidelines and those observed in clinical practice? Differences in how PC is used in various medical fields cannot be attributed to the contents of the European guidelines, which are similar for patients with HF, respiratory failure, or cancer . The proIn advanced HF patients, the available therapeutic strategies when PC starts are substantially related to palliative inotropes administration (dobutamine in continuous infusion or levosimendan in intermittent infusion) and to the management of implanted cardiac devices (Implantable cardioverter defibrillators (ICD), cardiac pacemakers (PM), left ventricular assist devices (LVAD)) and their possible deactivation at the end of life .One fundamental point to consider is the conceptual overlap between PC and EOL, although the non-synonymous nature of the terms has long been stressed by the WHO . Some auThe same obstacles to early implementation of PC are found in the literature regarding pediatric oncology ,17—some The debate over the terminology and the role it plays in preventing physicians from starting PC has led to the proposal of the alternative term supportive care (SC). The Multinational Association of Supportive Care in Cancer (MASCC) defines SC care in cancer as “the prevention and management of the adverse effects of the disease and its treatment. This includes management of physical and psychological symptoms and side effects across the cancer experience through diagnosis, through anticancer treatment, to post-treatment care. Enhancing rehabilitation, secondary cancer prevention, survivorship, and end-of-life care are integral to supportive care” . The terOncologists find that it is easier to involve patients with early-stage disease in an SC program than in one providing PC . An analThe stigma attached to the term palliative is even greater among specialists in non-oncological diseases, who have always been reluctant to discuss prognoses and EOL issues with patients and their families. Pulmonologists and cardiologists in Belgium were recently surveyed on the views and current practices for incorporating palliative measures into the care of patients with chronic obstructive pulmonary disease (COPD)/HF. The term palliative care emerged as having a bad reputation, with unpleasant connotations for patients and family members .Because the prognosis for HF/COPD is difficult to define and neither disease is identified with death in the minds of the general public, the survey participants reportedly avoided even mentioning the existence of PC services, especially in the earlier stages of illness . The terCardiac surgeons in the United States are also addressing the problem of terminology in relation to cardiac surgery patients admitted in a critical condition to intensive care units. Katz notes that the team responsible for EOL issues in this setting is generally called the PC team, a term he feels is in conflict with the basic objective of cardiac surgery, which is to restore the patient to a life of significant quality outside the hospital. The term palliative sends a negative message, while the term supportive is considered more appropriate and more likely to lead the surgeon to consult the team . In an eIn any case, despite the efforts of the WHO and MASCC, there is substantial confusion surrounding the meanings of the two terms . The UniThat there is some confusion and interchangeability between the two terms is also evident in the work of Lewin et al., who integrated PC specialists into the HF team from the very start, establishing a service referred to as “supportive cardiology” . SimilarHowever, if this type of care continues to be proposed only when patients are in the final stages of their illness, when disease-modifying therapies are being discontinued because they are ineffective or are refused by the patient, the stigma attached to this service will persist. In other words, change at the level of terminology alone is no more than a cosmetic intervention. It is well known that unlike in cancer patients, in HF cases, it is often difficult to formulate a short- to medium-term prognosis, particularly as HF has an extremely variable clinical course, with alternating phases of acute HF and phases of prolonged relative stability. This is especially true of advanced HF, in which palliative care needs to be implemented as part of the overall treatment program .It is important to stress that the difficulties involved in formulating a short- to mid-term prognosis for a HF Patient  are accoHowever, prognosis is still frequently used as a principal tool to decide whether to start PC, even if, in individual patients, the use of prognostic scores derived from clinical trials may often be inadequate .Using prognosis to start PC delays the implementation. The “surprise question” (SQ) (“Would I be surprised if this patient died in the next 12 months?”) has been proposed as an effective tool for identifying patients with an advanced chronic disease who need palliative care . It has The main limitation of the SQ, when applied as prognostic indicator to HF patients, is its low specificity (22%) .Straw et al. , in a prIn essence, the SQ has little or no prognostic value, because one HF patient out of two with a negative response will still be alive after one year ,46.Palliative or supportive care measures—or whatever else one might call them—should be included in the care plan from the initial stage of the illness and continued thereafter with revisions and adjustments guided by the clinical needs of the patient and their relatives/caregivers. With early integration of PC professionals into the team directly responsible for the patient’s care, the negative connotations surrounding them in the eyes of patients and their families—albeit unjustified—are likely to be less striking, and their acceptance can allow for a more holistic management of the patient’s problems—clinical, psychological, and spiritual. With this approach, prognosis-oriented care can be transformed into patient needs-oriented care .The lack of access to PC programs is often due to a lack of PC specialist availability. It is calculated that the shortage of PC specialists today is a serious problem (the ratio of PC doctors to eligible patients is 1:808) and in the future, it will be worse due also to 30% of physicians burnout and age (> 56 or older) .In another paper , Lupu etAttempts to integrate PC into care plans for patients with HF have generally been unsuccessful for several reasons, including the lack of reliable clinical prognostic criteria for initiating PC , the absThere are two interrelated problems: when to start HF patients on specialist PC and how to integrate the PC specialists into the care team.In general, HF patients are referred for PC during an advanced stage of their illness, and this may limit its effectiveness . EarlierEarly integration of a PC specialist into the team caring for a HF patient is recommended by scientific societies, but the recommendation is rarely implemented .The model shown in Secondly, the negative stigma attached to PC providers  could bVAD: ventricular assist device, Tx: cardiac transplant, EP Lab: electrophysiologic laboratory, Cath lab: catheterization laboratory modified from Hui et al. 27In subsequent phases, issues related to the implementation of planned treatments will be dealt with, including those destined for the most advanced stages of HF. This point heralds the beginning of the palliative phase of the patient’s care in sensu strict, when interventions such as palliative inotrope therapy are used , and theTo improve the effectiveness of this model and to make it applicable in a widespread manner, there is a need for cultural contamination among the different physicians involved.The PC team could learn the main problems in the clinical course of HF patients, with special attention paid to device management  at the end of life.The cardiologists might improve their attention to symptom evaluation and treatment; moreover, they could start dealing with particularly difficult conversations.Finally, this cooperation should improve the process of shared decision making in all stages of heart failure.The barriers to early implementation of PC in HF patients are still able to make the care insufficient and ineffective.The knowledge and attitudes of cardiologists in this field is quite low, and this also arises from the assumption that the frequent use of high-tech treatments, even in late HF stages, is beneficial.The best therapy for all diseases should be built on criteria designed to ensure proportionality of care, which is based on balancing the appropriateness and burdensomeness of treatments and adopting a correct, bioethical approach.The concept of proportionality is strictly linked with the patient–doctor relationship, which could be improved through a new approach towards HF patients, as described in this review;otherwise, it could be only the rough application of therapeutic techniques.Cultural changes and the continuous education of physicians are the only solutions to these still unresolved issues.