Recent clinical research on neuroengineering is primarily focused on biocompatible materials, which can be used to provide electroactive and topological cues, regulate the microenvironment, and perform other functions. Novel biomaterials for neuroengineering have been received much attention in the field of research, including graphene, photonic crystals, and organ-on-a-chip. Graphene, which has the advantage of high mechanical strength and chemical stability with the unique electrochemical performance for electrical signal detection and transmission, has significant potential as a conductive scaffolding in the field of medicine. Photonic crystal materials, known as a novel concept in nerve substrates, have provided a new avenue for neuroengineering research because of their unique ordered structure and spectral attributes. The “organ-on-a-chip” systems have shown significant prospects for the developments of the solutions to nerve regeneration by mimicking the microenvironment of nerve tissue. This paper presents a review of current progress in the designs of biomaterials and microenvironments and provides case studies in developing nerve system stents upon these biomaterials. In addition, we compose a conductive patterned compounded biomaterial, which could mimic neuronal microenvironment for neuroengineering by concentrating the advantage of such biomaterials. Nerve lesions, which cause a great number of disabilities around the world, have brought a tremendous impact on patients' productivity and life quality. In general, nerve regeneration is the prime hindrance to limb reattachment in clinical practice. In previous studies, neuroengineering research for the peripheral nervous system (PNS) is primarily concentrated on alternatives to neurografts; however, work on spinal cord damage is primarily focused on creating a permissive environment for functional recovery . During Nerve scaffolds consist of natural biological materials and synthetic materials. Thus far, many solutions have been introduced to derive the above two kinds of materials. For example, in , the autThe combination of materials and tissue engineering is a mature research field, and numerous materials have been applied in clinical therapies. In recent years, several novel materials have been exploited, which is mainly due to the fact that their excellent chemical and physical features have been applied to the field of neuroengineering. In particular, a clinical study has been performed to determine the feasibility and safety of the collagen scaffold NeuroRegen, and it is found that patients demonstrated improved autonomic nerve function, and meanwhile, there is a recovery of motor- and sensory-evoked potentials from the soma . The comGraphene consists of a single layer of carbon atoms, which have a high mechanical strength and chemical stability with unique electrochemical properties for electrical signal detection and transmission. This is important, due to the fact that, the promote diagnosis and nerve disease treatment mainly rely on the stimulation and recording of nerve impulses. A great number of biomaterials have been adopted as nerve scaffolds, and organ-on-chip devices provide novel in vitro microenvironments, which make progressed in the point where they are able to be used in the development and regeneration of nerve tissue. In reality, the latest progress in microtechnology allows more realistic mimicking of the naturally occurring microenvironment, where the behaviors and physiology of neurons and NSCs in response to the physical environment are more realistic. Neural interface biomaterials have become a topic of great interest; meanwhile, photonic materials are an emerging area in the production of stents in NTE. Ordered porous materials like photonic crystals provide a surface effect for studying the behavior of NSCs.This literature review covers recent studies on the three kinds of the above bioderived materials and their neuroengineering applications. Exploring the application of the compounded biomaterials in the field of neural interface materials could be serviceable in fabricating multifunctional neuron scaffold, which can be used not only for in vitro studies but also for therapeutic purposes. In addition, we combine the merit of such biomaterials to develop a compound design which has the advantage to further improve nerve cell growth.μm2 [Neurons are electrically active cells, which function is exceedingly closely related to electrical activity. Through depolarizing the excitable cell membranes, electrical stimulation can initiate a functional response in neurons. In theory, depolarization can be achieved by the ionic flow between two or more electrodes; meanwhile, at least one of the electrodes is close to the target tissue. In general, there are two categories of electrodes that have been used in neural stimulation in neuroengineering research. Microelectrodes show low-charge/density thresholds and high-charge/phase thresholds, and they are, respectively, fixed on the target organ surface and possess a geometric surface area (GSA) greater over approximately 100,000 μm2 , 9. Reseμm2 . Scaffolμm2 –14.In general, graphene is the strongest and thinnest known material, which has been received great attention since being separated from graphite by Novoselov and Geim in 2004 , 16. GraThe combination of outstanding thermal stability, biocompatibility, mechanical strength, and high electrical conductivity makes 2D graphene promising for a host of bioengineering applications , 19. GraIn vitro experiments on cell behaviors in the presence of graphene usually involve 2D graphene films, which lead to discrepancies between the 3D in vivo environment and the artificial 2D environment. Compared with the 2D scaffolds, 3D scaffolds are more accurate to mimic the chemical, physical, and biological properties of the in vivo environments –28. Due To develop practical applications for graphene, significant effort has gone into assembling 2D graphene sheets into 3D macroscopic structures that can serve as nerve scaffolds. The characteristics of 3D graphene are closely related to the size of such structures. Therefore, carefully controlling the size of the 3D preparation allows one to regulate the topographical cues of graphene, which can be used to meet different application requirements, and provides the opportunity to better understand the mechanism behind graphene effects in different applications. Many researchers have shown that 3D graphene stents cannot only promote the propagation of NSCs but also induce the selective differentiation of NSCs into functional neurons to a certain degree. For instance, porous three-dimensional graphene foam (3D-GF), which acts as a novel scaffold for NSCs, cannot only maintain NSC growth but also support the cells in an active propagation state through upregulation of Ki67 expression, when compared with 2D graphene films. It has also been shown that 3D-GFs can accelerate the differentiation of NSCs into astrocytes and neurons; meanwhile, the electrical coupling of 3D-GFs with differentiated NSCs demonstrated the effective electrical stimulation of these cells .In Tang's  and SongIn previous studies, a novel method is introduced to inhibit synapses by fabricating nanometer-scale GO fragments. This solution mainly affects cell activity rather than inhibiting neuron signaling, which has been widely used in the treatment of neurological diseases . Given tGraphene functions as an improved artificial graft can be used to support nerve repair and regeneration. The unique physical properties regulate cellular growth behavior and improve cell activity, function, and development. In the future, the primary goal of biomedical engineering will be to address the potential applications of using graphene as a support biomaterial in cell culture. For example, the conductive properties of graphene will allow us to apply directional electric current on living tissues. In summary, graphene addresses quite a few challenging clinical applications of bioengineering and has great prospects in neuroengineering.In 1987, Yablonovitch and John put forward the new concept of “photonic crystals” which expounds upon the effect that periodic dielectric structures have on the way that light propagates through certain crystalline materials. Photonic crystals consist of ordered arrays of two or more materials with different dielectric constants (refractive indexes). The materials form periodic patterns of dielectric constants, which generate a range of “forbidden” frequencies referred to as the photonic bandgap, and photons with energies in the bandgap cannot propagate through the material . AlthougRecently, the topological cues provided by biological scaffolds have been suggested to regulate cell behavior and stem cell fate –44. ThesThe development of photonic crystal microstructures has been a primary focus of research into tissue regeneration over the past thirty years, and these materials have found applications in a multitude of tissue engineering applications, such as controlling the spatial arrangement of cells, guiding cell behavior, and differentiating stem cells. To be specific , proposeα cells grew along with the oriented microchannels, and the interrelated pores in the scaffold's interior were beneficial for both nutrient diffusion and cell ingrowth [Nerve cell synapses can be easily guided by mechanical force in vivo, and the “random-to-aligned” cell gradients generated by such forces reproduce the part of the neuron that is inserted into connecting tissues and has significant potential for applications in neuroengineering. Photonic crystal materials like ordered microporous silicon are promising electrode materials in the nerve repair setting, which is mainly due to their advantage of biologically inert with excellent biocompatibility. Porous silicon has a large surface area, adheres firmly to tissues, and does not induce inflammatory response; all of which suggest that it would make a good biomaterial for use in implantable electronic nerve devices . Wang etingrowth . The adoingrowth , and ordThe photonic bandgap of periodic dielectric structures is the fundamental property of photonic crystals. The emergence of the photonic bandgap relies on the structure of the crystals, the ratio of the dielectric constants of the materials making up the crystal, and the geometric configuration of the crystal. In general, if the difference in the dielectric constant between the two kinds of material in the photonic crystal is obvious enough, then Bragg scattering will occur at the medium interface, and the dielectric constant ratio will become greater. In addition, the stronger the incident light is scattered, the greater the possibility to generate a photonic bandgap , 56. TheIn addition to the significant physical features with which periodic dielectric structures can guide the growth of nerve cells, photonic crystals can be used in a number of applications, which make use of the photonic bandgap. For example, their long-range ordered structures provide a stable code that can direct the growth of nerve cells according to changes in the refractive index. Huang et al. presented that lithographically patterned microporous silicon photonic crystals, which are functionalized with different bioactive peptide-doped surfaces, could be used as a spatial guidance for NSC differentiation and that NSCs can be spatially specified to suffer astrogenesis or neurogenesis as a multifunction of peptide identity as well as surface properties . In addiThe engineering of cellular environments has been shown to be crucial for improving the in vitro viability and in vivo-like function of cells and tissues, which is due to the fact that such environments are more accurate to mimic the situation in living organism . Organs-To successfully regenerate nerve tissue, axonal outgrowth from the proximal stumps requires growth without interference from the surrounding microenvironment, while it requires the formation of new connections with distal stumps. To address the above issue, Bryan et al. proposed a novel strategy to improve axonal sprouting in a guided way through a spatial neuron guidance channel . StudiesKim et al. created the neuron chellop through a surface-printed microdot array to control axon branch formation and showed that the majority of collateral axon branches stemmed from axonal regions on a dot and terminated on neighboring microdots. In that study, the results showed that the length of branches increased as the spacing between dots increased . This apThe blood-brain barrier (BBB) is derived from specialized endothelial cells, which isolates the blood from the brain tissue. Specifically, the BBB hinders the access of many exogenous compounds to the CNS selectively . It is wThe BBB-on-a-chip is a microfluidic platform, which can be used to mechanically and biochemically modulate BBB function . This teMicrofluidic devices are gaining ground as novel automated microsystems for neuron culture and real-time monitoring, and the BBB-on-a-chip model provides an in vitro environment to mimic the natural forms and functions of the BBB and might be of great benefit in developing methods for nerve disease and new clinical treatments . For insThe unique morphology of nerves and neurons—with their distinct functional units—makes nerve repair and regeneration particularly challenging. The field of clinical medical materials has progressed significance in the past several years and has given rise to the design and synthesis of functional biomaterials for the therapeutic and diagnostic applications. The present challenges and the future goals for such proof-of-concept research need to be emphasized as well. Electrical conductivity is the primary predictor of neural signal quality in nerve repair and regeneration, and conductive materials will be useful for a great number of applications. It is worth mentioning that the communication between neurons and their downstream target cells takes place through the specificity of synapses, and information is transmitted between neuronal circuit elements by electrical or chemical signals. Neural signals based on electric conduction are predicted to have a strong influence on nerve reparation and regeneration, and neural components made of conductive material are expected to have wide clinical potential.The development of graphene technology is a field at the frontier of biomedical research, and one of the primary focuses of such research is to find ways to manipulate the properties of graphene materials so as to modulate neuronal synapses and neuronal excitability. The directional morphology of cell culture scaffolds can promote various nerve cell behaviors, and thus, another promising technology is the stimulation of nerve cell growth by topological cues and electrical signals through the use of photonic crystals. These crystals are relatively easy to make. Specifically, they are highly conductive and controllable. There is still a significant room for the optimization of nerve conduits, because a number of the parameters which affect the clinical effects as well as the underlying mechanisms of their use are still not well understood . AccordiThe evolution of biomimetic ECMs is of great significance in neuron tissue reparation and regeneration. The existing research has shown that electrostimulation of neurons in the absence of topological characteristics can guide axonal extension. During nerve repair and regeneration, the growth behavior of nerve cells is regulated by the directional morphology of a scaffold, the mechanical stretching of the scaffold, and the electronic signals in the scaffold. However, the existing studies do not consider the above factors together to regulate cell growth behavior. A technical problem for neuroengineering is how to develop a strategy that can combine the advantages of all these factors to further improve nerve cell growth . Accordi


The MUSIC® Model of Motivation is used to help instructors select strategies that can increase students' motivation and engagement in courses. The MUSIC model is comprised of five categories of strategies titled: empowerment, usefulness, success, interest, and caring. The purpose of this study was to examine the extent to which the MUSIC® Model of Academic Motivation Inventory , demonstrates acceptable psychometric properties when used with students enrolled in a College of Veterinary Medicine. The inventory is comprised of five scales that correspond to the five MUSIC model components, and it measures the extent to which students perceive that: they have control in the course (empowerment); the activities in the course are useful to their future (usefulness); they can succeed in the course (success); the teaching activities and coursework are interesting (interest); and the instructor cares about students' learning and well-being (caring). The inventory has been validated for use with many different student populations, including students in different countries and of different ages . However, the inventory has not been validated for use with veterinary medicine students. We analyzed the data from 578 questionnaires that were obtained from students in six different courses at a College of Veterinary Medicine. We examined the psychometric properties of the MUSIC inventory by: (a) computing the internal consistency reliabilities for the scales; (b) calculating the fit indices and factor loadings obtained from confirmatory factor analyses; and (c) computing correlation coefficients between the inventory scales and students' self-reported effort in the course. The results provide evidence that the inventory demonstrates acceptable psychometric properties for use with veterinary medicine students. Consequently, the MUSIC Inventory can be used by researchers and instructors to assess students' motivation-related perceptions of courses. The MUSIC® Model of Motivation  is aempowered by having the ability to make decisions about some aspects of their learning, (2) understand why what they are learning is useful for their short- or long-term goals, (3) believe that they can succeed if they put forth the effort required, (4) are interested in the content and instructional activities, and (5) believe that others in the learning environment, such as the instructor and other students, care about their learning and about them as a person”  “measurventory” , p. 4]. Researchers have validated the College Student version of the MUSIC Inventory for use with undergraduate students in the U.S. , 14, ChiGiven the potential benefits of using the MUSIC model and associated MUSIC Inventory with students in professional schools, we sought to determine the extent to which the MUSIC Inventory would produce valid and reliable scores when used with veterinary medicine students. Because the MUSIC Inventory has been successfully validated with samples of students with various levels of education, including those in professional schools , we hypPace et al.  found thParticipants were enrolled as first- or second-year students in the College of Veterinary Medicine at a large, public university in the Eastern United States. Students completed an online questionnaire near the end of their course about their perceptions of the course. At the end of the questionnaire, students were invited to give their consent to allow their questionnaire responses to be used as part of our study. Only students who gave consent to participate in the study were included. This study protocol was approved by the Institutional Review Board (IRB) at the institution of the lead authors.We included the responses of students from six different courses and each course was comprised of about 132 students. The courses were typical of those offered by veterinary schools in the U.S. and included topics such as anatomy, physiology, radiology, histology, nutrition, pharmacology, immunology, communication skills, and professionalism.The number of students in each course who completed all of the questionnaire items and provided consent to participate in the study ranged from 82 (62.1%) to 106 (80.3%) see . More st1 = Strongly Disagree, 2 = Disagree, 3 = Somewhat Disagree, 4 = Somewhat Agree, 5 = Agree, 6 = Strongly Agree. A mean scale score is computed by averaging the items in each scale. For example, the four interest items are averaged to obtain a mean scale score for interest. The scales measure “the degree to which a student perceives that: he or she has control of his or her learning environment in the course [empowerment]; the coursework is useful to his or her future [usefulness]; he or she can succeed at the coursework [success]; the instructional methods and coursework are interesting [interest]; and the instructor cares about whether the student succeeds in the coursework and cares about the student's well-being [caring]” ” . aring]” [ and examaring]”  and thaWe assessed the internal consistency reliability for all of the MUSIC Inventory scales by calculating Cronbach's alpha values using SPSS (version 23). We used the criteria provided by Kline  to assesTo examine how the MUSIC Inventory items in our study fit the five-factor structure of the MUSIC model, we conducted confirmatory factor analyses (CFAs) using LISREL (version 8.80). We used three fit indices to assess the results of the CFA: the Comparative Fit Index (CFI), the Standardized Root Mean Square Residual (SRMR), and the Root Mean Square Error of Approximation (RMSEA). Based on Hu and Bentler , CFI valWe computed Pearson's correlation coefficients for the MUSIC scales and, based on prior studies , we expeTo provide evidence for the predictive validity of the scales, we computed Pearson's correlation coefficients using SPSS version 23) to assess the relationship between the MUSIC Inventory scales and students' course effort. Because increases in students' MUSIC perceptions should lead to greater effort , 2, 13, 3 to asse*(number of coding disagreements between coders/number of times that the codes were utilized). The inter-rater reliability rate was 89.5% for Course 5 and 90.8% for Course 6  involved an analysis of the students' responses based on a grounded theory approach , 27. Twon ranged from 82 to 106; see To obtain sufficient statistical power and precision to conduct the CFAs , we sought a sample size of about 200. Although no single criterion can be used to determine a sufficient sample size for a CFA, common rules of thumb used by researchers include: (a) obtaining a minimum of 100 to 200 cases –30 or b, 32, whiWe used the Cronbach's alpha values shown in The MUSIC Inventory scales were moderately correlated with each other as expected, with most correlations falling in the range of 0.30 to 0.60 see . The fitTo examine the predictive validity of the MUSIC Inventory components, we correlated the MUSIC scales with students' self-reported course effort and course rating. The correlation coefficients between the MUSIC scales and course effort were fairly low and ranged from −0.20 to 0.45 see Table 3). The correlation coefficients between the MUSIC scales and course rating ranged from 0.13 to 0.68, which indicated a moderate correlation  demonstrates acceptable psychometric properties when used with students enrolled in a College of Veterinary Medicine. To accomplish this purpose, we conducted the following analyses: (a) we calculated Cronbach's alpha values for each MUSIC Inventory scale to assess the reliability of the scales, (b) we computed the fit indices and factor loadings using CFA to assess the construct validity of the scales, and (c) we calculated correlation coefficients between the MUSIC Inventory scales and measures of effort and course quality to assess the predictive validity of the scales. In this section, we discuss the results of each of these three analyses and how they can be interpreted to provide evidence for the validity of the MUSIC Inventory.All of the Cronbach's alpha values were found to be acceptable, which indicates that the four items within each scale are highly correlated as expected. The Cronbach's alpha values were also fairly consistent across all three samples see , as is e2 = 31%), which indicates that over two-thirds (69%) of the variance was not shared. We expected the scales to be somewhat correlated because these constructs have been shown to be related .To understand why effort was correlated with some of the MUSIC scales and not others, we examined the reasons students provided for the open-ended item see . For theinterest component of the MUSIC model, some students reported that they put forth effort because the course or material was interesting or enjoyable; or conversely, that they did not put forth effort when the topics were not interesting. These findings were consistent with the positive correlations between interest and effort in the three samples .For the success component of the MUSIC model, it is impossible to determine students' success perceptions based on their responses to the open-ended item, with one exception . Some students reported that they did not put forth effort when they thought that the course was easy or when not much time was needed to study. Their belief that the course was easy implies that they believed that they could succeed. Therefore, they could have had high success perceptions, yet not had to put forth a lot of effort in the course, resulting in a negative correlation between the success and effort variables. Because the relationships between success perceptions and effort for other students in these classes could have been positive, negative, or insignificant, when all of the students were combined, it resulted in a small relationship between success perceptions and effort . Future studies could examine how students' perceptions of success interact with their perceptions of course difficulty to affect students' effort in courses.For the The responses to the open-ended item did not include reasons that directly related to students' empowerment or caring. Consistent with this finding, the correlations between students' effort and empowerment were insignificant and the correlations were small for caring in two samples and insignificant in one sample. It is possible, however, that empowerment and caring affect students' effort indirectly through their relationships to the other MUSIC components.In sum, veterinary medicine students are motivated by a variety of factors, some of which appear to be within the instructor's control  and other factors that may not be, such as students' desire to achieve a high class ranking and to maintain a work-life balance. Being aware of these different motivations may help instructors to design instruction that not only engages students in the coursework, but also takes into consideration students' other motivations in life.caused the high ratings, it may be possible for instructors to intentionally select teaching strategies that increase students' MUSIC perceptions, which may lead to increases in students' perceptions of the course quality. In fact, researchers have conducted interventions intended to increase students' perceptions of one or more MUSIC model components and these interventions have resulted in increased motivation and engagement [for examples, see caused thinstructors can use the scores from the MUSIC Inventory to enhance their instruction in areas that are rated lower. For example, if students' scores on the interest scale are low, instructors could choose one or more strategies to increase students' interest, such as varying instructional activities, involving students in discussions, or trying different teaching approaches [see ,,instructInstructors could also use the MUSIC Inventory scores at the individual-level, by examining individual students' scores to better understand why any one particular student is not putting forth effort in the course. For example, if a student reports low scores on the usefulness scale, an instructor could consider strategies to increase that student's perceptions of the usefulness of the content. At the program-level or college-level, the inventory could be used to compare students' perceptions across courses to identify strengths and weaknesses in particular courses, curricula, or teaching approaches.researchers can use the inventory to assess students' perceptions of instruction for a variety of purposes. For example, researchers could survey students before and after an intervention. Researchers could also investigate the relationships between students' MUSIC perceptions and other antecedents and consequences, such as students' professional goals and identity [e.g.,  Chair, David M Moore, approved the New Application request for the research protocol. Students were provided with an Informed Consent Form (approved by the IRB) at the end of the online questionnaire that was used to collect the data. Only students who elected to participate in the study were included in the study. Because the study was determined by the IRB to involve only minimal risk, the protocol was approved as Exempt, under 45 CFR 46.110 category(ies) 1,2,4.BJ and MB conceptualized the study and collected the data. BJ, MB, and MJ analyzed the data. BJ and MB drafted the manuscript with suggestions from MJ.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.


A thorough evaluation of the adequacy of clinical practice in a designated health care setting and temporal context is key for clinical care improvement. This study aimed to perform a clinical audit of primary care to evaluate clinical care delivered to patients with COPD in routine clinical practice.Community Assessment of COPD Health Care (COACH) study was an observational, multicenter, nationwide, non-interventional, retrospective, clinical audit of randomly selected primary care centers in Spain. Two different databases were built: the resources and organization database and the clinical database. From January 1, 2015 to December 31, 2016 consecutive clinical cases of COPD in each participating primary care center (PCC) were audited. For descriptive purposes, we collected data regarding the age at diagnosis of COPD and the age at audit, gender, the setting of the PCC , and comorbidities for each patient. Two guidelines widely and uniformly used in Spain were carefully reviewed to establish a benchmark of adequacy for the audited cases. Clinical performance was analyzed at the patient, center, and regional levels. The degree of adequacy was categorized as excellent (> 80%), good (60–80%), adequate (40–59%), inadequate (20–39%), and highly inadequate (< 20%).The During the study 4307 cases from 63 primary care centers in 6 regions of the country were audited. Most evaluated parameters were judged to fall in the inadequate performance category. A correct diagnosis based on previous exposure plus spirometric obstruction was made in an average of 17.6% of cases, ranging from 9.8 to 23.3% depending on the region. During the audited visit, only 67 (1.6%) patients had current post-bronchodilator obstructive spirometry; 184 (4.3%) patients had current post-bronchodilator obstructive spirometry during either the audited or initial diagnostic visit. Evaluation of dyspnea was performed in 11.1% of cases. Regarding treatment, 33.6% received no maintenance inhaled therapies (ranging from 31.3% in GOLD A to 7.0% in GOLD D). The two most frequently registered items were exacerbations in the previous year (81.4%) and influenza vaccination (87.7%).The results of this audit revealed a large variability in clinical performance across centers, which was not fully attributable to the severity of the disease. To the best of our knowledge, this is the first ever clinical audit of primary clinical care delivery to COPD patients in Spain. The results of this study indicate that there is considerable variability in clinical performance, not completely attributable to the severity of the disease. Identification of the determinants of this variability will help us understand clinical behavior, and establish strategies to strengthen clinical practice for COPD in primary care.Measurement of the adequacy of clinical practice in a designated health care setting and temporal context is key for clinical care improvement. In this regard, clinical audits provide an innovative tool to assess the quality of care, playing a significant role in highlighting the gaps between the recommended practices and the care that patients actually receive . AccordiChronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with extrapulmonary implications that poses a major burden for the patient and the health system , 4, withUntil the last few years, clinical audits for COPD were not frequently carried out. Over the last several decades, the United Kingdom , followehttps://www.rcplondon.ac.uk/COPD). Based on our previous audit experiences, we have developed a clinical audit for COPD patients in the primary care setting in Spain. In this manuscript, we describe the full methodology and main results of this clinical audit regarding guideline adherence in primary care centers (PCC) in Spain. The results of this audit will serve as a basis for an improvement in health care delivery for COPD patients.The information regarding how COPD patients are treated in the primary care setting is essential and would provide very relevant information on the process of care. It might also reveal the key areas wherein improvements are required in order to complete the picture obtained in secondary care audits. Therefore, formal clinical audits in primary care are emerging to evaluate clinical performance in this setting using a standardized methodology  study was an observational, cross-sectional, multicenter, national, retrospective, and non-interventional clinical audit aimed at evaluating the clinical care delivered to COPD patients in randomly selected primary care centers in Spain. This is the result of a joint project between the Spanish Primary Care Respiratory Group (GRAP) and the Spanish Society of Pneumology and Thoracic Surgery (SEPAR). The enrolment of participants and data collection was performed retrospectively.The The COACH study was managed by a steering committee comprising two primary care physicians and two pulmonologists, with expertise in COPD care and clinical audits. One of them acted as a project manager for the daily oversight of the project. Each participating region selected a primary care physician to act as regional project coordinator. Altogether, the steering committee including the project manager and all regional representatives formed the expert panel, an operational group that was responsible for ensuring the success of the data collection and which provided feedback on the process and suggested improvements through regular face-to-face meetings and teleconferences. Within each participating region, a number of PCC were selected, and primary care physicians were appointed as local investigators responsible for local data collection on patients and the organization of care.A list of all PCC in Spain was obtained from the official web pages of regional health systems in the country and entered into an Excel spreadsheet . Since the size of each region and their respective number of provinces varied, the arbitrary proportion of PCC to be selected in each province was 10%, as determined by the expert panel. The Excel spreadsheet was thus programmed to randomly select 10% of the PCC in every province. Each regional representative was responsible to contact their respective selected centers to explain the project, offer participation, and obtain the final local approval. If any center rejected participation, this was replaced by the next center on the randomization list.Two different databases were built: the resources and organization database for recording information on the availability of resources in the PCC regarding COPD care, and the clinical database for recording clinical information from audited cases. The steering committee created the first draft of the databases, which were further revised in a face-to-face kick-off meeting that took place in Madrid on September 13th, 2014, and by email and teleconferences thereafter to refine the final version.For descriptive purposes, we collected data on age at diagnosis of COPD and at audit, gender, setting of the PCC , and comorbidities. Rural areas were defined as areas with a population of less than 25,000. Comorbidities were evaluated by Charlson  and a COFor audit evaluation purposes, two guidelines widely and uniformly used in Spain – the Global Initiative for Obstructive Lung Disease (GOLD) guideline  and SpanThe accuracy of the diagnosis was confirmed by previous exposure to inhalational irritants plus a post-bronchodilator non-reversible obstruction on spirometry. Information regarding previous exposure to noxious particles or gases included a history of active smoking, passive smoking, occupational exposure, biomass exposure or any other form of exposure judged to be relevant to the diagnosis as reflected in the medical record. Limited reversal of airflow was assessed by post-bronchodilator spirometry; however, after the first evaluation we noted that most patients had only a pre-bronchodilator spirometry. Therefore, we used pre-bronchodilator values for those cases without post-bronchodilator spirometry values. The obstruction also had to be present during the last recorded visit to consider it non-reversible.2 agonist (LABA) or a long-acting muscarinic antagonist (LAMA), as the basis for pharmacological treatment, the compliance with the GOLD recommendations in pharmacological prescription, adequate recommendation on non-pharmacological treatments including advising to quit smoking, vaccine recommendations, and exercise recommendations, were recorded.From a therapeutic point of view, the use of a long acting bronchodilator (LABD), either a long-acting ßFor the adequacy of maintenance inhaled therapies, we assumed the following scenarios to reflect incorrect prescriptions: GOLD 2017 B-D patients without any medication recorded, any patient on inhaled corticosteroids (ICS) alone, and those treatment plans that duplicated drugs in combined and single therapies.Information was recorded by an ad-hoc built database via a centralized web page. A freelance web programmer with experience in database management was commissioned to create this website and the structure of the database. The website was organized as a hierarchical tool with different levels of responsibilities and rights to process data. Only members of the steering committee had full access to all data and the right to process them. At the regional level, there was a hierarchical access for regional administrators down to the level of local investigators coordinating the local data collection. To minimize a potential bias due to several auditors evaluating different medical records from different systems, we trained the auditors on how to proceed during data gathering and established limitations and rules in the database.Data was collected from January 1, 2015 to December 31, 2016. The doctors in charge of the patients were unaware of the audit. During this period, the local investigator consecutively reviewed the medical records for confirmed cases of COPD and recorded the audit information for 80 cases per PCC. Accordingly, the selection of cases was based on a registered diagnosis of COPD in the medical record. No diagnostic criteria were considered for inclusion, since assessing the quality of the diagnoses was an outcome of the audit. The classification of patients as having COPD within the medical records was sufficient to include them in the audit. No exclusion criteria were defined.The study complied with the ethical requirements of the Helsinki Declaration regarding studies involving human subjects and with the Spanish regulation on data protection and confidentiality . The study was evaluated by the Spanish Agency for Medicine and Health Products and classified as a not post-commercialization observational study. The main ethical approval was obtained from the regional ethical committee of Andalusia region  and any other participating region if required based on regional legislation. The clinical records were anonymized in the database by assigning a numerical code through an algorithm. No personal information that could be used directly or indirectly to identify an individual was entered. The relationship between the audit code and the clinical history number was kept locally, being the responsibility of the local investigator to avoid duplications. Because of the retrospective nature of the study, the anonymization of data, and the lack of active research interventions, the need for informed consent was waived. The ethics committee was aware of these circumstances clearly explained in the protocol, and approved this procedure.All computations were performed using SPSS Statistics version 20.0 . Before performing any analysis, the database was evaluated for quality. The values that were extreme from a clinical point of view, missing, or inconsistent were returned to the investigators for correction. The clinical variables are presented as means and standard deviations or absolute and relative frequencies, as appropriate, at the patient level. The variability was expressed by using the inter-regional range, which represents the highest and lowest mean values from the participating center at the regional level, and the inter-center range, representing the highest and lowest mean values from the audited cases at the PCC level. Five centers with less than 10 included cases were not considered in calculating the inter-center range. Due to the low number of cases in the Balearic Islands, they were not considered in the calculation of the inter-regional range. The significance of this variability among the different participating centers and regions was explored for quantitative variables by the ANOVA test, after checking the equality of the variances with the Levene test. If the homoscedasticity assumption was not met, we used the Welch test. For the analysis of the categorical variables, we used the Chi-square test. The alpha error was set at 0.05 (two-tailed).Based on previous experiences by our group , the deg1) was not significant.During the study, 4307 cases from 63 PCC in 6 regions of the country were finally audited Fig. . The desThe results of the clinical audit in terms of diagnostic and clinical evaluation are summarized in Table The most frequently registered non-pharmacological therapies were vaccinations. Interestingly, current smoking habit was registered in 43.5% of audits, similar to the value for registered exercise. Three other key aspects of non-pharmacological evaluation, namely treatment adherence, adverse effects, and inhaler satisfaction, were rarely registered.Regarding the complementary tests, spirometry was performed in a minority of cases. Alpha 1-antitrypsin determination was the only item showing no significant variability among regions, and this was anecdotal. Other tests and assessments including computed tomography scan and sputum eosinophils, as well as health-related quality of life, were more rarely obtained from the medical records (data not shown).The use of current therapies for COPD is summarized in Table The results of this study indicate that there is considerable variability in clinical performance that cannot completely be attributed to the severity of the disease. Most evaluated parameters were judged to fall under inadequate performance, except two  that were classified as excellent.https://www.rcplondon.ac.uk/COPD).There is increasing evidence and awareness that patients with various health problems do not consistently receive the recommended care despite the multitude of clinical practice guidelines and there is a gap between the clinical care provided and that recommended by practice guidelines . In thisThe diagnosis of COPD is of utmost importance. The latest version of the GOLD criteria requires three main components for a correct diagnosis including respiratory symptoms, previous exposure to noxious gases and particles, and obstruction on post-bronchodilator spirometry. Our results showed that in the primary care setting, some of these three criteria were missing in a high proportion of patients. Even if older versions of the GOLD criteria are applied  and the results of pre-bronchodilator spirometry in the absence of post-bronchodilator spirometry results are used, the number of acceptably diagnosed cases would still be low, only on the basis of previous exposure and the presence of obstruction. In this context, the availability and use of spirometry in primary care is essential. In the UK, a recent analysis pointed out that although the quality of spirometry procedure undertaken in primary care is high, this does not reflect the quality of interpretation, suggesting an unmet training target in primary care . In SpaiIn 33.6% of cases, there was no information on maintenance inhaled therapies. This finding has been previously reported but with a considerable difference. A recent analysis of the medical records of 3376 patients from a general practice in Denmark revealed that 74.4% of them did not receive any maintenance inhaled medication even after the spirometric diagnosis of COPD , receiveDouble bronchodilation was probably underestimated during the period of the audit, as double bronchodilator therapy was not widely available at the time. Only one (indacaterol-glycopyrronium) of the 4 double bronchodilator medications later approved in Europe for the treatment of COPD  was avaiPrevious studies have reported the overuse of ICS, as well as an increase in their use for all GOLD patient types. Price et al. have reported the use of ICS in 50% of COPD patients in primary care settings in the United Kingdom . In the 1 was not significant, suggesting that the variability found is not related to disease severity as measured by this parameter. Previous studies have demonstrated significant variability in the processes and outcomes of COPD care in different settings [Overall, there was a considerable variability among the different regions of the country and PCCs, which was significant for the majority of variables due to the large sample size. Interestingly, the variability of FEVsettings , 47. It settings . The cluClinical audits have gained traction in healthcare systems as a way of obtaining information on the clinical care being provided, as shown by a recent qualitative study in a primary care setting . This inThe strengths of this project are the potential to raise the profile of COPD, and provide an opportunity to promote respiratory medicine in the community, offer suggestions and recommendations on organization of care for the future COPD management guideline, and develop educational resources to support improved clinical practice in all areas, especially those identified as poor practice. Also, the audit provides a formal documentation of the difference between recommended best practices and the status quo, thereby identifying areas requiring improvement.To interpret the results correctly, several key aspects of the methodology must be considered. First, the audit assessed interventions that had already been performed, and not the results thereof. For instance, it assessed if the physician in charge registered the degree of dyspnea, rather than the intensity of dyspnea after intervention. Thus, the aim of the audit was not to have an idea of the clinical situation of the patient but to have an idea of the clinical performance of the practitioner. Second, the clinical audit made its evaluation from the contents of medical records. Therefore, what was not documented was not evaluated. This does not imply that no intervention had taken place. Accordingly, the estimates presented here were those inferred from the medical record and we may have underestimated the actual figures. The need to record every aspect of clinical practice in the medical record has been previously emphasized , and ourIn summary, our results show areas of greatest concerns in COPD care. Clinicians should be aware that only a correct diagnosis makes it possible to select proper pharmacological treatment for COPD, that COPD cannot be diagnosed without proving irreversible obstructive pattern on post-bronchodilator spirometry, that cigarette smoke exposure and especially duration of smoking in years is an important risk factor for the disease and should be systematically evaluated, that smoking cessation, physical activity, nutrition, vaccinations as well as recognition and treatment of comorbidities are key in the management of the disease beyond the use of bronchodilators, and that the use of the different pharmacological approaches should be patient-tailored, and confined to those who do get the benefit from them with no harm.In conclusion, the present analysis, to the best of our knowledge, is the first ever clinical audit carried out in SpanishPCC to evaluate clinical performance in stable COPD patients. The results show that there is a considerable variability in clinical performance not fully attributable to the severity of the disease and that the majority of the evaluated parameters fell in the range of inadequate performance. A study of the determinants of this variability will help us to understand clinical behavior, and establish strategies to strengthen the clinical practice of COPD management in primary care.


Intimate partner violence is a common social problem which causes considerable relationship stress and results in significant morbidity and mortality of the victims. Botswana, like many other countries in sub-Saharan Africa, has tried to address the problem of intimate partner violence with legislations prescribing punitive measures for the perpetrators and protection for the victims. The effectiveness of these measures in reducing the prevalence of intimate partner violence is doubtful. This article is to motivate for an alternative primary preventive approach to the problem as a more pragmatic option. They are often familiar with the individual and may be recognised socially as couples. However, sexual intimacy is not compulsory to define an intimate partner relationship.3 Chapter 2 of Section 7 of the Constitution of Botswana adopted in 1966, and amended in 2006, includes the following provision: No person shall be subjected to torture or to inhuman or degrading punishment or other treatment.4 By implication, IPV falls within the ambit of this provision. The Domestic Violence Act 2008 of Botswana specifically describes actions that constitute IPV and prescribes legal steps that can be resorted to by the victims for their protection and enforcement of their rights as enshrined in the constitution.5 It is doubtful if these legal measures have made any impact on the perpetration of IPV in Botswana. There are no consistent structured measures applied to prevent IPV in Botswana as most victims of IPV prefer keeping the problem to themselves. Health practitioners with a high index of suspicion, from the nature of lesions presented with by the patients, are sometimes able to identify IPV sufferers. However, these are often under-reported and consequently poorly managed. The aim of this article is to motivate for a primary preventive approach to addressing the problem of IPV in Botswana.Intimate partner violence (IPV) is a social problem with global prevalence. It is described as physical, emotional, stalking, sexual or psychological oppression of an individual by a person who is privy to the individual’s life by virtue of a current or past intimate relationship.6 A systematic review and meta-regression of 141 studies from 81 countries in 2010 estimated the global lifetime prevalence of IPV as 30% .7 However, this estimate excluded emotional and psychological intimate violence, which though not as readily substantiated is as traumatising and dehumanising as physical IPV.Intimate partner violence is a pervasive social problem with about one in three women having experienced it once in their lifetime.6. Intimate partner violence is thus the leading cause of female homicide globally, in South Africa and probably in most other countries in sub-Saharan Africa.9The World Health Organization (WHO) in a review of data on IPV between 1982 and 2011 estimated that as many as 38% of homicidal deaths of women globally resulted from murders committed by their intimate partners.11 Most IPV victims present with these medical conditions and are only detected to be IPV sufferers when the attending health practitioner has a holistic approach and a thorough clinical consultation. Thus, IPV causes increased health care utilisation with the attendant costs of managing the associated medical conditions.10Apart from injuries or death, victims of IPV are more likely to develop medical conditions like asthma, bladder and kidney infections, circulatory conditions, cardiovascular disease, fibromyalgia, irritable bowel syndrome, chronic pain syndromes, central nervous system disorders, gastrointestinal disorders, joint disease, migraines and headaches.13 This is even more likely in an environment with a high HIV prevalence like Botswana. Coercive male controlling behaviour which is common in Botswana, especially when associated with physical and emotional IPV, has been associated with HIV infection.14 They are also more likely to have other sexually transmitted infections, unintended or unwanted pregnancies and negative pregnancy outcomes like preterm deliveries, low birth weight babies and perinatal deaths.11Women who experience physical, emotional or sexual IPV are also more likely to get infected with HIV.10Psychological disorders associated with IPV include anxiety, depression, post-traumatic stress disorder, antisocial behaviour, deliberate self-harm and suicide in females, low self-esteem, inability to trust others especially in intimate relationships, emotional detachment, sleep disturbances and flashbacks.10Victims of IPV are also more likely to abuse psycho-active substances such as tobacco, alcohol and other illicit drugs as a maladaptive way of coping with stress. They may have multiple sexual partners, engage in high-risk sexual activities and transactional sex.Although data on IPV are not available in all countries, it appears that IPV is present in all countries globally. The intensity and extent may however vary according to different communities and cultures.Although data on actual prevalence of IPV in Botswana are scanty, unpublished reports indicate a high prevalence of IPV in Botswana, with extreme homicidal cases locally referred to as passion killing. Passion killing is the common parlance for the murder of an individual  by the intimate partner. The partner may be a current or estranged lover or even in some instances a man whose offer of a relationship was rejected by the victim.15 More than one-quarter of the women interviewed admitted that they experienced some form of IPV within 12 months prior to the survey, while close to half of the men interviewed admitted perpetrating IPV.15A 2012 self-reported survey of 1229  citizens of Botswana aged 15 years and above, from remote settlements, rural and urban areas of Botswana, reported a lifetime prevalence of IPV of 67% among the women.15 Emotional IPV could be in the form of verbal abuse, derogatory comments or actions, or by deprivation of physical, financial, psychological or material needs of the victim. Women aged 18–44 years were the most affected by IPV, and men aged 18–29 years perpetrated most of the IPV.15 A role for transgenerational relationships in IPV was not demonstrated in the survey conducted in Botswana.The most common type of IPV reportedly experienced by women interviewed was emotional.14 Here again, the role of lack of assertiveness as a result of economic dependence was not demonstrated in the Botswana context.In Botswana, educated and employed women appeared to experience more IPV compared with their unemployed and less educated counterparts, but it may be argued that educated and employed women in Botswana may be less tolerant of IPV and more likely to report their experience. Similarly, men with higher educational status admitted to perpetrating IPV more than men with lower levels of education.14As was found in other southern African countries, cultural beliefs about the unquestionable rights of men to have sex on demand in relationships, and acceptance of partner beating as permissible, played a major role in the prevalence of IPV in Botswana.15Childhood experience of abuse or violence seems to play an important role in later experience or perpetration of IPV in Botswana. Most (88%) of the women who had experienced IPV and about two-thirds of the men who admitted perpetrating IPV reported being abused as children. About half of these women had also witnessed their mothers experiencing IPV. A quarter of the men who admitted perpetrating IPV had witnessed their mothers experiencing IPV.16The key factors found to drive IPV in Botswana are gender attitude, alcohol and other substance abuse, and relationship conflicts.18The notion of male dominance and female subservience is common and accepted by many communities in Botswana. Some form of discipline, physical or psychological, inflicted on their female partners is commonly culturally accepted as the right or prerogative of men in relationships. Most communities will only frown at the excessive measures used by men, such as that which results in profound injury or death of the partner. This gender attitude is promoted from childhood where the male child is accepted to be more aggressive and dominant while the girl child is encouraged to be more domestic, subservient and tolerant.16Alcohol in both regulated and locally brewed forms are consumed by many youths in Botswana. Many also abuse other psycho-active substances, the most common of which is cannabis, locally known as dagga. About 25% of men who reported perpetrating IPV also admitted having taken alcohol and other intoxicating substances within 12 months prior to the survey.15Suspicion of infidelity appears to contribute to the experience of IPV in Botswana. Half of the women who reported experiencing IPV within 12 months prior to the survey felt that their partners were having other affairs and cheating them, and it may be inferred that their approach to the relationship conflict may have played a role in their experience of IPV.Various forms of educational materials, mainly in print media, are used to convey messages discouraging IPV. Once a while, non-governmental organisations promote walk-throughs in the community to draw attention to the evils of IPV.kgosi) of the community. Usually, the relatives of the IPV victim report the cases when the victim has suffered significant injury from the perpetrator. The perpetrator is then penalised with corporal punishment such as strokes of cane and the case is usually concluded. The impact of these courts as a deterrent to IPV perpetration is very doubtful.These courts provide jurisprudence over domestic issues and are a recourse for victims of IPV. The courts are presided over by the chief . This may help to prevent them from experiencing or perpetrating IPV in later life. However, CBT was not found to consistently prevent recidivism among adults who had experienced or perpetrated IPV.Addressing the feminist theory would need programmes targeting key leaders and influential stakeholders in the communities for continuous reorientation of their perception of gender roles. Workshops, seminars, theatrical performances and other means may be used to gradually change the paradigm of people in the community.26The programmes should be comprehensive in scope: different driving factors for behaviours leading to IPV in the Botswana context should be addressed concurrently. Aspects of the programme could focus on training healthy ways of communication and conflict resolution in relationships. Other aspects could dwell on motivating behavioural change on alcohol or other substance abuse at individual levels and developing communally acceptable strategies to discourage excessive alcohol intake.Ideally, the programmes should focus on preadolescents and adolescents, and they should be implemented in youth-friendly ways as this would promote better cooperation and participation by these youths.30The programmes should have a variety of presentation modalities. As much as possible, they should be interactive, engaging the youths themselves in lively hands-on learning sessions. Peer influence should be used positively by having fellow youths as guest speakers in discussions, symposia or seminars. Role plays, theatrical performances and peer education may also be effective ways of presenting the programmes. Involving the youths themselves in the programme delivery and the use of lively interactive formats would be more acceptable to the preadolescent and adolescent age groups targeted for the programme. The interventions should encourage healthy behaviours in both intimate and regular, non-intimate relationships such as with their teachers and neighbours32Programmes targeting community leaders may be enhanced by the use of video shows, highlighting the effects of IPV. Small group participatory workshops may also be efficient ways of challenging existing beliefs and encouraging collective action against IPV. There may be the need for adequate education and preparation of community leaders to obtain their acceptance and support for the programme. Every effort should be made to ensure that the programmes are sensitive to and respect the sociocultural norms of the community. This can be performed by avoiding direct criticism of the sociocultural mores of the community and facilitating their own self-appraisal of the consequences of their belief paradigm in ways similar to what is used in psychosocial counselling.33Intimate partner violence involves behaviours and beliefs that are deeply rooted. Many are encouraged by cultural mores that have existed for generations in the community. Programmes that would influence changes in belief paradigms and eventually motivate healthy relationship behaviours need to be delivered in sufficient time and consistently for considerable duration. There are no empirical data to support optimal timing of the intervention delivery, and they may be context specific depending on the prevalence of driving factors for IPV in the community. It is expedient to provide multiple sessions of programme interventions and continuous reinforcement over 2 years or more before expecting a significant impact on IPV.34The quality of the interaction with the participants during the delivery of the interventions is crucial to the success of the programmes. Thus, intervention leaders should be well trained and should adhere to the intervention protocols. They should be experienced in youth issues and have good knowledge of IPV. They should also be able to handle behavioural issues that may arise during the delivery of the interventions.27 A programme on the prevention of IPV may also be considered for inclusion in the primary and secondary education curriculum in Botswana. Increasing access to and encouraging participation in various sports like table tennis, chess, badminton, squash, football and swimming could engage the youths in safer activities and help reduce the recourse by youths to alcohol when idle. Inter-ward or inter-district sporting competitions may also be used to engage the interest of the youths in these sports, which may offer safer outlets for them to expend their energy.34Programmes addressing alcohol and other substance abuse as driving factors for IPV may consider provision of safer alternative recreational outlets for youths. Youths are usually energetic and tend to be restless when idle. Thus, occupying them with avenues to expend their energies on safer activities may help reduce their resorting to alcohol. Youths and adolescents are also more flexible and open to trying out new things. This should make this age group more amenable to change, the bastion for a primary preventive approach to addressing the problem of IPV.Opportunities for mass education of married men and women, and those about to get married, on the value of trust in relationships, stressing the avoidance of prying into the privacy of their partners, should be explored. This is a form of stalking and may result in relationship conflicts and IPV.21The goals and objectives of the programmes should be well outlined from the onset and should be feasible and measurable on achievement. Financial support for the programmes may require prioritisation by the government. This could be motivated for with appropriate, well-articulated proposals. Donor agencies may also be approached for financial leverage. Community-based randomised control trials are the best designs for demonstrating the impact of the programmes.To address the problem of IPV in Botswana, a shift in preventive modality from the present tertiary to a primary approach may yield more significant impact. However, a contextually relevant primary preventive strategy requires systematic, coordinated and sustained implementation of programmes with a comprehensive scope and commitment from all stakeholders. With proper planning and adequate financing, the primary preventive approach portends better prospects of significantly reducing the burden of IPV in Botswana.


In order for companies to realize their organizational visions, they need staff who are high-potential and looking toward the future. Due to the demographic, social and economic situation in Europe, the labor market is already reflecting a lack of high-quality human resources (HR), which inspires research into and planned management of high-potential, i.e., talented, employees. Companies are aware that only those organizations that recognize this area as crucial and invest resources into it will be successful in the “war for talent.” The purpose of the study was to research the field of talent management from the perspective of the definition of what the talent management process means for companies, how to attract and recognize talented employees, what development activities to provide them with and how to measure their performance and progress. We employed an exploratory approach, using the method of semi-structured interviews to gather information from 21 HR professionals who work at medium-sized and large Slovenian companies. We found that these organizations use various approaches and activities to attract and develop talented employees. At two thirds of the companies, performance is measured using annual evaluation interviews, by measuring the meeting of targets and evaluations by superiors. The biggest challenges in the field are attracting talented employees and positioning the organization as a desirable employer. The study is useful primarily as an overview of the field and of best practices, which companies can use to argument their existing processes. Human resources (HR) management professionals say that talent management, defined as the process through which organizations meet their needs for talent in strategic jobs , is one In addition to growing interest in research in the field of talent management, the labor market has also changed considerably in the last 10 years  due to dThe majority of definitions define talent management as a comprehensive, well-planned and systematic process that includes attracting, identifying, selecting, developing, and assessing talented employees, in order to increase efficiency of operations cf. . In compSome definitions mention an inclusive approach – the development of all employees so that they achieve their highest potentials cf. , where sThe definitions also vary with respect to how many areas they include under the concept of talent management; they can be divided into three groups – the first sees talent management merely as human resource management, predicting demand and personnel planning cf. , which oOne of the most important concepts relating to attracting and retaining talented employees is the corporate brand, as its qualities and popularity increase the perception of its value . Job selMany companies when planning talent management think first of all about attracting talented individuals from the labor market, but pay less attention to using scientifically proven methods and approaches to recognizing talent . A studyHuman Resources personnel frequently question the rationality of whether or not to notify employees about being classified as talented. During economic booms companies face increased fluctuation, which brings to the fore the question of how to create conditions so that the best employees are retained. One of the possible answers is to provide education and training and skills development opportunities for talented employees. The challenge is to connect all of the important parts in a systematic manner that allows the development of the individual’s competences and at the same time indicates their performance. First the individual has to be analyzed – their experience, knowledge, skills and qualities – and then a work plan can be developed based on their strengths and weaknesses and the desired competences for a specific position or generally within the organization. It is important to stick to the plan, create an optimal environment for learning, create feedback loops from both sides, etc., . Organizsuccession planning – developing a pool of individuals whose advancement is planned , which is also the size at which companies start thinking about introducing specialized HR positions .Studies e.g.,  indicateIn view of the above findings, we decided to conduct exploratory research with semi-structured interviews in order to obtain an insight into the practice of talent management in medium-sized and large enterprises (with respect to the number of employees). We wished to analyze how organizations in Slovenia define the talent management process, how the process itself proceeds , how effectiveness is measured, and the future development guidelines in this area. We foresaw that we would obtain the largest amount of information on this from the HR professionals who represented our participants. Through a review of the literature and practices we want to contribute to the understanding of the talent management process in Slovenia and in the broader European context.N = 11), followed by the financial and insurance industry (N = 4), the information and communications industry (N = 3), motor vehicle sales, maintenance and repair (N = 2) and electrical, gas and steam power generation (N = 1).The study included 21 employees who work in the field of talent management in medium-sized and large enterprises in Slovenia. They included 16 heads of HR departments, two personnel development specialists, a regional HR generalist, an HR specialist and a psychologist. The sample included 13 large companies with over 250 employees, and eight medium-sized companies with 50 to 250 employees (in 2016 there were 339 large companies and 2027 medium-sized companies registered in Slovenia). The largest number of the companies in our sample work in the processing industries (N = 6), they do not engage in personnel development or talent management processes (N = 2) or they do not see any advantage of participating in the study for their own organization (N = 1), while 20 organizations did not respond to the original invitation. We also decided to stop sampling after 21 participants, as we reached the theoretical saturation point , meaning that the responses from later interviews became more predictable and no longer created added value , the purpose of the research, a description of the duties and requirements of the participants, the duration of their participation, any compensation, dangers and benefits, the voluntary nature of participation and protection of privacy. The interviews were conducted by a psychologist who guaranteed the anonymity of the participants. Sampling was conducted using the snowball method, as the researchers posted the invitation to participate on social and corporate networks, via their own social networks and electronic mailing lists. Only one restriction was included in the invitation, as we wished to restrict the sample only to employees of medium-sized and large Slovenian enterprises. We contacted a total of 50 organizations, of which nine refused the invitation, stating that they did not wish to participate because of time constraints  based on literature review. The next step was categorization, in which we placed the codes into a hierarchical structure, i.e., categories. Finally we conducted a comparative analysis in which company size was selected as the basis of comparison and the processes at medium-sized and large enterprises were compared. We also employed interpretation, where we attempted to place the phenomena into a broader context .Table 1), consists of acting in line with organization’s values, positive personality features, above average job performance and results, positive work related behaviors and intellectual capacity. More detailed revision of the answers is stated below.Definition of talent, gathered from answers of our participants  defined the process as inclusive: “…we manage all of our employees in the same way – all of them have talents that they can develop.” The head of HR at a medium-sized company used a new expression. “Instead of talent management we call the field giving perspective.”To the question of how companies define the talent management process and how they define the concept of talent, 13 participants (62%) defined talent management as an exclusive approach. Head of HR, large company: N = 10) are associated with the stream which is entirely focused on the management of talented employees. Thus the head of HR at a large company defines talent management as “… a series of activities that starts with attracting and continues with identification and development of talented employees. Nowadays retaining staff is becoming increasingly important…” Participants from seven organizations emphasize succession planning, which can be summarized with the definition “Talented employees are our key staff and their potential replacements.” The lowest number of companies (N = 4) equated talent management with human resource management, with the head of HR at a medium-sized company stating that: “Part of the duties of the HR department is to ensure the development of its employees.” If we view the talent management process through the lens of employees at medium-sized and large companies we find that nine large companies understand the process as exclusive and four as inclusive, while this ratio is even among medium-sized companies .With regard to the three streams of thought relating to talent management , the majMax = 20%, Min = 1%). When comparing medium-sized and large companies, medium-sized companies have a higher average number of recognized talented individuals (M = 11%) than large companies (M = 4%).During the interviews we also asked the participants additional initial subordinate questions about the number of recognized talented employees, the duration of planned talent management activities at the company and any obstacles to working in this field. The percentage of talented employees within the organizations is difficult to define, as some companies include key staff  in this group. In contrast, some companies cannot supply this data since they manage talent inclusively and do not separate employees into talent brackets. At companies that had data available, 7% of employees on average are recognized as talented (N = 3) participants were unable to respond to the question, as they joined their companies later and did not know exactly when their company had initiated the talent management process.The participants from six companies stated that they began the planned development of the field of talent management in 2017, despite the fact that the initial stages of the process go back several years. At that time they started focusing on the field more intensively and in a more planned manner, and also started communicating about it more. Five companies began introducing talent management and a succession system between 2010 and 2014, while one large company reported a longer period of involvement reaching back to a project in 2008. Some , education level  or seniority within the company . Other companies have defined various groups of talented employees , which includes the group of high-potentials with an age limit of up to 33 or 35. Some also see young employees who are hired immediately out of college as talented employees.N = 10) attract talented employees through scholarships, for both college and high-school students, planned brand management and cooperation with universities . They attend job fairs , and allow students to gain experience during their school years through traineeships and apprenticeships , work with high schools , update job listings in order to increase the company’s attractiveness  and hold company open houses . Less common practices  include joining the BusinessClass program, mentorship for Bachelor’s and Master’s theses, the organization of business hackathon  and working with career development centers. The participants also mentioned  occasional support for professional field trips for students, summer schools or extended educational programs for students. Six companies also mentioned special projects designed to attract specific groups of talented employees.The largest number of companies  use developmental interviews led by HR (at which the employee’s wishes and plans are discussed), and two companies encourage their employees to visit the HR department or a psychologist and recognize their talents collectively. The participants also mentioned taking into account the suggestions of managers  who identify talented employees in their departments and the information that they collect through the annual evaluation interviews (with respect to their job performance and performance over a longer period of time). Frequently, companies identify talented employees using the technique of calibration between management and HR , followed by calibration with the board of directors . A full 29% (6) of companies use psychological testing to identify talented employees, and 14% (3) also use employee evaluation centers. Nearly one fifth of companies  use workplace observation  and project evaluations . Some companies  organize the talent recognition process through applications which are open to all employees who meet the criteria, followed by a further selection process. Similarly, 14% (3) of companies recognize talented employees based on skills evaluation (using various versions of the 360-degree method). Other approaches, which are used by only a few companies, include: employee evaluations by managers , design and implementation of independent projects (more under Discussion), employee evaluation during the onboarding process, and an information system that collects data on employees and then makes talent appraisals .In order to recognize talented employees, the largest number of companies  reported that they communicate transparently, 19% (N = 4) do not share such information with employees, 14% (N = 3) share only a part of such information . If we compare large and medium-sized enterprises, 85% (N = 11) of large companies communicate the recognition of talented employees transparently, while only 38% (N = 3) of medium-sized companies do so.After the identification of talented employees, the selected employees must be notified. Two thirds of participants , talented employees are also afforded additional opportunities such as training abroad, mobility, inclusion in interdisciplinary teams, knowledge-sharing with other employees, inclusion in various external programs, connections to start-ups, meetings with members of the board of directors, and internal personal development programs.In addition to the aforementioned methods and approaches (N = 10) have a succession plan which includes talented employees. In the majority of cases the talent pools and the successor pools overlap, but not entirely. The other companies do not have succession plans, but say that it proceeds on a more intuitive level and non-systematically , or that they are planning in implementing one in the near future . A comparison of medium-sized and large companies indicates that a larger number of large companies have systematically determined succession (N = 7) than those that do not (N = 6), while only three medium-sized companies have planned succession, and five determine successors on an intuitive basis.We were also interested in whether they have established succession plans and whether talented employees were included in them. Just under half of the companies  measure employee effectiveness through annual evaluation interviews. The largest number of companies  use KPIs  to measure performance on a monthly, quarterly or annual basis. The same number of companies  measure job performance through the development of the individual’s skills, using the 360-degree method, evaluation centers or other tools. Targeted management is used at 38.1% of companies (N = 8), where the achievement of goals is checked periodically. One fourth of companies  entrust the assessments to managers who evaluate employee performance using various tools – questionnaires, scales or descriptive evaluations. Some companies check effectiveness via project evaluations , and at one of them this assessment is made by the heads of the various project groups, who each check certain targets. The following approaches are used less frequently: acting in accordance with values , evaluation of effectiveness via proposals for promotion or actual promotions in a certain time period, informal opinions , self-evaluations, performance scores with respect to the performance of the company as a whole, performance scores with respect to the performance of the individual department as a group, number of proposals or ideas that the individual makes or has in a certain time period.The data indicate that two thirds of companies , followed by retaining personnel  (N = 6) and maintaining staff in organizations in which there is no possibility of advancement. They also listed challenges in the area of managing expectations (N = 2) and transparency in communicating the succession plan and talent pool system (N = 2). Individual participants see potential difficulties in the area of the objective recognition of potentials, the creation of a good model for developing potentials, measuring the effectiveness of the talent management process and personnel planning. They wonder how to balance the complexity of the talent management process and the time that has to be invested in it by managers and HR departments and for development activities for recognized employees.Human resources professionals see the greatest future challenges in the area of attracting personnel , while others emphasize the development of the strengths of all employees (inclusive approach). The results indicate a similar trend to the research of other authors e.g., , since lin the time after the crisis talent management became a competitive advantage for companies that are fighting to attract talented employees.” Furthermore, during this period some companies created more specialized development positions within their HR departments. The organizations have differing perspectives on age, educational and other limits when selecting talented employees. Large companies on average recognized 4% of their employees as talented, which is in line with the results of other studies . The recognition of talented current employees is most often based on managers’ proposals and the expression of a desire to develop in interviews conducted by HR. Similar to the German study  and conduct in accordance with values as the most important factors.In the majority of companies the measurement of the effectiveness of talented employees does not substantially differ from the measurement of the effectiveness of all employees. Annual performance appraisal interviews are used by two thirds of the companies in our sample. Companies usually use KPIs, skills evaluation using the 360-degree method and targeted management, while the majority of the assessments are based on the evaluations of superiors or self-evaluations. The head of the HR department at a large company noted that “getting the right people into the right positions at the right time.”The participants see the greatest challenges in attracting personnel, particularly from the point of view of positioning on the market as a desirable employer, attracting young candidates, staffing deficiencies and attracting people who are committed and passionate about their work and who work in accordance with company values. They feel it is important to present the corporate culture, work methods and organizational values as accurately as possible during the selection process, and for managers to internalize how important it is to engage with people. With regard to retaining personnel, a HR professional at a large company noted that the most important factor is The results of the study present another bridge between academic interest and practice e.g., . A systeOne of the limitations of our study was the small sample size, which is difficult to extrapolate to all medium-sized and large companies. The sample also seems to be made up of companies that are perhaps not completely representative of the situation, as the study was proactively participated in by HR professionals at organizations with well-formed processes and which would like to share these practices with others. The results could also be affected by the participants’ subjective reporting, as we were not able to monitor the disparity between the projects the companies would like to implement and those that they actually have implemented, and the quality thereof. Additionally, Slovenia does have cultural and economic specificities, so a reader has to consider that when applying conclusions to other contexts.In view of the fact that the participants in our study were Slovenian companies whose talent management activities are conducted mainly in a planned manner, it would also be valuable to analyze those companies that believe they do not engage in talent management and that decided not to participate in the study. In order to improve the research, the entire evaluation of the talent management process could be supported by a questionnaire that would be filled out by both talented employees, HR departments, senior management and the boards of directors. This would give us more reliable data on talent management in various areas and from various perspectives. Since our study focused on an analysis at the organizational level, in future research it would also be worthwhile to focus on the individual level, on the perspective of the talented employees, through a comparative analysis of the content planned by HR professionals, which is then implemented by talented employees and used for their own development.In this analysis we obtained an insight into the scope of the field of talent management at medium-sized and large companies in the period after the end of the recession. The results indicate that we are still unable to provide a uniform definition of the talent management process, as neither uniform definitions nor uniform practices exist. The concept of talent is defined as a combination of a fit with organizational values, personal qualities and job performance. The majority of companies have only been involved in the planned implementation of the talent management process for the last 3 years, which coincides with the end of the economic crisis. On average, 7% of employees are recognized as talented. Organizations attract talented employees through various activities and the planned development of the employer’s brand. Recognition is most often based on management proposals and through interviews, whereby medium-sized companies operate more informally in this respect. The majority of the companies are transparent in their communications with talented employees. They develop talented employees using various activities in which those employees are more intensively involved. Half of the companies have a systematic succession plan, whereby medium-sized companies carry out the planning at a more intuitive level due to the changing organizational structure occasioned by growth. Effectiveness is measured using annual discussions at two thirds of the companies, by measuring the achievement of targets and evaluations by superiors. HR professionals see the greatest challenges in attracting personnel and in positioning the company as a desirable employer.The research involved cooperation of the Slovenian organizations, in which employers provide researchers access to detailed data in return for help generating a systematic review of the current areas and uncovered a number of unresolved issues. The findings can be used by HR professionals to upgrade their existing talent management processes, and offer opportunities for further research for professionals in the fields of psychology, economics, HR management and other areas.The administration adhered to the requirements of privacy and informed consent in the Slovene Law  and the ethical standards for research of the Declaration of Helsinki revised in Fortaleza , followed and approved by the Department of Psychology of the University of Ljubljana (Slovenia). The administration adhered to the requirements of privacy in Slovenia law and informed consent was collected for each participant.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.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.


The development of a health evaluation system from human-related data is an important issue in preventive medicine. Previously, most studies have focused on disease assessment and prevention in patients. However, even if certain risk factors are all within normal ranges, individuals may not necessarily be completely healthy. This study focused on healthy individuals to develop a new index to assess health risks; this index can be used for the prevention of multiple diseases in healthy people. The kernel density technique was proposed to estimate the distribution of common risk factors and to develop a health risk index. A dataset of hypertension, hyperlipidemia, and hyperglycemia (Triple H) data from the National Health Insurance Research Database in Taiwan was used to demonstrate the proposed analytical process. The results of risk factor changes after six weeks of exercise were used to calculate the health risk index. The results showed that the subjects experienced a 7.29% reduction in their health risk index after the exercise intervention. This finding demonstrates the potential impact of an important reference index on quantifying the effect of maintenance in healthy people. For a long time, the diagnosis and treatment of diseases have been critical aspects of medical development. Many scholars have used data mining techniques on medical data to analyze the relationships between disorders and the real causes of those disorders ,2,3,4. ACertain health care practices have also recently become more accepted; for example, people have started to use exercise, meditation, and diet to control risk factors. Whelton et al.  studied However, there has been little research on a method to evaluate the health status of a healthy individual when their risk factors change even after exercise maintenance. For example, hypertension patients are defined by an SBP of >140 mmHg or a DBP of >90 mmHg. When the SBP ranges between 120 and 135 mmHg, which is within the normal range, the resulting health effects may differ in different individuals. Vasan et al. found that in 9845 subjects with normal blood pressure, only 5.3% became hypertensive after four years; however, 17.6% of the subjects who developed hypertension originally had an SBP between 120 and 129 mmHg and a DBP between 80 and 84 mmHg [Maintainability is widely used in industrial applications. Maintainability can be used to assess the life of a machinery or production system. The physical structures of the human body contain similar production systems; thus, an approach transferring the concepts of maintainability to human health assessment is the focus of this study. In practical applications, information on risk factors , and Electromyography (EMG) can be collected quickly with the widespread use of home medical equipment. Therefore, in this study, a kernel density technique was used to develop a health risk index based on risk factors from human-related data. In practice, changes in health risk indicators can be used to establish an early warning mechanism. When the health risk indicator is gradually declining, the patient will still be considered healthy; however, if they fail to control the risk factor, they will likely develop the disease. Thus, a health risk index can estimate the health status of people and help them better understand their health conditions. Additionally, manufacturers should apply new techniques ,15,16 toIn this paper, the health risk index was proposed to evaluate a person’s level of health. This study proposed a novel three-stage analysis procedure involving the feature selection method, the kernel density estimation method, and mathematical approaches to calculate the health risk index of healthy people. Stage 1 adopted the findings from our previous study . The proThe kernel density estimation approach was first described by Rosenblatt  and ParzIf When using the kernel density estimation method, we must choose the kernel function and set the bandwidth. The choice of kernel function was adopted through the six common types in The bandwidth of the kernel function is an important parameter that has a strong influence on the resulting estimate. A narrow bandwidth would allow more over-fitting of the data. Conversely, an overly wide bandwidth would not have an appropriate data fit. MISE) was used to choose the best bandwidth. The MISE can be calculated as follows:The mean integrated squared error  was calculated as follows:The AMISE regarding h by the first derivative. The optimal bandwidth h was:We estimated the optimal bandwidth by minimizing In practice, the above formula has an infinite loop problem when calculating both problems . Therefoproblems . The NDRFrom the above procedure, we can determine the probability density function of the risk factors using the kernel density estimation approach. Next, the health risk index was proposed to estimate the health status of healthy people. t value of the risk factor once it has reached a certain value for a physiological state that was still healthy. In other words, t for a particular risk factor. With an increase in the risk factor value, the disease or health risk will also increase. We assumed that n of multiple diseases were studied, and there was one normal state  and . Therefore, the health risk index t values of the risk factors. According to the health risk index curve, we can then evaluate the effect on health risks when risk factors change after a period of maintenance activities (such as exercise or diet control). We can plot the curve of the health risk index from In Hypertension, hyperlipidemia, and hyperglycemia are three common diseases that are associated with metabolic syndrome and related to metabolic abnormalities. If a person has these diseases, the risk of developing other chronic diseases increases as well. A dataset from the National Health Insurance Research Database in Taiwan was used to elucidate the proposed analytical procedures. The dataset included 6496 subjects  aged over 15 years old and 17 physiological indicators. Next, the analysis procedure established the appropriate kernel function for the common risk factors in every physiological state of hypertension, hyperlipidemia, and hyperglycemia. Based on the results in Based on the data in Ten subjects were randomly recruited to measure the risk factor data. The brackets in The dataset on hypertension, hyperlipidemia, and hyperglycemia (Triple H) from the National Health Insurance Research Database in Taiwan and the research results of Stewart et al.  were useBased on the analysis of the results, we can make several conclusions regarding research in this area. The human body is a complex system, and a single-disease study is insufficient to assess multiple diseases. Most previous studies that conducted medical data analyses focused on risk factor selection and creating prediction and control models of diseases. These studies were able to monitor risk factors and estimate the risk of developing various diseases. However, the human body may not necessarily be completely healthy even when risk factors are all within normal ranges. Therefore, our study focused on assessing the degree of health. In this paper, common risk factors for multiple diseases were used to estimate the optimal probability density function, and a novel health risk index was proposed to evaluate the health status of healthy people. In practice, a health risk curve can be used to elucidate the relationship between risk factors and health risk. Prevention is often more desirable than curing diseases, and proper maintenance (such as participating in sports) may reduce the likelihood of further health decline. Furthermore, the effectiveness of preventive maintenance can be assessed through a health risk curve to determine appropriate adjustments to the maintenance strategy.