In recent years, there has been a significant rise in the importance of sustainability in business and personal life. Unsustainable techniques are used throughout the whole lifecycle of the clothing and textiles business, from the time it is made to the time it is recycled or thrown away. The garment sector and its customers must be ready for a more sustainable future as the government, corporations, and society turn their focus toward it. An investigation of how the apparel design industry (ADI) might adhere to the global value chain (GVC) in light of sustainable economic development (SED) and their relevance in China. This study analyzes the ADI moves up from one functional level to another within the global apparel value chain and what factors allow them to break into the global market. Researchers demonstrate that the existing sustainable operations in the AD industry are a long way from attaining the aims of economic development going hand in hand with the goals of economic sustainability by studying both the relevant literature and the industrial practices in the sector. This study relies on various case studies, proposes the “apparel global value chain” of governance-based sustainability, explores the implications of these models for areas with very varied degrees of development and diverse AD structures, and considers their implications for regional development and sustainability. As a development of a better knowledge of how fashion design contributes to economic sustainability. The study aims to examine how ADI uses economically sustainable techniques and how designers contribute to the creation of environmentally friendly goods. Sustainable economic development (SED) is an excellent illustration of the new goals of economic, social, and environmental development. These new goals include things like eradicating poverty, fostering economic growth, and protecting the environment, among other things. SED needs participation from all global actors including governments, businesses, nonprofits, and individuals in order to achieve their objectives are stated by Jia et al. . An expoThe global production system capitalizes on the relatively cheap cost of labor in emerging nations from both an economic and a social point of view. Major goals for economic growth in low-income countries (LICs) continue to be structural change and export diversification away from basic commodities and towards items with greater value-added LICs. The apparel industry has historically been a gateway for LICs to diversify their exports, and it is generally regarded as the first step for developing countries that are beginning the process of export-oriented industrialization. Historically, the apparel industry has been a gateway to export diversification. As a result of its low entry hurdles (low fixed costs and relatively basic technology), the apparel industry was able to hire vast numbers of unskilled employees are reported by Nguyen et al.  and MoreFor the evaluated apparel global value chain, the apparel industry has a special position in the sustainable economy. The country's most significant industry is this one, which makes up the bulk of exports overall and has had tremendous growth over the last 20 years.The economy has a critical role in both the process of generating employment and the transfer of funds to those who are less fortunate.Establishing a cost-cutting strategy and a labor productivity cell to conduct a range of research in this field, as well as other supporting policies important to the growth, development, and survival of the apparel industry in the many countries under consideration SED.These may be helpful in addressing the issues, and value addition will enable the garment industry's contribution to the socioeconomic development of nations to be strengthened and sustained through time.The additional detail of this survey is as follows: The apparel industry is the perfect illustration of a buyer-driven commodity chain, since it is characterized by power imbalances between the worldwide consumers of finished fashion goods and the providers of those products are asserted by Gardas et al. . The mosThe value chain of the garment industry, like the value chains of other global businesses, depends on international standards to coordinate the operations of its suppliers. By the turn of the century, the majority of leading companies had already developed their own internal standards and codes of conduct based on factors such as cost, quality, punctuality, and corporate responsibility in terms of labor and environmental norms . Anner R & D, (2) design, (3) purchasing, (4) logistics (buying and distribution), (5) marketing and branding, and (6) services are the six pillars of an organization's apparel global value chain's curve of value-added stages are seen in It is possible to identify six key value-adding activities, which will help you understand how this division of labor happens and how attempts to improve the workforce may alter the role emerging nations play in the global value chain  as well as actions aimed at enhancing the physical product or process, as well as market and consumer research, falls within the purview of this value-adding function.Design: at this point in the value chain, a variety of persons and businesses are involved in providing services related to the esthetic design of various goods and components. Activities related to design and style are used to draw attention, enhance product performance, reduce manufacturing costs, and provide the product with a significant competitive edge in the market that is being targeted.Purchasing: this stage relates to the procedures involved in acquiring and delivering apparel items, which are known as inbound processes. It encompasses not only the actual act of moving things, but also the management of, or provision of, the technology and equipment necessary for supply chain coordination. Coordination in logistics may take place either inside a country or outside.Production: fabric may be woven or knitted, and then either the fabric or the garment can be cut and sewn straight from the yarn. The cut-and-sew categorization refers to a wide variety of businesses that produce whole lines of ready-to-wear as well as bespoke clothing. The term “apparel manufacturer” may refer to either an independent contractor who carries out cutting or sewing operations on materials held by third parties or a jobber or tailor who creates customized clothing for particular customers. Companies have the option of acquiring textiles from another organization or producing the textile components themselves.Distribution: there are a large number of companies that help supply and sell the clothing once it has been manufactured. These include merchants and agents as well as transportation and logistics companies.Marketing: afterward, the apparel is disseminated and marketed via a network of distributors, brokers, and other companies that are responsible for value-added operations that are not directly related to the manufacturing system.Services: this encompasses any form of activity that a company or industry delivers to its suppliers, customers, or workers, generally as a strategy to differentiate itself from rivals in the market  .The most important value-adding stages include the following:The apparel industry's purchaser responsibilities and expectations updating prospects operational , consumer , procedural (incorporating sophisticated technologies into production), and multisectoral (moving across companies) (Garg  and CasaAssembly/cut make and trim (CMT) entry into the chain: in this step of the clothing business, sewing factories assemble foreign inputs. The manufacturer cuts, sews, trims, and ships the finished garment. The customer buys fabric and gives it to the maker with production specs. The contract manufacturer has many clients and takes orders. “Export-Processing Zones (EPZs),” special in economic zones, exports to the buyer's nation are taxed less.“Free on board (FOB)/full package/original equipment manufacturing (OEM)”: the garment maker handles CMT, finishing, and distribution. The company must be able to procure and finance raw materials, component items, and trim. According to Uramoto et al.  the circ“Original design manufacturing (ODM)/full package with design”: it combines design and production. Full-service garment suppliers design, purchase fabric, cut, sew, trim, package, and distribute completed garments (Wilson ). Typica“Original brand manufacturing (OBM)”: this business strategy adds or replaces design and production with product branding; upgrading entails selling own-brand items. Many developing nations engage OBM to establish brands for home or nearby markets.The following descriptions of the four primary phases of economic upgrading for the apparel industry are seen in In the garment industry, like in many other industries, manufacturing and commerce are organized into GVCs, which include the manufacture of components and the assembly of those components into finished goods via interfirm networks operating on a worldwide scale. According to Uduwela et al.  stated tAs determined by Jin et al.  a directUpgrade of processes Product upgrading (the transition to goods that are more complicated and sophisticated)Modernization of the supply chain Upgrade of the end market (diversifying to new consumers or expanding into new geographic and product markets)Functional upgrading refers to extending the variety of functions that can be performed or shifting the balance of activities to include more high-value activitiesAs a result, LDCs in sub-Saharan Africa have been subjected to zero tariffs in European Union markets for a considerable amount of time; nevertheless, this has been accompanied by double transformation rules of origin (ROO). As specified by Bernardi et al.  and AbdeFunctional upgrading is important for garment providers, including a CMT manufacturer that sews, cuts, and trims clothing . Buyer supplies product specs and fabric. Instead of a product price, the manufacturer receives a processing charge. A full-package manufacturer FOB offers textile inputs, manufacturing, finishing, and packaging. The buyer selects textile suppliers. ODMs participate in product design and development, including sample approval and material selection, purchasing, and manufacturing are claimed by Vishwakarma et al. . OBMs crThe apparel industry has undergone significant economic upgrading processes . A value chain is a collection of operations that a corporation operating in a certain sector does in order to offer a useful product or service to the market. There are, concurrently, localization processes in terms of local linkages that go beyond the experience of the other main apparel exporting countries in sub-Saharan Africa (SSA) determined by Patti and Acierno . This isThe accessibility to end markets, the availability of inexpensive labor in abundance, and advantageous trade agreements are the key prerequisites for successful entrance. Although foreign direct investment is often helpful in developing assembly operations, 4 of the 5 nations surveyed joined the sector primarily due to advantageous trade agreements. Prior to Lesotho and Nicaragua benefiting from the African Development and Opportunity Act (AGOA) and CAFTA-DR TPL accords, respectively, Lesotho and Sri Lanka profited greatly from preferential trade deals with the EU and the United States, which aided their early admission and growth.Domestic or regional textile industry facilitates upgrading from assembly (CMT) to full-package (OEM) garment manufacture. Bangladesh's emerging textile sector helped it transition from assembly to full-package supply. Turkey's textile sector was robust when the clothing industry was founded, enabling it to jump into full-package supply. Sri Lanka used regional textile possibilities and backward links with India and Bangladesh to upgrade.Lead businesses' nationality and business methods determine a country's upgrading trajectory. Lesotho and Nicaragua's top enterprises are foreign-owned and part of big Asian supplier networks. These corporations adopt business strategies in which high-value upstream and downstream operations are performed in their Asian headquarters, with limited links or technological spillovers to local suppliers. Neither nation has upgraded much. Locally held enterprises play major roles in Bangladesh, Sri Lanka, and Turkey, with direct links to global customers who have upgraded local operations.Other aspects, meanwhile, start to matter as the chain advances into more advanced phases. They consist of the following:The public and private sectors must commit to industry growth to upgrade to ODM and OBM. Turkey is the only nation in our sample to make large breakthroughs in ODM and OBM. Strong industry groups and government organizations collaborated to boost Turkey's fashion and design competitiveness. Turkey's major integrated enterprises' full-package skills promote tight partnerships with global merchants that are eager to help upgrade Turkey's design and brand services. Sri Lanka's government and corporate sector established a 5-year strategy to enhance the industry, focusing on leveraging their tight relationships with global customers to build design and brand competencies. Sri Lankan enterprises have offices in important locations to cooperate with product development and design teams.One of the businesses that have seen the greatest degree of globalization in our day is the clothing industry. It is responsible for the employment of millions of people all around the globe, particularly in nations with low incomes. The ability of developing nations to join the value chain may be attributed to a number of crucial factors, including the availability of low-cost labor, advantageous trade agreements, and closeness to end markets. Workforce development programs receive little attention, despite the fact that the companies that dominate this value chain have strict requirements for their suppliers. Supervisors who can't instruct manufacturing workers often do so. Vocational schools don't provide courses that meet industry demands. Many firms feel expatriates are more efficient than native personnel. The influence of global purchasers to improve working conditions and moves in more mature suppliers to professionalize the clothing workforce imply that developing nations are coming closer to adopting more effective and meaningful workforce development procedures. This is because global buyers are working to improve working conditions. It devised a comprehensive industrial strategy with the goal of promoting industrialization through fostering the growth of the manufacturing industry, with textile and garment production being among the highest priority sectors. It has utilized governmental levers to give assistance to exporters without opening up the domestic market to international goods and FDI enterprises, allowing it instead to be dominated by indigenous businesses. The government has implemented a number of buyer attraction strategies in addition to actively seeking foreign direct investment from key garment manufacturing nations. One of the most important tools for luring in new investment is the creation of serviced industrial parks that provide specific advantages to businesses who export their products. It has supported integration between the production of textiles and clothing as well as the cotton industry in order to achieve the goal of creating a local value chain that is integrated. In addition to facilitating knowledge linkages between the industry and higher education institutions, it has created sector-focused institutions with a primary focus on building technological capability and capabilities in terms of skills, with managers, technicians, and workers as its primary targets. This research will be of significant value for specialists in choosing an acceptable and rigorous technique for sustainability evaluation in the textile sector. In a similar vein, due to the one-of-a-kind nature of the textile and apparel industry, it is essential for the researcher to carry out research that is both more universal and comprehensive on the topic of sustainability in this sector, and then use the findings to outline the directions in which they intend to take their future research. The evaluation levels, limits, source, and weight of indicators that are discussed in this research may be used as a checklist, and they cover the majority of the characteristics of the textile and clothing business. The prioritizing of source and weight of indication will aid the investors of textile apparel and industry in making the trade-off between multiple performances and measures. Furthermore, the assessment of the reviewed studies showed that the economy is the most researched and enhanced measurement in the garment industry although both social and economic aspects still demonstrate some struggles in their quantification because of a lack of applicable and measurable indicators. Therefore, we need to improve the relationship between apparel value chains and SEDs and then the global organization of the apparel design industry. The research refers to an overall sort of assessment of the textile and apparel sector and may be used to evaluate the textile industries of both developed and developing countries to determine how well they perform in terms of sustainability .


At present, the pathogenesis of non-erosive reflux disease (NERD) is still unclear, and proton pump inhibitors are the main treatment drug. However, the effect is limited. Traditional Chinese medicine treatment of NERD has advantages. Stagnated heat in liver and stomach syndrome is the most important traditional Chinese medicine syndrome type of this disease. Tongue diagnosis is an important basis for the diagnosis of stagnated heat in liver and stomach syndrome. The microecology of tongue coating suggests the occurrence and development of disease. The purpose of this study aims to clarify the regular changes of tongue coating microecology in stagnated heat in liver and stomach syndrome of NERD.This is a cross-sectional clinical trial. This study is divided into NERD stagnated heat in liver and stomach syndrome group, qi stagnation, and phlegm obstruction syndrome control group and normal control group, with 20 cases in each group. Tongue coating samples will be collected from 3 groups, and 16SrRNA gene sequencing technology will be used to detect the genome of tongue coating flora in patients with NERD with stagnated heat in liver and stomach syndrome, control group with qi stagnation and phlegm obstruction syndrome and normal control group. The main outcome measures are the distribution, diversity, and richness of the tongue flora in patients and healthy controls.The results of this study will clarify the internal relationship between NERD stagnated heat in liver and stomach syndrome and the microecological changes in tongue coating. GERD can be divided into reflux esophagitis, non-erosive reflux disease (NERD), and Barrett’s esophagus. A study in the United States showed that the incidence of GERD was about 26%, and about 70% of the patients were NERD. Recent studies show that the incidence of NERD in China also accounts for about 70% of GERD, and its incidence is increasing year by year, NERD has become 1 of the hot spots and difficulties in research of digestive system diseases.Gastroesophageal reflux disease (GERD) refers to a type of disease in which gastroduodenal content flows back into the esophagus, causing esophageal symptoms and complications, In Roman IV, the newly added “reflux hypersensitivity” also had no mucosal damage, but was distinguished from NERD due to physiological acid reflux sensitivity and normal esophageal acid exposure. Currently, proton pump inhibitors are often used as the preferred drugs for the treatment of NERD, but only about 50% of patients with NERD can be cured. Long-term use of proton pump inhibitor is prone to complications, and the risk of recurrence after withdrawal.NERD refers to reflux disease with typical gastroesophageal reflux symptoms but no visible mucosal damage under endoscopy, also known as endoscopic negative reflux disease. Treatment based on syndrome differentiation is the key to the traditional Chinese medicine (TCM) treatment of NERD. However, there is no material basis for TCM syndrome formation and identification in clinical practice, and the mechanism of disease occurrence is not yet clear.A large number of clinical studies have shown that Chinese medicine is flexible in the treatment of NERD based on syndrome differentiation, with few side effects, and has obvious advantages in effectively alleviating NERD-related symptoms, improving anxiety and depression, reducing the recurrence rate, and improving living standards. The latest consensus of experts on TCM diagnosis and treatment of GERD (2017) also ranked stagnated heat in liver and stomach syndrome as the first syndrome type. Therefore, a systematic study of stagnated heat in liver and stomach syndrome is an important strategy for the treatment of NERD. Tongue diagnosis is 1 of the unique diagnostic methods in TCM and is an important basis for the diagnosis of NERD of stagnated heat in liver and stomach syndrome. Microecology is an important method of modern scientific research on tongue coating, and also an important extension of tongue diagnosis. At present, the research on the microecology of tongue coating has been gradually carried out, but there is no clinical study on the regularity of the microecology of tongue coating in NERD stagnated heat in liver and stomach syndrome, which deserves further exploration and research in order to clarify the law.At present, a large number of studies on the syndrome type of NERD show that stagnated heat in liver and stomach syndrome is the most important TCM syndrome type of NERD, accounting for 32.2% to 32.6% of all types, accounting for the first.Therefore, on the basis of previous studies, we will collect tongue coating specimens from NERD patients with stagnated heat in liver and stomach syndrome, patients with qi stagnation and phlegm obstruction syndrome, and normal control group, using 16SrRNA gene sequencing technology to analyze the diversity and richness of tongue coating flora among the 3 groups, and find the different bacteria genus among the 3 groups, to explore the changes of stagnated heat in liver and stomach syndrome and tongue coating microecology of NERD. The purpose of this study is to further clarify the regular microecological changes of tongue coating in the stagnated heat in liver and stomach syndrome in NERD, to provide a microecological basis for clarifying the essence of stagnated heat in liver and stomach syndrome in NERD, and to provide a new idea and method for interpreting the theory of “tongue diagnosis” by using modern language.The trial is designed according to the “Ethical Review of Biomedical Research Involving Human Subjects” issued by Ministry of Health of the People’s Republic of China, CFDA “Code of Quality Management for Drug Clinical Trials (2020),” “Guiding Principles for Ethical Review of Drug Clinical Trials (2010),” and WMA “Declaration of Helsinki.” The implementation of this project has been reviewed and approved by the Ethical Review Committee of Fangshan Hospital of Traditional Chinese Medicine, Beijing University of Chinese Medicine for Boyi Jia ; Dr Hongzhang, director of the committee, is the authorized representative under subtitle ethics approval and consent . Written informed consent will be obtained from each subject and his/her guardians.This trial will be a cross-sectional clinical trial. The aim of this study is to clarify the regular changes of tongue coating microecology in stagnated heat in liver and stomach syndrome of NERD, providing a microecological basis for the essence of stagnated heat in liver and stomach syndrome of NERD, and provide new ideas and methods for interpreting the theory of “tongue diagnosis” in modern language by studying the difference of tongue coating microecology in the control group and normal control group of NERD with stagnated heat in liver and stomach syndrome and qi stagnation and phlegm obstruction syndrome Fig. . This reThis study is divided into NERD patients with stagnated heat in liver and stomach syndrome, qi stagnation, and phlegm obstruction syndrome control group and normal control group, with 20 cases in each group. The source of the case is outpatient and inpatient patients and healthy volunteers from Department of Spleen and Stomach, Fangshan Hospital of Beijing University of Chinese Medicine from October 1, 2020 to September 31, 2022. Participants are informed of details about the study which are purpose, duration, procedures, and key contacts, as well as risks and potential benefits. Participants may withdraw their consent for any reason without any consequences at any time.Modern Diagnosis of GERD: the Lyon Consensus published in 2018.Diagnostic criteria for Western medicine: refer to the Chinese Gastroesophageal Reflux Disease Expert Consensus Opinion (2014) formulated by the Chinese Gastroesophageal Reflux Disease Consensus Opinion Expert Group of the Chinese Gastroenterology Society of the Chinese Medical Association and the Diagnostic criteria for TCM: refer to the Consensus opinions of TCM Diagnosis and Treatment experts on Gastroesophageal reflux Disease 2017) formulated by the spleen and Stomach Diseases Branch of China Association of TCM, and formulate the scale of stagnated heat in liver and stomach syndrome, qi stagnation and phlegm obstruction syndrome combined with clinical practice  of TCM dialectically belong to peaceful constitution, and their body mass index is between 18.5 and 23.9. The diagnostic criteria of peaceful constitution refer to the Classification and Determination of TCM Constitution issued in 2009.No infectious diseases or inflammation after medical examination.Those who have hepatitis, syphilis, HIV, schistosomiasis, and other known infectious diseases.Those who have a history of gastroesophageal reflux disease.Those who have acute gastroenteritis within the last 6 months.Those who have taken antibiotics in the past 3 months.Those who have been to an epidemic area in the last 6 months.Those who have a high-risk life history such as yeyou in the past 6 months.Those who have a history of gastrointestinal bleeding in the last 3 months.Those who have had constipation in the last 3 months.Those who have used laxatives and weight-loss drugs in the past 3 months.Those who have taken immunosuppression such as hormones in the last 3 months.Those who have gastrointestinal polyposis, malignant tumor.Those who have chronic diseases such as diabetes, hypertension, and coronary heart disease.Those who have liver cirrhosis and autoimmune diseases.Those who have chronic obstructive pulmonary disease.Those who have severe food allergies.High-throughput sequencing 16SrRNA method will be used to detect the tongue coating flora, and the specific steps are as follows:After the patient sits still for 5 minutes, his face will be placed on the ZMT-1A TCM camera. After the placement, his tongue will be extended as far as possible, and the image will be taken and saved for later use.After morning rises, without brushing your teeth and gargling, we will use a sterile swab to roll the brush forward along the root of the tongue to take the coating 10 times, 2 times in total. We will immerse the sterile swab after brushing into a centrifuge tube containing 1 mL phosphate buffer and place it in 4 centrifuges for 5000r for 5 minutes. The centrifuge tube will be removed, the supernatant is discarded, and the precipitation is retained and stored in the −80 refrigerator for later use.Total microbial DNA will be extracted from the sampled tongue coating, and PCR amplification  will be performed on the V4 hypervariable region of the 16SrRNA gene of the extracted bacterial DNA, and 2% agarose electrophoresis will be used for detection. Finally, sequencing will be performed using the Illumina HiSep platform.It includes the doctor’s side and the patient side. After the patient side completes the filling and submission, the doctor can refer to it from the doctor’s side, and the statistician will conduct the next statistical analysis based on the data collected by the doctor’s side.Screened subjects fill in the clinical information collection form; clinical investigation should be carried out in a quiet and comfortable environment without interference; black pen shall be used to fill in the clinical information collection form; the observation form must be filled in true, accurate and clear, and must not be altered at will. If mistakes need to be corrected, a horizontal line should be drawn in the middle, and the name of the modifier and the modification time should be signed; the CRF table shall be properly kept and placed, and shall not be discarded at will.EpiData3.0 will be used to establish the database, and data entry will be carried out independently by 2 people. In case of inconsistency, the original data should be traced and processed by more than 2 experts in the research group. After data entry, a second inspection will be conducted, and 2 other people will modify it until the 2 databases are exactly the same. After data entry is completed, the data will be locked and submitted to the test statistician for statistical analysis.t test will be used for those in line with normal distribution, and a non-parametric test is used for those in line with normal distribution. For counting data, it will be described by the number of cases (percentage), as well as chi-square test, Fisher’s exact probability method, Wilcoxon rank-sum test, etc. All statistical tests adopt 2-sided tests, and P < .05 is considered to be statistically significant.After all data is exported by EpiData3.0, Illumina high-throughput sequencing platform will be used for data analysis and statistics. PCA will be used to analyze the difference in tongue coating flora between NERD patients and the normal group, and the LEfSe method will be used to analyze the specific bacteria genus between the normal group and NERD patients. The measurement data will be described in the form of mean ± standard deviation. A paired sample In the design of this study, possible biases in the study are considered as follows: ① at the beginning of the study, there is selection bias due to the lax inclusion criteria of the tested population; ② in view of possible information bias caused by defects in the methods of measuring exposure and outcome, this study intends to establish relevant SOP and strictly train researchers, and carry out quality control on the inclusion criteria of the tested population, and try to select new cases, use objective data, and pay attention to the way of questionnaire questioning and investigation techniques to avoid selection bias and information bias.Invite experts to optimize the scheme, formulate relevant Sops, and train the participants according to the requirements of Sops.Clinical intervention implementation personnel: those qualified physicians and relevant clinical work experience.Clinical evaluators: those with relevant clinical research experience.Data entry personnel: those with a medical background, familiar with routine computer operators.Quality inspector: those with relevant working experience.This trial will fully comply with the relevant provisions of data protection legislation. All appropriate and necessary precautions will be taken to keep medical data and personal information permanently confidential. Although the pathogenesis of NERD is complex, it is generally recognized that the esophageal mucosal barrier is damaged by acid and other gastric reflux substances due to the hypersensitivity of esophageal viscera and the abnormality of gut-brain.,17 Currently, the treatment of NERD is still dominated by drugs, while endoscopic treatment and surgical treatment are not widely used and the efficacy is not exact. Symptom relief and improvement of quality of life are still the main treatments direction for NERD.The pathogenesis of NERD is still unclear, and its pathogenesis is characterized by multiple factors. Among them, hypersensitivity of esophageal viscera, abnormal gut-brain, decreased pressure of lower esophageal sphincter, decreased ability of esophageal profile clearance, impaired esophageal mucosal barrier, attack of reflux, correlation with Helicobacter pylori, and genetic factors are all current research objects. A large number of clinical studies have shown that TCM is flexible in the treatment of NERD based on syndrome differentiation, with few side effects, and has obvious advantages in effectively alleviating NERD related symptoms, improving anxiety and depression, reducing recurrence rate, and improving living standards.,20 According to TCM theory, when the mood is not free, liver and gallbladder lose at catharsis, can cross spleen and stomach, and mood is not free for long. It smolders into fire, liver, and gallbladder fire is inverse, causing stomach gas to go up inverse, the occurrence is this disease. A large number of studies on the syndrome type of NERD have shown that stagnated heat in liver and stomach syndrome is the most important TCM syndrome type of NERD, accounting for 32.2% to 32.6% of all types, accounting for the first place.,23 The latest consensus of experts on TCM diagnosis and treatment of GERD (2017) also ranked it as the first syndrome type.There is no direct name for NERD in TCM. According to the symptoms, NERD belongs to the categories of “spitting acid” and “swallowing acid.” Therefore, different pathogenic pathogens are reflected in the tongue and their manifestations are also different. In the consensus opinions of TCM diagnosis and treatment experts for GERD (2017) edition, tongue images of different syndrome types are completely different, with obvious differences. For example, stagnated heat in liver and stomach syndrome is red tongue and yellow moss. Tongue coating, as an important part of tongue diagnosis, is often used to distinguish the rise and fall of vital qi, the deficiency, and reality of Zang and Fu, the cold and heat of evil qi, the depth of the disease, to judge the severity of the disease, to infer the prognosis of the disease, and to guide clinical medication, which has important clinical significance.Tongue diagnosis can judge the location of disease, the nature of disease, and the ebb and flow of good and evil, and provide a basis for syndrome differentiation. “Clinical Tongue Test Method” says: “According to the tongue, the deficiency and the excess are divided, but the deficiency and the excess are not satisfactory; According to the tongue, yin and yang are divided, and yin and yang are not absurd; According to the tongue, it is divided into 5 internal organs and matched with the main prescription, while the internal organs are not concealed and the main prescription is not mistaken. Further study on the microorganisms of tongue coating will provide new ideas for further understanding the relationship between disease and the change of tongue coating. Due to the self-cleaning function of the tongue, the tongue coating microecology of normal people plays a normal role, its microecological environment is stable, the total amount of bacteria is small and the species is single, and the epithelial cells of the tongue grow and differentiate normally without obvious inflammation, which constitutes the basis for the formation of the tongue image of thin white coating. Relevant studies have confirmed that changes in tongue flora caused by diseases can also lead to changes in tongue image, that is, different bacterial community structures may respond to different tongue images.Professor Wei Si, a famous expert in microecology in China, once predicted that “microecology is likely to become a golden key to open the door to the mystery of TCM.In this study, tongue coating specimens from patients with stagnated heat in liver and stomach syndrome, patients with qi stagnation and phlegm obstruction syndrome, and normal control group will be collected. 16SrRNA gene sequencing technology will be used to analyze the diversity and richness of tongue coating flora of the 3 groups, find the different bacteria genera among the 3 groups, explore the changes in stagnated heat in liver and stomach syndrome and tongue coating microecology of NERD, and provide a new idea and method for interpreting the theory of “tongue diagnosis” by using modern language.However, our study has limitations. The limitation concerns the fact that we will only recruit tongue coating specimens from NERD patients with stagnated heat in liver and stomach syndrome and qi stagnation and phlegm obstruction syndrome. The regularity of microecological changes in tongue coating in other NERD syndromes has not been explored.Therefore, a clinical trial about the regularity of microecological changes in tongue coating in different NERD syndromes is still needed.Conceptualization: Boyi Jia.Funding acquisition: Boyi Jia.Methodology: Naiwei Zhang.Project administration: Boyi Jia.Resources: Libao An.Supervision: Hongjie Cheng.Validation: Naiwei Zhang.Visualization: Fang Niu.Writing – original draft: Xinqi Jiang, Shanshan Xu, Libao An, Ling Yan.Writing – review & editing: Boyi Jia.


Science and technology have progressed in recent years, the deepening of talent education, a challenging learning method of human-computer interaction has gradually emerged. Human-Computer Interaction (HCI for short) is the communication and interaction between humans and machines. This essay aims to apply the challenging learning combined with HCI to vocational undergraduate colleges. The GMM  algorithm is proposed in this essay to recognize students' actions. The effect of HCI is achieved by feeding back the recognized actions to the system. This essay selects 200 students from a vocational undergraduate college for challenging learning . The challenging learning designed in this essay is divided into 15 weeks, the task chain contains a total of 196 tasks, and the learning time is 138 h. This essay analyzes the application effects of liberal arts, male and female students, and different grades. The results show that the overall average completion rates of learning tasks for freshman, sophomore, and junior students are about 70%, 75%, and 85%, respectively, and the overall average scores for challenging learning are about 70, 78, and 83. The overall completion rate of weekly tasks for boys and girls is about 68% and 70%, and the overall average score is about 70 points and 75 points. The weekly task completion rate of liberal arts students is generally above 75%, and the overall average score is about 70 points. The overall completion rate of science students is less than 75%, and most of the learning scores are higher than 75 points. In addition, the average accuracy of the GMM algorithm for face and gesture recognition is 90% and 87%. The average frequency of students using HCI is about 320 times a day; the average score of students' experience effect of HCI is about 80 points. It may be stated that the HCI demanding learning strategy proposed in this study worked well and has achieved satisfactory learning results in the application of vocational undergraduate colleges. With the gradual deepening of the national talent training plan, the educational methods of vocational undergraduate colleges have also begun to innovate. At present, a challenging learning focusing on cultivating students' abilities is emerging. Challenging learning refers to students' active participation and creativity in challenging thematic learning activities inspired by the real world, emphasizing the development of higher-order thinking, the application of skills, and the internalization of concepts. Challenging learning combines a variety of learning concepts and step-by-step learning methods and conducts periodic learning with goals and tasks. The proposal of challenging learning methods will change the traditional learning methods. The traditional learning method is single, and basically one-to-many undifferentiated learning is carried out according to the course content. The purpose of learning overemphasizes the acquisition of knowledge, ignoring the cultivation of students' learning style, learning attitude, comprehensive ability, and comprehensive quality. This will lead to students lack of independent thinking, self-directed learning habits, and thinking. The learning ability of each student is different, and teachers cannot adjust the curriculum according to the learning effect of different students. HCI is specialized in studying the way of communication between humans and machines. Combining HCI for challenging learning can make students more interesting in the learning process. It can cultivate different students' comprehensive abilities such as cognitive ability, learning ability, and cooperation ability and play a role in promoting the national talent training plan. Therefore, this essay applies the challenging learning combined with HCI technology to vocational undergraduate colleges, which is of great value and significance.Regarding the application of challenging learning, some scholars have conducted related research. Among them, Jeffries et al. examined challenging learning strategies in visually impaired (VI) adults. He recognized the importance of engineering and policy education, as well as the relationship between visually impaired mobility demands and new urban initiatives to encourage green mobility . DillettTo address the issues with students' lack of learning interest and low learning efficiency, some scholars have proposed methods using human-computer interaction. Among them: El Said reports thematic analysis of semistructured interviews with university students in 52 smart learner interfaces . Long anThis essay adopts the GMM algorithm of HCI to study the challenging learning and proposes a challenging learning method based on HCI. This essay uses machine vision technology to obtain students' action images, and then uses the GMM algorithm and Human 3.6 M action database to recognize the images and feeds the recognition content to the system to realize HCI. This essay picks 200 individuals at random from a college for challenging learning tests. The findings indicate that the challenging learning approach proposed in this essay will have different application effects for different grades, arts and sciences, and between male and female students, but all of them can achieve good learning effects. In addition, the GMM algorithm has a high recognition effect, and this essay's HCI system received a positive rating from the students.Challenging learning is a type of heuristic learning, which is a step-by-step learning strategy that helps to improve students' thinking and learning ability, etc. .  FigureThe traditional challenging learning is just to build a simple challenging learning scaffold, and teachers use the learning scaffold to challenge students to learn. Although this method can stimulate students' interest in learning to a certain extent, the teaching method is still in the form of one-to-many teachers, which cannot carry out differentiated teaching, and the students' self-challenging learning efficiency is not high , 14. TheHCI is the interaction between human and machine. The design of HCI should be optimized from human touch, vision, and hearing so that users can get a more comfortable experience effect .  FigureThe design of HCI should follow the principles of simplicity, beauty, and convenience, bringing fun and comfort to people. The goal of this essay's HCI system is to use machine vision to recognize human behaviors. Then, the meaning of the behavior is analyzed according to the human behavior database, and the analysis result is returned to the program, and the application side makes matching interaction information . This meThe GMM algorithm is an algorithm for unsupervised learning using a Gaussian model . In this essay, the GMM algorithm is used to identify students' action behaviors in challenging learning, so as to achieve the effect of HCI. The algorithm is identified as follows.μ is the mean, the deviation is denoted by ρ, and ρ2 is the variance.Assuming that the image is I, its pixels are represented by a Gaussian model, and its single initial model isλ is the adjustment parameter.The output image is represented by Iop, then the detection result isa is the update rate.With the change of time, the input and output images need to be updated, and the update method is as follows:The recognition accuracy and speed of a single model are insufficient and often cannot meet the inspection requirements. Therefore, multiple Gaussian models are often used for calculation. For the mixed Gaussian model,ωi is the weight of either model, andAmong them, K is the number of models.Among them: d is used to represent the weight increment, it isIf Then, the weighted weight isNormalize the weights :Use the ratio of weight to standard deviation as the basis for model ranking, namely,From this, the image recognition result of the mixture Gaussian model can be obtained.The development language used in this article is java, because this programming language is relatively simple, widely used, and has strong compatibility. The development software is OpenCV, because the software contains java language interface, and the software's visual processing algorithm is powerful and the processing speed is very fast. The visual recognition database is Human 3.6 M, which contains more than 3 million three-dimensional human poses, which can meet the recognition requirements of this essay. In addition, this essay randomly selects 200 students from a vocational undergraduate college for challenging learning. The selected students include freshmen, sophomores, juniors, and students from different majors. In addition, the challenging learning designed in this essay is divided into 15 weeks, the task chain contains a total of 196 tasks, and the learning time is 138 h. As shown in Through these 15 weeks of challenging learning, this essay makes statistics based on the students' task completion rate and teachers' scores on students' completion effects, as shown in From This essay does data analysis upon this proposal of male and female students to reflect the application influence of various things, as shown in As can be seen from In addition, this essay divides students into liberal arts majors and science majors according to different majors and conducts data analysis on these two categories, as shown in It can be seen from Finally, this essay collects the recognition results of students' faces and gestures according to the GMM algorithm during the challenging learning process and counts the frequency of students' HCI and the response effect of HCI. Among them, the response effect of HCI is that students score according to their own experience and feelings, and the full score is calculated as 100 points. The results are shown in It can be seen from As a new way of learning, challenging learning can stimulate students' interest in learning and improve learning efficiency, so it should be applied to vocational undergraduate colleges as soon as possible. Over the years, with said advancement of device vision technology, people have found HCI to be an efficient and interesting way to interact. Therefore, this essay first studies the specific content of challenging learning and HCI and finds that the key to challenging learning is to build a challenging learning scaffold, and the design of the HCI system requires the use of multiple recognition techniques. Then, this essay proposes a GMM recognition algorithm, applies it to the recognition of HCI systems and constructs a challenging learning system based on HCI. Secondly, the learning system was tested. From the grades, genders, and completion of challenging learning in the arts and sciences, it was known that the students' completion of learning tasks and scores were good. From the system performance test, it is concluded that the recognition accuracy of the GMM algorithm has become more sophisticated, and the students' perception of the use of HCI has become more complex. Therefore, the challenging learning system designed in this essay has obtained decent results in the application of vocational undergraduate colleges. However, the authors acknowledge that their capabilities are limited, and the research has much room for improvement. The author's research on HCI is insufficient, the experiment is not perfect, and the author still needs to conduct more in-depth research and exploration and strive to improve in future work.


Cognitive impairment in chronic diseases such as psoriasis is an increasing clinical challenge.To assess the frequency and extent of difficulties in cognitive functioning in people with psoriasis compared to healthy people.The systematic review was carried out on the 23rd July, 2021 by two trained psychologists resulting in a selection of 11 studies on 971 patients with psoriasis and 10,242 controls.A review of the studies showed irregularities in many cognitive domains, including working memory processes, executive functions, long-term verbal memory, attention, and the visuospatial domain. Depending on the methods used to assess cognitive dysfunctions and the characteristics of patients in different studies, large differences in the frequency of cognitive impairment in patients with psoriasis were observed, ranging from 0 to 91.9%.The authors conclude that there is a need for longitudinal studies to identify factors important for the development and persistence of cognitive impairment in psoriatic patients.The online version contains supplementary material available at 10.1007/s00415-022-11317-2. Psoriasis is a chronic inflammatory disease whose etiopathogenesis has not been fully elucidated . It affeHowever, little space has been devoted to the assessment of difficulties in cognitive functioning in psoriatic patients . There iAnother factor that may be associated with a higher risk of CI is the use of cytostatic treatment: many researchers link this with the phenomenon of "chemo-brain"/cancer-related cognitive dysfunction . HoweverTherefore, we performed a systematic review and meta-analysis of data from previously published studies to determine the severity of cognitive impairment in people diagnosed with psoriasis compared to healthy people and to estimate the frequency of this phenomenon. Additionally, we attempted to identify factors that may be moderators of the severity and frequency of cognitive impairment, in particular focusing on the severity of depressive symptoms.The database search was carried out on the 23rd July, 2021 by two psychologists (DP and KWP) who have undergone specialist training in this field with the PRISMA protocol . The revBased on the presence of the searched-for or synonymous terms, 38 articles were identified and subjected to further analysis. The full texts were completely analyzed to avoid the risk of missing potentially important data. The process for selecting articles in this phase is shown in Fig. The criteria for further inclusion in the analyses were: (1) the article must describe cognitive functioning in people with psoriasis; (2) the study must have been conducted on adults; and (3) it must have used objective neuropsychological methods. As a result of the research, articles meeting the criteria were identified, which were published between July, 2011 and March, 2021.DP and KWP extracted data from each study independently. The variables of interest for systematic review were: year of publication, country of origin, sample size, basic sociodemographic data , clinical data , method of assessing cognitive functioning, and the main findings of the study. For meta-analyses, we collected data on the means and standard deviations  of the results of tests that were used in at least two different studies, criteria for the diagnosis of cognitive impairment adopted in a given study, and the frequency of cognitive impairment in the tested sample. During data extraction, it was found that there were major differences in how data were reported. For tools that were used in at least two studies, when the reports did not provide information on means and standard deviations, the authors were contacted via email and ResearchGate.net (where possible). It was impossible to perform a meta-regression as, due to the lack of responses to our inquiries, there were very large lacunae in variables that could be potential moderators and there were not many studies using each tool in which the results were properly described. Due to the low number of replications and the inability to control the moderators, the meta-analysis of the collected results was not carried out.To evaluate the quality of the selected studies, we used an adapted version of the Newcastle–Ottawa cohort scale for case–control studies, which takes into consideration the selection of samples, comparability of subgroups and exposure. Using this scale, we scored each study independently. Inter-rater compatibility was satisfactory, and scoring differences were reconciled through discussion (Supplementary table 1).As no contact was needed with participants to carry out this research, the consent of the Local Ethics Board was not required.The search using the methodology described above yielded 11 studies that fulfilled all selection criteria , and thThe studies’ results indicated impaired cognitive functioning in people with psoriasis relative to people in the control group; however, these impairments pertained to many domains, preventing us from painting a clear description of the characteristics of these difficulties. The results showed irregularities in, among others, working memory processes , 23, exeThe large variety of research tools as well as the presentation of data about potential moderators make it very difficult to draw unambiguous conclusions about CI in this clinical group and prevents us from conducting a meta-analysis and meta-regression that would allow accurate quantitative assessment of CI severity and prevalence as well as the moderators thereof.The article attempted to systematically review and meta-analyze studies on cognitive impairment in people with psoriasis. We identified 11 eligible studies. The obtained results suggest that cognitive impairment in people diagnosed with psoriasis is a major clinical problem, encompassing many cognitive domains. On one hand, these difficulties may have a negative impact on the quality of life of patients, further hindering their daily functioning. In addition, people with cognitive deficits may be more prone to misinterpretation of, for example, the reaction of their environment to the disease; however, this requires empirical research. Difficulties of this type may also adversely affect compliance with medical recommendations and the ability to continue work or study, but this hypothesis also requires empirical confirmation. It is an open question whether these difficulties are permanent and may turn into dementia in the future or whether are they limited in time and are due to, for example, cytostatic therapy.First, attention should be paid to very large discrepancies between the obtained results. Studies show different orders of magnitude of differences in terms of cognitive impairment between people suffering from psoriasis and healthy people. Results differ greatly depending on the methods used  were eiThis study has some limitations: there is not enough data to carry out meta-analyses on a sufficiently large amount of data or to identify potential moderators. Moreover, the analyses indicate issues that may be modified in further research: there should be greater consistency in methods used to diagnose cognitive impairment and, especially, in reporting data. For this purpose, recommendations prepared by the authors may prove helpful (see Appendix 1).In addition to the above-mentioned limitations, an in-depth analysis of the texts indicated additional research directions that could be undertaken in the future. The collected data indicate the lack of longitudinal and prospective studies that could determine the role of individual factors in the formation and maintenance of cognitive impairment in psoriatic patients. In people diagnosed with psoriasis, it seems justified to conduct prospective studies on the influence of cytostatic treatment on cognitive functioning: in other groups of patients , different types of treatment are used  , which mAnother direction for analysis could also be the use of a person-centered perspective , which would allow us to determine profiles of cognitive functioning and their possible determinants, or to distinguish subgroups characterized by different dynamics of change of CIs within a specific time period. Performing such analyses would allow for a deeper understanding of this issue, but at the same time would require a fairly large study group. In addition to controlling the objective indicators of CI , it is also worth considering the determination of subjective difficulties in the field of cognitive functioning and their correlates, including psychological factors  and a broader analysis of the relationship between CI and indicators of adaptation to living with the disease, for example quality of life or satisfaction with life.Case–control studies on CI conducted with people with psoriasis use a variety of different measurement methods.There are no longitudinal studies that could help identify factors relevant to the development and maintenance of cognitive impairment in psoriasis. It would be worthwhile to conduct research that would help to better understand this phenomenon.Future research on this issue should have a unified methodology and data reporting method that allows for meta-analysis of the results and, thus, allow for a more comprehensive look at the problem of cognitive dysfunction in patients with psoriasis.The conducted analyses allow us to draw the following conclusions:https://doi.org/10.17605/OSF.IO/9ACJPSupplementary file1 (DOCX 13 KB)Appendix 1. Recommendations for reporting data from studies on cognitive impairment in chronic health conditions (DOCX 31 KB)Below is the link to the electronic supplementary material. Systematic Review was pre-registered at OSF—additional information will be made available after acceptance.


Delivering physical activity in cancer care requires knowledge, competence, and specific skills to adapt the exercise program to the patients’ specific needs. Kinesiology students could be one of the main stakeholders involved in the promotion of physical activity. This study aims to investigate the knowledge, perception, and competence about exercise in patients with oncological disease in a sample of students attending the Sports Science University. A total of 854 students (13% response rate) from four Italian universities completed the online survey between May and June 2021. About half of the study participants identified the correct amount of aerobic (44%) and strength (54%) activities proposed by the American College of Sports Medicine for patients with cancer. Almost all the students recognized the importance of physical activity in cancer prevention (96%), in the management of cancer before surgery (96%), during anticancer treatments (84%), and after therapies completion (98%). On the contrary, they reported a lack of university courses dedicated to cancer diseases, psychological implications, and prescription of physical activity in all types of cancer prevention. Overall, few students felt qualified in delivered counseling about physical activity and individual or group-based exercise programs in patients with cancer. Logistic regression revealed that the students attending the Master’s Degree in Preventive and Adapted Physical Activity were more likely to have knowledge and competence than other students. The present study suggests that kinesiology universities should increase the classes and internships about exercise oncology to train experts with specific skills who are able to adequately support patients in their lifestyle modification. Most recent worldwide estimates report that approximately a quarter 27.5%) of adults are insufficiently active . Physica7.5% of aCancer disease represents one of the leading causes of mortality worldwide, and its incidence and prevalence are expected to increase . AlthougDifferent national and international organizations recommend that patients with cancer should engage in regular exercise, comprised of aerobic and strength activities ,7,8. Desexercise oncology. Although clinicians recognize the importance of exercise in the cancer context, only a limited proportion of them recommend to their patients to engage in PA, and even less refer them to an exercise program , the leading of group-based exercise training , and the leading of individual-based exercise training .To our knowledge, this is the first investigation exploring the knowledge, perception, and confidence toward exercise oncology of students attending four Italian sports science universities. This study highlights that approximately 50% of kinesiologists’ students know the exercise guidelines for patients with cancer, and more than 80% recognize the importance of exercise in the cancer continuum, but the majority report a lack of knowledge and expertise for counseling, prescription, and leading of exercise in patients with cancer.About 44% and 54% of the students participating in the survey recognized the correct amount of aerobic and strength exercise recommended for patients with cancer. Prior studies on oncologists and healthcare providers reported less awareness about exercise guidelines than observed in the present study ,21. For hot sensitive topic for public opinion, being a woman gave the intrinsic motivation to prevent a disease that a female student feels nearer [Nevertheless, this result may be partially justifiable considering the limited presence of classes dedicated to the prescription of PA and exercise for patients with cancer. However, knowledge of the correct amount of exercise for patients with cancer was numerically higher than the presence of dedicated classes at their universities, thus suggesting that intrinsic motivation and a proactive approach to the academic path may be crucial. In this sense, logistic regression revealed that participants having a family member with a cancer diagnosis and being women are more likely to know the correct amount of physical exercise in the field of exercise oncology. Whether it is simple to understand the role of intrinsic motivation connected with having a family member with a cancer diagnosis, it is possible to speculate that the female gender is also linked with intrinsic motivation. As literature will testify the correlation among all grades of prevention of female cancers and physical exercise ,6,23, ans nearer .it is generally known that they are useful against diseases”.Almost all the students recognized the importance of PA and exercise as strategies to prevent cancer and as tools to increase the quality of life and obtain a range of benefits for patients with cancer, before surgery, during, and after medical treatments. The importance of exercise in oncology is rapidly growing, both among patients and healthcare providers ,22. ThisWe found that a low percentage of students felt competent in delivering counseling and exercise programs to patients with cancer. Moreover, just about half of the students felt qualified to counsel or prescribe exercise and deliver group-based or individual-based exercise training in different cancer settings. These results are comparable with previous research on family medicine residents , and theOur study presents some limitations. First, the response rate was low, only 13%, suggesting a general interest in the topic and making our result little generalizable. Secondly, even if the study actively involved 854 university students, the main limitation is related to the involvement of only a limited number of Italian sports science universities. Therefore, the observed results could not be fully representative of the Italian academic situation, also considering the existence of an active national research group that is highly contributing to teaching and research activities about the role of PA and exercise in all-grade prevention of cancer. Third, we did not ask about workplace learning or placements in our questionnaire, which may provide important information about students’ competence and knowledge. Future studies should consider these aspects to offer a more comprehensive picture of this topic.In conclusion, our study provides an important starting point to improve the training of kinesiologists to be able to stimulate healthcare providers to increase physical exercise prescription and to support patients with oncological diseases with PA counseling, appropriate exercise prescription, and conduction. We found that kinesiology students are aware of the benefits of exercise in the cancer setting. Nevertheless, only a small percentage feel competent to provide PA counseling and program exercise in patients with cancer. Since kinesiologists are one of the experts that may deliver exercise to the cancer population, sports science universities should implement their academic offers, including dedicated internships, about the all-grade prevention of cancer.


In Italian universities, bioinformatics courses are increasingly being incorporated into different study paths. However, the content of bioinformatics courses is usually selected by the professor teaching the course, in the absence of national guidelines that identify the minimum indispensable knowledge in bioinformatics that undergraduate students from different scientific fields should achieve. The Training&Teaching group of the Bioinformatics Italian Society (BITS) proposed to university professors a survey aimed at portraying the current situation of bioinformatics courses within undergraduate curricula in Italy . Furthermore, the Training&Teaching group took a cue from the survey outcomes to develop recommendations for the design and the inclusion of bioinformatics courses in academic curricula. Here, we present the outcomes of the survey, as well as the BITS recommendations, with the hope that they may support BITS members in identifying learning outcomes and selecting content for their bioinformatics courses. As we share our effort with the broader international community involved in teaching bioinformatics at academic level, we seek feedback and thoughts on our proposal and hope to start a fruitful debate on the topic, including how to better fulfill the real bioinformatics knowledge needs of the research and the labor market at both the national and international level. The publication of the first draft of the human genome in 2001 . In subsIn March 2021, in order to provide a snapshot of bioinformatics courses in Italian universities, the Italian Society of Bioinformatics (BITS) designed a survey asking BITS members involved in bioinformatics teaching at academic level to provide information about bioinformatics semester courses taught at their universities. The survey was not anonymous, to allow us to contact the compiler in case of need , and we decided to insert in the survey the following questions: the name of the course ; the code identifying, in Italy, the academic discipline   and are summarized here.The survey was delivered by means of an electronic platform (Google Modules) and made available for about 2 months; all members of the BITS  were informed of the survey via internal mailing lists, and solicited both to compile the survey and to spread the information to other colleagues. We obtained 51 answers on a voluntary basis , for 47 It turned out that roughly, 60% of respondent teachers in Bioinformatics are from life science academic disciplines , 20% are from the computer science area, 15% are computer engineers, with a marginal presence of physicians or statisticians . The SSDThe most frequently covered topics relate to databases of biological interest, alignment algorithms, genomics and transcriptomics, clustering, and the use of specific programs written in various programming languages such as R or Python; structural and applied bioinformatics in proteomics and metabolomics, applications of molecular mechanics, and bioinformatics applications of deep learning are generally less covered . In our Reflecting on the results of this survey, while acknowledging its limitations, and considering that bioinformatics approaches and technologies will become increasingly important in science in the future, BITS decided to start an effort to develop recommendations for teaching bioinformatics at the academic level. These recommendations were partially based on the survey results and their analysis, and partially based on the educational experience of the participants of the Training&Teaching group in the Italian academic scenario. In particular, the analysis of the ECTS and hours attributed to the bioinformatics courses and of the topics treated in the courses constituted the backbone of the suggestions about the recommended content to include in the course. Our intent was to suggest to the Italian teachers of bioinformatics courses what minimum indispensable knowledge in bioinformatics BITS believes is essential for a life scientist, or an engineer, or a computer scientist, and therefore should be present in a bioinformatics course embedded in a more general study path in life science/medicine, or engineering/computer science, both in BSc and MSc degrees. The Training&Teaching group of the Society focused on this work and concluded this activity in March 2022 by generating a document that includes recommended reference content for the different levels and scientific areas to which the degrees refer, and additional recommendations to frame the bioinformatics courses within a context that allows its optimal fruition by students. This document has been posted on the BITS website .We decided to present its contents here, because we would like to share it with the international bioinformatics community and, hopefully, open a discussion on this topic that will allow us to improve our future directions.Considering that the placement of bioinformatics courses is prevalent in study paths belonging to 2 main areas (life science/medicine versus computer science/engineering), and considering the different backgrounds and goals of students in these 2 areas, BITS believes it is appropriate to indicate the different skill sets of students according to the scientific area of their degree programs. Consequently, different recommended contents have been outlined, referring to those bioinformatics courses to be placed in a BSc degree and those to be placed in an MSc degree for the 2 main scientific areas mentioned above. Our survey highlighted that the median ECTS currently attributed to bioinformatics courses is 6, of which 1 is spent for practical activities . We felt that this teaching load is appropriate in the case of a course to be delivered in a BSc degree (180 ECTS), possibly increasing the time devoted to practicing to 2 ECTS. In the case of a bioinformatics course in an MSc (120 ECTS), however, we recommended a teaching load of at least 8 ECTS, with anything lower than 6 CFU strongly discouraged, and with an effort to increase the time devoted to practicals to 3 ECTS. Furthermore, taking into account the results of the survey, in which we found that frequently, custom content is delivered by the teacher, in our recommendations, we identified knowledge and essential skills to be delivered indicating the number of hours of front lessons/classroom exercises suggested for each main subject, and suggesting the non-essential topics that might be replaced by others freely selected by the teachers. The recommendations issued by BITS are reported in Tables In order to best contextualize a bioinformatics course within a study path and facilitate the achievement of the teaching objectives, BITS believes it is helpful to accompany the list of recommended contents with the following general considerations:Interdisciplinary skills are mandatory to learn bioinformatics properly. Learning an exquisitely interdisciplinary subject such as bioinformatics benefits enormously from knowledge transfer from other courses and disciplines. Such connections permit the acquisition of knowledge from other domains and a way to apply bioinformatic tools and techniques. If done correctly, interdisciplinarity will thus ensure the pertinency of formulated questions, the choice of the most appropriate tools, and the applicability of the answers.The choice of the disciplines to connect to the bioinformatic course will be consistently different between the BIO and INFO realms. In the first case, i.e., for bioinformatics courses delivered in study paths belonging to the life science/medicine area, BITS recommends that students strengthen their knowledge of hard science and skills belonging to the theoretical, formal, and technical spheres. These would be mathematics, statistics, computer science, and basic programming skills to understand theoretical  and practical  bases on which to hinge the foundations of the course. Conversely, for bioinformatics courses delivered in study paths belonging to the computer science/engineering area, BITS considers it mandatory to expose students to soft sciences and experimental thinking, with an introductory course in biochemistry and biology .Promote the introduction of bioinformatics courses in both levels of the academic degrees. The establishment of only 1 bioinformatics course in an Italian student’s entire academic career  forces teachers to excessively shrink the topics covered in the course. Therefore, BITS envisions that a BSc study path can include at least one 6 ECTS bioinformatics course, dedicated to the fundamentals of bioinformatics, and that the MSc study path can include a bioinformatics course of at least 8 CFU, dedicated to contemporary applications, such as “omics” sciences, structural bioinformatics, and systems biology.Prefer hands-on teaching. It is essential that students acquire full awareness of the significance of bioinformatics procedures for research, analysis, and data processing; for this reason, it is recommended to avoid as much as possible a “black box” approach to the use of bioinformatics tools . Furthermore, virtualization techniques now allow running complex multistep pipelines in 1 terminal command, but they should be taught as advanced courses and not at the beginning, letting the students build their own small workflows from scratch, to better appreciate the complexity of workflow management. BITS also suggests that the teaching of bioinformatics should not be limited to a purely descriptive approach, but should include examples of research projects, appropriately sized to the skills to be acquired. This would enable students not only to apply bioinformatics tools, but also to critically evaluate the results, understanding the differences that different types of tools and approaches may have on the data obtained.https://data.consilium.europa.eu/doc/document/ST-9526-2016-INIT/en/pdf), and ethics in scientific research [Make students aware of the importance of Open Science principles. BITS recommends raising students’ awareness of the importance of proper management, sharing, and reproducibility of all research outputs  by introducing the principles of “data FAIRness” , “data sresearch . For thihttp://www.cbui.it/wp/ and GRIN: http://www.grin-informatica.it/opencms/opencms/grin). Both have positively evaluated the work done, beginning a path of collaboration with the society for future evaluation of study paths.BITS has encouraged its members and faculty colleagues in charge of bioinformatics courses to adhere to these recommendations and to promote their adoption within the various academic teaching bodies. Moreover, we shared these recommendations with 2 Italian bodies that are involved in evaluating the quality of teaching at the academic level, both in the biological and computer science fields (CBUI: https://elixir-europe.org/platforms/training), and GOBLET , of which BITS is a member, which hosted in October 2021, as part of the joint GOBLET & EMBnet Annual General Meeting 2021, the presentation of these data, and that has issued materials to support the teaching of bioinformatics [BITS will periodically revise these recommendations based on the evolution of the discipline, on the feedback received from the faculties, and considering the development of bioinformatics in the international context. In particular, attention will be paid to suggestions arising from associations dedicated to education in bioinformatics, for example, the training platform of ELIXIR .(XLSX)Click here for additional data file.S1 TextExplanation of the terminology used in this contribution and of the meaning of some terminology referred to academic classifications currently used in Italy.(DOCX)Click here for additional data file.S1 Fighttps://commons.wikimedia.org/wiki/File:Map_of_Italy-it.svg).Panel (a): Detailed list of the Universities that participated to the survey, with information concerning their geographical location and the number of the answers collected for each University. Panel (b): Visual localization of universities on the map of Italy (map source: (TIF)Click here for additional data file.S2 FigDetailed distribution of the teachers (panel (a)) and of the course (panel (b)) with respect to the Italian academic disciplines classification (SSD). For the meaning of the codes, please refer to: https://www.cun.it/uploads/storico/settori_scientifico_disciplinari_english.pdf.(TIF)Click here for additional data file.S3 FigSince multiple answers were allowed in the survey, the total is higher than 100%.(TIF)Click here for additional data file.


Reinforced by the COVID-19 pandemic, the capacity of health systems to cope with increasing healthcare demands has been an abiding concern of both governments and the public. Health systems are made up from non-identical human and physical components interacting in diverse ways in varying locations. It is challenging to represent the function and dysfunction of such systems in a scientific manner. We describe a Network Science approach to that dilemma.General hospitals with large emergency caseloads are the resource intensive components of health systems. We propose that the care-delivery services in such entities are modular, and that their structure and function can be usefully analysed by contemporary Network Science. We explore that possibility in a study of Australian hospitals during 2019 and 2020.We accessed monthly snapshots of whole of hospital administrative patient level data in two general hospitals during 2019 and 2020. We represented the organisations inpatient services as network graphs and explored their graph structural characteristics using the Louvain algorithm and other methods. We related graph topological features to aspects of observable function and dysfunction in the delivery of care.We constructed a series of whole of institution bipartite hospital graphs with clinical unit and labelled wards as nodes, and patients treated by units in particular wards as edges. Examples of the graphs are provided. Algorithmic identification of community structures confirmed the modular structure of the graphs. Their functional implications were readily identified by domain experts. Topological graph features could be related to functional and dysfunctional issues such as COVID-19 related service changes and levels of hospital congestion.Contemporary Network Science is one of the fastest growing areas of current scientific and technical advance. Network Science confirms the modular nature of healthcare service structures. It holds considerable promise for understanding function and dysfunction in healthcare systems, and for reconceptualising issues such as hospital capacity in new and interesting ways. An abiding concern during the COVID-19 pandemic has been the capacity of health systems to cope with the demands of people infected with SARS-CoV-2. There has been anxiety that hospitals, overwhelmed by demands for care, might break under the strain. However, hospitals are not brittle objects. Nor are they static fortified positions that can be overwhelmed by an encroaching force. They are complicated, evolved, human artefacts whose designs include a range of mechanisms [Biomedical research and practice is appropriately concerned with identifying the right biomedical and psychosocial care for patients and communities. However, right care is the product of a system whose elements include providing right care, to the right patient, at the right time, in the right place, and, whenever possible, right first time. In that context, the provision of care is as much a function of the interactions between the components that make up a system of care as it is of the technical competencies required. But the complexity of the demands, and the diversity of the necessary responses, mean that it is challenging to represent the interactions involved in a scientifically robust manner  and to dThe aims of our program of work have therefore been, first, to create a quantitative, structured, representation of how the human and physical resources involved in delivering patient care work together  as a funIn the current study, whilst bearing the aims in mind, we have chosen to focus on a component part of health service provision, rather than a total service. A Public hospital is not a single functional entity. For example, out-patient clinic-type services work differently to inpatient services. Same-day procedural activities are different again. The primary focus of our current analysis has been overnight stay services, an important source of public concern when there is evidence of dysfunction. We conceptualise overnight care as the product of interactions within and between three general functional layers.A tripartite structure is common in analyses of complicated systems with fixed elements subject to variable demands. Examples include traditional telephone, and electrical transmission, systems . TripartThe current study is based on the proposition that the organisation of healthcare functional structures can be best understood using the construct of modularity, and analysed using the scientific and technical approaches of contemporary Network Science. Using a hypothesis testing format, the null hypothesis is that network graphs of inpatient healthcare processes have a random graph structure. The test hypothesis is that the network graphs  have a sSome years ago, Simon  expoundeThe evolution of cardiac stents from bare metal to drug-eluting has been an important therapeutic advance. The new stents could be incorporated into everyday use as a specific change in a restricted area of practice, that is, as an intramodular process change. The take-up at any scale of another important cardiac technology, implantable defibrillators, involves a much larger system redesign incorporating a number of modular components , 13 and Network Science has been described as relational science , a scienAn important feature of network graphs of complicated systems is that the structure of the graphs can be tested against the null hypothesis that the graphs depicts a random , or nullNewman  has madeThe depiction of healthcare systems as network graphs is not new. A number of healthcare related studies based on network graphs have been published. This includes a substantial literature of studies using social network analyses –23. ReceNetworks may be represented by many different types of graphs. We constructed a series of undirected bipartite graphs , 30  or in multiple wards (a cardiology unit might care for patients in a Coronary Care Unit and two cardiac-designated wards).Contrawise, a designated ward, and its geographically based staff, may host patients under the care of one, or many, clinical units.Network graphs may be undirected, or directed if there is a dependency that subordinates one node to another. However, both types of graphs can be analysed in similar ways. In hospitals and health services, patient care is the product of teamwork between many different groups of staffs: that teamwork is best represented by undirected interactions.All the analyses reported here were undertaken on anonymised data sets. The studies were performed in conformity to an institutional ethics review by the relevant health authority, as described below.Network graphs are arithmetic products. Their utility depends on their interpretability by domain experts. A series of meetings were convened with a multi-disciplinary range of healthcare domain experts who reviewed the bipartite undirected graphs. Their comments led to a novel analysis of the graphs’ modular structures.The current studies  made useAnonymised administrative data sets for two Australian public general hospitals, Hospital 1 and 2, were accessed. Both hospitals provided a range of secondary and tertiary care services to substantial catchment populations. Hospital 2 also provides a range of state-wide super-speciality services. It does not provide paediatric, gynaecological or obstetrics services. Both hospitals collect mandated inpatient administrative data as described above. Hospital 1 had also developed a searchable patient journey data base that overlays inpatient data with a computerised time and location stamp each time a patient is moved between locations within the hospital. This allows a ward and clinical unit to be identified at the point that data is extracted. The treating wards and units in Hospital 2 were as recorded at the point of discharge. For both hospitals, the data covered the whole of 2019, and up to September in 2020. The data collection could not be extended in Hospital 1. After that time any data extraction procedures would have had to be undertaken by analysts who were required to work exclusively on immediate COVID pandemic issues. For Hospital 2, the data collection was extended to cover the remaining months of 2020.For Hospital 1 and 2, adjacency matrices were developed based on each monthly snapshot. The snapshots were also merged for calendar year matrices. In the adjacency matrices, the complete set of wards and units formed both the column and the row headers, and the presence or absence of shared patients formed the cell content. This was not an accumulative procedure; only the link at the moment of overall data extraction was recorded. The data extraction was based on the same date each month, randomising the data in relation to the day of the week. Whilst data was available to weight the edges in relation to the numbers of patients involved, unless otherwise indicated, as previously stated, the studies were conducted on unweighted, undirected data.The matrix data was analysed using specialised open-source software Gephi  .The Coefficient of Variation (cv) for identified modular structures in each hospital was computed, and presented in Table The data base for the snapshots for Hospital 1 contained a surrogate measure of congestion, the number of patients at midnight who had earlier been accepted for admission, but who had still not been allocated an inpatient bed (delayed placement patients). The relationship between the number of delayed placement patients and modularity was examined by computing the correlation between their number, and monthly modularity values in the Hospital 1 snapshots. The correlations were examined for networks with, and without, the high coherence modules.Figure The network graphs confirmed the modular nature of the ward-unit structures through which inpatient care was delivered in both hospitals. The modularity value for the composite graph of Hospital 1 in Fig. The 2020 snapshots cover the initial period of the COVID 19 pandemic. Whilst Hospital 1 was involved as a community hospital in the response to the pandemic, Hospital 2 was a designated SARS-CoV-2 response hospital where elective admissions were restricted in anticipation of pandemic demands. At that stage, whilst the morbidity of the SARS-Cov19, a respiratory virus, was not yet clear, it was deemed important to ensure adequate resources were available, both in terms of intensive treatment facilities including ventilators in negative pressure environments, and the staff to support them.The network graphs appeared to be responsive to the changes in function. In Fig. Network graphs characterised by the presence of modular interactions between groups of nodes share a number of mathematical properties that reflect important functional characteristics of the systems represented. The degree of a node is the number of other nodes that connect directly to the node in question. As previously described, in graphs where inter-connections between nodes are random, the overall distribution of degrees will be normal, or Gaussian in nature. There will be a mean, or average number of connections, and a low likelihood of extreme numbers of connections. Network graphs with modular structures are complicated systems, and as such, they commonly have a non-linear node degree distribution that is unlikely to have occurred by chance . There iFigure In relation to the study of modular structures following the domain expert review, the sub-threshold modules in Hospital 1 included a mental health related module, a women’s health services module and a geriatric assessment unit. In Hospital 2 there was also a mental health unit, an acute medical assessment unit, and a haematology oncology cancer service. In both hospitals, the super-threshold cv modules were the more general acute medical and surgical services.r = 0.33).The relationship between the number of delayed placement patients and modularity was examined by computing the correlation between their number, and modularity in the Hospital 1 snapshots. The number of delayed placement patients varied from a low of 9 to a high of 24. Detailed specification of the numbers of delayed patients per snapshot has not been provided so as to avoid any possibility of a breach of privacy. The month-by-month variations in modularity for Hospital I are shown in Fig. r = 0.48 (p < 0.05) with lower modularity being linked to increases in numbers of delayed placement patients. We repeated that analysis excluding patients admitted as elective patients in the data set, and the correlation increased slightly to r = 0.53 (p < 0.05).We re-examined modularity, excluding the three low cv modules, based on the assumption that these services were not intensively involved in the high volume medical and surgical cases that made up the majority of the delayed placement patients . The aveA modern general hospital hosts, on a daily basis, a large number of encounters between patients and care providers. Whilst the majority of those encounters have a satisfactory outcome, substantial numbers are adversely affected by a variety of issues . We arguIn this set of studies, we represented important aspects of the functioning of two general hospitals’ inpatient services as bipartite network graphs. When named wards  and specified clinical units form the network nodes, and the patients connecting them, the edges, the bipartite graphs represent the clinical structures through which clinical care is delivered in inpatient facilities. The graphs presented here represented the inpatient services of two large Australian public hospitals whose everyday work includes managing large numbers of emergency patients. The graphs covered both a period of usual demand, and the first wave of responses to SARS-CoV-2.By comparing the modular structures that emerged against random graphs of the interactions between similar numbers of elements we were able to reject the null hypothesis that the processes are represented by random graphs. The identified structures were not the consequence of chance interactions. However, the network modules were the product of a purely ‘arithmetic’ combinatoric procedure. To what extent did the modular systems as represented make sense as representations of the real world systems from which they were derived? That is, whilst the combinatorics might create reliable mathematical structures, were they valid real world representations?The graphs had face and content validity. All wards, clinical units, and patients were represented. There was a clear pattern to the links between wards and clinical units that was readily interpreted as representing the patterns of care within the hospitals concerned. The patterns did not represent functional structures as multiple isolated ward-unit ‘silos’ , 42 or oGraphs were generated for each monthly snapshot, and for the accumulated data. The monthly graphs were sparser than the cumulative graphs, which is appropriate for the smaller number of edges in the monthly snapshot graphs. But the underlying modular structures were similar between the monthly and cumulative graphs, and made sense to domain experts. The modularity parameter, a graded, if not parametric, objective measure of the difference between a modular, and matching random graph , confirmNetwork graphs are state measures. They represent networks at particular points in time. They are descriptive rather than predictive. Nevertheless, we found a relationship between the modularity metric of a graph subsystem focused on the management of medical and surgical emergencies, and the number of emergency patients waiting at midnight for an inpatient bed within the body of the hospital. Substantial number of patients so identified is generally regarded as an index of hospital dysfunction. The Modularity metric represents the movement between organization and randomness, and in Hospital 1, the more random the modular subsystem, the greater the number of patients whose admission was delayed. A causal relationship has not been established, but the possibility that increasing randomness in the organization of relevant functional structures may be predictive of congestion and dysfunction in the relevant system is of considerable interest and requires further study. It may be that system modularity is a candidate metric for a quantitative measure of system functional status.The graphs confirmed that whilst the modules in the network graphs each had a distinct functional identity, there were a limited number of ‘shortcut’ direct links to other modules within the system. This system characteristic is commonly referred to in Network Science as ‘small-worldness’ , 45. GenThere are many limitations to these studies. Only two hospitals were involved, and both are part of the same health economy. Only a restricted amount of the very large volumes of data generated by hospitals was used in the studies. Despite having good access to data from diagnostic services, we did not include them in the studies reported here, mainly because their pervasive use means that they shed little light on the kind of structural concerns studied here. Further investigation is warranted. Also, we did not include the totality of emergency services in our analyses. We only included those Emergency Department patients in Hospital who had been designated as inpatients waiting for placement in the body of the hospital. More work is required before this and other healthcare studies can be merged into a whole of hospital connectome  of functWe restricted our analyses to one combinatoric algorithm. Other forms of analyses are possible, but the Louvain algorithm is widely used , and resWhilst managerial oversight in day-to-day processes was not itself readily identifiable in the data we had access to, experience indicates it has an important role in modular structures. When inter-modular incursions appear to be likely to be more extensive than are readily accommodated by existing shortcut paths, senior management intervention may be required to manage friction at the borders . This isThere is an emerging interest in the application of Network Science to a range of healthcare related issues –52. The Network graphs are topologies. They represent interactions irrespective of where they take place. This makes Network Science highly relevant to evaluating and improving the integration of virtual healthcare services with existing (and continuing) intra-mural services, an issue highlighted by responses to the COVID-19 pandemic . FurtherBipartite Network Graphs of the organizational and logistic layer of inpatient care systems in two general hospitals were developed using existing healthcare data sources. The graphs consistently represented the hospital structures as modular. The topological characteristics of the network graphs were consistent with those of a range of other complicated technical and social systems , 55, impNetwork Graphs are a purely arithmetic product. Their utility rests on their capacity to be meaningfully interpreted in relation to the system from which they are derived. The healthcare graphs were reviewed by independent domain experts with a detailed knowledge of healthcare systems. For each hospital, they found the graphs to be readily interpretable and that they represented systems that contained recognizable specialized modular components, together with a more loosely organized set of general medical and surgical modules. We had hypothesized that the pressure on hospitals’ systems, exerted by variations in demands for care, and by planned reorganizations, would be identifiable within the organizational and logistical middle layer. We were able to confirm this in two ways. First, by demonstrating a relationship between modularity values of subgraphs of the more general medical and surgical services and a hospital-wide congestion indicator. Then, by demonstrating that graph structures were responsive to the changes that occurred during the initial period of the COVID-19 pandemic. The hypothesis testing capacity of the Network graphs in a healthcare context is substantially enhanced by the fact that the values of the modularity metric are derived from tests against random or null state graphs.Finally, one of the challenges of a Network Graph approach is that the graphs are measures of a hospital state at a point in time. Finding ways for Network Graphs to represent the way networks change  is a rap