Marine spatial planning is increasingly used to manage the demands on marine areas, both spatially and temporally, where several different users may compete for resources or space, to ensure that development is as sustainable as possible. Diminishing sea-ice coverage in the Arctic will allow for potential increases in economic exploitation, and failure to plan for cross-sectoral management could have negative economic and environmental results. During the ACCESS programme, a marine spatial planning tool was developed for the Arctic, enabling the integrated study of human activities related to hydrocarbon exploitation, shipping and fisheries, and the possible environmental impacts, within the context of the next 30 years of climate change. In addition to areas under national jurisdiction, the Arctic Ocean contains a large area of high seas. Resources and ecosystems extend across political boundaries. We use three examples to highlight the need for transboundary planning and governance to be developed at a regional level. As sea-ice cover in the Arctic diminishes, the potential for future economic exploitation increases, most notably in shipping, oil and gas exploitation, fisheries and tourism. Failure to plan for cross-sectoral management could potentially lead to negative environmental impacts and user–user or user–environment disputes or conflicts  is increasingly used to manage the demands on marine areas, where several different users may compete for resources or space, and to ensure that activities at sea are as sustainable and efficient as possible. However, spatial planning for the future use of marine areas is a fairly new concept. Although marine areas are often regulated or allocated within individual economic sectors, there are at present few future looking and cross-sectoral examples of integrated marine spatial planning Douvere .Marine spatial planning provides a practical way to organise the use of marine space and the interactions of its users, both spatially and temporally. Resulting marine spatial plans aim to balance the demands for development with the need to preserve the environment, while also achieving social and economic objectives. Many countries already designate or zone marine space, but conflicts can arise where management plans have been developed on a sector-by-sector basis, without sufficient consideration of the effects on other users or the environment. Successful MSP must take into account the spatial and temporal diversity of the sea, and understanding and mapping these distributions is a key step in the process . Several recent studies, including the Millennium Ecosystem Assessment , have hiAn effective Marine Spatial Plan should apply EBM, balancing ecological, economic and social goals and objectives towards sustainable development. The plan should be integrated across all relevant sectors and agencies, both nationally and regionally, and should be adaptive and anticipatory, with focus on the long term, typically with a 10- to 20-year horizon. Marine spatial planning needs to be an iterative process that learns and adapts over time. The UNESCO’s Intergovernmental Oceanographic Commission (IOC) highlights six characteristics of effective marine spatial planning: (1) ecosystem-based, balancing ecological, economic and social goals and objectives towards sustainable development; (2) integrated, across sectors and agencies, and among levels of government; (3) place-based or area-based; (4) adaptive, capable of learning from experience; (5) strategic and anticipatory, focused on the long term; and (6) participatory, stakeholders actively involved in the process  is of relevance as it provides for the division of seas and oceans into maritime zones, some of which must be delimited by coastal states in order to have a legal effect. Equally of importance is the principle of freedom of navigation guaranteed under UNCLOS, which is conditional upon rules and standards on maritime safety and protection of the marine environment being met. Under UNCLOS Article 89, no state can unilaterally claim sovereignty or sovereign rights on the high seas and, as a result, cannot claim sole responsibility for MSP Maes . AlthougThe High Seas are a particular international component of the marine environment of the Arctic Ocean. Under the 1982 UNCLOS Convention, resources of the water column are available for exploitation by states external to the Arctic community (Part Vll), while sovereign rights to the exploitation of the resources of the underlying seabed and sub-seafloor may well belong to an Arctic coastal state (under Part Vl). This dual management regime is one which needs very careful planning and lends itself to the process of MSP.Arctic summer sea-ice extent has significantly reduced over the past 30 years  to accommodate those rescued presents a significant challenge , and the associated human activities related to and within these sectors. It was beyond the scope of the ACCESS programme to produce a marine spatial plan, but instead to establish a framework with which interdisciplinary planning could be effected.The MSP tool employs a Geographical information system (GIS), based on ArcGIS, to store, manage, interrogate and access the regulatory, spatial and temporal information outputs from the four theme areas. Two systems were developed, one desktop and a mirror online version. Users are able to visualise the various uses of marine space and identify overlapping activities. The MSP tool enables easy access to the regulation impacting on each sector which can be accessed as hyperlinks. Where future potential developments are envisaged, the MSP tool highlights the context and identifies the parameters of significance to the development allowing a prediction of any challenges.Figure To provide a schematic illustration of how the MSP tool functions within the framework of ACCESS, Fig. While the developed MSP tool covers the whole Arctic Ocean region, it is not possible to deliver detailed analysis for the entire region (largely due to lack of available data for some areas). Selected areas and themes have been targeted to demonstrate the MSP tool. The first example sets the context over the Arctic Ocean, while the following two examples look at regions under pressure from increasing economic exploitation: the Barents Sea, and the Chukchi Sea and Bering Strait region.The effects of climate change are apparent throughout the Arctic, with rising temperatures leading to a decline in sea-ice volume and changes to weather patterns, season length and ecosystems. The Arctic Ocean contains a range of different jurisdictional areas, including high seas and the Exclusive Economic Zones of the five Arctic coastal states. Current legislation ranges from supranational conventions, regional multinational or bilateral agreements, and finally national legislation. In addition to binding legislation, different sectors of the Arctic are also covered by various non-binding guidelines, codes and resolutions, for example the Arctic Offshore Oil and Gas Guidelines 2009 produced by the Arctic Council. This complex hierarchy and geographic coverage has led to jurisdictional and sectoral fragmentation of governance covering the Arctic Ocean Young . MSP allRetreating summer sea ice is allowing access to more areas of the Arctic Ocean both within and beyond national jurisdiction. Future economic development of these areas from a range of users may lead to possible cross-sectoral conflicts over the region as a whole Fig. . IncreasIn addition to hydrocarbon exploitation, retreating sea ice is also opening up the Arctic to shipping. The two main shipping routes the Northern Sea Route and the North West Passage are both located largely along the shallow water continental shelf, where the USGS have identified significant hydrocarbon prospectivity , for example the North East Atlantic Fisheries Commission (NEAFC) involving Denmark/Greenland, Norway and Russia as Contracting Partners which covers the Arctic from 42°W to 51°E longitude including a small area of High Seas in the central Arctic, many areas are not covered by any regional legislation. Current legislation is inadequate to fully protect these areas. Options to regulate potential emerging fisheries include the establishment of a new RFMO or arrangement for the Central Arctic Ocean , has therefore significant implications not only for the conservation of the cetacean species and their habitats, but also for the local communities that depend on marine mammals for both food supply and cultural cohesion. Through careful planning of shipping lanes, and temporal or spatial closures of feeding or calving areas (for example to oil and gas drilling), MSP could prove a vital tool to mitigate against the impacts of human activities on Arctic cetaceans, for example the reduction in sources of underwater noise.The Barents Sea is an area of rich living natural resources, while also experiencing growing exploitation of hydrocarbon resources, and an increase in maritime transport. As a result, this is an area where coordination and regulation of these activities is required to manage interactions between different economic sectors, and also with the natural environment. An integrated management plan is already in place for the Norwegian Barents Sea–Lofoten area, integrating fisheries management measures with those for oil and gas, transport and nature conservation. The plan covers Norwegian waters only; no marine spatial plans are in place for Russia.Gadus morhua) stock density for August 2057. The modelled results suggest that climate change does not lead to significant changes to cod stock from the present day, but do highlight that this area will continue to be a significant fisheries resource. Cod stocks are predicted to be high around the boundary between the Norwegian and Russian EEZs and the Loophole , and also further east in Russian waters offshore Novaya Zemlya, highlighting the need for transboundary management. The establishment of the Joint Norwegian-Russian Fisheries Commission in the 1970s has contributed towards sustainable management of the Barents Sea fisheries.We can use the MSP tool to analyse spatial and temporal data from all the economic sectors covered by ACCESS: fisheries, shipping and oil and gas Fig. . ResultsThe hydrocarbon sector is well developed in both the Norwegian and Russian sectors of the Barents Sea. In 2011, the maritime boundary dispute between Russia and Norway in the Barents Sea was resolved, opening up new areas for hydrocarbon exploitation. The Barents Sea is undoubtedly a major hydrocarbon province and exploration is likely to extend further offshore in the future. Retreating sea ice may allow further northwards exploitation of hydrocarbons.The Barents Sea is also an area of increasing shipping activity, which has recently seen large increases in the volume of petroleum products shipped along the Norwegian and Russian coasts. Shipping along the Northern Sea Route (including LNG) also passes through the Barents Sea. Reduction in summer ice extent is opening up the area to the north of Novaya Zemlya as a potential shipping route, which could significantly increase vessel traffic through the Barents Sea in southwest to northeast directions.The Barents Sea is clearly an area facing increasing pressure from shipping, fisheries and oil and gas exploitation, and the need for spatial planning for sustainable development is clear. In addition to potential user–user conflicts, user–environment conflicts are highly probable too. For example, the distribution of Minke whales, as well as one of several identified areas of heightened ecological significance within the Barents Sea Large Marine Ecosystem, overlaps with areas of increased economic exploitation Fig. . Minke wFigure The ACCESS MSP tool has been developed to address a unique combination of climatic and geopolitical issues and is designed to provide a data integration system for the purposes of identifying or mitigating against possible future events or activities. The tool allows the integrated study of information from all sectors under review: hydrocarbon exploitation, shipping and fisheries, and the associated human activities related to and within these sectors. Using the concepts of Ecosystem-Based Management, recognition of sectoral uses and practical methodologies of data and relationships analyses with a powerful geographical information system, users of the MSP tool can visualise and assess in a qualitative way the factors relevant to sustainable development in the region, as they are affected by long-term climate change.Marine spatial planning offers a transboundary, holistic approach to the governance of living and non-living resources. For this to succeed, there needs to be commitment at both national and regional levels. The involvement of stakeholders and users of the Arctic, including pan-national governance elements (such as the Arctic Council), is essential. Truly effective marine spatial planning needs to be considered at a multinational, Pan-Arctic scale.


Remotely sensed data can serve as an independent source of information about the location of residential structures in areas under demographic and health surveillance. We report on results obtained combining satellite imagery, imported from Bing, with location data routinely collected using the built-in GPS sensors of tablet computers, to assess completeness of population coverage in a Health and Demographic Surveillance System in Malawi. The Majete Malaria Project Health and Demographic Surveillance System, in Malawi, started in 2014 to support a project with the aim of studying the reduction of malaria using an integrated control approach by rolling out insecticide treated nets and improved case management supplemented with house improvement and larval source management. In order to support the monitoring of the trial a Health and Demographic Surveillance System was established in the area that surrounds the Majete Wildlife Reserve (1600 km2), using the OpenHDS data system. We compared house locations obtained using GPS recordings on mobile devices during the demographic surveillance census round with those acquired from satellite imagery. Volunteers were recruited through the crowdcrafting.org platform to identify building structures on the images, which enabled the compilation of a database with coordinates of potential residences. For every building identified on these satellite images by the volunteers  were part of the censused area), we calculated the distance to the nearest house enumerated on the ground by fieldworkers during the census round of the HDSS. A random sample of buildings (85 structures) identified on satellite images without a nearby location enrolled in the census were visited by a fieldworker to determine how many were missed during the baseline census survey, if any were missed. The findings from this ground-truthing effort suggest that a high population coverage was achieved in the census survey, however the crowd-sourcing did not locate many of the inhabited structures (52.3% of the 6543 recorded during the census round). We conclude that using auxiliary data can play a useful role in quality assurance in population based health surveillance, but improved algorithms would be needed if crowd-sourced house locations are to be used as the basis of population databases. Detailed, high resolution and up-to-date maps on human settlements are not available for many rural areas in low and middle income countries, but such information on human population distribution would be invaluable for measuring precisely the impacts of population growth, for monitoring changes and for planning interventions , in partOne approach to resolving these challenges is to establish Health and Demographic Surveillance Systems (HDSS). An HDSS is a system that collects longitudinal data on core demographic events  and certain health indicators at regular intervals  from a target population in an area where government-based data for these events and indicators are unreliable due to total absence of a Civil Registration System (CVRS) in the area or improperly recorded data . HDSS arThe Majete Malaria Project  in MalawAPI). There are many popular or less popular available online as Google Maps, Bing Maps, OpenStreetMaps, and MapQuest… All provide similar services with some more specialized on a specific feature . Bing map was used rather than Google Maps because of a suspected incompatibility between the OpenLayer library and Google Maps at the time of the development of the web application.Ensuring completeness and accuracy of the population database is essential for accurate characterization of core demographic as well as key health indicators in an HDSS, but ground censuses are labor-intensive, time-consuming, and are not necessarily complete. Unlike ground-truthed maps of house locations, high-resolution satellite images are generally available , and easWe present an approach for estimating the population coverage of an HDSS using geolocations of buildings, crowd-sourced from satellite imagery, to assess the completeness of the population data. This exploits features of the OpenHDS data system, which is increasingly used as a standard in HDSS sites, combined with volunteered geographic information (VGI) , and shoA crowd-sourcing approach was used to collect geo-locations of houses in the study area of the MMP from satellite images. This was used to establish a database of building geolocations for comparison with that established from the census of the population by field teams, allowing us to identify buildings which were possibly missed in the HDSS census. The population coverage of the census for the HDSS was estimated on the basis of visits by a supervisor to a sample of locations identified as buildings on the satellite images but absent from the census database at the end of the census-round (ground-truthing).The HDSS is run in the Chikhwawa District, an area in the lower Shire River Valley region of southern Malawi. The district, mainly rural, has a population of over 530,000 people distributed in an area of about 4,800 km2 . Since sThe HDSS data were managed using the OpenHDS System ,8,9. OpeThe OpenHDS System ,10 was sDuring the census, demographic surveillance visit to each location in the study site, location coordinates were captured through the tablets’ in-built GPS to build a database of inhabited buildings. This approach allowed the aggregation of data points in a central database in near-time, i.e. within days after a house was visited.12 fieldworkers recruited from the target communities for their knowledge of the area and to ensure good relations with the communities were trained on the use of the OpenHDS mobile system.Each HDSS has a defined location hierarchy in the area under surveillance. The lowest level of this location hierarchy is the one leading the ID generation for the HDSS entities and is important in our study for the identification of houses that became part of the ground-truthing (see section “Ground truthing”). A complete list of the villages (lowest location hierarchy level) was obtained from African Parks-Majete, the management authority of MWR and implementing partner in MMP. In the area targeted for the HDSS surrounding MWR, there are 62 villages .At village level during the census round, the fieldworker collected location information where individuals were living. This task was performed through OpenHDS mobile integrated with the ODK collect application. After the login into the OpenHDS mobile application, the fieldworker had to select the village where the house was located, going through selecting the hierarchies available in the OpenHDS mobile . Once heA software application called Rural Geolocator was developed using the PyBossa framework  and the The tasks processed by the volunteers were grouped into three batches corresponding to the three focal areas described above . The batch sizes for focal areas A, B and C were and 682, 2953, and 1031 tasks, respectively. The area covered by each batch was defined prior to the completion of the HDSS census, and therefore the spatial extent of each batch was greater than the village borders eventually identified by the HDSS census.At the end of the census, crowd-sourced geolocations were compared with the GPS-based coordinates collected by the study team to identify locations which were potentially missed in the census. In a first step, data points from the census were processed by grouping the points according to the village in which they were collected using the location id assigned by the fieldworker. A convex hull was placed around the points in each village . Next, tWe also tested if there were houses which were enrolled during the HDSS census but absent from the set of locations identified on satellite images. We used an approach analogous as described above, i.e. we classified HDSS locations as “distant” if they did not have a nearby location among the set of locations identified on the satellite imagery, again using a threshold of 40m.Ethical clearance for the HDSS was obtained from the University of Malawi, College of Medicine Research Ethics Committee (COMREC) in Malawi (P.05/14/1579). Permissions were obtained from the Ministry of Health and the district health authorities in Chikwawa District. Prior to the start of the study, a series of meetings were held in participating communities to explain the nature and purpose of the study. We obtained individual written informed consent from all participants.The census round in the MMP projects started on 20 August 2014 and ended on 14 November 2014, data were collected in one additional village in February 2015. During this census round 6,543 locations and 24,129 individuals were registered in the OpenHDS System.A group of volunteers from more than 30 different countries contributed to the crowd-sourced geolocation effort . 299 regThe data processed and the results of the crowdsourcing are available to be downloaded from the Crowdcrafting.org website .A total of 62,946 geolocations were submitted via mouse-clicks by the volunteers. When applying the replicate-consolidation algorithm to cluster points, a total of 26,247 suspected houses were identified. Of those, 11,046  were confirmed by being identified in all three replicates, and 3,424 of these were within the censused areas . 445 13.In all 85 cases where all three crowd-sourcing replicates identified a house that was absent from the GPS database, ground-truthing indicated that the location had been correctly excluded from census . Most ofFor a small number of locations, classification on the ground was not possible. None of these locations were inhabited houses that had been missed during census when empty houses were not taken into account in the system. This indicates that a high percentage of the population coverage was reached using the OpenHDS system in the census round of the HDSS.A total of 1,490 of the locations visited during the census were found to be distant from all houses identified by volunteers in all three replicates of a task . This nuThe collection of volunteer-provided geolocations for a sizable study area required about the same elapsed time as the ground survey. The crowd-sourcing provided a convincing check of the coverage of the ground census, demonstrating that the HDSS achieved a high coverage of the population of the study area.However, as implemented, the crowd-sourcing missed many of the inhabited locations.The cost of crowd-sourcing was negligible because the PyBossa software is a publicly available resource.The number of houses identified in all three replicates processed by the volunteers, deemed “eligible for ground-truthing” in For the application described here this is of no consequence, except that it introduces an asymmetry between the HDSS and volunteer-provided locations which makes it difficult to compare some results in absolute numbers. For example, the 455 points identified as distant probably represent a higher number of buildings. We think that it would be scientifically interesting to follow up with a more detailed analysis using a supervised learning algorithm ,30 to exThe large number of houses enrolled in the HDSS but not identified in all three replicates of a task was not expected and merits some discussion of possible reasons. One factor that may explain the classification of HDSS-enrolled houses as distant is that for a number of those databases records the reported GPS-accuracy was substantial (up to 50m). A more detailed analysis showed that many of the HDSS houses had close-by analogues in at least one of the task replicates. This raises a number of questions related to the optimal way of presenting tasks to volunteers.The first concerns the number of replicates. Is three replicates per task are sufficient, or would a higher number of replicates provide a more solid foundation for distinguishing reliably located buildings from spurious mouse clicks? There were 164 tasks in which one replicate was submitted with no clicks, but more than 10 clicks in both other replicates, suggesting that a quorum smaller than the replicate number might increase the quality of volunteered data.The second is related to task size. It may be useful to make the task size (i.e. the area to be inspected as part of a task) smaller. Due to a glitch of the PyBossa software at the time of the data collection, we lack information on how long it took a volunteer to process each task replicate. This issue has since been fixed, and we recommend that future applications focus on this metric for optimizing the size of the task.Most of the volunteer work was done by a small number of individuals, whereas most volunteers stopped contributing after a small number of tasks. It is possible that simpler tasks  would lead to a volunteer contributing more task replicates. Further, it might be possible to identify incentives for those who only contributed a few results to do more, rather than spending effort on recruiting more volunteers .To our knowledge this is the first time that VGI has been employed in an effort to establish the population coverage in an HDSS, and the approach is an important addition to the tools available to HDSS program managers, allowing them to ensure that the entire population was covered during the census or successive rounds. The approach is easily transferable to other areas, and could be used to estimate coverage in any surveillance system which requires geo-locations of houses.Beyond using the approach described here for quality control in population-based surveillance, we see further applications in the planning of observational or intervention field studies. Potentially, crowd-sourcing of such images could provide improved sampling frames for household surveys, even in areas where there is no population database. This could even be used for generating samples stratified according to other characteristics identifiable on satellite images . Similarly, crowd-sourcing could be used to count or localize the numbers of such features within a research area for comparison between different areas. All of these extra studies could be also decided after the data collection and not predetermined a priori.In general crowdsourcing projects have an outreach component , and the benefit is probably more than the data because people learn about the research ,33.VGI ,34,35 anIn last 3–4 years computer image recognition has improved significantly , but stiDeveloping and tuning an image analysis application is technically challenging, while crowd sourcing data is relatively straightforward and can be implemented quickly. On the other hand, the problem of identifying houses on satellite images is recurrent and will not go away because even existing population databases need frequent updating, so it is probably worth investing in automating it. VGI, combined with the ground-truthing methodology presented here, may contribute to the process of training image recognition algorithms.


P = 0.04, r = 0.046) between residents’ year of education and attitude toward ethical conflict; however, this relationship was not observed in other demographic characteristics. Taking the priorities of ethical conflicts in pediatrics into account may help improve the designing of medical ethics education programs in hospitals for residents, thereby reducing the conflicts related to the issues of medical ethics.Ethical conflicts are recognized as critical aspects in assessing competence in clinical communication. Moreover, pediatrics residents may face more problems, compared to other disciplines; due to the specific characteristics of the age group receiving services as well as the presence of their families. This study has been conducted with the aim of determining the attitude and perspective of pediatric residents toward ethical conflicts in the field of pediatrics. This descriptive, cross-sectional study was carried out on all residents of Tehran University of Medical Sciences (90 residents), selected through census method, in 2014. The data collection tool was a 32-item research-based questionnaire. Its validity and reliability were confirmed by the researchers and the medical faculty members. To analyze data, descriptive and inferential statistics were used. However, based on the results, lack of an advanced directive and written procedure for withdrawing life-sustaining treatment of an incompetent or critically-ill child (4.38 ± 0.80), lack of provision of sufficient information on obtaining informed consent (4.12 ± 1.10), and the absence of a legal written process for doing not resuscitate (DNR) orders (3.98 ± 0.95) were the most salient causes of ethical conflicts in pediatrics. Furthermore, in accordance with the linear regression analysis of demographic characteristics, there was a significant relationship ( Conflict is defined as an interpersonal or intrapersonal discord potentially causing serious harms . Our ethIn the field of pediatrics, the refusal of the provision of treatment, order to discontinue resuscitation in the event of cardiorespiratory arrest, measures such as resuscitation of premature or newborn infants in severe conditions, children’s privacy, obtaining consent for treatment or intervention, parental disapproval of the necessary treatment, and child abuse or neglect by guardians are of the most important issues facing residents. These issues are the main causes of ethical conflicts in pediatric residents’ clinical practice . AnotherIn this regard, the results of a study in England encompassing medical conflicts showed that decision-making processes for patients and communication between employees were the main ethical challenge in pediatric oncology from the perspective of professionals . In addiAccording to the results of a research conducted in Iran on the quality of medical ethics curriculum from the perspective of Iranian students, the program had an unfavorable condition . The resThe trend of educating medical ethics in medical schools has had rapid progress. However, residency training has been focused more on the development of clinical skills, and most of the teaching hospitals have failed to either hold medical ethics education classes for the residents or dedicate far less hours to this end. Furthermore, the educational programs for residents do not cover the relationship between medical ethics and ethical decisions revolving around physicians and human values which are focused by both the teaching hospitals and the educational curricula . TherefoUnfortunately, topics related to ethical conflicts of pediatricians are rarely argued in current medical ethics courses. In other words, although some researches have been performed to address the most common ethical challenges of medical ethics in Iran , 11-13, In this cross-sectional study, the research population included all pediatric residents studying in 3 teaching hospitals affiliated to Tehran University of Medical Sciences   for 9 months in 2014. Subjects were selected through census method (n = 90). The researchers, taking into account the ethical considerations, attempted to perform the study by gathering data using questionnaires filled out by the residents once obtaining permission from the Ethics Committee of Tehran University of Medical Sciences and the consent of residents.The studied variables included demographic variables and residents’ attitudes toward ethical conflicts. The demographic variables studied included age, gender, marital status, years of residency, training hospital, and previous medical ethics course track records. First, the relevant literature, including theses, articles, and electronic databases , were reviewed for an appropriate questionnaire. The used keywords were medical ethics, medical education, conflicts, challenges, and pediatric. The questionnaire used was made by the research group. For this purpose, during 3 sessions, the items were reviewed and revised using the views of 13 experts . Finally, the items were applied according to the latest comments and received the final approval of the panel of experts. Then, the final questionnaire was designed with 32 items. Each item was assessed based on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). The validity and reliability of this tool were justified by the researcher using content validity and test-retest methods. The content validity of this tool was measured by 10 faculty members of the department of pediatrics and department of medical ethics of Tehran University of Medical Sciences and their comments were applied. To verify the reliability of the mentioned tool, test-retest was conducted; 10 members of the sample group took the test 1 week apart. Results of the two tests were calculated using Pearson’s correlation coefficient to the accuracy of 0.78. P values < 0.05 were considered significance.The data were analyzed using descriptive (mean and standard deviation) and analytical (linear regression) statistics in SPSS software . All The findings related to the demographic characteristics of the participants are given in Evaluation of the attitude of pediatrics residents toward moral conflicts indicated that lack of a formal and written process to withdraw life-saving treatments of seriously ill children toward the end of life (4.38 ± 0.80), lack of provision of adequate information in attaining informed consent (4.12 ± 1.10), and absence of a written procedure for do not resuscitate (DNR) orders for children (3.98 ± 0.95) are the primary causes of moral conflicts in the domain of pediatrics. The mean and standard deviations related to other priorities are presented in Furthermore, according to the linear regression analysis of demographic characteristics, there was a significant relationship between the residents’ years of education and their attitudes toward ethical conflict, but this relationship was not seen in any other demographic characteristics. The linear regression analysis results are presented in Assessing pediatrics residents’ attitudes toward ethical conflicts illustrated the lack of an enacted and written process to withdraw life-sustaining treatment toward the end of the child’s life, provision of adequate information for an informed consent, and an established procedure for DNR orders as the most important causative factors of ethical conflicts in the field of pediatrics according to the residents’ point of views.By the same token, the findings of a study in the Netherlands showed that pediatricians face challenges regarding the issue of life-sustaining treatment for children, and therefore, they have focused on feeding medical information to their families . AnotherA study was conducted with the participation of pediatricians in the Netherlands on the end-of-life decision-making for children . AccordiHowever, it must be consisted that facing the death of children in the final stages of life is, by its very nature, a crucial factor shaping conflict in pediatricians. In this regard, the results of a research in the USA revealed that the factors playing a supportive role for pediatric residents in facing children’s death and helping them to reduce their perceived conflicts are teamwork and high quality end-of-life care provision .The findings of this study and the results of other studies in this field suggest that life-sustaining treatment and DNR at the end stage of life are still challenging issues for which there is no legally-pronounced and written mandate. This issue is potentially harmful as far as ethical conflicts in pediatrics are concerned. Therefore, taking the fact into account that physicians encounter many conflicts at the final stage of children’s life, it is essential to use the right strategies of conflict resolution. In Iran, no approved clinical and ethical directive document and guideline exist to determine when and how DNR orders are assigned, and in some cases, this was communicated orally without the knowledge of the patient or his/her family. These ambiguities about DNR caused much controversy and confusion among the health staff about their course of action when managing a clinical situation. The fact of the matter is that making comments on the continuing treatment of patients in the terminal phase is a fundamental skill required by physicians and has given rise to scientific, ethical, and legal challenges.Other results of this study showed that neglecting to provide enough information on obtaining informed consent is another effective factor in clinical conflicts in pediatrics. In this context, it should be acknowledged that although pediatricians play an important role in informing the patient about the consequences of disease , childreResults revealed that lack of respect for children and families, violation of children’s privacy and rights as an educational issue, and the improper process of breaking bad news to a sick child or parents are considered to constitute other important ethical conflicts in the field of pediatrics. These findings were also supported by a research carried out in Canada concerning this field of study . As beliAs a matter of fact, health-care providers in the field of pediatrics, in most cases, do not involve the patient and his/her family in the treatment decision-making process. As a result, they fall short of the patient’s values, concerns, preferences, and barriers perceived by them to follow up on the treatment regimens, and in this way they in fact disrespect them. In contrast, addressing the issue of participative decision-making can boost satisfaction with care and quality of life (QOL) for the child and his/her family, and thus, help decrease the existing conflicts . In factOn the other hand, educational programs in the health-care systems should be capable of training dexterous specialists. Therefore, patients need to be involved in medical education programs , yet theA study conducted in Sweden in collaboration with pediatricians in the field of cancer, illustrated that their biggest concern was the labels they allegedly received as messengers of life-threatening conditions and the breakers of bad news . This fiOther ethical conflicts considered important in this study were inappropriate professional behavior of physicians toward other health-care team members, and hospital rules and regulations which are in conflict with professional ethical principles. The results of a study in the USA indicated that negative factors related to professional behavior associated with the workplace that affect the work quality of pediatricians included the absence of professional autonomy, interpersonal challenges, poor communication among colleagues, non-supportive climate, and feeling of powerlessness . These fIn addition, lack of respect for cultural and religious beliefs of the sick children and their families was another ethical conflict of great importance from the viewpoint of the residents in this study. In a more realistic context, the process of both care and treatment of sick children is affected by cultural and social factors which are often misconceived by both the medical staff and families . TherefoLack of complete and appropriate control and management of children’s pain, lack of respect for children’s rights as a research subject, dealing with a decision-making conflict between sick children and their families in an awkward way, and failure to provide suitable physical facilities for the continued presence of the mother in the hospital were other issues recognized as responsible for emergence of ethical conflict in this study.Generally speaking, complementary education could be cited as one of the strategies that can assist residents in logically dealing with ethical conflicts. However, the findings of the study in Canada showed that medical ethics education is of very high value among residents, and familiarizing residents with moral conflicts during residency training is also important . In addiIn this study, improper appearance and clothing of medical staff were the least important factor in the area of ethical conflicts. It seems that more studies should be conducted in this regard.According to other findings, among the demographic characteristics, there was a significant relationship between year of residency and their attitude toward ethical conflict, but this relationship was not seen in any other demographic variable. This means that as residents proceeded to higher academic years, they may have developed a deeper understanding of the ethical conflicts related to their career. This finding may be explained in that the importance of ethical conflicts for residents has become more prominent with the passage of time along with further professional experiences.This study had the following limitations. The pediatrics residents’ attitudes toward ethical conflicts regarding children were evaluated. The study findings, however, cannot be generalized to ethical conflicts in other specialized medical disciplines. Furthermore, another limitation of this study was that the perspective of pediatrics residents was evaluated in only one university of medical sciences, which is the largest university in the country with the highest population of residents in the field of pediatrics. Therefore, it is recommended that the opinions of residents from other medical specialties regarding ethical conflicts be evaluated in future studies to provide better comparisons in this regard. It is also suggested that a relevant national survey be conducted in Iran. On the other hand, comparison of the current research findings with those of other studies was limited due to the poverty of similar studies in Iran.Based on the results, formulation of clinical ethics standards and relevant educational methodology and their institutionalization into health centers, determination of strategic plans for clinical ethics education, identification of methods, the need to expand clinical ethics, and ultimately, its institutionalization into a comprehensive health-care system constitute the most important issues which must be considered for pediatrics residents’ ethical conflicts. This may help reduce the conflicts related to issues of medical ethics for them. In addition, it seems that formal medical ethical education should be incorporated in the formal curriculum of pediatrics in the country and the importance of these issues should be emphasized during the education of pediatrics residents.


We propose a novel simple method for quantitative and qualitative finger-tapping assessment based on miniature inertial sensors (3D gyroscopes) placed on the thumb and index-finger. We propose a simplified description of the finger tapping by using a single angle, describing rotation around a dominant axis. The method was verified on twelve subjects, who performed various tapping tasks, mimicking impaired patterns. The obtained tapping angles were compared with results of a motion capture camera system, demonstrating excellent accuracy. The root-mean-square (RMS) error between the two sets of data is, on average, below 4°, and the intraclass correlation coefficient is, on average, greater than 0.972. Data obtained by the proposed method may be used together with scores from clinical tests to enable a better diagnostic. Along with hardware simplicity, this makes the proposed method a promising candidate for use in clinical practice. Furthermore, our definition of the tapping angle can be applied to all tapping assessment systems. During neurological examinations, assessment of motor performance is helpful in identifying the integrity of central nervous system components. Motor tests commonly include speed and strength level evaluation. Finger tapping is a test of the primary motor speed of the index finger . PatientThe tapping test has been widely used for assessment of ataxia , stroke In clinical practice, tapping is often evaluated visually, estimating speed, amplitude, and regularity of movements. However, small amplitude differences cannot be easily and correctly identified. It has been reported that the tapping score was one of the most difficult items to assess ,15. DeteSeveral research groups worked on increasing the accuracy of quantitative evaluation by using various finger-tapping measurement systems ,25,26,27In reference , an optiIn reference , a fingeAnother system used a magnetic sensor with two coils mounted on fingers . The coiSystems with gyroscopes have been used for evaluating bradykinesia ,15,16,28In this paper, we analyze these challenges and we propose a method for quantification of the finger-tapping angle based on miniature inertial sensors (3D gyroscopes) placed on the index finger and thumb, which could be further used for detailed observation and evaluation . The system comprises only one pair of inexpensive gyro sensors whose outputs can be recorded and processed with ease, following the algorithms proposed in this paper. Based on our pilot study comprising 37 patients and 12 healthy subjects, we have established that the finger tapping, defined as relative rotational movement of the index finger and thumb, can be considered as a general 3D movement. That movement can include rotations around various axes, but in all cases, there exists a dominant axis of rotation. This axis can vary from subject to subject, also depending on the sensor placement, but it can always be unambiguously found. Therefore, we provide a simplified description of the finger tapping in terms of a single scalar value, which describes the rotation around this dominant axis. This scalar is the angle between the main  axes of the thumb and the index finger, which is also a highly intuitive measure for clinicians. The maximal value of the tapping angle is equivalent to the finger-tapping amplitude, which is typically estimated visually within the MDS-UPDRS scale, part III . We dealThe results provided by the proposed method are compared with results obtained by an optical motion capture system (the reference system). The method was verified on twelve healthy subjects, who imitated impaired patterns identified from the pilot study.Our system enables objective assessment of the following parameters: tapping duration, angular speed, aperture , and various other derived quantities that could be easily exported in a form suitable for interpretation by clinicians.A pilot study was conducted on three groups of patients, recruited from the movement disorders outpatient clinic in the Institute of Neurology CCS, School of Medicine, University of Belgrade, Serbia: 15 patients with PD, 12 patients diagnosed with PSP, 10 patients with multiple system atrophy (MSA), and 12 age- and sex-matched healthy subjects with no history of neurological or psychiatric disease. All participants gave informed written consent prior to involvement in the study. Subjects were asked to sit comfortably in a chair and place their hand in front of them in the most convenient way. They were instructed to perform a sequence of two tasks within each recording. The first task was to hold fingers closed and still, and then make a circular or zigzag movement in space in order to perform autocalibration. The second task was to repeatedly tap their index finger and thumb for 15 s, performing the tapping as wide and fast as possible . On averA rest period of one minute was set between sequences. Each sequence began and ended with fingers closed. Six tapping sequences per subject were performed (three with each hand) and video-recorded. Observational analysis of 294 recorded tapping sequences  showed a variety of tapping patterns. While the control group showed periodically regular and rhythmical patterns, which differed mainly/only in the speed and aperture, the patients exhibited various irregular movements such as tremor, change of thumb or index orientation at connecting points, skipping/freezing of movement during maximal finger opening or closing, connecting fingers with a strong force, etc. The results for the pilot study are summarized in In order to quantify these tapping patterns in a systematic and comparable way, there was a need to define the angle between the thumb and the index finger as a single scalar quantity that could be always applied, and develop a measurement method that could be used with satisfactory accuracy.In addition to the patterns shown in The large pool of patients from the Neurology Institute  allowed a good selection of neurological cases. However, we did not have access there to a laboratory with high-precision measurement equipment, such as a motion capture system, which was available at the Institut des Systèmes Intelligents et de Robotique . Since it was not feasible to transfer the patients there, nor to organize a new clinical study at the ISIR  in a reasonable time, the validation of the angle estimation was performed on twelve healthy subjects (located in Paris), who emulated various tapping patterns captured in the pilot study. All of the participants gave informed written consent prior to the involvement in the study. The experimental protocol was similar as in the pilot study. The subjects were given tasks to perform the tapping in all of the patterns defined in The system comprises two sensor control units (SCU), which acquire signals from sensors and wirelessly transmit data to a remote computer, as in . A proprx-axes of the sensors aligned with the distal segments of the fingers  are mounted on the fingertips of the thumb and index finger, positioned over fingernails, with the nsversal , and thex-axis of the corresponding finger. The third marker is shifted along the y-axis.An optical motion capture system (MOCAP) with active markers  is used as the reference system for verification of the proposed system. We used the optical motion capture system due to its convenient usage and ability to record general 3D motions with a high resolution . The disposition of the MOCAP system is shown in The acquired signals are monitored online and automatically stored for further processing. The acquisition software was designed in LabWindows CVI , while the signal analysis was performed in Matlab 7.7.1 .The two gyro sensors measure the vectors of the angular velocities of the thumb and the index finger with respect to the fixed coordinate system (the laboratory). However, the components of these two vectors are obtained in the corresponding local coordinate systems. To estimate the relative movement of the fingers, we need to establish the mutual position (rotation) of the local coordinate systems. Hence, a calibration is performed at the beginning of each recorded sequence. The fingers are pressed against each other so to minimize their relative movement. Thereafter, the whole hand makes a move  during which both sensors measure at least some rotation about all three axes.Since the relative position of the two sensors is practically fixed, both sensors measure the same vector of angular rotation, The rotation (transformation) matrix x finger  With the aim to minimize the differences between the components Based on the suggested measurement protocol, the autocalibration sequence can be recognized automatically, by identifying the time interval at the beginning of the recording sequence when both sensors register vigorous movements , but the magnitudes of the angular velocities are practically equal. Matrix After completing the autocalibration sequence, the tapping commences, when the thumb and the index finger are in relative movement.In order to assess the tapping angle, we evaluate the relative movement between the thumb and the index finger . There are various ways to describe this movement. Generally, the movement is complex and requires taking into account all finger joints. It is a combination of rotation and translation and it cannot be exactly described in a way that is useful in clinical practice. To make simplifications, the finger bending is neglected and the movement is assumed to be approximately scissor-like, as suggested in reference , where tFrom the recordings, we have found that the index finger has substantially greater swings than the thumb. Additionally, the signal processing is more numerically stable if we observe the movement of the thumb from the index-finger coordinate system. The reason is in the drift that is inherent to the processing of data from gyro sensors. This drift causes errors in the relative rotation of the two local coordinate systems, i.e., it causes errors in matrix The relative rotation of the two fingers can be described in various ways. Generally, three angles are required for a full description. We observed the relative rotation of the thumb from the coordinate system of the index finger. A typical finger-tapping pattern is shown in ntegrals b. By obsIn rare cases  when the integral of The component tization .α (raw tapping angle) between α is considered as a signed function of time, We define the tapping angle as follows. First, we project the z2-plane . We denoα can be evaluated as:From  (p. 139)The function atan2 is built into C and Matlab. Its result is on the semi-closed interval Generally, the angle The camera system gives the Cartesian coordinates of the markers . At each time step, from these coordinates we obtain the rotation matrix of the thumb, The first step in the evaluation of the tapping angle from gyro sensors is to compute the relative angular velocity of the thumb with respect to the index finger, During tapping, the two coordinate systems rotate with respect to each other. Hence, the rotation matrix must be updated, using a time-stepping procedure. The updating starts from the calibration sequence. The rotations of the thumb coordinate system about the Cartesian axes of the index-finger system are  step as  (p. 142)In cases when the drift is large , we can approximately calculate the tapping angle in another way. We have already noted that the dominant rotation of the thumb is with respect to the The baseline position varies from tap to tap because the taps are not uniform and due to the drift associated with the processing of gyro signals. Hence, we have developed and implemented an algorithm for the baseline removal. The main task is to identify starting and ending time instants of individual taps. The algorithm includes finding the average tapping period using the autocorrelation of We compare angles obtained by the proposed method with angles obtained from the camera system using the following error measures: the intraclass correlation coefficient (ICC) , the absICC is evaluated for each tap, and then averaged for the whole recorded sequence. The results for all subjects are shown in As the second error measure, we evaluate the root-mean-square (RMS) error b. The avFinally, we compare apertures. The absolute and relative errors for the apertures are evaluated for each tap, and then averaged for the recorded sequence c,d. The The results obtained by the proposed method show a high correlation with those provided by the reference optical motion capture system, proving this method to be usable for clinical practice.The accuracy of AL-C algorithm was found to be reduced in cases of extremely energetic tapping (task 2), when the gyro sensors approached saturation. Due to these nonlinearities, drift increases, which tumbles the transformation matrix after several seconds. The accuracy of AL-R algorithm is reduced when the fingers slip during tapping or the tapping mode is changed within a recorded sequence .AL-C algorithm naturally follows the relative rotation of the coordinate systems and, hence, gives results close to the actual tapping angles. However, it is prone to drift, which occurs when the tapping is vigorous. In contrast to AL-C, AL-R algorithm is only approximate because it does not allow the relative rotation of the coordinate systems. In most cases, AL-R yields somewhat smaller tapping apertures than AL-C, but it is not prone to drift.In this paper we provide quantification of the finger-tapping angle based on 3D motion of the thumb and index finger. In spite of the complexity of the motion, we have managed to define the tapping angle as a single scalar quantity., has not been covered in the literature.The study highlights the importance of identifying the dominant tapping axis. The proposed method offers a simple procedure that allows autocalibration, i.e., defining the initial conditions for angle estimation, regardless of hand position and orientation. Although gyroscopes are frequently used for estimation of upper and lower limb angles and there are papers describing solutions that performed estimation of the finger-tapping amplitude, these issues have not been previously addressed. Additionally, the assessment of various tapping patterns, provoked by motor impairments of the patientsIn clinical applications, the procedure we suggest requires from 2 to 5 min for the complete system setup, out of which less than one minute is needed for mounting the sensors on a patient. Explanations and practicing the tapping require additional 2 min; the same time it takes for the standard clinical validation within the UPDRS test. The autocalibration is performed within each tapping sequence, and it lasts only a few seconds , while the tapping sequence is recorded for 15 s. The overall duration for one patient, including mounting the system, explaining the procedure, and recording both hands  is estimated to be between 15 and 20 min.The post-processing can be performed automatically or manually. For the automatic post-processing, all six sequences from one patient can be processed and parameters extracted in several seconds. For severely impaired patients or specific tapping patterns, one could be advised to perform manual post-processing which would include careful inspection if all taps were correctly identified and correction of the identified taps by adjusting the thresholds, which would increase the post-processing time to 5–7 min per patient.The system is inherently reusable and the vital components do not suffer degradation of their characteristics over usage in a long period of the time. The methodology we propose can be implemented with any commercially available inertial system. However, different producers offer different qualities of sensors, not only in terms of their sensitivity and resolution, but also in terms of the stability of calibration. Hence, we would advise periodic sensor checkups of signal quality and calibration coefficients. After purchasing the system, the estimated costs are related mainly to the time spent in the implementation of the setup and the measurement procedure, which is of the order of 10 min, with additional costs due to the periodic maintenance of the sensor system.By comparing tapping angles obtained by our method (using gyro sensors) with results obtained by the reference camera system for various tapping patterns , we have verified and validated that the proposed angle calculation can be used for various tapping patterns, from slow and very weak movements to fast and vigorous, for patterns affected by tremor, as well as patterns that comprise irregular tapping movements within a tapping sequence . Our method is validated for 15 s tapping sequences, as one of the standard assessment protocols performed in clinical settings. However, we have verified by experiments that this method could be applied for longer sequences . Auto-calibration should be performed just before the beginning of the tapping sequence. Although the finger tapping is a repetitive and often a rhythmical task, it can comprise changes in hand and finger orientation during a tapping sequence. Hence, the angle estimation method should be immune to these changes. Based on our pilot study, we were able to record various possible tapping patterns, which enabled us to set specifications for angle calculation algorithms.We introduced two angle calculation algorithms: continuous and resetting, and compared their results for various tapping patterns. The continuous algorithm can be prone to drift. For tapping patterns with changes in finger orientation during tapping (or at finger closing) the resetting algorithm may lose some information, thus increasing the error and leading to worse results than having a small influence of the drift  without considering other finger segments. Although placing sensors on each finger segment would be the most accurate and precise assessment, as in references ,36, thisAdditionally, considering the number of sensors, there is also a question where to place them in order to obtain full tapping assessment based on one angle. Literature offers fitting one angle based on all finger segments , calculaBased on the proposed measurement system and the angle assessment methodology, the clinicians can be provided with numerical values describing the patient’s tapping performance: tapping duration, angular speed, maximal aperture , as well as their deviations and trends within the sequence . This caBy using instrumentation, instead only visual observation, finger-tapping movements can be studied in more detail, including quantification of hypokinesia and/or bradykinesia, detection of start hesitations, freezing episodes, tremor, and other atypical movements.The benefit of the proposed system (as well as any instrumentation device that could be used for this purpose) is that it can provide the same parameters that clinicians are trained to observe during visual examination when they assign MDS-UPDRS III score (or similar test). These results can be used for automatic quantification of motor performance ,43.The definition and evaluation of the tapping angle that we propose requires only one pair of miniature gyro sensors, placed on the fingertips. This setup enables finger-tapping assessment for tapping patterns that include slow and fast tapping patterns, having small or large tapping apertures, changing hand orientation while tapping, as well as having occasional irregular tapping events, such as skipping taps and other events listed in Our study provides recommendations for tapping assessment procedure, suggesting an autocalibration sequence before the tapping sequence, angle estimation based on an identified dominant tapping axis, and calculation of the tapping angle based on 3D motion of both fingers. As with all angle estimations based on inertial sensors, drift is an important issue. To cope with it, we have designed an algorithm that involves resetting of the rotation matrix. We have considered pros and cons of this algorithm in comparison with an algorithm without resetting.The proposed assessment method can be used in clinical environment. It uses an affordable sensor system and the procedure is not time or skill demanding. The potential of such a light and inexpensive wearable system is to be used concurrently with scores from clinical tests, providing possibilities for diagnostic support and therapy follow-up.In the future, we hope to validate these results on patients, also including other patient groups (with motor impairments). We wish to perfect this system so that it could be adopted by clinicians in their everyday work, as well as by other research groups interested in such assessment.


Early modern humans developed mental capabilities that were immeasurably greater than those of non-human primates. We see this in the rapid innovation in tool making, the development of complex language, and the creation of sophisticated art forms, none of which we find in our closest relatives. While we can readily observe the results of this high-order cognitive capacity, it is difficult to see how it could have developed. We take up the topic of cave art and archeoacoustics, particularly the discovery that cave art is often closely connected to the acoustic properties of the cave chambers in which it is found. Apparently, early modern humans were able to detect the way sound reverberated in these chambers, and they painted artwork on surfaces that were acoustic “hot spots,” i.e., suitable for generating echoes. We argue that cave art is a form of cross-modality information transfer, in which acoustic signals are transformed into symbolic visual representations. This form of information transfer across modalities is an instance of how the symbolic mind of early modern humans was taking shape into concrete, externalized language. We also suggest that the earliest rock art found in Africa may constitute one of the first fossilized proxies for the expression of full-fledged human linguistic behavior. The FOXP2 gene is implicated for speech in humans and for other externalized communication forms in mice (FOXP2 underwent change in modern humans (The first three points relate to the observation that artistic artifacts, either deep in caves or closer to the surface, occur on every continent occupied by modern humans , 2003, a in mice  and song in mice , but onln humans  that affn humans . The POUThe symbolic thinking that developed in humans led to rapid technological innovation, sophisticated visual arts, and language. This newly formed cognitive capacity may have had another, unexpected result. After continuously growing in size over the span of the Pleistocene, our brain has contracted in size by 13% in the past 20,000 years or so . Our braAll authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Heat stress as a physical harmful agent can increase the risk of health and safety problems in different workplaces such as mining. Although there are different indices to assess the heat stress imposed on workers, choosing the best index for a specific workplace is so important. Since various criteria affect an index applicability, extracting the most effective ones and determining their weights help to prioritize the existing indices and select the optimal index.In order to achieve this aim, present study compared some heat stress indices using effective methods. The viewpoints of occupational health experts and the qualitative Delphi methods were used to extract the most important criteria. Then, the weights of 11 selected criteria were determined by Fuzzy Analytic Hierarchy Process. Finally, fuzzy TOPSIS technique was applied for choosing the most suitable heat stress index.According to result, simplicity, reliability, being low cost, and comprehensiveness were the most determinative criteria for a heat stress index. Based on these criteria and their weights, the existing indices were prioritized. Eventually, wet bulb glob temperature appropriated the first priority and it was proposed as an applicable index for evaluating the heat stress at outdoor hot environments such as surface mines.The use of these strong methods allows introducing the most simple, precise, and applicable tool for evaluation the heat stress in hot environments. It seems that WBGT acts as an appropriate index for assessing the heat stress in mining activities at outdoors. Most workplaces depending on specific jobs and tasks may include the chemical, physical, biological, and ergonomic hazards that they cause a variety of effects ranging from minor injuries to serious diseases and even death. Heat is one of the most important physical hazards in many workplaces. Heat, as an energy source, exist in many industrial processes and workers who expose to it may be at risk of health problems and disorders . TherforHeat stress is a combination of internal and external factors leading to heat related illnesses. The internal factors include internal body temperature, metabolic rate, and physiological adaptations to hot environments. The air temperature, thermal radiation, air velocity, and humidity contribute as the external factors . Short-tIn some industries, heat stress is a common problem by which workers continuously exposed to. These conditions are found in indoor workplaces such as ceramics, foundry, and glass and outdoor works like mining, agriculture and construction industries .Mining activities lead to workersʼ exposure to undesirable environmental conditions. There are various causes for heat stress in mines. The sources of heat in surface mines include sun, electrical tools, machines, and mechanical processes. The efficiency of diesel engines typically is 33% and two-thirds of input energy is lost as heat, resulting in irreparable damages and disorders . AccordiIn Iran there are a lot of jobs and tasks with heat-related problems due to the weather conditions and the hot nature of most mining activities. According to the Statistical Centre of Iran in 2012, the total miners who worked in 6206 surface mines was 84528 . UnfortuThere is a need for using the heat indices to assess the heat stress, protect the workers against extreme heat, and control the workplace heat stress. Based on literatures, since 1905 many efforts have been made to measure the levels of heat stress in workplaces and estimate the heat strain. The aim of presenting an suitable index is to specify the relationship between environmental parameters, clothing and activity as a number. Due to the complexity of variables related to heat stress in real working environment, determining a comprehensive heat stress index for each variable is maybe not possible. Differences in the physical work demands, health status, heat tolerance, and heat sources, as well as involvment of the heat-related mechanisms, job rotation, and environmental temperature may affect the risk levels [The history of introducing and applying the heat stress indices is related to over a hundred years ago. The wet-bulb temperature index was firstly proposed by Haldane in 1905 as a measure to express the heat stress. After that, many indices were developed and applied around the world. Some of them include wet bulb glob temperature (WBGT), Effective temperature index, the Oxford index, 4- h Sweat Rate (P4SR), The new Universal Thermal Climate Index (UTCI). But none has been widely accepted .This study was aimed to determine a heat stress index among the existing ones for sarface mines using a set of criteria. Considering the lack of certain and clear criteria for choosing a heat stress index, at first it was necessary to get the viewpoints of occupational health experts and use a qualitative method (Delphi) for defining some criteria to select an index.Delphi is a method for acquiring the group knowledge. It has a structural process to predict and make decisions by a series of rounds, gather the information and eventually, achieve a group consensus . Delphi The other advantages of the Delphi Method include high flexibility, elimination of the geographical impediments, providing open discussions, and focusing attention on the relevant issues . DetaileThis study is a qualitative practical research that was designed and implemented in 11 steps. Due to the fact that there were no common criteria for selecting a heat stress index, the Delphi technique was used.The formation of implementing team and monitoring the Delphi processSelecting the experts and participantsAdjusting the questionnaire for first roundEditing the questionnaire grammatically (deductive and remove ambiguities)Sending the questionnaire for expertsAnalyzing the obtained responses in the first roundPreparing the second round questionnaire considering the required revisionsSending the second questionnaire to the same expertsAnalyzing the results of second questionnaireDetermining the relative weights of each criterion using the fuzzy AHP.Choosing a heat stress index among the existing ones in the study using the fuzzy TOPSIS method.This study was accomplished in following steps:A team including experts and consultants was formed and the aims of study were reviewed and revised. The number of 30 experts and panel members was selected from occupational health professionals of medical universities, administrative experts working in the department of environmental health in ministry of health, post-graduate students who were working on a thesis related to heat stress. According to studies, if the group is homogeneous, a sample consistent of ten to fifteen people will be sufficient for Delphi . Therefom alternatives and n criteria was prepared and sent to the same experts. They were asked to assign a score for each alternative using the linguistic scale in order to select the most appropriate heat stress index for surface mines. Indices in this study were used with respect to their prevalence and validity, strong correlations with physiologic indices and other valid ones, and also their applicability for outdoor environments. Figure As a pilot test, an open question was designed and sent to 10 experts in order to survey their perceptions and response. Given the results of the pilot study, the questionnaire was sent to 30 mentioned participants. Then, the responses of first phase of study were analyzed, criteria extracted and prioritized. The criteria with less scores were also investigated. During several meetings with professors, some overlapped criteria with the same concept were merged. At the end of meetings, the criteria with the highest scores were extracted and used for prioritizing and pairwise comparing in the next step. The second questionnaire was designed and sent to the 30 previous members for pair-wise comparison between the criteria and finally determinig the weight of each criterion using Fuzzy AHP. For prioritizing the indices existing in the study using fuzzy TOPSIS, a questionnaire including The Analytic Hierarchy Process (AHP) was proposed first time by Thomas. El. Saaty. This technique combines the opinions of all experts and provides the decision-making in a simple way. Then, a scale is used to pair-wise comparisons of criteria and assess their priorities . This teDetermining the linguistic terms for pair-wise comparison the criteria  using TaUsing the triangular fuzzy numbers to form the pair-wise comparison matrix.l + m + u), and its membership function is illustrated as follow:In this study, to remove ambiguity of uncertainties in decision-making, the triangular fuzzy numbers presented in Table m is the maximum grade of membership function, l and u are the lower and upper bounds to allow more reasonable evaluation. A triangular fuzzy number  and the membership function μ (X) is expressed in Fig. The use of fuzzy Geometric Mean .3\documeCalculating the fuzzy weight of each elements.The use of best non fuzzy performance (BNP)Calculating the inconsistency rate of matrixThe subjective comparisons in this method leads to some inconsistencies in AHP. The consistency ratio (CR) can be calculated as follow. If the CR is unacceptable, pair-wise comparison should be reconsidered.Where, n is the size of pair-wise comparison matrix, λmax is the maximal value of comparison matrix, and RI is the random consistency index obtained randomly from related tables [The consistency index (CI) presents the deviation from the consistency and is calculated as follow:d tables . If CR <d tables .The TOPSIS is a multi criteria decision-making method introduced firstly by Hwang and Yoon. The basic concept of TOPSIS is providing an ideal solution to maximize the benefit criteria and minimize the cost criteria. Briefly, the positive ideal solution includes the best available criteria while the negative ideal solution is consistent of the worst values of criteria. Therefore, optimized alternative has the least distance from the positive ideal solution and the farthest distance from the negative one. The TOPSIS algorithm is a strong compensatory multi-criteria decision-making technique to prioritize the alternatives with regard to the ideal solution. It has a little sensitivity to type of weighting technique and its responses don’t significantly change. In addition, an advantage of this model is its ability for fast identifying the best alternative. In this algorithm, it is assumed that each index and criterion in decision-making increases or decreases uniformly .It is often difficult for decision-makers to present an precise value for criteria due to some errors in this respect. In this case, it is recommended the use of fuzzy numbers for assessments. Therfore, in this study the fuzzy TOPSIS was applied for prioritization. The steps of fuzzy TOPSIS are as follows:Step 1. Constructing the initial comparison matrix. The fuzzy values in this matrix have been defined in the scale of membership functions in Table 1 and J2 respectively present the criteria benefit and cost.Step 2. Determining the positive (benefits) and negative (costs) ideal solutions as A+ and A- respectively.Step 3. Calculating the distance of each alternative from negative and positive ideal solutions by Euclidian (n-dimension) method.di+and d− represents the distance of alternative from positive and negative ideals. Also, distance (d) between two fuzzy numbers  is calculated by following equation:Where Step 4. Calculating the relative closeness of each alternative to the best solution as follow:Step 5. Prioritizing the alternatives using the relative closeness. Each alternative which has the largest closeness is the best for choosing.The aim of this study was to determine the effective criteria for choosing a heat stress index by using the Delphi model and specify those criteria weights by fuzzy AHP. Using 30 completed questionnaires by experts and reviewing their viewpoints, 30 criteria were extracted. In another meeting, due to the same concepts of some criteria and the lack of relevance of some of them, the effective criteria to select the index decreased to 14. Finally, 11 criteria were selected considering the percentage of experts responses. They can be seen in Table As shown in Table Results related to the closeness factor  and prioritization of heat stress indices using fuzzy TOPSIS technique are seen in Table Heat stress is a hazardous physical agent in the workplaces. Nowadays, due to the technological advances, climate change, and consequently the increasing of global temperature, the heat stress is considered as a adverse factor in many workplaces. Exposure to heat causes heat syncope, heat exhaustion, heat stroke, confusion, poor concentration, and also exacerbation of some diseases, as well as reducing the production and increasing the indirect costs. Particularly, long-term exposure to hot conditions can result in so much stress on individuals . The heaIt should be applicable and precise when using;It should be consisted of all important factors ;Its measurements and calculations should be simple;The means and methods used to measure the workers’ exposure should not interfere with their activities;The index should be applicable in the wide range of environmental and metabolic conditions .Among the obtained responses, the simplicity criterion had the highest frequency. Simplicity of an index means the calculations are feasible without complex computing and multiple devices. Although this criterion appropriated the highest percentage of responses (76.6%), its relative weight was 0.041 (the least weight after the criterion of “being low-cost”) and had the less importance in comparison with other criteria. The next criterion with the most frequency was the reliability of index. Reliability refers to the fact that if the measurements are repeated several times in the same weather conditions, the similar results will obtain. The percentage of responses was 53.3%. The percentage for “being low-cost” the heat stress index was the same as the reliability (53.3%). The criteria of comprehensiveness, being direct reading, and precision were located in the next priorities with the percentage of 50, 50, and 46.6%, respectively. The Fuzzy analytic hierarchy process (AHP) showed that according to the opinions of experts, the maximum weight was related to “being standard” of index. This criterion means that if the index is acceptable by international organizations or not? For instance, The International Organization for Standardization (ISO) publish the standards in many fields . The criIt is worth mentioning that, the NIOSH recommendations to choose an appropriate index is aligned with the results of this study. So it can be concluded that to have a reliable and accurate measurements, the first step is choosing a suitable and precise index. To select an index based on the viewpoints of experts, its being standard is the most important criterion. The precision and reliability of index, and its strong correlation with the physiological strain indices should be considered. In this study for choosing an index among existing ones, the fuzzy TOPSIS technique was used. The TOPSIS algorithm is one of the most reliable scientific and management methods for decision-making. Using this technique, with regards to all effective aspects, it is possible assessing the criteria types, priorities, and weights toward each other, evaluating the indices relative to the criteria, and also prioritizing the indices in a resonable way. The results of closeness factor and indices priorities can be seen in Table It is said that, the WBGT index is simple to understand and use, and also it has suitable validity to organize the work–rest cycle. The fact that, there are some limitations related to WBGT and they would be preferable to consider for protecting the workers who work in hot environments . AccordiBased on Table 2) that it can be continuously tolerated in hot environments. The maximum level of work in hot environments is calculated by measuring dry, wet, and radiation temperatures, wind speed, and atmospheric pressure, and also by considering the adaptability status and type of clothing. Also the safe work duration and guidelines for work-rest cycle in hot environments can be determined by this index. It is able to calculate the sweat rate and determine the needs for fluid intak for preventing dehydration. This index has taken the code of practice from the Abu Dhabi management system of health safety and environment to manage the heat stress [Holmer in 2010 conducted an investigation using internationally proposed methods including WBGT-ISO 7243 and PHS-ISO 7933. The results obtained from the comparative evaluation of heat stress at the same conditions with PHS and WBGT showed the WBGT index has more conservative assessment approach compared to PHS, resulting in much shorter working time. It seems that, WBGT overestimates the heat stress. This is aligned with findings related to some developing countries in which work is done under climatic conditions. In this case, considerable limitations are necessary when following the WBGT recommendations. Although, considering the data from warm countries, the predicted physiological strain by PHS may be more appropriate, the conservative philosophy of WBGT can be valuable in regard to safety . Among tTable Among the indices, Environmental Stress Index (ESI) with the closeness coefficient of 0.517 had the fifth priority. Moran et al. (2001) proposed ESI based on the measurement of air temperature, relative humidity (RH), and solar radiation (SR). These three variables are commonly used due to the quick response and simple measurement. Also, they can be determined using commercially available fast-reading sensors . In addiAccording to the results of studies conducted in mines of different countries, the WBGT, TWL, and effective temperature indices have been used seperately or in combination with each other, that it is consistent with selected indices in present study . A studyTo determine the optimal heat stress indices, Omidvari et al. evaluated the SWreq, WBGT, P4SR, and CET in surface mines located in Kermanshah province of Iran. In this respect, the criteria of heart rate and skin and core temperatures were also considered. The obtained results recommended WBGT and SWreq as the most appropriate indices to assess the heat stress . GolbabaSince the activities in surface mines are performed under the sunlights, as a heat source, it can be concluded that in such conditions the WBGT index is more suitable than other indices and indicates the actual heat stress imposed by the environment. A study by Brief found that the WBGT index acts more accuratly than other indices in presence of radiation energy in the environment and it can indicated the actual thermal conditions. These findings are in line with results obtained in the present study.In conclusion, this study demonstrates that WBGT is often the most appropriate index to evaluate the heat stress in surface mines. Some criteria may affect prioritizing the heat stress indices and choosing a suitable index among them. In this respect, the most important criteria can be extracted using experts’ viewpoints and Delphi method. Simplicity, reliability, being low cost, and comprehensiveness are determinative criteria for applicability of an index. Determining the weights of criteria and prioritizing the indices are performed by the fuzzy AHP and TOPSIS techniques, respectively. The use of these strong methods allows introducing the most simple, precise, and applicable tool for evaluation the heat stress in hot environments. It seems that WBGT acts as an appropriate index for assessing the heat stress in mining activities at outdoors.