We present the first systematic analysis of global ionospheric disturbance current systems caused by multiple processes of solar and magnetospheric origin, including reorientations of the interplanetary magnetic field (IMF), sudden changes in the solar wind dynamic pressure, magnetospheric sawtooth substorms, and ultralow frequency (ULF) waves. Measurements from global magnetometer networks are used to derive the equivalent disturbance currents from the polar cap to the equator. A surprising result is that the equivalent disturbance current systems are very similar, although the driving processes are completely different. The equivalent disturbance current system in response to IMF reorientation or substorm onset is characterized by a large vortex on the dayside and evening sector and a smaller vortex near dawn, and the polarity of the current vortices depends on the IMF direction. The equivalent disturbance current system caused by a sudden change in the solar wind pressure or by ULF waves consists of a single vortex at middle and low latitudes and a very small vortex above ~60° magnetic latitude near dawn. The similar disturbance current systems caused by different solar wind and magnetospheric processes suggest that the global distribution of the ionospheric currents is determined by the intrinsic property of the ionosphere. The global current system takes only ~1 min to completely reconstruct, indicating that the current system can reach a new steady state within 1 min. A scenario is proposed to explain the global distribution and fast reconstruction of the current systems. Global ionospheric equivalent disturbance current systems caused by multiple processes are derived and systematically analyzed for the first timeA time scale of 1 min for global ionospheric disturbance current system to reconstruct is identifiedA scenario is proposed to explain the global distribution and fast reconstruction of the ionospheric current systems This study focuses on the processes that can generate nearly instantaneous response in equatorial ionospheric electric fields. A nearly instantaneous response means that when the solar wind or magnetospheric processes cause changes in electric fields in the polar ionosphere, corresponding or similar changes occur almost immediately in equatorial electric fields without obvious time delay. One such process is a southward turning of the interplanetary magnetic field (IMF) which causes the generation of penetration electric fields at low latitudes. Penetration electric fields are the electric fields of solar wind/magnetospheric origin observed equatorward of the shielding layer . Magnetic field perturbations caused by Pc5 pulsations have been detected with ground magnetometers at low latitudes  in the solar wind pressure is large and occurs within a couple of minutes. For substorms, we choose the cases in which the onset of the substorm expansion phase occurs during continuous, stable southward IMF, so the possible effects of a northward turning of the IMF on the magnetic field and currents can be reduced to minimum. For Pc5 pulsations, we choose the cases in which the wave amplitude can reach 30 nT or so at low latitudes, so the increase or decrease of the magnetic field relative to its mean value can be unambiguously determined.Sq current system is removed in our analysis, and the derived current system is the disturbance current system. In the following sections, we use the term, “current system” but not “disturbance current system” in the text for simplicity. It should be remembered that the current system used in this paper is in fact a disturbance current system.As already mentioned above, the quiet‐time 2.1https://omniweb.gsfc.nasa.gov/) and have been shifted to the bow shock nose of the Earth. The solar wind pressure is mostly stable. The IMF Bz shows quasiperiodic (1.5–2 hr) oscillations between southward and northward. Plotted in Figure F region vertical ion drift measured by the Jicamarca radar. The vertical ion drift is increased during southward IMF and decreased during northward IMF. This is a typical penetration electric field event.Figure H) component of the magnetic field data measured by these two magnetometer chains are depicted in Figures Bz is negative at 1725 UT, causing an increase in the vertical ion drift and northward magnetic field at low latitudes, corresponding to the occurrence of an eastward penetration electric field in the dayside equatorial ionosphere. At 1830 UT, the IMF Bz is positive, causing a decrease in the vertical ion drift and the northward magnetic field at low latitudes, corresponding to the occurrence of a westward shielding electric field. As discussed by Huang  is located near local noon during the time of interest, and the magnetic deviation at AAE is larger than those at other local times. The larger amplitude of magnetic field increase at AAE is an indirect evidence of the occurrence of an eastward penetration electric field caused by substorm onset, consistent with previous studies , plotted in Figure A sudden change, an increase or a decrease, in the solar wind pressure causes a corresponding change in the geomagnetic field. Figure Magnetic field data measured by two magnetometer chains, one along latitude and another along the equator, are plotted in Figures Figure Because the changes in the solar wind pressure and the subsequent geomagnetic field response occur very quickly, this case provides a very good opportunity to examine how long the ionospheric current system takes to reconstruct. The details are shown in Figure The equivalent current patterns at 1951, 1953, and 1954 UT are plotted in Figures In order to show that the current system remains stable between 1957 and 2012 UT, the current patterns at 2000, 2003, 2006, and 2009 UT are presented in Figure Bz is positive and enhanced at this moment  and Ascension Island , are used to calculate counter electrojet. Figure H represents electrojet or counter electrojet. The negative ΔH following the sudden drop in the solar wind pressure indicates the occurrence of counter electrojet (or westward electric field). No magnetometer measurements at the magnetic equator near noon or in the afternoon sector are available for calculating electrojet or counter electrojet in this case.In this case, no measurements of equatorial ionospheric ion drifts/electric fields are available. As shown in the cases of Figures The two vertical dotted lines in Figure Bz remains positive and stable. Figure Another example of the ionospheric current system caused by a sudden decrease in the solar wind pressure is presented in Figure 2.4Bz on 15–16 July 2000. The strong southward IMF after ~1900 UT on 15 July causes a severe magnetic storm with a minimum Dst of −301 nT. The Pc5 pulsations of interest occur during the recovery phase of the storm, denoted by the yellow shading in Figures Bz between 0722 and 0802 UT on 16 July. The IMF Bz during this interval is strongly positive, and the solar wind pressure has some irregular variations but not periodic wave activities.Pc5 pulsations, as well as Pc3, Pc4, and Pi2 pulsations, are often observed at low latitudes. For our purpose, we need to find large‐amplitude Pc5 pulsations in which the peak‐to‐valley difference of the magnetic field at middle and low latitudes can be 30 nT or larger, so the difference current distributions at the pulsation peaks and valleys can be unambiguously determined. We searched magnetometer data in 2000–2003 at solar maximum and selected two cases in which the pulsation amplitude is very large. The first Pc5 pulsation case is presented in Figure Figure Figure Figures Bz is strongly positive. The magnetic field measurements along the equatorial magnetometer chain is plotted in Figure A second case of large‐amplitude Pc5 pulsations on 31 October 2003 is shown in Figure 2.5In the previous subsections, magnetic perturbations along some latitudinal and equatorial magnetometer chains are presented. Note that these stations are located in a limited latitudinal range at middle and low latitudes. In addition, different scales are used for different stations to better show the magnetic perturbations caused by external processes. This may cause an impression that the magnetic perturbations at all latitudes have similar amplitude.In fact, magnetic perturbations in all cases are large at high latitudes, become much smaller at middle latitudes, and are enhanced by the Cowling effect over the magnetic equator. This feature can be seen in the global distribution of unnormalized magnetic perturbations in each case. In order to explicitly show the latitudinal variation of magnetic perturbations, the amplitude of the net magnetic field change in response to each solar or magnetospheric process is plotted as a function of magnetic latitude in Figure In the cases of penetration electric fields, the amplitude of the magnetic perturbation at each station is defined to be the net increase from the minimum before the IMF southward turning to the maximum after the IMF southward turning. In the cases of magnetospheric substorms, the amplitude of the magnetic perturbation is the net increase from the substorm onset to the maximum after the onset. In the cases of solar wind pressure changes, the amplitude of the magnetic perturbation is the net increase from the undisturbed reference to the maximum after the solar wind pressure enhancement or the net decrease from the undisturbed reference to the minimum after the solar wind pressure drop. In the case of Pc5 pulsations, the amplitude of the magnetic perturbation is the difference between the peak and valley divided by two. It should be noted that the magnetic perturbations can be in opposite phase across the auroral zone. The absolute value of the net change of the magnetic field is taken to be the amplitude, so the plotted amplitude is always positive.In Figure The latitudinal distributions of the magnetic perturbation amplitude are similar in all cases: penetration electric fields Figure , substorThe variation of geomagnetic field perturbations with latitude is investigated in some previous studies. Kikuchi et al.  derived 3The observed equivalent current patterns driven by different processes are presented in section Figure It should be mentioned that the purpose of Figure The equivalent current system consists of currents from different sources. We take Pc5 pulsations as example. Pc5 pulsations are excited in the magnetosphere and have periods of 150–600 s. Another type of long‐period pulsations is Pi2 pulsations that have periods of 40–150 s. Pi2 pulsations originate in the magnetosphere, often accompanying the onset of the substorm expansion phase and have been observed in low‐latitude and equatorial regions  or in the magnetosphere (substorms and ULF waves) are presented in this paper. Nishida , 1968b aIn this study, we use magnetometer data to derive ionospheric equivalent currents. Although this is an oversimplified method, Nishida , 1968b aOur study focuses on the current distribution at middle and low latitudes. The ionospheric current distribution at high latitudes (above 60° MLat) is not very well defined in some cases, and the current vortex near dawn denote only the approximate location. Although there is some uncertainty in the current distribution at high latitudes, the double vortex current system caused by IMF reorientations and substorm expansion onset  will also reach a quasi‐steady state within 1 min. The results imply that the ionospheric current system  also takes only 1 min to change from one steady state to a new steady state.The variation of the geomagnetic field in response to IMF reorientations, magnetospheric substorms, and ULF waves, is relatively slow, and the corresponding ionospheric current pattern evolves over a longer time scale. This longer time scale is determined by the driving process that changes gradually. If the external process is fast enough, the reconstruction of the ionospheric current system should be also very fast.Because a steady state of the ionospheric current system can be established within 1 min, it implies that electromagnetic changes can be transmitted from the source region at high latitudes to all latitudes/longitudes very quickly, in a time scale of shorter than 1 min. One mechanism is the propagation of a zeroth‐order transverse magnetic mode in the Earth‐ionosphere waveguide , a sudden increase or decrease in the solar wind pressure, onset of magnetospheric substorms during sawtooth events, and ULF waves. The background magnetic field is removed, and only the net changes in magnetic field are used to derive the equivalent currents. The derived equivalent disturbance current system represents the net current change caused by the solar wind or magnetospheric processes. The following conclusions are derived from 11 cases for the four processes.The equivalent disturbance current system caused by an IMF southward turning (occurrence of penetration electric fields) or by the onset of a substorm is characterized by a large counterclockwise vortex covering the prenoon sector, afternoon sector, and evening sector and a relatively small clockwise vortex in the midnight‐dawn sector (or near dawn). The current pattern following an IMF northward turning (occurrence of shielding electric fields) is nearly the same as that for an IMF southward turning, but the polarity of the current vortices is reversed.The equivalent disturbance current system caused by a sudden enhancement in the solar wind pressure or by ULF waves at wave peak is characterized by a large single counterclockwise vortex covering all longitudes/local times at middle and low latitudes and a very small clockwise vortex above ~60° MLat near dawn. The current pattern caused by a sudden drop in the solar wind pressure or by ULF waves at wave valley is nearly the same as that for a solar wind pressure enhancement and for a ULF wave peak, but the polarity of the current vortices is reversed.The ionosphere takes only 1 min to establish the equivalent disturbance current system caused by a solar wind pressure enhancement, and the new steady‐state current system remains for 20–30 min without obvious deformation. If the ionospheric background current system is assumed to remain unchanged across the solar wind discontinuity, the system of the total currents (the background currents plus the net current changes) also takes only 1 min to reach a new steady state.We propose the following scenario for the establishment of ionospheric equivalent disturbance current systems caused by a solar wind or magnetospheric process. An IMF southward turning, a sudden increase in the solar wind pressure, a substorm onset, or a ULF wave peak enhances the Region 1 FACs, depositing solar wind/magnetospheric energy and momentum to the high‐latitude ionosphere and causing enhanced convection electric fields. The electric fields at high latitudes, as well as energy and momentum, are transmitted, through the transverse magnetic mode or the fast magnetosonic wave mode, to low latitudes, generating penetration electric fields and related magnetic field changes. After several periods of the electromagnetic waves or the fast magnetosonic waves, the ion velocities in the global ionosphere, as well as electromagnetic fields, reach a new steady state, and a new steady‐state current system is established. Although the solar wind or magnetospheric processes can be very different, the ionospheric currents quickly reaches the quasi‐steady state within ~1 min. The single or double vortex current system depends on the distribution of the FACs in latitude and longitude/local time.


Dear Editor,The prognostication of neurological outcome in sedated ICU patients is challenging. Multiple clinical scoring schemes and examinations are used, where different motoric responses are important input variables. Accelerometery is a well-known technology widely applied in different fields of research and everyday electronic products. In medical research, accelerometers have been used in longitudinal epidemiological studies of physical activity and health as well as in ICU studies on the topic of activity, sleep and agitation monitoring. Similarly, accelerometric information could be a candidate to improve future neurological prognostication schemes. To the best of our knowledge, including a systematic review from 2015 [We investigated a small population expected to experience motoric changes over a limited time period. After institutional approval and patient consent, we connected four wireless 3D accelerometric AX3 sensors  to the limbs of 10 post-cardiac surgery patients in the cardiothoracic ICU while still in general anaesthesia. We collected accelerometric data and observed their limb movements as the sedation was pre-described and the patients woke up. Movement artefacts induced by the health personnel were kept at an absolute minimum.The raw data sampled at 100 Hz mandates processing before providing sensible information. The three-dimensional acceleration vector for each extremity was combined into one according toσ + μ, where σ was the standard deviation and μ the mean of the first stabilising period when the patient was fully immobile, set to 2 min. The time-distance of the function was set to 50 samples. The acceleration peaks were summed within 1-min epochs to visualise the movement data as heat maps. This greatly reduces the amount of data that the clinician encounters and eases the interpretation. Finally, all data were truncated to 10 min starting at least 2 min before the first detectable movement. All analyses were performed in the Python programming language [A peak finder function was applied with height 50In all patients, this approach detected a change from no limb movements to various degrees of movement in one or several limbs, as shown in Fig. We show the possibility of detecting the amount of movements in sedated patients and to present these data in a simplified manner to the clinician. As such, we are expanding the use and usability of accelerometric data from earlier studies which mainly focused on sedation and agitation levels , 4. In ILimitations to this trial are the low number of participants and the choice to study post-surgery patients and not the designated user population of critically ill patients with a potential brain injury.


In this paper, we propose an analytical rapid method to estimate the endocardial borders of the left ventricular walls on echocardiographic images for prospective clinical integration. The procedure was created as a diagnostic support tool for the clinician and it is based on the use of the anisotropic generalized Hough transform. Its application is guided by a Gabor-like filtering for the approximate delimitation of the region of interest without the need for computing further anatomical characteristics. The algorithm is applying directly a deformable template on the predetermined filtered region and therefore it is responsive and straightforward implementable. For accuracy considerations, we have employed a support vector machine classifier to determine the confidence level of the automated marking. The clinical tests were performed at the Cardiology Clinic of the County Emergency Hospital Timisoara and they improved the physicians perception in more than 50% of the cases. The report is concluded with medical discussions. In clinical cardiology, echocardiography has become nowadays one of the most employed diagnostic procedures ,2. SustaThe paper is structured as follows. In the next section, we present a mathematical brief where we review the necessary concepts on the Hough transform and the Gabor-like filtering. Hough transform (HT) is one of the most suitable techniques used in image analysis to extract features from an image ,9,10,11.m and c are the slope and the intercept that characterizes the line. Equation fm^,cfm^,c(1)fquation  on an ultrasound image done by hand by a trained cardiologist. That was the beginning of our approach. From this initial sketch (drawing), we extracted a draft template see .This template was used for the initial tests with our implementation of the GHT. We considered an anisotropic Hough transform to allow deformations of the template that could best fit the left ventricular wall. By directly applying the GHT with this template on an echocardiographic image, we obtained a rough marking of the left ventricular wall. The results are shown in As shown in The localization of a region of interest (ROI) on the echographic image is of crucial importance for accurate application of the GHT. The correct marking of ROI eliminates most of the detection problems encountered by the GHT. For the detection of the application area, we employed a Gabor-like filtering. The Gabor-like filtering gave us a corresponding region of interest for the application of the GHT see .Simultaneously, by following the second path, we decided to also make also the template deformable, not only its application to the Hough transform. Therefore, we used the septal wall of the LV as guidance because this side has a higher visibility as it is not usually covered by other anatomical structures such as lungs or bones when observed echographically. To obtain a thinner line, the deformation was made within the original template. This way we managed to obtain the refined deformable template, as shown in This template was then used as the guidance template. The medial wall was found and initially estimated. Afterwards, by applying the Hough transform, the deformation within the thick guidance template line was performed such that the delimitation of the lateral wall of the LV was obtained as accurately as possible while the rest of the template was thin because its primary use was for orientation purposes inside the echocardiographic image. The guidance template is suitable to adapt and localize within the ROI area of the left ventricle by making use of its visible anatomical features. This is needed also because the algorithm is adaptable to the phases of the heart and a fixed template would have not been able to recognize the boundaries of the LV in a lively-automatic fashion.By combining the two paths, we obtained the final marking of the left ventricle see . The marWe are now able to provide the full algorithm below in a straightforward implementation format.The application of the algorithm computes the ten best recognition positions and the selection of the most qualitative marking is done with a rate given by the maxima of the accumulator space.The algorithm was tested on several sets of ultrasound images provided by the Cardiology Clinic of the County Emergency Hospital Timisoara, the largest medical facility in the western part of Romania. The echographic images were anonymized and no link with the actual patients is possible. For the 18 datasets, we selected a healthy patient cohort without any abnormalities but different physiological and anatomical characteristics such as height, body weight, etc. The dataset is constituted by adult patients, aged between 30–50 years, without cardiovascular diseases in order to avoid the impact of morphological changes  or functional ones (hypo/a/dyskinesia) on the results of the algorithm. These patients had poor echocardiographic window due to pulmonary pathology or anatomical characteristics.The best matching was found for scale 0.885000 and angle 1.047 in position  with rate 67. This estimation is directly related with the maxima of the corresponding accumulator space. However, for accuracy reasons, we wanted to provide to the clinical medical personnel an error indicator regarding when the application of the procedure has a prospective positive impact on the precision of the diagnostic. Therefore, we trained a support vector machine classifier (SVM) on the accumulator space. SVM is an established machine learning supervised classifier based on a kernel function and using the well-known kernel trick )


Content used by Medical Physicists for fluoroscopy safety training to staff is deliverable via several formats, that is, online content or a live audience slide presentations. Here, we share one example of a kinesthetic  educational program in use at our facility for some time (~10 years). In this example, the format and content specifically target methods of reducing physician operator exposures from scattered x rays. A kinesthetic format identifies and promotes the adoption of exposure‐reducing behaviors. Key kinesthetic elements of this type of training include: physician hands‐on measurements of radiation levels at locations specific to their standing positions  in the room using handheld exposure rate meters, measurement of exposure rate reduction to physicians provided by using personal protective equipment, that is, wearable aprons, hanging lead drapes, and pull‐down shields. Physician choice of procedure‐specific tableside selectable controls affecting exposure rate from optional fluoroscopy, Cine or digital subtraction angiography (DSA), along with comparative measured contribution to physician exposure is demonstrated. The inverse square exposure rate reduction to physicians when stepping back from the table during DSA is a key observation. Kinesthetic simulations in the rooms used by physicians have been found to provide the highest level of understanding giving rise to adoption of practices that are impactful for physicians. Specific training scripts are in place for physician sub‐specialization in interventional radiology, cardiology, neurosurgery, vascular surgery, and gastroenterology. This training is used for new physician staff while classroom presentations (whose content mimics in room training) are used with staff who have had previously had in room training. Interventional radiologists and other specialty users are consistently and historically among the highest occupationally exposed workers in a hospital system due to their extensive use of fluoroscopic imaging and in particular the incorporation of digital subtraction angiography (DSA) and Cine acquisitions.Options exist in providing safety training education to physician staff, including an online educational self‐guided module such as a slide presentation or live learning streamed over the internet and live audience slide presentation by a qualified medical physicist (QMP).Kinesthetic intelligence has been separately recognized among those individuals who effectively best learn by doing.1.1Educational science has long recognized that “viewed only” content provides about 10% retention while both audio and visual content may achieve 30%–50% retention. Kinesthetic movement and actions performed by the participants achieve nearly 90% retention.2An educational kinesthetic class is preferably held in the fluoroscopy room used by the physicians. In the case of interventional equipment, the availability of the procedure room for instructional purposes is often a compromise with patient care needs and staff schedules and so time may be limited. At our facility, early morning sessions prior to the first patient of the day work best. It ensures a hard stop for the conclusion of the class. To start promptly the instructor must pre‐inventory the room for available equipment, device features, and their use. Items that are noteworthy include availability of physician's personal protective equipment (PPE), table hanging lead drapes, pull‐down shields, and arm boards. Physician's PPE can be variable and found to be skirt and vest, skull caps, leaded eyewear, and added extremity protection. Differences in physician preferences exist and should be noted. It is important to map out arterial access locations (including patient positioning), physician's right and left side approaches, table height for the reference point (RP), device display air kerma rate, cumulative air kerma, and air kerma product settings and foot pedal controls. Preferred choice or most frequently used programmed fluoroscopy settings are identified . As this is an interventional fluoroscopy focus training session, it is expected that procedures using cone beam CT and DSA, or Cine will be available and incorporated for class use. It is also important to note the presence of a power injector for contrast and its frequency of use with procedures. The QMP must be familiar with operating the device including modification of tableside settings, table and C‐arm movement controls, and location of tableside geometry display. Another option is to enlist the aid of an x‐ray technologist who is familiar with these device operations. The QMP must also be familiar with the movement of hanging drapes on the table and the range of movement and positioning of pull‐down shields from their storage position to their best location for physician protection with any access points used with procedures in that room. This information is incorporated into the Script for class use.2.1A handheld ionization survey meter is needed and an independent x‐ray beam dosimetry system can be useful. A distance measurement tool is quite important. We have selected a yellow plastic cord for which three knots are created at 0.5, 1, and 2 m. This string is tied to a large metal washer to anchor the end of the string in the center of the x‐ray beam. A stack of Poly(methyl)methacrylate (PMMA) is used along with a life like head, neck, trunk, and extremity phantom. While a human like form phantom is not necessary, it has helped in quickly identifying the standing positions and measurement points for x‐ray scatter.2.2A prepared script serves several functions. It ensures that the desired content is included in the exercise and that this content is discussed in the desired sequence. Each participant gets a copy of this script which they use to participate in the session. If in‐room training is early in the morning before patients, a well‐scripted program can ensure completion by the scheduled time. To emphasize the kinesthetic aspect of this education, the instructor engages each participant to handle all devices as much as possible. A participant that performs actions as the class is (not surprisingly) more engaged in the topic and memory of the teaching points are facilitated.Table 3Basic learning objectives are described below for each of the rows 1–8.3.1The class starts with the instructor pointing to markings on the x‐ray tube housing depicting the position of the x‐ray tube focal spot as the point at which the x rays are produced. In turn, each participant confirms seeing the mark of the x‐ray tube focus and collimation. Collimation is simply depicted as forming the beam as it travels to the patient. All participants are asked to step closer to see these parts of the C‐arm and they thus start the class together in their knowledge in this elementary concept. The beam strikes the supine patient in the back of the patient and creates scattered x rays as the dominate source of all x‐ray exposure to staff in the room. Recognizing the point of intercept of the beam with the patient as the location of origin of scatter is a critical learning objective. While this location is the clearly the point from which radiation can travel to staff, these scattered x‐radiations may or may not travel through and be attenuated by the patient before striking staff. This is also confirmed using the survey meter with the participants. Exposure to a physician's knees gives higher exposure rates of x‐ray scatter than the waist or head as they stand tableside . A technologist standing at the foot end of the table is seen to not receive much exposure due to attenuation and distance as measured by a participant. The area of the beam landing on the patient is also a factor in the amount of scatter. This can be easily demonstrated by a participant using the handheld survey meter at the waist level as the collimation or FOV is changed.to remember the origin of scatter as it will be part of the test at the end of the session as indicated in the Script.Radiation that is not scattered (the primary beam) will pass through the patient, but this radiation is considerably absorbed with roughly only ~10% passing through the patient to strike the image receptor. To emphasize the importance of knowing the origin of scatter, the instructor emphasizes to the class Good geometry is depicted with a phantom on a table and the table top at 15 cm below isocenter and the image receptor no more than 10 cm above the patient and preferably closer. As the vessels in mid‐brain, neck, chest, abdomen and legs are nearly all mid‐line, the majority of interventional imaging has these vessels at C‐arm rotational isocenter so as to ensure the vessels remain in the center of the image receptor with any C‐arm angulation. This table and receptor positioning is standard practice for initial patient positioning with x‐ray technologists in preparation for physician use. The physician recognizes that good geometry with table and receptor positioning is a worthwhile learning objective; table height affects the amount of x‐ray scatter and it also relates to “work height” by the operator. In this regard, table height differences will exist and this factor is a non‐controllable or only modestly controllable behavior.3.2Bad geometry is depicted with lowering the table closer to the x‐ray tube than needed and raising image receptor further above the patient. As the manufacturers table side values of Air Kerma rate are not accurate with this geometry a separate dosimeter is pre‐positioned prior to the start of the class under the patient is used to note patient skin exposure. These independent values are called out by a participant. The class computes the percent increase of patient exposure as a consequence of this geometry compared to good geometry. This difference is the amount of patient dose that is often controllable and often can be reduced without affecting the procedure. The learning objective with this section is to incorporate good geometry as standard practice. The table and image receptor are returned to good geometry for the next Script topic.3.3An anthropomorphic phantom was found to be an especially helpful addition in kinesthetic training (if available) as it allows for a concrete simulation of those specific access locations which depict the location of the physician relative to the origin of scatter. This Script has a learning objective to demonstrate the effect of larger size patients and/or thicker patient sections created with steep C‐arm angles since both cause significantly higher levels of scattered radiation. Adding 5–8 cm of PMMA to the life like patient is used to increase the x‐ray tube output to approximate the expected values for the uncontrollable variable of patient size.3.4Using the large patient size and good geometry, the amount of fluoroscopically scattered x rays at tableside at 0.5 m must always be measured and made known to the physician participants. The participants are then asked to predict an amount of scattered x rays from DSA. Generally, physicians significantly underestimate the increase in the scattered x‐ray exposure rate tableside with DSA in comparison to fluoroscopy. A measurement performed at 0.5 m tableside by a participant provides the calculation of the percent increase relative to fluoroscopy exposure rate. This demonstration has been the single most impactful moment for physician participants in our experience and is one of the primary learning objectives of the entire class. This measurement has always been strongly remembered by physicians especially by those who have held the survey meter. For physicians who use power injectors, it becomes compelling to step away from the table for these radiation events. For fluoroscopy suites which have lead drapes hanging from the table or pull‐down shields available, it decidedly motivates their routine use if handheld injections are used. The value of these behaviors, that is, stepping back and using shielding devices (including the availability of hanging tableside drapes), is determined by measurements and their value in routine use is emphasized.3.5The participants are directed to view the washer that is seen in the center of the image. The other end of the yellow string is extended and held outwards to 2 m by a participant. The first knot at a distance of 0.5 m is quite representative of the anterior waist of a performing physician to origin of scatter when using a femoral approach. With one participant holding the far end of the string, the survey meter is held by a physician at the 0.5 m location. The instructor asks the participants what value (mR/hour) might be found at 1 m? At 1 m, only a small step back is seen as quite doable by a physician. It is our experience that physicians and other participants almost always underestimate the reduction of scattered x rays reaching 1 m. Actually performing this measurement and seeing that the distances are inarguably correct, the value of stepping back is remembered and is convincing in the value of this behavior. At 2 m, the levels are measured and a dramatic drop off in exposure shows why allied health staff are told they are quite safe at this distance. For DSA IR procedures using power injection, the physician staff can distance themselves to 2 m. It is also useful to clarify and discuss which allied health or other staff should be joining the physician at tableside if fluoroscopy or DSA is being used and the value of calling out to procedure staff the episode of use of fluoroscopy and DSA as a reminder. At our facility, we have the 2 m location from the table center identified by a change in color of the flooring as a visual aid. It is also useful to make note to the participants that the total reduction of the measured value reduction between 0.5 to 2.0 m is more than 90%.3.6At a minimum, three types of protective equipment are discussed and their use clarified (and encouraged). A protective apron with thyroid shield is standard PPE for an IR fluoroscopy suite and it is worthwhile to demonstrate the protection factor provided by an apron, of course emphasizing the importance of a well‐fitted apron.Hanging tableside drapes are shown to reduce the exposure by more than 90% via measurement. It is an important pre‐procedure preparation that x‐ray technologists attach the hanging drapes as standard room preparation. Each site of access  should have available physician lower body protection. Room preparation also includes the movement of hanging drapes along the table. For any procedures that may be performed on the patients left side additional hanging drapes may be needed. Positioning for left femoral, arm and neck access points must be provided shielding for the physician if these access points are used. That the staff recognize that their controllable actions  are useful and impactful teaching points.Room preparation for all procedures includes sterile draping of the pull‐down shield and its placement. For procedures, rooms that incorporate both left and right side access an overhead boom that supports the pull‐down shield as well as the table brackets for hanging drapes must be available. While 90%, 95%, or 99% attenuation factors are differences that can be measured by various PPE, the most critical point is not if a particular PPE is incrementally more protective but rather that some (and certainly those available) PPE is actually used. Pull‐down shields in particular are of huge importance as the physician's head generally is not otherwise well protected by any other means. Using a pull‐down shield that is well positioned to block scatter to the physician's head and has been consistently positioned as close as possible to fully intercept the origin of scatter for ~80% of procedures will lower the physician's head cumulative exposure by ~80%. A simple yet very worthwhile quality metric (if it can be acquired) is the frequency of use for pull‐down shields for an interventional room for each procedure.It can be emphasized by the QMP that physician operators generally stand 0.5 m from the origin of scatter while other staff generally are positioned at ~2.0 m. The drop off in scatter to this location is ~90% or more — which is about the same reduction as an apron of 0.5 mm lead equivalence.3.7The C‐arm sometimes is used in a lateral or near lateral projection and frequently the image receptor is found to be positioned on the patients left side with the x‐ray tube near the physician on the patient's right side with a femoral access. For the final topic and quiz, this geometry is created. To emphasize this point added PMMA is stacked vertically on edge at the table at the patient side closest to the x‐ray tube so as to create excellent scatter at the point of beam intercept. The participants are quizzed as to whether they should be standing on the left side of the patient or the right side of the patient to lower their exposure to scatter. It is again surprising to find that frequently some participants pick the image receptor side as likely to have higher scatter levels. Of course the survey meter is used to confirm the answer and the situational use of lateral projections and staff location are discussed.3.8Class duration is generally 35–40 instructional minutes not including the time allowing for participants to put on their PPE. The QMP can summarize; origin of scatter, good geometry, use of the three important PPE , step and pause, and stepping back if possible — especially with power injector use with DSA. Ideally potential behavioral changes were seen to be useful and may be incorporated into routine practice.4The use of kinesthetic education hands on training was found impactful as it resulted in key behavioral changes actually taking place, including a dramatic increase in the use of pull‐down shields and hanging table drapes for all procedures. For example, recent review of use of pull‐down shield use averaged 90% or more which was an improvement of the initial use rate of ~25%. Badge readings of interventional radiologists were reduced ~45% in 2018 as compared to 2012. These training sessions took place in the specific rooms used by Interventional Radiologists, Cardiologists, Neurosurgeons, Vascular Surgeons, and Gastrologists. A phantom that better simulates arterial and venous accent points (or mouth access for ERCP procedures) is compelling to physicians as it correlates well with their experience and standing position relative to the patient and source of scatter.5While noted above that badge readings were significantly reduced over the time frame for which all radiology physician staff received hands‐on training, it is important to note other factors. During this time (2012–2018) digital flat panel devices replaced image intensifiers, pull‐down shields were added, and individual fluoroscopy dose rate curves were optimized and standardized. To be sure multiple factors were contributory to reduced physician staff exposures over this time. Importantly, the motivation to purchase, install, and actually use pull‐down shields was generally facilitated by knowledge gained during this training. An awareness of stepping back during power injections of iodine contrast with DSA was also established.It is also recognized that initiating a physician training program took an evolutionary route. Early on only one physician and one or two technologists were volunteers of their time to explore questions on factors which controlled their exposures. A curiosity existed for determining regions of elevated ambient exposure rates and its cause. Nursing and technologist teams did have mandatory education as did the radiology residents and now IR fellows. These educational sessions allowed for the development of a more clear picture of what is doable tableside and impactful in the hours prior to patient procedures.For interventional fluoroscopic devices that employ DSA or Cine, the physician operator can benefit from a specialty‐specific kinesthetic training experience as it provides for adoption of key behaviors into routine practice. These behaviors are gleaned during the kinesthetic session as measurements of radiation and the utility of shielding, its positioning, and device operable parameters are comparatively evaluated and the physician exhibits preference in its use. Conclusions are drawn with practice changes that can be replicated and incorporated into daily use. In our experience, a kinesthetic format is not needed on an annual basis for individuals who have already had kinesthetic education or for which routine practices have incorporated the applicable safe practices.Please note the values in the attached slides made with the survey meter are in units of mR/hour. This is not consistent with SI units (uSv/hour) for surveys or mGy/min given by all fluoroscopy devices. Generally the participants accept the meter values as the training is focused on measurements of x‐ray scatter.6A kinesthetic education format was developed and has been found to be impactful for improving operational safety of the physician staff — arguably the best testimony a measure of education quality. Physicians gained insights and recognition of the value of adopting controllable best practice behaviors. The key behaviors of table and receptor positioning, suggestions for dealing with the high exposure rates found with larger sized patients, understanding the dose rates associated with DSA relative to fluoroscopy and the value of stepping back if possible were demonstrated. While the session uses the term “controllable behaviors”, a kinesthetic education format whose content is aligned for each physician specialty was anecdotally found to be highly effective as compared to generalized educational formats using online self‐directed modules.William F. Sensakovic is founder of Telerad Physics Teaching, LLC. All other authors declare that having no conflicts of interest.


Frontiers in Plant Science (2019b). These options are now transformed into “design parameters” and are evaluated in terms of their contribution to stakeholder criteria. This evaluation is now performed in a quantitative way using MCA and is based on previous qualitative discussions with stakeholders that have been reported qualitatively in our previous paper in Frontiers in Plant Science referred to above. The final result of our MCA consists of pointing out which design parameters regarding access obtain the highest priority from the community of stakeholders and hence need to be present in national regulatory frameworks on ABS that will be implemented by member states. It is our intention to undertake similar research for the Benefit Sharing component of ABS agreements in the future.In this paper we conduct a multi-criteria analysis (MCA) from a multiple stakeholder point of view for the design of access and benefit sharing (ABS) agreements concerning genetic resources, in particular regarding the access component of such agreements. We start by analyzing the objectives defined by international law (viz. the Convention on Biodiversity and the Nagoya Protocol) that every party  must strive to attain when developing national legislation on ABS. As countries have a certain degree of freedom concerning the way and the extent to which they need to integrate these objectives into their national frameworks and since stakeholders attach different levels of importance to these objectives, such an MCA will help identify those options that command the highest value added from the community of stakeholders. Consequently, those options are expected to hold the highest potential for successful implementation. The MCA performed in this paper is based on Saaty’s analytic hierarchy process (AHP) and starts from the objectives  enshrined in international law, and then proceeds by assessing the relative importance of these criteria from the point of view of four different stakeholder groups . The alternatives to be evaluated in the MCA are based upon options discussed qualitatively in our previous study published in  Genetic resources (GR) constitute a crucial source of provisioning ecosystem services . On top Natural product research dates back to the 18th century when systematic explorations begun when the newly found species were appropriated by European colonial powers and shipped to Europe where they were used as herbs, food and medicine. During the colonial period, compensation schemes between the explorers and locals sharing their knowledge on the use of these species were completely non-existent .The value of GR has received a second boost since the 70s from modern biotechnology. Its economic value created a strong incentive to apply patents on inventions resulting from the use of GR. Since patenting is a rather costly procedure, patents on inventions resulting from the use of GR were mostly held by companies in developed countries. With the majority of the world’s biodiversity being present in developing countries and use of these GR being mainly undertaken by companies and institutions in developed countries, the perception of imbalance thereof led to discussions on fair and equitable sharing of benefits arising from the utilization of GR .The present system of access and benefit-sharing of GR (ABS) aims to balance the rights of provider countries (or simply “providers”) through the equitable sharing of benefits, and those of the users. Ultimately, ABS could increase the value of biodiversity, for users as a resource for R&D, as well as for providers as a source of benefits that create incentives for biodiversity conservation.Ad Hoc Open-Ended Working Group, which was the last one to have received a mandate. In addition, some countries already stipulated that they may regulate PGRFA under Annex I under domestic ABS measures. For instance, during the 8th Meeting of the Governing Body of the ITPGRFA in November 2019, Zambia stated that since there is no progress on benefit-sharing in the Treaty, Africa may explore regulating DSI related to PGRFA within the MLS under national ABS measures  conservation of biological diversity, (2) sustainable use of the components of biodiversity and (3) fair and equitable sharing of benefits arising from GR. Therefore, the importance of the ABS system enshrined in the Nagoya Protocol as well as the CBD is increasing for plant genetic resources under the ITPGRFA.Article 15 of the CBD reaffirms the states’ sovereign rights over their GR. This means that states have the right to regulate access to their GR, which includes the right to determine the conditions of such access and the fair and equitable benefit-sharing resulting from the utilization of GR .Regarding ABS in national jurisdiction, international law by means of the CBD and the NP puts in place general goals and principles for states to implement. Currently, every United Nations Member State except for the United States is a party to the CBD . The NP on the other hand currently has 123 Parties; a number which is expected to increase .ABS is currently a rapidly developing and evolving field that is shaped by the national implementation by the Parties concerned, which determines how ABS goals are realized and how ABS principles are formed within regulatory mechanisms.The current perception regarding the operationalization of ABS is that the system of national implementation brings complexities for both academic and industrial users of GR as well as collections  which result in less willingness to access GR . Users cThe overarching reason why ABS implementation is neither beneficial for the providers nor for the users is that the provider countries fail to implement an adequate institutional framework that is consistent with the international ABS goals and therefore implementation does not fulfill the objectives of the international ABS framework. This inevitably jeopardizes access to GR as well as benefit-sharing and thus damages trust between the provider and the user.Our previous research ,b aimed du choc des idées jaillit la lumière”). MCA can be viewed as an institution in action creating momentum to achieve this goal.To address the research objectives defined in section “Aim of This Paper” we will conduct a multi-criteria analysis (MCA). This MCA will be designed so that it can play the role of an “institution in action” as described in Hence, stakeholders will play a crucial role in this MCA. According to Looking into regulatory issues related to ABS, we have identified four key stakeholders: the government (as the provider), collections, academic users and industrial users. These have been identified in line with Freeman’s definition. These key stakeholders’ involvement in regulatory processes is vital to forming an ABS system that is effective and efficient and that attends to the international ABS goals . In otheThe value structure is shown in s) are shown. Here four main groups of stakeholders have been identified as “industrial users” , “academic users” (such as universities), “collections”  and “providers” or “provider states” . The level below the stakeholders  comprises the criteria that these stakeholders consider relevant. The degree to which these criteria are relevant for the different stakeholder groups is reflected in the weights (or priorities) of the criteria. These weights will be derived below (in section “Building Consensus Among Stakeholder Representatives’ Scorings”). The set of 11 criteria shown at level 3 of the criteria tree has been constructed based on our previous research (At the second level the stakeholders (research  on ident1:CPredictable conditions (NP Preamble).2:CLegal certainty .3:CTransparency .4:CFairness and equity in negotiations .5:CSustainable use of biodiversity components .6:CCost-effective measures .7:CScientific research based on GR (CBD Article 15.6).8:CStrengthening the ability of Indigenous People and Local Communities to benefit from the use of traditional knowledge .9:CTech transfer and cooperation to build research and innovation capacity in developing countries .10:CCreating incentives to conserve biodiversity .11:CInnovative solutions for transboundary situations (NP Preamble and Article 11).When developing this set of criteria special attention has been given to the technical conditions or requirements for a consistent family of criteria  yet decided to drop it since the conjunction of several criteria  made the 12th criterion redundant. This check also contributed to the simplicity of the criteria set.Comprehensibility of the criteria has been ensured by subjecting it to stakeholder review where they were asked to explain what they understand from the wording of the objectives.The criteria satisfy judgmental independence as a stakeholder’s perception of them does not depend on another criterion. For instance, a stakeholder does not exhibit preference dependence between “predictable conditions for ABS” and “transparency” meaning that the stakeholder’s perception on one will not depend on the other.The lowest level in the hierarchy shown in 1), three different options are possible, namely “in situ access only,” “in situ and ex situ access” and “in situ access, but ex situ access for DSI.” With “in situ access only,” a permit or notification is only required when access happens within the geographical borders of the provider country. In the event of “in situ and ex situ access,” a permit or notification is also required when access takes place through biodiversity biobanks  outside the geographical borders of the provider country. The third option also covers ex situ access to the digital sequence information (DSI), which is often referred to as the DNA sequence data of the GR that is downloadable from public databases. Here it should be noted that there currently is no unified definition of DSI both in the legal and scientific realm.For instance, regarding the material scope (DP2) three options are possible. With “access for sampling” the access requirements need to be triggered before the material is sampled in situ or obtained from an ex situ source. In the event of “access for utilization” the user first needs to obtain the ability to perform R&D. In the event of “access to previously utilized genetic resource for new utilization,” this requirement also needs to be triggered when a new utilization activity occurs with a genetic resource that was previously made available to the user.Regarding the temporal scope (DP3), the option “research” implies that access is only permitted for research purposes. With the option “development” access is permitted for product or process development purposes. Under the option “research and development” access is permitted for both purposes.As regards the utilization scope (DP4), two options are possible. The can be either mandatory or non-mandatory.In terms of benefit sharing agreements (BSA) (DP5), the access can be subject to either a permit or a mere notification. In the latter case the user can commence activities without having to wait for approval.Regarding the regulatory mechanism (DP6), either a single centralized institution can be made responsible or several decentralized institutions can be mandated according to the type of GR.Regarding the granting authority (DP7), the provider country can either opt for standardizing the access procedure or apply various conditions on a case-by-case basis.Regarding standardization (DP8) can either be a prior requirement or not.Making an agreement with a local partner (DP9) can be facilitated or not.Furthermore, access for non-commercial research (DP10) when the user changes or when the intent changes.And finally, the access agreement may be subject to renegotiation  are not made at this stage.Consequently, at this stage of the analysis, it is these options  that need to be evaluated and prioritized. Hence, comparisons or prioritizations of combinations of options across DPs  with the three options for design parameter “Material scope” (DP1), namely “in situ access,” “in situ, ex situ access” and “in situ, ex situ access for DSI” also represent causal relationships in the sense that each of the latter options contributes to the realization of the criterion “Predictability.” But each option of each design parameter also contributes to each of the 11 criteria (on level 3). For instance, the 11 arrows that link “in situ access” with the criteria C1…C11 indicate that “in situ access” contributes to the realization of each of these 11 criteria. In order not to overload the figure with arrows, the latter type of arrows have not been drawn up to their full length.The actual MCA technique will that will be used to obtain the priorities of the criteria and finally also those of the alternatives  is the analytic hierarchy process (AHP) of Another reason why we chose the AHP is that the final decision can be constructed step by step, using an interactive procedure based on input from stakeholders, policymakers and experts. The evaluative approach followed here is clearly a constructivist one that facilitates learning during the DM process. In fact, the evaluations (pairwise comparisons) that take place within each constituent part of the hierarchy shown in  are syntGiven the hierarchical decomposition of the DM problem, the priorities of the final solutions can be calculated from the perspective of each single stakeholder. The priorities obtained in this way can form the basis for the construction of a solution (in this case the design of particular types of access frameworks) that contributes to the objectives of the different stakeholders. Very important here is the degree of compatibility between the stakeholder priorities. Stakeholders are seen here as the critical (f)actors that determine whether a solution (here a type of access agreement) has the potential to be successful in practice or not. If the compatibility between stakeholder priorities is low, the potential of the solution to be accepted by all stakeholders and hence to make possible successful and sustainable access to GR may be problematic. The aim of the MCA developed here is to identify those solutions that have potential and those that have not. If the MCA shows that some solutions do not have the required potential, but that this is due to some specific reasons (as shown by the scores on the criteria), then at a second stage, the potential of these solutions may be enhanced through project redesign . This meAnother important advantage of the AHP-MCA is that the AHP makes it possible to take into account heterogeneous information  and to integrate it into the DM process. Particularly as regards the design of ABS frameworks, a lot of the information  will be qualitative.Finally, the AHP makes it possible to obtain a complete ranking of all the solutions and to calculate the logical consistency of all the pairwise comparisons on which the final priorities for the solutions are based.A) as shown in ai and ai”) the DM has to assign a value to the relative importance of one action (ai) as compared to another action (i’a) in terms of its contribution to a higher level objective or criterion (cj), as shown in Pgj expresses the DM’s intensity of preference for the row element  as compared to the column element  in terms of its contribution to the higher level element . This procedure is repeated at each level of the hierarchy, and hence is used for the prioritization of the actions  as well for the prioritization or weighting of the criteria . A computer program called ExpertChoice can be used for this purpose.In each subsystem of the AHP  pairwise comparisons need to be made to derive the relative priorities of all the lower level elements in terms of their contribution to the higher level elements. This is done using a pairwise comparison matrix , are expressed on a fundamental scale , ranging from 1 to 9 , is given as the right eigenvector (W) corresponding to the highest eigenvalue (maxλ) as shown in Eq. 1. The matrix A (in Eq. 1) is the matrix containing all the pairwise comparisons and corresponds with On the basis of the numerical information associated with these statements, relative priorities or weights are calculated using the eigenvector method. Mathematically the relative priorities, i.e., the weight vector (W) are weighted according to the global priorities of the parent criteria and synthesized. One starts from the top and by doing so, the final/global relative priorities for the lowest level elements  are obtained.In order to synthesize all local priorities, the various priority vectors (a compared to action c (in terms of their contribution to criterion gj) should, in the event of complete consistency of all pairwise comparisons within the same matrix, equal the product of the preference intensities of action a compared to action b and the preference intensity of action b compared to c, as shown by Eq. 2.In each matrix, a number of pairwise comparisons are redundant, since the preference intensity of action However, this redundancy is used for two purposes, namely to neutralize estimation errors that may have occurred in other pairwise comparisons of the same matrix (in fact information is being accumulated using multiple/redundant measurements) and to check the consistency of all pairwise comparisons within one matrix. According to Saaty  a limited amount of inconsistency is quite natural and does not pose a problem as long as the inconsistency ratio (ICR) does not exceed 10% .ceteris paribus. The reason is that there is decreasing marginal utility of income for an individual. In the former example (public expenditure) utility of income may not be decreasing because of the societal perspective taken. Also ordinal scales such as ++/+/0/−/−− do not necessarily possess this utility. This means that in that case pairwise comparisons will be necessary. However, some techniques can be used to transform these scales into ratio scales with underlying cardinal value properties, for instance by making the pairwise comparisons in terms of value or utility levels only once, but at the level of the score categories (as will be explained below).In some cases, the number of pairwise comparisons to be made in the AHP may become quite large. However, when for instance regarding the evaluation of the actions in terms of the higher-level criteria, information or scores expressed on a ratio scale that has the properties of a cardinal value function is available (or can be constructed), then this information can be used directly to derive the relative priorities. In that case pairwise comparisons are not necessary for that part or subsystem of the hierarchy. When an underlying cardinal value function exists, this means for instance that an action that obtains a score x times as high on this scale as another action is also considered to be associated with a utility  level that is also x times as high as the other action. This can be the case for instance for a criterion like “public expenditure.” A project that requires a level of public expenditure e.g., three times as low as another project can be considered to be three times as good (in terms of utility) as the other project. Not all ratio scales possess this property. For instance, as far as the criterion “salary” is concerned, a candidate evaluating different job offers will not necessarily consider a job paying a monthly salary of €6,000 to be twice as good as a job with a salary of €3,000, In order to obtain relative priorities (weights) for the criteria shown on level 3 of the hierarchy in , stakehoEach group of stakeholders  were asked to rank on a five-point scale the international ABS goals explained in section “Conclusions” of this paper, according to the perceived impact on their daily operations with regards to GR. This survey was conducted between March 13, 2018 and April 30, 2018 and was sent to over 600 stakeholders including all of the national competent authorities of parties to the CBD, all of the national focal points, academic institutions, collections and industrial users worldwide. The selection of the stakeholders is based on their role in their institution as well as their demonstrated interest in ABS . The survey has received 220 responses in total with 92 responses from providers, 60 from academic users, 31 from industrial users and 37 from collections. Even though the number of participants is not homogenously divided between the stakeholder groups, the answers of a strongly represented stakeholder group  did not have an impact on the overall result in comparison to a group with fewer responses. This is because four individual surveys were created for each stakeholder group .The survey is designed as separate blocks for each stakeholder in order to ease the process of delineating and processing data into units . It consThe survey did not request the names or contact details of the stakeholders except for question 4 in order to preserve anonymity to avoid socially desirable answers .The stakeholder interview has been designed in a semi-structured manner. The questions on access and compliance asked stakeholders to rank their preference per regulatory option on a scale of 1 to 3 with 1 being the most favorable and 3 being the least favorable. The questions on benefit-sharing asked the stakeholders to rank the impact (from very positive to very negative) and burden (from burden to very heavy burden) of engaging in the given monetary or non-monetary option.As the number criteria is quite high (11), the number of pairwise comparisons to be made becomes quite large as well. In an 11 by 11 matrix a total of 55 pairwise comparisons may need to be made . In addition, the number of stakeholder representatives is also quite large. Therefore, one of the techniques referred to in section “The Use of the Pairwise Comparison Mechanism in AHP ” to obtain a cardinal value function has been used. To derive the criterion weights, the various stakeholder representatives were asked to score the importance of the criteria to them on a five-point ordinal scale (viz.++/+/0/−/−−), whereby “++” corresponds to “very important,” “+” to “important,” “0” to “no effect or neither important, nor unimportant,” “−” to “low importance” and “−−” to “very low importance.” To make possible ratio scale comparisons and derive AHP-like relative priorities, this ordinal scale has been transformed into a ratio scale using pairwise comparisons at the level of the score categories. This is shown in For instance, the value 7  are calculated as the right eigenvector corresponding to the highest eigenvalue as outlined in Eq. 1. The results are presented in Since we surveyed quite a large number of representatives for each stakeholder, the scores (or importance levels) for the criteria as expressed on the five-point ordinal scale referred to above differ from each other to some extent. The ideal situation is that the various stakeholder representatives would achieve a consensus on the final importance level to be given to the 11 criteria. Such a consensus might be obtained when all these representatives gathered for a meeting. But since the number of representatives per stakeholders was quite high and these representatives come from different countries all over the world (ranging from Brazil to Japan and from Norway to South Africa) we had to follow a more pragmatic procedure to build the consensus score. This procedure is based on statistical measures like the median and is illustrated in 1), 30 representatives placed this criterion in the category “very important,” 22 placed it in the category “important,” 2 placed it in the category “no effect” and no representative placed it in the category “low importance” and 3 representatives placed it in the category “very low importance” (see 1 (Predictability) scored by 57 representatives from the stakeholder “Providers” , the consensus solution that would have emerged out of this meeting would be very close to the median score. If necessary, a sensitivity analysis will be performed where we will test to what extent the final ranking of the final alternative solutions might change when other weight sets were used.1 to C5 is “very important”  in 6  is 0.249/4.129 = 0.060.The final relative priorities for the criteria are shown in ant” see , Part A ant” see , Part A value in , Part A value in . These v3) for the stakeholder “Academic users”  = 0.091. The geometric mean was used here , we have utilized much of the related literature  to fine-Likewise, when refining our conclusions related to the temporal scope, as well as the activity scope, and the implications on criteria N°1 (predictability), N°2  and N°3 (transparency) thereof, we resorted to many sources of literature  in order1A, DP1B, DP1C; DP2A, …, DP10B) to the 11 criteria  are given in The scores that finally resulted from the procedure described above and that express the contribution of the different options within each single DP , there are three options, namely: “in situ access” (DP1A), “in situ and ex situ access” (DP1B) and “in situ, ex situ, and for DSI” (DP1B) and these three options need to be prioritized in terms of their contribution to the 11 criteria identified (C1…C11). The same exercise needs to be done for the options  within the remaining DP (DP2…DP10) and for all of the 11 criteria. For instance, also DP2A, DP2B and DP2C need to be compared in terms of their contribution to the 11 criteria. As far as the prioritization of the DP options in terms of the 11 criteria is concerned, the prioritization is based on the  performance levels (score categories) of the options, i.e., the five-point ordinal scale (++/+/0:−/−−) subsequently transformed into ratio scales according to the same method as explained in section “General” ” (and according to Eq. 1). Here, two steps can be identified. The first step comprises the prioritization of the different options for the design parameters (DP) in terms of the 11 criteria identified. For instance, regarding DPGeneral” . The resThe second step is to conduct an analysis from each separate stakeholder’s point of view. This means that the different DP options need to be prioritized in terms of their contribution to the overall objectives of each stakeholder group, as measured by the stakeholder criteria (and their associated weights). More concretely, this means that the prioritizations of the DP options need to be combined with the criterion priorities or weights as derived in section “Building Consensus Among Stakeholder Representatives’ Scorings” and shown in 1 , namely: “In situ access only” (DP1A), “In situ and ex situ access” (DP1B) and “In situ, ex situ, and access for DSI” (DP1C). The 11 criteria (C1…C11) are represented on the horizontal axis, and their weights are visualized by the height of the vertical bars starting at the criterion’s name. The value of these weights is to be read off from the left vertical axis. For instance, the criterion Predictability (C1) has a weight (or priority) of 0.129. The (colored) lines from left to right represent the alternatives . The intersection between these (colored) lines from left to right and the vertical lines starting at the criterion’s name represent the priority  of that alternative (c.q. DP option) on that specific criterion. The value of this priority is to be read off from the right vertical axis. For instance, DP1A  obtain a priority of 0.405 on the criterion Predictability (C1). Finally, the priority of the DP options in terms of all the 11 criteria taken together (and weighted) are given by the intersection of the (colored) lines from left to right with the right vertical axis. For instance, DP1A (“in situ access only”) obtains a score of 0.430 . This finding may be peculiar to the access component of ABS agreements to GR, but it is doubtful whether this is the case for benefit-sharing agreements. Here, one might expect that the degrees of conflict between stakeholders will be higher.The low level of conflict between the stakeholders is because, in essence, all of the stakeholders strive to have a system that provides them with the clarity, legal certainty and cost-effectiveness they require in order to either make an informed decision (in the case of providers) or obtain access to GR in a lawful and timely manner . SecondlThis, nevertheless, is unlikely to be the case concerning benefit-sharing. The data obtained during the previous study  on benef1) shown in 1C option . Only in relation to C8 (Strengthen IPLC) and C9 (Technology transfer and cooperation) do the scores of DP1C match with these of DP1A and DP1B. For all the other criteria the scores of DP1C are lower than those of DP1A and DP1B. Hence, a relation of “weak dominance” exists between DP1A and DP1B on the one hand and DP1C on the other hand. All stakeholders prefer DP1A or DP1B and the difference between these two is very small . Hence, the conclusion here is that the stakeholders prefer ABS frameworks to cover “in situ access” (DP1A) or “in situ and ex situ access” (DP1B). On the other hand, a majority of the stakeholders does not favor DSI being covered by the same obligations as those that are imposed on in situ or ex situ access. As stated in section “Prioritization of the Design Parameters,” this is because all stakeholders benefit from accessing DSI, it would bear high costs for all stakeholders to subject DSI to the same access conditions as GR.As far as the material scope of an ABS framework , the options for the design parameters play an important role in the design of specific types of ABS frameworks to GR. Such an approach relies heavily on what 2), presented in 2B option. This option even strongly dominates the two other options (DP2A and DP2C), which even obtain the same score on all criteria. Hence, the conclusion here is that future ABS frameworks will need to be designed in terms of “access for utilization” (DP2B) and not in terms of “access for sampling” (DP2A) or “access to previously obtained GR for new utilization” (DP2C) to fulfill the objectives of all stakeholder groups.Regarding the temporal scope of ABS frameworks (DP3) presented in 3B option (“Development”) is the most preferable, followed by the DP3A (“Research”) and the DP3C option (“Research and Development”). The good overall score of DP3B here can largely be attributed to the high score on C7, C6 and C3. Hence, it makes sense to test the sensitivity of the result for variations in the weight of these criteria. A sensitivity analysis revealed that the final score of the DP3B option is insensitive to  changes in the weights of the criteria C7, C6 and C3. Only in the event that the weight of C7 was reduced from 0.129 to less than 0.030  would DP3B be outperformed by DP3A and this outperformance would only be very small and it would occur only in terms of the industrial user point of view (and not in terms of the other stakeholders’ point of view).Regarding the Material scope  in order to be consistent with the objectives of all stakeholder groups.Here again, the conclusion is that ABS frameworks should be designed along the lines of the DP4), presented in 4A option (which includes mandatory BSA) outperforms the DP4B option (where BSA is non-mandatory)  on all separate criteria, except the cost-effectiveness criterion (C6). In the overall view per stakeholder , the DP4A option is the preferred option of each stakeholder. The sensitivity of this result is very low. The weight of the C6 criterion would hypothetically need to be increased to about 0.318 (and from some stakeholder points of view to an even higher level) before rank reversal would occur. This is an increase by a factor of 2.4 from the academic user point of view; from the other viewpoints, the increase would need to be even higher , which is very unrealistic. Hence one can conclude that the final result is rather insensitive to changes in the weights. In other words, sensitivity is low, which can be interpreted as a benefit.Regarding the Conditions of access (DP4A option (whereby BSA is mandatory) to be consistent with the objectives of all stakeholder groups.Here again, the conclusion is that ABS frameworks should be designed along the lines of the DP5), presented in 5B option  outperforms the DP5A option (with notification-based access) or yields at least an equal score on all separate criteria but two. The two so-called “discordant” criteria are C6 (Cost-effectiveness) and C7 (Scientific Research). On these criteria, the DP5A option is the preferred option and the score difference is rather high on C6 and somewhat lower on C7. In terms of the overall view per stakeholder , the DP5B option, however, remains the preferred option of each stakeholder.Regarding the type of regulatory mechanism . As regards the C7 criterion, rank reversal would only occur with an increase of the C7 weight by a factor of 2.41 from the academic user point of view .The sensitivity of this result is rather low, but not as low as in the case of DP6 and the C7 weights were increased simultaneously, rank reversal would occur somewhat more quickly. For instance, from the academic user point of view, an increase of both weights simultaneously by a factor of 1.46 would already result in rank reversal , but from the other points of view an increase by a higher factor is needed to cause rank reversal.However, if both the C4B option  to be consistent with the objectives of all stakeholder groups.Here again, the conclusion is that ABS frameworks should be designed along the lines of the DP6), presented in 6A option  is the preferred option. On 6 of the 11 criteria, however, this option scores the same as the alternative option, but in terms of the stakeholder points of view DP6A remains in all cases the preferred option.Regarding the options related to the Granting authority (DP7), presented in 7A and DP7B score the same. For the criterion C4 (Fairness and Equity) DP7B outperforms DP7A and on criterion C6 (Cost-Effectiveness), it is the other way around. Moreover, some level of conflict exists between the stakeholder points of view. All stakeholder points of view favor the DP7B option , except the academic user point of view that favors DP7A , but the differences are really very small so that academic users might not have a big problem with the DP7B option. However, the results are quite sensitive to changes in the weights of C4 and C6. A sensitivity analysis revealed that small changes in C4 and C6 may lead to a rank reversal of DP7B and DP7A, particularly in terms of the academic user point of view. On the other hand, this finding reinforces the argument that academic users may not have a big problem when the DP7B option would be chosen instead of DP7A option.Regarding Standardization , DP8B  is the preferred option, as shown in 8B option, but a minority of criteria support the DP8A option , namely C8 (strengthen IPLC), C9 (Technology transfer) and C10 (Incentives for biodiversity). As the weight of these criteria is not very high, a sensitivity analysis may be useful in this case.Regarding DP8, C9 or C10). The weight of these criteria would need to be increased more than fourfold (more precisely to at least 0.360 and for some stakeholders even to 0.450), which is very unrealistic, before rank reversal would occur. And when the weights of all these so-called “discordant” criteria  were increased simultaneously, then the sensitivity analysis revealed that even for a doubling of these three criterion weights simultaneously, rank reversal still does not occur.Here, the sensitivity analysis revealed that the result is relatively insensitive to a hypothetical increase in the weights of these criteria taken separately , 9A option). The only nuance that should be made here is that both options score the same on 5 of the 11 criteria. Hence, in terms of the separate criteria DP9A weakly dominates DP9B, but in terms of the stakeholder points of view , there is strong dominance.Regarding the DP10 options  there is, according to 10A option) is preferable to the option “when intent changes” . Again, the nuance that needs to be made is that both options score the same on 5 of the 11 criteria. Hence, in terms of the separate criteria DP10A weakly dominates DP10B, but in terms of the stakeholder points of view , there is strong dominance.Regarding the DP1…DP10). Consequently, each column corresponds to a separate design parameter and comprises the different possible options  for these design parameters (shown by the rows). The DP options  that command the highest priority are shaded. For instance, as regards DP2 , it is DP2B (Access for utilization) that commands the highest priority. When two options have been shaded within the same column, this means that both options are ranked (more or less) the same in terms of all the stakeholder groups. For instance, as regards DP1 , both DP1A (In situ access) and DP1B (In situ access and ex situ access) obtain nearly the same priority and the difference between the stakeholder groups is very low (as shown in 10 (Renegotiability) both options are non-exclusive, which means that the implementation of one of the options does not exclude the implementation of the other option. As they are ranked the same, one could advise integrating both options into the design of the ABS frameworks to be worked out.1), the results show that the majority of the stakeholders do not prefer the DSI to be regulated in the same way as GR is, whereas they agree with the regulation of in situ and ex situ access. Regarding temporal scope (DP2), the stakeholders prefer the trigger to be utilization as that would provide them with higher levels of clarity and legal certainty. Especially for provider countries, the cost of monitoring and tracking access would be significantly lower.As regards the material scope  as both the users and the providers prefer a one-stop shop.Regarding DP5 demonstrates a slight difference between the point of view of the industrial and academic users. Whereas the academic users prioritize speed in order to advance in scientific research, industrial users value legal certainty and prefer permits over notifications in order to make sure they have complied with the necessary requirements from the beginning in order to prevent jeopardizing the entire R&D project.DP7). Many of the stakeholders did prefer standard terms in terms of cost-effectiveness and legal certainty, yet at the same time they found this to have a lower level of fairness in terms of its flexibility, negotiability and adaptability to the situation at hand. Nonetheless, the stakeholders appreciated some level of standardization with the option to tweak the terms to fit a certain situation. The same flexibility is also preferred when it comes to DP10 as stakeholders do appreciate permission from the regulatory framework regarding the adaptability of contracts to newly occurring situations such as discovery of a new lead or newly established public-private partnerships.One option the stakeholders did not have a full consensus on is standardization  or it occurred only after applying sensitivity analysis .The reason why the level of conflict between stakeholder preferences is rather low is that the four stakeholder groups consider the same group of criteria to be relevant to them. Only the extent to which these criteria are relevant to them  differs between the stakeholders. We assume that this finding may be a peculiar one to ABS frameworks, but that it will no longer be valid for the case of benefit-sharing. Here, one might expect that the degrees of conflict between stakeholders will be higher. Future MCA research, focused on the design of benefit-sharing agreements, will tell us whether this assumption is valid.The preliminary research  demonstrAll datasets presented in this study are included in the article/supplementary material.AS collected the data, the authors designed the methodology together. KD designed the MCA, analyzed the methodology and both the authors contributed to the discussion and conclusions. All authors contributed to the article and approved the submitted version.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.